Hospital

VALLEY COUNTY HEALTH SYSTEM

Ord, NE · CCN 281353 · Rates published

1,781 distinct procedures filed

11 distinct payers

234,258 rate rows

2026-06-15 last MRF observed

Data quality

77,199 of 234,258 rate rows are consumer-grade (33.0%)

157,059 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 — reason	Rows
professional (physician) fee — not the facility price	156,787
percent-of-charges filed in the dollar field — excluded from medians	159
per-diem day rate — not a per-procedure price	59
below 25% of the Medicare reference for this code — likely a mislabeled per-diem or placeholder; excluded from medians	32
exceeds 10× this hospital's gross charge — excluded from medians	21
no usable negotiated amount (only an out-of-band fallback) — excluded from medians	1

Data source & audit trail ↓ Download audit trail (JSON)

Source MRF file	https://sthpiprd.blob.core.windows.net/machine-readable-files/10190/470485275_valley-county-hospital_standardcharges.csv
Found on page	https://search.hospitalpriceindex.com/hpi2/machineReadable/ValleyCountyHealthSystem/10190
Discovered via	Discovered by HANK
Last fetch	not_modified · 2026-08-01
Content fingerprint	eaf76e5c13413051… · 59,019,900 bytes · first seen 2026-07-31

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
C1820 HCPCS	Wavewriter Alpha Prime Ki	11	$9,753.00	$53,376.68	$37,166.22	nat. median $21,100 1.8× median
J3357 HCPCS	Ustekinumab 45mg/0.5ml Subq	11	$3,961.00	$19,408.90	$18,715.72	nat. median $20,264 0.9× median
C1767 HCPCS	Interstim-neurostimulator	11	$3,849.00	$18,860.10	$18,186.53	nat. median $25,172 0.7× median
C1772 HCPCS	Pump Implant Medtronic 86	11	$3,688.60	$18,074.14	$17,428.63	nat. median $18,271 1.0× median
J3380 HCPCS	Vedolizumab 300 Mg / 20 Ml Sdv (entyvio)	11	$3,642.00	$17,845.80	$17,208.45	nat. median $59 outlier · 292.6×
C1897 HCPCS	Coveredge 32 Surgical Lea	11	$3,246.40	$15,907.36	$15,339.24	nat. median $1,214 outlier · 12.6×
J3101 HCPCS	Tenecteplase 50 Mg Inj	11	$2,987.20	$14,637.28	$14,114.52	nat. median $498 outlier · 28.4×
J9217 HCPCS	Leuprolide 22.5 Mg (3 Mo) Depot Syr Kit	11	$2,434.00	$11,926.60	$11,500.65	nat. median $2,144 outlier · 5.4×
J1096 HCPCS	Dextenza 0.4 Mg Ophthalmic Insert	11	$2,304.00	$11,289.60	$10,886.40	nat. median $145 outlier · 75.0×
J0517 HCPCS	Benralizumab 30 Mg Subq Inj Pfs	11	$2,168.20	$10,624.18	$10,244.75	nat. median $404 outlier · 25.3×
J0491 HCPCS	Saphnelo 300 Mg / 2 Ml Sdv	11	$1,988.20	$9,742.18	$9,394.25	nat. median $45 outlier · 210.2×
78816 CPT	PET Image W/ct Full Body	11	$1,895.20	$9,286.48	$8,954.82	nat. median $1,696 outlier · 5.3×
J1449 HCPCS	Rolvedon 13.2 Mg Subq Syrg	11	$1,620.00	$7,938.00	$7,654.50	nat. median $39 outlier · 196.5×
J2506 HCPCS	Neulasta Onpro 6 Mg Kit	11	$1,611.60	$7,896.84	$7,614.81	nat. median $916 outlier · 8.3×
J2997 HCPCS	Alteplase (stroke) 100 Mg Inj Vial	11	$77.80	$15,524.18	$7,603.68	nat. median $428 outlier · 17.8×
Q5111 HCPCS	Udenyca 6 Mg / 0.6 Ml Syrg	11	$1,503.00	$7,364.70	$7,101.68	nat. median $665 outlier · 10.7×
78815 CPT	PET Image W/ct Skull-thigh	11	$1,453.20	$7,120.68	$6,866.37	nat. median $1,679 outlier · 4.1×
J1568 HCPCS	Octagam 20 Gm / 200 Ml Vial	11	$1,398.60	$6,853.14	$6,608.39	nat. median $383 outlier · 17.3×
J1306 HCPCS	Leqvio 284 Mg / 1.5 Ml Subq Syrg	11	$1,291.60	$6,328.84	$6,102.81	nat. median $25 outlier · 242.2×
Q5119 HCPCS	Ruxience 500 Mg / 50 Ml Sdv	11	$1,290.40	$6,322.96	$6,097.14	nat. median $318 outlier · 19.2×
C1763 HCPCS	Matriderm Acellular Derma	11	$1,270.00	$6,223.00	$6,000.75	nat. median $2,550 outlier · 2.4×
74178 CPT	CT Abd&plv Wo Cntr Flwd Cntr	11	$1,158.20	$5,675.18	$5,472.49	nat. median $539 outlier · 10.2×
J0840 HCPCS	Crotalidae Polyval Immune Fab Inj	11	$1,151.40	$5,641.86	$5,440.36	nat. median $3,496 1.6× median
74177 CPT	CT Abd & Pelvis W/contrast	11	$1,089.60	$5,339.04	$5,148.36	nat. median $501 outlier · 10.3×
C1783 HCPCS	Vantage Istent Msc0957	11	$1,079.80	$5,291.02	$5,102.06	nat. median $2,313 outlier · 2.2×
J3315 HCPCS	Triptorelin Pamoate 11.25 Mg Inj Vial	11	$1,036.20	$10,154.76	$4,896.05	nat. median $1,451 outlier · 3.4×
78452 CPT	Ht Muscle Image Spect Mult	11	$1,019.20	$4,994.08	$4,815.72	nat. median $1,464 outlier · 3.3×
74176 CPT	CT Abd & Pelvis Without Contrast	11	$1,004.80	$4,923.52	$4,747.68	nat. median $333 outlier · 14.2×
95811 CPT	Polysom 6/>yrs Cpap 4/> Parm	11	$986.20	$4,832.38	$4,659.80	nat. median $1,412 outlier · 3.3×
74183 CPT	MRI Abd Without Cntr Flwd Cntr	11	$974.00	$4,772.60	$4,602.15	nat. median $611 outlier · 7.5×
J3111 HCPCS	Romosozumab-aqqg 210mg Dose 2 Syr	11	$946.60	$4,638.34	$4,472.69	nat. median $19 outlier · 235.4×
70553 CPT	MRI Brain Stem Without & With Contrast	11	$929.40	$4,554.06	$4,391.41	nat. median $616 outlier · 7.1×
70543 CPT	MRI Orbt/fac/nck Without &with Contrast	11	$929.40	$4,554.06	$4,391.41	nat. median $605 outlier · 7.3×
71552 CPT	MRI Chest Without & With Contrast	11	$902.40	$4,421.76	$4,263.84	nat. median $691 outlier · 6.2×
C1776 HCPCS	Tibia Insert	11	$508.40	$73,725.40	$4,243.98	nat. median $3,543 1.2× median
72156 CPT	MRI Neck Spine Without & With Contrast	11	$884.60	$4,334.54	$4,179.73	nat. median $625 outlier · 6.7×
74181 CPT	MRI Abdomen Without Contrast	11	$884.60	$4,334.54	$4,179.73	nat. median $428 outlier · 9.8×
72158 CPT	MRI Lumbar Spine Without & With Contrast	11	$884.60	$4,334.54	$4,179.73	nat. median $616 outlier · 6.8×
70549 CPT	Mr Angiograph Neck W/O&with Contrast	11	$884.60	$4,334.54	$4,179.73	nat. median $606 outlier · 6.9×
72157 CPT	MRI Chest Spine Without & With Contrast	11	$884.60	$4,334.54	$4,179.73	nat. median $624 outlier · 6.7×
95810 CPT	Polysom 6/> Yrs 4/> Param	11	$858.00	$4,204.20	$4,054.05	nat. median $1,446 outlier · 2.8×
72197 CPT	MRI Pelvis Without & With Contrast	11	$851.00	$4,169.90	$4,020.97	nat. median $606 outlier · 6.6×
70552 CPT	MRI Brain Stem With Contrast	11	$851.00	$4,169.90	$4,020.97	nat. median $597 outlier · 6.7×
74185 CPT	MRA Abd W Or Without Cntrst	11	$851.00	$4,169.90	$4,020.97	nat. median $853 outlier · 4.7×
71551 CPT	MRI Chest With Contrast	11	$851.00	$4,169.90	$4,020.97	nat. median $921 outlier · 4.4×
74174 CPT	CTA Abd&plvs W/contrast	11	$839.60	$4,114.04	$3,967.11	nat. median $549 outlier · 7.2×
70551 CPT	MRI Brain Stem Without Contrast	11	$839.60	$4,114.04	$3,967.11	nat. median $429 outlier · 9.2×
70544 CPT	Mr Angiography Head Without Contrast	11	$839.60	$4,114.04	$3,967.11	nat. median $435 outlier · 9.1×
Q4177 HCPCS	Floweramnioflo Per .1cc	11	$835.20	$4,092.48	$3,946.32	nat. median $1,282 outlier · 3.1×
Q4159 HCPCS	Affinity Amniotic Membran	11	$826.40	$4,049.36	$3,904.74	nat. median $534 outlier · 7.3×

