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

ASPIRUS DIVINE SAVIOR HOSPITAL

Portage, WI · CCN 520041 · Rates published

291 distinct procedures filed
20 distinct payers
23,300 rate rows
2025-07-01 last MRF observed · ⚠ 12 mo old
Data quality

1,898 of 23,300 rate rows are consumer-grade (8.1%)

21,402 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
professional (physician) fee — not the facility price 14,281
no usable negotiated amount (only an out-of-band fallback) — excluded from medians 7,121

⚠ Possibly outdated The most recent machine-readable file we have for this hospital is 12 months old. CMS requires hospitals to refresh these files at least annually, so newer rates may exist that we haven't ingested yet. The prices below are exactly as last filed.

Data source & audit trail ↓ Download audit trail (JSON)
Source MRF file https://www.aspirus.org/Uploads/Public/Documents/PriceEstimate/TransparencyFY26/390806250_aspirus-divine-savior-hospital_standardcharges.json
Found on page https://www.aspirus.org/price-estimate
Discovered viaDiscovered by HANK
Last fetch Latest re-check couldn't be parsed — showing last good data · 2026-05-18
Content fingerprint 5a10fddce12bbca6… · 153,551,580 bytes · first seen 2026-05-09

Top 50 most expensive offerings

Outliers are flagged where this hospital's filed rate is ≥2× or ≤0.5× the national median for the same code.

Code Description Payers Min $ Max $ Avg median vs national
466
MS_DRG 		Revision Of Hip Or Knee Replacement With Mcc 2 $41,872.36 $72,981.39 $57,426.88 nat. median
$49,191
1.2× median
853
MS_DRG 		Infectious And Parasitic Diseases With O.r. Procedures With Mcc 2 $41,911.89 $67,430.43 $54,671.16 nat. median
$48,170
1.1× median
207
MS_DRG 		Respiratory System Diagnosis With Ventilator Support >96 Hours 2 $42,387.03 $59,014.95 $46,633.20 nat. median
$62,134
0.8× median
331
MS_DRG 		Major Small And Large Bowel Procedures Without Cc/Mcc 1 $38,851.60 $38,851.60 $38,851.60 nat. median
$17,703
outlier · 2.2×
616
MS_DRG 		Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With… 1 $33,293.01 $33,293.01 $33,293.01 nat. median
$35,856
0.9× median
59
MS_DRG 		Multiple Sclerosis And Cerebellar Ataxia With Cc 1 $31,897.89 $31,897.89 $31,897.89 nat. median
$13,000
outlier · 2.5×
467
MS_DRG 		Revision Of Hip Or Knee Replacement With Cc 1 $29,982.46 $29,982.46 $29,982.46 nat. median
$34,720
0.9× median
896
MS_DRG 		Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc 5 $15,995.28 $49,852.43 $27,659.39 nat. median
$16,145
1.7× median
443
MS_DRG 		Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without C… 1 $27,091.59 $27,091.59 $27,091.59 nat. median
$8,113
outlier · 3.3×
398
MS_DRG 		Appendix Procedures With Cc 1 $25,423.51 $25,423.51 $25,423.51 nat. median
$15,921
1.6× median
521
MS_DRG 		Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc 1 $24,482.60 $26,017.28 $25,249.94 nat. median
$28,961
0.9× median
480
MS_DRG 		Hip And Femur Procedures Except Major Joint With Mcc 1 $24,691.32 $24,691.32 $24,691.32 nat. median
$29,218
0.8× median
470
MS_DRG 		Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without… 2 $16,251.75 $24,984.88 $23,637.39 nat. median
$20,055
1.2× median
468
MS_DRG 		Revision Of Hip Or Knee Replacement Without Cc/Mcc 1 $23,502.18 $23,502.18 $23,502.18 nat. median
$27,218
0.9× median
149
MS_DRG 		Dysequilibrium 1 $23,157.74 $23,157.74 $23,157.74 nat. median
$8,477
outlier · 2.7×
743
MS_DRG 		Uterine And Adnexa Procedures For Non-malignancy Without Cc/Mcc 1 $22,396.66 $22,396.66 $22,396.66 nat. median
$13,186
1.7× median
394
MS_DRG 		Other Digestive System Diagnoses With Cc 1 $22,136.62 $22,136.62 $22,136.62 nat. median
$10,259
outlier · 2.2×
483
MS_DRG 		Major Joint Or Limb Reattachment Procedures Of Upper Extremities 3 $20,336.19 $46,951.38 $21,187.55 nat. median
$26,699
0.8× median
419
MS_DRG 		Laparoscopic Cholecystectomy Without C.d.e. Without Cc/Mcc 1 $20,851.02 $20,851.02 $20,851.02 nat. median
$14,421
1.4× median
417
MS_DRG 		Laparoscopic Cholecystectomy Without C.d.e. With Mcc 1 $20,677.64 $20,677.64 $20,677.64 nat. median
$23,829
0.9× median
787
MS_DRG 		Cesarean Section Without Sterilization With Cc 2 $16,633.66 $21,201.37 $18,917.51 nat. median
$11,413
1.7× median
643
MS_DRG 		Endocrine Disorders With Mcc 2 $13,076.75 $24,622.87 $18,849.81 nat. median
$16,781
1.1× median
208
MS_DRG 		Respiratory System Diagnosis With Ventilator Support <=96 Hours 3 $13,734.72 $24,018.32 $18,642.07 nat. median
$26,748
0.7× median
629
MS_DRG 		Other Endocrine, Nutritional And Metabolic O.r. Procedures With Cc 1 $18,431.93 $18,431.93 $18,431.93 nat. median
$22,198
0.8× median
768
