Hospital

ROBERT PACKER HOSPITAL

Sayre, PA · CCN 390079 · Rates published

204 distinct procedures filed

30 distinct payers

521,733 rate rows

2026-05-06 last MRF observed

Data quality

520,938 of 521,733 rate rows are consumer-grade (99.8%)

795 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
exceeds 10× this hospital's gross charge — excluded from medians	310
no usable negotiated amount (only an out-of-band fallback) — excluded from medians	247
placeholder amount (≤ $0.02) — excluded from medians	121
per-diem day rate — not a per-procedure price	70
percent-of-charges filed in the dollar field — excluded from medians	47

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

Source MRF file	https://rca.centaurihs.com/ptapp/api/cdm/export/oneclick?recno=8ac50bc93b5f606f4972a35ffd770c2908f6979dd3d224e83eaabf02a8c40427
Found on page	https://www.guthrie.org/about-us/hospital-price-transparency
Discovered via	Discovered by HANK
Last fetch	not_modified · 2026-05-15
Content fingerprint	9c6e8adada63b5f0… · 265,672,980 bytes · first seen 2026-05-05

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
0275 OTHER	Defib Card 76gm 35cc W40xh73mm Thk14mm Df1 Is1 Conn Sgl	30	$18.89	$59,743.75	$10,019.17	nat. median $6,575 1.5× median
0681 OTHER	Full Trauma Team Resp W/Prehosp, W/30 Min Critical Care	30	$445.32	$22,482.00	$9,018.40	nat. median $6,742 1.3× median
0256 OTHER	Fecal Microbiota Preparation	30	$1,093.50	$7,251.30	$7,251.30	nat. median $3,626 outlier · 2.0×
0404 OTHER	Cardiace PET Metabol Eval	30	$636.30	$15,387.82	$5,788.00	nat. median $3,351 1.7× median
0637 OTHER	Potassium Iodide (expectorant) 1 Gm/ml Po Soln	23	$827.54	$5,629.50	$5,629.50	nat. median $23 outlier · 242.7×
0323 OTHER	A-gram Rima	29	$382.16	$18,010.20	$4,876.00	nat. median $2,997 1.6× median
0720 OTHER	Delivery Of Placenta	30	$126.67	$10,593.25	$4,475.63	nat. median $1,061 outlier · 4.2×
0612 OTHER	MRI C-spine Wo Contrast	30	$265.49	$8,836.23	$4,221.84	nat. median $1,591 outlier · 2.7×
0616 OTHER	MRA Lextrem Wo Contr	30	$265.49	$3,570.00	$3,570.00	nat. median $1,208 outlier · 3.0×
0750 OTHER	Hc Fac Esop.GI Reflux Test; W/Muco.Att	28	$2.28	$17,107.00	$3,380.18	nat. median $1,747 1.9× median
0618 OTHER	Pelvis MRA W And Wo Contr	30	$238.23	$5,974.00	$2,900.00	nat. median $1,462 2.0× median
0360 OTHER	Endometrial Bx W/wo Endocervix Bx Without Dilat Spx	30	$0.11	$118,024.37	$2,621.00	nat. median $2,271 1.2× median
0619 OTHER	3d Render Without Postprocess 08119	30	$44.56	$6,807.74	$2,341.68	nat. median $1,607 1.5× median
0333 OTHER	Sbrt Delivery Per Fraction	30	$20.21	$36,119.00	$2,169.45	nat. median $1,230 1.8× median
0614 OTHER	Card MRI W/Stress Img And Dye	30	$23.37	$6,736.08	$2,140.90	nat. median $1,195 1.8× median
0610 OTHER	Unlisted Magnetic Resonance Proced	30	$6.67	$11,453.70	$2,132.90	nat. median $1,272 1.7× median
0391 OTHER	Transf,Bl/Bl Comp-2c	30	$117.33	$11,858.00	$2,037.00	nat. median $929 outlier · 2.2×
0351 OTHER	CT Head With Contrast	30	$127.26	$4,935.17	$1,884.63	nat. median $1,039 1.8× median
0361 OTHER	Bronch W/Ther Asp Br	30	$1.00	$33,711.50	$1,854.88	nat. median $1,125 1.6× median