Other procedures at this hospital

Browse this hospital's 1,781 published procedures. Use the slice to choose what to show, then sort or filter any column.

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

0099U	CPT	Respiratory Pathogen Pane	28	11	$882.00	$793.80	$176.40	$864.36	$833.49	2026-06-15
0170	RC	Nursery Room Rate	4	3	$841.00	$756.90	$765.31	$824.18	$807.36	2026-06-15
0278	RC	Modular Cemented Stem	604	11	$3,168.00	$2,851.20	$41.20	$16,595.32	$1,278.40	2026-06-15
0360	RC	Or Chg Up To 15 Min Sched	476	11	$2,996.00	$2,696.40	$46.40	$6,209.28	$994.92	2026-06-15
0450	RC	Thoracentesis	28	11	$1,197.00	$1,077.30	$239.40	$1,173.06	$1,131.16	2026-06-15
10081	CPT	Amb Inc & DRG Of Pilondia	29	11	$883.00	$794.70	$176.60	$865.34	$834.43	2026-06-15
10121	CPT	Remove Foreign Body Compl	45	11	$1,876.00	$1,688.40	$134.20	$1,838.48	$900.48	2026-06-15
11000	CPT	Debride Infected Skin	28	11	$1,270.00	$1,143.00	$254.00	$1,244.60	$1,200.15	2026-06-15
11043	CPT	Debride Muscle And/or Fas	45	11	$2,286.00	$2,057.40	$117.20	$2,240.28	$1,097.28	2026-06-15
11406	CPT	Exc B9les Mrgn Xcp Sk Tg	29	11	$800.00	$720.00	$160.00	$784.00	$756.00	2026-06-15
11426	CPT	Exc B9les Mgn Xcp Sktg S/	30	11	$836.00	$752.40	$167.20	$819.28	$790.02	2026-06-15
11446	CPT	Exc B9les Mgn Xcp Sktg F/	29	11	$974.00	$876.60	$194.80	$954.52	$920.43	2026-06-15
11604	CPT	Exc Mal Les T/a/l 3.1-4.0	29	11	$791.00	$711.90	$158.20	$775.18	$747.50	2026-06-15
11606	CPT	Exc Mal Les T/a/l >4.0 Cm	29	11	$1,125.00	$1,012.50	$225.00	$1,102.50	$1,063.12	2026-06-15
11626	CPT	Exc Mal Les S/n/h/fg >4.0	29	11	$1,024.00	$921.60	$204.80	$1,003.52	$967.68	2026-06-15
11643	CPT	Exc Mal Les F/e/e/n/l 2.1	29	11	$801.00	$720.90	$160.20	$784.98	$756.95	2026-06-15
11644	CPT	Exc Mal Les F/e/e/n/l 3.1	29	11	$985.00	$886.50	$197.00	$965.30	$930.83	2026-06-15
11646	CPT	Exc Mal Les F/e/e/n/l >4.	29	11	$1,274.00	$1,146.60	$254.80	$1,248.52	$1,203.93	2026-06-15
12036	CPT	Int Rpr S/a/t/e 20.1-30 C	29	11	$1,084.00	$975.60	$216.80	$1,062.32	$1,024.38	2026-06-15
12037	CPT	Int Rpr S/a/t/e >30 Cm	29	11	$1,213.00	$1,091.70	$242.60	$1,188.74	$1,146.29	2026-06-15
12042	CPT	Int Rpr N/h/hxtrnl 2.6-7.	29	11	$793.00	$713.70	$158.60	$777.14	$749.38	2026-06-15
12044	CPT	Int Rpr N/h/hxtrnl 7.6-12	29	11	$973.00	$875.70	$194.60	$953.54	$919.49	2026-06-15
12045	CPT	Int Rpr N/h/hxtrnl 12.6-2	29	11	$1,047.00	$942.30	$209.40	$1,026.06	$989.41	2026-06-15
12046	CPT	Int Rpr N/h/hxtrnl 20.1-3	29	11	$1,250.00	$1,125.00	$250.00	$1,225.00	$1,181.25	2026-06-15
12047	CPT	Int Rpr N/h/hxtrnl >30.0	29	11	$1,364.00	$1,227.60	$272.80	$1,336.72	$1,288.98	2026-06-15
12053	CPT	Int Repair F/e/e/n/l 5.1-	29	11	$930.00	$837.00	$186.00	$911.40	$878.85	2026-06-15
12054	CPT	Int Repair F/e/e/n/l 7.6-	29	11	$978.00	$880.20	$195.60	$958.44	$924.21	2026-06-15
12055	CPT	Int Repair F/e/e/n/l 12.6	29	11	$1,282.00	$1,153.80	$256.40	$1,256.36	$1,211.49	2026-06-15
13100	CPT	Cmplx Rpr Trunk 1.1-2.5 C	29	11	$871.00	$783.90	$174.20	$853.58	$823.10	2026-06-15
13101	CPT	Cmplx Rpr Trunk 2.6-7.5 C	29	11	$1,016.00	$914.40	$203.20	$995.68	$960.12	2026-06-15
13120	CPT	Complex Repair Arm 1.1-2.	45	11	$1,974.00	$1,776.60	$181.60	$1,934.52	$947.52	2026-06-15
13121	CPT	Complex Repair Arm 2.6-7.	45	11	$1,519.00	$1,367.10	$217.60	$1,488.62	$835.45	2026-06-15
13131	CPT	Cmplx Rpr F/c/c/m/n/ax/g/	29	11	$993.00	$893.70	$198.60	$973.14	$938.38	2026-06-15
13132	CPT	Cmplx Rpr F/c/c/m/n/ax/g/	29	11	$1,206.00	$1,085.40	$241.20	$1,181.88	$1,139.67	2026-06-15
13151	CPT	Cmplx Rpr E/e/n/l 1.1-2.5	29	11	$1,081.00	$972.90	$216.20	$1,059.38	$1,021.54	2026-06-15
13152	CPT	Cmplx Rpr E/e/n/l 2.6-7.5	29	11	$1,268.00	$1,141.20	$253.60	$1,242.64	$1,198.26	2026-06-15
23600	CPT	Clsd Tx Of Proximal Humer	28	11	$997.00	$897.30	$199.40	$977.06	$942.16	2026-06-15
24605	CPT	Tx Closed Elbow Disloc With	45	11	$1,419.00	$1,277.10	$283.80	$1,742.44	$1,049.02	2026-06-15
25505	CPT	Closed Trtmt Radial Shaft	45	11	$1,133.00	$1,019.70	$226.60	$1,867.88	$1,048.30	2026-06-15
25565	CPT	Closed Trtmt Radial/ulnar	45	11	$2,733.00	$2,459.70	$390.20	$2,678.34	$1,503.15	2026-06-15
25605	CPT	Closed Tx Of Distal Radia	29	11	$1,352.00	$1,216.80	$270.40	$1,324.96	$1,277.64	2026-06-15
27266	CPT	Closed Tx Post Hip Artho	28	11	$1,885.00	$1,696.50	$377.00	$1,847.30	$1,781.33	2026-06-15
27750	CPT	Closed Reduction Of Tibia	28	11	$1,636.00	$1,472.40	$327.20	$1,603.28	$1,546.02	2026-06-15
