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

Vibra Hospital of Southeastern Michigan - DMC Campus

Detroit, MI · CCN 230283 · Rates published

4,424 distinct procedures filed
26 distinct payers
48,118 rate rows
2026-05-22 last MRF observed
Data quality

48,082 of 48,118 rate rows are consumer-grade (99.9%)

36 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
per-diem day rate — not a per-procedure price 36
Data source & audit trail ↓ Download audit trail (JSON)
Source MRF file https://vhsemichigan.com/wp-content/uploads/sites/36/2026/03/261789242_vibra-hospital-of-southeastern-michigan_standardcharges.csv
Found on page https://vhsemichigan.com/about-us/price-transparency/
Discovered viaCMS hospital list
Last fetch not_modified · 2026-05-17
Content fingerprint ab752c4c70a4efe0… · 3,903,905 bytes · first seen 2026-05-09

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
4
OTHER 		Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Nec… 20 $130,734.64 $149,347.92 $130,734.64 nat. median
$134,983
1.0× median
166
OTHER 		Other Respiratory System O.r. Procedures With Mcc 20 $99,047.05 $106,515.42 $106,515.42 nat. median
$38,129
outlier · 2.8×
981
OTHER 		Extensive O.r. Procedures Unrelated To Principal Diagnosis With Mcc 20 $99,610.96 $106,501.77 $106,501.77 nat. median
$33,955
outlier · 3.1×
68875010201
OTHER 		Gattex 3 $3,000.00 $99,999.99 $99,999.99 nat. median
$100,000
1.0× median
207
OTHER 		Respiratory System Diagnosis With Ventilator Support >96 Hours 26 $1,244.00 $92,349.23 $87,609.40 nat. median
$66,849
1.3× median
853
OTHER 		Infectious And Parasitic Diseases With O.r. Procedures With Mcc 19 $68,998.84 $68,998.84 $68,998.84 nat. median
$39,509
1.7× median
500
OTHER 		Soft Tissue Procedures With Mcc 20 $13,250.94 $56,051.88 $56,051.88 nat. median
$30,721
1.8× median
939
OTHER 		O.r. Procedures With Diagnoses Of Other Contact With Health Services With Mcc 19 $31,022.09 $53,944.88 $53,944.88 nat. median
$33,053
1.6× median
208
OTHER 		Respiratory System Diagnosis With Ventilator Support <=96 Hours 20 $600.00 $103,299.12 $53,735.54 nat. median
$26,262
outlier · 2.0×
55292070255
OTHER 		Hemin For Injection 3 $3,000.00 $51,333.70 $51,333.70 nat. median
$51,334
1.0× median
438
OTHER 		Disorders Of Pancreas Except Malignancy With Mcc 20 $5,941.21 $47,678.46 $47,678.46 nat. median
$16,329
outlier · 2.9×
189
OTHER 		Pulmonary Edema And Respiratory Failure 20 $8,137.81 $50,998.70 $44,538.43 nat. median
$12,533
outlier · 3.6×
539
OTHER 		Osteomyelitis With Mcc* 20 $21,448.74 $44,110.65 $44,110.65 nat. median
$18,893
outlier · 2.3×
811
OTHER 		Red Blood Cell Disorders With Mcc 20 $41,489.13 $105,195.52 $42,335.85 nat. median
$11,662
outlier · 3.6×
757
OTHER 		Infections, Female Reproductive System With Mcc 20 $41,489.13 $42,335.85 $42,335.85 nat. median
$10,867
outlier · 3.9×
56
OTHER 		Degenerative Nervous System Disorders With Mcc 19 $39,339.76 $41,325.58 $41,325.58 nat. median
$21,582
1.9× median
371
OTHER 		Major Gastrointestinal Disorders And Peritoneal Infections With Mcc 20 $12,595.05 $40,661.17 $40,661.17 nat. median
$16,993
outlier · 2.4×
637
OTHER 		Diabetes With Mcc 20 $29,437.18 $40,237.94 $40,237.94 nat. median
$91
outlier · 442.7×
592
OTHER 		Skin Ulcers With Mcc 19 $37,841.31 $40,046.81 $40,046.81 nat. median
$18,496
outlier · 2.2×
682
OTHER 		Renal Failure With Mcc 20 $10,822.98 $39,714.61 $39,714.61 nat. median
$14,531
outlier · 2.7×
59627033304
OTHER 		Avonex Pen 30 mcg/0.5mL 3 $3,000.00 $39,676.03 $39,676.03 nat. median
$39,676
1.0× median
59627022205
OTHER 		Avonex 3 $3,000.00 $39,676.03 $39,676.03 nat. median
$39,676
1.0× median
74368303
OTHER 		Lupron Depot 3 $3,000.00 $39,246.62 $39,246.62 nat. median
$39,247
1.0× median
871
OTHER 		Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc 20 $15,058.48 $38,631.52 $38,631.52 nat. median
$16,181
outlier · 2.4×
91
OTHER 		Other Disorders Of Nervous System With Mcc 19 $34,659.94 $37,880.64 $37,880.64 nat. median
$17,635
outlier · 2.1×
70
OTHER 		Nonspecific Cerebrovascular Disorders With Mcc* 20 $10,313.56 $37,202.58 $37,202.58 nat. median
$17,159
outlier · 2.2×
177
OTHER 		Respiratory Infections And Inflammations With Mcc* 20 $31,896.00 $36,888.57 $36,888.57 nat. median
$16,359
outlier · 2.3×
559
OTHER 		Aftercare, Musculoskeletal System And Connective Tissue With Mcc* 20 $14,215.05 $36,679.24 $36,679.24 nat. median
$18,760
2.0× median
391
