| 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 |
| Cardiac Ablation | other | $0 | $751 to $11,790 | High |
| Carotid Ultrasound | imaging | $0 | $36 to $2,342 | High |
| Central Line Insertion | other | $0 | $78 to $1,809 | High |
| Chest X-Ray | imaging | $0 | $83 to $400 | High |
| Cholesterol Management | cardiac | $0 | $7 to $50 | High |
| Circumcision | surgery | $0 | $669 to $6,973 | High |
| Colonoscopy with Polypectomy | other | $0 | $213 to $3,490 | High |
| Complete Blood Count (CBC) | lab | $0 | $6 to $80 | High |
| Critical Care | emergency | $0 | $327 to $2,628 | High |
| CT Abdomen and Pelvis | imaging | $0 | $90 to $3,318 | High |
| CT Chest | imaging | $0 | $81 to $3,464 | High |
| CT Spine | imaging | $0 | $54 to $3,002 | High |
| Cystoscopy | diagnostic | $0 | $114 to $1,744 | High |
| Diabetes Management | other | $0 | $70 to $524 | High |
| Endoscopy | preventive | $0 | $684 to $2,572 | High |
| Epidural Steroid Injection | other | $0 | $380 to $1,430 | High |
| Exam of Chest Using an Endoscope | other | $0 | $39,401 to $39,401 | Low |
| Foot X-Ray | imaging | $0 | $83 to $501 | High |
| Hand/Wrist X-Ray | imaging | $0 | $8 to $320 | High |
| Hernia Repair (Umbilical) | surgery | $0 | $404 to $3,036 | High |
| Hip/Pelvis X-Ray | imaging | $0 | $100 to $497 | High |
| Hospital Admission | other | $0 | $133 to $998 | High |
| Hospital Discharge | other | $0 | $76 to $572 | High |
| Hospital Follow-up Care | other | $0 | $68 to $514 | High |
| Hospital Observation | other | $0 | $59 to $1,334 | High |
| Hypertension Management | cardiac | $0 | $49 to $370 | High |
| Incision and Drainage of Abscess of External Female Genitals | other | $0 | $56,405 to $56,405 | Low |
| Intermediate Joint Injection | surgery | $0 | $124 to $468 | High |
| IV Drug Infusion | therapy | $0 | $28 to $364 | High |
| IV Hydration | therapy | $0 | $12 to $182 | High |
| Knee Arthroscopy | other | $0 | $602 to $7,208 | High |
| Laceration Repair | emergency | $0 | $81 to $608 | High |
| Laryngoscopy | other | $0 | $130 to $1,438 | High |
| Liver Function Panel | lab | $0 | $8 to $114 | High |
| Lumbar Puncture (Spinal Tap) | other | $0 | $387 to $1,456 | High |
| Lumbar Spine X-Ray | imaging | $0 | $100 to $814 | High |
| Lumpectomy (Breast) | surgery | $0 | $6 to $6,438 | High |
| Moderate Sedation | other | $0 | $9 to $69 | High |
| Mole Removal | other | $0 | $89 to $964 | High |
| MRI of the Abdomen | imaging | $0 | $335 to $5,124 | High |
| MRI of the Brain | imaging | $0 | $335 to $5,245 | High |
| MRI of the Knee | imaging | $0 | $335 to $4,851 | High |
| MRI of the Shoulder | imaging | $0 | $335 to $6,843 | High |
| MRI Spine | imaging | $0 | $335 to $4,465 | High |
| Newborn Care | obstetric | $0 | $85 to $640 | High |
| Obstetric Ultrasound | imaging | $0 | $45 to $490 | High |
| Paracentesis | diagnostic | $0 | $89 to $2,460 | High |
| Pathology (Surgical Specimen) | lab | $0 | $64 to $482 | High |
| Pelvic Ultrasound | imaging | $0 | $23 to $600 | High |
| PET Scan | imaging | $0 | $1,371 to $7,275 | High |
| Septoplasty | surgery | $0 | $559 to $4,200 | High |
| Shoulder X-Ray | imaging | $0 | $9 to $282 | High |
