| Abscess Drainage (I&D) | emergency | $0 | $116 to $874 | High |
| Allergy Testing Panel | diagnostic | $0 | $9 to $64 | High |
| Ankle X-Ray | imaging | $0 | $8 to $242 | High |
| Annual Wellness Visit (Established) | preventive | $0 | $75 to $562 | High |
| Annual Wellness Visit (New) | preventive | $0 | $92 to $690 | High |
| Asthma Management | other | $0 | $10 to $376 | High |
| Basic Metabolic Panel (BMP) | lab | $0 | $8 to $110 | High |
| Blood Draw (Venipuncture) | lab | $0 | $9 to $34 | High |
| Bronchoscopy | diagnostic | $0 | $473 to $1,780 | High |
| Bunionectomy | other | $0 | $462 to $5,712 | High |
| 5fr Obturator | other | $1 | $1 to $4 | Low |
| 6fr Obturator | other | $1 | $1 to $4 | Low |
| 7fr Obturator | other | $1 | $1 to $4 | Low |
| Acetaminophen 650mg/20.3ml Cup | other | $1 | $1 to $2 | Low |
| Acetylcysteine, Inhalation Solution, Fda-approved Final Product, Non-compound... | other | $1 | $1 to $1 | Low |
| Adaptor Meconium Aspiration #n0101 40ea/bx | other | $1 | $1 to $5 | Low |
| Adhesive, Liquid OR Equal, Any Type, Per Oz | other | $1 | $1 to $5 | Low |
| Airway Ovassapian #bd6075 5/cs | other | $1 | $1 to $4 | Low |
| Albuterol, Inhalation Solution, Fda-approved Final Product, Non-compounded, A... | other | $1 | $1 to $1 | Low |
| Aliskiren 150 Mg Tablet | other | $1 | $1 to $5 | Low |
| Allegra-d 24 Hour Tablet | other | $1 | $1 to $2 | Low |
| Amox-clav 200-28.5 Mg/5 Ml Sus | other | $1 | $1 to $5 | Low |
| Amox-clav 400-57 Mg/5 Ml Susp | other | $1 | $1 to $5 | Low |
| Amphetamine-dextroamphet ER 10 Mg Po Cp24 | other | $1 | $1 to $4 | Low |
| Amphetamine-dextroamphet ER 15 Mg Po Cp24 | other | $1 | $1 to $1 | Low |
| Amphetamine-dextroamphetamine 10 Mg Po Tabs | other | $1 | $1 to $1 | Low |
| Amphetamine-dextroamphetamine 15 Mg Po Tabs | other | $1 | $1 to $1 | Low |
| Anes Breathing Circuit Adult 3l #a4y520xxf | other | $1 | $1 to $5 | Low |
| Anesthesia for Other Repair of Upper Abdomen Hernia | surgery | $1 | $1 to $750 | Low |
| Anesthesia for Procedure On Veins in Upper Leg | other | $1 | $1 to $1,260 | Low |
| Arformoterol, Inhalation Solution, Fda Approved Final Product, Non-compounded... | other | $1 | $1 to $2 | Low |
| Aripiprazole 5 Mg Po Tabs | other | $1 | $1 to $5 | Low |
| Aripiprazole 5 Mg Tablet | other | $1 | $1 to $5 | Low |
| Arnuity Ellipta 100 Mcg Inh | other | $1 | $1 to $5 | Low |
| Aspirin 300 Mg Suppository | other | $1 | $1 to $1 | Low |
| Aspirin-dipyridam ER 25-200 Mg | other | $1 | $1 to $5 | Low |
| Aspirin-dipyridamole ER 25-200 Mg Po Cp12 | other | $1 | $1 to $5 | Low |
| Assessment By Trained Clinical Staff of Implant And/or Foreign Body for Mr Sa... | surgery | $1 | $1 to $76,015 | Low |
| Atazanavir Sulfate 200 Mg Cap | other | $1 | $1 to $1 | Low |
| Azithromycin 500 Mg Po Tabs | other | $1 | $1 to $5 | Low |
| Azithromycin 500 Mg Tablet | other | $1 | $1 to $5 | Low |
| Bacitracin 500 Unit/gm Ointmnt | other | $1 | $1 to $2 | Low |
| Bactine Max 0.13% Solution | other | $1 | $1 to $5 | Low |
| Bag Phlebotomy Set 25/bx #bk-64a | other | $1 | $1 to $6 | Low |
| Banatrol Plus Powder Packet | other | $1 | $1 to $1 | Low |
| Belt Gait W/ Buckle 72" #655702 | other | $1 | $1 to $5 | Low |
| Benadryl Itch Stop 1%-0.1% Crm | other | $1 | $1 to $4 | Low |
| Blade Laryngoscope Disp Led Millr Sz00 1039.c | other | $1 | $1 to $4 | Low |
| Blade Laryngoscope Dispo Robert Shaw 1 2011.c | other | $1 | $1 to $4 | Low |
| Boot Cast Extra Large 1ea | other | $1 | $1 to $5 | Low |
| Boot Cast Gelo Unna's 12ea/1cs | other | $1 | $1 to $4 | Low |
| Boot Cast Small #2035-02 1ea | other | $1 | $1 to $5 | Low |
| Boot Cast-large | other | $1 | $1 to $5 | Low |
| Boot Cast-medium | other | $1 | $1 to $5 | Low |
| Boudreauxs Butt Paste | other | $1 | $1 to $5 | Low |
| Brace Thumb Splint Universal #5026 | other | $1 | $1 to $5 | Low |
| Brace Wrist Right Small #79 | other | $1 | $1 to $4 | Low |
| Brimonidine 0.2% Eye Drop | other | $1 | $1 to $5 | Low |
| Bromocriptine 2.5 Mg Tablet | other | $1 | $1 to $1 | Low |
| Bss Eye Solution | other | $1 | $1 to $5 | Low |
| Bupropion Hcl 100 Mg Tablet | other | $1 | $1 to $1 | Low |
| Bupropion Hcl 75 Mg Po Tabs | other | $1 | $1 to $2 | Low |
| Bupropion Hcl 75 Mg Tablet | other | $1 | $1 to $2 | Low |
| Bupropion Hcl ER (xl) 150 Mg Po Tb24 | other | $1 | $1 to $4 | Low |
| Bupropion Hcl Xl 150 Mg Tablet | other | $1 | $1 to $4 | Low |
| Butalb-acetamin-caff 50-325 | other | $1 | $1 to $1 | Low |
| Butalbital-apap-caffeine 50-325-40 Mg Po Tabs | other | $1 | $1 to $1 | Low |
| **discontinued** Endotrach Tube 2.0 Uncuffed 10ea/1bx | other | $2 | $2 to $3 | Low |
| 1/2 Circle Rev Cut Richard Allen #209106 | other | $2 | $2 to $6 | Low |
| 20fr Y Ports #m00580641 10ea/bx | other | $2 | $2 to $8 | Low |
| 24fr Y Ports #m00580651 10ea/bx | other | $2 | $2 to $8 | Low |
| 6 Fr Cas 1 | other | $2 | $2 to $9 | Low |
| 6 Fr Ultimate 4-t40 | other | $2 | $2 to $9 | Low |
| Abdominal Support 9in 1ea | other | $2 | $2 to $9 | Low |
| Acetaminophen 120 Mg Re Supp | other | $2 | $2 to $2 | Low |
| Adaptic Finger Dressing Large 1-1/8" #mad023u Case=17bx=170each | other | $2 | $2 to $6 | Low |
| Adaptic Finger Dressing Small 3/4" #mad003u Case=17bx=170each | other | $2 | $2 to $6 | Low |
| Adaptic Toe Dressing 1-1/8" Size Lg #mad062u 10ea/bx | other | $2 | $2 to $6 | Low |
| Adderall Xr 20 Mg Capsule | other | $2 | $2 to $7 | Low |
| Adderall Xr 25 Mg Capsule | other | $2 | $2 to $7 | Low |
| Adderall Xr 30 Mg Capsule | other | $2 | $2 to $7 | Low |
| Adderall Xr 5 Mg Capsule | other | $2 | $2 to $7 | Low |
| Addition to Ctlso OR Scoliosis Orthosis, Kyphosis Pad | other | $2 | $2 to $128 | Low |
| Alaris Pump Module Admin Set 10942011 20ea/cs | other | $2 | $2 to $4 | Low |
| Alginate OR Other Fiber Gelling Dressing, Wound Filler, Sterile, Per 6 Inches | other | $2 | $2 to $8 | Low |
| Ammonium Lactate 12% Lotion | other | $2 | $2 to $4 | Low |
| Amox-clav 250-62.5 Mg/5 Ml Sus | other | $2 | $2 to $8 | Low |
| Amoxicillin 125 Mg/5ml Po Susr | other | $2 | $2 to $3 | Low |
| Amoxicillin 200 Mg/5 Ml Susp | other | $2 | $2 to $7 | Low |
| Amoxicillin 250 Mg/5 Ml Susp | other | $2 | $2 to $3 | Low |
| Amoxicillin 400 Mg/5 Ml Susp | other | $2 | $2 to $6 | Low |
| Anes Breathing Circuit Ped 1l 20/cs B1554xx4 | other | $2 | $2 to $7 | Low |
| Anes Breathing Circuit Ped 2l W/mask B1557xx4 | other | $2 | $2 to $6 | Low |
| Anesthesia for Access to Central Vein | other | $2 | $2 to $532 | Low |
| Anesthesia for Amputation On Upper 2/3rd of Thigh Bone | other | $2 | $2 to $1,232 | Low |
| Anesthesia for Closed Procedure On Lower 1/3rd of Thigh Bone | other | $2 | $2 to $1,340 | Low |
| Anesthesia for Closed Procedure On Lower Leg, Ankle, and Foot | other | $2 | $2 to $1,462 | Low |
| Anesthesia for Closed Procedure On Top of Arm Bone and Shoulder Joint | other | $2 | $2 to $1,620 | Low |
| Anesthesia for Closed Procedure On Upper 2/3rd of Thigh Bone | other | $2 | $2 to $1,220 | Low |
| Anesthesia for Exam of Knee Joint Using an Endoscope | other | $2 | $2 to $1,382 | Low |
| Anesthesia for Exam of Shoulder Joint Using an Endoscope | other | $2 | $2 to $1,622 | Low |
| Anesthesia for Exam of Uterus Using an Endoscope | other | $2 | $2 to $952 | Low |
| Anesthesia for Extensive Partial Removal of Rib | surgery | $2 | $2 to $474 | Low |
| Anesthesia for Extensive Procedure On Perineum | other | $2 | $2 to $904 | Low |
| Anesthesia for Extensive Removal of Prostate | surgery | $2 | $2 to $865 | Low |
| Anesthesia for Fragmenting, Manipulation And/or Removal of Kidney Stone Inclu... | surgery | $2 | $2 to $918 | Low |
| Anesthesia for Heart Artery Bypass Grafting | cardiac | $2 | $2 to $566 | Low |
| Anesthesia for Heart Artery Bypass Grafting On Heart-lung Machine | cardiac | $2 | $2 to $567 | Low |
| Anesthesia for Insertion of Penile Prosthesis | other | $2 | $2 to $938 | Low |
| Anesthesia for Insertion of Permanent Heart Pacemaker | cardiac | $2 | $2 to $530 | Low |
| Anesthesia for Insertion OR Replace of Pacing Heart Defibrillator | cardiac | $2 | $2 to $534 | Low |
| Anesthesia for Lens Surgery | surgery | $2 | $2 to $142 | Low |
| Anesthesia for Open Amputation Below the Knee | other | $2 | $2 to $1,482 | Low |
| Anesthesia for Open OR Endoscopic Total Shoulder Joint Replacement | surgery | $2 | $2 to $1,638 | Low |
| Anesthesia for Other Procedure On Arteries of Upper Arm and Elbow | other | $2 | $2 to $1,770 | Low |
| Anesthesia for Other Procedure On Artery of Knee | other | $2 | $2 to $1,440 | Low |
| Anesthesia for Other Procedure On Artery of Upper Leg | other | $2 | $2 to $1,270 | Low |
| Anesthesia for Other Procedure On Collar Bone and Shoulder Blade | other | $2 | $2 to $450 | Low |
| Anesthesia for Other Procedure On Elbow | other | $2 | $2 to $1,740 | Low |
| Anesthesia for Other Procedure On Esophagus, Stomach, OR Upper Small Bowel Us... | other | $2 | $2 to $731 | Low |
| Anesthesia for Other Procedure On External Middle and Inner Ear | other | $2 | $2 to $120 | Low |
| Anesthesia for Other Procedure On Face Bones OR Skull | other | $2 | $2 to $190 | Low |
| Anesthesia for Other Procedure On Female Genitals | other | $2 | $2 to $940 | Low |
| Anesthesia for Other Procedure On Hip Joint | other | $2 | $2 to $1,210 | Low |
| Anesthesia for Other Procedure On Large Blood Vessel of Neck | other | $2 | $2 to $350 | Low |
| Anesthesia for Other Procedure On Large Bowel Using an Endoscope | other | $2 | $2 to $811 | Low |
| Anesthesia for Other Procedure On Lower Abdomen | other | $2 | $2 to $840 | Low |
| Anesthesia for Other Procedure On Lower Abdomen Outside Abdominal Cavity | other | $2 | $2 to $860 | Low |
| Anesthesia for Other Procedure On Lower Front Abdomen | other | $2 | $2 to $800 | Low |
| Anesthesia for Other Procedure On Lower Leg, Ankle, and Foot Bones | other | $2 | $2 to $1,480 | Low |
| Anesthesia for Other Procedure On Lower Spine | other | $2 | $2 to $630 | Low |
| Anesthesia for Other Procedure On Male Genitals | other | $2 | $2 to $920 | Low |
| Anesthesia for Other Procedure On Mouth | other | $2 | $2 to $170 | Low |
| Anesthesia for Other Procedure On Neck Area | other | $2 | $2 to $320 | Low |
| Anesthesia for Other Procedure On Nerves, Muscles, Tendons, and Tissue of Low... | other | $2 | $2 to $1,470 | Low |
| Anesthesia for Other Procedure On Nose and Sinuses | other | $2 | $2 to $160 | Low |
| Anesthesia for Other Procedure On Skin of Arms, Legs, and Front Body | other | $2 | $2 to $400 | Low |
| Anesthesia for Other Procedure On Skin, Muscles, OR Nerves of Head, Neck, and... | other | $2 | $2 to $300 | Low |
| Anesthesia for Other Procedure On Top of Arm Bone and Shoulder Joint | other | $2 | $2 to $1,630 | Low |
