Hospital

BOX BUTTE GENERAL HOSPITAL

Alliance, NE · CCN 281360 · Rates published

4,757 distinct procedures filed

7 distinct payers

35,391 rate rows

2026-05-13 last MRF observed

Data quality

10,710 of 35,391 rate rows are consumer-grade (30.3%)

24,681 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
no usable negotiated amount (only an out-of-band fallback) — excluded from medians	22,894
per-diem day rate — not a per-procedure price	1,262
exceeds 10× this hospital's gross charge — excluded from medians	525

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

Source MRF file	https://apim.services.craneware.com/api-pricing-transparency/api/public/17918c17c905f5eee281a0f0352904f3/charges/mrf
Found on page	https://www.bbgh.org/patients-visitors/patient-financial-resources/price-transparency/
Discovered via	Discovered by HANK (automated)
Last fetch	not_modified · 2026-10-13
Content fingerprint	03e99c38db2e564c… · 3,120,477 bytes · first seen 2026-05-14

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
99285 OTHER	Emergency Department Visit For Life Threatening Or Functioning Severity	6	$4,077.00	$4,077.00	$4,077.00	—
99291 OTHER	Critical Care; First 30-74 Minutes	6	$4,077.00	$4,077.00	$4,077.00	—
99292 OTHER	Critical Care Addl 30 Min	6	$4,077.00	$4,077.00	$4,077.00	—
99284 OTHER	Emergency Department Visit For Problem Of High Severity	6	$2,280.00	$2,280.00	$2,280.00	—
74185 OTHER	MRA Abd W Or Without Cntrst	6	$2,040.00	$2,040.00	$2,040.00	—
73719 OTHER	MRI Lower Extremity With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73220 OTHER	MRI Scan Of Arm Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72195 OTHER	MRI Scan Of Pelvis Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73223 OTHER	MRI Scan Of Arm Joint Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73222 OTHER	MRI Scan Of Arm Joint With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73725 OTHER	Mr Ang Lwr Ext W Or Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
74183 OTHER	MRI Scan Of Abdomen Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72142 OTHER	MRI Neck Spine With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73720 OTHER	MRI Scan Of Leg Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70546 OTHER	Mr Angiograph Head W/O&with Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70543 OTHER	MRI Scan Of Bone Of Eye Socket; Face; And/or Neck Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70552 OTHER	MRI Brain Stem With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72141 OTHER	MRI Scan Of Upper Spinal Canal Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72149 OTHER	MRI Lumbar Spine With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72158 OTHER	MRI Scan Of Lower Spinal Canal Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73218 OTHER	MRI Scan Of Arm Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73221 OTHER	MRI Scan Of Arm Joint Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73721 OTHER	MRI Scan Of Leg Joint Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73723 OTHER	MRI Scan Of Leg Joint Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
74181 OTHER	MRI Scan Of Abdomen Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
74182 OTHER	MRI Abdomen W/contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70547 OTHER	Mr Angiography Neck Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72146 OTHER	MRI Scan Of Middle Spinal Canal Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73718 OTHER	MRI Scan Of Leg Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73722 OTHER	MRI Scan Of Leg Joint With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70336 OTHER	MRI Scan Of Jaw Joint	6	$2,040.00	$2,040.00	$2,040.00	—
70540 OTHER	MRI Orbit/face/neck Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70544 OTHER	MRI Scan Of Blood Vessels Of Head Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70545 OTHER	Mr Angiography Head With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70549 OTHER	Mr Angiograph Neck W/O&with Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70551 OTHER	MRI Scan Of Brain Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
70553 OTHER	MRI Scan Of Brain Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
71551 OTHER	MRI Chest With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72147 OTHER	MRI Chest Spine With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72148 OTHER	MRI Scan Of Lower Spinal Canal Without Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72156 OTHER	MRI Scan Of Upper Spinal Canal Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72157 OTHER	MRI Scan Of Middle Spinal Canal Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72196 OTHER	MRI Pelvis With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
72197 OTHER	MRI Scan Of Pelvis Before And After Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
73219 OTHER	MRI Upper Extremity With Contrast	6	$2,040.00	$2,040.00	$2,040.00	—
00093970101 OTHER	Carbidopa-levodopa	6	$1,818.45	$1,818.45	$1,818.45	—
00093417773 OTHER	Cephalexin	6	$1,818.45	$1,818.45	$1,818.45	—
001 OTHER	Heart Transplant Or Implant Of Heart Assist System With Mcc	5	$1,818.45	$1,818.45	$1,818.45	nat. median $177,883 outlier · 0.0×
00093-3426-01 OTHER	Lorazepam	6	$1,818.45	$1,818.45	$1,818.45	—
00093-2027-23 OTHER	Azithromycin	6	$1,818.45	$1,818.45	$1,818.45	—