OTHER 		Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc 20 $33,005.93 $35,241.19 $35,241.19 nat. median
$9,924
outlier · 3.6×
291
OTHER 		Heart Failure And Shock With Mcc 20 $29,317.76 $35,018.21 $35,018.21 nat. median
$13,078
outlier · 2.7×
444
OTHER 		Disorders Of The Biliary Tract With Mcc* 20 $30,631.51 $34,608.64 $34,608.64 nat. median
$11,816
outlier · 2.9×
299
OTHER 		Peripheral Vascular Disorders With Mcc 20 $33,813.89 $34,503.97 $34,503.97 nat. median
$15,709
outlier · 2.2×
432
OTHER 		Cirrhosis And Alcoholic Hepatitis With Mcc 20 $12,007.91 $33,584.71 $33,584.71 nat. median
$15,560
outlier · 2.2×
74055402
OTHER 		Humira(Cf) Pen 3 $3,000.00 $33,228.58 $33,228.58 nat. median
$33,229
1.0× median
2144511
OTHER 		Taltz Autoinjector 3 $3,000.00 $33,195.46 $33,195.46 nat. median
$33,195
1.0× median
372
OTHER 		Major Gastrointestinal Disorders And Peritoneal Infections With Cc 19 $32,351.08 $33,011.32 $33,011.32 nat. median
$10,312
outlier · 3.2×
540
OTHER 		Osteomyelitis With Cc* 20 $12,868.89 $32,369.66 $32,369.66 nat. median
$12,642
outlier · 2.6×
638
OTHER 		Diabetes With Cc 20 $29,740.84 $33,624.99 $32,023.80 nat. median
$9,351
outlier · 3.4×
558
OTHER 		Tendonitis, Myositis And Bursitis Without Mcc 19 $2,143.60 $31,905.48 $31,905.48 nat. median
$8,830
outlier · 3.6×
949
OTHER 		Aftercare With Cc/mcc 20 $22,225.60 $44,539.93 $31,655.18 nat. median
$11,081
outlier · 2.9×
193
OTHER 		Simple Pneumonia And Pleurisy With Mcc 19 $31,632.43 $31,632.43 $31,632.43 nat. median
$12,881
outlier · 2.5×
25682000101
OTHER 		Soliris 3 $3,000.00 $31,310.40 $31,310.40 nat. median
$19,882
1.6× median
694
OTHER 		Urinary Stones Without Mcc 19 $27,604.21 $31,013.53 $31,013.53 nat. median
$7,981
outlier · 3.9×
55513019201
OTHER 		Neulasta Onpro 3 $3,000.00 $30,806.35 $30,806.35 nat. median
$19,562
1.6× median
55513019001
OTHER 		Neulasta 6 Mg 3 $3,000.00 $30,806.35 $30,806.35 nat. median
$5,436
outlier · 5.7×
190
OTHER 		Chronic Obstructive Pulmonary Disease With Mcc* 19 $9,276.12 $29,739.31 $29,739.31 nat. median
$10,954
outlier · 2.7×
68982085005
OTHER 		Octagam 3 $3,000.00 $30,051.00 $27,972.00 nat. median
$27,972
1.0× median
683
OTHER 		Renal Failure With Cc 19 $17,011.18 $27,545.84 $27,545.84 nat. median
$9,135
outlier · 3.0×
50633012011
OTHER 		Digifab 3 $3,000.00 $30,051.00 $22,958.40 nat. median
$11,227
outlier · 2.0×
78081881
OTHER 		SandoSTATIN Lar Depot 3 $3,000.00 $30,051.00 $22,158.24 nat. median
$22,158
1.0× median

Other procedures at this hospital

Browse this hospital's 4,424 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
             
4 OTHER Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Nec… 52 20 $1,425,631.27 — $130,734.64 $149,347.92 $130,734.64 2026-05-22
166 OTHER Other Respiratory System O.r. Procedures With Mcc 50 20 $1,028,014.56 — $99,047.05 $106,515.42 $106,515.42 2026-05-22
981 OTHER Extensive O.r. Procedures Unrelated To Principal Diagnosis With Mcc 58 20 $984,643.87 — $99,610.96 $106,501.77 $106,501.77 2026-05-22
68875010201 OTHER Gattex 10 3 $99,999.99 — $3,000.00 $99,999.99 $99,999.99 2026-05-22
207 OTHER Respiratory System Diagnosis With Ventilator Support >96 Hours 112 26 $770,385.51 — $1,244.00 $92,349.23 $87,609.40 2026-05-22
853 OTHER Infectious And Parasitic Diseases With O.r. Procedures With Mcc 48 19 $1,170,151.11 — $68,998.84 $68,998.84 $68,998.84 2026-05-22
500 OTHER Soft Tissue Procedures With Mcc 52 20 $267,055.02 — $13,250.94 $56,051.88 $56,051.88 2026-05-22
939 OTHER O.r. Procedures With Diagnoses Of Other Contact With Health Services With Mcc 50 19 $359,288.27 — $31,022.09 $53,944.88 $53,944.88 2026-05-22
208 OTHER Respiratory System Diagnosis With Ventilator Support <=96 Hours 66 20 $242,851.63 — $600.00 $103,299.12 $53,735.54 2026-05-22
55292070255 OTHER Hemin For Injection 10 3 $51,333.70 — $3,000.00 $51,333.70 $51,333.70 2026-05-22
438 OTHER Disorders Of Pancreas Except Malignancy With Mcc 48 20 $920,473.10 — $5,941.21 $47,678.46 $47,678.46 2026-05-22
189 OTHER Pulmonary Edema And Respiratory Failure 68 20 $449,557.36 — $8,137.81 $50,998.70 $44,538.43 2026-05-22
539 OTHER Osteomyelitis With Mcc* 56 20 $372,567.23 — $21,448.74 $44,110.65 $44,110.65 2026-05-22
811 OTHER Red Blood Cell Disorders With Mcc 52 20 $442,462.77 — $41,489.13 $105,195.52 $42,335.85 2026-05-22
757 OTHER Infections, Female Reproductive System With Mcc 50 20 $654,586.00 — $41,489.13 $42,335.85 $42,335.85 2026-05-22
56 OTHER Degenerative Nervous System Disorders With Mcc 50 19 $557,650.61 — $39,339.76 $41,325.58 $41,325.58 2026-05-22