0722 OTHER	Tubal During C Section	30	$277.10	$1,837.50	$1,837.50	nat. median $1,488 1.2× median
0880 OTHER	Dialysis One Evaluation Crrt	30	$252.96	$1,720.80	$1,720.80	nat. median $1,205 1.4× median
0352 OTHER	CT Guide For Needle Place, Radio Super & Interp	30	$80.97	$7,082.68	$1,628.46	nat. median $1,143 1.4× median
0350 OTHER	CT Upper Extrem Without Contrast	30	$61.07	$5,398.16	$1,623.55	nat. median $712 outlier · 2.3×
0341 OTHER	Bm Imaging; Multiple Areas	30	$19.08	$12,097.51	$1,383.53	nat. median $907 1.5× median
0820 OTHER	Non Esrd Hemodialysis One Evaluation (685)	30	$201.60	$1,555.00	$1,321.75	nat. median $828 1.6× median
0801 OTHER	Acute Hemodialysis	30	$196.90	$4,058.59	$1,318.64	nat. median $1,207 1.1× median
0278 OTHER	Clp Aneur Blde L5mm Max Opn 4mm 110gm Ti Mini Perm Yasrg	30	$1.35	$159,345.00	$1,264.21	nat. median $1,993 0.6× median
0761 OTHER	Punch Bx Skin Single Lesion	30	$24.51	$14,708.00	$1,188.08	nat. median $630 1.9× median
0611 OTHER	MRI Brain Inc Brain Stem WO/Contrast	30	$265.49	$7,302.30	$1,145.52	nat. median $1,201 1.0× median
0509 OTHER	Femto Laser Utilization	30	$159.08	$1,082.16	$1,082.16	nat. median $902 1.2× median
0922 OTHER	Amb Continuous Glucose Monitoring Min 72hrs Sensor Placement/Training/Removal	30	$48.84	$11,702.81	$1,069.00	nat. median $388 outlier · 2.8×
0450 OTHER	Emergency Dept Visit High Mdm	30	$1.00	$13,552.00	$1,030.27	nat. median $715 1.4× median
0483 OTHER	Congenital Transthoracis Echo	30	$15.74	$6,168.74	$960.48	nat. median $785 1.2× median
0540 OTHER	Bls Emergency	30	$140.80	$1,221.57	$933.70	nat. median $319 outlier · 2.9×
278 OTHER	Protege Stent 12x80x80	1	$898.36	$898.36	$898.36	nat. median $1,931 outlier · 0.5×
0342 OTHER	Radioph Rx By IV Admin	29	$131.42	$2,356.90	$894.00	nat. median $480 1.9× median
0740 OTHER	EEG-extended Monitoring 41-60 Minutes	30	$22.33	$4,058.59	$778.60	nat. median $647 1.2× median
0841 OTHER	Capd Training	30	$98.05	$2,360.00	$667.00	nat. median $667 1.0× median
0851 OTHER	Ccpd Training	30	$98.05	$2,224.00	$667.00	nat. median $667 1.0× median
0762 OTHER	Hourly Observation	30	$17.10	$2,042.67	$635.88	nat. median $106 outlier · 6.0×
0320 OTHER	Percutaneous Transhepatic Dilation Of Bili Duct Stricture	30	$15.15	$18,010.20	$630.00	nat. median $333 1.9× median
0390 OTHER	Rc Leuko Removed Rbc	30	$30.00	$12,451.00	$624.15	nat. median $464 1.3× median
276 OTHER	Clareon Monofocal Toric T3 Iol 10.0 - Uv Only	1	$599.89	$599.89	$599.89	nat. median $3,947 outlier · 0.2×
0343 OTHER	Myoview Per Dose (Tetrofosmin)	30	$5.77	$12,787.75	$595.10	nat. median $443 1.3× median
0981 OTHER	Rad. Head. Sub Child	30	$5.24	$26,344.00	$512.92	nat. median $492 1.0× median
0276 OTHER	Crystalens 10.00 Diopter	30	$3.43	$11,331.20	$508.40	nat. median $611 0.8× median
340 OTHER	Tumor Loc Whole Body 2 Or More Days Imaging	1	$481.69	$481.69	$481.69	nat. median $991 outlier · 0.5×
0340 OTHER	Intra Arterial Rpharm Rx	30	$68.94	$8,641.08	$469.00	nat. median $892 0.5× median
0402 OTHER	Bladder Scan	30	$4.24	$5,398.16	$458.00	nat. median $319 1.4× median
0732 OTHER	Telemetry Per Day	30	$69.05	$457.92	$457.92	nat. median $431 1.1× median