Other procedures at this hospital

Browse this hospital's 4,757 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

99291	OTHER	Critical Care; First 30-74 Minutes	7	6	$1,572.50	$1,415.25	$4,077.00	$4,077.00	$4,077.00	2026-05-13
99292	OTHER	Critical Care Addl 30 Min	7	6	$878.50	$790.65	$4,077.00	$4,077.00	$4,077.00	2026-05-13
99285	OTHER	Emergency Department Visit For Life Threatening Or Functioning Severity	18	6	$1,758.00	$1,582.20	$4,077.00	$4,077.00	$4,077.00	2026-05-13
99284	OTHER	Emergency Department Visit For Problem Of High Severity	13	6	$516.00	$464.40	$2,280.00	$2,280.00	$2,280.00	2026-05-13
72195	OTHER	MRI Scan Of Pelvis Without Contrast	6	6	$1,959.00	$1,763.10	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70551	OTHER	MRI Scan Of Brain Without Contrast	6	6	$2,224.50	$2,002.05	$2,040.00	$2,040.00	$2,040.00	2026-05-13
74182	OTHER	MRI Abdomen W/contrast	6	6	$4,471.00	$4,023.90	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70552	OTHER	MRI Brain Stem With Contrast	6	6	$4,433.00	$3,989.70	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72156	OTHER	MRI Scan Of Upper Spinal Canal Before And After Contrast	6	6	$2,597.00	$2,337.30	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73218	OTHER	MRI Scan Of Arm Without Contrast	12	6	$3,542.00	$3,187.80	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73720	OTHER	MRI Scan Of Leg Before And After Contrast	12	6	$2,408.00	$2,167.20	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70547	OTHER	Mr Angiography Neck Without Contrast	6	6	$3,894.00	$3,504.60	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73222	OTHER	MRI Scan Of Arm Joint With Contrast	18	6	$4,025.00	$3,622.50	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70545	OTHER	Mr Angiography Head With Contrast	6	6	$4,433.00	$3,989.70	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70544	OTHER	MRI Scan Of Blood Vessels Of Head Without Contrast	18	6	$3,820.00	$3,438.00	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73722	OTHER	MRI Scan Of Leg Joint With Contrast	6	6	$2,200.50	$1,980.45	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73220	OTHER	MRI Scan Of Arm Before And After Contrast	12	6	$2,408.00	$2,167.20	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72197	OTHER	MRI Scan Of Pelvis Before And After Contrast	6	6	$4,572.00	$4,114.80	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73221	OTHER	MRI Scan Of Arm Joint Without Contrast	18	6	$3,542.00	$3,187.80	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70543	OTHER	MRI Scan Of Bone Of Eye Socket; Face; And/or Neck Before And After Contrast	6	6	$2,408.00	$2,167.20	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72141	OTHER	MRI Scan Of Upper Spinal Canal Without Contrast	6	6	$2,200.50	$1,980.45	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73725	OTHER	Mr Ang Lwr Ext W Or Without Contrast	6	6	$4,433.00	$3,989.70	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70540	OTHER	MRI Orbit/face/neck Without Contrast	6	6	$3,934.00	$3,540.60	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72157	OTHER	MRI Scan Of Middle Spinal Canal Before And After Contrast	6	6	$2,564.00	$2,307.60	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73721	OTHER	MRI Scan Of Leg Joint Without Contrast	18	6	$2,147.00	$1,932.30	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72142	OTHER	MRI Neck Spine With Contrast	6	6	$4,433.00	$3,989.70	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73223	OTHER	MRI Scan Of Arm Joint Before And After Contrast	6	6	$4,572.00	$4,114.80	$2,040.00	$2,040.00	$2,040.00	2026-05-13
74185	OTHER	MRA Abd W Or Without Cntrst	6	6	$4,433.00	$3,989.70	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72147	OTHER	MRI Chest Spine With Contrast	6	6	$4,392.00	$3,952.80	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70549	OTHER	Mr Angiograph Neck W/O&with Contrast	6	6	$4,825.00	$4,342.50	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72146	OTHER	MRI Scan Of Middle Spinal Canal Without Contrast	6	6	$2,200.50	$1,980.45	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73718	OTHER	MRI Scan Of Leg Without Contrast	12	6	$1,959.00	$1,763.10	$2,040.00	$2,040.00	$2,040.00	2026-05-13
74181	OTHER	MRI Scan Of Abdomen Without Contrast	6	6	$2,012.00	$1,810.80	$2,040.00	$2,040.00	$2,040.00	2026-05-13
74183	OTHER	MRI Scan Of Abdomen Before And After Contrast	6	6	$2,496.50	$2,246.85	$2,040.00	$2,040.00	$2,040.00	2026-05-13
