Hospital

LBJ TROPICAL MEDICAL CENTER

Pago Pago, AS · CCN 640001 · Rates published

139 distinct procedures filed

1 distinct payers

27,480 rate rows

2026-05-14 last MRF observed

Data quality

27,456 of 27,480 rate rows are consumer-grade (99.9%)

24 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
placeholder amount (≤ $0.02) — excluded from medians	18
percent-of-charges filed in the dollar field — excluded from medians	6

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

Source MRF file	http://rca.elevatepfs.com/ptapp/api/cdm/export/oneclick?recno=8bd0a45af1f0f9b2a7d56f47dc7f9363623b9324d22929343acea9cf6fac83b9
Found on page	https://lbjtmc.org/cms-hpt.txt
Discovered via	CMS hospital list
Last fetch	not_modified · 2026-05-19
Content fingerprint	59b4c46ebe2c6d0c… · 7,838,164 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
200 OTHER	Covid ICU Room-board/isolation	1	$2,900.00	$4,000.00	$3,450.00	nat. median $10,206 outlier · 0.3×
190 OTHER	Covid Room-board/isolation	1	$3,000.00	$3,000.00	$3,000.00	nat. median $10,982 outlier · 0.3×
360 OTHER	Artery Bypass Graft	1	$23.94	$61,612.80	$2,592.22	nat. median $7,392 outlier · 0.4×
160 OTHER	Room-board/isolation	1	$1,600.00	$1,600.00	$1,600.00	nat. median $4,091 outlier · 0.4×
110 OTHER	Room-board/private	1	$1,440.00	$1,600.00	$1,520.00	nat. median $1,680 0.9× median
209 OTHER	Intensive Care	1	$1,500.00	$1,500.00	$1,500.00	nat. median $23,389 outlier · 0.1×
860 OTHER	Meg Recording And Analysis; For Evoked Magnetic Fields, Sngl Mod	1	$385.94	$2,600.90	$1,493.42	nat. median $4 outlier · 376.2×
404 OTHER	Brain Imaging (pet)	1	$154.66	$2,571.44	$1,363.05	nat. median $3,927 outlier · 0.3×
120 OTHER	Room-board/semi	1	$1,200.00	$1,440.00	$1,320.00	nat. median $1,852 0.7× median
721 OTHER	Antepartum Care Only	1	$1,305.32	$1,305.32	$1,305.32	nat. median $24 outlier · 54.0×
121 OTHER	Inpatient R&b	1	$990.00	$1,440.00	$1,215.00	nat. median $10,782 outlier · 0.1×
206 OTHER	Intensive Care	1	$1,200.00	$1,200.00	$1,200.00	nat. median $9,116 outlier · 0.1×
130 OTHER	Room-board/3&4 Bed	1	$1,070.00	$1,070.00	$1,070.00	nat. median $1,931 0.6× median
170 OTHER	Nursery - Newborn - Lvl 1	1	$600.00	$1,440.00	$1,020.00	nat. median $1,398 0.7× median
150 OTHER	Surg Ward Inpatient	1	$990.00	$990.00	$990.00	nat. median $12,874 outlier · 0.1×
761 OTHER	Abdom Paracentesisi Dx/ther Without Imaging Guidance	1	$80.92	$4,470.80	$975.74	nat. median $1,231 0.8× median
901 OTHER	Electroconvulsive Therapy	1	$892.24	$892.24	$892.24	nat. median $29,541 outlier · 0.0×
450 OTHER	Closure Of Split Wound	1	$12.44	$8,475.90	$859.90	nat. median $1,147 0.7× median
612 OTHER	Mr Angio Pelvis W/o&w Dye	1	$572.60	$965.78	$853.76	nat. median $2,164 outlier · 0.4×
611 OTHER	Magnetic Image, Jaw Joint	1	$572.60	$965.78	$853.76	nat. median $1,777 outlier · 0.5×