Other procedures at this hospital

Browse this hospital's 204 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

0275	OTHER	Defib Card 76gm 35cc W40xh73mm Thk14mm Df1 Is1 Conn Sgl	2,992	30	$18,947.89	$15,158.31 20% off	$18.89	$59,743.75	$10,019.17	2026-05-06
0681	OTHER	Full Trauma Team Resp W/Prehosp, W/30 Min Critical Care	214	30	$11,305.00	$9,044.00 20% off	$445.32	$22,482.00	$9,018.40	2026-05-06
0256	OTHER	Fecal Microbiota Preparation	59	30	$7,251.30	$5,801.04 20% off	$1,093.50	$7,251.30	$7,251.30	2026-05-06
0404	OTHER	Cardiace PET Metabol Eval	293	30	$10,271.00	$8,216.80 20% off	$636.30	$15,387.82	$5,788.00	2026-05-06
0637	OTHER	Potassium Iodide (expectorant) 1 Gm/ml Po Soln	45	23	$5,629.50	$4,503.60	$827.54	$5,629.50	$5,629.50	2026-05-06
0323	OTHER	A-gram Rima	460	29	$6,622.00	$5,297.60	$382.16	$18,010.20	$4,876.00	2026-05-06
0720	OTHER	Delivery Of Placenta	583	30	$6,131.00	$4,904.80 20% off	$126.67	$10,593.25	$4,475.63	2026-05-06
0612	OTHER	MRI C-spine Wo Contrast	327	30	$6,476.57	$5,181.26	$265.49	$8,836.23	$4,221.84	2026-05-06
0616	OTHER	MRA Lextrem Wo Contr	60	30	$3,570.00	$2,856.00 20% off	$265.49	$3,570.00	$3,570.00	2026-05-06
0750	OTHER	Hc Fac Esop.GI Reflux Test; W/Muco.Att	3,694	28	$5,068.38	$4,054.70 20% off	$2.28	$17,107.00	$3,380.18	2026-05-06
0618	OTHER	Pelvis MRA W And Wo Contr	229	30	$3,570.00	$2,856.00 20% off	$238.23	$5,974.00	$2,900.00	2026-05-06
0360	OTHER	Endometrial Bx W/wo Endocervix Bx Without Dilat Spx	17,591	30	$3,712.80	$2,970.24 20% off	$0.11	$118,024.37	$2,621.00	2026-05-06
0619	OTHER	3d Render Without Postprocess 08119	356	30	$4,838.21	$3,870.57	$44.56	$6,807.74	$2,341.68	2026-05-06
0333	OTHER	Sbrt Delivery Per Fraction	2,837	30	$4,455.00	$3,564.00 20% off	$20.21	$36,119.00	$2,169.45	2026-05-06
0614	OTHER	Card MRI W/Stress Img And Dye	316	30	$5,648.76	$4,519.01	$23.37	$6,736.08	$2,140.90	2026-05-06
0610	OTHER	Unlisted Magnetic Resonance Proced	1,586	30	$5,158.72	$4,126.98	$6.67	$11,453.70	$2,132.90	2026-05-06
0391	OTHER	Transf,Bl/Bl Comp-2c	248	30	$2,037.00	$1,629.60 20% off	$117.33	$11,858.00	$2,037.00	2026-05-06
0351	OTHER	CT Head With Contrast	550	30	$3,731.36	$2,985.09	$127.26	$4,935.17	$1,884.63	2026-05-06
0361	OTHER	Bronch W/Ther Asp Br	4,888	30	$3,027.27	$2,421.82	$1.00	$33,711.50	$1,854.88	2026-05-06
0722	OTHER	Tubal During C Section	59	30	$1,837.50	$1,470.00 20% off	$277.10	$1,837.50	$1,837.50	2026-05-06
0880	OTHER	Dialysis One Evaluation Crrt	64	30	$1,720.80	$1,376.64	$252.96	$1,720.80	$1,720.80	2026-05-06
0352	OTHER	CT Guide For Needle Place, Radio Super & Interp	1,120	30	$3,357.97	$2,686.38	$80.97	$7,082.68	$1,628.46	2026-05-06
0350	OTHER	CT Upper Extrem Without Contrast	994	30	$3,130.38	$2,504.30 20% off	$61.07	$5,398.16	$1,623.55	2026-05-06
0341	OTHER	Bm Imaging; Multiple Areas	1,993	30	$2,295.02	$1,836.02	$19.08	$12,097.51	$1,383.53	2026-05-06
0820	OTHER	Non Esrd Hemodialysis One Evaluation (685)	89	30	$1,555.00	$1,244.00 20% off	$201.60	$1,555.00	$1,321.75	2026-05-06
0801	OTHER	Acute Hemodialysis	171	30	$1,375.92	$1,100.74	$196.90	$4,058.59	$1,318.64	2026-05-06
0278	OTHER	Clp Aneur Blde L5mm Max Opn 4mm 110gm Ti Mini Perm Yasrg	89,562	30	$2,025.74	$1,620.59 20% off	$1.35	$159,345.00	$1,264.21	2026-05-06
0761	OTHER	Punch Bx Skin Single Lesion	3,331	30	$1,918.62	$1,534.90	$24.51	$14,708.00	$1,188.08	2026-05-06
0611	OTHER	MRI Brain Inc Brain Stem WO/Contrast	146	30	$6,206.95	$4,965.56	$265.49	$7,302.30	$1,145.52	2026-05-06
0509	OTHER	Femto Laser Utilization	60	30	$1,082.16	$865.73	$159.08	$1,082.16	$1,082.16	2026-05-06
0922	OTHER	Amb Continuous Glucose Monitoring Min 72hrs Sensor Placement/Training/Removal	559	30	$4,594.97	$3,675.98	$48.84	$11,702.81	$1,069.00	2026-05-06