27810	CPT	Closed Tx Ankle Fx With Man	28	11	$2,815.00	$2,533.50	$563.00	$2,758.70	$2,660.18	2026-06-15
27818	CPT	Closed Tx Ankle With Mani	45	11	$1,259.00	$1,133.10	$251.80	$1,806.14	$1,087.37	2026-06-15
27842	CPT	Closed Treatment Of Ankle	45	11	$3,166.00	$2,849.40	$364.40	$3,102.68	$1,728.32	2026-06-15
30906	CPT	Control Nasal Hemorrhage	29	11	$952.00	$856.80	$190.40	$932.96	$899.64	2026-06-15
36430	CPT	Blood Administration	29	11	$1,038.00	$934.20	$207.60	$1,017.24	$980.91	2026-06-15
47562	CPT	Lap Chole Tech Fee	28	11	$1,232.00	$1,108.80	$246.40	$1,207.36	$1,164.24	2026-06-15
47563	CPT	Cholecystectomy With Chola	28	11	$1,342.00	$1,207.80	$268.40	$1,315.16	$1,268.19	2026-06-15
49082	CPT	Abdominal Paracentesis	28	11	$2,536.00	$2,282.40	$507.20	$2,485.28	$2,396.52	2026-06-15
49083	CPT	Abdominal Paracentesis Ul	28	11	$3,081.00	$2,772.90	$616.20	$3,019.38	$2,911.55	2026-06-15
58262	CPT	Vag Hyster Tech	46	11	$1,342.00	$1,207.80	$268.40	$1,746.36	$1,244.70	2026-06-15
59409	CPT	Vaginal Delivery Only	28	11	$1,690.00	$1,521.00	$338.00	$1,656.20	$1,597.05	2026-06-15
59425	CPT	Anteptartum Care 4-6 Visi	29	11	$1,366.00	$1,229.40	$273.20	$1,338.68	$1,290.87	2026-06-15
59426	CPT	Anteptartum Care 7+ Visit	29	11	$2,495.00	$2,245.50	$499.00	$2,445.10	$2,357.78	2026-06-15
70336	CPT	Magnetic Image Jaw Joint	28	11	$2,726.00	$2,453.40	$545.20	$2,671.48	$2,576.07	2026-06-15
70450	CPT	CT Head/brain Without Contrast	29	11	$2,415.00	$2,173.50	$483.00	$2,366.70	$2,282.18	2026-06-15
70460	CPT	CT Head/brain With Contrast	28	11	$2,428.00	$2,185.20	$485.60	$2,379.44	$2,294.46	2026-06-15
70470	CPT	CT Head/brain Without & With Contrast	29	11	$2,890.00	$2,601.00	$578.00	$2,832.20	$2,731.05	2026-06-15
70480	CPT	CT Orbit/ear/fossa Without Contrast	28	11	$2,364.00	$2,127.60	$472.80	$2,316.72	$2,233.98	2026-06-15
70481	CPT	CT Orbit/ear/fossa With Contrast	28	11	$2,853.00	$2,567.70	$570.60	$2,795.94	$2,696.09	2026-06-15
70482	CPT	CT Orbit/ear/fossa W/O&with Contrast	28	11	$2,856.00	$2,570.40	$571.20	$2,798.88	$2,698.92	2026-06-15
70486	CPT	CT Maxillofacial Without Contrast	29	11	$2,142.00	$1,927.80	$428.40	$2,099.16	$2,024.19	2026-06-15
70487	CPT	CT Maxillofacial With Contrast	29	11	$2,690.00	$2,421.00	$538.00	$2,636.20	$2,542.05	2026-06-15
70488	CPT	CT Maxillofacial Without & With Contrast	28	11	$2,985.00	$2,686.50	$597.00	$2,925.30	$2,820.82	2026-06-15
70490	CPT	CT Soft Tissue Neck Without Contrast	29	11	$2,428.00	$2,185.20	$485.60	$2,379.44	$2,294.46	2026-06-15
70491	CPT	CT Soft Tissue Neck With Contrast	29	11	$2,701.00	$2,430.90	$540.20	$2,646.98	$2,552.45	2026-06-15
70492	CPT	CT Sft Tsue Nck Without & With Contrast	28	11	$2,856.00	$2,570.40	$571.20	$2,798.88	$2,698.92	2026-06-15
70496	CPT	CT Angiography Head	29	11	$3,518.00	$3,166.20	$703.60	$3,447.64	$3,324.51	2026-06-15
70498	CPT	CT Angiography Neck	29	11	$3,768.00	$3,391.20	$753.60	$3,692.64	$3,560.76	2026-06-15
70540	CPT	MRI Orbit/face/neck Without Contrast	29	11	$3,747.00	$3,372.30	$749.40	$3,672.06	$3,540.91	2026-06-15
70543	CPT	MRI Orbt/fac/nck Without &with Contrast	29	11	$4,647.00	$4,182.30	$929.40	$4,554.06	$4,391.41	2026-06-15
70544	CPT	Mr Angiography Head Without Contrast	28	11	$4,198.00	$3,778.20	$839.60	$4,114.04	$3,967.11	2026-06-15
70547	CPT	Mr Angiography Neck Without Contrast	28	11	$3,437.00	$3,093.30	$687.40	$3,368.26	$3,247.97	2026-06-15
70549	CPT	Mr Angiograph Neck W/O&with Contrast	28	11	$4,423.00	$3,980.70	$884.60	$4,334.54	$4,179.73	2026-06-15
70551	CPT	MRI Brain Stem Without Contrast	29	11	$4,198.00	$3,778.20	$839.60	$4,114.04	$3,967.11	2026-06-15
70552	CPT	MRI Brain Stem With Contrast	28	11	$4,255.00	$3,829.50	$851.00	$4,169.90	$4,020.97	2026-06-15
70553	CPT	MRI Brain Stem Without & With Contrast	29	11	$4,647.00	$4,182.30	$929.40	$4,554.06	$4,391.41	2026-06-15
71250	CPT	CT Thorax Dx C-	29	11	$2,890.00	$2,601.00	$578.00	$2,832.20	$2,731.05	2026-06-15
71260	CPT	CT Thorax Dx C+	29	11	$3,075.00	$2,767.50	$615.00	$3,013.50	$2,905.88	2026-06-15
71270	CPT	CT Thorax Dx C-/c+	28	11	$3,263.00	$2,936.70	$652.60	$3,197.74	$3,083.53	2026-06-15
71275	CPT	CT Angiography Chest	29	11	$3,835.00	$3,451.50	$767.00	$3,758.30	$3,624.07	2026-06-15
71550	CPT	MRI Chest Without Contrast	28	11	$4,002.00	$3,601.80	$800.40	$3,921.96	$3,781.89	2026-06-15
71551	CPT	MRI Chest With Contrast	28	11	$4,255.00	$3,829.50	$851.00	$4,169.90	$4,020.97	2026-06-15
71552	CPT	MRI Chest Without & With Contrast	28	11	$4,512.00	$4,060.80	$902.40	$4,421.76	$4,263.84	2026-06-15