202 OTHER	ICU Medical	1	$100.00	$1,900.00	$845.00	nat. median $9,777 outlier · 0.1×
610 OTHER	Mr Ang Lwr Ext W Or Without Contrast	1	$572.60	$965.78	$809.82	nat. median $2,142 outlier · 0.4×
174 OTHER	Nursery - Newborn - Lvl 4	1	$800.00	$800.00	$800.00	nat. median $4,092 outlier · 0.2×
111 OTHER	Med/pvt	1	$30.00	$1,440.00	$735.00	nat. median $4,074 outlier · 0.2×
720 OTHER	Cesarean Delivery Only	1	$183.16	$3,690.94	$713.13	nat. median $2,844 outlier · 0.3×
173 OTHER	Nursery - Newborn - Lvl 3	1	$680.00	$680.00	$680.00	nat. median $25,789 outlier · 0.0×
341 OTHER	Abscess Imaging, Ltd Area	1	$30.78	$2,571.44	$669.08	nat. median $1,279 0.5× median
123 OTHER	Gy/2bed	1	$305.00	$990.00	$647.50	nat. median $6,551 outlier · 0.1×
960 OTHER	Repair Blood Vessel Lesion	1	$1.13	$6,840.79	$631.82	nat. median $542 1.2× median
825 OTHER	Esrd Srv,1 Visit,2-11 Yrs	1	$15.76	$1,897.46	$596.44	nat. median $10,241 outlier · 0.1×
481 OTHER	Cardiac Output Measurement	1	$32.48	$29,681.20	$581.42	nat. median $11,210 outlier · 0.1×
342 OTHER	Interstitial Nuclear Therapy	1	$553.64	$553.64	$553.64	nat. median $1,130 outlier · 0.5×
351 OTHER	CT Angiography, Head	1	$100.00	$800.00	$551.43	nat. median $11,639 outlier · 0.0×
352 OTHER	Abdomen 2 Views	1	$126.64	$1,284.00	$551.43	nat. median $6,313 outlier · 0.1×
172 OTHER	Nursery - Newborn - Lvl 2	1	$525.00	$525.00	$525.00	nat. median $2,832 outlier · 0.2×
831 OTHER	Dialysis, One Evaluation	1	$250.60	$773.58	$512.09	nat. median $12,362 outlier · 0.0×
991 OTHER	Cafeteria Charges	1	$10.00	$1,000.00	$505.00	nat. median $19 outlier · 26.2×
929 OTHER	Duplex Scan Lower Ext Lt Artery Unilateral	1	$388.02	$639.81	$481.92	nat. median $1,920 outlier · 0.3×
359 OTHER	CT Soft Tissue Neck With Contrast	1	$481.66	$481.66	$481.66	nat. median $2,225 outlier · 0.2×
124 OTHER	Psych Ward R & B All Incl.	1	$475.00	$475.00	$475.00	nat. median $12,277 outlier · 0.0×
821 OTHER	Intro Cath Dialysis Circuit	1	$101.68	$9,074.90	$435.71	nat. median $17,778 outlier · 0.0×
750 OTHER	Acid Perfusion Of Esophagus	1	$282.24	$657.22	$427.40	nat. median $2,494 outlier · 0.2×
413 OTHER	Hyperbaric Oxygen Therapy	1	$416.34	$416.34	$416.34	nat. median $15,267 outlier · 0.0×
921 OTHER	Extremity Study	1	$225.34	$871.26	$413.80	nat. median $1,000 outlier · 0.4×
333 OTHER	Radiation Therapy Planning	1	$35.14	$14,922.80	$386.34	nat. median $4,903 outlier · 0.1×
483 OTHER	Echo Transesophageal	1	$80.48	$1,473.60	$379.10	nat. median $15,534 outlier · 0.0×
322 OTHER	Arthrogram Rt Hip	1	$354.15	$354.15	$354.15	nat. median $15,755 outlier · 0.0×
480 OTHER	Electrophysiology Evaluation	1	$16.46	$20,000.00	$345.84	nat. median $2,811 outlier · 0.1×
987 OTHER	Hosp D/c Management <= 30 Min	1	$93.02	$2,109.45	$342.62	nat. median $28,388 outlier · 0.0×
350 OTHER	Cat Scan Follow-up Study	1	$118.68	$481.66	$330.31	nat. median $1,785 outlier · 0.2×