| Anesthesia for Other Procedure On Upper Abdomen | other | $2 | $2 to $790 | Low |
| Anesthesia for Other Procedure On Upper Front Abdomen | other | $2 | $2 to $700 | Low |
| Anesthesia for Other Procedure On Upper Spine | other | $2 | $2 to $600 | Low |
| Anesthesia for Other Procedure On Urinary System Through Urethra | other | $2 | $2 to $910 | Low |
| Anesthesia for Other Procedure OR Exam of Knee Joint Using an Endoscope | other | $2 | $2 to $1,400 | Low |
| Anesthesia for Other Procedures On Nerves, Muscles, Tendons, and Tissue of Up... | other | $2 | $2 to $1,710 | Low |
| Anesthesia for Other Repair of Lower Abdomen Hernia | surgery | $2 | $2 to $834 | Low |
| Anesthesia for Procedure for Total Knee Joint Replacement | surgery | $2 | $2 to $1,402 | Low |
| Anesthesia for Procedure On Ankle OR Foot Using an Endoscope | other | $2 | $2 to $1,464 | Low |
| Anesthesia for Procedure On Anus and Rectum | other | $2 | $2 to $902 | Low |
| Anesthesia for Procedure On Chest with 1 Lung Inflated | other | $2 | $2 to $541 | Low |
| Anesthesia for Procedure On Eye for Corneal Transplant | surgery | $2 | $2 to $144 | Low |
| Anesthesia for Procedure On Gallbladder, Pancreas, OR Liver Using an Endoscope | other | $2 | $2 to $732 | Low |
| Anesthesia for Procedure On Kneecap And/or Upper Part of Lower Leg Bones | other | $2 | $2 to $1,392 | Low |
| Anesthesia for Procedure On Lower 1/3rd of Thigh Bone | other | $2 | $2 to $1,360 | Low |
| Anesthesia for Procedure On Lower Rear Abdomen | other | $2 | $2 to $820 | Low |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, and Tissue of Knee | other | $2 | $2 to $1,320 | Low |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, and Tissue of Upper Leg | other | $2 | $2 to $1,250 | Low |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, Fascia, and Bursae of S... | other | $2 | $2 to $1,610 | Low |
| Anesthesia for Procedure On Saliva Gland | other | $2 | $2 to $100 | Low |
| Anesthesia for Procedure On Tendon of Elbow to Shoulder | other | $2 | $2 to $1,712 | Low |
| Anesthesia for Procedure On Tendon of Upper Arm Muscle | other | $2 | $2 to $1,716 | Low |
| Anesthesia for Procedure On Upper 2/3rd of Thigh Bone | other | $2 | $2 to $1,230 | Low |
| Anesthesia for Procedure On Upper Urinary Tubes OR Removal of Kidney for Tran... | surgery | $2 | $2 to $862 | Low |
| Anesthesia for Procedure to Control Urinary System Bleeding Including Use of ... | other | $2 | $2 to $916 | Low |
| Anesthesia for Procedure to Correct Abnormal Heart Rhythm | cardiac | $2 | $2 to $410 | Low |
| Anesthesia for Procedure to Repair Upper Abdominal Incisional Hernia And/or W... | surgery | $2 | $2 to $752 | Low |
| Anesthesia for Reconstruction of Breast | other | $2 | $2 to $402 | Low |
| Anesthesia for Relocation of Undescended Testicle Into Scrotum | other | $2 | $2 to $930 | Low |
| Anesthesia for Removal of All OR Part of Breast | surgery | $2 | $2 to $404 | Low |
| Anesthesia for Removal of Breast Bone Tissue | surgery | $2 | $2 to $550 | Low |
| Anesthesia for Removal of Prostate Including Use of an Endoscope | surgery | $2 | $2 to $914 | Low |
| Anesthesia for Removal of Testicle Through Groin | surgery | $2 | $2 to $926 | Low |
| Anesthesia for Removal of Tissue From Around Lung | surgery | $2 | $2 to $542 | Low |
| Anesthesia for Removal of Urinary Bladder Tumors Including Use of an Endoscope | surgery | $2 | $2 to $912 | Low |
| Anesthesia for Repair of Abdominal Wall Hernia | surgery | $2 | $2 to $832 | Low |
| Anesthesia for Repair of Achilles Tendon | surgery | $2 | $2 to $1,472 | Low |
| Anesthesia for Repair of Bulging (aneurysm) Defect in Knee Artery | surgery | $2 | $2 to $1,444 | Low |
| Anesthesia for Repair of Calf Muscle | surgery | $2 | $2 to $1,474 | Low |
| Anesthesia for Repair of Elbow to Shoulder Tendon | surgery | $2 | $2 to $1,714 | Low |
| Anesthesia for Repair OR Removal of Vagina and Urinary Procedure | surgery | $2 | $2 to $942 | Low |
| Anesthesia for Total Elbow Joint Replacement | surgery | $2 | $2 to $1,760 | Low |
| Anesthesia for Vaginal Removal of Uterus | surgery | $2 | $2 to $944 | Low |
| Ankle Gel Splint #79 | other | $2 | $2 to $9 | Low |
| Aquacel Adhesive Foam Dressing 4 X 10 #421153 140ea/case | other | $2 | $2 to $3 | Low |
| Aripiprazole 2 Mg Tablet | other | $2 | $2 to $6 | Low |
| Arnuity Ellipta 200 Mcg Inh | other | $2 | $2 to $6 | Low |
| Arthritis Hot 15%-10% Cream | other | $2 | $2 to $3 | Low |
| Atomizer Mucosal Atomization Device | other | $2 | $2 to $9 | Low |
| Auryxia 210 Mg Tablet | other | $2 | $2 to $7 | Low |
| Azelastine 0.1% (137 Mcg) Spry | other | $2 | $2 to $8 | Low |
| Azithromycin 250 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Bandage Comprilan 10cm 20ea/1cs | other | $2 | $2 to $7 | Low |
| Bandage Comprilan 6cm 20ea/1cs | other | $2 | $2 to $6 | Low |
| Bandage Comprilan 8cm 20ea/1cs | other | $2 | $2 to $7 | Low |
| Benzoyl Peroxide 5 % Ex Gel | other | $2 | $2 to $4 | Low |
| Bile Bag with Straps 0015850 12ea/case | other | $2 | $2 to $8 | Low |
| Binder Abdominal 10" 27"-48" #ort21200 | other | $2 | $2 to $6 | Low |
| Binder Abdominal 12" 27"-48" #ort21300 | other | $2 | $2 to $7 | Low |
| Biofreeze W/ilex 4oz Tube 1ea | other | $2 | $2 to $7 | Low |
| Biotene Moisturizing Mouth Spr | other | $2 | $2 to $7 | Low |
| Blade Beaver #bb365r Aesculap | other | $2 | $2 to $3 | Low |
| Blood Count, Hemoglobin | other | $2 | $2 to $85,018 | Low |
| Bra Compression White 34 #e5001 | other | $2 | $2 to $9 | Low |
| Bra Compression White 36 #e5001 | other | $2 | $2 to $9 | Low |
| Bra Compression White 38 #e5001 | other | $2 | $2 to $9 | Low |
| Bra Compression White 40 #e5001 | other | $2 | $2 to $9 | Low |
| Bra Compression White 42 #e5001 | other | $2 | $2 to $9 | Low |
| Bra Compression White 44 #e5001 | other | $2 | $2 to $9 | Low |
| Brace Ankle Air Gel 8.5in Med #79 | other | $2 | $2 to $9 | Low |
| Brace Ankle Air Gel 9in Small #79 | other | $2 | $2 to $9 | Low |
| Brace Wrist Elastic Right Sm #79 | other | $2 | $2 to $3 | Low |
| Brace Wrist/forearm Support Left #79 | other | $2 | $2 to $6 | Low |
| Brilinta 60 Mg Tablet | other | $2 | $2 to $7 | Low |
| Brilinta 90 Mg Tablet | other | $2 | $2 to $7 | Low |
| **discontinued** Filter Line H Set M1920a 25ea/1cs | other | $3 | $3 to $10 | Low |
| 12 Ga Sertera Introducer5ea/bx #sertera Intro | other | $3 | $3 to $11 | Low |
| Abdominal Support 10in 1ea | other | $3 | $3 to $10 | Low |
| Acuvail 0.45% Ophth Solution | other | $3 | $3 to $10 | Low |
| Adaptive Mug Alimed #2970010571 Pk/20ea | other | $3 | $3 to $10 | Low |
| Administration and Interpretation of Caregiver-focused Health Risk Assessment | other | $3 | $3 to $96,161 | Low |
| Administration and Interpretation of Patient-focused Health Risk Assessment | other | $3 | $3 to $96,160 | Low |
| Alginate OR Other Fiber Gelling Dressing, Wound Cover, Sterile, Pad Size 16 S... | other | $3 | $3 to $24 | Low |
| Anesthesia for Closed Exam of Chest Using an Endoscope with 1 Lung Inflated | other | $3 | $3 to $529 | Low |
| Anesthesia for Closed Procedure On Hip Joint | other | $3 | $3 to $1,200 | Low |
| Anesthesia for Closed Procedure On Knee Joint | other | $3 | $3 to $1,380 | Low |
| Anesthesia for Exam of Colon Using an Endoscope | other | $3 | $3 to $812 | Low |
| Anesthesia for Extensive Surgery On Spine | surgery | $3 | $3 to $670 | Low |
| Anesthesia for Other Procedure On Eye | other | $3 | $3 to $140 | Low |
| Anesthesia for Procedure On Eyelid | other | $3 | $3 to $103 | Low |
| Anesthesia for Procedure On Heart and Large Blood Vessels Using Heart-lung Ma... | cardiac | $3 | $3 to $563 | Low |
| Anesthesia for Procedure to Assess Heart Electrical Activity | cardiac | $3 | $3 to $537 | Low |
| Anesthesia for Retinal Surgery | surgery | $3 | $3 to $145 | Low |
| Angiocath 16ga 3-1/4 Bd #382258 | other | $3 | $3 to $12 | Low |
| Ankle Brace-air/gel 10" Universal | other | $3 | $3 to $10 | Low |
| Anucort-hc 25 Mg Suppository | other | $3 | $3 to $12 | Low |
| Aspirin 1 Mg/1 Ml Po Suspension | other | $3 | $3 to $10 | Low |
| Automated White Blood Cell Count | other | $3 | $3 to $85,048 | Low |
| Bandage Comprilan 12cm 20ea/1cs | other | $3 | $3 to $10 | Low |
| Bard Foley Drainage Syestem #a304400a | other | $3 | $3 to $13 | Low |
| Bcg Live Intravesical Instillation, 1 Mg | other | $3 | $3 to $318 | Low |
| Belt Gait W/buckle 48" 1ea | other | $3 | $3 to $10 | Low |
| Belt Gait W/buckle 60" 1ea | other | $3 | $3 to $10 | Low |
| Betamethasone Va 0.1% Cream | other | $3 | $3 to $13 | Low |
| Blm Mouthwash - 10 Ml - Compounded | other | $3 | $3 to $10 | Low |
| Blood Glucose (sugar) Test Performed By Hand-held Instrument | other | $3 | $3 to $82,962 | Low |
| Blood Group Typing | other | $3 | $3 to $86,900 | Low |
| Blood Typing for Rh (d) Antigen | other | $3 | $3 to $86,901 | Low |
| Bone Wax 2.5 Gram Non-absorbable #bw25g | other | $3 | $3 to $13 | Low |
| Boots Sta-dri Knee-hi #kh | other | $3 | $3 to $12 | Low |
| Brace Ankle As0 Large #ab2900 | other | $3 | $3 to $11 | Low |
| Brace Ankle As0 Medium #ab2900 | other | $3 | $3 to $11 | Low |
| Brace Ankle As0 Small #ab2900 | other | $3 | $3 to $11 | Low |
| Brace Ankle As0 Xlarge #ab2900 | other | $3 | $3 to $11 | Low |
| Breast Comfort Gel Pads #17264 50ea/1cs | other | $3 | $3 to $10 | Low |
| Budesonide, Inhalation Solution, Fda-approved Final Product, Non-compounded, ... | other | $3 | $3 to $9 | Low |
| 25-40cc Iabp Adaptor#0684-00-0510-01 5ea/pk | other | $4 | $4 to $15 | Low |
| 4fr Simmons 1 | other | $4 | $4 to $15 | Low |
| 4fr Sos 1 | other | $4 | $4 to $15 | Low |
| 5 Fr Barbeau | other | $4 | $4 to $13 | Low |
| 5 Fr IM | other | $4 | $4 to $13 | Low |
| 5 Fr Jr 3.5 | other | $4 | $4 to $13 | Low |
| 5fr Simmons 2 | other | $4 | $4 to $15 | Low |
| 5fr Sos 2 | other | $4 | $4 to $15 | Low |
| Abdominal Support 12in 1ea | other | $4 | $4 to $15 | Low |
| Antithrombin Iii (human), Per I.u. | other | $4 | $4 to $6,748 | Low |
| Application of Hot OR Cold Packs | other | $4 | $4 to $97,010 | Low |
| Arch Support Medium #mdy10520 | other | $4 | $4 to $14 | Low |
| Atovaquone 750 Mg/5ml Susp Cup | other | $4 | $4 to $14 | Low |
| Binder Abdominal 12" 46-62" #13982000 | other | $4 | $4 to $15 | Low |
| Blanket-nsy Disp Therm Med #37.09.15 | other | $4 | $4 to $15 | Low |
| Blanket-nsy Disp Therm Sm #37.09.14 | other | $4 | $4 to $15 | Low |
| Blood Glucose (sugar) Level | other | $4 | $4 to $82,947 | Low |
| Blood Glucose (sugar) Tolerance Test, Each Additional Beyond 3 Specimens | lab | $4 | $4 to $82,952 | Low |
| Blood Typing for Red Blood Cell Antigens | other | $4 | $4 to $86,905 | Low |
| Body Fluid Ph Level | other | $4 | $4 to $83,986 | Low |