371 OTHER Major Gastrointestinal Disorders And Peritoneal Infections With Mcc 54 20 $331,032.76 — $12,595.05 $40,661.17 $40,661.17 2026-05-22
637 OTHER Diabetes With Mcc 50 20 $560,505.20 — $29,437.18 $40,237.94 $40,237.94 2026-05-22
592 OTHER Skin Ulcers With Mcc 50 19 $684,412.51 — $37,841.31 $40,046.81 $40,046.81 2026-05-22
682 OTHER Renal Failure With Mcc 52 20 $266,003.35 — $10,822.98 $39,714.61 $39,714.61 2026-05-22
59627033304 OTHER Avonex Pen 30 mcg/0.5mL 10 3 $39,676.03 — $3,000.00 $39,676.03 $39,676.03 2026-05-22
59627022205 OTHER Avonex 10 3 $39,676.03 — $3,000.00 $39,676.03 $39,676.03 2026-05-22
74368303 OTHER Lupron Depot 10 3 $39,246.62 — $3,000.00 $39,246.62 $39,246.62 2026-05-22
871 OTHER Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc 50 20 $383,354.53 — $15,058.48 $38,631.52 $38,631.52 2026-05-22
91 OTHER Other Disorders Of Nervous System With Mcc 50 19 $527,931.98 — $34,659.94 $37,880.64 $37,880.64 2026-05-22
70 OTHER Nonspecific Cerebrovascular Disorders With Mcc* 50 20 $72,078.71 — $10,313.56 $37,202.58 $37,202.58 2026-05-22
177 OTHER Respiratory Infections And Inflammations With Mcc* 50 20 $271,033.48 — $31,896.00 $36,888.57 $36,888.57 2026-05-22
559 OTHER Aftercare, Musculoskeletal System And Connective Tissue With Mcc* 50 20 $451,917.63 — $14,215.05 $36,679.24 $36,679.24 2026-05-22
391 OTHER Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc 50 20 $465,130.66 — $33,005.93 $35,241.19 $35,241.19 2026-05-22
291 OTHER Heart Failure And Shock With Mcc 50 20 $479,288.07 — $29,317.76 $35,018.21 $35,018.21 2026-05-22
444 OTHER Disorders Of The Biliary Tract With Mcc* 50 20 $811,087.33 — $30,631.51 $34,608.64 $34,608.64 2026-05-22
299 OTHER Peripheral Vascular Disorders With Mcc 50 20 $397,704.38 — $33,813.89 $34,503.97 $34,503.97 2026-05-22
432 OTHER Cirrhosis And Alcoholic Hepatitis With Mcc 50 20 $170,140.32 — $12,007.91 $33,584.71 $33,584.71 2026-05-22
74055402 OTHER Humira(Cf) Pen 10 3 $33,228.58 — $3,000.00 $33,228.58 $33,228.58 2026-05-22
2144511 OTHER Taltz Autoinjector 10 3 $33,195.46 — $3,000.00 $33,195.46 $33,195.46 2026-05-22
372 OTHER Major Gastrointestinal Disorders And Peritoneal Infections With Cc 50 19 $703,919.04 — $32,351.08 $33,011.32 $33,011.32 2026-05-22
540 OTHER Osteomyelitis With Cc* 50 20 $164,429.99 — $12,868.89 $32,369.66 $32,369.66 2026-05-22
638 OTHER Diabetes With Cc 52 20 $332,506.57 — $29,740.84 $33,624.99 $32,023.80 2026-05-22
558 OTHER Tendonitis, Myositis And Bursitis Without Mcc 52 19 $51,072.35 — $2,143.60 $31,905.48 $31,905.48 2026-05-22
949 OTHER Aftercare With Cc/mcc 52 20 $512,754.05 — $22,225.60 $44,539.93 $31,655.18 2026-05-22
193 OTHER Simple Pneumonia And Pleurisy With Mcc 48 19 $337,848.39 — $31,632.43 $31,632.43 $31,632.43 2026-05-22
25682000101 OTHER Soliris 10 3 $31,310.40 — $3,000.00 $31,310.40 $31,310.40 2026-05-22
694 OTHER Urinary Stones Without Mcc 50 19 $535,378.38 — $27,604.21 $31,013.53 $31,013.53 2026-05-22
55513019001 OTHER Neulasta 6 Mg 10 3 $30,806.35 — $3,000.00 $30,806.35 $30,806.35 2026-05-22
55513019201 OTHER Neulasta Onpro 10 3 $30,806.35 — $3,000.00 $30,806.35 $30,806.35 2026-05-22
190 OTHER Chronic Obstructive Pulmonary Disease With Mcc* 50 19 $73,417.72 — $9,276.12 $29,739.31 $29,739.31 2026-05-22
68982085005 OTHER Octagam 10 3 $27,972.00 — $3,000.00 $30,051.00 $27,972.00 2026-05-22
683 OTHER Renal Failure With Cc 50 19 $215,762.13 — $17,011.18 $27,545.84 $27,545.84 2026-05-22
50633012011 OTHER Digifab 10 3 $22,958.40 — $3,000.00 $30,051.00 $22,958.40 2026-05-22
78081881 OTHER SandoSTATIN Lar Depot 10 3 $22,158.24 — $3,000.00 $30,051.00 $22,158.24 2026-05-22
603 OTHER Cellulitis Without Mcc 50 19 $287,446.71 — $21,911.98 $21,911.98 $21,911.98 2026-05-22
950 OTHER Aftercare Without Cc/mcc 50 20 $253,093.61 — $2,996.54 $21,752.70 $21,752.70 2026-05-22
2840001 OTHER Forteo 10 3 $20,591.47 — $3,000.00 $30,051.00 $20,591.47 2026-05-22
50458060901 OTHER Invega Trinza 10 3 $19,046.87 — $3,000.00 $30,051.00 $19,046.87 2026-05-22
68982085004 OTHER Octagam 10 3 $18,648.00 — $3,000.00 $30,051.00 $18,648.00 2026-05-22
55513003201 OTHER Aranesp 10 3 $18,576.00 — $3,000.00 $30,051.00 $18,576.00 2026-05-22
78063998 OTHER Cosentyx 10 3 $17,781.50 — $3,000.00 $30,051.00 $17,781.50 2026-05-22
173089201 OTHER Mepolizumab Injection 10 3 $17,706.38 — $3,000.00 $30,051.00 $17,706.38 2026-05-22