Other procedures at this hospital

Browse this hospital's 139 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

200	OTHER	Covid ICU Room-board/isolation	6	1	$3,450.00	$3,450.00	$2,900.00	$4,000.00	$3,450.00	2026-05-14
190	OTHER	Covid Room-board/isolation	3	1	$3,000.00	$3,000.00	$3,000.00	$3,000.00	$3,000.00	2026-05-14
360	OTHER	Artery Bypass Graft	5,025	1	$2,592.22	$2,592.22	$23.94	$61,612.80	$2,592.22	2026-05-14
160	OTHER	Room-board/isolation	3	1	$1,600.00	$1,600.00	$1,600.00	$1,600.00	$1,600.00	2026-05-14
110	OTHER	Room-board/private	6	1	$1,520.00	$1,520.00	$1,440.00	$1,600.00	$1,520.00	2026-05-14
209	OTHER	Intensive Care	3	1	$1,500.00	$1,500.00	$1,500.00	$1,500.00	$1,500.00	2026-05-14
860	OTHER	Meg Recording And Analysis; For Evoked Magnetic Fields, Sngl Mod	6	1	$1,493.42	$1,493.42	$385.94	$2,600.90	$1,493.42	2026-05-14
404	OTHER	Brain Imaging (pet)	6	1	$1,363.05	$1,363.05	$154.66	$2,571.44	$1,363.05	2026-05-14
120	OTHER	Room-board/semi	6	1	$1,320.00	$1,320.00	$1,200.00	$1,440.00	$1,320.00	2026-05-14
721	OTHER	Antepartum Care Only	3	1	$1,305.32	$1,305.32	$1,305.32	$1,305.32	$1,305.32	2026-05-14
121	OTHER	Inpatient R&b	6	1	$1,215.00	$1,215.00	$990.00	$1,440.00	$1,215.00	2026-05-14
206	OTHER	Intensive Care	3	1	$1,200.00	$1,200.00	$1,200.00	$1,200.00	$1,200.00	2026-05-14
130	OTHER	Room-board/3&4 Bed	3	1	$1,070.00	$1,070.00	$1,070.00	$1,070.00	$1,070.00	2026-05-14
170	OTHER	Nursery - Newborn - Lvl 1	6	1	$1,020.00	$1,020.00	$600.00	$1,440.00	$1,020.00	2026-05-14
150	OTHER	Surg Ward Inpatient	3	1	$990.00	$990.00	$990.00	$990.00	$990.00	2026-05-14
761	OTHER	Abdom Paracentesisi Dx/ther Without Imaging Guidance	27	1	$975.74	$975.74	$80.92	$4,470.80	$975.74	2026-05-14
901	OTHER	Electroconvulsive Therapy	3	1	$892.24	$892.24	$892.24	$892.24	$892.24	2026-05-14
450	OTHER	Closure Of Split Wound	333	1	$859.90	$859.90	$12.44	$8,475.90	$859.90	2026-05-14
612	OTHER	Mr Angio Pelvis W/o&w Dye	15	1	$853.76	$853.76	$572.60	$965.78	$853.76	2026-05-14
611	OTHER	Magnetic Image, Jaw Joint	9	1	$853.76	$853.76	$572.60	$965.78	$853.76	2026-05-14
202	OTHER	ICU Medical	12	1	$845.00	$845.00	$100.00	$1,900.00	$845.00	2026-05-14
610	OTHER	Mr Ang Lwr Ext W Or Without Contrast	21	1	$809.82	$809.82	$572.60	$965.78	$809.82	2026-05-14
174	OTHER	Nursery - Newborn - Lvl 4	3	1	$800.00	$800.00	$800.00	$800.00	$800.00	2026-05-14
111	OTHER	Med/pvt	18	1	$735.00	$735.00	$30.00	$1,440.00	$735.00	2026-05-14
720	OTHER	Cesarean Delivery Only	24	1	$713.13	$713.13	$183.16	$3,690.94	$713.13	2026-05-14
173	OTHER	Nursery - Newborn - Lvl 3	3	1	$680.00	$680.00	$680.00	$680.00	$680.00	2026-05-14
