"PROPOSED NEW TECHNOLOGY ADD-ON PAYMENTS THRESHOLDS1,2 FOR APPLICATIONS FOR FY 2021"				
MS?DRG	Number of Cases	Threshold		
001	2309	"$661,538"		
002	239	"$404,231"		
003	15158	"$422,799"		
004	13759	"$257,970"		
005	1160	"$272,473"		
006	574	"$168,139"		
007	554	"$322,753"		
008	457	"$175,301"		
010	41	"$129,050"		
011	1647	"$137,868"		
012	1851	"$117,046"		
013	961	"$87,765"		
014	959	"$294,121"		
016	2332	"$170,241"		
017	106	"$129,061"		
020	1486	"$293,994"		
021	509	"$214,887"		
022	120	"$131,860"		
023	10792	"$151,943"		
024	4542	"$119,924"		
025	17851	"$129,608"		
026	11903	"$94,317"		
027	12175	"$78,937"		
028	1899	"$145,734"		
029	3815	"$94,917"		
030	1867	"$74,825"		
031	760	"$117,552"		
032	2029	"$73,329"		
033	2931	"$62,589"		
034	943	"$118,714"		
035	2604	"$80,269"		
036	4850	"$64,368"		
037	2912	"$106,059"		
038	9857	"$67,602"		
039	26244	"$52,081"		
040	3961	"$110,850"		
041	6733	"$79,975"		
042	2894	"$68,011"		
052	813	"$53,732"		
053	239	"$41,595"		
054	12037	"$48,039"		
055	4837	"$42,437"		
056	9458	"$57,082"		
057	31844	"$42,256"		
058	713	"$57,624"		
059	2769	"$44,337"		
060	2602	"$38,574"		
061	5005	"$97,849"		
062	10710	"$82,404"		
063	2581	"$74,846"		
064	66823	"$59,990"		
065	114537	"$46,643"		
066	40431	"$36,910"		
067	698	"$55,874"		
068	4146	"$43,907"		
069	41076	"$40,164"		
070	12759	"$55,028"		
071	20236	"$43,091"		
072	4684	"$34,763"		
073	3394	"$53,357"		
074	20670	"$42,195"		
075	642	"$57,947"		
076	250	"$39,404"		
077	1424	"$57,596"		
078	3481	"$45,537"		
079	763	"$36,642"		
080	560	"$60,096"		
081	834	"$36,812"		
082	5557	"$69,038"		
083	9864	"$49,060"		
084	5186	"$40,552"		
085	6492	"$67,473"		
086	16143	"$48,314"		
087	9853	"$38,255"		
088	525	"$54,490"		
089	1838	"$45,669"		
090	842	"$41,187"		
091	11042	"$53,528"		
092	23937	"$41,691"		
093	9072	"$35,412"		
094	1470	"$89,690"		
095	1172	"$75,381"		
096	553	"$74,061"		
097	1766	"$93,477"		
098	1795	"$63,195"		
099	596	"$50,183"		
100	20690	"$58,407"		
101	47219	"$39,326"		
102	892	"$48,646"		
103	9682	"$37,765"		
113	437	"$69,845"		
114	174	"$50,168"		
115	707	"$55,611"		
116	371	"$60,673"		
117	183	"$46,900"		
121	580	"$41,637"		
122	186	"$27,448"		
123	2644	"$39,317"		
124	595	"$49,148"		
125	3512	"$34,733"		
129	1280	"$86,568"		
130	1878	"$61,546"		
131	1163	"$84,423"		
132	550	"$63,905"		
133	1515	"$67,107"		
134	1241	"$50,574"		
135	267	"$75,523"		
136	117	"$53,433"		
137	823	"$49,432"		
138	513	"$40,054"		
139	319	"$50,127"		
146	704	"$61,359"		
147	1078	"$46,094"		
148	339	"$37,400"		
149	15672	"$35,184"		
150	604	"$45,716"		
151	2566	"$27,838"		
152	3166	"$41,706"		
153	11457	"$30,023"		
154	1616	"$50,893"		
155	4281	"$39,196"		
156	1885	"$29,209"		
157	1323	"$53,136"		
158	3566	"$38,599"		