MS_DRG 		Vaginal Delivery With O.r. Procedures Except Sterilization And/Or D&c 2 $17,749.29 $18,958.62 $18,353.96 nat. median
$10,536
1.7× median
5673
OTHER 		Level 3 Pathology 10 $195.06 $27,983.48 $18,160.03 nat. median
$393
outlier · 46.2×
522
MS_DRG 		Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc 4 $14,633.20 $41,709.23 $18,116.53 nat. median
$21,760
0.8× median
330
MS_DRG 		Major Small And Large Bowel Procedures With Cc 3 $16,650.33 $44,673.93 $17,996.18 nat. median
$24,346
0.7× median
325
MS_DRG 		Coronary Intravascular Lithotripsy Without Intraluminal Device 1 $17,907.53 $17,907.53 $17,907.53 nat. median
$29,977
0.6× median
854
MS_DRG 		Infectious And Parasitic Diseases With O.r. Procedures With Cc 3 $7,175.79 $31,630.63 $17,884.05 nat. median
$20,421
0.9× median
64
MS_DRG 		Intracranial Hemorrhage Or Cerebral Infarction With Mcc 2 $14,557.56 $32,300.22 $17,547.59 nat. median
$20,254
0.9× median
387
MS_DRG 		Inflammatory Bowel Disease Without Cc/Mcc 1 $17,404.72 $17,404.72 $17,404.72 nat. median
$7,938
outlier · 2.2×
871
MS_DRG 		Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc 7 $8,890.12 $39,096.20 $17,326.76 nat. median
$19,634
0.9× median
811
MS_DRG 		Red Blood Cell Disorders With Mcc 1 $11,852.64 $22,305.48 $17,079.06 nat. median
$14,380
1.2× median
385
MS_DRG 		Inflammatory Bowel Disease With Mcc 5 $14,136.60 $31,238.43 $16,935.55 nat. median
$16,227
1.0× median
481
MS_DRG 		Hip And Femur Procedures Except Major Joint With Cc 3 $13,000.93 $18,183.72 $16,909.71 nat. median
$21,529
0.8× median
432
MS_DRG 		Cirrhosis And Alcoholic Hepatitis With Mcc 2 $12,529.90 $71,264.39 $16,876.35 nat. median
$19,681
0.9× median
920
MS_DRG 		Complications Of Treatment With Cc 1 $16,875.39 $16,875.39 $16,875.39 nat. median
$10,962
1.5× median
788
MS_DRG 		Cesarean Section Without Sterilization Without Cc/Mcc 6 $4,285.76 $28,929.74 $16,760.86 nat. median
$10,164
1.6× median
868
MS_DRG 		Other Infectious And Parasitic Diseases Diagnoses With Cc 1 $16,709.87 $16,709.87 $16,709.87 nat. median
$11,260
1.5× median
862
MS_DRG 		Postoperative And Post-traumatic Infections With Mcc 1 $16,018.01 $16,018.01 $16,018.01 nat. median
$18,227
0.9× median
0961
OTHER 		Albumin (human),5%, 50ml 2 $5,427.34 $26,425.16 $15,926.25 nat. median
$142
outlier · 112.4×
5414
OTHER 		Level 4 Gynecologic Procedures 1 $15,841.08 $15,841.08 $15,841.08 nat. median
$3,545
outlier · 4.5×
441
MS_DRG 		Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc 1 $15,191.93 $15,191.93 $15,191.93 nat. median
$18,509
0.8× median
493
MS_DRG 		Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc 1 $14,913.75 $14,913.75 $14,913.75 nat. median
$24,757
0.6× median
199
MS_DRG 		Pneumothorax With Mcc 1 $14,554.97 $14,554.97 $14,554.97 nat. median
$17,612
0.8× median
5791
OTHER 		Pulmonary Treatment 2 $871.81 $27,992.57 $14,432.19 nat. median
$231
outlier · 62.5×
372
MS_DRG 		Major Gastrointestinal Disorders And Peritoneal Infections With Cc 3 $12,528.45 $18,620.40 $14,214.81 nat. median
$11,087
1.3× median
786
MS_DRG 		Cesarean Section Without Sterilization With Mcc 1 $14,068.54 $14,068.54 $14,068.54 nat. median
$15,316
0.9× median
564
MS_DRG 		Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc 1 $13,930.62 $13,930.62 $13,930.62 nat. median
$15,782
0.9× median

Other procedures at this hospital

Browse this hospital's 291 published procedures. Use the slice to choose what to show, then sort or filter any column.

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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
             
466 MS_DRG Revision Of Hip Or Knee Replacement With Mcc 2 2 — — $41,872.36 $72,981.39 $57,426.88 2025-07-01
853 MS_DRG Infectious And Parasitic Diseases With O.r. Procedures With Mcc 2 2 — — $41,911.89 $67,430.43 $54,671.16 2025-07-01
207 MS_DRG Respiratory System Diagnosis With Ventilator Support >96 Hours 3 2 — — $42,387.03 $59,014.95 $46,633.20 2025-07-01
331 MS_DRG Major Small And Large Bowel Procedures Without Cc/Mcc 1 1 — — $38,851.60 $38,851.60 $38,851.60 2025-07-01
616 MS_DRG Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With… 1 1 — — $33,293.01 $33,293.01 $33,293.01 2025-07-01
59 MS_DRG Multiple Sclerosis And Cerebellar Ataxia With Cc 1 1 — — $31,897.89 $31,897.89 $31,897.89 2025-07-01
467 MS_DRG Revision Of Hip Or Knee Replacement With Cc 1 1 — — $29,982.46 $29,982.46 $29,982.46 2025-07-01
896 MS_DRG Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc 5 5 — — $15,995.28 $49,852.43 $27,659.39 2025-07-01
443 MS_DRG Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without C… 1 1 — — $27,091.59 $27,091.59 $27,091.59 2025-07-01
