Price Transparencybeta Hospital negotiated rates

Hospital facility prices. What the hospital charges for the facility side of care — the surgeon’s and anesthesiologist’s fees are billed separately and are not included. How we scope prices →

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Hospital

San Joaquin Valley Rehabilitation Hosp

Fresno, CA · CCN 053032 · Rates published

4,414 distinct procedures filed
59 distinct payers
235,338 rate rows
2026-07-31 last MRF observed
Data quality

217,405 of 235,338 rate rows are consumer-grade (92.4%)

17,933 rows are marked excluded from the consumer medians — these stay visible in the raw drill-down with the same reason shown here, so nothing is silently hidden.

Excluded — reasonRows
template filing: same amount across many unrelated codes — excluded 17,850
below 25% of the Medicare reference for this code — likely a mislabeled per-diem or placeholder; excluded from medians 80
no usable negotiated amount (only an out-of-band fallback) — excluded from medians 3
Data source & audit trail ↓ Download audit trail (JSON)
Source MRF file https://sjvrehab.com/wp-content/uploads/sites/15/2025/09/030501943_san-joaquin-valley-rehab_standardcharges.csv
Found on page https://sjvrehab.com/about-us/price-transparency/
Discovered viaDiscovered by HANK
Last fetch not_modified · 2026-10-03
Content fingerprint ae82410c96211dd7… · 9,961,822 bytes · first seen 2026-05-08

Top 50 most expensive offerings

Outliers are flagged where this hospital's filed rate is ≥2× or ≤0.5× the national median for the same code.

Code Description Payers Min $ Max $ Avg median vs national
68875010201
OTHER 		Gattex 22 $19,590.00 $99,999.99 $99,999.99 nat. median
$100,000
1.0× median
407
OTHER 		Traumatic Spinal Cord Injury M <24.50 And A >=61.50 Tier 1 B 19 $78,030.33 $99,477.32 $87,169.12 nat. median
$16,665
outlier · 5.2×
404
OTHER 		Traumatic Spinal Cord Injury M <31.50 And A <61.50 Tier 1 B 19 $56,249.23 $71,708.00 $62,836.26 nat. median
$1,967
outlier · 32.0×
406
OTHER 		Traumatic Spinal Cord Injury M >=24.50 And M <31.50 And A >=61.50 Tier 3 D 24 $34,236.80 $120,579.90 $62,813.91 nat. median
$20,431
outlier · 3.1×
1904
OTHER 		Guillain-barr� M <38.50 None A 25 $59,468.51 $86,077.36 $61,750.39 nat. median
$120,722
0.5× median
1806
OTHER 		Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50 None A 24 $56,164.88 $157,760.46 $61,322.15 nat. median
$2,186
outlier · 28.1×
106
OTHER 		Stroke M <41.50 And A <84.50 Tier 1 B 24 $20,049.34 $134,624.04 $59,308.04 nat. median
$3,044
outlier · 19.5×
505
OTHER 		Non-traumatic Spinal Cord Injury M <39.50 Tier 3 D 24 $5,787.35 $70,971.53 $52,162.18 nat. median
$14,495
outlier · 3.6×
55292070255
OTHER 		Hemin For Injection 22 $19,590.00 $52,162.17 $51,333.70 nat. median
$51,334
1.0× median
205
OTHER 		Traumatic Brain Injury M <35.50 Tier 1 B 24 $28,157.62 $87,372.35 $51,131.60 nat. median
$14,633
outlier · 3.5×
405
OTHER 		Traumatic Spinal Cord Injury M >=31.50 And M <41.50 Tier2 C 24 $44,731.62 $70,648.99 $49,228.07 nat. median
$41,548
1.2× median
1705
OTHER 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50 Tier 1 B 25 $33,187.19 $74,335.85 $47,955.14 nat. median
$3
outlier · 17566.0×
105
OTHER 		Stroke M <41.50 And A >=84.50 None A 24 $23,920.57 $75,247.94 $47,649.26 nat. median
$1,950
outlier · 24.4×
305
OTHER 		Non-traumatic Brain Injury M <42.50 And A <78.50 Tier 1 B 24 $32,293.44 $64,938.59 $44,886.91 nat. median
$68
outlier · 658.5×
1004
OTHER 		Amputation Lower Extremity M <47.50 Tier 1 B 24 $31,187.42 $67,778.22 $44,778.68 nat. median
$2,665
outlier · 16.8×
1903
OTHER 		Guillain-barr� M >=38.50 And M <51.50 Tier 1 B 19 $41,656.33 $59,091.57 $43,909.27 nat. median
$120,722
outlier · 0.4×
604
OTHER 		Neurological M <43.50 Tier 1 B 24 $21,315.41 $89,085.37 $43,870.44 nat. median
$11,636
outlier · 3.8×
1805
OTHER 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50 T… 25 $29,837.60 $68,224.21 $43,178.68 nat. median
$2,374
outlier · 18.2×
2005
OTHER 		Miscellaneous M <46.50 And A <77.50 Tier 1 B 25 $30,851.87 $61,832.47 $41,745.75 nat. median
$2,886
outlier · 14.5×
2102
OTHER 		Burns M <52.50 Tier 1 B 19 $35,388.12 $54,531.59 $41,437.51 nat. median
$2,154
outlier · 19.2×
1504
OTHER 		Pulmonary M <45.50 Tier 3 D 24 $37,628.22 $84,985.63 $40,849.28 nat. median
$259
outlier · 157.7×
1304
OTHER 		Rheumatoid Other Arthritis M <44.50 And A >=64.50 Tier 1 B 19 $36,997.53 $50,390.42 $40,716.33 nat. median
$3,015
outlier · 13.5×
904
OTHER 		Other Orthopedic M <44.5 Tier 1 B 24 $32,130.97 $68,705.92 $40,359.87 nat. median
$2,146
outlier · 18.8×
403
OTHER 		Traumatic Spinal Cord Injury M >=41.50 And M <47.50 Tier 1 B 19 $36,025.76 $45,926.91 $40,244.57 nat. median
$115
outlier · 351.0×
704
OTHER 		Fracture Of Lower Extremity M <41.50 None A 25 $19,263.25 $65,509.42 $40,126.93 nat. median
$334
outlier · 120.2×
59627022205
OTHER 		Avonex 22 $19,590.00 $52,162.17 $39,676.03 nat. median
$39,676
1.0× median
59627033304
OTHER 		Avonex Pen 30 mcg/0.5mL 22 $19,590.00 $52,162.17 $39,676.03 nat. median
$39,676
1.0× median
2004
OTHER 		Miscellaneous M <46.50 And A >=77.50 Tier 1 B 25 $14,642.45 $63,530.28 $39,604.58 nat. median
$3,044
outlier · 13.0×
74368303
OTHER 		Lupron Depot 22 $19,590.00 $52,162.17 $39,246.62 nat. median
$39,247
1.0× median
1604
OTHER 		Pain Syndrome M <43.50 Tier 1 B 19 $34,326.95 $55,235.11 $39,053.99 nat. median
$2,886
outlier · 13.5×
1305
OTHER 		Rheumatoid Other Arthritis M <51.50 And A <64.50 Tier 1 B 19 $35,430.47 $48,256.31 $38,991.64 nat. median
$2,154
outlier · 18.1×
805
OTHER 		Replacement Of Lower-extremity Joint M <42.50 Tier 1 B 24 $30,832.76 $65,791.91 $38,917.52 nat. median
$21
outlier · 1815.2×
104
OTHER 		Stroke M >=41.50 And M <50.50 Tier 3 D 24 $31,792.34 $63,080.31 $38,105.76 nat. median
$1,688
outlier · 22.6×
1103
OTHER 		Amputation Non-lower Extremity M <52.50 Tier 1 B 19 $37,166.94 $47,190.43 $37,933.99 nat. median
$2,886
outlier · 13.1×
1704
OTHER 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50… 25 $19,941.82 $81,654.24 $37,844.58 nat. median
$2
outlier · 24574.4×
1204
OTHER 		Osteoarthritis M <49.50 And A <74.50 Tier 1 B 19 $33,484.60 $51,381.01 $37,844.58 nat. median
$2,886
outlier · 13.1×
504
OTHER 		Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50 Tier 2 C 24 $3,356.00 $64,973.18 $37,538.70 nat. median
$15,186
outlier · 2.5×
1804
OTHER 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=40.50 And M <45.50 T… 25 $33,021.07 $89,916.01 $37,515.17 nat. median
$3,015
outlier · 12.4×
304
OTHER 		Non-traumatic Brain Injury M <42.50 And A >=78.50 Tier 2 C 24 $13,863.09 $57,042.75 $37,388.11 nat. median
$9,874
outlier · 3.8×
1404
OTHER 		Cardiac M <45.50 Tier 3 D 24 $33,081.17 $58,985.44 $36,981.06 nat. median
$3,015
outlier · 12.3×
204
OTHER 		Traumatic Brain Injury M >=35.50 And M <49.50 Tier 3 D 24 $30,954.62 $62,288.95 $36,256.35 nat. median
$7,505
outlier · 4.8×
603
OTHER 		Neurological M >=43.50 And M <52.50 Tier 1 B 24 $18,426.52 $95,835.75 $34,981.06 nat. median
$7,721
outlier · 4.5×
1003
OTHER 		Amputation Lower Extremity M >=47.50 And M <55.50 Tier 2 C 24 $28,625.79 $61,498.39 $34,976.36 nat. median
$2,374
outlier · 14.7×
1203
OTHER 		Osteoarthritis M <49.50 And A >=74.50 Tier 3 D 24 $31,929.31 $48,997.49 $34,926.94 nat. median
$12
outlier · 2879.4×
703
OTHER 		Fracture Of Lower Extremity M >=41.50 And M <52.50 Tier 1 B 24 $16,965.85 $75,648.43 $34,675.18 nat. median
$3
outlier · 10604.0×
1703
OTHER 		Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50… 25 $29,198.75 $57,877.70 $33,437.54 nat. median
$3,015
outlier · 11.1×
1803
OTHER 		Major Multiple Trauma With Brain Or Spinal Cord Injury M >=45.50 And M <55.50 T… 19 $30,197.55 $43,002.21 $33,437.53 nat. median
$2,886
outlier · 11.6×
74055402
OTHER 		Humira(Cf) Pen 22 $19,590.00 $52,162.17 $33,228.58 nat. median
$33,229
1.0× median
2144511
OTHER 		Taltz Autoinjector 22 $19,590.00 $52,162.17 $33,195.46 nat. median
$33,195
1.0× median
2003
OTHER 		Miscellaneous M >=46.50 And M <55.50 Tier 1 B 25 $13,713.00 $60,096.92 $33,124.60 nat. median
$3,044
outlier · 10.9×