159	1152	"$29,388"		
163	10388	"$132,597"		
164	14141	"$86,297"		
165	11086	"$69,524"		
166	11781	"$101,520"		
167	7550	"$68,288"		
168	3410	"$54,649"		
175	26414	"$51,893"		
176	31308	"$37,729"		
177	73009	"$58,048"		
178	37520	"$46,184"		
179	7282	"$34,958"		
180	17953	"$58,207"		
181	11029	"$46,285"		
182	1586	"$41,383"		
183	4857	"$52,827"		
184	9234	"$43,723"		
185	3185	"$32,548"		
186	8433	"$52,954"		
187	7494	"$44,260"		
188	2107	"$32,760"		
189	151221	"$45,686"		
190	141867	"$44,220"		
191	71615	"$37,001"		
192	36003	"$29,714"		
193	149359	"$48,389"		
194	138663	"$37,741"		
195	41549	"$28,608"		
196	8441	"$53,145"		
197	3075	"$42,233"		
198	1018	"$33,245"		
199	5924	"$57,665"		
200	8705	"$44,373"		
201	3133	"$30,833"		
202	38112	"$39,430"		
203	12624	"$29,052"		
204	8464	"$36,792"		
205	8279	"$52,245"		
206	11046	"$38,093"		
207	20214	"$152,031"		
208	57611	"$76,952"		
215	6820	"$249,732"		
216	5733	"$283,835"		
217	2317	"$206,236"		
218	599	"$173,059"		
219	13177	"$227,434"		
220	16201	"$166,325"		
221	6070	"$144,156"		
222	1710	"$238,293"		
223	642	"$187,169"		
224	2038	"$218,395"		
225	1804	"$177,308"		
226	4601	"$190,528"		
227	5598	"$153,613"		
228	3475	"$186,811"		
229	5535	"$130,091"		
231	857	"$268,702"		
232	802	"$204,342"		
233	11021	"$230,734"		
234	16258	"$172,631"		
235	8819	"$177,965"		
236	21666	"$134,499"		
239	5709	"$123,778"		
240	11900	"$79,547"		
241	1150	"$54,095"		
242	16627	"$110,736"		
243	24687	"$86,378"		
244	18731	"$74,590"		
245	2119	"$148,008"		
246	42283	"$117,549"		
247	92620	"$88,978"		
248	3007	"$114,222"		
249	4959	"$85,725"		
250	3316	"$96,266"		
251	6472	"$76,418"		
252	17724	"$113,290"		
253	40039	"$81,569"		
254	15124	"$67,584"		
255	953	"$86,304"		
256	3456	"$59,237"		
257	245	"$44,151"		
258	604	"$92,628"		
259	1085	"$72,214"		
260	2473	"$104,335"		
261	3323	"$69,877"		
262	1868	"$62,068"		
263	332	"$68,030"		
264	10770	"$81,686"		
265	656	"$89,151"		
266	16857	"$192,997"		
267	26285	"$158,906"		
268	3320	"$187,591"		
269	17284	"$121,379"		
270	15388	"$146,304"		
271	16475	"$110,742"		
272	6939	"$85,108"		
273	5958	"$125,518"		
274	22526	"$107,996"		
280	80584	"$54,658"		
281	50309	"$44,449"		
282	26986	"$38,064"		
283	10246	"$56,468"		
284	1510	"$36,522"		
285	380	"$24,713"		
286	39090	"$75,512"		
287	64056	"$55,280"		
288	1671	"$68,233"		
289	409	"$54,938"		
290	132	"$41,003"		
291	379745	"$46,582"		
292	94799	"$36,913"		
293	35837	"$27,122"		
294	245	"$44,439"		
295	34	"$27,957"		
296	3891	"$55,177"		
297	585	"$37,501"		
298	221	"$23,841"		
299	13776	"$48,064"		
300	29996	"$40,803"		
301	11627	"$30,076"		
302	2688	"$43,582"		
303	15002	"$31,017"		
304	9328	"$44,732"		
305	35988	"$34,050"		
306	3017	"$45,868"		
307	3677	"$37,952"		
308	62802	"$45,475"		