398 MS_DRG Appendix Procedures With Cc 1 1 — — $25,423.51 $25,423.51 $25,423.51 2025-07-01
521 MS_DRG Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc 2 1 — — $24,482.60 $26,017.28 $25,249.94 2025-07-01
480 MS_DRG Hip And Femur Procedures Except Major Joint With Mcc 1 1 — — $24,691.32 $24,691.32 $24,691.32 2025-07-01
470 MS_DRG Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without … 3 2 — — $16,251.75 $24,984.88 $23,637.39 2025-07-01
468 MS_DRG Revision Of Hip Or Knee Replacement Without Cc/Mcc 1 1 — — $23,502.18 $23,502.18 $23,502.18 2025-07-01
149 MS_DRG Dysequilibrium 1 1 — — $23,157.74 $23,157.74 $23,157.74 2025-07-01
743 MS_DRG Uterine And Adnexa Procedures For Non-malignancy Without Cc/Mcc 1 1 — — $22,396.66 $22,396.66 $22,396.66 2025-07-01
394 MS_DRG Other Digestive System Diagnoses With Cc 1 1 — — $22,136.62 $22,136.62 $22,136.62 2025-07-01
483 MS_DRG Major Joint Or Limb Reattachment Procedures Of Upper Extremities 3 3 — — $20,336.19 $46,951.38 $21,187.55 2025-07-01
419 MS_DRG Laparoscopic Cholecystectomy Without C.d.e. Without Cc/Mcc 1 1 — — $20,851.02 $20,851.02 $20,851.02 2025-07-01
417 MS_DRG Laparoscopic Cholecystectomy Without C.d.e. With Mcc 1 1 — — $20,677.64 $20,677.64 $20,677.64 2025-07-01
787 MS_DRG Cesarean Section Without Sterilization With Cc 2 2 — — $16,633.66 $21,201.37 $18,917.51 2025-07-01
643 MS_DRG Endocrine Disorders With Mcc 2 2 — — $13,076.75 $24,622.87 $18,849.81 2025-07-01
208 MS_DRG Respiratory System Diagnosis With Ventilator Support <=96 Hours 3 3 — — $13,734.72 $24,018.32 $18,642.07 2025-07-01
629 MS_DRG Other Endocrine, Nutritional And Metabolic O.r. Procedures With Cc 1 1 — — $18,431.93 $18,431.93 $18,431.93 2025-07-01
768 MS_DRG Vaginal Delivery With O.r. Procedures Except Sterilization And/Or D&c 2 2 — — $17,749.29 $18,958.62 $18,353.96 2025-07-01
5673 OTHER Level 3 Pathology 13 10 — — $195.06 $27,983.48 $18,160.03 2025-07-01
522 MS_DRG Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc 6 4 — — $14,633.20 $41,709.23 $18,116.53 2025-07-01
330 MS_DRG Major Small And Large Bowel Procedures With Cc 3 3 — — $16,650.33 $44,673.93 $17,996.18 2025-07-01
325 MS_DRG Coronary Intravascular Lithotripsy Without Intraluminal Device 1 1 — — $17,907.53 $17,907.53 $17,907.53 2025-07-01
854 MS_DRG Infectious And Parasitic Diseases With O.r. Procedures With Cc 5 3 — — $7,175.79 $31,630.63 $17,884.05 2025-07-01
64 MS_DRG Intracranial Hemorrhage Or Cerebral Infarction With Mcc 3 2 — — $14,557.56 $32,300.22 $17,547.59 2025-07-01
387 MS_DRG Inflammatory Bowel Disease Without Cc/Mcc 1 1 — — $17,404.72 $17,404.72 $17,404.72 2025-07-01
871 MS_DRG Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc 15 7 — — $8,890.12 $39,096.20 $17,326.76 2025-07-01
811 MS_DRG Red Blood Cell Disorders With Mcc 2 1 — — $11,852.64 $22,305.48 $17,079.06 2025-07-01
385 MS_DRG Inflammatory Bowel Disease With Mcc 5 5 — — $14,136.60 $31,238.43 $16,935.55 2025-07-01
481 MS_DRG Hip And Femur Procedures Except Major Joint With Cc 3 3 — — $13,000.93 $18,183.72 $16,909.71 2025-07-01
432 MS_DRG Cirrhosis And Alcoholic Hepatitis With Mcc 3 2 — — $12,529.90 $71,264.39 $16,876.35 2025-07-01
920 MS_DRG Complications Of Treatment With Cc 1 1 — — $16,875.39 $16,875.39 $16,875.39 2025-07-01
788 MS_DRG Cesarean Section Without Sterilization Without Cc/Mcc 7 6 — — $4,285.76 $28,929.74 $16,760.86 2025-07-01
868 MS_DRG Other Infectious And Parasitic Diseases Diagnoses With Cc 1 1 — — $16,709.87 $16,709.87 $16,709.87 2025-07-01
862 MS_DRG Postoperative And Post-traumatic Infections With Mcc 1 1 — — $16,018.01 $16,018.01 $16,018.01 2025-07-01
0961 OTHER Albumin (human),5%, 50ml 2 2 — — $5,427.34 $26,425.16 $15,926.25 2025-07-01
5414 OTHER Level 4 Gynecologic Procedures 1 1 — — $15,841.08 $15,841.08 $15,841.08 2025-07-01
441 MS_DRG Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc 1 1 — — $15,191.93 $15,191.93 $15,191.93 2025-07-01
493 MS_DRG Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc 1 1 — — $14,913.75 $14,913.75 $14,913.75 2025-07-01
199 MS_DRG Pneumothorax With Mcc 1 1 — — $14,554.97 $14,554.97 $14,554.97 2025-07-01
5791 OTHER Pulmonary Treatment 2 2 — — $871.81 $27,992.57 $14,432.19 2025-07-01
372 MS_DRG Major Gastrointestinal Disorders And Peritoneal Infections With Cc 3 3 — — $12,528.45 $18,620.40 $14,214.81 2025-07-01
786 MS_DRG Cesarean Section Without Sterilization With Mcc 1 1 — — $14,068.54 $14,068.54 $14,068.54 2025-07-01
564 MS_DRG Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc 1 1 — — $13,930.62 $13,930.62 $13,930.62 2025-07-01
482 MS_DRG Hip And Femur Procedures Except Major Joint Without Cc/Mcc 3 3 — — $11,024.48 $13,880.56 $13,688.53 2025-07-01