Other procedures at this hospital

Browse this hospital's 4,414 published procedures. Use the slice to choose what to show, then sort or filter any column.

Slice
Sortable, filterable data table. Use the column headers to sort, the filter row to narrow results.
Code Type Description Rate rows Payers Gross Cash Min $ Max $ Avg median Last observed
             
10005 OTHER Needle Biopsy W US 1st Lesion 46 22 $2,465.40 $2,465.40 $2,033.95 $23,640.00 $2,465.40 2026-05-09
1001 OTHER Amputation Lower Extremity M >=64.50 Tier 3 D 98 24 $23,564.63 $22,545.81 $19,039.42 $37,126.08 $21,526.99 2026-05-09
1002 OTHER Amputation Lower Extremity M >=55.50 And M <64.50 Tier 3 D 118 24 $36,096.35 $28,561.08 21% off $21,841.93 $65,868.14 $27,270.50 2026-05-09
1003 OTHER Amputation Lower Extremity M >=47.50 And M <55.50 Tier 2 C 117 24 $42,291.63 $33,463.42 21% off $28,625.79 $61,498.39 $34,976.36 2026-05-09
1004 OTHER Amputation Lower Extremity M <47.50 Tier 1 B 158 24 $48,912.33 $42,841.04 $31,187.42 $67,778.22 $44,778.68 2026-05-09
101 OTHER Stroke M >=72.50 Tier 1 B 76 19 $19,117.58 $19,117.58 $17,397.59 $23,035.22 $19,117.58 2026-05-08
102 OTHER Stroke M >=63.50 And M <72.50 None A 100 25 $25,350.51 $24,257.57 $21,593.67 $30,961.29 $23,164.63 2026-05-09
103 OTHER Stroke M >=50.50 And M <63.50 Tier 1 B 166 25 $37,675.17 $31,266.96 $20,525.17 $52,356.82 $30,624.07 2026-05-09
104 OTHER Stroke M >=41.50 And M <50.50 Tier 3 D 122 24 $48,082.20 $39,902.23 $31,792.34 $63,080.31 $38,105.76 2026-05-09
105 OTHER Stroke M <41.50 And A >=84.50 None A 139 24 $60,124.51 $49,896.31 $23,920.57 $75,247.94 $47,649.26 2026-05-09
106 OTHER Stroke M <41.50 And A <84.50 Tier 1 B 165 24 $68,385.66 $56,752.76 $20,049.34 $134,624.04 $59,308.04 2026-05-09
10631009160 OTHER Eurax 46 22 $2,428.42 $2,428.42 $2,003.44 $23,640.00 $2,428.42 2026-05-09
1101 OTHER Amputation Non-lower Extremity M >=58.50 Tier 1 B 57 19 $23,926.98 $23,926.98 $23,444.63 $29,764.61 $23,926.98 2026-05-08
1102 OTHER Amputation Non-lower Extremity M >=52.50 And M <58.50 Tier 1 B 57 19 $30,418.72 $30,418.72 $29,804.61 $37,842.23 $30,418.72 2026-05-08
1103 OTHER Amputation Non-lower Extremity M <52.50 Tier 1 B 57 19 $37,933.99 $37,933.99 $37,166.94 $47,190.43 $37,933.99 2026-05-08
11043 OTHER Wc Debride Subq/musc Bx/bs 46 22 $2,286.00 $2,286.00 $1,885.95 $20,184.04 $2,286.00 2026-05-09
11044 OTHER Wc Debride Subq/musc/bone Bx/b 46 22 $6,511.00 $6,511.00 $5,371.57 $52,162.17 $6,511.00 2026-05-09
118 OTHER R&b - Private - Irf 71 32 $2,642.95 $2,642.95 $1,442.00 $23,640.00 $2,642.95 2026-05-09
1201 OTHER Osteoarthritis M >=61.50 Tier 1 B 76 19 $23,009.33 $23,009.33 $20,357.58 $31,239.90 $23,009.33 2026-05-08
1202 OTHER Osteoarthritis M >=49.50 And M <61.50 Tier 1 B 76 19 $27,856.38 $27,856.38 $24,646.98 $37,821.05 $27,856.38 2026-05-08
1203 OTHER Osteoarthritis M <49.50 And A >=74.50 Tier 3 D 98 24 $37,249.29 $36,088.12 $31,929.31 $48,997.49 $34,926.94 2026-05-09
1204 OTHER Osteoarthritis M <49.50 And A <74.50 Tier 1 B 76 19 $37,844.58 $37,844.58 $33,484.60 $51,381.01 $37,844.58 2026-05-08
12044 OTHER Wc Neck/hands/feet 7.6-12.5cm 46 22 $2,286.00 $2,286.00 $1,885.95 $20,184.04 $2,286.00 2026-05-09
128 OTHER R&b - Semi Pvt - Irf 74 35 $2,642.95 $2,642.95 $1,442.00 $23,640.00 $2,642.95 2026-07-31
1301 OTHER Rheumatoid Other Arthritis M >=62.50 Tier 1 B 76 19 $20,731.70 $20,731.70 $18,837.59 $25,658.74 $20,731.70 2026-05-08
1302 OTHER Rheumatoid Other Arthritis M >=51.50 And M <62.50 Tier 3 D 98 24 $28,999.90 $28,341.08 $25,750.50 $47,795.95 $27,682.26 2026-05-09
1303 OTHER Rheumatoid Other Arthritis M >=44.50 And M <51.50 And A >=64.50 Tier 1 B 76 19 $32,242.25 $32,242.25 $29,296.37 $39,901.05 $32,242.25 2026-05-08
1304 OTHER Rheumatoid Other Arthritis M <44.50 And A >=64.50 Tier 1 B 76 19 $40,716.33 $40,716.33 $36,997.53 $50,390.42 $40,716.33 2026-05-08
1305 OTHER Rheumatoid Other Arthritis M <51.50 And A <64.50 Tier 1 B 76 19 $38,991.64 $38,991.64 $35,430.47 $48,256.31 $38,991.64 2026-05-08
13533063402 OTHER Hypertet S-d 250 Unit 46 22 $3,116.02 $3,116.02 $2,570.72 $23,640.00 $3,116.02 2026-05-09
13533080071 OTHER Gamunex-c 46 22 $6,804.00 $6,804.00 $5,613.30 $52,162.17 $6,804.00 2026-05-09
1401 OTHER Cardiac M >=68.50 Tier 1 B 117 24 $20,987.53 $20,183.47 $17,080.19 $34,860.69 $20,917.58 2026-05-09
1402 OTHER Cardiac M >=55.50 And M <68.50 Tier 3 D 118 24 $30,581.02 $25,597.56 $17,463.45 $50,448.36 $24,665.80 2026-05-09
1403 OTHER Cardiac M >=45.50 And M <55.50 Tier 1 B 156 24 $37,713.86 $31,321.08 $26,705.36 $51,659.12 $32,461.07 2026-05-09
1404 OTHER Cardiac M <45.50 Tier 3 D 116 24 $50,489.25 $38,377.52 24% off $33,081.17 $58,985.44 $36,981.06 2026-05-09
1501 OTHER Pulmonary M >=68.50 Tier 1 B 76 19 $23,603.45 $23,603.45 $21,402.28 $29,974.02 $23,603.45 2026-05-08
1502 OTHER Pulmonary M >=56.50 And M <68.50 Tier 3 D 117 24 $29,023.43 $29,942.26 $15,909.35 $44,708.40 $29,023.43 2026-05-09