| Bovie High Temp Fine Tip Cautery Surgical Disposable Aspen # Aa01 10ea/1bx | surgery | $4 | $4 to $14 | Low |
| Breast Pump One-hand Manual #17161 | other | $4 | $4 to $16 | Low |
| **discontinued** Catheter Imager Ii Cobra 5fr M0064003011 5/bx | cardiac | $5 | $5 to $17 | Low |
| 4fr Sos Mini Omni 65cm - Must Be Ordered in Qty's of 5 Ea | other | $5 | $5 to $21 | Low |
| 5fr Sos 80cm | other | $5 | $5 to $17 | Low |
| Akten 3.5% Gel Drops | other | $5 | $5 to $19 | Low |
| Albumin (protein) Level | other | $5 | $5 to $82,040 | Low |
| Ambien 10 Mg Tablet | other | $5 | $5 to $20 | Low |
| Anesthesia for Exam of Ear Using an Endoscope | other | $5 | $5 to $124 | Low |
| Anesthesia for Incision of Ear Drum | other | $5 | $5 to $126 | Low |
| Anesthesia for Procedure On Small and Large Bowel Using an Endoscope | other | $5 | $5 to $813 | Low |
| Angiographic Catheter 5f (1.8mm) X 90cm Cobra 2 #10719711 5ea/bx | imaging | $5 | $5 to $20 | Low |
| Arch Support Large #mdy10530 | other | $5 | $5 to $17 | Low |
| Avitene Ultrafoam Collagen Hemostatic Sponge 3/4 X 2-1/2 X 1/4 12 Ea/bx 1050020 | other | $5 | $5 to $17 | Low |
| Bilirubin Level, Direct | other | $5 | $5 to $82,248 | Low |
| Bilirubin Level, Total | other | $5 | $5 to $82,247 | Low |
| Bleeding Time | other | $5 | $5 to $85,002 | Low |
| Blood Chloride Level | other | $5 | $5 to $82,435 | Low |
| Blood Creatinine Level | other | $5 | $5 to $82,565 | Low |
| Blood Glucose (sugar) Level After Receiving Dose of Glucose | other | $5 | $5 to $82,950 | Low |
| Blood Glucose (sugar) Measurement Using Reagent Strip | other | $5 | $5 to $82,948 | Low |
| Blood Potassium Level | other | $5 | $5 to $84,132 | Low |
| Blood Sodium Level | other | $5 | $5 to $84,295 | Low |
| Body Fluid Cell Count | other | $5 | $5 to $89,050 | Low |
| Brace Elbow 11 Inch Adult #79 | other | $5 | $5 to $18 | Low |
| Brace Foot Left Large Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Left Medium Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Left Small Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Left Xlarge Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Left Xsmall Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Right Large Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Right Medium Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Right Small Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Right Xlarge Ab2801 | other | $5 | $5 to $20 | Low |
| Brace Foot Right Xsmall Ab2801 | other | $5 | $5 to $20 | Low |
| Abreva 10% Cream | other | $6 | $6 to $21 | Low |
| Albuterol Hfa 90 Mcg Inhaler | other | $6 | $6 to $22 | Low |
| Albuterol Sulfate Hfa 108 (90 Base) Mcg/act in Aers | other | $6 | $6 to $22 | Low |
| All Potassium Hydroxide (koh) Preparations | other | $6 | $6 to $62 | Low |
| Amerigel Wound Dressing Gel | other | $6 | $6 to $24 | Low |
| Amylase (enzyme) Level | other | $6 | $6 to $82,150 | Low |
| Application of Hot Wax Bath | other | $6 | $6 to $97,018 | Low |
| Bacitracin-polymyxin Eye Oint | other | $6 | $6 to $21 | Low |
| Adapter Connecting Ureteral Cath #uca5 | other | $7 | $7 to $26 | Low |
| Adapter Tuohy-borst #g18813 | other | $7 | $7 to $25 | Low |
| Antimicrobial Study, Mycobacteria | other | $7 | $7 to $87,190 | Low |
| Antivenin (latrodectus) Vial | other | $7 | $7 to $28 | Low |
| Arch Support Xlarge #mdy10540 | other | $7 | $7 to $25 | Low |
| Aztreonam 1 Gm/ Ns 50 Ml Mini Bag Plus - Compounded | other | $7 | $7 to $25 | Low |
| Ball Electrode 3mm Vaginal #e1563 | other | $7 | $7 to $27 | Low |
| Ball Electrode 5mm Vaginal #e1564 | other | $7 | $7 to $28 | Low |
| Blood Osmolality (concentration) Measurement | other | $7 | $7 to $83,930 | Low |
| Administration of Vaccine OR Toxoid Component with Counseling (18 Years OR Yo... | therapy | $8 | $8 to $90,461 | Low |
| Administration of Vaccine, Each Additional Vaccine | preventive | $8 | $8 to $90,472 | Low |
| Algicell 4 X 4 #88044 4ea/1cs | other | $8 | $8 to $30 | Low |
| Anesthesia for Removal of Blood Clot From Upper Arm OR Elbow Artery | surgery | $8 | $8 to $8 | Low |
| Bacterial Colony Count, Urine | other | $8 | $8 to $87,086 | Low |
| Blood Test | lab | $8 | $8 to $80,047 | High |
| Blood Typing Rh Phenotyping | other | $8 | $8 to $86,906 | Low |
| Boot Prevalon Heel Protector I #7305 8/cs | other | $8 | $8 to $31 | Low |
| 0.054 Wire Ws-1407st | other | $9 | $9 to $33 | Low |
| 6/7 Glidesheath Slender #50-1070 10ea/box | other | $9 | $9 to $35 | Low |
| Administration of Nasal OR Oral Vaccine, Each Additional Vaccine | preventive | $9 | $9 to $90,474 | Low |
| Annual, Face-to-face Intensive Behavioral Therapy for Cardiovascular Disease,... | cardiac | $9 | $9 to $66 | Low |
| Application of Electrical Stimulation | other | $9 | $9 to $97,014 | Low |
| Bacterial Culture | lab | $9 | $9 to $87,075 | Low |
| Biopsy Inst Max-core Disposable Core #mc1820 | lab | $9 | $9 to $35 | Low |
| Bone Density Scan | imaging | $9 | $9 to $550 | High |
| Butorphanol 10 Mg/ml Spray | other | $9 | $9 to $34 | Low |
| Button Cannula 10mm Idx4 #ar-6592-10 | other | $9 | $9 to $32 | Low |
| Button Cannula 10mm Idx5 #ar-6592-10 | other | $9 | $9 to $32 | Low |
| Aldolase (enzyme) Level | other | $10 | $10 to $82,085 | Low |
| Analysis for Antibody to Bartonella | other | $10 | $10 to $86,611 | Low |
| Analysis for Antibody to Ehrlichia | other | $10 | $10 to $86,666 | Low |
| Aortical Surgical Flat 4.0 Punch #080-401 6ea/box | surgery | $10 | $10 to $37 | Low |
| Ascorbic Acid (vitamin C) Level, Blood | other | $10 | $10 to $82,180 | Low |
| Betamethasone Dp 0.05% Lot | other | $10 | $10 to $37 | Low |
| Blood Culture | lab | $10 | $10 to $87,040 | Low |
| Bra Compression Pink Post Surgery Large #042l | surgery | $10 | $10 to $36 | Low |
| Bra Compression Pink Post Surgery Medium #042m | surgery | $10 | $10 to $36 | Low |
| Bra Post Surgery Compression 2xl #0422xl | surgery | $10 | $10 to $36 | Low |
| Bra Post Surgery Compression 3xl #0423xl | surgery | $10 | $10 to $36 | Low |
| Bra Post Surgery Compression Xl #042xl | surgery | $10 | $10 to $36 | Low |
| Breather/speech/rehab 1ea | other | $10 | $10 to $36 | Low |
| **obsolete** Suture 0 Poly Prolene #833 | other | $11 | $11 to $41 | Low |
| 5fr Sos Omni (0) 80cm H787107120085 | other | $11 | $11 to $41 | Low |
| 5fr Sos Omni (3) 80cm | other | $11 | $11 to $41 | Low |
| Aminocaproic Acid 500 Mg Tab | other | $11 | $11 to $42 | Low |
| Analysis for Antibody to Coccidioides | other | $11 | $11 to $86,635 | Low |
| Application of Blood Vessel Compression Device | other | $11 | $11 to $97,016 | Low |
| Butrans 5 Mcg/hr Patch | other | $11 | $11 to $42 | Low |
| Administration of Hepatitis B Vaccine | preventive | $12 | $12 to $92 | Low |
| Administration of Influenza Virus Vaccine | preventive | $12 | $12 to $92 | Low |
| Administration of Pneumococcal Vaccine | preventive | $12 | $12 to $92 | Low |
| Analysis of Substance Using Immunoassay Technique, Multiple Step Method | other | $12 | $12 to $83,516 | Low |
| Antithrombin Iii Antigen (clotting Inhibitor) Activity | other | $12 | $12 to $85,300 | Low |
| Assessment of Emotional OR Behavioral Problems | other | $12 | $12 to $96,127 | Low |
| Betamethasone Dp 0.05% Oint | other | $12 | $12 to $44 | Low |
| Blood Viscosity Measurement | other | $12 | $12 to $85,810 | Low |
| Brexpiprazole 2 Mg Po Tabs | other | $12 | $12 to $45 | Low |
| 5% Dextrose in Lactated Ringers Infusion, Up to 1000 Cc | surgery | $13 | $13 to $50 | Low |
| 5% Dextrose/normal Saline | other | $13 | $13 to $50 | Low |
| 5% Dextrose/water | other | $13 | $13 to $50 | Low |
| Adenovirus Type 4 Vaccine | preventive | $13 | $13 to $90,476 | Low |
| Administration of First Vaccine OR Toxoid Component with Counseling | therapy | $13 | $13 to $90,460 | Low |
| Administration of Nasal OR Oral Vaccine, 1 Vaccine | preventive | $13 | $13 to $90,473 | Low |
| Administration of Vaccine | preventive | $13 | $13 to $90,471 | Low |
| Analysis for Antibody to Blastomyces | other | $13 | $13 to $86,612 | Low |
| Analysis for Antibody to Enterovirus | other | $13 | $13 to $86,658 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Early Antigen | other | $13 | $13 to $86,663 | Low |
| Analysis for Antibody to Mumps Virus | other | $13 | $13 to $86,735 | Low |
| Analysis for Antibody to Mycoplasma | other | $13 | $13 to $86,738 | Low |
| Analysis for Antibody to Rubeola | other | $13 | $13 to $86,765 | Low |
| Analysis for Antibody to Varicella-zoster Virus | other | $13 | $13 to $86,787 | Low |
| Analysis for Antibody to Virus | other | $13 | $13 to $86,790 | Low |
| Avitene Ultrafoam Collagen Sponge 100 SQ Cm 8cm X 12.5cm 3-1/18" X 5" 1050040 | other | $13 | $13 to $49 | Low |
| Bacteriostatic Saline Vial | other | $13 | $13 to $50 | Low |
| Blood Glucose (sugar) Tolerance Test, 3 Specimens | lab | $13 | $13 to $82,951 | Low |
| Boot Prevalon Iii W/wedge #7355 8ea/cs | other | $13 | $13 to $48 | Low |
| Bupivacaine-epinephrine (pf) 0.5% -1:200000 Ij Soln | other | $13 | $13 to $50 | Low |
| Buprenorphine 10 Mcg/hr Patch | other | $13 | $13 to $49 | Low |
| Addition to Lower Extremity Orthosis, Drop Lock Retainer, Each | other | $14 | $14 to $53 | Low |
| Addition to Upper Extremity Orthosis, Sock, Fracture OR Equal, Each | other | $14 | $14 to $54 | Low |
| Analysis for Antibody to Cryptococcus | other | $14 | $14 to $86,641 | Low |
| Analysis for Antibody to Cytomegalovirus | other | $14 | $14 to $86,644 | Low |
| Analysis for Antibody to Herpes Simplex Virus | other | $14 | $14 to $86,694 | Low |
| Analysis for Antibody to Histoplasma | other | $14 | $14 to $86,698 | Low |
| Analysis for Antibody to Hiv-2 Virus | other | $14 | $14 to $86,702 | Low |
| Analysis for Antibody to Rubella | other | $14 | $14 to $86,762 | Low |
| Analysis for Antibody to Toxoplasma | other | $14 | $14 to $86,777 | Low |
| Analysis Using Chemiluminescent Technique (light and Chemical )reaction | other | $14 | $14 to $82,397 | Low |
| Benzoyl Peroxide-erythromycin 5-3 % Ex Gel | other | $14 | $14 to $51 | Low |
| Boot Prevalon Heel Protector Petite #7310 | other | $14 | $14 to $52 | Low |
| Bowl Cement Smart Mix #5401-76 | other | $14 | $14 to $54 | Low |
| 4fr Pigtail | other | $15 | $15 to $55 | Low |
| Albuterol, Up to 2.5 Mg and Ipratropium Bromide, Up to 0.5 Mg, Fda-approved F... | other | $15 | $15 to $29 | Low |
| Amikacin (antibiotic) Level | other | $15 | $15 to $80,150 | Low |
| Ammonia Level | other | $15 | $15 to $82,140 | Low |
| Analysis for Antibody to Aspergillus | other | $15 | $15 to $86,606 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Nuclear An... | imaging | $15 | $15 to $86,664 | Low |