72125	CPT	CT Neck Spine Without Contrast	29	11	$2,890.00	$2,601.00	$578.00	$2,832.20	$2,731.05	2026-06-15
72126	CPT	CT Neck Spine With Contrast	28	11	$2,833.00	$2,549.70	$566.60	$2,776.34	$2,677.18	2026-06-15
72128	CPT	CT Chest Spine Without Contrast	29	11	$2,890.00	$2,601.00	$578.00	$2,832.20	$2,731.05	2026-06-15
72129	CPT	CT Chest Spine With Contrast	28	11	$2,705.00	$2,434.50	$541.00	$2,650.90	$2,556.22	2026-06-15
72130	CPT	CT Chest Spine Without & With Contrast	28	11	$3,419.00	$3,077.10	$683.80	$3,350.62	$3,230.95	2026-06-15
72131	CPT	CT Lumbar Spine Without Contrast	29	11	$2,890.00	$2,601.00	$578.00	$2,832.20	$2,731.05	2026-06-15
72132	CPT	CT Lumbar Spine With Contrast	28	11	$3,158.00	$2,842.20	$631.60	$3,094.84	$2,984.31	2026-06-15
72133	CPT	CT Lumbar Spine Without & With Contrast	28	11	$3,250.00	$2,925.00	$650.00	$3,185.00	$3,071.25	2026-06-15
72141	CPT	MRI Neck Spine Without Contrast	29	11	$3,971.00	$3,573.90	$794.20	$3,891.58	$3,752.59	2026-06-15
72142	CPT	MRI Neck Spine With Contrast	28	11	$4,002.00	$3,601.80	$800.40	$3,921.96	$3,781.89	2026-06-15
72146	CPT	MRI Chest Spine Without Contrast	28	11	$3,971.00	$3,573.90	$794.20	$3,891.58	$3,752.59	2026-06-15
72147	CPT	MRI Chest Spine With Contrast	28	11	$4,002.00	$3,601.80	$800.40	$3,921.96	$3,781.89	2026-06-15
72148	CPT	MRI Lumbar Spine Without Contrast	29	11	$3,971.00	$3,573.90	$794.20	$3,891.58	$3,752.59	2026-06-15
72149	CPT	MRI Lumbar Spine With Contrast	28	11	$4,002.00	$3,601.80	$800.40	$3,921.96	$3,781.89	2026-06-15
72156	CPT	MRI Neck Spine Without & With Contrast	29	11	$4,423.00	$3,980.70	$884.60	$4,334.54	$4,179.73	2026-06-15
72157	CPT	MRI Chest Spine Without & With Contrast	28	11	$4,423.00	$3,980.70	$884.60	$4,334.54	$4,179.73	2026-06-15
72158	CPT	MRI Lumbar Spine Without & With Contrast	29	11	$4,423.00	$3,980.70	$884.60	$4,334.54	$4,179.73	2026-06-15
72192	CPT	CT Pelvis Without Contrast	28	11	$2,589.00	$2,330.10	$517.80	$2,537.22	$2,446.61	2026-06-15
72193	CPT	CT Pelvis With Contrast	28	11	$3,038.00	$2,734.20	$607.60	$2,977.24	$2,870.91	2026-06-15
72194	CPT	CT Pelvis Without & With Contrast	28	11	$3,225.00	$2,902.50	$645.00	$3,160.50	$3,047.62	2026-06-15
72195	CPT	MRI Pelvis Without Contrast	28	11	$3,747.00	$3,372.30	$749.40	$3,672.06	$3,540.91	2026-06-15
72196	CPT	MRI Pelvis With Contrast	28	11	$4,002.00	$3,601.80	$800.40	$3,921.96	$3,781.89	2026-06-15
72197	CPT	MRI Pelvis Without & With Contrast	28	11	$4,255.00	$3,829.50	$851.00	$4,169.90	$4,020.97	2026-06-15
73200	CPT	CT Upper Extremity Without Contrast	29	11	$2,518.00	$2,266.20	$503.60	$2,467.64	$2,379.51	2026-06-15
73201	CPT	CT Upper Extremity With Contrast	28	11	$2,428.00	$2,185.20	$485.60	$2,379.44	$2,294.46	2026-06-15
73206	CPT	CT Angio Upr Extrm W/O&with Contrast	28	11	$3,614.00	$3,252.60	$722.80	$3,541.72	$3,415.23	2026-06-15
73218	CPT	MRI Upper Extremity Without Contrast	28	11	$3,300.00	$2,970.00	$660.00	$3,234.00	$3,118.50	2026-06-15
73220	CPT	MRI Uppr Extremity W/O&with Contrast	28	11	$3,749.00	$3,374.10	$749.80	$3,674.02	$3,542.80	2026-06-15
73221	CPT	MRI Joint Upr Extrem Without Contrast	29	11	$3,300.00	$2,970.00	$660.00	$3,234.00	$3,118.50	2026-06-15
73223	CPT	MRI Joint Upr Extr W/O&with Contrast	29	11	$3,749.00	$3,374.10	$749.80	$3,674.02	$3,542.80	2026-06-15
73700	CPT	CT Lower Extremity Without Contrast	29	11	$2,518.00	$2,266.20	$503.60	$2,467.64	$2,379.51	2026-06-15
73701	CPT	CT Lower Extremity With Contrast	28	11	$2,428.00	$2,185.20	$485.60	$2,379.44	$2,294.46	2026-06-15
73702	CPT	CT Lwr Extremity W/O&with Contrast	28	11	$2,969.00	$2,672.10	$593.80	$2,909.62	$2,805.70	2026-06-15
73706	CPT	CT Angio Lwr Extr W/O&with Contrast	28	11	$2,875.00	$2,587.50	$575.00	$2,817.50	$2,716.88	2026-06-15
73718	CPT	MRI Lower Extremity Without Contrast	28	11	$3,300.00	$2,970.00	$660.00	$3,234.00	$3,118.50	2026-06-15
73720	CPT	MRI Lwr Extremity W/O&with Contrast	29	11	$3,238.00	$2,914.20	$647.60	$3,173.24	$3,059.91	2026-06-15
73721	CPT	MRI Jnt Of Lwr Extre Without Contrast	29	11	$3,300.00	$2,970.00	$660.00	$3,234.00	$3,118.50	2026-06-15
73722	CPT	MRI Joint Of Lwr Extr With Contrast	28	11	$4,072.00	$3,664.80	$814.40	$3,990.56	$3,848.04	2026-06-15
73723	CPT	MRI Joint Lwr Extr W/O&with Contrast	28	11	$3,749.00	$3,374.10	$749.80	$3,674.02	$3,542.80	2026-06-15
74150	CPT	CT Abdomen Without Contrast	28	11	$2,707.00	$2,436.30	$541.40	$2,652.86	$2,558.11	2026-06-15
