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

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 — reasonRows
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 viaDiscovered by HANK (automated)
Last fetch not_modified · 2026-10-31
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
99291
OTHER 		Critical Care; First 30-74 Minutes 6 $4,077.00 $4,077.00 $4,077.00 nat. median
$824
outlier · 4.9×
99292
OTHER 		Critical Care Addl 30 Min 6 $4,077.00 $4,077.00 $4,077.00 nat. median
$299
outlier · 13.6×
99285
OTHER 		Emergency Department Visit For Life Threatening Or Functioning Severity 6 $4,077.00 $4,077.00 $4,077.00 nat. median
$639
outlier · 6.4×
99284
OTHER 		Emergency Department Visit For Problem Of High Severity 6 $2,280.00 $2,280.00 $2,280.00 nat. median
$434
outlier · 5.3×
72195
OTHER 		MRI Scan Of Pelvis Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$857
outlier · 2.4×
70551
OTHER 		MRI Scan Of Brain Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$370
outlier · 5.5×
74182
OTHER 		MRI Abdomen W/contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$663
outlier · 3.1×
70552
OTHER 		MRI Brain Stem With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$743
outlier · 2.7×
72156
OTHER 		MRI Scan Of Upper Spinal Canal Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$573
outlier · 3.6×
73218
OTHER 		MRI Scan Of Arm Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$359
outlier · 5.7×
73720
OTHER 		MRI Scan Of Leg Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$798
outlier · 2.6×
70547
OTHER 		Mr Angiography Neck Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$413
outlier · 4.9×
73222
OTHER 		MRI Scan Of Arm Joint With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$798
outlier · 2.6×
70545
OTHER 		Mr Angiography Head With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$471
outlier · 4.3×
70544
OTHER 		MRI Scan Of Blood Vessels Of Head Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$386
outlier · 5.3×
73722
OTHER 		MRI Scan Of Leg Joint With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$805
outlier · 2.5×
73220
OTHER 		MRI Scan Of Arm Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$521
outlier · 3.9×
72197
OTHER 		MRI Scan Of Pelvis Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$1,236
1.7× median
73221
OTHER 		MRI Scan Of Arm Joint Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$372
outlier · 5.5×
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 nat. median
$623
outlier · 3.3×
72141
OTHER 		MRI Scan Of Upper Spinal Canal Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$413
outlier · 4.9×
73725
OTHER 		Mr Ang Lwr Ext W Or Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$617
outlier · 3.3×
70540
OTHER 		MRI Orbit/face/neck Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$411
outlier · 5.0×
72157
OTHER 		MRI Scan Of Middle Spinal Canal Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$682
outlier · 3.0×
73721
OTHER 		MRI Scan Of Leg Joint Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$357
outlier · 5.7×
72142
OTHER 		MRI Neck Spine With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$648
outlier · 3.1×
73223
OTHER 		MRI Scan Of Arm Joint Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$538
outlier · 3.8×
74185
OTHER 		MRA Abd W Or Without Cntrst 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$1,796
1.1× median
72147
OTHER 		MRI Chest Spine With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$643
outlier · 3.2×
70549
OTHER 		Mr Angiograph Neck W/O&with Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$549
outlier · 3.7×
72146
OTHER 		MRI Scan Of Middle Spinal Canal Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$411
outlier · 5.0×
73718
OTHER 		MRI Scan Of Leg Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$351
outlier · 5.8×
74181
OTHER 		MRI Scan Of Abdomen Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$457
outlier · 4.5×
74183
OTHER 		MRI Scan Of Abdomen Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$579
outlier · 3.5×
71551
OTHER 		MRI Chest With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$850
outlier · 2.4×
70336
OTHER 		MRI Scan Of Jaw Joint 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$392
outlier · 5.2×
70553
OTHER 		MRI Scan Of Brain Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$587
outlier · 3.5×
72196
OTHER 		MRI Pelvis With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$669
outlier · 3.1×
73219
OTHER 		MRI Upper Extremity With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$585
outlier · 3.5×
73719
OTHER 		MRI Lower Extremity With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$1,231
1.7× median
72149
OTHER 		MRI Lumbar Spine With Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$607
outlier · 3.4×
70546
OTHER 		Mr Angiograph Head W/O&with Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$739
outlier · 2.8×
73723
OTHER 		MRI Scan Of Leg Joint Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$518
outlier · 3.9×
72158
OTHER 		MRI Scan Of Lower Spinal Canal Before And After Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$573
outlier · 3.6×
72148
OTHER 		MRI Scan Of Lower Spinal Canal Without Contrast 6 $2,040.00 $2,040.00 $2,040.00 nat. median
$430
outlier · 4.7×
076
OTHER 		Viral Meningitis Without Cc/mcc 5 $1,818.45 $1,818.45 $1,818.45 nat. median
$7,457
outlier · 0.2×
063
OTHER 		Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic A… 5 $1,818.45 $1,818.45 $1,818.45 nat. median
$12,389
outlier · 0.1×
077
OTHER 		Hypertensive Encephalopathy With Mcc 5 $1,818.45 $1,818.45 $1,818.45 nat. median
$13,844
outlier · 0.1×
053
OTHER 		Spinal Disorders And Injuries Without Cc/mcc 5 $1,818.45 $1,818.45 $1,818.45 nat. median
$8,333
outlier · 0.2×
031
OTHER 		Ventricular Shunt Procedures With Mcc 5 $1,818.45 $1,818.45 $1,818.45 nat. median
$32,035
outlier · 0.1×

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.