1503 OTHER Pulmonary M >=45.50 And M <56.50 None A 98 24 $35,072.83 $34,029.30 $30,005.27 $43,213.98 $32,985.77 2026-05-09
1504 OTHER Pulmonary M <45.50 Tier 3 D 117 24 $53,515.12 $42,142.21 21% off $37,628.22 $84,985.63 $40,849.28 2026-05-09
15110 OTHER Wc Epdrml Autogrft Leg 1st 100 46 22 $7,332.00 $7,332.00 $6,048.90 $52,162.17 $7,332.00 2026-05-09
15115 OTHER Wc Epdrml Autogrft Ft 1st 100 46 22 $7,332.00 $7,332.00 $6,048.90 $52,162.17 $7,332.00 2026-05-09
15271 OTHER Wc Apply High Cost Ss Leg 46 22 $7,332.00 $7,332.00 $6,048.90 $52,162.17 $7,332.00 2026-05-09
15275 OTHER Wc Apply High Cost Ss Foot 46 22 $7,332.00 $7,332.00 $6,048.90 $52,162.17 $7,332.00 2026-05-09
1601 OTHER Pain Syndrome M >=65.50 Tier 1 B 76 19 $21,782.28 $21,782.28 $19,145.82 $30,804.60 $21,782.28 2026-05-08
1602 OTHER Pain Syndrome M >=58.50 And M <65.50 Tier 1 B 76 19 $24,959.92 $24,959.92 $21,938.75 $35,301.06 $24,959.92 2026-05-08
1603 OTHER Pain Syndrome M >=43.50 And M <58.50 Tier 1 B 76 19 $31,521.07 $31,521.07 $27,705.79 $44,581.03 $31,521.07 2026-05-08
1604 OTHER Pain Syndrome M <43.50 Tier 1 B 76 19 $39,053.99 $39,053.99 $34,326.95 $55,235.11 $39,053.99 2026-05-08
16110081230 OTHER Fluoroplex 1 % 46 22 $4,454.16 $4,454.16 $3,674.68 $33,133.97 $4,454.16 2026-05-09
169413013 OTHER Semaglutide Injection 46 22 $4,648.90 $4,648.90 $3,835.34 $33,133.97 $4,648.90 2026-05-09
169418113 OTHER Semaglutide 46 22 $4,648.90 $4,648.90 $3,835.34 $33,133.97 $4,648.90 2026-05-09
169477212 OTHER Semaglutide (2 Mg/dose) 46 22 $4,648.90 $4,648.90 $3,835.34 $33,133.97 $4,648.90 2026-05-09
1701 OTHER Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=57.50 None A 98 24 $22,649.34 $23,551.69 $16,527.22 $31,461.07 $22,649.34 2026-05-09
1702 OTHER Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=50.50 And M <57.50… 119 25 $39,086.93 $29,261.08 25% off $24,724.73 $57,635.21 $28,138.73 2026-05-09
1703 OTHER Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50… 120 25 $46,446.91 $34,770.48 25% off $29,198.75 $57,877.70 $33,437.54 2026-05-09
1704 OTHER Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50… 139 25 $37,844.58 $39,353.99 $19,941.82 $81,654.24 $37,844.58 2026-05-09
1705 OTHER Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50 Tier 1 B 141 25 $59,823.64 $46,183.38 23% off $33,187.19 $74,335.85 $47,955.14 2026-05-09
173088710 OTHER Trelegy Ellipta 100-62.5 46 22 $3,156.86 $3,156.86 $2,604.41 $23,640.00 $3,156.86 2026-05-09
173089201 OTHER Mepolizumab Injection 46 22 $17,706.38 $17,706.38 $14,607.76 $52,162.17 $17,706.38 2026-05-09
1801 OTHER Major Multiple Trauma With Brain Or Spinal Cord Injury M >=67.50 Tier 1 B 76 19 $19,397.58 $19,397.58 $17,517.59 $24,948.15 $19,397.58 2026-05-08
1802 OTHER Major Multiple Trauma With Brain Or Spinal Cord Injury M >=55.50 And M <67.50 T… 76 19 $26,025.80 $26,025.80 $23,503.45 $33,470.48 $26,025.80 2026-05-08
1803 OTHER Major Multiple Trauma With Brain Or Spinal Cord Injury M >=45.50 And M <55.50 T… 76 19 $33,437.53 $33,437.53 $30,197.55 $43,002.21 $33,437.53 2026-05-08
1804 OTHER Major Multiple Trauma With Brain Or Spinal Cord Injury M >=40.50 And M <45.50 T… 119 25 $37,515.17 $36,564.58 $33,021.07 $89,916.01 $37,515.17 2026-05-09
1805 OTHER Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50 T… 119 25 $57,013.93 $44,330.44 22% off $29,837.60 $68,224.21 $43,178.68 2026-05-09
1806 OTHER Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50 None A 99 24 $64,592.73 $62,957.44 $56,164.88 $157,760.46 $61,322.15 2026-05-09
1901 OTHER Guillain-barr� M >=66.50 Tier 1 B 76 19 $18,187.00 $18,187.00 $17,254.06 $24,475.21 $18,187.00 2026-05-08
1902 OTHER Guillain-barr� M >=51.50 And M <66.50 Tier 1 B 76 19 $29,103.44 $29,103.44 $27,609.32 $39,164.58 $29,103.44 2026-05-08
1903 OTHER Guillain-barr� M >=38.50 And M <51.50 Tier 1 B 76 19 $43,909.27 $43,909.27 $41,656.33 $59,091.57 $43,909.27 2026-05-08
1904 OTHER Guillain-barr� M <38.50 None A 99 25 $61,750.39 $63,963.32 $59,468.51 $86,077.36 $61,750.39 2026-05-09
2001 OTHER Miscellaneous M >=66.50 Tier 1 B 139 25 $22,185.81 $21,455.22 $18,863.47 $36,451.07 $22,185.81 2026-05-09
2002 OTHER Miscellaneous M >=55.50 And M <66.50 Tier 1 B 160 25 $31,145.78 $26,750.50 $3,916.35 $47,245.03 $27,661.09 2026-05-09
2003 OTHER Miscellaneous M >=46.50 And M <55.50 Tier 1 B 161 25 $46,946.11 $32,034.01 32% off $13,713.00 $60,096.92 $33,124.60 2026-05-09
2004 OTHER Miscellaneous M <46.50 And A >=77.50 Tier 1 B 164 25 $49,583.37 $38,301.06 23% off $14,642.45 $63,530.28 $39,604.58 2026-05-09
2005 OTHER Miscellaneous M <46.50 And A <77.50 Tier 1 B 162 25 $52,263.36 $40,371.63 23% off $30,851.87 $61,832.47 $41,745.75 2026-05-09
201 OTHER Traumatic Brain Injury M >=73.50 Tier 1 B 76 19 $18,856.41 $18,856.41 $16,898.77 $23,995.22 $18,856.41 2026-05-08
202 OTHER Traumatic Brain Injury M >=61.50 And M <73.50 Tier 3 D 119 24 $25,844.62 $24,658.74 $14,779.69 $76,110.01 $23,472.86 2026-05-09