341	OTHER	Abscess Imaging, Ltd Area	84	1	$669.08	$669.08	$30.78	$2,571.44	$669.08	2026-05-14
123	OTHER	Gy/2bed	6	1	$647.50	$647.50	$305.00	$990.00	$647.50	2026-05-14
960	OTHER	Repair Blood Vessel Lesion	16,740	1	$631.82	$631.82	$1.13	$6,840.79	$631.82	2026-05-14
825	OTHER	Esrd Srv,1 Visit,2-11 Yrs	39	1	$596.44	$596.44	$15.76	$1,897.46	$596.44	2026-05-14
481	OTHER	Cardiac Output Measurement	57	1	$581.42	$581.42	$32.48	$29,681.20	$581.42	2026-05-14
342	OTHER	Interstitial Nuclear Therapy	3	1	$553.64	$553.64	$553.64	$553.64	$553.64	2026-05-14
352	OTHER	Abdomen 2 Views	54	1	$551.43	$551.43	$126.64	$1,284.00	$551.43	2026-05-14
351	OTHER	CT Angiography, Head	30	1	$551.43	$551.43	$100.00	$800.00	$551.43	2026-05-14
172	OTHER	Nursery - Newborn - Lvl 2	3	1	$525.00	$525.00	$525.00	$525.00	$525.00	2026-05-14
831	OTHER	Dialysis, One Evaluation	6	1	$512.09	$512.09	$250.60	$773.58	$512.09	2026-05-14
991	OTHER	Cafeteria Charges	6	1	$505.00	$505.00	$10.00	$1,000.00	$505.00	2026-05-14
929	OTHER	Duplex Scan Lower Ext Lt Artery Unilateral	9	1	$481.92	$481.92	$388.02	$639.81	$481.92	2026-05-14
359	OTHER	CT Soft Tissue Neck With Contrast	3	1	$481.66	$481.66	$481.66	$481.66	$481.66	2026-05-14
124	OTHER	Psych Ward R & B All Incl.	3	1	$475.00	$475.00	$475.00	$475.00	$475.00	2026-05-14
821	OTHER	Intro Cath Dialysis Circuit	39	1	$435.71	$435.71	$101.68	$9,074.90	$435.71	2026-05-14
750	OTHER	Acid Perfusion Of Esophagus	9	1	$427.40	$427.40	$282.24	$657.22	$427.40	2026-05-14
413	OTHER	Hyperbaric Oxygen Therapy	3	1	$416.34	$416.34	$416.34	$416.34	$416.34	2026-05-14
921	OTHER	Extremity Study	24	1	$413.80	$413.80	$225.34	$871.26	$413.80	2026-05-14
333	OTHER	Radiation Therapy Planning	57	1	$386.34	$386.34	$35.14	$14,922.80	$386.34	2026-05-14
483	OTHER	Echo Transesophageal	27	1	$379.10	$379.10	$80.48	$1,473.60	$379.10	2026-05-14
322	OTHER	Arthrogram Rt Hip	3	1	$354.15	$354.15	$354.15	$354.15	$354.15	2026-05-14
480	OTHER	Electrophysiology Evaluation	102	1	$345.84	$345.84	$16.46	$20,000.00	$345.84	2026-05-14
987	OTHER	Hosp D/c Management <= 30 Min	48	1	$342.62	$342.62	$93.02	$2,109.45	$342.62	2026-05-14
350	OTHER	Cat Scan Follow-up Study	15	1	$330.31	$330.31	$118.68	$481.66	$330.31	2026-05-14
410	OTHER	Aerosol Inhala Pentamidine Pc Pneumon	15	1	$329.12	$329.12	$35.97	$748.10	$329.12	2026-05-14
740	OTHER	Electroencephalogram (eeg)	54	1	$320.12	$320.12	$103.50	$1,707.92	$320.12	2026-05-14
444	OTHER	Behavioral And Qualitative Analysis Of Voice And Resonance	15	1	$306.57	$306.57	$181.16	$615.48	$306.57	2026-05-14
657	OTHER	Inpatient Consultation	42	1	$267.08	$267.08	$89.50	$2,441.82	$267.08	2026-05-14