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
             
J7042 HCPCS 5% Dextrose/normal Saline 6 6 $71.00 $63.90 $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
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
00574052174 OTHER Actidose-aqua 6 6 $62.63 $56.37 $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
00487-9501-01 OTHER Albuterol Sulfate 6 6 $8.00 $7.20 $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
014 OTHER Allogeneic Bone Marrow Transplant 5 5 — — $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
00409592216 OTHER Aminophylline 6 6 $47.17 $42.45 $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
00143988701 OTHER Amoxicillin 6 6 $41.69 $37.52 $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
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
016 OTHER Autologous Bone Marrow Transplant With Cc/mcc 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
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
00904-6708-06 OTHER Azithromycin 6 6 $10.54 $9.49 $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
00904-7237-61 OTHER Banophen 6 6 $3.10 $2.79 $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
00574704012 OTHER Belladonna/opium 6 6 $100.36 $90.32 $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
00487970101 OTHER Budesonide 6 6 $27.95 $25.16 $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
00487-9601-01 OTHER Budesonide 6 6 $27.95 $25.16 $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
00409-1162-02 OTHER Bupivacaine Hcl 6 6 $18.96 $17.06 $1,818.45 $1,818.45 $1,818.45 2026-05-13
00409-1159-02 OTHER Bupivacaine Hcl 6 6 $18.25 $16.43 $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
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
00456140563 OTHER Bystolic 6 6 $17.42 $15.68 $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
035 OTHER Carotid Artery Stent Procedures With Cc 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
036 OTHER Carotid Artery Stent Procedures Without Cc/mcc 5 5 — — $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
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
00555-0159-02 OTHER Chlordiazepoxide Hcl 6 6 $6.20 $5.58 $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
00121119030 OTHER Citric Acid/sodium Citrate 6 6 $8.00 $7.20 $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
00338954524 OTHER Clindamycin Phosphate-sodium Chloride 6 6 $24.84 $22.36 $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
00591350904 OTHER Clonidine 6 6 $108.86 $97.97 $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
074 OTHER Cranial And Peripheral Nerve Disorders Without Mcc 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
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
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
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
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
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
056 OTHER Degenerative Nervous System Disorders With Mcc 5 5 — — $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
00378972055 OTHER Denavir 6 6 $1,221.22 $1,099.10 $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
00409751716 OTHER Dextrose 6 6 $48.44 $43.60 $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
00409-7517-16 OTHER Dextrose 6 6 $61.87 $55.68 $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
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
00990792609 OTHER Dextrose-sodium Chloride 6 6 $55.00 $49.50 $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
00990794109 OTHER Dextrose-sodium Chloride 6 6 $65.00 $58.50 $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
J3490 HCPCS Drugs Unclassified Injection 12 6 $54.47 $49.02 $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
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
00409318301 OTHER Epinephrine-lidocaine Hcl 6 6 $76.02 $68.42 $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
00143950601 OTHER Etomidate 6 6 $39.86 $35.87 $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
037 OTHER Extracranial Procedures With 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
00378-9121-16 OTHER Fentanyl 6 6 $62.73 $56.46 $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
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
00574-0608-11 OTHER Ferrous Sulfate 6 6 $3.10 $2.79 $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
00143968410 OTHER Flumazenil Novaplus 6 6 $42.54 $38.29 $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
00904578461 OTHER Fluoxetine Hcl 6 6 $10.28 $9.25 $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
00121174400 OTHER Guaifenesin 6 6 $8.00 $7.20 $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
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
00409724803 OTHER Hetastarch/sodium Chloride 6 6 $66.93 $60.24 $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
00283061026 OTHER Hurricaine One 6 6 $31.34 $28.21 $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
077 OTHER Hypertensive Encephalopathy With 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
J7131 HCPCS Hypertonic Saline Sol 6 6 $35.09 $31.58 $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
J3480 HCPCS Inj Potassium Chloride 6 6 $17.00 $15.30 $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
J1815 HCPCS Insulin Injection 6 6 $272.00 $244.80 $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
064 OTHER Intracranial Hemorrhage Or Cerebral Infarction With Mcc 5 5 — — $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
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
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
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
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
00378967193 OTHER Ipratropium Bromide-albuterol Sulfate 6 6 $9.10 $8.19 $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
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
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
00143962201 OTHER Labetalol Hcl 6 6 $21.20 $19.08 $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
00990-7953-09 OTHER Lactated Ringer's 6 6 $65.00 $58.50 $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
00990795309 OTHER Lactated Ringer's 6 6 $65.00 $58.50 $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