203 OTHER Traumatic Brain Injury M >=49.50 And M <61.50 Tier 2 C 136 24 $39,077.52 $30,709.31 21% off $25,808.79 $51,786.87 $30,356.58 2026-05-09
204 OTHER Traumatic Brain Injury M >=35.50 And M <49.50 Tier 3 D 120 24 $48,465.72 $38,088.11 21% off $30,954.62 $62,288.95 $36,256.35 2026-05-09
205 OTHER Traumatic Brain Injury M <35.50 Tier 1 B 156 24 $56,114.70 $48,786.90 $28,157.62 $87,372.35 $51,131.60 2026-05-09
2101 OTHER Burns M >=52.50 Tier 1 B 57 19 $26,905.79 $26,905.79 $22,978.75 $35,409.30 $26,905.79 2026-05-08
2102 OTHER Burns M <52.50 Tier 1 B 57 19 $41,437.51 $41,437.51 $35,388.12 $54,531.59 $41,437.51 2026-05-08
2143611 OTHER Galcanezumab-gnlm Pen 46 22 $3,390.58 $3,390.58 $2,797.23 $33,133.97 $3,390.58 2026-05-09
2144511 OTHER Taltz Autoinjector 46 22 $33,195.46 $33,195.46 $19,590.00 $52,162.17 $33,195.46 2026-05-09
23114501 OTHER Botox 100 Unit 46 22 $3,100.80 $3,100.80 $2,558.16 $23,640.00 $3,100.80 2026-05-09
23320505 OTHER Bimatoprost 0.01% 5ml 46 22 $2,412.34 $2,412.34 $1,990.18 $23,640.00 $2,412.34 2026-05-09
23392102 OTHER Botox 46 22 $6,201.60 $6,201.60 $5,116.32 $52,162.17 $6,201.60 2026-05-09
23923201 OTHER Botox Cosmetic 46 22 $3,148.80 $3,148.80 $2,597.76 $23,640.00 $3,148.80 2026-05-09
24201040002 OTHER Calcitonin,salmon Inj 400 Unit 46 22 $15,028.80 $15,028.80 $12,398.76 $52,162.17 $15,028.80 2026-05-09
24208050405 OTHER Vyzulta 46 22 $2,451.17 $2,451.17 $2,022.21 $23,640.00 $2,451.17 2026-05-09
24591401 OTHER Dupixent Syringe 46 22 $9,127.68 $9,127.68 $7,530.34 $52,162.17 $9,127.68 2026-05-09
25682000101 OTHER Soliris 46 22 $31,310.40 $31,310.40 $19,590.00 $52,162.17 $31,310.40 2026-05-09
28005 OTHER Incision, Bone Cortex, Foot 46 22 $8,491.00 $8,491.00 $7,005.07 $52,162.17 $8,491.00 2026-05-09
2840001 OTHER Forteo 46 22 $20,591.47 $20,591.47 $16,987.97 $52,162.17 $20,591.47 2026-05-09
2850101 OTHER HumuLIN R U-500 82 22 $7,137.60 $3,572.36 50% off $7.12 $52,162.17 $6,513.06 2026-05-09
299598035 OTHER Mirvaso 46 22 $3,060.10 $3,060.10 $2,524.59 $23,640.00 $3,060.10 2026-05-09
301 OTHER Non-traumatic Brain Injury M >=65.50 Tier 3 D 117 24 $28,204.61 $21,646.99 23% off $19,536.41 $59,403.45 $20,729.34 2026-05-09
302 OTHER Non-traumatic Brain Injury M >=52.50 And M <65.50 Tier 3 D 117 24 $36,465.76 $27,988.14 23% off $23,507.74 $40,256.58 $26,799.91 2026-05-09
303 OTHER Non-traumatic Brain Injury M >=42.50 And M <52.50 Tier 2 C 136 24 $35,103.41 $33,675.18 $28,191.03 $72,084.50 $32,317.66 2026-05-09
304 OTHER Non-traumatic Brain Injury M <42.50 And A >=78.50 Tier 2 C 136 24 $40,701.04 $39,044.57 $13,863.09 $57,042.75 $37,388.11 2026-05-09
305 OTHER Non-traumatic Brain Injury M <42.50 And A <78.50 Tier 1 B 157 24 $47,366.77 $43,059.86 $32,293.44 $64,938.59 $44,886.91 2026-05-09
3085222 OTHER SpryceL 46 22 $2,919.41 $2,919.41 $2,408.51 $23,640.00 $2,919.41 2026-05-09
310461612 OTHER Budesonide/Glycopyr/Formoterol 46 22 $3,096.67 $3,096.67 $2,554.76 $23,640.00 $3,096.67 2026-05-09
310651201 OTHER Byetta 46 22 $4,079.76 $4,079.76 $3,365.80 $33,133.97 $4,079.76 2026-05-09
310652401 OTHER Byetta 46 22 $4,079.76 $4,079.76 $3,365.80 $33,133.97 $4,079.76 2026-05-09
31525 OTHER Laryngscpy Dir W/wo Trach Diag 46 22 $4,506.60 $4,506.60 $3,717.95 $33,133.97 $4,506.60 2026-05-09
31600 OTHER Percutaneous Tracheostomy 46 22 $11,022.90 $11,022.90 $9,093.90 $52,162.17 $11,022.90 2026-05-09
31622 OTHER Rt Bronchoscopy 46 22 $2,803.24 $2,803.24 $2,312.68 $23,640.00 $2,803.24 2026-05-09
31623 OTHER Bronch W/brushing 46 22 $6,439.65 $6,439.65 $5,312.71 $52,162.17 $6,439.65 2026-05-09
31624 OTHER Bronch W/alveolar Lavage 46 22 $6,439.65 $6,439.65 $5,312.71 $52,162.17 $6,439.65 2026-05-09
31625 OTHER Bronch Biop Lung End 46 22 $4,313.40 $4,313.40 $3,558.55 $33,133.97 $4,313.40 2026-05-09
31626 OTHER Bronch Ins Rad Mark 46 22 $16,215.15 $16,215.15 $13,377.50 $52,162.17 $16,215.15 2026-05-09
31627 OTHER Electromag Nav Bronch 46 22 $7,754.15 $7,754.15 $6,397.18 $52,162.17 $7,754.15 2026-05-09
31628 OTHER Transbronch Lung Biopsy Sgl 46 22 $12,329.50 $12,329.50 $10,171.84 $52,162.17 $12,329.50 2026-05-09
31629 OTHER Bronch Trnsbronch Ndl Asp 46 22 $12,329.50 $12,329.50 $10,171.84 $52,162.17 $12,329.50 2026-05-09
31635 OTHER Bronch W/for Body Removal 46 22 $4,489.00 $4,489.00 $3,703.43 $33,133.97 $4,489.00 2026-05-09
31641 OTHER Bronch Dest Grth Lung 46 22 $8,633.10 $8,633.10 $7,122.31 $52,162.17 $8,633.10 2026-05-09
31652 OTHER Bronch Ebus 1 Or 2 Stat 46 22 $12,329.50 $12,329.50 $10,171.84 $52,162.17 $12,329.50 2026-05-09
31653 OTHER Bronch Ebus 3 Or > Stat 46 22 $12,329.50 $12,329.50 $10,171.84 $52,162.17 $12,329.50 2026-05-09
31722062921 OTHER Atovaquone (Bulk Bottle) 46 22 $6,307.16 $6,307.16 $5,203.40 $52,162.17 $6,307.16 2026-05-09
3218811 OTHER Orencia 46 22 $6,834.32 $6,834.32 $5,638.31 $52,162.17 $6,834.32 2026-05-09
36569 OTHER Picc Line Insertion 46 22 $4,308.48 $4,308.48 $3,554.49 $33,133.97 $4,308.48 2026-05-09