884 MS_DRG Organic Disturbances And Intellectual Disability 3 3 — — $6,424.08 $13,725.81 $13,633.34 2025-07-01
440 MS_DRG Disorders Of Pancreas Except Malignancy Without Cc/Mcc 1 1 — — $13,601.78 $13,601.78 $13,601.78 2025-07-01
866 MS_DRG Viral Illness Without Mcc 2 2 — — $8,544.98 $18,547.50 $13,546.24 2025-07-01
9291 OTHER Inj, Clindamycin Phosp 300mg 2 2 — — $11,775.34 $15,069.21 $13,422.27 2025-07-01
177 MS_DRG Respiratory Infections And Inflammations With Mcc 7 4 — — $11,389.61 $29,409.47 $13,420.24 2025-07-01
700 MS_DRG Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc 1 1 — — $13,386.87 $13,386.87 $13,386.87 2025-07-01
551 MS_DRG Medical Back Problems With Mcc 2 2 — — $11,658.17 $15,065.57 $13,361.87 2025-07-01
602 MS_DRG Cellulitis With Mcc 1 1 — — $13,342.82 $13,342.82 $13,342.82 2025-07-01
867 MS_DRG Other Infectious And Parasitic Diseases Diagnoses With Mcc 1 1 — — $13,310.95 $13,310.95 $13,310.95 2025-07-01
913 MS_DRG Traumatic Injury With Mcc 1 1 — — $13,098.38 $13,098.38 $13,098.38 2025-07-01
571 MS_DRG Skin Debridement With Cc 1 1 — — $13,051.39 $13,051.39 $13,051.39 2025-07-01
351 MS_DRG Inguinal And Femoral Hernia Procedures With Cc 1 1 — — $13,016.61 $13,016.61 $13,016.61 2025-07-01
917 MS_DRG Poisoning And Toxic Effects Of Drugs With Mcc 3 3 — — $12,580.09 $13,936.43 $12,801.49 2025-07-01
438 MS_DRG Disorders Of Pancreas Except Malignancy With Mcc 1 1 — — $12,783.89 $12,783.89 $12,783.89 2025-07-01
418 MS_DRG Laparoscopic Cholecystectomy Without C.d.e. With Cc 1 1 — — $12,722.13 $12,722.13 $12,722.13 2025-07-01
682 MS_DRG Renal Failure With Mcc 5 4 — — $3,153.91 $65,237.03 $12,684.02 2025-07-01
377 MS_DRG Gastrointestinal Hemorrhage With Mcc 3 2 — — $8,509.79 $15,726.23 $12,613.99 2025-07-01
785 MS_DRG Cesarean Section With Sterilization Without Cc/Mcc 4 3 — — $4,298.40 $14,289.79 $12,598.04 2025-07-01
83 MS_DRG Traumatic Stupor And Coma >1 Hour With Cc 1 1 — — $12,574.24 $12,574.24 $12,574.24 2025-07-01
698 MS_DRG Other Kidney And Urinary Tract Diagnoses With Mcc 4 4 — — $8,785.07 $14,668.49 $12,565.70 2025-07-01
5361 OTHER Level 1 Laparoscopy And Related Services 1 1 — — $12,422.09 $12,422.09 $12,422.09 2025-07-01
699 MS_DRG Other Kidney And Urinary Tract Diagnoses With Cc 2 2 — — $9,371.84 $15,315.84 $12,343.84 2025-07-01
57 MS_DRG Degenerative Nervous System Disorders Without Mcc 2 2 — — $11,877.28 $12,330.63 $12,103.95 2025-07-01
9132 OTHER Prothrombin Complex Kcentra 4 4 — — $2,269.86 $19,329.96 $11,924.30 2025-07-01
813 MS_DRG Coagulation Disorders 2 1 — — $9,767.28 $14,034.05 $11,900.67 2025-07-01
299 MS_DRG Peripheral Vascular Disorders With Mcc 1 1 — — $11,824.37 $11,824.37 $11,824.37 2025-07-01
416 MS_DRG Cholecystectomy Except By Laparoscope Without C.d.e. Without Cc/Mcc 1 1 — — $11,710.95 $11,710.95 $11,710.95 2025-07-01
637 MS_DRG Diabetes With Mcc 2 2 — — $11,206.02 $11,924.94 $11,565.48 2025-07-01
872 MS_DRG Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc 10 6 — — $4,739.92 $50,423.25 $11,453.07 2025-07-01
193 MS_DRG Simple Pneumonia And Pleurisy With Mcc 8 6 — — $6,112.27 $12,257.89 $11,301.23 2025-07-01
180 MS_DRG Respiratory Neoplasms With Mcc 2 2 — — $6,775.67 $15,764.19 $11,269.93 2025-07-01
641 MS_DRG Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Withou… 3 3 — — $7,493.58 $16,972.07 $11,062.21 2025-07-01
1233 OTHER Inj, Vasopressin, 1 Unit 4 4 — — $1,500.22 $20,847.16 $10,834.46 2025-07-01
439 MS_DRG Disorders Of Pancreas Except Malignancy With Cc 2 2 — — $6,056.90 $15,082.33 $10,569.61 2025-07-01
123 MS_DRG Neurological Eye Disorders 2 2 — — $7,244.08 $13,753.49 $10,498.78 2025-07-01
202 MS_DRG Bronchitis And Asthma With Cc/Mcc 1 1 — — $10,468.12 $10,468.12 $10,468.12 2025-07-01
375 MS_DRG Digestive Malignancy With Cc 1 1 — — $10,425.30 $10,425.30 $10,425.30 2025-07-01
93 MS_DRG Other Disorders Of Nervous System Without Cc/Mcc 1 1 — — $10,353.26 $10,353.26 $10,353.26 2025-07-01
897 MS_DRG Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc 5 5 — — $4,184.47 $29,194.92 $10,287.06 2025-07-01
189 MS_DRG Pulmonary Edema And Respiratory Failure 8 4 — — $7,632.66 $24,384.49 $10,093.92 2025-07-01
291 MS_DRG Heart Failure And Shock With Mcc 13 8 — — $1,041.77 $21,200.55 $10,034.70 2025-07-01
5694 OTHER Level 4 Drug Administration 1 1 — — $10,000.83 $10,000.83 $10,000.83 2025-07-01
201 MS_DRG Pneumothorax Without Cc/Mcc 2 2 — — $6,515.41 $13,469.30 $9,992.35 2025-07-01
535 MS_DRG Fractures Of Hip And Pelvis With Mcc 2 2 — — $7,894.15 $12,074.20 $9,984.17 2025-07-01
175 MS_DRG Pulmonary Embolism With Mcc Or Acute Cor Pulmonale 1 1 — — $9,880.69 $9,880.69 $9,880.69 2025-07-01