44206043820 OTHER Privigen 10% 10 3 $17,379.84 — $3,000.00 $30,051.00 $17,379.84 2026-05-22
78081181 OTHER SandoSTATIN Lar Depot 10 3 $16,912.46 — $3,000.00 $30,051.00 $16,912.46 2026-05-22
50458056401 OTHER Invega Sustenna 234 Mg 10 3 $16,697.76 — $3,000.00 $30,051.00 $16,697.76 2026-05-22
74379902 OTHER Humira 10 3 $16,614.29 — $3,000.00 $30,051.00 $16,614.29 2026-05-22
944270006 OTHER Gammagard Liquid 10 3 $16,273.92 — $3,000.00 $30,051.00 $16,273.92 2026-05-22
55513073001 OTHER Denosumab 120 mg/1.7mL 10 3 $15,770.26 — $3,000.00 $30,051.00 $15,770.26 2026-05-22
51759063010 OTHER risperiDONE ER Inj 125 Mg/0.35 10 3 $15,375.36 — $3,000.00 $30,051.00 $15,375.36 2026-05-22
24201040002 OTHER Calcitonin,salmon Inj 400 Unit 10 3 $15,028.80 — $3,000.00 $30,051.00 $15,028.80 2026-05-22
206 OTHER R&b Intermediate - Semi Privat 40 12 $15,550.10 — $1,244.00 $34,198.00 $15,009.55 2026-05-22
120 OTHER R&b - Med/surge Private 40 12 $15,500.10 — $1,113.00 $34,198.00 $14,984.55 2026-05-22
42367054032 OTHER Ryanodex 10 3 $14,040.84 — $3,000.00 $30,051.00 $14,040.84 2026-05-22
59148001971 OTHER Abilify Maintena 10 3 $13,535.23 — $3,000.00 $30,051.00 $13,535.23 2026-05-22
59148007280 OTHER Abilify Maintena 400 Mg 10 3 $13,535.23 — $3,000.00 $30,051.00 $13,535.23 2026-05-22
67457067502 OTHER Miacalcin 10 3 $12,974.72 — $3,000.00 $30,051.00 $12,974.72 2026-05-22
70539000102 OTHER Tymlos 10 3 $12,801.60 — $3,000.00 $30,051.00 $12,801.60 2026-05-22
55513022101 OTHER Nplate 250 Mcg 10 3 $12,585.22 — $3,000.00 $30,051.00 $12,585.22 2026-05-22
50474070062 OTHER Cimzia 10 3 $12,239.24 — $3,000.00 $30,051.00 $12,239.24 2026-05-22
55513011101 OTHER Aranesp 10 3 $11,145.60 — $3,000.00 $30,051.00 $11,145.60 2026-05-22
50458056301 OTHER Invega Sustenna 156 Mg 10 3 $11,132.11 — $3,000.00 $30,051.00 $11,132.11 2026-05-22
50458056101 OTHER Invega Sustenna 10 3 $11,131.49 — $3,000.00 $30,051.00 $11,131.49 2026-05-22
50458056001 OTHER Invega Sustenna 10 3 $11,131.01 — $3,000.00 $30,051.00 $11,131.01 2026-05-22
944265804 OTHER Gammagard S-d 10 Gram 10 3 $10,764.48 — $3,000.00 $30,051.00 $10,764.48 2026-05-22
61953000405 OTHER Flebogamma Dif 10 3 $10,164.48 — $3,000.00 $30,051.00 $10,164.48 2026-05-22
59148004580 OTHER Abilify Maintena 10 3 $10,151.42 — $3,000.00 $30,051.00 $10,151.42 2026-05-22
67457083306 OTHER Pegfilgrastim-jmdb 10 3 $10,020.00 — $3,000.00 $30,051.00 $10,020.00 2026-05-22
74364203 OTHER Lupron Depot 10 3 $9,811.68 — $3,000.00 $30,051.00 $9,811.68 2026-05-22
68982085003 OTHER Octagam 10% 10 3 $9,324.00 — $3,000.00 $30,051.00 $9,324.00 2026-05-22
58406003204 OTHER EnbreL Sureclick 10 3 $9,148.70 — $3,000.00 $30,051.00 $9,148.70 2026-05-22
24591401 OTHER Dupixent Syringe 10 3 $9,127.68 — $3,000.00 $30,051.00 $9,127.68 2026-05-22
44206043710 OTHER Privigen 10% 10 3 $8,689.92 — $3,000.00 $30,051.00 $8,689.92 2026-05-22
55513071001 OTHER Prolia 10 3 $8,573.38 — $3,000.00 $30,051.00 $8,573.38 2026-05-22
57970010001 OTHER Dalbavancin Hcl 10 3 $8,539.82 — $3,000.00 $30,051.00 $8,539.82 2026-05-22
50458056201 OTHER Invega Sustenna 117 Mg 10 3 $8,348.78 — $3,000.00 $30,051.00 $8,348.78 2026-05-22
31600 OTHER Tracheostomy 10 3 $8,209.00 — $3,000.00 $30,051.00 $8,209.00 2026-05-22
944270005 OTHER Gammagard Liquid 10% 10 3 $8,136.96 — $3,000.00 $30,051.00 $8,136.96 2026-05-22
64842072709 OTHER Decitabine/Cedazuridine 35/100 10 3 $7,931.30 — $3,000.00 $30,051.00 $7,931.30 2026-05-22
65757030001 OTHER VivitroL 10 3 $7,877.33 — $3,000.00 $30,051.00 $7,877.33 2026-05-22
55513000601 OTHER Aranesp 10 3 $7,430.40 — $3,000.00 $30,051.00 $7,430.40 2026-05-22
55513002801 OTHER Aranesp 10 3 $7,430.40 — $3,000.00 $30,051.00 $7,430.40 2026-05-22
59676082001 OTHER Monovisc 10 3 $7,200.00 — $3,000.00 $30,051.00 $7,200.00 2026-05-22
9029703 OTHER Gelfilm 25x50mm 10 3 $7,140.96 — $3,000.00 $30,051.00 $7,140.96 2026-05-22
517065001 OTHER Injectafer 10 3 $6,862.56 — $3,000.00 $30,051.00 $6,862.56 2026-05-22
3218811 OTHER Orencia 10 3 $6,834.32 — $3,000.00 $30,051.00 $6,834.32 2026-05-22
13533080071 OTHER Gamunex-c 10 3 $6,804.00 — $3,000.00 $30,051.00 $6,804.00 2026-05-22
65162091322 OTHER Voriconazole Oral Susp (bulk) 10 3 $6,753.68 — $3,000.00 $30,051.00 $6,753.68 2026-05-22
4026129 OTHER Cellcept (160ml Bottle) 10 3 $6,628.18 — $3,000.00 $30,051.00 $6,628.18 2026-05-22
50484081015 OTHER Regranex 10 3 $6,526.56 — $3,000.00 $30,051.00 $6,526.56 2026-05-22
62935022305 OTHER Leuprolide Acetate 10 3 $6,504.34 — $3,000.00 $30,051.00 $6,504.34 2026-05-22