71551	OTHER	MRI Chest With Contrast	6	6	$4,471.00	$4,023.90	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70336	OTHER	MRI Scan Of Jaw Joint	6	6	$4,146.00	$3,731.40	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70553	OTHER	MRI Scan Of Brain Before And After Contrast	6	6	$2,470.00	$2,223.00	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72196	OTHER	MRI Pelvis With Contrast	6	6	$4,471.00	$4,023.90	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73219	OTHER	MRI Upper Extremity With Contrast	6	6	$4,471.00	$4,023.90	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73719	OTHER	MRI Lower Extremity With Contrast	6	6	$4,340.00	$3,906.00	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72149	OTHER	MRI Lumbar Spine With Contrast	6	6	$4,304.00	$3,873.60	$2,040.00	$2,040.00	$2,040.00	2026-05-13
70546	OTHER	Mr Angiograph Head W/O&with Contrast	6	6	$4,592.00	$4,132.80	$2,040.00	$2,040.00	$2,040.00	2026-05-13
73723	OTHER	MRI Scan Of Leg Joint Before And After Contrast	6	6	$2,408.00	$2,167.20	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72158	OTHER	MRI Scan Of Lower Spinal Canal Before And After Contrast	6	6	$2,531.00	$2,277.90	$2,040.00	$2,040.00	$2,040.00	2026-05-13
72148	OTHER	MRI Scan Of Lower Spinal Canal Without Contrast	6	6	$2,200.50	$1,980.45	$2,040.00	$2,040.00	$2,040.00	2026-05-13
076	OTHER	Viral Meningitis Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
063	OTHER	Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic A…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
077	OTHER	Hypertensive Encephalopathy With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
053	OTHER	Spinal Disorders And Injuries Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
031	OTHER	Ventricular Shunt Procedures With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
054	OTHER	Nervous System Neoplasms With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
078	OTHER	Hypertensive Encephalopathy With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
012	OTHER	Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7983-03	OTHER	Sodium Chloride	6	6	$55.00	$49.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
023	OTHER	Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Wi…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
030	OTHER	Spinal Procedures Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
038	OTHER	Extracranial Procedures With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
052	OTHER	Spinal Disorders And Injuries With Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
059	OTHER	Multiple Sclerosis And Cerebellar Ataxia With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
062	OTHER	Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic A…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
068	OTHER	Nonspecific Cva And Precerebral Occlusion Without Infarction Without Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
075	OTHER	Viral Meningitis With Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
013	OTHER	Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7926-09	OTHER	Dextrose-sodium Chloride	6	6	$130.00	$117.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990790209	OTHER	Potassium Chloride In Dextrose And Sodium Chloride	6	6	$70.00	$63.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990792609	OTHER	Dextrose-sodium Chloride	6	6	$55.00	$49.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
014	OTHER	Allogeneic Bone Marrow Transplant	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-7237-61	OTHER	Banophen	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6730-61	OTHER	Acetaminophen	6	6	$0.12	$0.11	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904723761A	OTHER	Banophen	6	6	$4.00	$3.60	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6461-61	OTHER	Promethazine Hcl	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904531360	OTHER	Prenatal Vitamin	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904646161A	OTHER	Promethazine Hcl	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990710709	OTHER	Potassium Chloride In Dextrose And Sodium Chloride	6	6	$55.00	$49.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
016	OTHER	Autologous Bone Marrow Transplant With Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
079	OTHER	Hypertensive Encephalopathy Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00641921910	OTHER	Diltiazem Hcl Novaplus	6	6	$48.96	$44.06	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00591350804	OTHER	Clonidine	6	6	$64.66	$58.19	$1,818.45	$1,818.45	$1,818.45	2026-05-13