309	80376	"$34,219"		
310	75514	"$24,757"		
311	5720	"$31,382"		
312	70746	"$36,743"		
313	43906	"$34,147"		
314	34383	"$63,066"		
315	29592	"$41,733"		
316	5392	"$33,168"		
319	1651	"$124,398"		
320	707	"$81,454"		
326	9255	"$137,406"		
327	10606	"$83,097"		
328	9884	"$61,843"		
329	30188	"$133,023"		
330	48771	"$85,775"		
331	38333	"$64,668"		
332	115	"$118,315"		
333	506	"$75,138"		
334	735	"$59,348"		
335	4556	"$116,391"		
336	9326	"$77,294"		
337	5615	"$62,867"		
338	12	"$93,755"		
339	50	"$64,803"		
340	25	"$52,434"		
341	1161	"$87,723"		
342	4574	"$64,862"		
343	5506	"$53,315"		
344	831	"$86,498"		
345	2033	"$60,398"		
346	1327	"$51,625"		
347	653	"$82,770"		
348	1906	"$55,818"		
349	1722	"$44,739"		
350	1151	"$82,222"		
351	3297	"$59,842"		
352	2984	"$49,809"		
353	2187	"$94,363"		
354	7007	"$65,345"		
355	7442	"$55,050"		
356	6163	"$115,479"		
357	6552	"$77,644"		
358	2402	"$61,751"		
368	2352	"$63,591"		
369	3963	"$46,243"		
370	1223	"$36,889"		
371	12566	"$55,366"		
372	31238	"$42,469"		
373	8812	"$31,296"		
374	8522	"$60,469"		
375	14142	"$47,471"		
376	3081	"$42,367"		
377	50786	"$59,578"		
378	108999	"$44,375"		
379	55747	"$34,647"		
380	4479	"$61,969"		
381	7536	"$47,071"		
382	2844	"$36,568"		
383	910	"$52,214"		
384	4745	"$42,236"		
385	2110	"$54,277"		
386	7642	"$42,673"		
387	4538	"$31,764"		
388	14688	"$52,298"		
389	47226	"$37,678"		
390	37386	"$26,515"		
391	27857	"$48,697"		
392	158886	"$35,282"		
393	18059	"$55,292"		
394	41222	"$41,953"		
395	14928	"$30,716"		
405	3794	"$141,615"		
406	3948	"$91,956"		
407	2807	"$78,512"		
408	814	"$102,247"		
409	682	"$82,286"		
410	370	"$64,334"		
411	213	"$116,346"		
412	221	"$86,647"		
413	161	"$65,828"		
414	1758	"$103,126"		
415	2571	"$76,201"		
416	1900	"$56,888"		
417	12253	"$83,967"		
418	19567	"$69,572"		
419	18861	"$58,370"		
420	631	"$97,495"		
421	603	"$71,645"		
422	397	"$56,807"		
423	763	"$113,407"		
424	463	"$76,722"		
425	123	"$60,188"		
432	14233	"$59,169"		
433	13359	"$43,289"		
434	829	"$29,071"		
435	12157	"$58,374"		
436	7968	"$46,104"		
437	1717	"$40,270"		
438	11131	"$57,121"		
439	26250	"$39,671"		
440	16058	"$29,161"		
441	16452	"$56,840"		
442	19727	"$40,290"		
443	3655	"$30,660"		
444	12173	"$56,135"		
445	16670	"$46,676"		
446	10047	"$39,347"		
453	3031	"$237,335"		
454	13036	"$162,849"		
455	22937	"$133,729"		
456	1233	"$234,788"		
457	3226	"$173,810"		
458	2062	"$137,126"		
459	3744	"$170,476"		
460	56160	"$110,829"		
461	270	"$140,161"		
462	7276	"$96,327"		
463	4604	"$127,125"		
464	9970	"$83,150"		
465	5320	"$67,995"		
466	3752	"$131,968"		
467	14460	"$102,550"		
468	26846	"$87,693"		
469	24318	"$94,727"		
470	453376	"$68,507"		
471	2812	"$145,173"		
472	14670	"$95,153"		
473	15072	"$81,666"		