31722062921 OTHER Atovaquone (Bulk Bottle) 10 3 $6,307.16 — $3,000.00 $30,051.00 $6,307.16 2026-05-22
55513022301 OTHER Romiplostim 10 3 $6,292.70 — $3,000.00 $30,051.00 $6,292.70 2026-05-22
78043561 OTHER Reclast 5 Mg 10 3 $6,283.44 — $3,000.00 $30,051.00 $6,283.44 2026-05-22
23392102 OTHER Botox 10 3 $6,201.60 — $3,000.00 $30,051.00 $6,201.60 2026-05-22
81436 OTHER Hereditary Colon Ca Dsordrs 10 3 $6,141.00 — $3,000.00 $30,051.00 $6,141.00 2026-05-22
44146 OTHER Colec Part W Colopros W/colost 10 3 $5,934.18 — $3,000.00 $30,051.00 $5,934.18 2026-05-22
50458030811 OTHER RisperDAL Consta 50 Mg 10 3 $5,900.21 — $3,000.00 $30,051.00 $5,900.21 2026-05-22
59338077501 OTHER Feraheme 510 Mg 10 3 $5,729.38 — $3,000.00 $30,051.00 $5,729.38 2026-05-22
57894003001 OTHER Remicade 100 Mg 10 3 $5,605.54 — $3,000.00 $30,051.00 $5,605.54 2026-05-22
44208 OTHER Laparosc, Surg Colectomy, Part 10 3 $5,584.11 — $3,000.00 $30,051.00 $5,584.11 2026-05-22
55513002704 OTHER Aranesp 10 3 $5,572.80 — $3,000.00 $30,051.00 $5,572.80 2026-05-22
61958180101 OTHER Harvoni 10 3 $5,400.00 — $3,000.00 $30,051.00 $5,400.00 2026-05-22
944265603 OTHER Gammagard S-d 5 Gram 10 3 $5,382.24 — $3,000.00 $30,051.00 $5,382.24 2026-05-22
82154044901 OTHER Peginterferon Alfa-2a 10 3 $5,344.42 — $3,000.00 $30,051.00 $5,344.42 2026-05-22
59676034001 OTHER Procrit 10 3 $5,131.20 — $3,000.00 $30,051.00 $5,131.20 2026-05-22
2850101 OTHER HumuLIN R U-500 16 3 $7,137.60 — $7.12 $30,051.00 $5,068.80 2026-05-22
43246 OTHER Peg 10 3 $4,875.00 — $3,000.00 $30,051.00 $4,875.00 2026-05-22
74181 OTHER Mr Abdomen Wo 10 3 $4,819.04 — $3,000.00 $30,051.00 $4,819.04 2026-05-22
61958150101 OTHER Sovaldi 10 3 $4,800.00 — $3,000.00 $30,051.00 $4,800.00 2026-05-22
68982085002 OTHER Octagam 10 3 $4,662.00 — $3,000.00 $30,051.00 $4,662.00 2026-05-22
50742031025 OTHER Mafenide Acetate For Topical S 10 3 $4,661.36 — $3,000.00 $30,051.00 $4,661.36 2026-05-22
169477212 OTHER Semaglutide (2 Mg/dose) 10 3 $4,648.90 — $3,000.00 $30,051.00 $4,648.90 2026-05-22
169413013 OTHER Semaglutide Injection 10 3 $4,648.90 — $3,000.00 $30,051.00 $4,648.90 2026-05-22
169418113 OTHER Semaglutide 10 3 $4,648.90 — $3,000.00 $30,051.00 $4,648.90 2026-05-22
65757040203 OTHER Aristada 10 3 $4,637.50 — $3,000.00 $30,051.00 $4,637.50 2026-05-22
65757040103 OTHER Aristada 10 3 $4,633.98 — $3,000.00 $30,051.00 $4,633.98 2026-05-22
65757040303 OTHER Aristada 10 3 $4,633.96 — $3,000.00 $30,051.00 $4,633.96 2026-05-22
65757040403 OTHER Aristada 10 3 $4,586.84 — $3,000.00 $30,051.00 $4,586.84 2026-05-22
66794015702 OTHER Gablofen 10 3 $4,536.67 — $3,000.00 $30,051.00 $4,536.67 2026-05-22
65054301 OTHER Triesence 40 Mg 10 3 $4,531.20 — $3,000.00 $30,051.00 $4,531.20 2026-05-22
50242005121 OTHER Rituxan 10 3 $4,509.70 — $3,000.00 $30,051.00 $4,509.70 2026-05-22
31622 OTHER Rt Bronchoscopy 10 3 $4,482.10 — $3,000.00 $30,051.00 $4,482.10 2026-05-22
78608 OTHER PET Brain Metabolic 10 3 $4,474.60 — $3,000.00 $30,051.00 $4,474.60 2026-05-22
16110081230 OTHER Fluoroplex 1 % 10 3 $4,454.16 — $3,000.00 $30,051.00 $4,454.16 2026-05-22
50458030711 OTHER RisperDAL Consta 37.5 Mg 10 3 $4,425.02 — $3,000.00 $30,051.00 $4,425.02 2026-05-22
44206043605 OTHER Privigen 10 3 $4,344.96 — $3,000.00 $30,051.00 $4,344.96 2026-05-22
59572041500 OTHER Revlimid 10 3 $4,279.44 — $3,000.00 $30,051.00 $4,279.44 2026-05-22
59572041028 OTHER Revlimid 10 3 $4,279.44 — $3,000.00 $30,051.00 $4,279.44 2026-05-22
59572042521 OTHER Revlimid 10 3 $4,279.44 — $3,000.00 $30,051.00 $4,279.44 2026-05-22
61958220101 OTHER Epclusa 10 3 $4,272.00 — $3,000.00 $30,051.00 $4,272.00 2026-05-22
44087002203 OTHER Rebif 22 mcg/0.5mL 10 3 $4,226.26 — $3,000.00 $30,051.00 $4,226.26 2026-05-22
44087004403 OTHER Rebif 10 3 $4,226.26 — $3,000.00 $30,051.00 $4,226.26 2026-05-22
36569 OTHER Picc Line Insertion 10 3 $4,201.50 — $3,000.00 $30,051.00 $4,201.50 2026-05-22
42388002426 OTHER Cabometyx 10 3 $4,093.57 — $3,000.00 $30,051.00 $4,093.57 2026-05-22
42388002326 OTHER Cabometyx 10 3 $4,093.57 — $3,000.00 $30,051.00 $4,093.57 2026-05-22
42388002526 OTHER Cabometyx 10 3 $4,093.57 — $3,000.00 $30,051.00 $4,093.57 2026-05-22
310652401 OTHER Byetta 10 3 $4,079.76 — $3,000.00 $30,051.00 $4,079.76 2026-05-22
310651201 OTHER Byetta 10 3 $4,079.76 — $3,000.00 $30,051.00 $4,079.76 2026-05-22
944270004 OTHER Gammagard Liquid 10% 10 3 $4,068.48 — $3,000.00 $30,051.00 $4,068.48 2026-05-22
378972055 OTHER Denavir 1 % 10 3 $3,897.55 — $3,000.00 $30,051.00 $3,897.55 2026-05-22