361	OTHER	Dissolve Clot, Heart Vessel; ER	15	1	$263.38	$263.38	$90.54	$390.24	$263.38	2026-05-14
920	OTHER	Analyze Neurostim, Complex	57	1	$261.86	$261.86	$6.44	$3,804.96	$261.86	2026-05-14
780	OTHER	Mental-physician Telephone Eval 11 To 20 Min	15	1	$257.00	$257.00	$104.70	$385.00	$257.00	2026-05-14
319	OTHER	Electron Microscopy	3	1	$255.29	$255.29	$255.29	$255.29	$255.29	2026-05-14
312	OTHER	Analysis Nerve	9	1	$255.29	$255.29	$172.87	$320.02	$255.29	2026-05-14
330	OTHER	Chemo, Infuse Method Add-on	24	1	$254.28	$254.28	$65.14	$570.00	$254.28	2026-05-14
983	OTHER	Prep Of Report	3	1	$250.00	$250.00	$250.00	$250.00	$250.00	2026-05-14
4450	OTHER	Autopsy Mortician (each)	24	1	$250.00	$250.00	$10.00	$1,039.00	$250.00	2026-05-14
311	OTHER	Cell Cryopreserve/storage	24	1	$249.06	$249.06	$28.76	$989.90	$249.06	2026-05-14
762	OTHER	Observation Care	12	1	$238.44	$238.44	$146.06	$374.48	$238.44	2026-05-14
314	OTHER	Biopsy Of Breast, Open	9	1	$237.26	$237.26	$228.98	$531.75	$237.26	2026-05-14
917	OTHER	Biofeedback Peri/uro/rectal	3	1	$226.38	$226.38	$226.38	$226.38	$226.38	2026-05-14
490	OTHER	Ablation, 1 Or More Liver Tumor(s), Percutaneous, Radiofrequency	12	1	$225.55	$225.55	$22.84	$8,188.58	$225.55	2026-05-14
4460	OTHER	Embalming Adult	6	1	$225.00	$225.00	$150.00	$300.00	$225.00	2026-05-14
943	OTHER	Cardiac Rehab	3	1	$206.52	$206.52	$206.52	$206.52	$206.52	2026-05-14
320	OTHER	Chest X-ray	288	1	$205.37	$205.37	$15.00	$10,645.04	$205.37	2026-05-14
820	OTHER	Dialysis Training, Complete	9	1	$190.46	$190.46	$20.00	$209.80	$190.46	2026-05-14
916	OTHER	Family Psytx Without Patient	6	1	$189.98	$189.98	$132.06	$247.90	$189.98	2026-05-14
922	OTHER	Autonomic Nerv Function Test	15	1	$189.86	$189.86	$81.52	$545.20	$189.86	2026-05-14
914	OTHER	Psychophysiological Therapy	12	1	$187.90	$187.90	$123.88	$230.94	$187.90	2026-05-14
570	OTHER	Prolonged Service, Inpatient	15	1	$184.74	$184.74	$179.72	$261.34	$184.74	2026-05-14
770	OTHER	Prev Visit, Est, Age 18-39	3	1	$181.16	$181.16	$181.16	$181.16	$181.16	2026-05-14
434	OTHER	Eval For Rx Of Non-speech-generating Augment And Alter Comm Devi	3	1	$181.16	$181.16	$181.16	$181.16	$181.16	2026-05-14
403	OTHER	Mammogram - Unilat Screening	9	1	$180.44	$180.44	$165.40	$269.94	$180.44	2026-05-14
272	OTHER	Needle	18	1	$179.35	$179.35	$106.00	$212.70	$179.35	2026-05-14
230	OTHER	Rest Home Visit, Est Pat <= 15 Min	18	1	$175.78	$175.78	$110.98	$279.96	$175.78	2026-05-14
112	OTHER	Normal Vag Delivery, Non Res, Facility Fee	6	1	$175.00	$175.00	$50.00	$300.00	$175.00	2026-05-14
401	OTHER	Diagnostic Mammo, Including (cad) Bilateral	21	1	$173.61	$173.61	$50.00	$232.00	$173.61	2026-05-14