0450	OTHER	Emergency Dept Visit High Mdm	15,183	30	$1,632.75	$1,306.20 20% off	$1.00	$13,552.00	$1,030.27	2026-05-06
0483	OTHER	Congenital Transthoracis Echo	1,159	30	$2,098.82	$1,679.06	$15.74	$6,168.74	$960.48	2026-05-06
0540	OTHER	Bls Emergency	124	30	$933.70	$746.96 20% off	$140.80	$1,221.57	$933.70	2026-05-06
278	OTHER	Protege Stent 12x80x80	1	1	$2,566.73	$2,053.38 20% off	$898.36	$898.36	$898.36	2026-05-06
0342	OTHER	Radioph Rx By IV Admin	121	29	$894.00	$715.20	$131.42	$2,356.90	$894.00	2026-05-06
0740	OTHER	EEG-extended Monitoring 41-60 Minutes	539	30	$1,011.38	$809.10 20% off	$22.33	$4,058.59	$778.60	2026-05-06
0841	OTHER	Capd Training	126	30	$2,360.00	$1,888.00 20% off	$98.05	$2,360.00	$667.00	2026-05-06
0851	OTHER	Ccpd Training	126	30	$2,224.00	$1,779.20 20% off	$98.05	$2,224.00	$667.00	2026-05-06
0762	OTHER	Hourly Observation	101	30	$794.85	$635.88 20% off	$17.10	$2,042.67	$635.88	2026-05-06
0320	OTHER	Percutaneous Transhepatic Dilation Of Bili Duct Stricture	7,081	30	$940.00	$752.00 20% off	$15.15	$18,010.20	$630.00	2026-05-06
0390	OTHER	Rc Leuko Removed Rbc	974	30	$932.06	$745.65	$30.00	$12,451.00	$624.15	2026-05-06
276	OTHER	Clareon Monofocal Toric T3 Iol 10.0 - Uv Only	1	1	$1,788.21	$1,430.57	$599.89	$599.89	$599.89	2026-05-06
0343	OTHER	Myoview Per Dose (Tetrofosmin)	2,090	30	$643.25	$514.60	$5.77	$12,787.75	$595.10	2026-05-06
0981	OTHER	Rad. Head. Sub Child	15,369	30	$730.00	$584.00 20% off	$5.24	$26,344.00	$512.92	2026-05-06
0276	OTHER	Crystalens 10.00 Diopter	3,436	30	$557.71	$446.17	$3.43	$11,331.20	$508.40	2026-05-06
340	OTHER	Tumor Loc Whole Body 2 Or More Days Imaging	1	1	$8,641.08	$6,912.86 20% off	$481.69	$481.69	$481.69	2026-05-06
0340	OTHER	Intra Arterial Rpharm Rx	131	30	$469.00	$375.20 20% off	$68.94	$8,641.08	$469.00	2026-05-06
0402	OTHER	Bladder Scan	3,007	30	$832.80	$666.24	$4.24	$5,398.16	$458.00	2026-05-06
0732	OTHER	Telemetry Per Day	59	30	$457.92	$366.34	$69.05	$457.92	$457.92	2026-05-06
0344	OTHER	I 131 Tx Solution Per Mci	170	30	$405.50	$324.40 20% off	$20.88	$6,916.00	$405.50	2026-05-06
0912	OTHER	Activity Therapy 45 Minutes Or Longer	10	3	$134.00	$107.20 20% off	$134.00	$609.00	$402.19	2026-05-06
0921	OTHER	Unilateral Or Limited Dvt	1,348	30	$735.30	$588.24	$9.34	$4,058.59	$394.70	2026-05-06
323	OTHER	Abd A-gram & Follow Down	1	1	$7,539.65	$6,031.72	$382.18	$382.18	$382.18	2026-05-06
0274	OTHER	Brace, Knee Post Op Lg	3,168	30	$532.88	$426.30 20% off	$3.01	$7,555.80	$369.68	2026-05-06
0280	OTHER	Chemo Extend IV Infus W/Pum	1	1	$1,456.35	$1,165.08 20% off	$364.31	$364.31	$364.31	2026-05-06
0514	OTHER	Fetal Non-stress Test	553	30	$467.25	$373.80 20% off	$15.91	$4,326.00	$360.15	2026-05-06
0444	OTHER	St Eval Rx Spch Devc 1st Hr	687	30	$678.00	$542.40 20% off	$34.63	$4,058.59	$355.94	2026-05-06
0510	OTHER	Hc Fac Routine Ophthalmological Exa	22,620	30	$460.60	$368.48 20% off	$0.18	$12,197.27	$337.49	2026-05-06
0310	OTHER	Igh Rearrange Abnormal Clonal Pop Amplified	6,419	30	$717.00	$573.60	$5.88	$45,054.00	$332.00	2026-05-06
0413	OTHER	Hbot, Full Body Chamber, 30m	73	29	$1,049.75	$839.80 20% off	$57.06	$1,049.75	$330.42	2026-05-06
0482	OTHER	Cardiac Stress With Electro Cardiac Monitoring	177	30	$579.92	$463.94	$21.03	$1,645.50	$318.14	2026-05-06
740	OTHER	EEG Incld Record Awake & Drowsy	4	1	$1,111.49	$889.19 20% off	$82.74	$364.02	$318.04	2026-05-06
0331	OTHER	Chemo, Im/Sq, Non-hormonal	303	30	$745.50	$596.40 20% off	$16.94	$1,105.09	$316.16	2026-05-06
0370	OTHER	Anesthesia Per Min Mac	537	30	$352.80	$282.24 20% off	$2.54	$5,478.72	$303.45	2026-05-06