55 MS_DRG Nervous System Neoplasms Without Mcc 2 2 — — $9,809.90 $9,809.90 $9,809.90 2025-07-01
919 MS_DRG Complications Of Treatment With Mcc 1 1 — — $9,769.91 $9,769.91 $9,769.91 2025-07-01
78 MS_DRG Hypertensive Encephalopathy With Cc 1 1 — — $9,641.65 $9,641.65 $9,641.65 2025-07-01
184 MS_DRG Major Chest Trauma With Cc 1 1 — — $9,420.04 $9,420.04 $9,420.04 2025-07-01
694 MS_DRG Urinary Stones Without Mcc 1 1 — — $9,408.05 $9,408.05 $9,408.05 2025-07-01
392 MS_DRG Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc 4 3 — — $4,735.62 $17,902.55 $9,376.51 2025-07-01
9002 OTHER Tenecteplase Injection 8 7 — — $2,678.86 $26,169.63 $9,349.43 2025-07-01
565 MS_DRG Other Musculoskeletal System And Connective Tissue Diagnoses With Cc 1 1 — — $9,192.95 $9,192.95 $9,192.95 2025-07-01
378 MS_DRG Gastrointestinal Hemorrhage With Cc 3 3 — — $7,930.65 $18,648.02 $9,063.79 2025-07-01
101 MS_DRG Seizures Without Mcc 2 2 — — $4,825.76 $13,170.50 $8,998.13 2025-07-01
552 MS_DRG Medical Back Problems Without Mcc 3 3 — — $8,741.42 $13,914.17 $8,919.82 2025-07-01
92 MS_DRG Other Disorders Of Nervous System With Cc 1 1 — — $8,874.16 $8,874.16 $8,874.16 2025-07-01
241 MS_DRG Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc… 1 1 — — $8,761.00 $8,761.00 $8,761.00 2025-07-01
307 MS_DRG Cardiac Congenital And Valvular Disorders Without Mcc 1 1 — — $8,739.15 $8,739.15 $8,739.15 2025-07-01
159 MS_DRG Dental And Oral Diseases Without Cc/Mcc 1 1 — — $8,554.49 $8,554.49 $8,554.49 2025-07-01
134 MS_DRG Other Ear, Nose, Mouth & Throat O.r. Procedures Without Cc/Mcc 1 1 — — $8,455.51 $8,455.51 $8,455.51 2025-07-01
9041 OTHER Epoetin Beta Esrd Use 7 4 — — $2,560.68 $9,352.12 $8,381.40 2025-07-01
190 MS_DRG Chronic Obstructive Pulmonary Disease With Mcc 3 2 — — $2,595.68 $10,390.55 $8,370.26 2025-07-01
315 MS_DRG Other Circulatory System Diagnoses With Cc 1 1 — — $8,328.80 $8,328.80 $8,328.80 2025-07-01
864 MS_DRG Fever And Inflammatory Conditions 1 1 — — $8,246.21 $8,246.21 $8,246.21 2025-07-01
191 MS_DRG Chronic Obstructive Pulmonary Disease With Cc 1 1 — — $8,209.64 $8,209.64 $8,209.64 2025-07-01
638 MS_DRG Diabetes With Cc 3 3 — — $6,953.10 $12,233.14 $8,193.12 2025-07-01
65 MS_DRG Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours 5 4 — — $7,090.52 $9,445.71 $7,913.16 2025-07-01
103 MS_DRG Headaches Without Mcc 1 1 — — $7,875.69 $7,875.69 $7,875.69 2025-07-01
807 MS_DRG Vaginal Delivery Without Sterilization Or D&c Without Cc/Mcc 9 7 — — $2,692.45 $9,782.96 $7,775.21 2025-07-01
556 MS_DRG Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc 1 1 — — $7,653.48 $7,653.48 $7,653.48 2025-07-01
176 MS_DRG Pulmonary Embolism Without Mcc 3 3 — — $6,484.27 $12,457.24 $7,618.92 2025-07-01
45 MS_DRG Neurological Eye Disorders 1 1 — — $7,589.21 $7,589.21 $7,589.21 2025-07-01
389 MS_DRG Gastrointestinal Obstruction With Cc 2 2 — — $7,366.37 $7,764.30 $7,565.34 2025-07-01
915 MS_DRG Allergic Reactions With Mcc 1 1 — — $7,474.61 $7,474.61 $7,474.61 2025-07-01
603 MS_DRG Cellulitis Without Mcc 5 3 — — $6,960.34 $10,324.83 $7,410.28 2025-07-01
281 MS_DRG Acute Myocardial Infarction, Discharged Alive With Cc 1 1 — — $7,319.65 $7,319.65 $7,319.65 2025-07-01
894 MS_DRG Alcohol, Drug Abuse Or Dependence, Left Ama 1 1 — — $7,287.92 $7,287.92 $7,287.92 2025-07-01
536 MS_DRG Fractures Of Hip And Pelvis Without Mcc 3 3 — — $4,513.32 $7,569.60 $7,272.76 2025-07-01
9221 OTHER Inj, Vancomycin Hcl (mylan) 1 1 — — $7,258.51 $7,258.51 $7,258.51 2025-07-01
519 MS_DRG Back And Neck Procedures Except Spinal Fusion With Cc 1 1 — — $7,214.49 $7,214.49 $7,214.49 2025-07-01
918 MS_DRG Poisoning And Toxic Effects Of Drugs Without Mcc 3 3 — — $3,780.04 $7,309.95 $7,185.41 2025-07-01
282 MS_DRG Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc 3 3 — — $2,230.26 $8,378.91 $7,106.26 2025-07-01
806 MS_DRG Vaginal Delivery Without Sterilization Or D&c With Cc 3 3 — — $6,604.31 $11,816.53 $7,055.62 2025-07-01
69 MS_DRG Transient Ischemia Without Thrombolytic 2 2 — — $6,571.49 $7,522.17 $7,046.83 2025-07-01
178 MS_DRG Respiratory Infections And Inflammations With Cc 2 2 — — $5,840.06 $8,185.12 $7,012.59 2025-07-01
445 MS_DRG Disorders Of The Biliary Tract With Cc 1 1 — — $6,959.03 $6,959.03 $6,959.03 2025-07-01
70 MS_DRG Nonspecific Cerebrovascular Disorders With Mcc 1 1 — — $6,951.83 $6,951.83 $6,951.83 2025-07-01
113 MS_DRG Orbital Procedures With Cc/Mcc 1 1 — — $6,932.24 $6,932.24 $6,932.24 2025-07-01
9143 OTHER Inj Acetaminophen -fresenius 16 8 — — $824.68 $26,735.40 $6,930.27 2025-07-01
194 MS_DRG Simple Pneumonia And Pleurisy With Cc 5 4 — — $5,348.56 $10,412.60 $6,927.56 2025-07-01
313 MS_DRG Chest Pain 2 2 — — $5,140.11 $8,697.67 $6,918.89 2025-07-01