007	OTHER	Lung Transplant	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00574052174	OTHER	Actidose-aqua	6	6	$62.63	$56.37	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00487970101	OTHER	Budesonide	6	6	$27.95	$25.16	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00574-0608-11	OTHER	Ferrous Sulfate	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00703951493	OTHER	Sulfamethoxazole/trimethoprim Novaplus	6	6	$97.67	$87.90	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00456140563	OTHER	Bystolic	6	6	$17.42	$15.68	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-9094-25	OTHER	Fentanyl Citrate	3	3	$21.04	$18.94	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00456430001	OTHER	Monurol	6	6	$188.78	$169.90	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00487930103	OTHER	Sodium Chloride	6	6	$4.00	$3.60	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00487-9701-01	OTHER	Budesonide	6	6	$27.95	$25.16	$1,818.45	$1,818.45	$1,818.45	2026-05-13
005	OTHER	Liver Transplant With Mcc Or Intestinal Transplant	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00555-0159-02	OTHER	Chlordiazepoxide Hcl	6	6	$6.20	$5.58	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00574704012	OTHER	Belladonna/opium	6	6	$100.36	$90.32	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00591267930	OTHER	Lidocaine Novaplus	6	6	$28.00	$25.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00597014030	OTHER	Tradjenta	6	6	$70.70	$63.63	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00641600710	OTHER	Bumetanide	6	6	$25.12	$22.61	$1,818.45	$1,818.45	$1,818.45	2026-05-13
008	OTHER	Simultaneous Pancreas And Kidney Transplant	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-0530-61	OTHER	Tab-a-vite	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6007-61	OTHER	Lorazepam	3	3	$4.95	$4.46	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6373-61	OTHER	Ropinirole Hcl	6	6	$6.20	$5.58	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6551-61	OTHER	Ondansetron Hcl	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6717-61	OTHER	Cetirizine Hcl	6	6	$10.58	$9.52	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6794-80	OTHER	Aspirin Low Dose	6	6	$0.04	$0.04	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-7177-61	OTHER	Furosemide	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990771503	OTHER	Mannitol	6	6	$188.72	$169.85	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990782808	OTHER	Lactated Ringer's	6	6	$45.09	$40.58	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7922-09	OTHER	Dextrose	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7926-02	OTHER	Noc Drugs; Other Than Inhalation Drugs; Administered Through Dme	6	6	$90.00	$81.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7953-09	OTHER	Lactated Ringer's	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990798302	OTHER	Sodium Chloride	6	6	$45.00	$40.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990798309	OTHER	Sodium Chloride	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
011	OTHER	Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
019	OTHER	Simultaneous Pancreas And Kidney Transplant With Hemodialysis	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
022	OTHER	Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
026	OTHER	Craniotomy And Endovascular Intracranial Procedures With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
029	OTHER	Spinal Procedures With Cc Or Spinal Neurostimulators	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
034	OTHER	Carotid Artery Stent Procedures With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
037	OTHER	Extracranial Procedures With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
041	OTHER	Periph/cranial Nerve & Other Nerv Syst Proc With Complication Or Periph Neurosti…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
042	OTHER	Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
056	OTHER	Degenerative Nervous System Disorders With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
058	OTHER	Multiple Sclerosis And Cerebellar Ataxia With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
060	OTHER	Multiple Sclerosis And Cerebellar Ataxia Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
061	OTHER	Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic A…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
065	OTHER	Intracranial Hemorrhage Or Cerebral Infarction With Complication Or Tpa In 24 Hr…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