0324	OTHER	Xray Chest 1 View	194	29	$645.58	$516.46 20% off	$25.70	$877.20	$295.75	2026-05-06
0400	OTHER	3d Redner Without Post Processing	109	30	$342.00	$273.60	$44.56	$919.98	$290.70	2026-05-06
450	OTHER	Application Ll Cast	23	1	$1,433.00	$1,146.40	$44.90	$490.40	$278.07	2026-05-06
610	OTHER	Mr Guidance For Needle Placement/Aspiration	2	1	$2,955.50	$2,364.40 20% off	$237.01	$318.12	$277.56	2026-05-06
636	OTHER	Durolane 1mg/60mg Inj	17	1	$275.89	$220.71 20% off	$1.05	$3,082.80	$275.89	2026-05-06
750	OTHER	Ugi W Removal Of Fb	1	1	$4,508.00	$3,606.40 20% off	$272.27	$272.27	$272.27	2026-05-06
0636	OTHER	HIV Prep, Inj, Cabotegravir	34,076	30	$441.00	$352.80 20% off	$0.03	$352,705.25	$271.38	2026-05-06
0943	OTHER	Cardiac Rehab Phase Ii Op	125	28	$423.30	$338.64 20% off	$31.37	$423.30	$265.49	2026-05-06
0441	OTHER	St Speech/Hearing Therapy Indiv	122	28	$695.10	$556.08	$36.03	$695.10	$260.97	2026-05-06
510	OTHER	Anoscopy	31	1	$693.84	$555.07 20% off	$23.26	$490.40	$254.25	2026-05-06
0401	OTHER	Dx Mammo Incl Cad Un	215	30	$460.00	$368.00 20% off	$14.37	$1,375.69	$239.21	2026-05-06
618	OTHER	Pelvis MRA W And Wo Contr	1	1	$3,362.00	$2,689.60 20% off	$238.23	$238.23	$238.23	2026-05-06
0335	OTHER	Chemo, IV Infusion, 1st Hr	503	30	$429.65	$343.72	$0.16	$2,637.16	$235.71	2026-05-06
981	OTHER	Application Of Forearm Cast	38	1	$1,250.00	$1,000.00 20% off	$21.42	$490.40	$233.98	2026-05-06
619	OTHER	MRA Chest Without And With Contrast	1	1	$3,834.00	$3,067.20 20% off	$233.32	$233.32	$233.32	2026-05-06
0460	OTHER	Incentive Spiromtry Rx	1,294	30	$346.75	$277.40 20% off	$2.57	$2,601.00	$227.69	2026-05-06
0272	OTHER	Maxframe(tm) Bridging Plate	161,439	30	$292.43	$233.94 20% off	$0.04	$88,525.00	$227.59	2026-05-06
341	OTHER	Bone Scan 3 Phase	21	1	$2,243.00	$1,794.40	$136.08	$649.01	$227.49	2026-05-06
0260	OTHER	IV Infusion, Hydration; Initial, Up To 1 Hour	721	30	$340.76	$272.61	$5.30	$1,503.00	$226.65	2026-05-06
0949	OTHER	Wound Non-selective Debridement	134	30	$270.90	$216.72	$18.62	$662.01	$218.24	2026-05-06
0513	OTHER	Hc Fac Psychiatric Diagnosis Evaluation	71	30	$230.23	$184.18 20% off	$32.30	$429.53	$214.18	2026-05-06
352	OTHER	CT Angio Abd Aorta And Bilat Ileofem W/c Non If Perf	6	1	$3,135.23	$2,508.18	$80.97	$281.21	$213.41	2026-05-06
0961	OTHER	Emergency Dept Visit High Mdm	2,199	30	$279.00	$223.20 20% off	$4.50	$2,601.00	$206.96	2026-05-06
0410	OTHER	Cont Vent Int	796	30	$301.00	$240.80	$3.03	$2,601.00	$201.25	2026-05-06
0940	OTHER	Phlebotomy Therapeutic	637	30	$371.45	$297.16	$8.66	$26,076.00	$193.78	2026-05-06
0372	OTHER	Mod Sed Endo Service 5 Years And Older	70	30	$317.00	$253.60 20% off	$16.17	$317.00	$193.21	2026-05-06
350	OTHER	CT Angio Abd&Pelv W/O&with Contrast	6	1	$3,082.59	$2,466.07 20% off	$106.99	$259.72	$187.93	2026-05-06
0312	OTHER	Surg Path G&m Level V	900	30	$505.72	$404.58	$10.35	$2,721.67	$176.08	2026-05-06
481	OTHER	Intro Of Catheter, Aorta	1	1	$1.00	$0.80	$173.66	$173.66	$173.66	2026-05-06
335	OTHER	Refill/Maint Portable Pump	1	1	$892.05	$713.64 20% off	$170.23	$170.23	$170.23	2026-05-06
514	OTHER	Antepartum Care 4-6 Visits	3	1	$374.76	$299.81	$26.99	$397.66	$163.81	2026-05-06
0434	OTHER	Ot Eval Low Complex 30 Min	200	30	$193.80	$155.04 20% off	$28.49	$332.26	$163.51	2026-05-06
0424	OTHER	Pt Eval Low Complex 20 Min	193	29	$220.50	$176.40 20% off	$33.25	$368.23	$160.97	2026-05-06
0920	OTHER	Upper Extremity Study	1,585	30	$219.00	$175.20 20% off	$5.43	$8,274.88	$154.35	2026-05-06
0403	OTHER	Scr Mammo Bi Incl Cad	131	30	$998.40	$798.72	$17.87	$998.40	$150.56	2026-05-06
920	OTHER	Autism Screenng	7	1	$1,036.88	$829.50 20% off	$10.67	$492.48	$146.45	2026-05-06