| Skin Lesion Destruction | other | $0 | $70 to $550 | High |
| Skin Tag Removal | other | $0 | $12 to $156 | High |
| Small Joint Injection | surgery | $0 | $38 to $655 | High |
| Therapeutic Injection | preventive | $0 | $15 to $206 | High |
| Thoracentesis | other | $0 | $124 to $4,198 | High |
| Thyroid Test (TSH) | lab | $0 | $17 to $188 | High |
| Toenail Removal | surgery | $0 | $160 to $603 | High |
| Trigger Point Injection | therapy | $0 | $39 to $456 | High |
| Urgent Care Visit | other | $0 | $67 to $251 | High |
| Vasectomy | surgery | $0 | $187 to $1,406 | High |
| Vitamin D Test | lab | $0 | $30 to $438 | High |
| Weight Management Program | preventive | $0 | $33 to $250 | High |
| Wound Debridement | surgery | $0 | $3,619 to $36,578 | High |
| X-Ray of the Knee | imaging | $0 | $100 to $617 | High |
| Dressing Colactive Plus Nonsilver2x2 10160000 | other | $1 | $1 to $4 | Low |
| Fesoterodine ER 4 Mg Tablet | other | $1 | $1 to $1 | Low |
| Olmesartan Medoxomil 20 Mg Po Tabs | other | $1 | $1 to $4 | Low |
| Oseltamivir Phos 30 Mg Capsule | other | $1 | $1 to $2 | Low |
| Picc Cath Statlock Secure Device 50ea/1ca | other | $1 | $1 to $4 | Low |
| Preemie Little Sucker W/cover #n204c | other | $1 | $1 to $4 | Low |
| Slings | other | $1 | $1 to $11 | Low |
| Teds Thigh 2x-large Regular Novaplus #v8805r | other | $1 | $1 to $4 | Low |
| Teds Thigh Large Long Novaplus #v9303l | other | $1 | $1 to $4 | Low |
| Teds Thigh Large Short Novaplus #v8303s | other | $1 | $1 to $4 | Low |
| Teds Thigh Medium Long Novaplus #v9302l | other | $1 | $1 to $4 | Low |
| Teds Thigh Medium Regular Novaplus #v8802r | other | $1 | $1 to $4 | Low |
| Teds Thigh Small Regular Novaplus #v8801r | other | $1 | $1 to $4 | Low |
| Teds Thigh Small Short Novaplus #v8301s | other | $1 | $1 to $4 | Low |
| Teds Thigh W/belt Xl Long Novaplus #v9304l | other | $1 | $1 to $4 | Low |
| Teds Thigh W/belt Xl Regular Novaplus #v8804r | other | $1 | $1 to $4 | Low |
| Unclassified Drugs | other | $1 | $1 to $4 | Low |
| Zonisamide 100 Mg Capsule | other | $1 | $1 to $1 | Low |
| Zonisamide 100 Mg Po Caps | other | $1 | $1 to $1 | Low |
| Blade Laryngoscope Disp Led Millr Sz00 1039.c | other | $1 | $1 to $4 | 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 |
| Carbamide Peroxide 6.5 % Ot Soln | other | $1 | $1 to $4 | Low |
| Desogestrel-ethinyl Estradiol 0.15-30 Mg-mcg Po Tabs | other | $1 | $1 to $2 | Low |
| Dexmethylphenidate Hcl 10 Mg Po Tabs | other | $1 | $1 to $1 | Low |
| Dressing Aquacel Foam 7x7 #420621 10ea/1bx | other | $1 | $1 to $4 | Low |
| Ear Drops 6.5% | other | $1 | $1 to $4 | Low |
| Fluconazole 100 Mg Tablet | other | $1 | $1 to $1 | Low |
| Glipizide ER 2.5 Mg Tablet | other | $1 | $1 to $1 | Low |
| Loperamide 2 Mg Capsule | other | $1 | $1 to $1 | Low |
| Loperamide Hcl 2 Mg Po Caps | other | $1 | $1 to $1 | Low |
| Phenytoin 25 Mg Chewable Half Tablet | other | $1 | $1 to $1 | Low |
| Phenytoin 50 Mg Tablet Chew | other | $1 | $1 to $1 | Low |
| Sodium Chl 0.9% Irrigation 500ml Btl 18ea/1ca | other | $1 | $1 to $4 | Low |
| Wound Filler, Gel/paste, Per Fluid Ounce, Not Otherwise Specified | other | $1 | $1 to $8 | Low |