378932232 OTHER Wixela Inhub 500/50 46 22 $2,362.52 $2,362.52 $1,949.08 $20,184.04 $2,362.52 2026-05-09
378972055 OTHER Denavir 1 % 46 22 $3,897.55 $3,897.55 $3,215.48 $33,133.97 $3,897.55 2026-05-09
401 OTHER Traumatic Spinal Cord Injury M >=56.50 None A 98 24 $24,496.39 $24,865.80 $16,753.72 $28,376.38 $24,496.39 2026-05-09
402 OTHER Traumatic Spinal Cord Injury M >=47.50 And M <56.50 Tier 1 B 117 24 $31,592.84 $32,069.31 $24,970.43 $41,361.92 $31,592.84 2026-05-09
4026129 OTHER Cellcept (160ml Bottle) 46 22 $6,628.18 $6,628.18 $5,468.25 $52,162.17 $6,628.18 2026-05-09
403 OTHER Traumatic Spinal Cord Injury M >=41.50 And M <47.50 Tier 1 B 76 19 $40,244.57 $40,244.57 $36,025.76 $45,926.91 $40,244.57 2026-05-08
404 OTHER Traumatic Spinal Cord Injury M <31.50 And A <61.50 Tier 1 B 76 19 $62,836.26 $62,836.26 $56,249.23 $71,708.00 $62,836.26 2026-05-08
405 OTHER Traumatic Spinal Cord Injury M >=31.50 And M <41.50 Tier2 C 118 24 $49,228.07 $49,970.42 $44,731.62 $70,648.99 $49,228.07 2026-05-09
406 OTHER Traumatic Spinal Cord Injury M >=24.50 And M <31.50 And A >=61.50 Tier 3 D 117 24 $62,813.91 $63,760.96 $34,236.80 $120,579.90 $62,813.91 2026-05-09
407 OTHER Traumatic Spinal Cord Injury M <24.50 And A >=61.50 Tier 1 B 76 19 $87,169.12 $87,169.12 $78,030.33 $99,477.32 $87,169.12 2026-05-08
42367054032 OTHER Ryanodex 46 22 $14,040.84 $14,040.84 $11,583.69 $52,162.17 $14,040.84 2026-05-09
42388002326 OTHER Cabometyx 46 22 $4,093.57 $4,093.57 $3,377.20 $33,133.97 $4,093.57 2026-05-09
42388002426 OTHER Cabometyx 46 22 $4,093.57 $4,093.57 $3,377.20 $33,133.97 $4,093.57 2026-05-09
42388002526 OTHER Cabometyx 46 22 $4,093.57 $4,093.57 $3,377.20 $33,133.97 $4,093.57 2026-05-09
43214 OTHER Eso Flx W/dil Balloon 30mm Dia 46 22 $6,768.95 $6,768.95 $5,584.39 $52,162.17 $6,768.95 2026-05-09
43231 OTHER Eso Flx W/end US Exm 46 22 $6,768.95 $6,768.95 $5,584.39 $52,162.17 $6,768.95 2026-05-09
43235 OTHER Upper Gastro/Endoscopy 46 22 $2,834.00 $2,834.00 $2,338.05 $23,640.00 $2,834.00 2026-05-09
43246 OTHER Peg 46 22 $4,875.00 $4,875.00 $4,021.88 $33,133.97 $4,875.00 2026-05-09
43247 OTHER Egd Flx Transoral W/for Bdy Rm 46 22 $2,476.53 $2,476.53 $2,043.13 $23,640.00 $2,476.53 2026-05-09
43598000451 OTHER Augmentin 46 22 $2,935.68 $2,935.68 $2,421.93 $23,640.00 $2,935.68 2026-05-09
44087002203 OTHER Rebif 22 mcg/0.5mL 46 22 $4,226.26 $4,226.26 $3,486.66 $33,133.97 $4,226.26 2026-05-09
44087004403 OTHER Rebif 46 22 $4,226.26 $4,226.26 $3,486.66 $33,133.97 $4,226.26 2026-05-09
44146 OTHER Colec Part W Colopros W/colost 46 22 $5,934.18 $5,934.18 $4,895.70 $52,162.17 $5,934.18 2026-05-09
44206043605 OTHER Privigen 46 22 $4,344.96 $4,344.96 $3,584.59 $33,133.97 $4,344.96 2026-05-09
44206043710 OTHER Privigen 10% 46 22 $8,689.92 $8,689.92 $7,169.19 $52,162.17 $8,689.92 2026-05-09
44206043820 OTHER Privigen 10% 46 22 $17,379.84 $17,379.84 $14,338.37 $52,162.17 $17,379.84 2026-05-09
44208 OTHER Laparosc, Surg Colectomy, Part 46 22 $5,584.11 $5,584.11 $4,606.89 $52,162.17 $5,584.11 2026-05-09
45330 OTHER Sigmoidoscopy Flx Diag 46 22 $3,385.95 $3,385.95 $2,793.41 $33,133.97 $3,385.95 2026-05-09
480372056 OTHER Pyrimethamine 46 22 $3,420.00 $3,420.00 $2,821.50 $33,133.97 $3,420.00 2026-05-09
49084 OTHER Paracentesis 46 22 $2,428.80 $2,428.80 $2,003.76 $23,640.00 $2,428.80 2026-05-09
49471000105 OTHER Pre-pen .25 Ml 46 22 $3,244.80 $3,244.80 $2,676.96 $23,640.00 $3,244.80 2026-05-09
5001 OTHER Short-stay Cases, Length Of Stay Is 3 Days Or Fewer None A 19 19 $4,023.52 $4,023.52 $4,023.52 $4,023.52 $4,023.52 2026-05-08
50090073200 OTHER Advair Diskus 46 22 $2,486.88 $2,486.88 $2,051.68 $23,640.00 $2,486.88 2026-05-09
501 OTHER Non-traumatic Spinal Cord Injury M >=60.50 Tier 3 D 117 24 $29,879.90 $22,602.28 24% off $19,368.75 $38,049.01 $21,959.93 2026-05-09
502 OTHER Non-traumatic Spinal Cord Injury M >=53.50 And M <60.50 Tier 3 D 118 24 $27,550.50 $28,355.20 $23,235.60 $38,803.04 $27,550.50 2026-05-09
50242005121 OTHER Rituxan 46 22 $4,509.70 $4,509.70 $3,720.50 $33,133.97 $4,509.70 2026-05-09
503 OTHER Non-traumatic Spinal Cord Injury M >=48.50 And M <53.50 Tier 3 D 118 24 $42,966.92 $32,502.24 24% off $26,608.05 $49,981.47 $31,578.72 2026-05-09
504 OTHER Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50 Tier 2 C 141 24 $51,075.13 $38,636.35 24% off $3,356.00 $64,973.18 $37,538.70 2026-05-09
50419052435 OTHER Betaseron 46 22 $3,343.82 $3,343.82 $2,758.65 $33,133.97 $3,343.82 2026-05-09
50458030611 OTHER RisperDAL Consta 25 Mg 46 22 $2,949.89 $2,949.89 $2,433.66 $23,640.00 $2,949.89 2026-05-09
50458030711 OTHER RisperDAL Consta 37.5 Mg 46 22 $4,425.02 $4,425.02 $3,650.64 $33,133.97 $4,425.02 2026-05-09
50458030811 OTHER RisperDAL Consta 50 Mg 46 22 $5,900.21 $5,900.21 $4,867.68 $52,162.17 $5,900.21 2026-05-09
50458056001 OTHER Invega Sustenna 46 22 $11,131.01 $11,131.01 $9,183.08 $52,162.17 $11,131.01 2026-05-09