| Analysis for Antibody to Legionella | other | $15 | $15 to $86,713 | Low |
| Angiotensin L - Converting Enzyme (ace) Level | other | $15 | $15 to $82,164 | Low |
| Blower Mister Kit Clearview #22150 | other | $15 | $15 to $55 | Low |
| Brachytherapy Needle | other | $15 | $15 to $58 | Low |
| Brachytherapy Source, Non-stranded, Iodine-125, Per Source | other | $15 | $15 to $58 | Low |
| 10.0mm Shiley Flex Cuffless Reus Trach 10un10r | other | $16 | $16 to $60 | Low |
| 20fr Standard Peg Kit Push Box of 2 #m00568211 | other | $16 | $16 to $60 | Low |
| 24fr Standard Peg Kit Pull with Enfit M00509061 | other | $16 | $16 to $60 | Low |
| Aminolevulinic Acid (protein) Level | other | $16 | $16 to $82,135 | Low |
| Anesthesia for Electroshock Therapy | other | $16 | $16 to $148 | Low |
| Aveta Waste Management Accessory 3.0 #205-2036 6ea/ct | other | $16 | $16 to $60 | Low |
| Beta-2 Microglobulin (protein) Level | other | $16 | $16 to $82,232 | Low |
| Breast Prosthesis, Mastectomy Bra, without Integrated Breast Prosthesis Form,... | other | $16 | $16 to $60 | Low |
| Addition to Lower Extremity, Below Knee, Fork Strap | other | $17 | $17 to $63 | Low |
| Alpha-fetoprotein (afp) Level, Serum | other | $17 | $17 to $82,105 | Low |
| Analysis for Antibody | other | $17 | $17 to $86,645 | Low |
| Analysis for Antibody Borrelia Burgdorferi | other | $17 | $17 to $86,618 | Low |
| Analysis for Antibody to Helicobacter Pylori | other | $17 | $17 to $86,677 | Low |
| Analysis for Antibody to Hepatitis D Virus | other | $17 | $17 to $86,692 | Low |
| Aprepitant, Oral, 5 Mg | other | $17 | $17 to $63 | Low |
| Balloon Armada 35 Wh 12x80x135cm #b2120 | other | $17 | $17 to $65 | Low |
| Bellaire Comfort Lso Universal Fits Waist Circumference: 25-60inch (64-152cm)... | other | $17 | $17 to $65 | Low |
| Bile Acids Level, Total | other | $17 | $17 to $82,239 | Low |
| 10.0mm Shiley Flex Cuffed Reus Trach 10cn10r | other | $18 | $18 to $66 | Low |
| 14fr Entuit Gastrostomy Tube #g35615 | other | $18 | $18 to $68 | Low |
| 6.5mm Shiley Flex Cuffed Reus Trach 4cn65r | other | $18 | $18 to $66 | Low |
| 7.5mm Shiley Flex Cuffed Reus Trach 6cn75r | other | $18 | $18 to $69 | Low |
| 8.5mm S Shiley Flex Cuffed Reus Trach 8cn85r | other | $18 | $18 to $66 | Low |
| Amox-clav 600-42.9 Mg/5 Ml Sus | other | $18 | $18 to $66 | Low |
| Amoxicillin-pot Clavulanate 600-42.9 Mg/5ml Po Susr | other | $18 | $18 to $66 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Viral Capsid | other | $18 | $18 to $86,665 | Low |
| Antibody Identification Test, Platelet Antibodies | other | $18 | $18 to $86,022 | Low |
| Auto Effluent Set #115370 Ca/ 8ea | other | $18 | $18 to $69 | Low |
| Aztreonam 2 Gm/ Ns 50 Ml Mini Bag Plus - Compounded | other | $18 | $18 to $68 | Low |
| Blood Pressure Monitoring | other | $18 | $18 to $93,790 | High |
| Breast Biopsy | other | $18 | $18 to $2,510 | High |
| 4fr Pedal Access Set Micropuncture Transitionless #g02972 | other | $19 | $19 to $70 | Low |
| 5fr Pedal Access Set Micropuncture Transitionless #g02988 | other | $19 | $19 to $70 | Low |
| Analysis for Antibody to Rickettsia | other | $19 | $19 to $86,757 | Low |
| Arsenic Level | other | $19 | $19 to $82,175 | Low |
| Barron Vacuum Punch 9.0mm | other | $19 | $19 to $72 | Low |
| Bivona Uncuffed Tracheostomy Tube Flextend Size 8.0 Pediatric #60pfs55 | other | $19 | $19 to $70 | Low |
| Blood Smear Interpretation By Physician with Written Report | other | $19 | $19 to $85,060 | Low |
| 3d Ultrasound Imaging of Heart for Evaluation of Heart Structure Performed Du... | imaging | $20 | $20 to $93,319 | Low |
| Abdominal Ultrasound | imaging | $20 | $20 to $75 | High |
| Addition to Lower Extremity, Limited Ankle Motion, Each Joint | other | $20 | $20 to $77 | Low |
| Aerotech I Aerosol Unit Ca-1124 | other | $20 | $20 to $75 | Low |
| Blake Drain 19fr R/f #2230 Case/10ea | other | $20 | $20 to $74 | Low |
| Bone Hemostasis 2.5gm #bw012 Ostene | other | $20 | $20 to $75 | Low |
| Bowl and Spatula Bone Cement Mixing Universal System Vacuum Rotor without Noz... | other | $20 | $20 to $74 | Low |
| Brace Knee Post Op Warrior Kb9000 | other | $20 | $20 to $76 | Low |
| 45 Degree Kelman Mini-flare Tip | other | $21 | $21 to $78 | Low |
| Acclarent Balloon Inflation Device 5 Ea/bxdib30 | other | $21 | $21 to $78 | Low |
| Addition to Lower Extremity, Below Knee, Waist Belt, Webbing | other | $21 | $21 to $79 | Low |
| Analysis for Detection of Tumor Marker | other | $21 | $21 to $86,316 | Low |
| Beta 2 Glycoprotein 1 Antibody (autoantibody) Measurement | other | $21 | $21 to $86,146 | Low |
| Bio-medicus Venous Insertion Kit 5 Ea/pk 96551 | other | $21 | $21 to $79 | Low |
| Brace Rcai Contour Fit Lso Med 451-cf-lso-m | other | $21 | $21 to $79 | Low |
| Brace Rcai Control Fit Lso Large 451-cf-lso-l | other | $21 | $21 to $79 | Low |
| 4.2mm Trocar 210mm 03.010.070 | other | $22 | $22 to $83 | Low |
| Addition to Lower Extremity, Extended Steel Shank | other | $22 | $22 to $84 | Low |
| Addition to Lower Extremity, Varus/valgus Correction ('t') Strap, Padded/line... | other | $23 | $23 to $87 | Low |
| Alcohol And/or Substance (other Than Tobacco) Misuse Structured Assessment (e... | other | $23 | $23 to $176 | Low |
| Alcohol And/or Substance Abuse Screening and Intervention, 15-30 Minutes | preventive | $23 | $23 to $99,408 | Low |
| Amino Acid Analysis, Quantitative, Each Specimen | lab | $23 | $23 to $82,131 | Low |
| Application of Vein Wound Compression Bandages On Lower Leg, Ankle, and Foot | other | $23 | $23 to $29,581 | Low |
| Barron Vacuum Punch 7.5mm | other | $23 | $23 to $85 | Low |
| Barron Vacuum Punch 8.0mm | other | $23 | $23 to $85 | Low |
| Barron Vacuum Punch 8.25mm | other | $23 | $23 to $88 | Low |
| Brace Knee T-scope Post Op #08814 | other | $23 | $23 to $87 | Low |
| Brush Biopsy Deflection 3.2frx115cm #g15045 | lab | $23 | $23 to $85 | Low |
| 1.5mm Quick Release Drill Msdc15 Ms-dc15 | other | $24 | $24 to $92 | Low |
| 16fr Entuit Gastrostomy Tube #g35616 | other | $24 | $24 to $92 | Low |
| 3d Radiographic Procedure | imaging | $24 | $24 to $76,376 | Low |
| 9986-21-20 Flexible Osteotome Short 8 Mm | other | $24 | $24 to $90 | Low |
| 9986-21-21 Flexible Osteotome Short 10 Mm | other | $24 | $24 to $90 | Low |
| 9986-21-22 Flexible Osteotome Short 12 Mm | other | $24 | $24 to $90 | Low |
| 9986-21-24 Flexible Osteotome Short Curved | other | $24 | $24 to $90 | Low |
| 9986-21-26 Flexible Osteotome Long 10 Mm | other | $24 | $24 to $90 | Low |
| 9986-21-27 Flexible Osteotome Long 8 Mm | other | $24 | $24 to $90 | Low |
| Addition to Lower Extremity, Below Knee, Cuff Suspension | other | $24 | $24 to $91 | Low |
| Application of Nonmoveable Finger Splint | other | $24 | $24 to $29,130 | Low |
| Bard Single Lumen Picc 5fr #3195335 | other | $24 | $24 to $92 | Low |
| Bra Cardiac Surgery Sz-40b-52dd 1ea | surgery | $24 | $24 to $90 | Low |
| 5.5x85mm Rod Ti Alloy Curved Vitality #07.02015.014 | other | $25 | $25 to $95 | Low |
| Adapter/extension, Pacing Lead OR Neurostimulator Lead | other | $25 | $25 to $94 | Low |
| Aplisol 5t Unit/0.1 Ml Vial | other | $25 | $25 to $95 | Low |
| Basket Retrieval 2.5x230cm Disp Roth 00711050 | other | $25 | $25 to $94 | Low |
| Addition to Lower Extremity Orthosis, Knee Control, Full Kneecap | other | $26 | $26 to $99 | Low |
| Adhesion Barrier | other | $26 | $26 to $98 | Low |
| Anticoagulant Management for an Outpatient Taking Warfarin, Physician Review ... | other | $26 | $26 to $99,364 | Low |
| Blood Gases Measurement | other | $26 | $26 to $82,803 | Low |
| Bone Marrow Asp Sys Dstl Hole 11g 710.150.97s | other | $26 | $26 to $99 | Low |
| 3.0mm Round Diamond 5820-012-030d | other | $27 | $27 to $103 | Low |
| 4.0mm Round Diamond 5820-012-040d | other | $27 | $27 to $103 | Low |
| Addition to Lower Extremity Orthosis, Femoral Length Sock, Fracture OR Equal,... | other | $27 | $27 to $100 | Low |
| Albendazole 200 Mg Po Tabs | other | $27 | $27 to $102 | Low |
| Alkaloids Levels | other | $27 | $27 to $80,323 | Low |
| Balloon Wedge Pressure Catheter 5fr 110cm | cardiac | $27 | $27 to $100 | Low |
| Belt, Strap, Sleeve, Garment, OR Covering, Any Type | other | $27 | $27 to $103 | Low |
| 2.2mm Match Head 5820-107 | other | $28 | $28 to $105 | Low |
| Addition to Lower Extremity Fracture Orthosis, Drop Lock Knee Joint | other | $28 | $28 to $107 | Low |
| 7fr Single Sensor W/lumen/coude Tip | other | $29 | $29 to $110 | Low |
| Application of Hinged Finger Splint | other | $29 | $29 to $29,131 | Low |
| 2.3mm Tapered Router5407-fa2 | other | $30 | $30 to $111 | Low |
| 3.0mm Tapered Router5407-fa3 | other | $30 | $30 to $111 | Low |
| Ankle Orthosis, Ankle Gauntlet OR Similar, with OR without Joints, Prefabrica... | other | $30 | $30 to $226 | Low |
| Antibody Evaluation, Each Additional Single Antibody Stain Procedure | other | $30 | $30 to $88,350 | Low |
| 12.6mm X 10.4mm Boring Toolstryker #5130-123 | other | $31 | $31 to $117 | Low |
| 9.5mm X 10.4mm Boring Tool 5130-123 | other | $31 | $31 to $117 | Low |
| Addition to Lower Extremity Orthosis, Non-corrosive Finish, Per Bar | other | $31 | $31 to $116 | Low |
| Avitene Microfibril Collagen Hemostat 1010020 | other | $32 | $32 to $119 | Low |
| Basket Roth Net Pedia Foreign Body Bx00711057 | other | $32 | $32 to $121 | Low |
| Blood Gases Measurement, with O2 Saturation | other | $32 | $32 to $82,805 | Low |
| Button Replacement 24fr X 2.4cm Low Profile | surgery | $32 | $32 to $120 | Low |
| 2.0mm Round Diamond 5820-012-020d | other | $33 | $33 to $125 | Low |
| Addition to Lower Extremity Orthosis, Rocker Bottom for Total Contact Ankle F... | other | $33 | $33 to $124 | Low |
| Addition to Lower Extremity, Dorsiflexion Assist (plantar Flexion Resist), Ea... | other | $33 | $33 to $125 | Low |
| Addition to Lower Extremity, Split Flat Caliper Stirrups and Plate Attachment | other | $33 | $33 to $124 | Low |
| Ankle Control Orthosis, Stirrup Style, Rigid, Includes Any Type Interface (e.... | other | $33 | $33 to $250 | Low |
| Addition to Knee Joint, Lift Loop for Drop Lock Ring | other | $34 | $34 to $129 | Low |
| Adh (antidiuretic Hormone) Level | other | $34 | $34 to $84,588 | Low |
| Biktarvy 50-200-25 Mg Tablet | other | $34 | $34 to $129 | Low |
| Addition to Lower Extremity, Torsion Control, Ankle Joint and Half Solid Stirrup | other | $35 | $35 to $132 | Low |
| Alvimopan 12 Mg Capsule | other | $35 | $35 to $130 | Low |
| Amplifed Dna OR Rna Probe Detection of Severe Acute Respiratory Syndrome Coro... | other | $35 | $35 to $87,635 | Low |
| Application of Lower and Upper Arm Splint | other | $35 | $35 to $29,105 | Low |
| Aveta Fluid Management Accessory #205-212 3/ctn | other | $35 | $35 to $130 | Low |