| Fleet Pedia-lax Enema | other | $1 | $1 to $2 | Low |
| Isosorbide Dinitrate 5 Mg Po Tabs | other | $1 | $1 to $1 | Low |
| Isosorbide Dinitrate 5 Mg Tab | other | $1 | $1 to $1 | Low |
| Methylphenidate ER 36 Mg Tab | other | $1 | $1 to $4 | Low |
| Nicotine 14 Mg/24hr Patch | other | $1 | $1 to $2 | Low |
| Nicotine 21 Mg/24hr Patch | other | $1 | $1 to $2 | Low |
| Paroxetine ER 12.5 Mg Tablet | other | $1 | $1 to $1 | Low |
| Pencan Spinal Needle 24g X 4" with 20g Introducer Sterile 25ea/ct #333884 | 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 |
| Cath Coude Tiemann 20fr Rusch 50ea/1bx | other | $1 | $1 to $4 | Low |
| Celecoxib 200 Mg Capsule | other | $1 | $1 to $1 | Low |
| Celecoxib 200 Mg Po Caps | other | $1 | $1 to $1 | Low |
| Cozaar 100 Mg Tablet | other | $1 | $1 to $4 | Low |
| Handle Laryngoscope Dispos Led Medium 2015.c | other | $1 | $1 to $4 | Low |
| Handle Laryngoscope Dispos Led Pediatr 2016.c | other | $1 | $1 to $4 | Low |
| Handle Laryngoscope Dispos Std Stubby 2017.c | other | $1 | $1 to $4 | Low |
| Menest 0.3 Mg Tablet | other | $1 | $1 to $2 | Low |
| Milk of Magnesia - 30ml - Repackaging | other | $1 | $1 to $2 | Low |
| Niacin ER (antihyperlipidemic) 500 Mg Po Tbcr | lab | $1 | $1 to $4 | Low |
| Niacin ER 500 Mg Tablet | other | $1 | $1 to $4 | Low |
| Oxycodone-acetaminophen 10 | other | $1 | $1 to $2 | Low |
| Paliperidone ER 3 Mg Tablet | other | $1 | $1 to $2 | Low |
| Pepto-bismol 525 Mg/30 Ml Susp | other | $1 | $1 to $1 | Low |
| Piroxicam 10 Mg Capsule | other | $1 | $1 to $1 | Low |
| Prazosin 1 Mg Capsule | other | $1 | $1 to $1 | Low |
| Prochlorperazine Maleate, 5 Mg, Oral, Fda Approved Prescription Anti-emetic, ... | other | $1 | $1 to $1 | Low |
| Chlorhexidine 0.12% 15 Ml Cup | other | $1 | $1 to $1 | Low |
| Chlorhexidine 0.12% Soln - 15 Ml - Repackaging | other | $1 | $1 to $1 | Low |
| Docusate Sod 100 Mg/10 Ml Cup | other | $1 | $1 to $2 | Low |
| Dressing Hydrocolloid 6 X 6in | other | $1 | $1 to $4 | Low |
| Finasteride 5 Mg Po Tabs | other | $1 | $1 to $1 | Low |
| Finasteride 5 Mg Tablet | other | $1 | $1 to $1 | Low |
| Injection, Azithromycin, 500 Mg | other | $1 | $1 to $2 | Low |
| Nipple Shield 20mm Sma Contact 6ea/1cs | other | $1 | $1 to $4 | Low |
| Strong Iodine Solution | other | $1 | $1 to $1 | Low |
| Valproic Acid 250 Mg/5 Ml Cup | other | $1 | $1 to $2 | Low |
| Valproic Acid Oral Soln 250 Mg/5 Ml - Repackaging | other | $1 | $1 to $2 | 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 |
| Assessment By Trained Clinical Staff of Implant And/or Foreign Body for Mr Sa... | surgery | $1 | $1 to $76,015 | Low |
| Banatrol Plus Powder Packet | other | $1 | $1 to $1 | Low |
| Cannula Nasal Adult Oral 7ft O2 #4797-7-7 | other | $1 | $1 to $4 | Low |
| Dextrose 10%-water IV Solution | other | $1 | $1 to $4 | Low |
| Dressing Comfeel Plus 3" Butterfly #3350 | other | $1 | $1 to $4 | Low |
| Dressing Foam Adhesive Heel Design #m90619 | other | $1 | $1 to $4 | Low |
| Nyamyc 100,000 Unit/gm Powder | other | $1 | $1 to $4 | Low |
| Sore Throat 1.4% Spray | other | $1 | $1 to $2 | Low |
| Speculum Vaginal Small Disp Lighted C020100-1 Bx/18ea | other | $1 | $1 to $4 | Low |