067	OTHER	Nonspecific Cva And Precerebral Occlusion Without Infarction With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
071	OTHER	Nonspecific Cerebrovascular Disorders With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
074	OTHER	Cranial And Peripheral Nerve Disorders Without Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409751716	OTHER	Dextrose	6	6	$48.44	$43.60	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409724803	OTHER	Hetastarch/sodium Chloride	6	6	$66.93	$60.24	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409781124	OTHER	Metronidazole	6	6	$28.20	$25.38	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00485015130	OTHER	Urogesic-blue	6	6	$22.61	$20.35	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409662522	OTHER	Sodium Bicarbonate	6	6	$18.25	$16.43	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409555502	OTHER	Sodium Bicarbonate	6	6	$46.62	$41.96	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409663724	OTHER	Sodium Bicarbonate	6	6	$54.35	$48.92	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409427717	OTHER	Lidocaine Hcl	6	6	$24.64	$22.18	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409330101	OTHER	Precedex Novaplus	6	6	$25.00	$22.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-4699-53	OTHER	Propofol	3	3	$75.62	$68.06	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409663724A	OTHER	Sodium Bicarbonate	6	6	$61.00	$54.90	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00487-5901-99	OTHER	S-2 Inhalant	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00713052612	OTHER	Promethegan	6	6	$66.39	$59.75	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409177510	OTHER	Dextrose	6	6	$43.26	$38.93	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-1162-02	OTHER	Bupivacaine Hcl	6	6	$18.96	$17.06	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-1778-05	OTHER	Metoprolol Tartrate	6	6	$18.25	$16.43	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00407141491	OTHER	Omnipaque 350	6	6	$3.00	$2.70	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00407-1413-65	OTHER	Omnipaque 300	6	6	$450.00	$405.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-1159-02	OTHER	Bupivacaine Hcl	6	6	$18.25	$16.43	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409177805	OTHER	Metoprolol Tartrate	6	6	$46.48	$41.83	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00406911276	OTHER	Fentanyl Transdermal System	6	6	$49.74	$44.77	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00406905076	OTHER	Fentanyl Transdermal System	6	6	$51.40	$46.26	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00406912576	OTHER	Fentanyl Transdermal System	6	6	$52.10	$46.89	$1,818.45	$1,818.45	$1,818.45	2026-05-13
004	OTHER	Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Nec…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00407-1413-63	OTHER	Omnipaque 300	6	6	$300.00	$270.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00407141363	OTHER	Omnipaque 300	6	6	$3.00	$2.70	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00407141365	OTHER	Omnipaque 300	6	6	$3.00	$2.70	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00407-1414-91	OTHER	Omnipaque 350	6	6	$300.00	$270.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J1815	HCPCS	Insulin Injection	6	6	$272.00	$244.80	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409115902	OTHER	Bupivacaine Hcl	6	6	$18.25	$16.43	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409116202	OTHER	Bupivacaine Hcl	6	6	$18.25	$16.43	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409166020	OTHER	Precedex	6	6	$110.25	$99.23	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409318301	OTHER	Epinephrine-lidocaine Hcl	6	6	$76.02	$68.42	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-3301-01	OTHER	Precedex Novaplus	6	6	$25.00	$22.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409337504	OTHER	Levophed	6	6	$86.37	$77.73	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409427602	OTHER	Lidocaine Hcl	6	6	$21.09	$18.98	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409492834	OTHER	Calcium Chloride	6	6	$47.63	$42.87	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409553414	OTHER	Sodium Bicarbonate	6	6	$47.51	$42.76	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409592216	OTHER	Aminophylline	6	6	$47.17	$42.45	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-6625-22	OTHER	Sodium Bicarbonate	6	6	$18.25	$16.43	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-7101-02	OTHER	Sodium Chloride	6	6	$45.00	$40.