74160	CPT	CT Abdomen W/contrast	29	11	$3,189.00	$2,870.10	$637.80	$3,125.22	$3,013.61	2026-06-15
74170	CPT	CT Abd Wo Cntrst Flwd Cntrst	29	11	$3,408.00	$3,067.20	$681.60	$3,339.84	$3,220.56	2026-06-15
74174	CPT	CTA Abd&plvs W/contrast	28	11	$4,198.00	$3,778.20	$839.60	$4,114.04	$3,967.11	2026-06-15
74175	CPT	CTA Abdomen W/contrast	28	11	$3,819.00	$3,437.10	$763.80	$3,742.62	$3,608.95	2026-06-15
74176	CPT	CT Abd & Pelvis Without Contrast	29	11	$5,024.00	$4,521.60	$1,004.80	$4,923.52	$4,747.68	2026-06-15
74177	CPT	CT Abd & Pelvis W/contrast	29	11	$5,448.00	$4,903.20	$1,089.60	$5,339.04	$5,148.36	2026-06-15
74178	CPT	CT Abd&plv Wo Cntr Flwd Cntr	29	11	$5,791.00	$5,211.90	$1,158.20	$5,675.18	$5,472.49	2026-06-15
74181	CPT	MRI Abdomen Without Contrast	28	11	$4,423.00	$3,980.70	$884.60	$4,334.54	$4,179.73	2026-06-15
74182	CPT	MRI Abdomen W/contrast	28	11	$4,088.00	$3,679.20	$817.60	$4,006.24	$3,863.16	2026-06-15
74183	CPT	MRI Abd Without Cntr Flwd Cntr	29	11	$4,870.00	$4,383.00	$974.00	$4,772.60	$4,602.15	2026-06-15
74185	CPT	MRA Abd W Or Without Cntrst	28	11	$4,255.00	$3,829.50	$851.00	$4,169.90	$4,020.97	2026-06-15
74270	CPT	X-ray Xm Colon 1cntrst Std	28	11	$774.00	$696.60	$154.80	$758.52	$731.43	2026-06-15
74280	CPT	X-ray Xm Colon 2cntrst Std	28	11	$1,088.00	$979.20	$217.60	$1,066.24	$1,028.16	2026-06-15
74400	CPT	Urography IV +-kub Tomog	28	11	$944.00	$849.60	$188.80	$925.12	$892.08	2026-06-15
74415	CPT	Urography Nfs Drip&/bls W/nf	28	11	$1,388.00	$1,249.20	$277.60	$1,360.24	$1,311.66	2026-06-15
75635	CPT	CT Angio Abdominal Arteries	28	11	$3,749.00	$3,374.10	$749.80	$3,674.02	$3,542.80	2026-06-15
75809	CPT	Nonvascular Shunt X-ray	28	11	$795.00	$715.50	$159.00	$779.10	$751.27	2026-06-15
76380	CPT	Cat Scan Follow-up Study	28	11	$1,286.00	$1,157.40	$257.20	$1,260.28	$1,215.27	2026-06-15
76700	CPT	US Exam Abdom Complete	29	11	$952.00	$856.80	$190.40	$932.96	$899.64	2026-06-15
76770	CPT	US Exam Abdo Back Wall Comp	29	11	$904.00	$813.60	$180.80	$885.92	$854.28	2026-06-15
76776	CPT	US Exam K Transpl W/doppler	28	11	$954.00	$858.60	$190.80	$934.92	$901.53	2026-06-15
76801	CPT	Uls Preg Uterus <14wks Si	29	11	$808.00	$727.20	$161.60	$791.84	$763.56	2026-06-15
76805	CPT	Uls Preg Uterus >or=14wks	29	11	$1,040.00	$936.00	$208.00	$1,019.20	$982.80	2026-06-15
76856	CPT	US Exam Pelvic Complete	29	11	$910.00	$819.00	$182.00	$891.80	$859.95	2026-06-15
76870	CPT	US Exam Scrotum	29	11	$858.00	$772.20	$171.60	$840.84	$810.81	2026-06-15
76872	CPT	US Transrectal	28	11	$819.00	$737.10	$163.80	$802.62	$773.96	2026-06-15
76937	CPT	US Guide Vascular Access	28	11	$792.00	$712.80	$158.40	$776.16	$748.44	2026-06-15
76942	CPT	Echo Guide For Biopsy	28	11	$915.00	$823.50	$183.00	$896.70	$864.67	2026-06-15
76998	CPT	US Guide Intraop	28	11	$860.00	$774.00	$172.00	$842.80	$812.70	2026-06-15
77001	CPT	Fluoroguide For Vein Device	28	11	$1,050.00	$945.00	$210.00	$1,029.00	$992.25	2026-06-15
77002	CPT	Needle Localization By Xray	28	11	$1,187.00	$1,068.30	$237.40	$1,163.26	$1,121.71	2026-06-15
77047	CPT	MRI Breast C- Bilateral	28	11	$2,472.00	$2,224.80	$494.40	$2,422.56	$2,336.04	2026-06-15
77075	CPT	Radex Osseous Survey Compl	28	11	$1,032.00	$928.80	$206.40	$1,011.36	$975.24	2026-06-15
78014	CPT	Thyroid Imaging W/blood Flow	28	11	$1,545.00	$1,390.50	$309.00	$1,514.10	$1,460.03	2026-06-15
78070	CPT	Parathyroid Planar Imaging	28	11	$1,506.00	$1,355.40	$301.20	$1,475.88	$1,423.17	2026-06-15
78071	CPT	Parathyrd Planar W/wo Subtrj	28	11	$1,737.00	$1,563.30	$347.40	$1,702.26	$1,641.46	2026-06-15
78215	CPT	Lvr&spleen Img Static Only	28	11	$1,869.00	$1,682.10	$373.80	$1,831.62	$1,766.20	2026-06-15
78226	CPT	Hepatobiliary System Imaging	28	11	$2,102.00	$1,891.80	$420.40	$2,059.96	$1,986.39	2026-06-15
78227	CPT	Hepatobil Syst Image W/drug	29	11	$2,220.00	$1,998.00	$444.00	$2,175.60	$2,097.90	2026-06-15
78264	CPT	Gastric Emptying Img Study	28	11	$1,893.00	$1,703.70	$378.60	$1,855.14	$1,788.88	2026-06-15
78278	CPT	Acute Gi Blood Loss Imaging	28	11	$1,906.00	$1,715.40	$381.20	$1,867.88	$1,801.17	2026-06-15
78290	CPT	Intestine Imaging	28	11	$1,488.00	$1,339.20	$297.60	$1,458.24	$1,406.16	2026-06-15
78300	CPT	Bone Imaging Limited Area	28	11	$989.00	$890.10	$197.80	$969.22	$934.61	2026-06-15
78305	CPT	Bone Imaging Multiple Areas	28	11	$1,455.00	$1,309.50	$291.00	$1,425.90	$1,374.97	2026-06-15