| Ted Hose Anti Emb Thigh Sm Short 3071lf- | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Lg Long Open Toe 3856lf | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Lg Reg Open Toe 3728lf- | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Lg Short Open Toe 3634lf | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Med Long Open Toe 3549lf | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Med Reg Close Toe 3416lf- | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Short Med Open Toe 3310lf | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Small Reg Open Toe 3130lf | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Xl Long Open Toe 3182lf | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Xl Reg Open Toe 3181lf | other | $1 | $1 to $4 | Low |
| Ted Hose Comp Thigh Xxl Reg Open Toe 3184lf | other | $1 | $1 to $4 | Low |
| Aspirin 300 Mg Suppository | other | $1 | $1 to $1 | Low |
| Carbamazepine ER 100 Mg Cap | other | $1 | $1 to $1 | Low |
| Cimetidine 800 Mg Tablet | other | $1 | $1 to $1 | Low |
| Emtricitabine-tenofovir Df 200-300 Mg Po Tabs #3 Dispense Pack | other | $1 | $1 to $2 | Low |
| Endotrach Tube Cuffed Oral 5.0 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Cuffed Oral 5.5 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Cuffed Oral 6.0 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Cuffed Oral 6.5 | other | $1 | $1 to $4 | Low |
| Irrigation Kit Stoma Cone/tube Hollister #7721 1ea/1bx | other | $1 | $1 to $4 | Low |
| Lansoprazole Dr 15 Mg Capsule | other | $1 | $1 to $2 | Low |
| Lansoprazole Dr 30 Mg Capsule | other | $1 | $1 to $2 | Low |
| Liquid E-z Paque 60% Susp | other | $1 | $1 to $2 | Low |
| Paroxetine ER 25 Mg Tablet | other | $1 | $1 to $1 | Low |
| Paroxetine Hcl ER 25 Mg Po Tb24 | other | $1 | $1 to $1 | Low |
| Tube Endo Trach Nasal Cuffed 4.5 | other | $1 | $1 to $4 | Low |
| Tube Endo Trach Nasal Cuffed 5.0 | other | $1 | $1 to $4 | Low |
| Tube Endo Trach Nasal Cuffed 5.5 | other | $1 | $1 to $4 | Low |
| Tube Endo Trach Nasal/cuffed 4.0 | other | $1 | $1 to $4 | Low |
| Bupropion Hcl 100 Mg Tablet | other | $1 | $1 to $1 | Low |
| Dressing Silvasorb Circular #msc9310ep | other | $1 | $1 to $4 | Low |
| Fenofibrate Micronized 200 Mg Po Caps | other | $1 | $1 to $4 | Low |
| Mag-al Plus Xs Susp 30 Ml Cup | other | $1 | $1 to $1 | Low |
| Mesalamine Dr 400 Mg Capsule | other | $1 | $1 to $2 | Low |
| Metoclopramide Hcl 10 Mg Po Tabs #2 Dispense Pack | other | $1 | $1 to $1 | Low |
| Milk of Magnesia Suspension | other | $1 | $1 to $2 | Low |
| Morphine Sulfate Ir 30 Mg Tab | other | $1 | $1 to $1 | Low |
| Perfusion Adaptor 1/4" #10007 Dlp | surgery | $1 | $1 to $4 | Low |
| Readi-cat 2 2% Suspension | other | $1 | $1 to $2 | Low |
| Skin Trac Large 3"x40" #3874-13 24ea/1bx | other | $1 | $1 to $4 | Low |
| Amphetamine-dextroamphet ER 15 Mg Po Cp24 | other | $1 | $1 to $1 | Low |
| Dextroamp-amphet ER 15 Mg Cap | other | $1 | $1 to $1 | Low |
| Dressing Aquagel Adv Hydrofiber 2x2" #422297 | other | $1 | $1 to $4 | Low |
| Hydrocortisone 1% Ointment | other | $1 | $1 to $2 | Low |
| Hydrocortisone-aloe 1% Cream | other | $1 | $1 to $2 | Low |
| Mct Oil | other | $1 | $1 to $1 | Low |