| Application of Long Leg Splint From Thigh to Ankle OR Toe | other | $36 | $36 to $29,505 | Low |
| Application of Nonmoveable Forearm to Hand Splint | other | $36 | $36 to $29,125 | Low |
| Application of Short Leg Splint From Calf to Foot | other | $36 | $36 to $29,515 | Low |
| Biopsy of Ear | lab | $36 | $36 to $69,100 | Low |
| Bonopty Biopsy Set 16cm #10 | lab | $36 | $36 to $135 | Low |
| Bonopty Penetration Set 9.5cms #10 | other | $36 | $36 to $135 | Low |
| Addition to Lower Extremity Orthosis, Soft Interface for Molded Plastic, Belo... | other | $37 | $37 to $141 | Low |
| Ball 24fr Monopolar Coag 3mm 27050n-s Cysview | other | $37 | $37 to $138 | Low |
| 1203105 9.0 Uniblocker 1/ea | other | $38 | $38 to $143 | Low |
| Addition to Lower Extremity, Dorsiflexion and Plantar Flexion Assist/resist, ... | other | $38 | $38 to $143 | Low |
| Addition to Lower Extremity, Torsion Control, Straight Knee Joint, Each Joint | other | $38 | $38 to $144 | Low |
| Aspiration And/or Injection of Fluid From Small Joint Using Ultrasound Guidance | imaging | $38 | $38 to $20,604 | Low |
| Bone Marrow, Smear Interpretation | other | $38 | $38 to $85,097 | Low |
| Adrenocorticotropic Hormone (acth) Level | other | $39 | $39 to $82,024 | Low |
| Blood Bank Physician Services for Cross Match And/or Evaluation and Written R... | other | $39 | $39 to $86,077 | Low |
| Blood Bank Physician Services for Investigation of Transfusion Reaction with ... | surgery | $39 | $39 to $86,078 | Low |
| Addition to Knee Joint, Drop Lock, Each | other | $40 | $40 to $152 | Low |
| Alcohols Levels, 1 OR 2 | other | $40 | $40 to $80,321 | Low |
| Aspiration And/or Injection of Cyst of Thyroid | other | $40 | $40 to $60,300 | Low |
| Barbiturates Levels | other | $40 | $40 to $80,345 | Low |
| Budesonide 32 Mcg/act Na Susp | other | $40 | $40 to $149 | Low |
| Aldosterone Hormone Level | other | $41 | $41 to $82,088 | Low |
| Anesthesia for Procedure to Drain Brain and Spinal Cord Fluid | other | $41 | $41 to $378 | Low |
| Addition to Lower Extremity Orthosis, Soft Interface for Molded Plastic, Abov... | other | $42 | $42 to $158 | Low |
| Addition to Lower Extremity, Straight Knee Joint, Heavy Duty, Each Joint | other | $42 | $42 to $156 | Low |
| Antipsychotics Levels, 1 | other | $42 | $42 to $80,342 | Low |
| Biopsy of Lobe of Lung Using an Endoscope, Each Additional Lobe | lab | $42 | $42 to $31,632 | Low |
| Blood Unit Compatibility Test, Antiglobulin Technique | other | $42 | $42 to $86,922 | Low |
| 25 Left Quick Pass Lasso #ar-6068-25tl | other | $43 | $43 to $160 | Low |
| 25 Right Quick Pass Lasso #ar-6068-25tr | other | $43 | $43 to $160 | Low |
| 45 Left Quick Pass Lasso #ar-6068-45l | other | $43 | $43 to $160 | Low |
| 45 Right Quick Pass Lasso #ar-6068-45r | other | $43 | $43 to $160 | Low |
| 90 Degree Curve Left Quick Pass Lasso #ar-6068-90l | other | $43 | $43 to $160 | Low |
| 90 Degree Curve Right Quick Pass Lasso #ar-6068-90r | other | $43 | $43 to $160 | Low |
| 90 Degree Curve Straight Quick Pass Lasso #ar-6068 | other | $43 | $43 to $160 | Low |
| Ankle Foot Orthosis, Multiligamentous Ankle Support, Prefabricated, Off-the-s... | other | $43 | $43 to $320 | Low |
| Application of Moveable OR Hinged Forearm to Hand Splint | other | $43 | $43 to $29,126 | Low |
| Bonopty Biopsy Set 16.5cm #12 | lab | $43 | $43 to $160 | Low |
| Bonopty Penetration Set 10cm #12 | other | $43 | $43 to $160 | Low |
| Addition to Knee Lock with Integrated Release Mechanism (bail, Cable, OR Equa... | other | $44 | $44 to $165 | Low |
| Application of Finger Cast | other | $44 | $44 to $29,086 | Low |
| Alpena Contour Lso Universal Fits Waist Circumference: 25-60inch (64-152cm) #... | other | $45 | $45 to $168 | Low |
| Application of On-body Injector for Under Skin Injection | other | $45 | $45 to $96,377 | Low |
| Aspiration Tubing Kit #72-00114 | other | $45 | $45 to $168 | Low |
| Breast Prosthesis, Mastectomy Bra, with Integrated Breast Prosthesis Form, Un... | other | $46 | $46 to $173 | Low |
| Barone Jejunostomy Set | other | $47 | $47 to $178 | Low |
| 2.5mm Mtch Hd 16cm Stryker #8470-107 | other | $48 | $48 to $180 | Low |
| Acute Hepatitis Panel | lab | $48 | $48 to $80,074 | Low |
| Advance Care Planning, Each Additional 30 Minutes | other | $48 | $48 to $99,498 | Low |
| Application of Elbow to Finger Cast | other | $49 | $49 to $29,075 | Low |
| Application of Walking Cast Covering Below Knee to Toe | other | $49 | $49 to $29,425 | Low |
| Addition to Lower Extremity Fracture Orthosis, Plastic Shoe Insert with Ankle... | other | $50 | $50 to $190 | Low |
| Addition to Lower Extremity Prosthesis, Below Knee, Suspension/sealing Sleeve... | other | $51 | $51 to $193 | Low |
| Addition to Lower Extremity, Long Tongue Stirrup | other | $51 | $51 to $191 | Low |
| Antidepressants Levels, 1 OR 2 | other | $51 | $51 to $80,335 | Low |
| Blood Unit Compatibility Test, Immediate Spin Technique | other | $51 | $51 to $86,920 | Low |
| Addition to Lower Extremity, Below Knee, Molded Distal Cushion | other | $52 | $52 to $195 | Low |
| Application of Hand and Lower Forearm Cast | other | $52 | $52 to $29,085 | Low |
| Arc Smart Argon Probe 2.3/220 G1140001 | other | $52 | $52 to $196 | Low |
| Basket Nitinol 1.9 #390 | other | $52 | $52 to $195 | Low |
| Application of Short Leg Cast | other | $53 | $53 to $29,405 | Low |
| Alcohol And/or Substance Abuse Screening and Intervention, More Than 30 Minutes | preventive | $54 | $54 to $99,409 | Low |
| Biopsy of Ear Canal | lab | $54 | $54 to $69,105 | Low |
| Biopsy of Lip | lab | $54 | $54 to $40,490 | Low |
| Application of Stress By Physician for Joint Imaging | other | $55 | $55 to $77,071 | Low |
| Arista Surgical Hemostatic Powder 5 Gm Polysaccharide Hemospheres Absorbable ... | surgery | $55 | $55 to $205 | Low |
| Acu-dispo-cautery2 Fine Tip-s #dcft2 | other | $56 | $56 to $211 | Low |
| Addition to Lower Extremity, Varus/valgus Correction, Plastic Modification, P... | other | $56 | $56 to $212 | Low |
| Annual Wellness Visit; Includes a Personalized Prevention Plan of Service (pp... | preventive | $56 | $56 to $420 | Low |
| Advance Care Planning, First 30 Minutes | other | $57 | $57 to $99,497 | Low |
| Amplatz Grad Renal Dilation Set | other | $58 | $58 to $217 | Low |
| Arc Smart Argon Probe 2.3/330 G1140002 | other | $58 | $58 to $218 | Low |
| Biopsy of Lining of Nose | lab | $58 | $58 to $30,100 | Low |
| Blade Shave Biopsy Flex Dermablade 8ea/1cs | lab | $58 | $58 to $217 | Low |
| A-scope 4 Rhinolaryngo Slim 510001000 5ea/1bx | other | $59 | $59 to $220 | Low |
| Addition, Endoskeletal System, Above Knee OR Hip Disarticulation, Knee Extens... | other | $59 | $59 to $221 | Low |
| 2.0 Mm Drive Shaft for Quickfix Screw System Ar-8930d | other | $60 | $60 to $225 | Low |
| 2.0mm Carbide Round 5820-110-020c | other | $60 | $60 to $225 | Low |
| 2.5mm Prcsn Mtch Hd 13cm8450-107 | other | $60 | $60 to $224 | Low |
| 3.0 Drive Shft for Quickfix Screw System Ar-8930d | other | $60 | $60 to $225 | Low |
| 3.0mm Carbide Round5820-110-030c | other | $60 | $60 to $225 | Low |
| 4.0mm Carbide Round 5820-110-040c | other | $60 | $60 to $225 | Low |
| Application of Shoulder to Hand Cast | other | $60 | $60 to $29,065 | Low |
| Addition to Lower Extremity Orthosis, High Strength, Lightweight Material, Al... | other | $61 | $61 to $228 | Low |
| Alcohols Levels | other | $61 | $61 to $80,320 | Low |
| Breast Prosthesis, Mastectomy Bra, with Integrated Breast Prosthesis Form, Bi... | other | $61 | $61 to $228 | Low |
| 2.0 Cann Driver Tip Ht | other | $62 | $62 to $234 | Low |
| Arndt Endobronchial Blocker Set 7fr G44114 | other | $62 | $62 to $235 | Low |
| 3.0 Precision Round 2flute5820-009 | other | $63 | $63 to $236 | Low |
| 4.0 Precision Round 2flute5820-009 | other | $63 | $63 to $236 | Low |
| 5.0 Precision Round 2flute5820-009 | other | $63 | $63 to $236 | Low |
| 6.0 Precision Round 2flute5820-009 | other | $63 | $63 to $236 | Low |
| Biopsy of Lower Large Bowel Using a Flexible Endoscope | lab | $63 | $63 to $45,331 | Low |
| Balloon Oval Kidney Shape Str #omspdbs2 | other | $65 | $65 to $246 | Low |
| Biopsies of Rectum And/or Lower Large Bowel Using a Rigid Endoscope | other | $65 | $65 to $45,305 | Low |
| Biopsy of Small Bowel Using an Endoscope Inserted Through Surgically Created ... | surgery | $65 | $65 to $44,382 | Low |
| Adapalene 0.3% Gel | other | $66 | $66 to $248 | Low |
| Administration of Hormonal Anti-neoplastic Chemotherapy Under Skin OR Into Mu... | other | $67 | $67 to $96,402 | Low |
| Alvarado Traction Boot #00132021000 | other | $67 | $67 to $252 | Low |
| Assistive Listening Device, Television Amplifier, Any Type | other | $67 | $67 to $500 | Low |
| Aveta Coral Disposable Hysteroscope 4.6mm #214 | other | $67 | $67 to $250 | Low |
| Aveta Pearl Disposable Hysteroscope 5.7mm #214 | other | $67 | $67 to $250 | Low |
| Biopsy of Anus Using an Endoscope | lab | $67 | $67 to $46,606 | Low |
| Bypass of Diseased OR Blocked Artery with Prosthetic and Vein | other | $67 | $67 to $35,681 | Low |
| 8813e Suture Kit Dr Dumicz Oh Only 5kt/bx | other | $68 | $68 to $256 | Low |
| Administration of Non-hormonal Anti-neoplastic Chemotherapy Under Skin OR Int... | other | $68 | $68 to $96,401 | Low |
| Amnioexcel, Amnioexcel Plus OR Biodexcel, Per Square Centimeter | other | $68 | $68 to $257 | Low |
| Antibody Evaluation, Initial Single Antibody Stain Procedure | other | $68 | $68 to $88,346 | Low |
| Back Brace Aspen Summit 637 X-large 992380 | other | $68 | $68 to $255 | Low |
| **discontinued 2/19/2021** Percut Kit 19fr X 18cm Femoral Arterial | other | $69 | $69 to $259 | Low |
| 8815e Suture Dr Halligan CABG 1ea=1kt 5kt/1bx | other | $69 | $69 to $259 | Low |
| Administration of Additional New Drug OR Substance Into Vein Using Push Techn... | other | $69 | $69 to $96,411 | Low |
| Administration of Additional New Drug OR Substance Into Vein, 1 Hour OR Less | other | $69 | $69 to $96,417 | Low |
| Administration of Chemotherapy Into Vein, Each Additional Hour | other | $69 | $69 to $96,415 | Low |
| Balloon Dilation of Lower Large Bowel Using a Flexible Endoscope | other | $69 | $69 to $45,340 | Low |
| Basket Trapezoid 3cm #m00510890 | other | $69 | $69 to $258 | Low |
| Basket Wireguided Retrieval 2.0 X .035 | other | $69 | $69 to $258 | Low |
| Basket Wireguided Retrieval 2.5 X .035 | other | $69 | $69 to $258 | Low |
| Assessment for Hearing Aid | other | $70 | $70 to $8,400 | Low |
| Bflex 2 Slim 3.8 Single-use Bronchoscope 0570-0448 Bx=pk/5ea | other | $71 | $71 to $269 | Low |