444 MS_DRG Disorders Of The Biliary Tract With Mcc 1 1 — — $6,911.30 $6,911.30 $6,911.30 2025-07-01
74 MS_DRG Cranial And Peripheral Nerve Disorders Without Mcc 1 1 — — $6,888.51 $6,888.51 $6,888.51 2025-07-01
723 MS_DRG Malignancy, Male Reproductive System With Cc 1 1 — — $6,793.41 $6,793.41 $6,793.41 2025-07-01
135 MS_DRG Sinus And Mastoid Procedures With Cc/Mcc 1 1 — — $6,652.11 $6,652.11 $6,652.11 2025-07-01
696 MS_DRG Kidney And Urinary Tract Signs And Symptoms Without Mcc 1 1 — — $6,638.05 $6,638.05 $6,638.05 2025-07-01
869 MS_DRG Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc 1 1 — — $6,633.34 $6,633.34 $6,633.34 2025-07-01
66 MS_DRG Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc 3 3 — — $5,609.63 $6,848.09 $6,468.07 2025-07-01
465 MS_DRG Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective … 1 1 — — $6,418.00 $6,418.00 $6,418.00 2025-07-01
280 MS_DRG Acute Myocardial Infarction, Discharged Alive With Mcc 5 3 — — $1,025.77 $14,444.63 $6,305.51 2025-07-01
644 MS_DRG Endocrine Disorders With Cc 3 3 — — $5,337.31 $15,562.39 $6,303.62 2025-07-01
9290 OTHER Inj, Bupivacaine, Nos, 0.5mg 21 12 — — $1,012.19 $30,657.21 $6,259.14 2025-07-01
68 MS_DRG Nonspecific Cva And Precerebral Occlusion Without Infarction Without Mcc 1 1 — — $6,157.62 $6,157.62 $6,157.62 2025-07-01
805 MS_DRG Vaginal Delivery Without Sterilization Or D&c With Mcc 1 1 — — $6,111.20 $6,111.20 $6,111.20 2025-07-01
309 MS_DRG Cardiac Arrhythmia And Conduction Disorders With Cc 3 3 — — $1,744.88 $7,611.54 $6,058.72 2025-07-01
54 MS_DRG Nervous System Neoplasms With Mcc 1 1 — — $5,993.02 $5,993.02 $5,993.02 2025-07-01
5112 OTHER Level 2 Musculoskeletal Procedures 10 7 — — $313.61 $19,718.65 $5,960.22 2025-07-01
683 MS_DRG Renal Failure With Cc 9 6 — — $1,081.14 $18,726.24 $5,932.59 2025-07-01
292 MS_DRG Heart Failure And Shock With Cc 1 1 — — $5,898.10 $5,898.10 $5,898.10 2025-07-01
133 MS_DRG Other Ear, Nose, Mouth & Throat O.r. Procedures W Cc/Mcc 2 2 — — $5,604.86 $6,150.02 $5,877.44 2025-07-01
690 MS_DRG Kidney And Urinary Tract Infections Without Mcc 4 3 — — $1,646.36 $12,235.29 $5,870.01 2025-07-01
812 MS_DRG Red Blood Cell Disorders Without Mcc 1 1 — — $5,864.60 $5,864.60 $5,864.60 2025-07-01
233 MS_DRG Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc 2 2 — — $2,000.31 $9,617.59 $5,808.95 2025-07-01
342 MS_DRG Appendectomy Without Complicated Principal Diagnosis With Cc 1 1 — — $5,670.94 $5,670.94 $5,670.94 2025-07-01
310 MS_DRG Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc 7 5 — — $4,772.39 $10,574.55 $5,582.41 2025-07-01
379 MS_DRG Gastrointestinal Hemorrhage Without Cc/Mcc 1 1 — — $5,494.55 $5,494.55 $5,494.55 2025-07-01
192 MS_DRG Chronic Obstructive Pulmonary Disease Without Cc/Mcc 3 2 — — $5,094.10 $6,355.52 $5,432.42 2025-07-01
390 MS_DRG Gastrointestinal Obstruction Without Cc/Mcc 5 5 — — $4,672.89 $16,652.49 $5,423.42 2025-07-01
305 MS_DRG Hypertension Without Mcc 2 2 — — $5,128.22 $5,206.71 $5,167.47 2025-07-01
784 MS_DRG Cesarean Section With Sterilization With Cc 1 1 — — $5,167.01 $5,167.01 $5,167.01 2025-07-01
140 MS_DRG Major Head And Neck Procedures With Mcc 1 1 — — $4,943.67 $4,943.67 $4,943.67 2025-07-01
139 MS_DRG Salivary Gland Procedures 1 1 — — $4,580.99 $4,580.99 $4,580.99 2025-07-01
5072 OTHER Level 2 Excision/ Biopsy/ Incision And Drainage 8 6 — — $1,809.12 $5,776.02 $4,386.12 2025-07-01
541 MS_DRG Osteomyelitis Without Cc/Mcc 1 1 — — $4,384.67 $4,384.67 $4,384.67 2025-07-01
312 MS_DRG Syncope And Collapse 2 2 — — $1,033.39 $7,670.17 $4,351.78 2025-07-01
639 MS_DRG Diabetes Without Cc/Mcc 1 1 — — $4,322.05 $4,322.05 $4,322.05 2025-07-01
391 MS_DRG Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc 1 1 — — $4,314.38 $4,314.38 $4,314.38 2025-07-01
539 MS_DRG Osteomyelitis With Mcc 1 1 — — $4,298.40 $4,298.40 $4,298.40 2025-07-01
540 MS_DRG Osteomyelitis With Cc 3 3 — — $4,285.76 $4,885.76 $4,285.76 2025-07-01
383 MS_DRG Uncomplicated Peptic Ulcer With Mcc 1 1 — — $4,131.32 $4,131.32 $4,131.32 2025-07-01
323 MS_DRG Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc 1 1 — — $3,963.58 $3,963.58 $3,963.58 2025-07-01
816 MS_DRG Reticuloendothelial And Immunity Disorders Without Cc/Mcc 1 1 — — $3,945.95 $3,945.95 $3,945.95 2025-07-01
581 MS_DRG Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc 4 4 — — $1,085.15 $6,136.82 $3,871.16 2025-07-01
244 MS_DRG Permanent Cardiac Pacemaker Implant Without Cc/Mcc 1 1 — — $3,868.56 $3,868.56 $3,868.56 2025-07-01
71 MS_DRG Nonspecific Cerebrovascular Disorders With Cc 1 1 — — $3,828.94 $3,828.94 $3,828.94 2025-07-01
951 MS_DRG Other Factors Influencing Health Status 2 2 — — $1,742.20 $5,899.82 $3,821.01 2025-07-01