| Metoprolol Succ ER 50 Mg Tab | other | $1 | $1 to $1 | Low |
| Metoprolol Succinate ER 50 Mg Po Tb24 | other | $1 | $1 to $1 | Low |
| Nafcillin 25 Mg/ml Ns Syringe-peds - Compounded | other | $1 | $1 to $1 | Low |
| Neomycin 500 Mg Tablet | other | $1 | $1 to $1 | Low |
| Ranolazine ER 500 Mg Tablet | other | $1 | $1 to $1 | Low |
| Rasagiline Mesylate 1 Mg Po Tabs | other | $1 | $1 to $2 | Low |
| Rasagiline Mesylate 1 Mg Tab | other | $1 | $1 to $2 | Low |
| Flexinet Sz 3 Width 7/8"x25yds/bx #mto3a | other | $1 | $1 to $4 | Low |
| Methylphenidate Hcl 20 Mg Po Tabs | other | $1 | $1 to $1 | Low |
| Mineral Oil 30 Ml Cup | other | $1 | $1 to $1 | Low |
| Mineral Oil 30 Ml Ud - Repackaging | other | $1 | $1 to $1 | Low |
| Oxycontin ER 10 Mg Tablet | other | $1 | $1 to $4 | Low |
| Hydrocodone-acetamn 7.5-325/15 | other | $1 | $1 to $4 | Low |
| Methylphenidate ER 54 Mg Tab | other | $1 | $1 to $4 | Low |
| Stopcock Plastic Three-way Ptws-2fll-mll-r #g00219 | other | $1 | $1 to $4 | Low |
| Hydralazine 50 Mg Tablet | other | $1 | $1 to $4 | Low |
| Luki-disp Aspirating Tubes Argyle 20ml 6.25in #8886864604 48ea/1cs | other | $1 | $1 to $4 | Low |
| Mesalamine Dr 1.2 Gm Tablet | other | $1 | $1 to $1 | Low |
| Nisoldipine ER 17 Mg Po Tb24 | other | $1 | $1 to $4 | Low |
| Nisoldipine ER 17 Mg Tablet | other | $1 | $1 to $4 | Low |
| Nystatin 100000 Unit/ml Mt Susp | other | $1 | $1 to $4 | Low |
| Nystatin 500,000 Unit/5 Ml Cup | other | $1 | $1 to $4 | Low |
| Phenobarbital 20 Mg/5 Ml Cup | other | $1 | $1 to $2 | Low |
| Amphetamine-dextroamphet ER 10 Mg Po Cp24 | other | $1 | $1 to $4 | Low |
| Captopril 25 Mg Tablet | other | $1 | $1 to $1 | Low |
| Emergency Room Visit | emergency | $1 | $1 to $3,112 | High |
| Lamotrigine ER 50 Mg Po Tb24 | other | $1 | $1 to $1 | Low |
| Lamotrigine ER 50 Mg Tablet | other | $1 | $1 to $1 | Low |
| Ortho-glass Splint W2xl12in Fiberglass Double Sided Padded #og-2pc 10ea/bx | other | $1 | $1 to $4 | Low |
| Primaquine 26.3 Mg Tablet | other | $1 | $1 to $2 | Low |
| Sevelamer 0.8 Gm Powder Packet | other | $1 | $1 to $2 | Low |
| Yasmin 28 Tablet | other | $1 | $1 to $4 | Low |
| Cinacalcet Hcl 30 Mg Tablet | other | $1 | $1 to $4 | Low |
| Dipyridamole 50 Mg Tablet | other | $1 | $1 to $1 | Low |
| Dressing Aquacel Foam Sacral Sm 8"x7" #421579 | other | $1 | $1 to $4 | Low |
| Dressing Steri-strip 1/4x1-1/2 (6/bx) #r1542 | other | $1 | $1 to $4 | Low |
| Feeding Administration Set Kangaroo 1000ml for Pump Flush Baf Dehp-free Latex... | other | $1 | $1 to $4 | Low |
| Fenofibrate 160 Mg Tablet | other | $1 | $1 to $2 | Low |
| Glucerna Shake | other | $1 | $1 to $2 | Low |
| Injector N35-o #515052 1cs/200ea | other | $1 | $1 to $4 | Low |
| Memantine Hcl ER 28 Mg Capsule | other | $1 | $1 to $2 | Low |
| Memantine Hcl ER 28 Mg Po Cp24 | other | $1 | $1 to $2 | Low |
| Saf-gel 1ea #145730 | other | $1 | $1 to $4 | Low |
| Sirolimus, Oral, 1 Mg | other | $1 | $1 to $4 | Low |
| Feed Tube 12fr Kendall #8884-711501 10ea/1cs | other | $1 | $1 to $4 | Low |
| Feeding Set Kangaroo Omni W/flush Bag 1000ml and Enplus Spike #bspff 30ea/case | other | $1 | $1 to $4 | Low |
| Lactulose 10 Gm/15ml Po Soln | other | $1 | $1 to $1 | Low |