513	OTHER	Hc Fac Psychiatric Diagnosis Evaluation	1	1	$214.18	$171.34 20% off	$141.31	$141.31	$141.31	2026-05-06
0918	OTHER	Hc Facalth Risk Assessment, Patient Focused, Per Std Instrument (Chg)	362	30	$135.98	$108.78 20% off	$2.00	$448.73	$135.19	2026-05-06
0904	OTHER	Activity Therapy 45 Minutes Or Longer	59	28	$134.00	$107.20 20% off	$20.21	$609.00	$134.00	2026-05-06
0915	OTHER	Group Therapy	60	28	$134.00	$107.20 20% off	$20.21	$609.00	$134.00	2026-05-06
0440	OTHER	St Assessment Aphasia W/i&r Per Hour	750	30	$210.90	$168.72 20% off	$0.16	$674.00	$133.97	2026-05-06
0948	OTHER	Phys/Qhp Svcs Op Pulm Rehab Without Cont Oximtry Mntr	109	29	$175.76	$140.61	$26.50	$258.37	$131.82	2026-05-06
0300	OTHER	Unlisted Chemistry Procedure	6,208	30	$206.00	$164.80	$1.74	$4,286.65	$126.00	2026-05-06
0311	OTHER	Molecular Cytogenetics DNA Probe Each	2,242	30	$253.57	$202.86	$5.39	$2,721.67	$122.23	2026-05-06
921	OTHER	Doppler	5	1	$694.94	$555.95 20% off	$28.17	$189.73	$109.68	2026-05-06
0730	OTHER	12 Lead Ekg: Tracing Only	119	30	$368.13	$294.50 20% off	$13.60	$368.13	$107.31	2026-05-06
0430	OTHER	Ot Wound Care < Than 20sq Cms	2,200	30	$162.75	$130.20 20% off	$2.49	$884.83	$100.80	2026-05-06
0420	OTHER	Pt Wound Care < Than 20sq Cms	2,427	30	$171.00	$136.80	$2.49	$1,157.64	$100.80	2026-05-06
0490	OTHER	4n Hourly Spu Charge	345	28	$98.28	$78.62 20% off	$0.16	$374.76	$98.28	2026-05-06
434	OTHER	Ot Eval Low Complex 30 Min	1	1	$193.80	$155.04 20% off	$97.73	$97.73	$97.73	2026-05-06
0731	OTHER	Holter Monitor 48	193	30	$273.00	$218.40 20% off	$5.02	$643.86	$97.09	2026-05-06
0306	OTHER	Virus Isolat; Centrifuge Ea Virus	6,218	30	$187.55	$150.04 20% off	$2.90	$3,612.11	$96.38	2026-05-06
0530	OTHER	Omt 1-2 Regions	236	30	$157.29	$125.83 20% off	$12.52	$231.52	$90.87	2026-05-06
0471	OTHER	Hc Fac Screening Test,Pure Tone,Air On	705	30	$121.80	$97.44 20% off	$5.30	$521.28	$90.00	2026-05-06
0470	OTHER	Evoked Otoacoustic Emissions Screen Auto Analys	117	30	$87.15	$69.72 20% off	$12.81	$328.70	$87.15	2026-05-06
310	OTHER	Egfr Mutation	8	1	$909.62	$727.70	$32.78	$412.00	$86.77	2026-05-06
444	OTHER	Endoscopy Swallow (Fees) Vid	5	1	$664.65	$531.72	$62.52	$127.36	$86.28	2026-05-06
440	OTHER	St Assessment Aphasia W/i&r Per Hour	1	1	$210.90	$168.72 20% off	$84.86	$84.86	$84.86	2026-05-06
0924	OTHER	All Tstg Perq&Iq Drugs/Biol	331	30	$82.88	$66.30 20% off	$1.55	$1,767.80	$82.88	2026-05-06
0302	OTHER	Echinococcus Ab	9,564	30	$171.48	$137.18 20% off	$2.04	$6,157.00	$81.70	2026-05-06
401	OTHER	Breast Tomosynthesis Unilateral/Bilateral	3	1	$905.06	$724.05	$14.43	$102.69	$80.59	2026-05-06
0942	OTHER	Dm Training, Inidividual, 30 Min	632	30	$129.00	$103.20 20% off	$4.06	$609.00	$79.68	2026-05-06
0729	OTHER	Epidural Ea Add Hr> 2 Hr	13	5	$127.20	$101.76 20% off	$18.70	$237.83	$79.60	2026-05-06
0255	OTHER	Visipaque 320/100ml	565	30	$137.50	$110.00 20% off	$0.04	$4,553.59	$78.75	2026-05-06
0301	OTHER	General Health Panel	21,217	30	$202.86	$162.29	$1.26	$8,185.96	$78.57	2026-05-06
0279	OTHER	O2 Transport	122	30	$77.70	$62.16 20% off	$11.42	$102.90	$77.70	2026-05-06
331	OTHER	Chemo Cns (Intrathecal) W Lumbar Puncture	2	1	$918.75	$735.00 20% off	$71.77	$78.58	$75.17	2026-05-06
483	OTHER	Doppler Echo Limited/ F-up	2	1	$1,692.95	$1,354.36	$30.27	$117.97	$74.12	2026-05-06
333	OTHER	Port Films	2	1	$609.85	$487.88 20% off	$20.21	$126.80	$73.50	2026-05-06
0309	OTHER	Crystals, Fluid	430	30	$175.00	$140.00 20% off	$4.95	$1,435.00	$73.11	2026-05-06
312	OTHER	Frozen Section	10	1	$304.02	$243.22 20% off	$22.95	$265.55	$72.53	2026-05-06
0270	OTHER	Acapella Device	8,285	30	$86.89	$69.51 20% off	$0.96	$5,160.75	$71.14	2026-05-06