469	OTHER	Measure Blood Oxygen Level	3	1	$164.42	$164.42	$164.42	$164.42	$164.42	2026-05-14
969	OTHER	Home Visit, Est Patient	60	1	$163.97	$163.97	$9.20	$442.50	$163.97	2026-05-14
512	OTHER	Complete Dentures (full Set) Res	84	1	$162.62	$162.62	$18.00	$1,829.10	$162.62	2026-05-14
440	OTHER	Speech/hearing Therapy	33	1	$158.96	$158.96	$47.26	$1,295.68	$158.96	2026-05-14
940	OTHER	Chiropractic Manipulation	15	1	$157.58	$157.58	$39.64	$340.80	$157.58	2026-05-14
731	OTHER	Auto Activated ECG Rhythm Derived Event Recording	15	1	$156.88	$156.88	$53.70	$256.36	$156.88	2026-05-14
510	OTHER	Preventive Counseling, Indiv	477	1	$147.12	$147.12	$2.14	$4,470.80	$147.12	2026-05-14
402	OTHER	Detail Anatomic Evaluation For More Than One Fetus	102	1	$143.40	$143.40	$30.00	$845.16	$143.40	2026-05-14
471	OTHER	Endoscopy Swallow Tst (fees)	120	1	$141.67	$141.67	$8.32	$986.51	$141.67	2026-05-14
636	OTHER	Adenovirus Vaccine, Type 4	90	1	$141.61	$141.61	$12.04	$495.14	$141.61	2026-05-14
470	OTHER	Auditory Function + 15 Min	6	1	$139.00	$139.00	$42.19	$235.80	$139.00	2026-05-14
329	OTHER	Bone Survey Infant	24	1	$135.69	$135.69	$105.03	$359.91	$135.69	2026-05-14
915	OTHER	Group Psychotherapy	3	1	$132.06	$132.06	$132.06	$132.06	$132.06	2026-05-14
300	OTHER	Growth Hormone Panel	426	1	$115.77	$115.77	$5.48	$1,577.48	$115.77	2026-05-14
961	OTHER	Hypnotherapy	21	1	$108.95	$108.95	$37.74	$230.94	$108.95	2026-05-14
310	OTHER	Lab Pathology Consultation	51	1	$108.52	$108.52	$28.63	$1,654.38	$108.52	2026-05-14
460	OTHER	Breath Recording, Infant	27	1	$104.70	$104.70	$27.30	$2,532.72	$104.70	2026-05-14
324	OTHER	Chest X-ray, Single View	3	1	$103.50	$103.50	$103.50	$103.50	$103.50	2026-05-14
900	OTHER	Behavior Health Inter, Ea 15 Min, Face-face; Fam (w/out The Pt	21	1	$100.24	$100.24	$20.00	$230.94	$100.24	2026-05-14
482	OTHER	Cardiovascular Stress Test	12	1	$100.02	$100.02	$29.36	$475.90	$100.02	2026-05-14
985	OTHER	Ecg/review Interpret Only	6	1	$93.64	$93.64	$54.54	$132.74	$93.64	2026-05-14
260	OTHER	Hydration Adtnl Hrs Ea	21	1	$87.47	$87.47	$61.74	$216.40	$87.47	2026-05-14
290	OTHER	Advantage Meter	12	1	$80.62	$80.62	$49.35	$243.51	$80.62	2026-05-14
430	OTHER	Aquatic Therapy/exercises	42	1	$80.37	$80.37	$5.38	$317.58	$80.37	2026-05-14
292	OTHER	Walker	3	1	$78.21	$78.21	$78.21	$78.21	$78.21	2026-05-14
730	OTHER	ECG Routine W/least 12 Lds Trcg Only Without Ir	24	1	$70.94	$70.94	$15.00	$647.84	$70.94	2026-05-14
962	OTHER	Office Consult Strt Forward	3	1	$68.02	$68.02	$68.02	$68.02	$68.02	2026-05-14
270	OTHER	Bandage Muslin Triangular	585	1	$66.00	$66.00	$0.35	$2,339.50	$66.00	2026-05-14