| Lactulose 20 Gm/30 Ml Soln Cup | other | $1 | $1 to $1 | Low |
| Nifedipine ER 90 Mg Po Tb24 | other | $1 | $1 to $2 | Low |
| Nitrofurantoin Mcr 50 Mg Cap | other | $1 | $1 to $1 | Low |
| Optilock Nonadhesive Super Absorbant Wound Dressing Msc64610ep 10ea/bx 5bx/ca... | other | $1 | $1 to $4 | Low |
| Sodium Chloride 0.9 % in Aers | other | $1 | $1 to $4 | Low |
| Triple Dye Swab | other | $1 | $1 to $4 | Low |
| Zenpep Dr 5,000 Unit Capsule | other | $1 | $1 to $2 | Low |
| Boot Cast Gelo Unna's 12ea/1cs | other | $1 | $1 to $4 | Low |
| Cefpodoxime Proxetil 100 Mg Po Tabs | other | $1 | $1 to $4 | Low |
| Electrode Needle Tip #0013m 12/bx | other | $1 | $1 to $4 | Low |
| Nebulizer Kit 1000ml #ck0010 | other | $1 | $1 to $4 | Low |
| Airway Ovassapian #bd6075 5/cs | other | $1 | $1 to $4 | Low |
| Benadryl Itch Stop 1%-0.1% Crm | other | $1 | $1 to $4 | Low |
| Mirtazapine 7.5 Mg Tablet | other | $1 | $1 to $2 | Low |
| Neo-synephrine 0.5% Spray | other | $1 | $1 to $4 | Low |
| Piroxicam 20 Mg Capsule | other | $1 | $1 to $2 | Low |
| Quinine Sulfate 324 Mg Capsule | other | $1 | $1 to $4 | Low |
| Blade Laryngoscope Dispo Robert Shaw 1 2011.c | other | $1 | $1 to $4 | Low |
| Divalproex Sod ER 250 Mg Tab | other | $1 | $1 to $1 | Low |
| Doxycycline Hyclate 100 Mg Po Caps | other | $1 | $1 to $4 | Low |
| Endotrach Tube 6.5mm Nasal Rae #96365 | other | $1 | $1 to $4 | Low |
| Endotrach Tube 7.0mm Nasal Rae #96370 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Oral Rae 5.0mm Cuff #76251 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Oral Rae 5.5mm Cuff #76255 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Oral Rae 6.0mm Cuff #76260 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Oral Rae 6.5mm Cuff #76265 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Oral Rae 7.5mm Cuff #76275 | other | $1 | $1 to $4 | Low |
| Endotrach Tube Oral Rae Cuffed 4.0mm 10/bx | other | $1 | $1 to $4 | Low |
| Lubiprostone 8 Mcg Capsule | other | $1 | $1 to $1 | Low |
| Nicotine 7 Mg/24hr Patch | other | $1 | $1 to $1 | Low |
| Oxybutynin Cl ER 5 Mg Tablet | other | $1 | $1 to $1 | Low |
| Oxymorphone Hcl ER 5 Mg Tablet | other | $1 | $1 to $4 | Low |
| Sleeve Smoke Evac Suction 165mm 10/pk 0703-005 | other | $1 | $1 to $4 | Low |
| 5fr Obturator | other | $1 | $1 to $4 | Low |
| 6fr Obturator | other | $1 | $1 to $4 | Low |
| 7fr Obturator | other | $1 | $1 to $4 | Low |
| Arformoterol, Inhalation Solution, Fda Approved Final Product, Non-compounded... | other | $1 | $1 to $2 | Low |
| Brace Wrist Right Small #79 | other | $1 | $1 to $4 | Low |
| Clotrimazole-betamethasone Crm | other | $1 | $1 to $4 | Low |
| Injection, Cytarabine, 100 Mg | other | $1 | $1 to $54 | Low |
| Pradaxa 110 Mg Capsule | other | $1 | $1 to $2 | Low |
| Cevimeline Hcl 30 Mg Capsule | other | $1 | $1 to $2 | Low |
| Injection, Cefazolin Sodium, 500 Mg | other | $1 | $1 to $1 | Low |
| Jackson Pratt Drain Flat 10mm | other | $1 | $1 to $5 | Low |
| Light Compression Bandage, Elastic, Knitted/woven, Width Less Than Three Inch... | other | $1 | $1 to $4 | Low |
| Ondansetron, Oral, 4 Mg | other | $1 | $1 to $4 | Low |