62856070430 OTHER Lenvima 10 3 $3,880.80 — $3,000.00 $30,051.00 $3,880.80 2026-05-22
90935 OTHER Hemodialysis 10 3 $3,863.25 — $3,000.00 $30,051.00 $3,863.25 2026-05-22
69098038 OTHER Sutent 10 3 $3,853.62 — $3,000.00 $30,051.00 $3,853.62 2026-05-22
73562011201 OTHER Lipase/Protea/Amyl 20-63-84k U 10 3 $3,846.24 — $3,000.00 $30,051.00 $3,846.24 2026-05-22
55513002504 OTHER Darbepoetin Alfa 100 M 100 Mcg 10 3 $3,715.20 — $3,000.00 $30,051.00 $3,715.20 2026-05-22
55513000504 OTHER Aranesp 10 3 $3,715.20 — $3,000.00 $30,051.00 $3,715.20 2026-05-22
55724021121 OTHER Eucrisa 10 3 $3,661.87 — $3,000.00 $30,051.00 $3,661.87 2026-05-22
69018821 OTHER Ibrance 10 3 $3,653.12 — $3,000.00 $30,051.00 $3,653.12 2026-05-22
55513084301 OTHER Erenumab-aooe 10 3 $3,612.58 — $3,000.00 $30,051.00 $3,612.58 2026-05-22
36000 OTHER Mid Line Cath 10 3 $3,604.15 — $3,000.00 $30,051.00 $3,604.15 2026-05-22
60793090910 OTHER Thrombi-gel 100 Cm2 10 3 $3,556.46 — $3,000.00 $30,051.00 $3,556.46 2026-05-22
51759020210 OTHER Ajovy Autoinjector 10 3 $3,519.16 — $3,000.00 $30,051.00 $3,519.16 2026-05-22
51759020410 OTHER Ajovy 225 mg/1.5mL Syringe 10 3 $3,519.16 — $3,000.00 $30,051.00 $3,519.16 2026-05-22
480372056 OTHER Pyrimethamine 10 3 $3,420.00 — $3,000.00 $30,051.00 $3,420.00 2026-05-22
2143611 OTHER Galcanezumab-gnlm Pen 10 3 $3,390.58 — $3,000.00 $30,051.00 $3,390.58 2026-05-22
50419052435 OTHER Betaseron 10 3 $3,343.82 — $3,000.00 $30,051.00 $3,343.82 2026-05-22
49471000105 OTHER Pre-pen .25 Ml 10 3 $3,244.80 — $3,000.00 $30,051.00 $3,244.80 2026-05-22
78056751 OTHER Afinitor 10 Mg 10 3 $3,200.31 — $3,000.00 $30,051.00 $3,200.31 2026-05-22
173088710 OTHER Trelegy Ellipta 100-62.5 10 3 $3,156.86 — $3,000.00 $30,051.00 $3,156.86 2026-05-22
23923201 OTHER Botox Cosmetic 10 3 $3,148.80 — $3,000.00 $30,051.00 $3,148.80 2026-05-22
78068715 OTHER Promacta 10 3 $3,147.39 — $3,000.00 $30,051.00 $3,147.39 2026-05-22
13533063402 OTHER Hypertet S-d 250 Unit 10 3 $3,116.02 — $3,000.00 $30,051.00 $3,116.02 2026-05-22
23114501 OTHER Botox 100 Unit 10 3 $3,100.80 — $3,000.00 $30,051.00 $3,100.80 2026-05-22
310461612 OTHER Budesonide/Glycopyr/Formoterol 10 3 $3,096.67 — $3,000.00 $30,051.00 $3,096.67 2026-05-22
58914030180 OTHER Rectiv 10 3 $3,075.55 — $3,000.00 $30,051.00 $3,075.55 2026-05-22
299598035 OTHER Mirvaso 10 3 $3,060.10 — $3,000.00 $30,051.00 $3,060.10 2026-05-22
70510217102 OTHER Radicava 10 3 $3,053.81 — $3,000.00 $30,051.00 $3,053.81 2026-05-22
60793070210 OTHER Bicillin L-a 2400000 Unit 10 3 $2,999.86 — $2,549.88 $3,000.00 $2,999.86 2026-05-22
50458030611 OTHER RisperDAL Consta 25 Mg 10 3 $2,949.89 — $2,507.41 $3,000.00 $2,949.89 2026-05-22
43598000451 OTHER Augmentin 10 3 $2,935.68 — $2,495.33 $3,000.00 $2,935.68 2026-05-22
60793090701 OTHER Thrombi-gel 10 Cm2 10 3 $2,931.41 — $2,491.70 $3,000.00 $2,931.41 2026-05-22
72511077001 OTHER Evolocumab 420 mg/3.5mL 10 3 $2,919.74 — $2,481.78 $3,000.00 $2,919.74 2026-05-22
3085222 OTHER SpryceL 10 3 $2,919.41 — $2,481.50 $3,000.00 $2,919.41 2026-05-22
72157 OTHER Mr Spine Thoracic W/wo 10 3 $2,900.44 — $2,465.38 $3,000.00 $2,900.44 2026-05-22
72156 OTHER Mr Spine Cervical W/wo 10 3 $2,900.44 — $2,465.38 $3,000.00 $2,900.44 2026-05-22
61958290102 OTHER Veklury 10 3 $2,877.50 — $2,445.88 $3,000.00 $2,877.50 2026-05-22
72158 OTHER MRI Spine Lumbar W/wo 10 3 $2,855.64 — $2,427.30 $3,000.00 $2,855.64 2026-05-22
70553 OTHER MRI Brain/stem Wo/w 10 3 $2,852.72 — $2,424.81 $3,000.00 $2,852.72 2026-05-22
51672137108 OTHER clobetasoL Propionate 10 3 $2,842.36 — $2,416.01 $3,000.00 $2,842.36 2026-05-22
43235 OTHER Upper Gastro/Endoscopy 10 3 $2,834.00 — $2,408.90 $3,000.00 $2,834.00 2026-05-22
72197 OTHER Mr Pelvis W/wo 10 3 $2,828.92 — $2,404.58 $3,000.00 $2,828.92 2026-05-22
74183 OTHER Mr Abdomen W/wo 10 3 $2,827.44 — $2,403.32 $3,000.00 $2,827.44 2026-05-22
57962042028 OTHER Imbruvica 10 3 $2,809.99 — $2,388.49 $3,000.00 $2,809.99 2026-05-22
59353040509 OTHER Methoxy Peg-epoetin 200 Mcg/0. 10 3 $2,769.36 — $2,353.95 $3,000.00 $2,769.36 2026-05-22
90937 OTHER Peritoneal Dialysis 10 3 $2,688.70 — $2,285.39 $3,000.00 $2,688.70 2026-05-22
69238101302 OTHER Testosterone 10 3 $2,682.88 — $2,280.45 $3,000.00 $2,682.88 2026-05-22
9379401 OTHER Corvert 10 3 $2,634.48 — $2,239.31 $3,000.00 $2,634.48 2026-05-22
A0426 OTHER Amb Non Emr Als Rnd Trip 10 3 $2,600.00 — $2,210.00 $3,000.00 $2,600.00 2026-05-22