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409710102	OTHER	Sodium Chloride	6	6	$45.00	$40.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409729501	OTHER	Potassium Phosphate	6	6	$91.61	$82.45	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-7517-16	OTHER	Dextrose	6	6	$61.87	$55.68	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-9045-16	OTHER	Bupivacaine Hcl With Epinephrine	6	6	$49.79	$44.81	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409904516	OTHER	Bupivacaine Hcl With Epinephrine	6	6	$49.79	$44.81	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409-9558-49	OTHER	Rocuronium Bromide Novaplus	6	6	$55.04	$49.54	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409955849	OTHER	Rocuronium Bromide Novaplus	6	6	$27.52	$24.77	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00487590199	OTHER	S-2 Inhalant	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00487-9301-03	OTHER	Sodium Chloride	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00487-9501-01	OTHER	Albuterol Sulfate	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00487-9601-01	OTHER	Budesonide	6	6	$27.95	$25.16	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00496-0882-07	OTHER	Lmx 4	6	6	$93.74	$84.37	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00496088207	OTHER	Lmx 4	6	6	$93.74	$84.37	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00536114397	OTHER	Petrolatum 42%	6	6	$14.25	$12.83	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00536440601	OTHER	Vitamin B6	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00574200815	OTHER	Nystop	6	6	$53.78	$48.40	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00574-4024-11	OTHER	Erythromycin	6	6	$21.39	$19.25	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00574-7050-50	OTHER	Bisacodyl	6	6	$5.95	$5.36	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00591-2679-30	OTHER	Lidocaine Novaplus	6	6	$27.61	$24.85	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00591350904	OTHER	Clonidine	6	6	$108.86	$97.97	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00597007575	OTHER	Spiriva Handihaler	6	6	$174.84	$157.36	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00597035556	OTHER	Pradaxa	6	6	$28.35	$25.52	$1,818.45	$1,818.45	$1,818.45	2026-05-13
006	OTHER	Liver Transplant Without Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00781602352	OTHER	Clarithromycin	6	6	$138.58	$124.72	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00781-7296-85	OTHER	Albuterol Sulfate Hfa	6	6	$132.24	$119.02	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00832603212	OTHER	Fluoxetine	6	6	$276.13	$248.52	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00869087143	OTHER	Swan Hydrogen Peroxide	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-5463-35	OTHER	Ibuprofen Children's	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904578461	OTHER	Fluoxetine Hcl	6	6	$10.28	$9.25	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6008-61	OTHER	Lorazepam	6	6	$4.95	$4.46	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6370-61	OTHER	Amlodipine Besylate	6	6	$6.20	$5.58	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6475-61	OTHER	Baclofen	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6550-61	OTHER	Propranolol Hcl	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6575-61	OTHER	Phenobarbital	6	6	$6.20	$5.58	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6708-06	OTHER	Azithromycin	6	6	$10.54	$9.49	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904673061A	OTHER	Acetaminophen	6	6	$2.00	$1.80	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-6773-61	OTHER	Acetaminophen	6	6	$0.15	$0.14	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-7083-61	OTHER	Ciprofloxacin	6	6	$3.10	$2.79	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00904-7124-61	OTHER	Levetiracetam	6	6	$6.20	$5.58	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7670-09	OTHER	Normosol-r Ph 7.4	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990767009	OTHER	Normosol-r Ph 7.4	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J2802	HCPCS	Inj, Romiplostim 1 Microgram	6	6	$6,726.24	$6,053.62	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7828-08	OTHER	Lactated Ringer's	6	6	$107.78	$97.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990792202	OTHER	Dextrose	6	6	$35.00	$31.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990792203	OTHER	Dextrose	6	6	$55.00	$49.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990792209	OTHER	Dextrose	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990792402	OTHER	Dextrose-sodium Chloride	6	6	$45.00	$40.