00121-1154-40 OTHER Lactulose 6 6 $8.37 $7.53 $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
00409337504 OTHER Levophed 6 6 $86.37 $77.73 $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
00409427602 OTHER Lidocaine Hcl 6 6 $21.09 $18.98 $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
00591-2679-30 OTHER Lidocaine Novaplus 6 6 $27.61 $24.85 $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
006 OTHER Liver Transplant Without Mcc 5 5 — — $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
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
00904-6007-61 OTHER Lorazepam 3 3 $4.95 $4.46 $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
007 OTHER Lung Transplant 5 5 — — $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
00409-1778-05 OTHER Metoprolol Tartrate 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
00409781124 OTHER Metronidazole 6 6 $28.20 $25.38 $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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
00270-5164-14 OTHER Multihance 6 6 $198.00 $178.20 $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
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
059 OTHER Multiple Sclerosis And Cerebellar Ataxia With Cc 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
00338012612 OTHER Myxredlin 6 6 $136.00 $122.40 $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
055 OTHER Nervous System Neoplasms Without Mcc 5 5 — — $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
00338105102 OTHER Nitroglycerin-dextrose 6 6 $90.51 $81.46 $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
071 OTHER Nonspecific Cerebrovascular Disorders With Cc 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
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
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
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
J7050 HCPCS Normal Saline Solution Infus 6 6 $50.00 $45.00 $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
00264446010 OTHER Nutrilipid 6 6 $107.04 $96.34 $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
00574200815 OTHER Nystop 6 6 $53.78 $48.40 $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
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
00407-1413-61 OTHER Omnipaque 300 6 6 $12.00 $10.80 $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
00407141491 OTHER Omnipaque 350 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
00904-6551-61 OTHER Ondansetron Hcl 6 6 $3.10 $2.79 $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
010 OTHER Pancreas Transplant 5 5 — — $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
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
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
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
00536114397 OTHER Petrolatum 42% 6 6 $14.25 $12.83 $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
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
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
00409729501 OTHER Potassium Phosphate 6 6 $91.61 $82.45 $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
00409166020 OTHER Precedex 6 6 $110.25 $99.23 $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
00409-3301-01 OTHER Precedex Novaplus 6 6 $25.00 $22.50 $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
00904531360 OTHER Prenatal Vitamin 6 6 $3.10 $2.79 $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
00904646161A OTHER Promethazine Hcl 6 6 $3.10 $2.79 $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
00713052612 OTHER Promethegan 6 6 $66.39 $59.75 $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
00904-6550-61 OTHER Propranolol Hcl 6 6 $3.10 $2.79 $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
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
00904-6373-61 OTHER Ropinirole Hcl 6 6 $6.20 $5.58 $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
00487590199 OTHER S-2 Inhalant 6 6 $8.00 $7.20 $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
008 OTHER Simultaneous Pancreas And Kidney Transplant 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
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
00409663724A OTHER Sodium Bicarbonate 6 6 $61.00 $54.90 $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
00409-6625-22 OTHER Sodium Bicarbonate 6 6 $18.25 $16.43 $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
00487930103 OTHER Sodium Chloride 6 6 $4.00 $3.60 $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
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
00487-9301-03 OTHER Sodium Chloride 6 6 $8.00 $7.20 $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
00264-1800-31 OTHER Sodium Chloride 6 6 $35.00 $31.50 $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
00264-7805-10 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
00409196607 OTHER Sodium Chloride Bacteriostatic 6 6 $18.25 $16.43 $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
052 OTHER Spinal Disorders And Injuries With Cc/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
029 OTHER Spinal Procedures With Cc Or Spinal Neurostimulators 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
030 OTHER Spinal Procedures Without Cc/mcc 5 5 — — $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
00703951493 OTHER Sulfamethoxazole/trimethoprim Novaplus 6 6 $97.67 $87.90 $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
00869087143 OTHER Swan Hydrogen Peroxide 6 6 $8.00 $7.20 $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
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
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
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
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
00597014030 OTHER Tradjenta 6 6 $70.70 $63.63 $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
00485015130 OTHER Urogesic-blue 6 6 $22.61 $20.35 $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
032 OTHER Ventricular Shunt Procedures With Cc 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
033 OTHER Ventricular Shunt Procedures Without Cc/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
076 OTHER Viral Meningitis Without Cc/mcc 5 5 — — $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
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