474	2148	"$108,633"		
475	4712	"$68,868"		
476	1018	"$49,775"		
477	2777	"$95,495"		
478	6451	"$77,931"		
479	2842	"$66,936"		
480	24055	"$92,347"		
481	65096	"$73,760"		
482	41517	"$64,397"		
483	63122	"$78,442"		
485	1264	"$95,459"		
486	2439	"$74,065"		
487	1201	"$62,022"		
488	1860	"$67,312"		
489	3038	"$52,677"		
492	5136	"$101,453"		
493	17150	"$78,222"		
494	16408	"$65,940"		
495	412	"$102,011"		
496	1654	"$66,912"		
497	1426	"$56,869"		
498	1004	"$76,396"		
499	394	"$52,786"		
500	1885	"$89,302"		
501	6112	"$60,234"		
502	4191	"$51,951"		
503	652	"$84,316"		
504	3266	"$60,320"		
505	1496	"$57,584"		
506	469	"$51,603"		
507	428	"$69,404"		
508	228	"$56,392"		
509	60	"$51,528"		
510	891	"$88,088"		
511	3143	"$70,114"		
512	2732	"$59,840"		
513	1551	"$57,149"		
514	804	"$46,682"		
515	3919	"$93,995"		
516	12294	"$70,204"		
517	14661	"$56,776"		
518	2414	"$101,125"		
519	7786	"$68,762"		
520	8765	"$54,862"		
533	648	"$50,217"		
534	3022	"$30,270"		
535	5699	"$44,971"		
536	26610	"$30,373"		
537	746	"$37,356"		
538	472	"$29,401"		
539	2017	"$57,830"		
540	4255	"$44,320"		
541	795	"$35,783"		
542	5750	"$55,973"		
543	13845	"$43,133"		
544	5930	"$32,740"		
545	3056	"$64,747"		
546	4303	"$44,708"		
547	1605	"$33,561"		
548	558	"$61,243"		
549	1219	"$44,649"		
550	521	"$37,771"		
551	10493	"$54,457"		
552	54752	"$39,314"		
553	1882	"$45,235"		
554	12798	"$30,833"		
555	1566	"$47,828"		
556	10570	"$33,643"		
557	3282	"$50,110"		
558	11382	"$35,247"		
559	2573	"$53,427"		
560	5447	"$37,924"		
561	3391	"$27,921"		
562	4895	"$48,504"		
563	26640	"$34,622"		
564	3776	"$53,141"		
565	9345	"$41,543"		
566	2459	"$32,594"		
570	2209	"$75,702"		
571	6888	"$55,368"		
572	2198	"$46,691"		
573	579	"$110,230"		
574	1601	"$80,906"		
575	341	"$57,425"		
576	386	"$130,971"		
577	1225	"$79,601"		
578	1426	"$61,577"		
579	3415	"$81,545"		
580	10661	"$56,779"		
581	6570	"$49,499"		
582	382	"$62,198"		
583	952	"$54,460"		
584	576	"$62,667"		
585	919	"$60,684"		
592	2176	"$49,791"		
593	5895	"$40,899"		
594	747	"$29,899"		
595	772	"$57,555"		
596	2967	"$36,848"		
597	1283	"$56,657"		
598	1498	"$43,982"		
599	257	"$37,280"		
600	756	"$38,208"		
601	479	"$24,042"		
602	19845	"$48,154"		
603	108734	"$31,487"		
604	2471	"$52,905"		
605	13766	"$38,578"		
606	1251	"$48,123"		
607	6337	"$32,050"		
614	1812	"$82,311"		
615	1518	"$61,889"		
616	2985	"$97,895"		
617	14832	"$64,645"		
618	135	"$49,123"		
619	463	"$112,805"		
620	3521	"$67,227"		
621	13604	"$60,322"		
622	1494	"$90,616"		
623	6495	"$59,776"		
624	336	"$43,642"		
625	391	"$108,573"		
626	1384	"$71,331"		
627	1701	"$53,767"		
628	2049	"$108,788"		
629	6522	"$71,648"		
630	356	"$56,773"		
637	26511	"$49,219"		
638	59099	"$35,609"		
639	11838	"$25,852"		