50458056101 OTHER Invega Sustenna 46 22 $11,131.49 $11,131.49 $9,183.48 $52,162.17 $11,131.49 2026-05-09
50458056201 OTHER Invega Sustenna 117 Mg 46 22 $8,348.78 $8,348.78 $6,887.74 $52,162.17 $8,348.78 2026-05-09
50458056301 OTHER Invega Sustenna 156 Mg 46 22 $11,132.11 $11,132.11 $9,183.99 $52,162.17 $11,132.11 2026-05-09
50458056401 OTHER Invega Sustenna 234 Mg 46 22 $16,697.76 $16,697.76 $13,775.65 $52,162.17 $16,697.76 2026-05-09
50458060901 OTHER Invega Trinza 46 22 $19,046.87 $19,046.87 $15,713.67 $52,162.17 $19,046.87 2026-05-09
50474070062 OTHER Cimzia 46 22 $12,239.24 $12,239.24 $10,097.38 $52,162.17 $12,239.24 2026-05-09
50484081015 OTHER Regranex 46 22 $6,526.56 $6,526.56 $5,384.41 $52,162.17 $6,526.56 2026-05-09
505 OTHER Non-traumatic Spinal Cord Injury M <39.50 Tier 3 D 125 24 $52,162.18 $53,688.06 $5,787.35 $70,971.53 $52,162.18 2026-05-09
50633012011 OTHER Digifab 46 22 $22,958.40 $22,958.40 $18,940.68 $52,162.17 $22,958.40 2026-05-09
50742031025 OTHER Mafenide Acetate For Topical S 46 22 $4,661.36 $4,661.36 $3,845.62 $33,133.97 $4,661.36 2026-05-09
51672137108 OTHER clobetasoL Propionate 46 22 $2,842.36 $2,842.36 $2,344.95 $23,640.00 $2,842.36 2026-05-09
517065001 OTHER Injectafer 46 22 $6,862.56 $6,862.56 $5,661.61 $52,162.17 $6,862.56 2026-05-09
51759020210 OTHER Ajovy Autoinjector 46 22 $3,519.16 $3,519.16 $2,903.30 $33,133.97 $3,519.16 2026-05-09
51759020410 OTHER Ajovy 225 mg/1.5mL Syringe 46 22 $3,519.16 $3,519.16 $2,903.30 $33,133.97 $3,519.16 2026-05-09
51759063010 OTHER risperiDONE ER Inj 125 Mg/0.35 46 22 $15,375.36 $15,375.36 $12,684.67 $52,162.17 $15,375.36 2026-05-09
51991082328 OTHER Everolimus 46 22 $2,422.24 $2,422.24 $1,998.35 $23,640.00 $2,422.24 2026-05-09
5200010 OTHER Pneumoc 20-val Conj-dip Crm/Pf 46 22 $2,503.78 $2,503.78 $2,065.62 $23,640.00 $2,503.78 2026-05-09
55292070255 OTHER Hemin For Injection 46 22 $51,333.70 $51,333.70 $19,590.00 $52,162.17 $51,333.70 2026-05-09
55513000504 OTHER Aranesp 46 22 $3,715.20 $3,715.20 $3,065.04 $33,133.97 $3,715.20 2026-05-09
55513000601 OTHER Aranesp 46 22 $7,430.40 $7,430.40 $6,130.08 $52,162.17 $7,430.40 2026-05-09
55513002504 OTHER Darbepoetin Alfa 100 M 100 Mcg 46 22 $3,715.20 $3,715.20 $3,065.04 $33,133.97 $3,715.20 2026-05-09
55513002704 OTHER Aranesp 46 22 $5,572.80 $5,572.80 $4,597.56 $52,162.17 $5,572.80 2026-05-09
55513002801 OTHER Aranesp 46 22 $7,430.40 $7,430.40 $6,130.08 $52,162.17 $7,430.40 2026-05-09
55513003201 OTHER Aranesp 46 22 $18,576.00 $18,576.00 $15,325.20 $52,162.17 $18,576.00 2026-05-09
55513011101 OTHER Aranesp 46 22 $11,145.60 $11,145.60 $9,195.12 $52,162.17 $11,145.60 2026-05-09
55513019001 OTHER Neulasta 6 Mg 46 22 $30,806.35 $30,806.35 $19,590.00 $52,162.17 $30,806.35 2026-05-09
55513019201 OTHER Neulasta Onpro 46 22 $30,806.35 $30,806.35 $19,590.00 $52,162.17 $30,806.35 2026-05-09
55513020901 OTHER Neupogen 46 22 $2,550.86 $2,550.86 $2,104.46 $23,640.00 $2,550.86 2026-05-09
55513022101 OTHER Nplate 250 Mcg 46 22 $12,585.22 $12,585.22 $10,382.81 $52,162.17 $12,585.22 2026-05-09
55513022301 OTHER Romiplostim 46 22 $6,292.70 $6,292.70 $5,191.48 $52,162.17 $6,292.70 2026-05-09
55513054610 OTHER Neupogen 480 Mcg 46 22 $2,406.38 $2,406.38 $1,985.27 $23,640.00 $2,406.38 2026-05-09
55513071001 OTHER Prolia 46 22 $8,573.38 $8,573.38 $7,073.04 $52,162.17 $8,573.38 2026-05-09
55513073001 OTHER Denosumab 120 mg/1.7mL 46 22 $15,770.26 $15,770.26 $13,010.47 $52,162.17 $15,770.26 2026-05-09
55513084301 OTHER Erenumab-aooe 46 22 $3,612.58 $3,612.58 $2,980.38 $33,133.97 $3,612.58 2026-05-09
55566830301 OTHER Firmagon 46 22 $2,344.56 $2,344.56 $1,934.26 $20,184.04 $2,344.56 2026-05-09
55724021121 OTHER Eucrisa 46 22 $3,661.87 $3,661.87 $3,021.05 $33,133.97 $3,661.87 2026-05-09
57894003001 OTHER Remicade 100 Mg 46 22 $5,605.54 $5,605.54 $4,624.57 $52,162.17 $5,605.54 2026-05-09
57962042028 OTHER Imbruvica 46 22 $2,809.99 $2,809.99 $2,318.24 $23,640.00 $2,809.99 2026-05-09
57970010001 OTHER Dalbavancin Hcl 46 22 $8,539.82 $8,539.82 $7,045.35 $52,162.17 $8,539.82 2026-05-09
58406003204 OTHER EnbreL Sureclick 46 22 $9,148.70 $9,148.70 $7,547.68 $52,162.17 $9,148.70 2026-05-09
58914030180 OTHER Rectiv 46 22 $3,075.55 $3,075.55 $2,537.33 $23,640.00 $3,075.55 2026-05-09
59148001971 OTHER Abilify Maintena 46 22 $13,535.23 $13,535.23 $11,166.57 $52,162.17 $13,535.23 2026-05-09
59148002050 OTHER Samsca 15 Mg 46 22 $2,496.95 $2,496.95 $2,059.99 $23,640.00 $2,496.95 2026-05-09
59148002150 OTHER Samsca 30 Mg 46 22 $2,590.29 $2,590.29 $2,136.99 $23,640.00 $2,590.29 2026-05-09
59148004580 OTHER Abilify Maintena 46 22 $10,151.42 $10,151.42 $8,374.92 $52,162.17 $10,151.42 2026-05-09
59148007280 OTHER Abilify Maintena 400 Mg 46 22 $13,535.23 $13,535.23 $11,166.57 $52,162.17 $13,535.23 2026-05-09
59338077501 OTHER Feraheme 510 Mg 46 22 $5,729.38 $5,729.38 $4,726.74 $52,162.17 $5,729.38 2026-05-09