402	OTHER	Bladder Scan	19	1	$834.34	$667.47 20% off	$16.30	$191.57	$71.08	2026-05-06
413	OTHER	Hbot, Full Body Chamber, 30m	1	1	$1,049.75	$839.80 20% off	$68.67	$68.67	$68.67	2026-05-06
360	OTHER	Inj Proc Extremity Venography, Inc Needle Intro	1	1	$480.00	$384.00 20% off	$68.29	$68.29	$68.29	2026-05-06
0480	OTHER	Pm Device Program Eval	845	28	$107.01	$85.61	$6.65	$845.25	$68.25	2026-05-06
0253	OTHER	Albuterol Sulfate Hfa 108 (90 Base) Mcg/act In Aers	405	23	$92.75	$74.20	$0.59	$2,255.75	$67.71	2026-05-06
424	OTHER	Pt Re-eval Est Plan Care	1	1	$220.50	$176.40 20% off	$67.46	$67.46	$67.46	2026-05-06
0250	OTHER	Ensure Plus	17,505	30	$75.75	$60.60 20% off	$0.04	$48,154.75	$65.63	2026-05-06
922	OTHER	Musc Tst Done W/Nerv Tst Lim	1	1	$584.23	$467.38 20% off	$65.26	$65.26	$65.26	2026-05-06
0481	OTHER	Cardiac Cath Lab Staff	275	30	$64.80	$51.84	$0.15	$7,209.00	$64.80	2026-05-06
761	OTHER	Punch Bx Skin Single Lesion	1	1	$1,039.54	$831.63 20% off	$63.25	$63.25	$63.25	2026-05-06
731	OTHER	Hc Fac ECG Monitor 24 Hrs; Scanning An	1	1	$273.00	$218.40 20% off	$62.20	$62.20	$62.20	2026-05-06
0923	OTHER	Thin Prep Pap Smear	3	1	$369.25	$295.40 20% off	$49.79	$61.46	$61.46	2026-05-06
961	OTHER	Hc IP/Obs Consltj New/Est Pt Sf Mdm 35 Minutes	4	1	$294.00	$235.20	$26.27	$125.08	$60.09	2026-05-06
0271	OTHER	Hc Fac Cimerli 0.1mg	2,868	30	$79.01	$63.21	$0.93	$5,358.94	$59.60	2026-05-06
0770	OTHER	Cervical/Vaginal Ca Screen	292	30	$58.80	$47.04 20% off	$6.75	$429.36	$56.78	2026-05-06
320	OTHER	Aortography, Abd/Bilat Ileofem	32	1	$708.65	$566.92	$18.96	$382.18	$56.72	2026-05-06
0771	OTHER	Imm Admn Sarcov2 Vaccine Single Dose	730	30	$110.25	$88.20 20% off	$5.07	$1,350.00	$56.00	2026-05-06
311	OTHER	Cp Smr Othr; Scrn & Int	11	1	$146.50	$117.20 20% off	$20.19	$295.69	$53.58	2026-05-06
403	OTHER	Breast Tomosynthesis Bi - Screening	2	1	$624.39	$499.51 20% off	$22.10	$84.96	$53.53	2026-05-06
0259	OTHER	Pureflow Bicarbonate Solution/Case 2 5l Bags	1,655	30	$62.25	$49.80 20% off	$0.40	$1,874.50	$53.34	2026-05-06
430	OTHER	Ot Appl Cast; Shoulder To Hand	2	1	$265.00	$212.00 20% off	$33.50	$66.49	$49.99	2026-05-06
260	OTHER	IV Infusion, Hydration; Initial, Up To 1 Hour	1	1	$1,185.24	$948.19 20% off	$49.49	$49.49	$49.49	2026-05-06
390	OTHER	Ffp 8-24 Hrs Of Collect, Ea Unit	1	1	$332.88	$266.30 20% off	$46.94	$46.94	$46.94	2026-05-06
0305	OTHER	Prothrombin Time	3,061	30	$190.00	$152.00 20% off	$2.02	$2,721.67	$46.47	2026-05-06
0900	OTHER	Intensive Behavioral Therapy For Obesity	70	30	$45.50	$36.40 20% off	$6.86	$308.18	$45.50	2026-05-06
0254	OTHER	Omnipaque 240	338	27	$41.39	$33.11 20% off	$0.04	$798.50	$42.17	2026-05-06
420	OTHER	Pt Aquatic Therapy (15 Min)	2	1	$259.00	$224.40	$33.50	$42.24	$37.87	2026-05-06
361	OTHER	I & D Simple	1	1	$1,017.90	$814.32	$36.77	$36.77	$36.77	2026-05-06
480	OTHER	Interrogation Eval Remote </30 D Cv Mntr Sys	2	1	$68.88	$55.11	$32.78	$37.95	$35.37	2026-05-06
482	OTHER	Cv Strs Tst Xers&/or Rx Cont ECG Trcg Only	1	1	$579.92	$463.94	$35.16	$35.16	$35.16	2026-05-06
441	OTHER	St Speech/Hearing Therapy Indiv	1	1	$695.10	$556.08	$33.95	$33.95	$33.95	2026-05-06
0914	OTHER	Hc Fac Group Psychotherapy	180	30	$48.29	$38.63 20% off	$1.13	$176.47	$33.89	2026-05-06
949	OTHER	Negative Pressure Wound Therapy Dme >50 Sq Cm	2	1	$197.19	$157.75 20% off	$25.17	$42.24	$33.70	2026-05-06
530	OTHER	Omt 1-2 Regions	3	1	$119.80	$95.84	$21.42	$65.15	$32.51	2026-05-06
942	OTHER	Dm Training, Inidividual, 30 Min	3	1	$69.30	$55.44 20% off	$23.26	$51.55	$30.58	2026-05-06
900	OTHER	Intensive Behavioral Therapy For Obesity	1	1	$45.50	$36.40 20% off	$28.34	$28.34	$28.34	2026-05-06