640	43647	"$46,045"		
641	117233	"$32,577"		
642	1912	"$42,348"		
643	8756	"$53,031"		
644	13212	"$42,080"		
645	5353	"$31,455"		
652	11308	"$113,338"		
653	1357	"$144,891"		
654	3491	"$94,494"		
655	2314	"$78,234"		
656	2210	"$108,921"		
657	6904	"$73,498"		
658	7860	"$63,579"		
659	7654	"$76,923"		
660	16875	"$56,922"		
661	15636	"$49,248"		
662	557	"$89,581"		
663	1235	"$58,077"		
664	850	"$47,259"		
665	590	"$88,801"		
666	1395	"$63,648"		
667	781	"$47,413"		
668	1868	"$85,053"		
669	4974	"$59,390"		
670	2721	"$46,854"		
671	355	"$62,177"		
672	230	"$46,878"		
673	8093	"$108,536"		
674	9684	"$72,027"		
675	692	"$57,482"		
682	87569	"$50,182"		
683	148581	"$36,982"		
684	24215	"$26,545"		
686	1330	"$57,096"		
687	2581	"$43,235"		
688	567	"$37,129"		
689	69651	"$42,571"		
690	141822	"$32,397"		
693	1300	"$48,785"		
694	8025	"$33,702"		
695	957	"$43,134"		
696	6452	"$28,084"		
697	480	"$40,382"		
698	56729	"$50,872"		
699	38063	"$40,511"		
700	5480	"$30,233"		
707	3098	"$73,243"		
708	10799	"$62,468"		
709	399	"$72,560"		
710	273	"$55,092"		
711	419	"$68,460"		
712	168	"$46,447"		
713	4822	"$53,231"		
714	2036	"$42,578"		
715	330	"$71,124"		
716	181	"$57,992"		
717	1430	"$61,466"		
718	544	"$49,935"		
722	666	"$58,092"		
723	1504	"$44,620"		
724	337	"$34,881"		
725	612	"$46,997"		
726	2654	"$31,204"		
727	1034	"$48,704"		
728	4830	"$33,542"		
729	638	"$40,948"		
730	138	"$29,710"		
734	559	"$82,322"		
735	871	"$61,281"		
736	628	"$118,886"		
737	1825	"$75,717"		
738	1295	"$63,565"		
739	445	"$111,249"		
740	1468	"$71,999"		
741	2672	"$58,999"		
742	3392	"$65,541"		
743	7152	"$50,865"		
744	1127	"$60,607"		
745	443	"$47,094"		
746	1109	"$57,538"		
747	1745	"$44,195"		
748	1521	"$52,846"		
749	666	"$81,440"		
750	274	"$59,028"		
754	1321	"$56,644"		
755	2659	"$42,660"		
756	432	"$37,177"		
757	698	"$48,881"		
758	1470	"$40,254"		
759	540	"$28,323"		
760	1328	"$38,010"		
761	512	"$26,827"		
768	186	"$32,863"		
769	87	"$47,818"		
770	68	"$33,748"		
776	530	"$27,586"		
779	62	"$35,631"		
783	160	"$55,735"		
784	564	"$42,128"		
785	529	"$30,934"		
786	555	"$50,729"		
787	1928	"$37,938"		
788	1737	"$31,632"		
793	1	"$16,194"		
794	4	"$18,387"		
796	18	"$54,008"		
797	109	"$31,429"		
798	118	"$29,530"		
799	437	"$139,394"		
800	272	"$90,107"		
801	251	"$68,964"		
802	727	"$91,504"		
803	945	"$65,846"		
804	534	"$57,558"		
805	404	"$30,384"		
806	2230	"$20,707"		
807	3532	"$18,071"		
808	7322	"$61,417"		
809	11386	"$45,870"		
810	4816	"$37,370"		
811	20072	"$49,021"		
812	62169	"$35,797"		
813	17372	"$49,210"		
814	1343	"$57,895"		
815	2786	"$42,502"		
816	1023	"$33,569"		
817	53	"$70,496"		
818	92	"$47,769"		
819	46	"$43,887"		
820	1029	"$149,534"		
821	914	"$85,030"		
822	1243	"$55,086"		