| Addition to Knee Joint, Disc OR Dial Lock for Adjustable Knee Flexion, Each J... | other | $72 | $72 to $270 | Low |
| Acp Max Prp System W/acda Abs | other | $73 | $73 to $275 | Low |
| Anesthesia for Tying OR Incision of Fallopian Tubes Using an Endoscope | other | $73 | $73 to $851 | Low |
| Biopsy of Breast and Placement of Locating Device Using Mri, Each Additional ... | imaging | $73 | $73 to $19,086 | Low |
| 3d Radiographic Procedure with Computerized Image Postprocessing | imaging | $75 | $75 to $76,377 | Low |
| Benzodiazepines Levels, 1 | other | $75 | $75 to $80,346 | Low |
| 11mm Mcglamry Metatarsal Elevator Ar-8930m | other | $76 | $76 to $285 | Low |
| All Lower Extremity Prosthesis, Solid Ankle Cushion Heel (sach) Foot, Replace... | other | $77 | $77 to $290 | Low |
| Biopsy of Small Bowel Pouch Using an Endoscope | lab | $77 | $77 to $44,386 | Low |
| Bone Mill #bm210 Fine | other | $77 | $77 to $290 | Low |
| Balloon Cre Rx Biliary 10-11-12mm #m00558930 | other | $78 | $78 to $294 | Low |
| Balloon Cre Rx Biliary 6-7-8mmx5.5 #m00558860 | other | $78 | $78 to $295 | Low |
| Balloon Cre Rx Biliary 8-9-10mm #m00558920 | other | $78 | $78 to $295 | Low |
| Balloon Cre Rx Biliary12-13.5-15mm #m00558940 | other | $78 | $78 to $295 | Low |
| Bio-tenodesis Disp Kit #ar-1530ds | other | $78 | $78 to $295 | Low |
| Biopsy of Mouth | lab | $78 | $78 to $40,808 | Low |
| Addition to Lower Extremity Fracture Orthosis, Adjustable Motion Knee Joint, ... | other | $79 | $79 to $296 | Low |
| Biopsy of Floor of Mouth | lab | $79 | $79 to $41,108 | Low |
| Balloon Seeker 6x17mm Em Sphn #1830617sph | other | $80 | $80 to $301 | Low |
| Breast Prosthesis, Mastectomy Form | other | $83 | $83 to $312 | Low |
| Brav0 Cf Capsule Delivery Dev 5-pk #fgs | obstetric | $85 | $85 to $320 | Low |
| 10.5mm Short Flipcutter #ar-1204as | other | $86 | $86 to $325 | Low |
| Application of Long Leg Cast From Thigh to Toe | other | $86 | $86 to $29,345 | Low |
| Bflex 2 Ultraslim 2.8 Single-use Bronchoscope 0570-0447 Bx=pk/5ea | other | $86 | $86 to $322 | Low |
| Aspiration And/or Injection of Fluid Large Joint Using Ultrasound Guidance | imaging | $87 | $87 to $20,611 | Low |
| Acyclovir 200 Mg/5 Ml Susp | other | $88 | $88 to $331 | Low |
| ACL Reconstruction | surgery | $89 | $89 to $9,920 | High |
| Arthrex Acl Fibertag Tightrope Abs Implant #ar-1588tnt | surgery | $89 | $89 to $335 | Low |
| 2.3mm X 30.0mm Tapered Routerstryker# 5130-071-223s1 | other | $91 | $91 to $341 | Low |
| Application of Walking Cast Covering Thigh to Toe | other | $91 | $91 to $29,355 | Low |
| Biopsy of Front 2/3 of Tongue | lab | $92 | $92 to $41,100 | Low |
| Angiojet Power Pulse Kit #104834 | other | $94 | $94 to $354 | Low |
| Biocomposite Corkscrew Ft Suture Anchor 4.75 Mm X 14 Mm W/two 1.3 Mm Sutureta... | other | $94 | $94 to $355 | Low |
| Biopsy of Back 1/3 of Tongue | lab | $95 | $95 to $41,105 | Low |
| Brachytherapy Source, Non-stranded, Non-high Dose Rate Iridium-192, Per Source | other | $95 | $95 to $909 | Low |
| Biopsy of Roof of Mouth | lab | $96 | $96 to $42,100 | Low |
| Arterial Cannula 19fr 96530 | other | $97 | $97 to $366 | Low |
| Biopsy of Voice Box Using a Flexible Endoscope | lab | $98 | $98 to $31,576 | Low |
| Basket Memory 2x4cm Eight Wire ERCP G21538 | other | $99 | $99 to $374 | Low |
| 3d Breast Mammography of Both Breasts | imaging | $100 | $100 to $77,062 | Low |
| Biopsy of Back of Throat | lab | $100 | $100 to $42,800 | Low |
| 6' Dx Cable 10 Pin #c6tmrmst10sa | other | $101 | $101 to $379 | Low |
| Administration of Prolonged Chemotherapy Into Vein | other | $101 | $101 to $96,416 | Low |
| Balloon Seeker 6x7mm Em Maxl #1830607max | other | $101 | $101 to $378 | Low |
| Alexis Extraction System #gtk17 | other | $102 | $102 to $385 | Low |
| Ankle Foot Orthosis, Plastic OR Other Material, Prefabricated, Includes Fitti... | other | $102 | $102 to $383 | Low |
| Aztreonam 1 G/3ml Ij | other | $102 | $102 to $385 | Low |
| Aztreonam 1 Gm Vial | other | $102 | $102 to $385 | Low |
| Bacillus Calmette-guerin Vaccine for Bladder Cancer | preventive | $102 | $102 to $90,586 | Low |
| Blind Obt 22.5fr for A20914a #a20906a | other | $102 | $102 to $382 | Low |
| Blind Obturator for A20931a 17fr #a20909a | other | $102 | $102 to $382 | Low |
| Ambulatory Infusion Pump, Single OR Multiple Channels, Electric OR Battery Op... | surgery | $104 | $104 to $782 | Low |
| 3d Breast Mammography of 1 Breast | imaging | $106 | $106 to $77,061 | Low |
| All Lower Extremity Prostheses, Foot, Single Axis Ankle/foot | other | $107 | $107 to $402 | Low |
| Adult Venous Cannula 25fr 96600 | other | $109 | $109 to $411 | Low |
| Adult Venous Cannula 96600 | other | $109 | $109 to $411 | Low |
| Adapalene 0.1 % Ex Gel | other | $111 | $111 to $417 | Low |
| Addition to Lower Extremity Fracture Orthosis, Hip Joint, Pelvic Band, Thigh ... | other | $112 | $112 to $421 | Low |
| Assistant W/stable Soft 3l #401-209s | other | $112 | $112 to $422 | Low |
| **discontinued**laser Fiber 200 Ball Tip #m0068403961 | other | $116 | $116 to $438 | Low |
| Atrovent 17 Mcg Hfa Inhaler | other | $116 | $116 to $436 | Low |
| Bss Plus Eye Irrig Solution | other | $118 | $118 to $445 | Low |
| Arthroflex, Per Square Centimeter | other | $119 | $119 to $3,889 | Low |
| Allograft Mis Dispenser Bl-1900-gun | other | $120 | $120 to $450 | Low |
| Aspiration of Bladder with Insertion of Bladder Tube to Skin | other | $120 | $120 to $51,102 | Low |
| Breast Prosthesis, Silicone OR Equal, with Integral Adhesive | other | $120 | $120 to $451 | Low |
| Breast Prosthesis, Silicone OR Equal, without Integral Adhesive | other | $120 | $120 to $451 | Low |
| Balloon Dilation of Vein with Review By Radiologist, Each Additional Vein | other | $121 | $121 to $37,249 | Low |
| Aspiration of Subsequent Secretions of Lung Airway Using an Endoscope During ... | other | $124 | $124 to $31,646 | Low |
| All Lower Extremity Prostheses, Foot, Flexible Keel | other | $125 | $125 to $468 | Low |
| Addition to Lower Extremity, Test Socket, Below Knee | other | $127 | $127 to $479 | Low |
| Addition to Lower Extremity, Socket Insert, Below Knee | other | $129 | $129 to $485 | Low |
| Bone Dowel Revision Kit 10 Mm #abs-2850 | other | $130 | $130 to $490 | Low |
| Addition to Lower Extremity, Below Knee, Total Contact | other | $132 | $132 to $498 | Low |
| Addition to Lower Extremity, Lacer Molded to Patient Model, for Custom Fabric... | other | $132 | $132 to $495 | Low |
| Biopsy of Wedge of Lung Tissue Followed By Partial Removal of Lung | surgery | $132 | $132 to $32,668 | Low |
| Blade Kahook Dual#kdb Glide | other | $132 | $132 to $495 | Low |
| 12x11x14mm 7 Degree Vista-s Dev #06-401 | other | $133 | $133 to $500 | Low |
| 5x11x14mm Vista-s Dev #06-401 | other | $133 | $133 to $500 | Low |
| Administration of Chemotherapy Into Vein Using Push Technique | other | $133 | $133 to $96,409 | Low |
| Bear Claw Otsc Sys Set 11/6t 165cm #100.10 | other | $135 | $135 to $509 | Low |
| Bear Claw Otsc Sys Set 12/6t 220cm #100.31 | other | $135 | $135 to $509 | Low |
| Arexvy Vial Kit | other | $139 | $139 to $523 | Low |
| 3.0 Knotless Suture Tak Anchor #ar-8934bck | other | $140 | $140 to $525 | Low |
| Arthrex Acl Fibertag Tightrope Implant #ar-1588rtt | surgery | $140 | $140 to $525 | Low |
| Autoinjector Endologix #tv-a101-n | other | $141 | $141 to $530 | Low |
| Balloon Dilation of Artery with Review By Radiologist, Each Additional Artery | other | $143 | $143 to $37,247 | Low |
| Biopsy of Prostate Gland | lab | $145 | $145 to $55,700 | Low |
| Addition to Lower Extremity, Below Knee, Acrylic Socket | other | $146 | $146 to $548 | Low |
| Acutrak 2 Drill Acumed #at2-m1813 | other | $148 | $148 to $558 | Low |
| Atrial Depressor W/quick Connect Clearview Mv | other | $148 | $148 to $557 | Low |
| Amputation of Toe At Toe Joint | other | $149 | $149 to $28,825 | Low |
| Balloon Dilation Treatment of Stricture of Ureter Using Imaging Guidance with... | other | $149 | $149 to $50,706 | Low |
| Bipolar Sealer 2.3 Neuro Aquamantys | other | $150 | $150 to $563 | Low |
| 8mm Blunt Xi #470008 | other | $154 | $154 to $578 | Low |
| Amputation of Toe At Joint Between Forefoot and Toes | other | $154 | $154 to $28,820 | Low |
| Biopsy of Voice Box Using an Endoscope | lab | $154 | $154 to $31,535 | Low |
| Addition to Lower Extremity, Suction Suspension, Above Knee OR Knee Disarticu... | other | $156 | $156 to $586 | Low |
| Astigmatism Correcting Function of Intraocular Lens | other | $158 | $158 to $595 | Low |
| Aveta Smol Disposable Resecting Device 2.9mm #210-100 3/ctn | other | $160 | $160 to $600 | Low |
| Auto-id Quad Cable; Vizigo Cable #cy1212ct | other | $161 | $161 to $604 | Low |
| Addition, Endoskeletal System, Below Knee, Alignable System | other | $166 | $166 to $624 | Low |
| Addition to Lower Extremity, Test Socket, Above Knee | other | $167 | $167 to $627 | Low |
| Azactam 2 Gm Vial | other | $169 | $169 to $634 | Low |
| Biopsy of Large Bowel Using a Flexible Endoscope | lab | $169 | $169 to $45,380 | Low |
| Biopsy of Voice Box Using an Endoscope with Operating Microscope OR Telescope | lab | $170 | $170 to $31,536 | Low |
| Ankle Foot Orthosis, Plastic OR Other Material with Ankle Joint, Prefabricate... | other | $173 | $173 to $650 | Low |
| Addition to Lower Extremity, Pelvic Control, Hip Joint, Adjustable Flexion, E... | other | $179 | $179 to $675 | Low |
| Analysis Test By Nucleic Acid for Hepatitis C Virus | other | $179 | $179 to $87,902 | Low |
| Balloon Dilation of Large Bowel Using a Flexible Endoscope | other | $179 | $179 to $45,386 | Low |
| Biomed Fiber Optic Probe Assembly Pteye | other | $182 | $182 to $683 | Low |
| All Lower Extremity Prostheses, Energy Storing Foot | other | $184 | $184 to $692 | Low |
| Biopsy of Saliva Gland | lab | $191 | $191 to $42,405 | Low |
| Ankle Orthosis, Supramalleolar with Straps, with OR without Interface/pads, C... | other | $196 | $196 to $738 | Low |
| All Endoskeletal Lower Extremity Prosthesis, Axial Rotation Unit, with OR wit... | other | $200 | $200 to $752 | Low |
| Bactisure Wound Lavage #00888700200(qtys of 6 | other | $200 | $200 to $750 | Low |
| Addition to Lower Extremity, Above Knee OR Knee Disarticulation, Acrylic Socket | other | $202 | $202 to $758 | Low |
| Ankle Foot Orthosis, Double Upright Free Plantar Dorsiflexion, Solid Stirrup,... | other | $203 | $203 to $763 | Low |
| Aspiration And/or Injection of Fluid From Medium Joint Using Ultrasound Guidance | imaging | $203 | $203 to $20,606 | Low |
| Aortic Balloon Pump Cath 7.5fr 34cc 0684-00-0479-01u | other | $205 | $205 to $771 | Low |
| Balloon Seeker 70dg Frt 6x17 #1830617frt0 | other | $207 | $207 to $778 | Low |