59353040509 OTHER Methoxy Peg-epoetin 200 Mcg/0. 46 22 $2,769.36 $2,769.36 $2,284.72 $23,640.00 $2,769.36 2026-05-09
59572041028 OTHER Revlimid 46 22 $4,279.44 $4,279.44 $3,530.54 $33,133.97 $4,279.44 2026-05-09
59572041500 OTHER Revlimid 46 22 $4,279.44 $4,279.44 $3,530.54 $33,133.97 $4,279.44 2026-05-09
59572042521 OTHER Revlimid 46 22 $4,279.44 $4,279.44 $3,530.54 $33,133.97 $4,279.44 2026-05-09
59627022205 OTHER Avonex 46 22 $39,676.03 $39,676.03 $19,590.00 $52,162.17 $39,676.03 2026-05-09
59627033304 OTHER Avonex Pen 30 mcg/0.5mL 46 22 $39,676.03 $39,676.03 $19,590.00 $52,162.17 $39,676.03 2026-05-09
59676034001 OTHER Procrit 46 22 $5,131.20 $5,131.20 $4,233.24 $33,133.97 $5,131.20 2026-05-09
59676082001 OTHER Monovisc 46 22 $7,200.00 $7,200.00 $5,940.00 $52,162.17 $7,200.00 2026-05-09
597002402 OTHER Combivent Respimat 46 22 $2,348.83 $2,348.83 $1,937.79 $20,184.04 $2,348.83 2026-05-09
597016061 OTHER Spiriva Respimat 46 22 $2,531.47 $2,531.47 $2,088.47 $23,640.00 $2,531.47 2026-05-09
601 OTHER Neurological M >=64.50 Tier 1 B 159 24 $29,817.03 $22,629.33 24% off $5,877.00 $59,715.96 $23,406.98 2026-05-09
602 OTHER Neurological M >=52.50 And M <64.50 Tier 1 B 159 24 $39,653.99 $28,702.26 28% off $11,654.00 $56,945.51 $29,689.31 2026-05-09
603 OTHER Neurological M >=43.50 And M <52.50 Tier 1 B 165 24 $46,724.55 $33,818.71 28% off $18,426.52 $95,835.75 $34,981.06 2026-05-09
604 OTHER Neurological M <43.50 Tier 1 B 163 24 $60,979.78 $42,412.80 30% off $21,315.41 $89,085.37 $43,870.44 2026-05-09
60793070210 OTHER Bicillin L-a 2400000 Unit 46 22 $2,999.86 $2,999.86 $2,474.89 $23,640.00 $2,999.86 2026-05-09
60793090701 OTHER Thrombi-gel 10 Cm2 46 22 $2,931.41 $2,931.41 $2,418.41 $23,640.00 $2,931.41 2026-05-09
60793090910 OTHER Thrombi-gel 100 Cm2 46 22 $3,556.46 $3,556.46 $2,934.08 $33,133.97 $3,556.46 2026-05-09
61953000403 OTHER Flebogamma Dif 46 22 $2,541.12 $2,541.12 $2,096.43 $23,640.00 $2,541.12 2026-05-09
61953000405 OTHER Flebogamma Dif 46 22 $10,164.48 $10,164.48 $8,385.69 $52,162.17 $10,164.48 2026-05-09
61958150101 OTHER Sovaldi 46 22 $4,800.00 $4,800.00 $3,960.00 $33,133.97 $4,800.00 2026-05-09
61958180101 OTHER Harvoni 46 22 $5,400.00 $5,400.00 $4,455.00 $52,162.17 $5,400.00 2026-05-09
61958220101 OTHER Epclusa 46 22 $4,272.00 $4,272.00 $3,524.40 $33,133.97 $4,272.00 2026-05-09
61958290102 OTHER Veklury 46 22 $2,877.50 $2,877.50 $2,373.94 $23,640.00 $2,877.50 2026-05-09
62856070430 OTHER Lenvima 46 22 $3,880.80 $3,880.80 $3,201.66 $33,133.97 $3,880.80 2026-05-09
62935022305 OTHER Leuprolide Acetate 46 22 $6,504.34 $6,504.34 $5,366.08 $52,162.17 $6,504.34 2026-05-09
63323064810 OTHER Levothyroxine Sodium 46 22 $2,533.97 $2,533.97 $2,090.53 $23,640.00 $2,533.97 2026-05-09
64842072709 OTHER Decitabine/Cedazuridine 35/100 46 22 $7,931.30 $7,931.30 $6,543.32 $52,162.17 $7,931.30 2026-05-09
65054301 OTHER Triesence 40 Mg 46 22 $4,531.20 $4,531.20 $3,738.24 $33,133.97 $4,531.20 2026-05-09
65162091322 OTHER Voriconazole Oral Susp (bulk) 46 22 $6,753.68 $6,753.68 $5,571.78 $52,162.17 $6,753.68 2026-05-09
65757030001 OTHER VivitroL 46 22 $7,877.33 $7,877.33 $6,498.80 $52,162.17 $7,877.33 2026-05-09
65757040103 OTHER Aristada 46 22 $4,633.98 $4,633.98 $3,823.03 $33,133.97 $4,633.98 2026-05-09
65757040203 OTHER Aristada 46 22 $4,637.50 $4,637.50 $3,825.94 $33,133.97 $4,637.50 2026-05-09
65757040303 OTHER Aristada 46 22 $4,633.96 $4,633.96 $3,823.01 $33,133.97 $4,633.96 2026-05-09
65757040403 OTHER Aristada 46 22 $4,586.84 $4,586.84 $3,784.14 $33,133.97 $4,586.84 2026-05-09
66794015702 OTHER Gablofen 46 22 $4,536.67 $4,536.67 $3,742.76 $33,133.97 $4,536.67 2026-05-09
67457067502 OTHER Miacalcin 46 22 $12,974.72 $12,974.72 $10,704.15 $52,162.17 $12,974.72 2026-05-09
67457083306 OTHER Pegfilgrastim-jmdb 46 22 $10,020.00 $10,020.00 $8,266.50 $52,162.17 $10,020.00 2026-05-09
68546032512 OTHER Copaxone 40 Mg 46 22 $2,332.80 $2,332.80 $1,924.56 $20,184.04 $2,332.80 2026-05-09
68875010201 OTHER Gattex 46 22 $99,999.99 $99,999.99 $19,590.00 $99,999.99 $99,999.99 2026-05-09
68982085002 OTHER Octagam 46 22 $4,662.00 $4,662.00 $3,846.15 $33,133.97 $4,662.00 2026-05-09
68982085003 OTHER Octagam 10% 46 22 $9,324.00 $9,324.00 $7,692.30 $52,162.17 $9,324.00 2026-05-09
68982085004 OTHER Octagam 46 22 $18,648.00 $18,648.00 $15,384.60 $52,162.17 $18,648.00 2026-05-09
68982085005 OTHER Octagam 46 22 $27,972.00 $27,972.00 $19,590.00 $52,162.17 $27,972.00 2026-05-09
69018821 OTHER Ibrance 46 22 $3,653.12 $3,653.12 $3,013.82 $33,133.97 $3,653.12 2026-05-09
69098038 OTHER Sutent 46 22 $3,853.62 $3,853.62 $3,179.24 $33,133.97 $3,853.62 2026-05-09
69238101302 OTHER Testosterone 46 22 $2,682.88 $2,682.88 $2,213.38 $23,640.00 $2,682.88 2026-05-09
701 OTHER Fracture Of Lower Extremity M >=61.50 Tier 3 D 118 24 $29,510.49 $22,226.99 25% off $18,997.09 $38,974.29 $21,625.81 2026-05-09