324	OTHER	Xray Chest 1 View	1	1	$492.81	$394.25	$24.22	$24.22	$24.22	2026-05-06
460	OTHER	Car Seat Challenge Additional 30 Minutes	6	1	$223.00	$178.40 20% off	$7.58	$30.63	$22.05	2026-05-06
940	OTHER	Cmt; 1-2 Regions	4	1	$80.48	$64.38 20% off	$15.65	$32.10	$20.30	2026-05-06
0307	OTHER	Urinalysis Dipstick On	521	30	$32.00	$25.60	$2.02	$138.18	$19.00	2026-05-06
771	OTHER	Admin Of Influenza Virus Vaccin	4	1	$48.75	$39.00 20% off	$8.21	$21.51	$18.55	2026-05-06
770	OTHER	Cervical/Vaginal Ca Screen	2	1	$79.02	$63.22	$8.51	$25.19	$16.85	2026-05-06
370	OTHER	Mod Sed Same Phys/Qhp 5 Years Of Age Or Older	1	1	$1,369.68	$1,095.74 20% off	$15.49	$15.49	$15.49	2026-05-06
410	OTHER	Cont Vent Sub Day	4	1	$213.50	$170.80	$9.45	$60.05	$13.55	2026-05-06
471	OTHER	Comprehensive Audiometry Threshold Eval & Speech Recognition	3	1	$61.85	$49.48 20% off	$10.08	$30.01	$12.52	2026-05-06
0710	OTHER	Delivery/Recovery Serv	496	27	$12.10	$9.68 20% off	$0.20	$954.80	$12.10	2026-05-06
302	OTHER	TB Test Intradermal	1	1	$31.50	$25.20 20% off	$9.14	$9.14	$9.14	2026-05-06
730	OTHER	EKG 12 Lead Tracing Only	1	1	$107.31	$85.85	$5.76	$5.76	$5.76	2026-05-06
918	OTHER	Hc Facalth Risk Assessment, Patient Focused, Per Std Instrument (Chg)	1	1	$13.23	$10.58 20% off	$5.44	$5.44	$5.44	2026-05-06
0258	OTHER	Sterile Saline Sol Per 500 Ml	512	29	$4.46	$3.57	$0.12	$4,058.59	$4.20	2026-05-06
924	OTHER	Percut Tests (Scratch,Punct,Pri	1	1	$10.29	$8.23 20% off	$2.35	$2.35	$2.35	2026-05-06
0780	OTHER	Hc Fac Phys/Qhp Telephone Evaluation 5-10 Min	58	29	$61.40	$49.12 20% off	$0.35	$2.32	$2.32	2026-05-06
0990	OTHER	Guest Tray	116	30	$12.00	$9.60 20% off	$0.15	$12.00	$1.81	2026-05-06
MOD50	OTHER	150% Payment Adjustment For The Item Or Service To Which The Modifier Is Appende…	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MOD51	OTHER	50% Payment Adjustment For The Item Or Service To Which The Modifier Is Appended	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MOD52	OTHER	50% Payment Adjustment For The Item Or Service To Which The Modifier Is Appended	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MOD53	OTHER	120% Payment Adjustment For The CPTs 59400 Or 59610 To Which The Modifier Is App…	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MOD62	OTHER	37.5% Payment Adjustment For The Item Or Service To Which The Modifier Is Append…	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MOD80	OTHER	84% Payment Adjustment For The Item Or Service To Which The Modifier Is Appended	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MOD81	OTHER	84% Payment Adjustment For The Item Or Service To Which The Modifier Is Appended	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MOD82	OTHER	84% Payment Adjustment For The Item Or Service To Which The Modifier Is Appended	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MODAD	OTHER	300% (3 Units) Payment Adjustment For The Item Or Service To Which The Modifier …	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MODAS	OTHER	Calculated By Multiplying The Facility Specific Mpfs Amount By 16%, Subtracting …	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MODQK	OTHER	50% Payment Adjustment For The Item Or Service To Which The Modifier Is Appended	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
MODQY	OTHER	50% Payment Adjustment For The Item Or Service To Which The Modifier Is Appended	18	15	$1.00	$1.00	$1.00	$1.00	$1.00	2026-05-06
0329	OTHER	Hc Clinical Decision Support For Applied Pathways	64	30	$1.00	$0.80	$0.15	$1.00	$1.00	2026-05-06
0999	OTHER	Hg A1c Level <7.0%	0	0	$0.01	—	—	—	—	2026-05-06

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