| Aveta Flex Disposable Resecting Device 2.9mm #210-080 3/ctn | other | $213 | $213 to $800 | Low |
| Amniotic Membrane for Surgical Reconstruction, Per Procedure | surgery | $215 | $215 to $810 | Low |
| Addition, Endoskeletal System, Below Knee, Flexible Protective Outer Surface ... | other | $223 | $223 to $837 | Low |
| Biopsy of Lung Lining Using an Endoscope | lab | $223 | $223 to $32,609 | Low |
| Additions to Lower Extremity, Total Contact, Above Knee OR Knee Disarticulati... | other | $224 | $224 to $842 | Low |
| Biopsy OR Removal of Lymph Nodes | surgery | $228 | $228 to $38,500 | Low |
| Addition, Endoskeletal System, Below Knee, Ultra-light Material | other | $230 | $230 to $865 | Low |
| Ankle Foot Orthosis, Plastic OR Other Material, Custom Fabricated | other | $230 | $230 to $865 | Low |
| Addition to Lower Extremity, Pre-tibial Shell, Molded to Patient Model | other | $235 | $235 to $882 | Low |
| Administration of Chemotherapy Into Vein, 1 Hour OR Less | other | $235 | $235 to $96,413 | Low |
| Anchor/screw for Opposing Bone-to-bone OR Soft Tissue-to-bone | other | $238 | $238 to $895 | Low |
| Ankle Foot Orthosis, Posterior Solid Ankle, Plastic, Custom Fabricated | other | $239 | $239 to $897 | Low |
| Addition, Endoskeletal System, Above Knee OR Hip Disarticulation, Alignable S... | other | $243 | $243 to $915 | Low |
| Biopsy of Small Bowel Using an Endoscope | lab | $249 | $249 to $44,377 | Low |
| Bupivacaine, Collagen-matrix Implant, 1 Mg | surgery | $255 | $255 to $959 | Low |
| Addition, Endoskeletal Knee-shin System, Single Axis, Friction Swing and Stan... | other | $259 | $259 to $975 | Low |
| Aveta Wave+ Disposable Resecting Device 3.9mm #210-2005 3/ctn | other | $263 | $263 to $990 | Low |
| Addition to Lower Extremity, Below Knee / Above Knee Suspension Locking Mecha... | other | $264 | $264 to $991 | Low |
| Brevital Sodium 500 Mg Vial | other | $265 | $265 to $995 | Low |
| Application of Walking Cast Covering Foot, Ankle, and Lower Leg | other | $268 | $268 to $29,445 | Low |
| Biopsy of Anal And/or Rectal Wall Through Anus | lab | $268 | $268 to $45,100 | Low |
| Biopsy of Fluid Collection of Lung Using an Endoscope | lab | $269 | $269 to $32,607 | Low |
| Addition to Lower Extremity, Below Knee/above Knee, Custom Fabricated From Ex... | other | $272 | $272 to $1,022 | Low |
| All Lower Extremity Prostheses, Multi-axial Rotation Unit | other | $274 | $274 to $1,031 | Low |
| Ankle Foot Orthosis, Spiral, (institute of Rehabilitative Medicine Type), Pla... | other | $280 | $280 to $1,051 | Low |
| Addition to Lower Extremity, Below Knee Suction Socket | other | $284 | $284 to $1,069 | Low |
| Afo, Rigid Anterior Tibial Section, Total Carbon Fiber OR Equal Material, Pre... | other | $293 | $293 to $1,103 | Low |
| Alexis Ces W/gel Point Mini #gtm14 | other | $297 | $297 to $1,115 | Low |
| Accessory Kit Ams 700 #72401850 | other | $299 | $299 to $1,125 | Low |
| Bridion 200 Mg/2 Ml Vial | other | $301 | $301 to $1,131 | Low |
| Biopsy of Abdomen Using an Endoscope | lab | $307 | $307 to $49,321 | Low |
| Bone And/or Joint Imaging; Tomographic | other | $315 | $315 to $78,320 | Low |
| Biopsy of Growth of Lung Using an Endoscope | lab | $328 | $328 to $32,608 | Low |
| Accessory Kit Ams 800 #720066 | other | $340 | $340 to $1,280 | Low |
| Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Cast Orthosis, Custom... | other | $346 | $346 to $1,301 | Low |
| Ankle Foot Orthosis, Plastic with Ankle Joint, Custom Fabricated | other | $353 | $353 to $1,327 | Low |
| Biopsy OR Removal of Deep Lymph Nodes of Neck | surgery | $355 | $355 to $38,510 | Low |
| Biopsy OR Removal of Deep Lymph Nodes of Underarm | surgery | $359 | $359 to $38,525 | Low |
| Addition, Endoskeletal System, Above Knee, Ultra-light Material | other | $360 | $360 to $1,352 | Low |
| Banding of Hemorrhoids Using a Flexible Endoscope | other | $367 | $367 to $45,350 | Low |
| Amputation of Toe and Midfoot Bone | other | $375 | $375 to $28,810 | Low |
| Addition, Endoskeletal Knee-shin System, Polycentric, Mechanical Stance Phase... | other | $392 | $392 to $1,475 | Low |
| Biopsy of Tissue of Chest Using an Endoscope | lab | $398 | $398 to $32,606 | Low |
| Bexsero Prefilled Syringe | other | $401 | $401 to $1,508 | Low |
| Biopsy OR Removal of Lymph Nodes of Neck with Removal of Fat Pad | surgery | $406 | $406 to $38,520 | Low |
| Aspiration of Initial Secretion of Lung Airway Using an Endoscope | other | $408 | $408 to $31,645 | Low |
| Aspiration And/or Injection of Cyst of Kidney | other | $449 | $449 to $50,390 | Low |
| Biopsy and Removal of Lymph Nodes of Abdominal Cavity Using an Endoscope | surgery | $450 | $450 to $38,570 | Low |
| Bydureon Bcise 2 Mg Autoinject | other | $456 | $456 to $1,714 | Low |
| Biopsy of Esophagus Using a Flexible Endoscope Through Mouth | lab | $461 | $461 to $43,202 | Low |
| Balloon Dilation of Esophagus Using a Flexible Endoscope, Less Than 3.0 Cm | other | $464 | $464 to $43,220 | Low |
| Biopsy of Lung Airway Using an Endoscope | lab | $473 | $473 to $31,625 | Low |
| Addition to Lower Extremity, Below Knee/above Knee, Custom Fabricated Socket ... | other | $475 | $475 to $1,787 | Low |
| Amniomatrix OR Biodmatrix, Injectable, 1 Cc | other | $479 | $479 to $1,799 | Low |
| Biopsy OR Removal of Lymph Nodes of Breast | surgery | $496 | $496 to $38,530 | Low |
| 23x11x14mm Vbr-s Dev #06-115 | other | $505 | $505 to $1,900 | Low |
| 41x11x14mm Vbr-s Dev #06-115 | other | $505 | $505 to $1,900 | Low |
| Balloon Dilation of Pulmonary Artery, Single Vessel | other | $514 | $514 to $92,997 | Low |
| Addition to Lower Extremity, Endoskeletal System, Above Knee - Knee Disarticu... | other | $529 | $529 to $1,989 | Low |
| Ankle Foot Orthosis, Walking Boot Type, Varus/valgus Correction, Rocker Botto... | other | $538 | $538 to $2,023 | Low |
| Addition to Lower Extremity, Above Knee, Flexible Inner Socket, External Frame | other | $551 | $551 to $2,070 | Low |
| Addition to Lower Extremity, Below Knee, Flexible Inner Socket, External Frame | other | $551 | $551 to $2,070 | Low |
| Biopsy of Small Bowel (except Ileum) Using an Endoscope | lab | $561 | $561 to $44,361 | Low |
| 8x21x32mm 7 Degree Tm-400 Dev #06-131 | other | $572 | $572 to $2,150 | Low |
| Amputation of Foot Across Instep | other | $574 | $574 to $28,805 | Low |
| Biopsy of Large Bowel Using an Endoscope Inserted Through Surgically Created ... | surgery | $578 | $578 to $44,389 | Low |
| Amputation of Thigh Through Thigh Bone Leaving Wound | other | $585 | $585 to $27,592 | Low |
| Adhesion of Linings of Lung Using an Endoscope | other | $605 | $605 to $32,650 | Low |
| Anchoring of Flexing Tendon of Fingers to Wrist Bone | other | $614 | $614 to $25,300 | Low |
| Amputation of Finger OR Thumb with Direct Closure | other | $620 | $620 to $26,951 | Low |
| Annuloplasty Ring 25mm #tarp | other | $637 | $637 to $2,395 | Low |
| Annuloplasty Ring 29mm #tarp | other | $637 | $637 to $2,395 | Low |
| Annuloplasty Ring 31mm #tarp | other | $637 | $637 to $2,395 | Low |
| Annuloplasty Ring 33mm #tarp | other | $637 | $637 to $2,395 | Low |
| Aspiration of Bone Marrow Sample for Diagnosis | other | $637 | $637 to $38,220 | Low |
| Addition to Lower Limb Prosthesis, Vertical Shock Reducing Pylon Feature | other | $668 | $668 to $2,512 | Low |
| Amputation of Thigh Through Thigh Bone | other | $670 | $670 to $27,590 | Low |
| Biopsy of Lung Lining | lab | $671 | $671 to $32,098 | Low |
| Biopsy of Esophagus, Stomach, And/or Upper Small Bowel Using a Flexible Endos... | lab | $684 | $684 to $43,239 | Low |
| Balloon Dilation of Groin Artery, Each Additional Vessel | other | $692 | $692 to $37,222 | Low |
| Amputation of Finger OR Thumb | other | $693 | $693 to $26,910 | Low |
| Biopsy of Fluid Collection of Lung | lab | $710 | $710 to $32,096 | Low |
| Biopsy of Growth of Lung | lab | $716 | $716 to $32,097 | Low |
| Byfavo 20 Mg Vial | other | $752 | $752 to $2,826 | Low |
| Amputation of Both Lower Leg Bones | other | $765 | $765 to $27,880 | Low |
| Biopsy and Aspiration of Bone Marrow Sample for Diagnosis | lab | $772 | $772 to $38,222 | Low |
| Balloon Dilation of Artery of Leg, Each Additional Vessel | other | $807 | $807 to $37,232 | Low |
| Addition, Endoskeletal, Knee-shin System, Stance Flexion Feature, Adjustable | other | $831 | $831 to $3,125 | Low |
| Biopsy OR Removal of Foreign Body in Large Bowel | surgery | $855 | $855 to $44,025 | Low |
| Balloon Dilation of Coronary Artery OR Branch, Each Additional Artery OR Branch | cardiac | $880 | $880 to $92,921 | Low |
| Bypass of Diseased OR Blocked Chest to Opposite Chest Artery with Other Than ... | other | $884 | $884 to $35,612 | Low |
| Bypass of Diseased OR Blocked Upper Leg to Lower Thigh Artery with Other Than... | other | $902 | $902 to $35,656 | Low |
| Bypass of Diseased OR Blocked Upper Leg to Opposite Upper Leg Artery with Oth... | other | $911 | $911 to $35,661 | Low |
| Bypass of Diseased OR Blocked Arm to Chest Artery with Other Than Vein | other | $919 | $919 to $35,621 | Low |
| Bypass of Diseased OR Blocked Upper Arm to Opposite Arm Artery with Vein | other | $928 | $928 to $35,525 | Low |
| Balloon Viabahn Bx 7mmx59mm 7fr Bxa075902a | other | $948 | $948 to $3,563 | Low |
| Bypass of Diseased OR Blocked Knee to Lower Leg Arteries with Other Than Vein | other | $954 | $954 to $35,671 | Low |
| Bypass of Diseased OR Blocked Under Arm to Arm Artery with Vein | other | $987 | $987 to $35,522 | Low |
| Bypass of Diseased OR Blocked Neck to Chest Artery with Other Than Vein | other | $988 | $988 to $35,606 | Low |
| Bypass of Diseased OR Blocked Groin to Upper Leg Artery with Other Than Vein | other | $989 | $989 to $35,665 | Low |
| Bypass of Diseased OR Blocked Upper Leg to Opposite Upper Leg Artery with Vein | other | $1,024 | $1,024 to $35,558 | Low |
| Bypass of Diseased OR Blocked Upper Arm to Arm Artery with Vein | other | $1,038 | $1,038 to $35,523 | Low |
| **obsolete** Valve Mitral 25mm Bicor #b100-25m | other | $1,064 | $1,064 to $4,000 | Low |
| Bypass of Diseased OR Blocked Upper Leg to Lower Leg Artery with Other Than Vein | other | $1,083 | $1,083 to $35,666 | Low |
| Addition to Lower Extremity, Ischial Containment/narrow M-l Socket | other | $1,094 | $1,094 to $4,113 | Low |
| Bypass of Diseased OR Blocked Lower Leg to Lower Leg Artery with Vein | other | $1,113 | $1,113 to $35,571 | Low |
| Biopsy of Gallbladder, Pancreatic, Liver, and Bile Ducts Using a Flexible End... | lab | $1,134 | $1,134 to $43,261 | Low |
| Biopsy of Lobe of Lung Using an Endoscope, 1 Lobe | lab | $1,147 | $1,147 to $31,628 | Low |