59148002150 OTHER Samsca 30 Mg 10 3 $2,590.29 — $2,201.74 $3,000.00 $2,590.29 2026-05-22
55513020901 OTHER Neupogen 10 3 $2,550.86 — $2,168.23 $3,000.00 $2,550.86 2026-05-22
85433101 OTHER Noxafil 10 3 $2,546.16 — $2,164.24 $3,000.00 $2,546.16 2026-05-22
61953000403 OTHER Flebogamma Dif 10 3 $2,541.12 — $2,159.95 $3,000.00 $2,541.12 2026-05-22
63323064810 OTHER Levothyroxine Sodium 10 3 $2,533.97 — $2,153.88 $3,000.00 $2,533.97 2026-05-22
597016061 OTHER Spiriva Respimat 10 3 $2,531.47 — $2,151.75 $3,000.00 $2,531.47 2026-05-22
5200010 OTHER Pneumoc 20-val Conj-dip Crm/Pf 10 3 $2,503.78 — $2,128.22 $3,000.00 $2,503.78 2026-05-22
59148002050 OTHER Samsca 15 Mg 10 3 $2,496.95 — $2,122.41 $3,000.00 $2,496.95 2026-05-22
78206018401 OTHER Adalimumab-bwwd 10 3 $2,491.20 — $2,117.52 $3,000.00 $2,491.20 2026-05-22
50090073200 OTHER Advair Diskus 10 3 $2,486.88 — $2,113.85 $3,000.00 $2,486.88 2026-05-22
43247 OTHER Egd Flx Transoral W/for Bdy Rm 10 3 $2,476.53 — $2,105.05 $3,000.00 $2,476.53 2026-05-22
24208050405 OTHER Vyzulta 10 3 $2,451.17 — $2,083.49 $3,000.00 $2,451.17 2026-05-22
71571033383 OTHER Loteprednol Etabonate 0.25% Op 10 3 $2,438.50 — $2,072.72 $3,000.00 $2,438.50 2026-05-22
49084 OTHER Paracentesis 10 3 $2,428.80 — $2,064.48 $3,000.00 $2,428.80 2026-05-22
10631009160 OTHER Eurax 10 3 $2,428.42 — $2,064.16 $3,000.00 $2,428.42 2026-05-22
74185 OTHER MRI Angio Abdom W Or Without Contrast 10 3 $2,422.72 — $2,059.31 $3,000.00 $2,422.72 2026-05-22
51991082328 OTHER Everolimus 10 3 $2,422.24 — $2,058.91 $3,000.00 $2,422.24 2026-05-22
23320505 OTHER Bimatoprost 0.01% 5ml 10 3 $2,412.34 — $2,050.49 $3,000.00 $2,412.34 2026-05-22
55513054610 OTHER Neupogen 480 Mcg 10 3 $2,406.38 — $2,045.42 $3,000.00 $2,406.38 2026-05-22
378932232 OTHER Wixela Inhub 500/50 10 3 $2,362.52 — $2,008.14 $3,000.00 $2,362.52 2026-05-22
597002402 OTHER Combivent Respimat 10 3 $2,348.83 — $1,996.51 $3,000.00 $2,348.83 2026-05-22
55566830301 OTHER Firmagon 10 3 $2,344.56 — $1,992.88 $3,000.00 $2,344.56 2026-05-22
68546032512 OTHER Copaxone 40 Mg 10 3 $2,332.80 — $1,982.88 $3,000.00 $2,332.80 2026-05-22
72142 OTHER Mr Spine Cervical W 10 3 $2,332.16 — $1,982.34 $3,000.00 $2,332.16 2026-05-22
72147 OTHER Mr Spine Thoracic W 10 3 $2,314.32 — $1,967.17 $3,000.00 $2,314.32 2026-05-22
72196 OTHER Mr Pelvis W 10 3 $2,291.84 — $1,948.07 $3,000.00 $2,291.84 2026-05-22
74182 OTHER MRI Abdomen With 10 3 $2,290.36 — $1,946.81 $3,000.00 $2,290.36 2026-05-22
173086910 OTHER Anoro Ellipta 10 3 $2,279.23 — $1,937.35 $3,000.00 $2,279.23 2026-05-22
597008717 OTHER Atrovent Hfa 10 3 $2,265.89 — $1,926.01 $3,000.00 $2,265.89 2026-05-22
24208053535 OTHER Zirgan 10 3 $2,256.34 — $1,917.89 $3,000.00 $2,256.34 2026-05-22
73720 OTHER MRI Extremity Lower Rt W/wo 10 3 $2,230.28 — $1,895.74 $3,000.00 $2,230.28 2026-05-22
55513002304 OTHER Aranesp 60 Mcg 10 3 $2,229.12 — $1,894.75 $3,000.00 $2,229.12 2026-05-22
55513000404 OTHER Aranesp 10 3 $2,229.12 — $1,894.75 $3,000.00 $2,229.12 2026-05-22
73220 OTHER MRI Upper Ext W/wo Dye Lt 20 3 $2,216.04 — $1,883.63 $3,000.00 $2,216.04 2026-05-22
713063337 OTHER metroNIDAZOLE 0.75 % 10 3 $2,199.48 — $1,869.56 $3,000.00 $2,199.48 2026-05-22
49281019020 OTHER Imogam Rabies-ht 150 Unit 10 3 $2,172.31 — $1,846.46 $3,000.00 $2,172.31 2026-05-22
46087221 OTHER Premarin .625 Mg 10 3 $2,160.24 — $1,836.20 $3,000.00 $2,160.24 2026-05-22
14789001101 OTHER Isoproterenol Hcl Inj 10 3 $2,160.00 — $1,836.00 $3,000.00 $2,160.00 2026-05-22
99999998396 OTHER Tacrolimus 0.5mg/mL - 240mL Bo 10 3 $2,140.80 — $1,819.68 $3,000.00 $2,140.80 2026-05-22
69130904 OTHER Retacrit 10 3 $2,117.76 — $1,800.10 $3,000.00 $2,117.76 2026-05-22
173071720 OTHER Advair Hfa 230-21mcg 10 3 $2,110.66 — $1,794.06 $3,000.00 $2,110.66 2026-05-22
61314032601 OTHER Zarxio 10 3 $2,107.10 — $1,791.04 $3,000.00 $2,107.10 2026-05-22
37683015 OTHER Cortifoam 10 % 10 3 $2,105.28 — $1,789.49 $3,000.00 $2,105.28 2026-05-22
78068615 OTHER Promacta 10 3 $2,098.26 — $1,783.52 $3,000.00 $2,098.26 2026-05-22
49281025051 OTHER Imovax Rabies Vaccine 2.5 Unit 10 3 $2,082.29 — $1,769.94 $3,000.00 $2,082.29 2026-05-22
73223 OTHER Mr Ext Lower Joint Ww Lt 20 3 $2,081.36 — $1,769.15 $3,000.00 $2,081.36 2026-05-22
59353040409 OTHER Methoxy Peg-epoetin 150 Mcg/0. 10 3 $2,077.01 — $1,765.46 $3,000.00 $2,077.01 2026-05-22
61958080101 OTHER Letairis 10 3 $2,076.89 — $1,765.36 $3,000.00 $2,076.89 2026-05-22
46287002004 OTHER Carospir 10 3 $2,074.56 — $1,763.38 $3,000.00 $2,074.56 2026-05-22