78306	CPT	Bone Imaging Whole Body	28	11	$2,179.00	$1,961.10	$435.80	$2,135.42	$2,059.16	2026-06-15
78315	CPT	Bone Imaging 3 Phase	28	11	$2,260.00	$2,034.00	$452.00	$2,214.80	$2,135.70	2026-06-15
78451	CPT	Ht Muscle Image Spect Sing	28	11	$3,599.00	$3,239.10	$719.80	$3,527.02	$3,401.05	2026-06-15
78452	CPT	Ht Muscle Image Spect Mult	29	11	$5,096.00	$4,586.40	$1,019.20	$4,994.08	$4,815.72	2026-06-15
78472	CPT	Gated Heart Planar Single	28	11	$2,102.00	$1,891.80	$420.40	$2,059.96	$1,986.39	2026-06-15
78580	CPT	Lung Perfusion Imaging	28	11	$1,353.00	$1,217.70	$270.60	$1,325.94	$1,278.59	2026-06-15
78582	CPT	Lung Ventilat&perfus Imaging	28	11	$1,847.00	$1,662.30	$369.40	$1,810.06	$1,745.41	2026-06-15
78707	CPT	K Flow/funct Image Without Drug	28	11	$1,523.00	$1,370.70	$304.60	$1,492.54	$1,439.23	2026-06-15
78709	CPT	K Flow/funct Image Multiple	28	11	$1,743.00	$1,568.70	$348.60	$1,708.14	$1,647.13	2026-06-15
78761	CPT	Testicular Imaging W/flow	28	11	$1,796.00	$1,616.40	$359.20	$1,760.08	$1,697.22	2026-06-15
78803	CPT	Rp Loclzj Tum Spect 1 Area	28	11	$2,280.00	$2,052.00	$456.00	$2,234.40	$2,154.60	2026-06-15
78815	CPT	PET Image W/ct Skull-thigh	28	11	$7,266.00	$6,539.40	$1,453.20	$7,120.68	$6,866.37	2026-06-15
78816	CPT	PET Image W/ct Full Body	28	11	$9,476.00	$8,528.40	$1,895.20	$9,286.48	$8,954.82	2026-06-15
81206	CPT	Bcr/abli Major Breakpoin	28	11	$942.00	$847.80	$188.40	$923.16	$890.19	2026-06-15
81207	CPT	Bcr/abli Minor Breakpoin	28	11	$942.00	$847.80	$188.40	$923.16	$890.19	2026-06-15
81219	CPT	Calr Gene Com Variants	28	11	$787.00	$708.30	$157.40	$771.26	$743.72	2026-06-15
81382	CPT	Hla Class Ii Typing	28	11	$933.00	$839.70	$186.60	$914.34	$881.68	2026-06-15
81401	CPT	Apolipoprotein E(apoe) Mu	28	11	$886.00	$797.40	$177.20	$868.28	$837.27	2026-06-15
81403	CPT	Molecular Path Proc Leve	28	11	$840.00	$756.00	$168.00	$823.20	$793.80	2026-06-15
81443	CPT	Severe Congenital & Cycli	28	11	$2,500.00	$2,250.00	$500.00	$2,450.00	$2,362.50	2026-06-15
86711	CPT	Antibody Jc(john Cunningh	28	11	$2,890.00	$2,601.00	$578.00	$2,832.20	$2,731.05	2026-06-15
86978	CPT	Ptx Of Rbc By Using Rbc	28	11	$884.00	$795.60	$176.80	$866.32	$835.38	2026-06-15
88237	CPT	Tissue Culture Neoplastic	28	11	$1,017.00	$915.30	$203.40	$996.66	$961.07	2026-06-15
88261	CPT	Chromosome Analysis Count	28	11	$936.00	$842.40	$187.20	$917.28	$884.52	2026-06-15
88360	CPT	Tumor Immunohistochem/manual	28	11	$888.00	$799.20	$177.60	$870.24	$839.16	2026-06-15
90375	CPT	Hyperrab 1,500 Unit / 5 Ml	60	11	$3,749.00	$3,374.10	$291.60	$6,002.50	$2,007.40	2026-06-15
92950	CPT	Cardiopulmonary Resucitat	28	11	$1,085.00	$976.50	$217.00	$1,063.30	$1,025.33	2026-06-15
92960	CPT	Cardioversion	46	11	$2,092.00	$1,882.80	$395.00	$2,050.16	$1,846.62	2026-06-15
92977	CPT	Thrombolytic Infusion	28	11	$1,306.00	$1,175.40	$261.20	$1,279.88	$1,234.17	2026-06-15
93017	CPT	Cardiovascular Stress Tes	29	11	$1,365.00	$1,228.50	$273.00	$1,337.70	$1,289.92	2026-06-15
93243	CPT	Zio ECG > 48 Hr Upto 7 Da	29	11	$1,147.00	$1,032.30	$229.40	$1,124.06	$1,083.91	2026-06-15
93246	CPT	Zio ECG > 7days Up To 15	29	11	$1,063.00	$956.70	$212.60	$1,041.74	$1,004.53	2026-06-15
93247	CPT	Zio ECG > 7days Up To 15	29	11	$1,719.00	$1,547.10	$343.80	$1,684.62	$1,624.45	2026-06-15
93306	CPT	Tte W/doppler Complete	29	11	$2,345.00	$2,110.50	$469.00	$2,298.10	$2,216.03	2026-06-15
93308	CPT	Tte F-up Or Lmtd	28	11	$932.00	$838.80	$186.40	$913.36	$880.74	2026-06-15
93660	CPT	Tilt Table Evaluation	28	11	$2,071.00	$1,863.90	$414.20	$2,029.58	$1,957.10	2026-06-15
93880	CPT	Extracranial Bilat Study	28	11	$1,637.00	$1,473.30	$327.40	$1,604.26	$1,546.96	2026-06-15
93882	CPT	Extracranial Uni/ltd Study	28	11	$1,200.00	$1,080.00	$240.00	$1,176.00	$1,134.00	2026-06-15
93923	CPT	Upr/lxtr Art Stdy 3+ Lvls	28	11	$958.00	$862.20	$191.60	$938.84	$905.31	2026-06-15
93924	CPT	Lwr Xtr Vasc Stdy Bilat	28	11	$1,061.00	$954.90	$212.20	$1,039.78	$1,002.64	2026-06-15
93925	CPT	Lower Extremity Study	28	11	$1,322.00	$1,189.80	$264.40	$1,295.56	$1,249.29	2026-06-15
93926	CPT	Lower Extremity Study	28	11	$1,010.00	$909.00	$202.00	$989.80	$954.45	2026-06-15
93930	CPT	Upper Extremity Study	28	11	$1,335.00	$1,201.50	$267.00	$1,308.30	$1,261.58	2026-06-15
93931	CPT	Upper Extremity Study	28	11	$990.00	$891.00	$198.00	$970.20	$935.55	2026-06-15
93970	CPT	Extremity Study	29	11	$1,509.00	$1,358.10	$301.80	$1,478.82	$1,426.01	2026-06-15
93971	CPT	Extremity Study	31	11	$1,129.00	$1,016.10	$225.80	$1,106.42	$1,066.90	2026-06-15