| Osmolite 1 Cal Liquid | other | $1 | $1 to $2 | Low |
| Ramelteon 8 Mg Tablet | other | $1 | $1 to $1 | Low |
| Dressing Border 6x6 Mepilex #295400b | other | $1 | $1 to $5 | Low |
| Enema | other | $1 | $1 to $1 | Low |
| Focalin Xr 5 Mg Capsule | other | $1 | $1 to $5 | Low |
| Ketorolac 10 Mg Tablet | other | $1 | $1 to $5 | Low |
| Acetaminophen 650mg/20.3ml Cup | other | $1 | $1 to $2 | Low |
| Arnuity Ellipta 100 Mcg Inh | other | $1 | $1 to $5 | Low |
| Cast Splint 4"x 15" Comformable 10ea/1cs | other | $1 | $1 to $5 | Low |
| Dutasteride 0.5 Mg Capsule | other | $1 | $1 to $5 | Low |
| Dutasteride 0.5 Mg Po Caps | other | $1 | $1 to $5 | Low |
| Levalbuterol, Inhalation Solution, Fda-approved Final Product, Non-compounded... | other | $1 | $1 to $5 | Low |
| Nitro-bid 2% Ointment | other | $1 | $1 to $2 | Low |
| Ure-na 15 Gram Powder Packet | other | $1 | $1 to $5 | Low |
| Belt Gait W/ Buckle 72" #655702 | other | $1 | $1 to $5 | Low |
| Fluvastatin Sodium 20 Mg Po Caps | other | $1 | $1 to $5 | Low |
| Fluvastatin Sodium 40 Mg Po Caps | other | $1 | $1 to $5 | Low |
| Focalin Xr 10 Mg Capsule | other | $1 | $1 to $5 | Low |
| Mesalamine ER 0.375 Gram Cap | other | $1 | $1 to $5 | Low |
| Tobramycin 0.3% Eye Drop | other | $1 | $1 to $5 | Low |
| Albuterol, Inhalation Solution, Fda-approved Final Product, Non-compounded, A... | other | $1 | $1 to $1 | Low |
| Boot Cast Extra Large 1ea | other | $1 | $1 to $5 | 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 |
| Cannula Anterior Chamber 27 Ga | other | $1 | $1 to $5 | Low |
| Darifenacin ER 7.5 Mg Tablet | other | $1 | $1 to $2 | Low |
| Dextroamphetamine Sulfate ER 15 Mg Po Cp24 | other | $1 | $1 to $5 | Low |
| First Aid Antiseptic 10% Oint | other | $1 | $1 to $1 | Low |
| Fluoxetine 20 Mg/ 5 Ml Oral Solution - Repackaging | other | $1 | $1 to $2 | Low |
| Fluoxetine 20 Mg/5 Ml Soln Cup | other | $1 | $1 to $2 | Low |
| Ortho-glass Splint W3xl12in Fiberglass Double Sided Padded #og-3pc 10ea/bx | other | $1 | $1 to $5 | Low |
| Ziprasidone Hcl 20 Mg Capsule | other | $1 | $1 to $2 | Low |
| Ziprasidone Hcl 80 Mg Capsule | other | $1 | $1 to $2 | Low |
| Ziprasidone Hcl 80 Mg Po Caps | other | $1 | $1 to $2 | Low |
| Amox-clav 200-28.5 Mg/5 Ml Sus | other | $1 | $1 to $5 | Low |
| Atazanavir Sulfate 200 Mg Cap | other | $1 | $1 to $1 | Low |
| Partitioned Scoop Dish #1388 | other | $1 | $1 to $5 | Low |
| Anes Breathing Circuit Adult 3l #a4y520xxf | other | $1 | $1 to $5 | Low |
| Cannula Nasal 50' #0150 | other | $1 | $1 to $5 | Low |
| Ciprofloxacin 0.3% Eye Drop | other | $1 | $1 to $5 | Low |
| Fluconazole 200 Mg Po Tabs | other | $1 | $1 to $1 | Low |
| Fluconazole 200 Mg Tablet | other | $1 | $1 to $1 | Low |
| Focalin Xr 15 Mg Capsule | other | $1 | $1 to $5 | Low |
| Focalin Xr 20 Mg Capsule | other | $1 | $1 to $5 | Low |
| Pilocarpine Hcl 5 Mg Tablet | other | $1 | $1 to $2 | Low |
| Polyethylene Glycol 3350 Powd | other | $1 | $1 to $1 | Low |
| Splint Wrist Cockup Left Universal | other | $1 | $1 to $5 | Low |
| Splint Wrist Cockup Right Universal | other | $1 | $1 to $5 | Low |
| Valganciclovir 225 Mg Half Tablet | other | $1 | $1 to $2 | Low |
| Valganciclovir 450 Mg Tablet | other | $1 | $1 to $2 | Low |