7048 OTHER Alteplase Recombinant 4 2 — — $143.20 $5,000.00 $3,675.12 2025-07-01
775 MS_DRG Vaginal Delivery Without Complicating Diagnoses 3 3 — — $2,332.41 $5,568.10 $3,662.66 2025-07-01
916 MS_DRG Allergic Reactions Without Mcc 2 2 — — $1,159.14 $5,863.44 $3,511.29 2025-07-01
794 MS_DRG Neonate With Other Significant Problems 4 3 — — $1,488.53 $5,654.59 $3,346.44 2025-07-01
795 MS_DRG Normal Newborn 10 8 — — $1,260.00 $6,816.23 $3,176.87 2025-07-01
9200 OTHER Inj, Remdesivir, 1 Mg 1 1 — — $3,118.67 $3,118.67 $3,118.67 2025-07-01
5113 OTHER Level 3 Musculoskeletal Procedures 1 1 — — $3,056.63 $3,056.63 $3,056.63 2025-07-01
5183 OTHER Level 3 Vascular Procedures 7 5 — — $2,755.46 $15,487.36 $3,007.86 2025-07-01
0902 OTHER Injection,onabotulinumtoxinA 1 1 — — $2,964.72 $2,964.72 $2,964.72 2025-07-01
542 MS_DRG Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With… 1 1 — — $2,954.52 $2,954.52 $2,954.52 2025-07-01
5312 OTHER Level 2 Lower Gi Procedures 35 15 — — $409.48 $7,979.94 $2,848.50 2025-07-01
560 MS_DRG Aftercare, Musculoskeletal System And Connective Tissue With Cc 8 6 — — $2,524.75 $17,915.48 $2,776.30 2025-07-01
1468 OTHER Inj, Abilify Maintena, 1 Mg 2 2 — — $2,136.87 $3,318.85 $2,727.86 2025-07-01
1446 OTHER Visualization Adjunct 1 1 — — $2,657.23 $2,657.23 $2,657.23 2025-07-01
5302 OTHER Level 2 Upper Gi Procedures 20 10 — — $408.75 $12,559.30 $2,582.85 2025-07-01
5073 OTHER Level 3 Excision/ Biopsy/ Incision And Drainage 1 1 — — $2,576.97 $2,576.97 $2,576.97 2025-07-01
566 MS_DRG Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc 2 2 — — $2,163.33 $2,969.69 $2,566.51 2025-07-01
789 MS_DRG Neonates, Died Or Transferred To Another Acute Care Facility 2 2 — — $1,633.84 $3,170.55 $2,402.20 2025-07-01
249 MS_DRG Percutaneous Cardiovascular Procedures With Non-drug-eluting Stent Without Mcc 1 1 — — $2,394.22 $2,394.22 $2,394.22 2025-07-01
5671 OTHER Level 1 Pathology 28 12 — — $44.85 $21,429.13 $2,366.35 2025-07-01
689 MS_DRG Kidney And Urinary Tract Infections With Mcc 3 3 — — $1,369.24 $8,437.64 $2,294.27 2025-07-01
9230 OTHER Abatacept Injection 2 2 — — $883.72 $3,459.76 $2,171.74 2025-07-01
9160 OTHER Inj, Acetaminophen (b Braun) 1 1 — — $2,155.66 $2,155.66 $2,155.66 2025-07-01
N905 OTHER Not Recognized By Opps 12 7 — — $190.65 $9,203.18 $2,122.25 2025-07-01
561 MS_DRG Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc 1 1 — — $2,044.34 $2,044.34 $2,044.34 2025-07-01
5053 OTHER Level 3 Skin Procedures 2 2 — — $1,264.39 $2,789.94 $2,027.16 2025-07-01
792 MS_DRG Prematurity Without Major Problems 1 1 — — $1,996.75 $1,996.75 $1,996.75 2025-07-01
640 MS_DRG Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With M… 12 8 — — $1,488.53 $25,099.20 $1,877.12 2025-07-01
554 MS_DRG Bone Diseases And Arthropathies Without Mcc 1 1 — — $1,819.13 $1,819.13 $1,819.13 2025-07-01
9255 OTHER Inj, Invega Sustenna, 1 Mg 2 2 — — $19.24 $3,613.47 $1,816.36 2025-07-01
5041 OTHER Critical Care 31 13 — — $502.24 $12,253.13 $1,770.88 2025-07-01
5592 OTHER Level 2 Nuclear Medicine And Related Services 13 8 — — $152.70 $3,647.25 $1,765.57 2025-07-01
5431 OTHER Level 1 Nerve Procedures 20 10 — — $1,063.36 $10,309.42 $1,748.20 2025-07-01
1847 OTHER Injection, Inflectra 1 1 — — $1,673.62 $1,673.62 $1,673.62 2025-07-01
9272 OTHER Inj, Denosumab 9 7 — — $1,341.72 $2,625.58 $1,593.50 2025-07-01
5781 OTHER Resuscitation And Cardioversion 4 4 — — $190.00 $7,698.99 $1,587.99 2025-07-01
5182 OTHER Level 2 Vascular Procedures 2 2 — — $1,488.95 $1,526.24 $1,507.60 2025-07-01
5594 OTHER Level 4 Nuclear Medicine And Related Services 6 6 — — $554.37 $1,652.60 $1,475.57 2025-07-01
5593 OTHER Level 3 Nuclear Medicine And Related Services 28 12 — — $365.71 $4,944.64 $1,337.36 2025-07-01
5311 OTHER Level 1 Lower Gi Procedures 29 14 — — $409.48 $3,832.26 $1,277.09 2025-07-01
1829 OTHER Penicillin G Benzathine Inj 1 1 — — $1,265.94 $1,265.94 $1,265.94 2025-07-01
5025 OTHER Level 5 Type A Ed Visits 45 16 — — $319.03 $6,334.78 $1,079.16 2025-07-01
9522 OTHER Rbc Leukoreduced Irradiated 2 2 — — $898.44 $1,257.28 $1,077.86 2025-07-01
5443 OTHER Level 3 Nerve Injections 26 12 — — $317.41 $6,593.75 $1,074.78 2025-07-01
5771 OTHER Cardiac Rehabilitation 21 9 — — $324.20 $2,631.06 $1,002.56 2025-07-01
5101 OTHER Level 1 Strapping And Cast Application 8 5 — — $210.06 $5,143.35 $978.45 2025-07-01
9036 OTHER Injection, Renflexis 2 2 — — $725.37 $1,182.05 $953.71 2025-07-01
5301 OTHER Level 1 Upper Gi Procedures 27 12 — — $400.73 $5,336.78 $859.62 2025-07-01
5241 OTHER Level 1 Blood Product Exchange And Related Services 1 1 — — $800.44 $800.44 $800.44 2025-07-01