702 OTHER Fracture Of Lower Extremity M >=52.50 And M <61.50 Tier 1 B 143 24 $36,451.65 $27,454.03 25% off $21,315.41 $51,654.46 $26,710.50 2026-05-09
703 OTHER Fracture Of Lower Extremity M >=41.50 And M <52.50 Tier 1 B 163 24 $51,111.65 $33,761.07 34% off $16,965.85 $75,648.43 $34,675.18 2026-05-09
704 OTHER Fracture Of Lower Extremity M <41.50 None A 147 25 $54,759.82 $41,243.40 25% off $19,263.25 $65,509.42 $40,126.93 2026-05-09
70510217102 OTHER Radicava 46 22 $3,053.81 $3,053.81 $2,519.39 $23,640.00 $3,053.81 2026-05-09
70539000102 OTHER Tymlos 46 22 $12,801.60 $12,801.60 $10,561.32 $52,162.17 $12,801.60 2026-05-09
71571033383 OTHER Loteprednol Etabonate 0.25% Op 46 22 $2,438.50 $2,438.50 $2,011.77 $23,640.00 $2,438.50 2026-05-09
72511077001 OTHER Evolocumab 420 mg/3.5mL 46 22 $2,919.74 $2,919.74 $2,408.78 $23,640.00 $2,919.74 2026-05-09
73562011201 OTHER Lipase/Protea/Amyl 20-63-84k U 46 22 $3,846.24 $3,846.24 $3,173.15 $33,133.97 $3,846.24 2026-05-09
74055402 OTHER Humira(Cf) Pen 46 22 $33,228.58 $33,228.58 $19,590.00 $52,162.17 $33,228.58 2026-05-09
74364203 OTHER Lupron Depot 46 22 $9,811.68 $9,811.68 $8,094.64 $52,162.17 $9,811.68 2026-05-09
74368303 OTHER Lupron Depot 46 22 $39,246.62 $39,246.62 $19,590.00 $52,162.17 $39,246.62 2026-05-09
74379902 OTHER Humira 46 22 $16,614.29 $16,614.29 $13,706.79 $52,162.17 $16,614.29 2026-05-09
78043561 OTHER Reclast 5 Mg 46 22 $6,283.44 $6,283.44 $5,183.84 $52,162.17 $6,283.44 2026-05-09
78056751 OTHER Afinitor 10 Mg 46 22 $3,200.31 $3,200.31 $2,640.26 $23,640.00 $3,200.31 2026-05-09
78063998 OTHER Cosentyx 46 22 $17,781.50 $17,781.50 $14,669.74 $52,162.17 $17,781.50 2026-05-09
78068715 OTHER Promacta 46 22 $3,147.39 $3,147.39 $2,596.59 $23,640.00 $3,147.39 2026-05-09
78081181 OTHER SandoSTATIN Lar Depot 46 22 $16,912.46 $16,912.46 $13,952.78 $52,162.17 $16,912.46 2026-05-09
78081881 OTHER SandoSTATIN Lar Depot 46 22 $22,158.24 $22,158.24 $18,280.55 $52,162.17 $22,158.24 2026-05-09
78206018401 OTHER Adalimumab-bwwd 46 22 $2,491.20 $2,491.20 $2,055.24 $23,640.00 $2,491.20 2026-05-09
801 OTHER Replacement Of Lower-extremity Joint M >=63.50 Tier 1 B 137 24 $23,311.80 $21,939.93 $15,387.71 $37,660.50 $20,926.99 2026-05-09
802 OTHER Replacement Of Lower-extremity Joint M >=57.50 And M <63.50 Tier 3 D 123 25 $32,430.48 $24,874.03 23% off $20,041.97 $46,118.22 $23,724.63 2026-05-09
803 OTHER Replacement Of Lower-extremity Joint M >=51.50 And M <57.50 Tier 1 B 157 24 $39,633.93 $27,685.79 30% off $3,943.03 $61,141.75 $28,964.61 2026-05-09
804 OTHER Replacement Of Lower-extremity Joint M >=42.50 And M <51.50 Tier 3 D 142 25 $40,439.87 $31,017.55 23% off $23,408.00 $49,765.17 $29,585.79 2026-05-09
805 OTHER Replacement Of Lower-extremity Joint M <42.50 Tier 1 B 158 24 $48,501.02 $37,199.88 23% off $30,832.76 $65,791.91 $38,917.52 2026-05-09
82154044901 OTHER Peginterferon Alfa-2a 46 22 $5,344.42 $5,344.42 $4,409.15 $52,162.17 $5,344.42 2026-05-09
85433101 OTHER Noxafil 46 22 $2,546.16 $2,546.16 $2,100.58 $23,640.00 $2,546.16 2026-05-09
901 OTHER Other Orthopedic M >=63.50 Tier 3 D 118 24 $28,275.20 $21,877.57 23% off $18,086.86 $42,328.33 $21,108.17 2026-05-09
902 OTHER Other Orthopedic M >=51.50 And M <63.50 Tier 2 C 138 24 $35,216.35 $27,248.15 23% off $22,004.96 $52,406.69 $26,289.33 2026-05-09
9029703 OTHER Gelfilm 25x50mm 46 22 $7,140.96 $7,140.96 $5,891.29 $52,162.17 $7,140.96 2026-05-09
903 OTHER Other Orthopedic M >=44.50 And M <51.50 Tier 1 B 138 24 $42,053.98 $32,538.71 23% off $27,195.76 $60,720.41 $31,395.19 2026-05-09
904 OTHER Other Orthopedic M <44.5 Tier 1 B 160 24 $63,571.45 $38,989.29 39% off $32,130.97 $68,705.92 $40,359.87 2026-05-09
90935 OTHER Hemodialysis 47 23 $2,424.90 $2,424.90 $2,000.54 $23,640.00 $2,424.90 2026-05-09
9379401 OTHER Corvert 46 22 $2,634.48 $2,634.48 $2,173.45 $23,640.00 $2,634.48 2026-05-09
944265603 OTHER Gammagard S-d 5 Gram 46 22 $5,382.24 $5,382.24 $4,440.35 $52,162.17 $5,382.24 2026-05-09
944265804 OTHER Gammagard S-d 10 Gram 46 22 $10,764.48 $10,764.48 $8,880.69 $52,162.17 $10,764.48 2026-05-09
944270004 OTHER Gammagard Liquid 10% 46 22 $4,068.48 $4,068.48 $3,356.49 $33,133.97 $4,068.48 2026-05-09
944270005 OTHER Gammagard Liquid 10% 46 22 $8,136.96 $8,136.96 $6,712.99 $52,162.17 $8,136.96 2026-05-09
944270006 OTHER Gammagard Liquid 46 22 $16,273.92 $16,273.92 $13,425.99 $52,162.17 $16,273.92 2026-05-09
A0426 HCPCS Amb Non Emr Als Rnd Trip 46 22 $2,600.00 $2,600.00 $2,145.00 $23,640.00 $2,600.00 2026-05-09
C5271 HCPCS Wc Apply Low Cost Ss Leg 46 22 $2,286.00 $2,286.00 $1,885.95 $20,184.04 $2,286.00 2026-05-09
C5272 HCPCS Wc Apply Lc Ss Leg Ea >25cm 46 22 $2,286.00 $2,286.00 $1,885.95 $20,184.04 $2,286.00 2026-05-09
C5275 HCPCS Wc Apply Low Cost Ss Foot 46 22 $2,286.00 $2,286.00 $1,885.95 $20,184.04 $2,286.00 2026-05-09
C5276 HCPCS Wc Apply Lc Ss Foot Ea > 25cm 46 22 $2,286.00 $2,286.00 $1,885.95 $20,184.04 $2,286.00 2026-05-09
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