| Bypass of Diseased OR Blocked Arm to Both Lower Thigh Arteries with Other Tha... | other | $1,147 | $1,147 to $35,654 | Low |
| Bypass of Diseased OR Blocked Upper to Lower Leg Artery with Vein | other | $1,171 | $1,171 to $35,556 | Low |
| Bypass of Diseased OR Blocked Neck to Opposite Neck Artery with Vein | other | $1,191 | $1,191 to $35,509 | Low |
| Angiojet Solent Dista Set #111303 | other | $1,202 | $1,202 to $4,520 | Low |
| Bypass of Diseased OR Blocked Thigh to Knee Artery with Vein Graft | other | $1,208 | $1,208 to $35,583 | Low |
| Addition to Lower Limb Prosthesis, Multiaxial Ankle with Swing Phase Active D... | other | $1,229 | $1,229 to $4,619 | Low |
| Bypass of Diseased OR Blocked Aorta to Upper Leg Artery with Other Than Vein | other | $1,260 | $1,260 to $35,647 | Low |
| Below Knee, Molded Socket, Shin, Sach Foot, Endoskeletal System | other | $1,261 | $1,261 to $4,742 | Low |
| Bronchitis and Asthma without Cc/mcc | other | $1,292 | $1,292 to $12,852 | Low |
| Addition, Endoskeletal System, High Activity Knee Control Frame | other | $1,293 | $1,293 to $4,861 | Low |
| Addition, Endoskeletal Knee-shin System, Single Axis, Fluid Swing and Stance ... | other | $1,295 | $1,295 to $4,868 | Low |
| Addition, Endoskeletal Knee-shin System, Polycentric, Hydraulic Swing Phase C... | other | $1,342 | $1,342 to $5,045 | Low |
| 25mj-501 Valve Mitral Size 25 Mm Rotatable Standard Cuff Mechanical | other | $1,357 | $1,357 to $5,100 | Low |
| Biopsy of Breast and Placement of Locating Device Using Mri, First Growth | imaging | $1,357 | $1,357 to $19,085 | Low |
| All Lower Extremity Prostheses, Flex-walk System OR Equal | other | $1,373 | $1,373 to $5,164 | Low |
| Bypass of Diseased OR Blocked Arm to Lower Thigh OR Leg Artery with Other Tha... | other | $1,376 | $1,376 to $35,626 | Low |
| Bypass of Diseased OR Blocked Major Upper to Lower Leg Artery with Vein | other | $1,393 | $1,393 to $35,566 | Low |
| Bypass of Diseased OR Blocked Aorta to Groin Artery with Other Than Vein | other | $1,398 | $1,398 to $35,637 | Low |
| Bypass of Diseased OR Blocked Upper Leg to Lower Leg Artery with Vein Graft | other | $1,398 | $1,398 to $35,585 | Low |
| Alcohol, Drug Abuse OR Dependence, Left Ama | other | $1,427 | $1,427 to $12,069 | Low |
| Bypass of Diseased OR Blocked Artery Aorta to Upper Leg and Opposite Upper Le... | other | $1,431 | $1,431 to $35,646 | Low |
| Atricure Isolator Synergy Encompass Long #olh | other | $1,436 | $1,436 to $5,400 | Low |
| Addition to Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume Manageme... | other | $1,446 | $1,446 to $5,436 | Low |
| Atriclip Pro-v Device 35mm #prov35 | other | $1,463 | $1,463 to $5,500 | Low |
| Atriclip Pro-v Device 45mm #prov45 | other | $1,463 | $1,463 to $5,500 | Low |
| Atriclip Pro-v Device 50mm #prov50 | other | $1,463 | $1,463 to $5,500 | Low |
| Atriclip Prov-5 Device 40mm #prov40 | other | $1,463 | $1,463 to $5,500 | Low |
| Bypass of Diseased OR Blocked Aorta to Groin to Opposite Groin Artery with Ot... | other | $1,467 | $1,467 to $35,638 | Low |
| Byetta 10 Mcg Dose Pen Inj | other | $1,487 | $1,487 to $5,591 | Low |
| Byetta 5 Mcg Dose Pen Inj | other | $1,487 | $1,487 to $5,591 | Low |
| Acute Myocardial Infarction, Expired without Cc/mcc | other | $1,497 | $1,497 to $25,738 | Low |
| Bypass of Diseased OR Blocked Artery Aorta to Abdominal OR Kidney Artery with... | other | $1,553 | $1,553 to $35,631 | Low |
| Addition, Endoskeletal Knee/shin System, 4-bar Linkage OR Multiaxial, Pneumat... | other | $1,609 | $1,609 to $6,048 | Low |
| Balloon Dilation of Groin Artery, Initial Vessel | other | $1,687 | $1,687 to $37,220 | Low |
| All Lower Extremity Prostheses, Flex Foot System | other | $1,700 | $1,700 to $6,392 | Low |
| Anesthesia for Procedure On Esophagus | other | $1,722 | $500 to $15,746 | Low |
| Balloon Dilation of Artery of Leg | other | $1,786 | $1,786 to $37,224 | Low |
| Above Knee, Molded Socket, Open End, Sach Foot, Endoskeletal System, Single A... | other | $1,828 | $1,828 to $6,873 | Low |
| Balloon Dilation of Artery with Review By Radiologist, Initial Artery | other | $2,101 | $2,101 to $37,246 | Low |
| Balloon Dilation of Artery of Leg, Initial Vessel | other | $2,179 | $2,179 to $37,228 | Low |
| Anesthesia for Closed Drainage of Lung Fluid | other | $2,245 | $524 to $20,528 | Low |
| Balloon Dilation of Vein with Review By Radiologist, Initial Vein | other | $2,481 | $2,481 to $37,248 | Low |
| Ascending Aorta Graft, with Cardiopulmonary Bypass, Includes Valve Suspension... | other | $2,568 | $2,568 to $33,860 | Low |
| Allergic Reactions without Mcc | other | $2,868 | $2,868 to $16,652 | Low |
| Acute Myocardial Infarction, Expired with Cc | other | $2,933 | $2,933 to $25,738 | Low |
| Abortion without D&c | other | $3,038 | $3,038 to $15,891 | Low |
| Alloderm 1518320 | other | $3,248 | $3,248 to $12,210 | Low |
| All Lower Extremity Prosthesis, Shank Foot System with Vertical Loading Pylon | other | $3,336 | $3,336 to $12,541 | Low |
| Aftercare without Cc/mcc | other | $3,522 | $3,522 to $39,155 | Low |
| Bifurcated Stent #bea28-90/i16 | cardiac | $3,818 | $3,818 to $14,355 | Low |
| Bifurcated Stent #bea28-90/i20 | cardiac | $3,818 | $3,818 to $14,355 | Low |
| Bifurcated Stent Bea22-60/i16 | cardiac | $3,818 | $3,818 to $14,355 | Low |
| Bronchitis and Asthma with Cc/mcc | other | $3,828 | $3,828 to $20,967 | Low |
| Abortion with D&c, Aspiration Curettage OR Hysterotomy | other | $3,878 | $3,878 to $21,239 | Low |
| Balloon Dilation Repair of Aortic Valve | surgery | $3,881 | $3,881 to $92,986 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue without Cc/mcc | other | $4,124 | $4,124 to $33,389 | Low |
| Acute Major Eye Infections with Cc/mcc | other | $4,350 | $4,350 to $23,264 | Low |
| Amplatzer Amulet Laao 16mm 9-acp2-007 | other | $4,788 | $4,788 to $18,000 | Low |
| Amplatzer Amulet Laao 18mm 9-acp2-007 | other | $4,788 | $4,788 to $18,000 | Low |
| Amplatzer Amulet Laao 20mm 9-acp2-007 | other | $4,788 | $4,788 to $18,000 | Low |
| Amplatzer Amulet Laao 22mm 9-acp2-007 | other | $4,788 | $4,788 to $18,000 | Low |
| Amplatzer Amulet Laao 25mm 9-acp2-010 | other | $4,788 | $4,788 to $18,000 | Low |
| Amplatzer Amulet Laao 28mm 9-acp2-010 | other | $4,788 | $4,788 to $18,000 | Low |
| Amplatzer Amulet Laao 31mm 9-acp2-010 | other | $4,788 | $4,788 to $18,000 | Low |
| Amplatzer Amulet Laao 34mm 9-acp2-010 | other | $4,788 | $4,788 to $18,000 | Low |
| Anal and Stomal Procedures with Cc | other | $4,811 | $4,811 to $26,525 | Low |
| Acute and Subacute Endocarditis with Cc | other | $5,035 | $5,035 to $58,749 | Low |
| Alcohol/Drug Abuse or Dependence without Rehabilitation without MCC | therapy | $5,597 | $5,597 to $21,040 | Low |
| Atherosclerosis without Mcc | other | $5,736 | $5,736 to $21,563 | Low |
| Angina Pectoris | other | $5,758 | $5,758 to $21,646 | Low |
| Acute Myocardial Infarction Discharged Alive without CC/MCC | cardiac | $6,317 | $6,317 to $38,831 | Low |
| Amputation for Musculoskeletal System and Connective Tissue Disorders without... | other | $6,323 | $6,323 to $42,064 | Low |
| Allergic Reactions with Mcc | other | $6,327 | $6,327 to $44,911 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue with Mcc | other | $6,839 | $6,839 to $51,562 | Low |
| Aftercare with Cc/mcc | other | $7,058 | $7,058 to $59,796 | Low |
| Bone Diseases and Arthropathies without Mcc | other | $7,252 | $7,252 to $33,381 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue with Cc | other | $7,327 | $7,327 to $37,637 | Low |
| Biliary Tract Procedures Except Only Cholecystectomy with OR without C.d.e. w... | other | $7,586 | $7,586 to $39,260 | Low |
| Acute Myocardial Infarction Discharged Alive with CC | cardiac | $8,030 | $8,030 to $38,657 | Low |
| Appendectomy (Laparoscopic) | surgery | $8,148 | $537 to $30,632 | High |
| Acute Adjustment Reaction and Psychosocial Dysfunction | other | $8,193 | $8,193 to $30,803 | Low |
| Biopsies of Musculoskeletal System and Connective Tissue without Cc/mcc | other | $8,406 | $8,406 to $44,901 | Low |
| Alcohol, Drug Abuse OR Dependence without Rehabilitation Therapy with Mcc | therapy | $8,528 | $8,528 to $32,060 | Low |
| Acute Myocardial Infarction Discharged Alive with MCC | cardiac | $9,526 | $9,526 to $42,983 | Low |
| Adrenal and Pituitary Procedures with CC/MCC | surgery | $9,544 | $9,544 to $45,698 | Low |
| Appendix Procedures without Cc/mcc | other | $10,001 | $10,001 to $44,389 | Low |
| Benign Prostatic Hypertrophy with Mcc | other | $10,223 | $10,223 to $60,175 | Low |
| Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders w... | lab | $10,462 | $10,462 to $50,494 | Low |
| Appendix Procedures with Cc | other | $10,958 | $10,958 to $41,196 | Low |
| Bone Diseases and Arthropathies with Mcc | other | $11,325 | $11,325 to $43,779 | Low |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe without... | other | $12,095 | $12,095 to $74,716 | Low |
| Adrenal and Pituitary Procedures without Cc/mcc | other | $12,225 | $12,225 to $53,133 | Low |
| Bilateral or Multiple Major Joint Procedures of Lower Extremity | surgery | $13,799 | $13,799 to $110,757 | Low |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Cc | other | $13,944 | $13,944 to $77,299 | Low |
| Anal and Stomal Procedures with Mcc | other | $14,725 | $14,725 to $67,343 | Low |
| Biopsies of Musculoskeletal System and Connective Tissue with Cc | other | $15,744 | $15,744 to $61,620 | Low |
| Acute Myocardial Infarction, Expired with Mcc | other | $16,614 | $16,614 to $62,459 | Low |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Mcc | other | $16,792 | $16,792 to $122,712 | Low |
| Amputation for Musculoskeletal System and Connective Tissue Disorders with Cc | other | $17,022 | $17,022 to $68,425 | Low |
| Bacterial and Tuberculous Infections of Nervous System with Cc | other | $20,182 | $20,182 to $75,871 | Low |
| Back and Neck Procedures except Spinal Fusion without CC/MCC | surgery | $20,644 | $20,644 to $90,579 | Low |
| Bacterial and Tuberculous Infections of Nervous System without Cc/mcc | other | $20,811 | $20,811 to $78,236 | Low |
| Appendix Procedures with Mcc | other | $20,923 | $20,923 to $81,065 | Low |
| Acute and Subacute Endocarditis with Mcc | other | $23,642 | $23,642 to $133,961 | Low |
| Aortic and Heart Assist Procedures Except Pulsation Balloon without Mcc | cardiac | $29,028 | $29,028 to $109,128 | Low |
| Aortic and Heart Assist Procedures Except Pulsation Balloon with Mcc | cardiac | $33,878 | $33,878 to $218,222 | Low |
| Aicd Generator Procedures | other | $39,859 | $39,859 to $286,323 | Low |
| Angioplasty with Stent (PCI) | other | $44,214 | $44,214 to $190,761 | High |