420	OTHER	Electrical Stimulation	93	1	$64.83	$64.83	$12.18	$245.49	$64.83	2026-05-14
302	OTHER	Cytotoxic Antibody Screening	159	1	$60.88	$60.88	$10.32	$331.34	$60.88	2026-05-14
942	OTHER	Behav Chng Smoking > 10 Min	27	1	$55.14	$55.14	$26.75	$176.99	$55.14	2026-05-14
309	OTHER	Abo Blood Group	24	1	$54.53	$54.53	$12.30	$255.29	$54.53	2026-05-14
273	OTHER	0.9% Normal Saline Irrigation H20	120	1	$52.30	$52.30	$1.17	$418.89	$52.30	2026-05-14
771	OTHER	Adm Sarscov2 30mc G/0.3ml 1st	21	1	$50.84	$50.84	$20.64	$150.00	$50.84	2026-05-14
301	OTHER	Assay Of Progesterone	543	1	$47.33	$47.33	$3.93	$510.59	$47.33	2026-05-14
972	OTHER	CT - 3d Reconstr	6	1	$46.45	$46.45	$25.00	$67.91	$46.45	2026-05-14
306	OTHER	Dark Field Examination	120	1	$45.71	$45.71	$11.62	$510.59	$45.71	2026-05-14
424	OTHER	Body Muscle Testing, Manual	12	1	$44.13	$44.13	$32.94	$63.72	$44.13	2026-05-14
530	OTHER	Osteopathic Manipulation	3	1	$39.64	$39.64	$39.64	$39.64	$39.64	2026-05-14
540	OTHER	Ems Per Mile Facility Fee	15	1	$30.00	$30.00	$3.00	$70.00	$30.00	2026-05-14
999	OTHER	Lbj Pbs Processing Fee	6	1	$29.00	$29.00	$28.00	$30.00	$29.00	2026-05-14
924	OTHER	Allergy Skin Tests	42	1	$27.53	$27.53	$8.73	$172.65	$27.53	2026-05-14
305	OTHER	Acth Stimulation Panel	141	1	$23.95	$23.95	$6.46	$510.59	$23.95	2026-05-14
370	OTHER	Anes Dx Shoulder Arthroscopy	15	1	$22.11	$22.11	$2.30	$75.00	$22.11	2026-05-14
340	OTHER	Breath Tst Attain/anal C-14	3	1	$21.40	$21.40	$21.40	$21.40	$21.40	2026-05-14
589	OTHER	Home Visit Assist With Activities Of Daily Living And Personal Care	3	1	$20.00	$20.00	$20.00	$20.00	$20.00	2026-05-14
274	OTHER	Device Handling	3	1	$20.00	$20.00	$20.00	$20.00	$20.00	2026-05-14
279	OTHER	Patient Education Materials	3	1	$20.00	$20.00	$20.00	$20.00	$20.00	2026-05-14
981	OTHER	Direct Advanced Life Support	3	1	$20.00	$20.00	$20.00	$20.00	$20.00	2026-05-14
489	OTHER	Assembly&operj Pump Oxygenator/heat Exch Ea Hr	3	1	$20.00	$20.00	$20.00	$20.00	$20.00	2026-05-14
918	OTHER	Developmental Test, Lim	3	1	$18.42	$18.42	$18.42	$18.42	$18.42	2026-05-14
307	OTHER	Pregnancy Test; Ur	36	1	$16.63	$16.63	$3.48	$510.59	$16.63	2026-05-14
250	OTHER	Butalbital-acet-caff 50-325-40mg Tab 100	36	1	$15.00	$15.00	$0.34	$126.00	$15.00	2026-05-14
7200	OTHER	Immigration Clearance Non Res	6	1	$7.50	$7.50	$5.00	$10.00	$7.50	2026-05-14
294	OTHER	0.9% Sod/ch.irrig 1000ml Btl	18	1	$6.71	$6.71	$2.40	$46.65	$6.71	2026-05-14
4820	OTHER	Med Supply/equip Res	3	1	$5.00	$5.00	$5.00	$5.00	$5.00	2026-05-14
990	OTHER	Med Rec Misc	3	1	$5.00	$5.00	$5.00	$5.00	$5.00	2026-05-14

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