5024 OTHER Level 4 Type A Ed Visits 45 17 — — $81.44 $6,042.27 $780.85 2025-07-01
5573 OTHER Level 3 Imaging With Contrast 30 13 — — $179.94 $7,217.10 $759.47 2025-07-01
5071 OTHER Level 1 Excision/ Biopsy/ Incision And Drainage 8 8 — — $145.97 $18,775.84 $756.57 2025-07-01
5591 OTHER Level 1 Nuclear Medicine And Related Services 17 8 — — $152.70 $6,940.03 $745.98 2025-07-01
1670 OTHER Tetanus Immune Globulin Inj 2 2 — — $622.11 $845.21 $733.66 2025-07-01
9133 OTHER Rabies Ig, Im/sc 5 3 — — $70.71 $9,471.46 $726.00 2025-07-01
5373 OTHER Level 3 Urology And Related Services 1 1 — — $675.59 $675.59 $675.59 2025-07-01
5442 OTHER Level 2 Nerve Injections 23 11 — — $317.41 $2,637.50 $661.69 2025-07-01
N805 OTHER Durable Medical Equipment 3 2 — — $397.88 $1,376.38 $623.94 2025-07-01
N902 OTHER Packaged Services 28 11 — — $4.20 $8,320.23 $603.24 2025-07-01
5051 OTHER Level 1 Skin Procedures 17 9 — — $137.00 $2,112.35 $580.84 2025-07-01
1237 OTHER Inj Iron Dextran 1 1 — — $567.43 $567.43 $567.43 2025-07-01
5441 OTHER Level 1 Nerve Injections 12 7 — — $197.62 $1,182.76 $549.72 2025-07-01
5524 OTHER Level 4 Imaging Without Contrast 33 14 — — $179.94 $14,786.85 $523.16 2025-07-01
5723 OTHER Level 3 Diagnostic Tests And Related Services 15 6 — — $161.62 $1,669.19 $502.30 2025-07-01
9470 OTHER Aripirazole Lauroxil 1 Mg 1 1 — — $469.92 $469.92 $469.92 2025-07-01
5052 OTHER Level 2 Skin Procedures 4 4 — — $149.83 $1,366.85 $461.39 2025-07-01
0965 OTHER Albumin (human), 25%, 50ml 1 1 — — $457.22 $457.22 $457.22 2025-07-01
5411 OTHER Level 1 Gynecologic Procedures 7 6 — — $73.17 $717.40 $432.26 2025-07-01
0759 OTHER Naltrexone, Depot Form 6 6 — — $19.24 $4,901.28 $425.29 2025-07-01
5731 OTHER Level 1 Minor Procedures 19 10 — — $23.26 $14,697.74 $407.70 2025-07-01
9139 OTHER Rabies Vaccine, IM 3 3 — — $389.54 $933.22 $405.24 2025-07-01
N809 OTHER Other Medicine 9 7 — — $136.20 $841.77 $382.21 2025-07-01
5735 OTHER Level 5 Minor Procedures 1 1 — — $372.43 $372.43 $372.43 2025-07-01
5023 OTHER Level 3 Type A Ed Visits 43 17 — — $28.60 $1,522.23 $369.48 2025-07-01
5572 OTHER Level 2 Imaging With Contrast 32 14 — — $126.32 $5,486.16 $367.00 2025-07-01
5012 OTHER Clinic Visits And Related Services 3 2 — — $306.14 $730.60 $362.21 2025-07-01
9042 OTHER Glucagon Hydrochloride 1 1 — — $344.62 $344.62 $344.62 2025-07-01
5691 OTHER Level 1 Drug Administration 21 10 — — $144.38 $31,153.72 $331.41 2025-07-01
5102 OTHER Level 2 Strapping And Cast Application 2 2 — — $239.32 $403.94 $321.63 2025-07-01
5111 OTHER Level 1 Musculoskeletal Procedures 1 1 — — $307.45 $307.45 $307.45 2025-07-01
5722 OTHER Level 2 Diagnostic Tests And Related Services 32 13 — — $68.86 $1,653.99 $296.93 2025-07-01
5412 OTHER Level 2 Gynecologic Procedures 1 1 — — $250.54 $250.54 $250.54 2025-07-01
5523 OTHER Level 3 Imaging Without Contrast 35 14 — — $100.26 $3,897.84 $233.95 2025-07-01
N801 OTHER Therapy Services 41 16 — — $57.22 $1,166.82 $211.22 2025-07-01
5693 OTHER Level 3 Drug Administration 20 10 — — $122.40 $9,855.05 $205.33 2025-07-01
5571 OTHER Level 1 Imaging With Contrast 28 12 — — $64.04 $6,560.81 $187.38 2025-07-01
5672 OTHER Level 2 Pathology 13 8 — — $112.53 $4,477.01 $162.22 2025-07-01
5022 OTHER Level 2 Type A Ed Visits 38 15 — — $64.00 $644.96 $155.73 2025-07-01
N800 OTHER Clinical Diagnostic Lab Services 45 17 — — $26.07 $480.10 $150.13 2025-07-01
5721 OTHER Level 1 Diagnostic Tests And Related Services 25 11 — — $63.08 $737.47 $148.13 2025-07-01
N903 OTHER Influenza Vaccines & Pneumococcal Pneumonia Vaccines 6 6 — — $77.38 $156.80 $147.38 2025-07-01
N804 OTHER Mammography Services 40 17 — — $29.73 $578.63 $143.22 2025-07-01
N900 OTHER Non-covered Services 15 8 — — $12.69 $851.20 $134.52 2025-07-01
9398 OTHER Covid-19 Vaccine Admin Dose 2 Of 2, Single Dose Product Or Additional Dose 8 5 — — $92.49 $5,500.00 $133.84 2025-07-01
5734 OTHER Level 4 Minor Procedures 32 13 — — $25.72 $1,362.00 $120.84 2025-07-01
5522 OTHER Level 2 Imaging Without Contrast 40 16 — — $23.33 $1,286.47 $105.56 2025-07-01
5521 OTHER Level 1 Imaging Without Contrast 38 15 — — $23.33 $628.21 $87.93 2025-07-01
5021 OTHER Level 1 Type A Ed Visits 12 7 — — $52.23 $265.95 $84.64 2025-07-01
5733 OTHER Level 3 Minor Procedures 32 14 — — $10.68 $479.08 $59.19 2025-07-01
9292 OTHER Inj, Clindamycin (baxter) 1 1 — — $46.83 $46.83 $46.83 2025-07-01
5692 OTHER Level 2 Drug Administration 8 8 — — $19.24 $314.00 $43.62 2025-07-01
5732 OTHER Level 2 Minor Procedures 28 13 — — $25.66 $1,041.81 $38.03 2025-07-01
5741 OTHER Level 1 Electronic Analysis Of Devices 18 9 — — $17.33 $366.79 $35.77 2025-07-01
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