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990792909	OTHER	Lactated Ringer's And 5% Dextrose	6	6	$55.00	$49.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990794109	OTHER	Dextrose-sodium Chloride	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990795309	OTHER	Lactated Ringer's	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7983-02	OTHER	Sodium Chloride	6	6	$45.00	$40.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990798303	OTHER	Sodium Chloride	6	6	$55.00	$49.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990-7983-09	OTHER	Sodium Chloride	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00990798509	OTHER	Sodium Chloride	6	6	$65.00	$58.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
010	OTHER	Pancreas Transplant	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
017	OTHER	Autologous Bone Marrow Transplant Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
018	OTHER	Chimeric Antigen Receptor (car) T-cell And Other Immunotherapies	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
020	OTHER	Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
021	OTHER	Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
024	OTHER	Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Wi…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
025	OTHER	Craniotomy And Endovascular Intracranial Procedures With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
027	OTHER	Craniotomy And Endovascular Intracranial Procedures Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
028	OTHER	Spinal Procedures With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
032	OTHER	Ventricular Shunt Procedures With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
033	OTHER	Ventricular Shunt Procedures Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
035	OTHER	Carotid Artery Stent Procedures With Cc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
036	OTHER	Carotid Artery Stent Procedures Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
039	OTHER	Extracranial Procedures Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
040	OTHER	Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
04142-0000-07	OTHER	Florastor	6	6	$3.96	$3.56	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J3480	HCPCS	Inj Potassium Chloride	6	6	$17.00	$15.30	$1,818.45	$1,818.45	$1,818.45	2026-05-13
G0277	HCPCS	Hbot, Full Body Chamber, 30m	6	6	$286.00	$257.40	$1,818.45	$1,818.45	$1,818.45	2026-05-13
055	OTHER	Nervous System Neoplasms Without Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J3490	HCPCS	Drugs Unclassified Injection	12	6	$54.47	$49.02	$1,818.45	$1,818.45	$1,818.45	2026-05-13
057	OTHER	Degenerative Nervous System Disorders Without Comorbity	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J7030	HCPCS	Normal Saline Solution Infus	6	6	$21.00	$18.90	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J7040	HCPCS	Normal Saline Solution Infus	6	6	$60.00	$54.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J7042	HCPCS	5% Dextrose/normal Saline	6	6	$71.00	$63.90	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J7050	HCPCS	Normal Saline Solution Infus	6	6	$50.00	$45.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
064	OTHER	Intracranial Hemorrhage Or Cerebral Infarction With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J7120	HCPCS	Ringers Lactate Infusion	6	6	$60.00	$54.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
J7131	HCPCS	Hypertonic Saline Sol	6	6	$35.09	$31.58	$1,818.45	$1,818.45	$1,818.45	2026-05-13
066	OTHER	Intracranial Hemorrhage Or Cerebral Infarction Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
069	OTHER	Transient Ischemia Without Thrombolytic	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
070	OTHER	Nonspecific Cerebrovascular Disorders With Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
072	OTHER	Nonspecific Cerebrovascular Disorders Without Cc/mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