93975	CPT	Vascular Study	28	11	$1,181.00	$1,062.90	$236.20	$1,157.38	$1,116.05	2026-06-15
93978	CPT	Vascular Study	28	11	$1,183.00	$1,064.70	$236.60	$1,159.34	$1,117.93	2026-06-15
93979	CPT	Vascular Study	28	11	$869.00	$782.10	$173.80	$851.62	$821.21	2026-06-15
94002	CPT	Ventilation Assisted Mgmt	28	11	$1,037.00	$933.30	$207.40	$1,016.26	$979.97	2026-06-15
94070	CPT	Evaluation Of Wheezing	28	11	$1,082.00	$973.80	$216.40	$1,060.36	$1,022.49	2026-06-15
94660	CPT	Cpap Initial	28	11	$951.00	$855.90	$190.20	$931.98	$898.70	2026-06-15
95805	CPT	Multiple Sleep Latency Test	28	11	$2,595.00	$2,335.50	$519.00	$2,543.10	$2,452.28	2026-06-15
95810	CPT	Polysom 6/> Yrs 4/> Param	28	11	$4,290.00	$3,861.00	$858.00	$4,204.20	$4,054.05	2026-06-15
95811	CPT	Polysom 6/>yrs Cpap 4/> Parm	28	11	$4,931.00	$4,437.90	$986.20	$4,832.38	$4,659.80	2026-06-15
95816	CPT	EEG Awake And Drowsy	28	11	$877.00	$789.30	$175.40	$859.46	$828.76	2026-06-15
95819	CPT	EEG Awake And Asleep	28	11	$941.00	$846.90	$188.20	$922.18	$889.25	2026-06-15
97607	CPT	Wound Vac Prevena Disposa	28	11	$1,138.00	$1,024.20	$227.60	$1,115.24	$1,075.41	2026-06-15
99291	CPT	Critical Care ER 30-74 Mi	47	11	$2,110.00	$1,899.00	$141.00	$2,067.80	$1,012.80	2026-06-15
A4649	HCPCS	Derma Close	28	11	$1,801.00	$1,620.90	$360.20	$1,764.98	$1,701.94	2026-06-15
A9552	HCPCS	Fdg/f-19 Up To 45mci	28	11	$1,142.00	$1,027.80	$228.40	$1,119.16	$1,079.19	2026-06-15
C1755	HCPCS	Ascenda Intrathecal 8780	28	11	$2,159.00	$1,943.10	$431.80	$2,115.82	$2,040.26	2026-06-15
C1762	HCPCS	Podiatry Nerve Protector	124	11	$3,794.00	$3,414.60	$32.40	$7,816.48	$1,835.04	2026-06-15
C1763	HCPCS	Matriderm Acellular Derma	28	11	$6,350.00	$5,715.00	$1,270.00	$6,223.00	$6,000.75	2026-06-15
C1767	HCPCS	Interstim-neurostimulator	28	11	$19,245.00	$17,320.50	$3,849.00	$18,860.10	$18,186.53	2026-06-15
C1772	HCPCS	Pump Implant Medtronic 86	28	11	$18,443.00	$16,598.70	$3,688.60	$18,074.14	$17,428.63	2026-06-15
C1776	HCPCS	Tibia Insert	108	11	$6,641.00	$5,976.90	$508.40	$73,725.40	$4,243.98	2026-06-15
C1783	HCPCS	Vantage Istent Msc0957	28	11	$5,399.00	$4,859.10	$1,079.80	$5,291.02	$5,102.06	2026-06-15
C1787	HCPCS	Interstim-patient Program	44	11	$2,892.00	$2,602.80	$578.40	$3,026.24	$2,165.06	2026-06-15
C1788	HCPCS	Port 8fr Powerport Implan	28	11	$1,197.00	$1,077.30	$239.40	$1,173.06	$1,131.16	2026-06-15
C1820	HCPCS	Wavewriter Alpha Prime Ki	44	11	$54,466.00	$49,019.40	$9,753.00	$53,376.68	$37,166.22	2026-06-15
C1897	HCPCS	Coveredge 32 Surgical Lea	28	11	$16,232.00	$14,608.80	$3,246.40	$15,907.36	$15,339.24	2026-06-15
C8957	HCPCS	Synchromed Ii Intrathecal	28	11	$1,042.00	$937.80	$208.40	$1,021.16	$984.69	2026-06-15
C9088	HCPCS	Bupivacaine-meloxicam 400-12 Mg / 14 Ml	28	11	$781.00	$702.90	$156.20	$765.38	$738.04	2026-06-15
G0390	HCPCS	Trauma Team Activation (f	28	11	$2,900.00	$2,610.00	$580.00	$2,842.00	$2,740.50	2026-06-15
J0248	HCPCS	Remdesivir 100 Mg Vial	28	11	$1,367.00	$1,230.30	$273.40	$1,339.66	$1,291.82	2026-06-15
J0491	HCPCS	Saphnelo 300 Mg / 2 Ml Sdv	28	11	$9,941.00	$8,946.90	$1,988.20	$9,742.18	$9,394.25	2026-06-15
J0517	HCPCS	Benralizumab 30 Mg Subq Inj Pfs	28	11	$10,841.00	$9,756.90	$2,168.20	$10,624.18	$10,244.75	2026-06-15
J0666	HCPCS	Bupivicaine Liposome Pf 266 Mg / 20 Ml	28	11	$880.00	$792.00	$176.00	$862.40	$831.60	2026-06-15
J0840	HCPCS	Crotalidae Polyval Immune Fab Inj	28	11	$5,757.00	$5,181.30	$1,151.40	$5,641.86	$5,440.36	2026-06-15
J0875	HCPCS	Dalvance 500 Mg Vial	28	11	$3,203.00	$2,882.70	$640.60	$3,138.94	$3,026.84	2026-06-15
J0881	HCPCS	Darbepoetin Alfa 200 Mcg / 0.4 Ml	28	11	$2,787.00	$2,508.30	$557.40	$2,731.26	$2,633.72	2026-06-15
J0897	HCPCS	Prolia 60 Mg / 1 Ml Syringe	44	11	$3,376.00	$3,038.40	$675.20	$6,268.08	$3,190.32	2026-06-15
J1096	HCPCS	Dextenza 0.4 Mg Ophthalmic Insert	28	11	$11,520.00	$10,368.00	$2,304.00	$11,289.60	$10,886.40	2026-06-15
J1306	HCPCS	Leqvio 284 Mg / 1.5 Ml Subq Syrg	28	11	$6,458.00	$5,812.20	$1,291.60	$6,328.84	$6,102.81	2026-06-15
J1439	HCPCS	Injectafer 750 Mg / 15 Ml Sdv	28	11	$2,900.00	$2,610.00	$580.00	$2,842.00	$2,740.50	2026-06-15
J1449	HCPCS	Rolvedon 13.2 Mg Subq Syrg	28	11	$8,100.00	$7,290.00	$1,620.00	$7,938.00	$7,654.50	2026-06-15
J1459	HCPCS	Privigen 10% 10 Gm / 100 Ml Sdv	44	11	$3,558.00	$3,202.20	$711.60	$3,577.00	$2,622.64	2026-06-15
J1568	HCPCS	Octagam 20 Gm / 200 Ml Vial	28	11	$6,993.00	$6,293.70	$1,398.60	$6,853.14	$6,608.39	2026-06-15