42023021910 OTHER Vasopressin 40 units/100mL 10 3 $2,038.80 — $1,732.98 $3,000.00 $2,038.80 2026-05-22
173052100 OTHER Salmeterol Xinafoate 10 3 $2,032.61 — $1,727.72 $3,000.00 $2,032.61 2026-05-22
71550 OTHER Mr Chest Wo 10 3 $2,017.80 — $1,715.13 $3,000.00 $2,017.80 2026-05-22
71551 OTHER Mr Chest W 10 3 $2,017.80 — $1,715.13 $3,000.00 $2,017.80 2026-05-22
71552 OTHER Mr Chest W/wo 10 3 $2,017.80 — $1,715.13 $3,000.00 $2,017.80 2026-05-22
51224001210 OTHER Phentolamine Mesylate 5 Mg 10 3 $2,006.40 — $1,705.44 $3,000.00 $2,006.40 2026-05-22
60793090804 OTHER Thrombi-gel 40 Cm2 10 3 $1,957.87 — $1,664.19 $3,000.00 $1,957.87 2026-05-22
173091610 OTHER Fluticasone/Vilanterol 50-25 M 10 3 $1,954.66 — $1,661.46 $3,000.00 $1,954.66 2026-05-22
173088210 OTHER Breo Ellipta 10 3 $1,954.66 — $1,661.46 $3,000.00 $1,954.66 2026-05-22
93318 OTHER Tee 10 3 $1,931.00 — $1,641.35 $3,000.00 $1,931.00 2026-05-22
63459091211 OTHER Granix 480 Mcg 10 3 $1,919.44 — $1,631.53 $3,000.00 $1,919.44 2026-05-22
456270010 OTHER Avycaz 2.5 Gram 10 3 $1,898.81 — $1,613.99 $3,000.00 $1,898.81 2026-05-22
94003 OTHER Rt Vent Subseq Daily 16 3 $2,032.65 — $258.56 $3,000.00 $1,880.20 2026-05-22
94002 OTHER Rt Vent Init Day 16 3 $2,032.65 — $156.10 $3,000.00 $1,880.20 2026-05-22
23932110 OTHER Alphagan P - 10mL 10 3 $1,865.76 — $1,585.89 $3,000.00 $1,865.76 2026-05-22
68982085001 OTHER Octagam 10 3 $1,864.80 — $1,585.08 $3,000.00 $1,864.80 2026-05-22
72146 OTHER Mr Spine Thoracic Without 10 3 $1,851.72 — $1,573.96 $3,000.00 $1,851.72 2026-05-22
72141 OTHER Mr Spine Cervical Wo 10 3 $1,851.72 — $1,573.96 $3,000.00 $1,851.72 2026-05-22
168016360 OTHER clobetasoL Propionate 0.05% Cr 10 3 $1,835.84 — $1,560.46 $3,000.00 $1,835.84 2026-05-22
597013830 OTHER Gilotrif 10 3 $1,831.73 — $1,556.97 $3,000.00 $1,831.73 2026-05-22
8065183905 OTHER Viscoat 40-30mg/ml 10 3 $1,830.14 — $1,555.62 $3,000.00 $1,830.14 2026-05-22
72148 OTHER Mr Spine Lumbar Wo 10 3 $1,826.32 — $1,552.37 $3,000.00 $1,826.32 2026-05-22
70551 OTHER MRI Brain Wo 10 3 $1,824.96 — $1,551.21 $3,000.00 $1,824.96 2026-05-22
81284052201 OTHER Penicillin G Benzathine 10 3 $1,824.00 — $1,550.40 $3,000.00 $1,824.00 2026-05-22
72195 OTHER MRI Pelvis Wo 10 3 $1,823.36 — $1,549.86 $3,000.00 $1,823.36 2026-05-22
73221 OTHER Mr Extr Left Upper Joint Without 20 3 $1,802.40 — $1,532.04 $3,000.00 $1,802.40 2026-05-22
73721 OTHER Mr Ext Lower Joint Without Lt 20 3 $1,800.92 — $1,530.78 $3,000.00 $1,800.92 2026-05-22
A0429 OTHER Amb Emr Bls One Way 10 3 $1,800.00 — $1,530.00 $3,000.00 $1,800.00 2026-05-22
73718 OTHER Mr Extremity Left Lower Wo 20 3 $1,796.52 — $1,527.04 $3,000.00 $1,796.52 2026-05-22
378932132 OTHER Wixela Inhub 250/50mcg 10 3 $1,796.32 — $1,526.87 $3,000.00 $1,796.32 2026-05-22
73719 OTHER Mr Extremity Right Lower W/wo 10 3 $1,794.92 — $1,525.68 $3,000.00 $1,794.92 2026-05-22
73219 OTHER MRI Upper Ext With Contrast Lt 10 3 $1,791.00 — $1,522.35 $3,000.00 $1,791.00 2026-05-22
70542 OTHER Mr Orbit, Face, Neck W 10 3 $1,787.00 — $1,518.95 $3,000.00 $1,787.00 2026-05-22
46074905 OTHER Premarin 25 Mg 10 3 $1,766.64 — $1,501.64 $3,000.00 $1,766.64 2026-05-22
70544 OTHER MRI Angiogram Head Without Contrast 10 3 $1,763.72 — $1,499.16 $3,000.00 $1,763.72 2026-05-22
73206 OTHER CTA Up Extr Without & With Contrast 20 3 $1,268.84 — $542.30 $3,000.00 $1,757.20 2026-05-22
70547 OTHER MRI Angiography Neck 10 3 $1,748.32 — $1,486.07 $3,000.00 $1,748.32 2026-05-22
51672130308 OTHER Econazole Nitrate 1% Cream 10 3 $1,738.80 — $1,477.98 $3,000.00 $1,738.80 2026-05-22
23391950 OTHER Botox Cosmetic 10 3 $1,737.60 — $1,476.96 $3,000.00 $1,737.60 2026-05-22
93350 OTHER US Stress Tte Only����� 10 3 $1,723.47 — $1,464.95 $3,000.00 $1,723.47 2026-05-22
24208060203 OTHER Prolensa 10 3 $1,712.98 — $1,456.04 $3,000.00 $1,712.98 2026-05-22
310461639 OTHER Breztri Aerosphere 160-9-4.8 10 3 $1,707.60 — $1,451.46 $3,000.00 $1,707.60 2026-05-22
78060715 OTHER Gilenya 10 3 $1,701.03 — $1,445.88 $3,000.00 $1,701.03 2026-05-22
173087310 OTHER Incruse Ellipta 10 3 $1,699.68 — $1,444.73 $3,000.00 $1,699.68 2026-05-22
66993087761 OTHER Calcipotriene 10 3 $1,694.76 — $1,440.55 $3,000.00 $1,694.76 2026-05-22
73722 OTHER Mr Ext Lower Joint Rt With 10 3 $1,693.52 — $1,439.49 $3,000.00 $1,693.52 2026-05-22
70557 OTHER MRI - Brain Without Contrast 10 3 $1,686.00 — $1,433.10 $3,000.00 $1,686.00 2026-05-22
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