073	OTHER	Cranial & Peripheral Nerve Disorders With Comorbity	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00378-9671-93	OTHER	Ipratropium Bromide-albuterol Sulfate	6	6	$9.10	$8.19	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00406-0512-62	OTHER	Oxycodone Hcl-acetaminophen	6	6	$9.14	$8.23	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00407-1413-61	OTHER	Omnipaque 300	6	6	$12.00	$10.80	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00338012612	OTHER	Myxredlin	6	6	$136.00	$122.40	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00283-0610-26	OTHER	Hurricaine One	6	6	$32.59	$29.33	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00338105102	OTHER	Nitroglycerin-dextrose	6	6	$90.51	$81.46	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00270-5164-14	OTHER	Multihance	6	6	$198.00	$178.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00264446010	OTHER	Nutrilipid	6	6	$107.04	$96.34	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00270516414	OTHER	Multihance	6	6	$18.00	$16.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00338954524	OTHER	Clindamycin Phosphate-sodium Chloride	6	6	$24.84	$22.36	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00407141361	OTHER	Omnipaque 300	6	6	$3.00	$2.70	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00409196607	OTHER	Sodium Chloride Bacteriostatic	6	6	$18.25	$16.43	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00225-0525-47	OTHER	Ayr Saline Nasal	6	6	$10.00	$9.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00143988701	OTHER	Amoxicillin	6	6	$41.69	$37.52	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00228-2027-10	OTHER	Alprazolam	6	6	$6.20	$5.58	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00143968410	OTHER	Flumazenil Novaplus	6	6	$42.54	$38.29	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00143957010	OTHER	Sodium Ferric Gluconate Complex In Sucrose	6	6	$40.52	$36.47	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00143968910	OTHER	Nicardipine Hcl	6	6	$94.60	$85.14	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00264-1800-31	OTHER	Sodium Chloride	6	6	$35.00	$31.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00121119030	OTHER	Citric Acid/sodium Citrate	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00121-1154-40	OTHER	Lactulose	6	6	$8.37	$7.53	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00121174400	OTHER	Guaifenesin	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00121075908	OTHER	Prednisolone Sodium Phosphate	6	6	$8.00	$7.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00121-0759-08	OTHER	Prednisolone Sodium Phosphate	6	6	$16.00	$14.40	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00132020220	OTHER	Pedia-lax	6	6	$5.95	$5.36	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00143950601	OTHER	Etomidate	6	6	$39.86	$35.87	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00143962201	OTHER	Labetalol Hcl	6	6	$21.20	$19.08	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00143963710	OTHER	Valproate Sodium Novaplus	6	6	$82.60	$74.34	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00143-9887-01	OTHER	Amoxicillin	6	6	$41.69	$37.52	$1,818.45	$1,818.45	$1,818.45	2026-05-13
Q0169	HCPCS	Promethazine Hcl 12.5mg Oral	3	3	$4.62	$4.16	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00173069604	OTHER	Advair Diskus 250/50	6	6	$250.62	$225.56	$1,818.45	$1,818.45	$1,818.45	2026-05-13
002	OTHER	Heart Transplant Or Implant Of Heart Assist System Without Mcc	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00264180032	OTHER	Sodium Chloride	6	6	$35.00	$31.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00264-4460-10	OTHER	Nutrilipid	6	6	$107.04	$96.34	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00264-7805-10	OTHER	Sodium Chloride	6	6	$45.88	$41.29	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00264780510	OTHER	Sodium Chloride	6	6	$53.70	$48.33	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00270-5164-15	OTHER	Multihance	6	6	$360.00	$324.00	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00270516415	OTHER	Multihance	6	6	$18.00	$16.20	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00283061026	OTHER	Hurricaine One	6	6	$31.34	$28.21	$1,818.45	$1,818.45	$1,818.45	2026-05-13
003	OTHER	Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth…	5	5	—	—	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00378-6470-99	OTHER	Scopolamine	6	6	$50.96	$45.86	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00378-9121-16	OTHER	Fentanyl	6	6	$62.73	$56.46	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00378967193	OTHER	Ipratropium Bromide-albuterol Sulfate	6	6	$9.10	$8.19	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00378972055	OTHER	Denavir	6	6	$1,221.22	$1,099.10	$1,818.45	$1,818.45	$1,818.45	2026-05-13
Q9967	HCPCS	Locm 300-399mg/ml Iodine,1ml	6	6	$5.00	$4.50	$1,818.45	$1,818.45	$1,818.45	2026-05-13
00121085416	OTHER	Sulfatrim Pediatric	6	6	$17.00	$15.30	$1,818.45	$1,818.45	$1,818.45	2026-05-13

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