J1602	HCPCS	Simponi Aria 50 Mg / 4 Ml Sdv	28	11	$3,599.00	$3,239.10	$719.80	$3,527.02	$3,401.05	2026-06-15
J2357	HCPCS	Omalizumab 150 Mg / Ml Syringe	28	11	$2,651.00	$2,385.90	$530.20	$2,597.98	$2,505.20	2026-06-15
J2426	HCPCS	Invega Sustenna 78 Mg IM Syrg	28	11	$2,193.00	$1,973.70	$438.60	$2,149.14	$2,072.39	2026-06-15
J2506	HCPCS	Neulasta Onpro 6 Mg Kit	28	11	$8,058.00	$7,252.20	$1,611.60	$7,896.84	$7,614.81	2026-06-15
J2760	HCPCS	Phentolamine 5 Mg Vial	28	11	$882.00	$793.80	$176.40	$864.36	$833.49	2026-06-15
J2997	HCPCS	Alteplase (stroke) 100 Mg Inj Vial	44	11	$15,841.00	$14,256.90	$77.80	$15,524.18	$7,603.68	2026-06-15
J3101	HCPCS	Tenecteplase 50 Mg Inj	28	11	$14,936.00	$13,442.40	$2,987.20	$14,637.28	$14,114.52	2026-06-15
J3111	HCPCS	Romosozumab-aqqg 210mg Dose 2 Syr	28	11	$4,733.00	$4,259.70	$946.60	$4,638.34	$4,472.69	2026-06-15
J3315	HCPCS	Triptorelin Pamoate 11.25 Mg Inj Vial	44	11	$5,181.00	$4,662.90	$1,036.20	$10,154.76	$4,896.05	2026-06-15
J3357	HCPCS	Ustekinumab 45mg/0.5ml Subq	28	11	$19,805.00	$17,824.50	$3,961.00	$19,408.90	$18,715.72	2026-06-15
J3380	HCPCS	Vedolizumab 300 Mg / 20 Ml Sdv (entyvio)	28	11	$18,210.00	$16,389.00	$3,642.00	$17,845.80	$17,208.45	2026-06-15
J7168	HCPCS	Hum Prothrombin Cplx 400-620 U (kcentra	28	11	$2,986.00	$2,687.40	$597.20	$2,926.28	$2,821.77	2026-06-15
J7296	HCPCS	Levonorgestrel Implant 19.2 Mg (kyleena)	28	11	$3,644.00	$3,279.60	$728.80	$3,571.12	$3,443.58	2026-06-15
J7300	HCPCS	Paragard IUD Copper	28	11	$3,560.00	$3,204.00	$712.00	$3,488.80	$3,364.20	2026-06-15
J7307	HCPCS	Amb Nexplanon	44	11	$2,493.00	$2,243.70	$498.60	$3,600.52	$2,144.66	2026-06-15
J7325	HCPCS	Synvisc-one 48 Mg / 6 Ml Syr	28	11	$2,466.00	$2,219.40	$493.20	$2,416.68	$2,330.37	2026-06-15
J7326	HCPCS	Hyaluronate Sod. X-linked 30 Mg Inj	28	11	$2,070.00	$1,863.00	$414.00	$2,028.60	$1,956.15	2026-06-15
J7327	HCPCS	Hyaluronate Sod 88mg/4ml Syr Monovisc	28	11	$2,700.00	$2,430.00	$540.00	$2,646.00	$2,551.50	2026-06-15
J7328	HCPCS	Gelsyn-3 Intraartic Syringe	28	11	$815.00	$733.50	$163.00	$798.70	$770.17	2026-06-15
J9217	HCPCS	Leuprolide 22.5 Mg (3 Mo) Depot Syr Kit	28	11	$12,170.00	$10,953.00	$2,434.00	$11,926.60	$11,500.65	2026-06-15
L0456	HCPCS	Back Brace	44	11	$1,174.00	$1,056.60	$234.80	$1,336.72	$909.27	2026-06-15
L0457	HCPCS	Tlso Aspen Horizon 456 Ba	28	11	$778.00	$700.20	$155.60	$762.44	$735.21	2026-06-15
L0464	HCPCS	Tlso Aspen Vista 464 Back	28	11	$897.00	$807.30	$179.40	$879.06	$847.66	2026-06-15
L1831	HCPCS	Leg Training Brace Adult	28	11	$3,541.00	$3,186.90	$708.20	$3,470.18	$3,346.24	2026-06-15
L1843	HCPCS	Unloader One X Right Medi	28	11	$958.00	$862.20	$191.60	$938.84	$905.31	2026-06-15
L3671	HCPCS	So-custom-inc Fit/adj	28	11	$925.00	$832.50	$185.00	$906.50	$874.12	2026-06-15
L3765	HCPCS	Ewhfo Rigid Without Joints Cf	28	11	$2,276.00	$2,048.40	$455.20	$2,230.48	$2,150.82	2026-06-15
P9035	HCPCS	Platelets Pheresis Leukoc	28	11	$1,289.00	$1,160.10	$257.80	$1,263.22	$1,218.11	2026-06-15
P9037	HCPCS	Plt [heresis Leuko Reduce	28	11	$1,490.00	$1,341.00	$298.00	$1,460.20	$1,408.05	2026-06-15
P9053	HCPCS	Plt Pheresis Leuko Reduce	28	11	$1,175.00	$1,057.50	$235.00	$1,151.50	$1,110.38	2026-06-15
Q0138	HCPCS	Feraheme 510 Mg / 17 Ml Sdv Inj	28	11	$2,149.00	$1,934.10	$429.80	$2,106.02	$2,030.81	2026-06-15
Q4159	HCPCS	Affinity Amniotic Membran	28	11	$4,132.00	$3,718.80	$826.40	$4,049.36	$3,904.74	2026-06-15
Q4177	HCPCS	Floweramnioflo Per .1cc	28	11	$4,176.00	$3,758.40	$835.20	$4,092.48	$3,946.32	2026-06-15
Q4282	HCPCS	Cygnus Dual Amniotic Allo	28	11	$878.00	$790.20	$175.60	$860.44	$829.71	2026-06-15
Q5103	HCPCS	Infliximab-dyyb 100 Mg Sdv (inflectra)	29	11	$1,704.00	$1,533.60	$340.80	$1,669.92	$1,610.28	2026-06-15
Q5106	HCPCS	Retacrit 40,000 U / 1 Ml Sdv	28	11	$950.00	$855.00	$190.00	$931.00	$897.75	2026-06-15
Q5108	HCPCS	Pegfilgrastim-jmdb 6 Mg Inj	28	11	$3,758.00	$3,382.20	$751.60	$3,682.84	$3,551.31	2026-06-15
Q5111	HCPCS	Udenyca 6 Mg / 0.6 Ml Syrg	28	11	$7,515.00	$6,763.50	$1,503.00	$7,364.70	$7,101.68	2026-06-15
Q5119	HCPCS	Ruxience 500 Mg / 50 Ml Sdv	29	11	$6,452.00	$5,806.80	$1,290.40	$6,322.96	$6,097.14	2026-06-15
Q5135	HCPCS	Tyenne 200 Mg / 10 Ml Sdv	44	11	$1,763.00	$1,586.70	$352.60	$3,455.48	$1,666.04	2026-06-15
V2632	HCPCS	Intraocular Lens	28	11	$1,447.00	$1,302.30	$289.40	$1,418.06	$1,367.41	2026-06-15

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