823	1955	"$120,196"		
824	2247	"$82,314"		
825	916	"$56,773"		
826	698	"$139,571"		
827	1053	"$85,813"		
828	1162	"$64,191"		
829	1477	"$90,145"		
830	628	"$60,125"		
831	407	"$38,441"		
832	1461	"$25,392"		
833	797	"$20,298"		
834	3722	"$113,690"		
835	2723	"$63,825"		
836	445	"$41,756"		
837	1014	"$156,501"		
838	2075	"$69,998"		
839	989	"$42,615"		
840	7338	"$78,548"		
841	8333	"$54,766"		
842	1910	"$43,721"		
843	1752	"$60,341"		
844	2167	"$46,298"		
845	441	"$39,121"		
846	1981	"$70,163"		
847	6736	"$51,337"		
848	7095	"$45,104"		
849	399	"$58,922"		
853	76428	"$130,500"		
854	32595	"$75,351"		
855	1185	"$60,432"		
856	7813	"$106,303"		
857	9503	"$64,291"		
858	1787	"$51,790"		
862	11898	"$55,489"		
863	11871	"$38,384"		
864	9991	"$36,307"		
865	2887	"$48,298"		
866	8337	"$34,170"		
867	2502	"$58,406"		
868	2068	"$41,850"		
869	463	"$30,990"		
870	34867	"$168,175"		
871	591846	"$58,508"		
872	187761	"$43,543"		
876	658	"$76,606"		
880	7384	"$36,578"		
881	4425	"$23,748"		
882	2034	"$27,163"		
883	1157	"$33,050"		
884	19253	"$42,022"		
885	71743	"$31,608"		
886	339	"$33,284"		
887	432	"$39,866"		
894	4033	"$20,944"		
895	3703	"$36,831"		
896	8888	"$52,387"		
897	31208	"$28,830"		
901	782	"$109,339"		
902	2384	"$63,987"		
903	821	"$47,262"		
904	982	"$88,243"		
905	313	"$60,753"		
906	535	"$58,620"		
907	8436	"$108,726"		
908	10466	"$67,506"		
909	4436	"$53,175"		
913	600	"$52,654"		
914	2854	"$38,803"		
915	2163	"$56,414"		
916	4263	"$25,964"		
917	28705	"$49,530"		
918	19725	"$32,249"		
919	11553	"$57,045"		
920	13462	"$42,012"		
921	5203	"$31,066"		
922	1377	"$51,470"		
923	2319	"$34,956"		
927	152	"$422,270"		
928	1165	"$132,332"		
929	360	"$76,901"		
933	143	"$63,265"		
934	513	"$44,251"		
935	1782	"$46,530"		
939	502	"$104,240"		
940	1662	"$71,230"		
941	1125	"$63,829"		
945	1481	"$45,465"		
946	422	"$43,162"		
947	5791	"$44,889"		
948	34219	"$33,139"		
949	1350	"$38,240"		
950	422	"$24,275"		
951	1835	"$22,303"		
955	452	"$169,453"		
956	6130	"$101,225"		
957	2232	"$197,942"		
958	1635	"$122,956"		
959	228	"$94,198"		
963	2698	"$79,403"		
964	4570	"$53,849"		
965	1015	"$41,698"		
969	369	"$156,041"		
970	186	"$95,949"		
974	3917	"$75,879"		
975	3377	"$49,163"		
976	473	"$36,783"		
977	1462	"$45,459"		
981	22793	"$121,596"		
982	19824	"$76,605"		
983	4344	"$59,429"		
987	7930	"$93,213"		
988	9073	"$61,703"		
989	2141	"$49,626"		
				
1Geometric mean plus the lesser of .75 of the national adjusted operating standardized payment amount (increased to reflect the difference between costs and charges) or .75 of one standard deviation of mean charges by medicare severity diagnosis related group (ms drg)				
2Cases taken from the FY 2018 MedPAR file; MS-DRGs are from GROUPER Version37.0.				