| Adaptor Meconium Aspiration #n0101 40ea/bx | other | $1 | $1 to $5 | Low |
| Boudreauxs Butt Paste | other | $1 | $1 to $5 | Low |
| Bromocriptine 2.5 Mg Tablet | other | $1 | $1 to $1 | Low |
| Eye Itch Relief 0.025% Drops | other | $1 | $1 to $5 | Low |
| Foam Dressing, Wound Cover, Sterile, Pad Size More Than 16 Sq. In. But Less T... | other | $1 | $1 to $28 | Low |
| Hemorrhoidal Ointment | other | $1 | $1 to $2 | Low |
| Juven Packet | other | $1 | $1 to $2 | Low |
| Propranolol ER 80 Mg Capsule | other | $1 | $1 to $2 | Low |
| Propranolol Hcl ER 80 Mg Po Cp24 | other | $1 | $1 to $2 | Low |
| Zidovudine 100 Mg Capsule | 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 |
| Cannula Inner 6.0 Xltin Ext Length | other | $1 | $1 to $5 | Low |
| Cannula Inner 7.0 Xltin Ext Length 12.3/100mm | other | $1 | $1 to $5 | Low |
| Cannula Inner 8.0 Xltin Ext Length 13.3/105mm | other | $1 | $1 to $5 | Low |
| Fenofibrate 48 Mg Po Tabs | other | $1 | $1 to $2 | Low |
| Fenofibrate 48 Mg Tablet | other | $1 | $1 to $2 | Low |
| Methylphenidate ER 18 Mg Tab | other | $1 | $1 to $5 | Low |
| Namenda 5-10 Mg Titration Pk | other | $1 | $1 to $5 | Low |
| Ritonavir 100 Mg Tablet | other | $1 | $1 to $2 | Low |
| Splint Wrist/forearm Left Large 1ea | other | $1 | $1 to $5 | Low |
| Splint Wrist/forearm Left Medium 1ea | other | $1 | $1 to $5 | Low |
| Splint Wrist/forearm Rt Medium 1ea | other | $1 | $1 to $5 | Low |
| Acetylcysteine, Inhalation Solution, Fda-approved Final Product, Non-compound... | other | $1 | $1 to $1 | Low |
| Brace Thumb Splint Universal #5026 | other | $1 | $1 to $5 | Low |
| Catheter Coude 14fr #120614 Cs/12ea | cardiac | $1 | $1 to $5 | Low |
| Injection, Octreotide, Non-depot Form for Subcutaneous OR Intravenous Injecti... | other | $1 | $1 to $125 | Low |
| Aripiprazole 5 Mg Po Tabs | other | $1 | $1 to $5 | Low |
| Aripiprazole 5 Mg Tablet | other | $1 | $1 to $5 | Low |
| Tube Salem Sump Multi-functional Port Enfit Connection 18fr #7771810e | other | $1 | $1 to $5 | Low |
| Vilazodone Hcl 10 Mg Tablet | other | $1 | $1 to $5 | Low |
| Vilazodone Hcl 20 Mg Po Tabs | other | $1 | $1 to $5 | Low |
| Vilazodone Hcl 20 Mg Tablet | other | $1 | $1 to $5 | Low |
| Vilazodone Hcl 40 Mg Po Tabs | other | $1 | $1 to $5 | Low |
| Vilazodone Hcl 40 Mg Tablet | other | $1 | $1 to $5 | Low |
| Eye Protector Regular/newborn 33-38cm | obstetric | $1 | $1 to $5 | Low |
| Olanzapine Odt 5 Mg Tablet | other | $1 | $1 to $1 | Low |
| Propylthiouracil 50 Mg Tablet | other | $1 | $1 to $2 | Low |
| Timolol Maleate 0.25% Eye Drop | other | $1 | $1 to $2 | Low |
| Bupropion Hcl 75 Mg Po Tabs | other | $1 | $1 to $2 | Low |
| Bupropion Hcl 75 Mg Tablet | other | $1 | $1 to $2 | Low |
| Eye Drops 0.05% | other | $1 | $1 to $1 | Low |
| Injection, Von Willebrand Factor Complex (humate-p), Per Iu Vwf:rco | other | $1 | $1 to $7,454 | Low |
| Quinidine Gluc ER 324 Mg Tab | other | $1 | $1 to $5 | Low |
| Silver Nitrate Applicators - #10 - Repackaged | other | $1 | $1 to $2 | Low |
| Synthroid 200 Mcg Tablet | other | $1 | $1 to $1 | Low |
| Urinary Catheter Anchoring Device, Adhesive Skin Attachment, Each | cardiac | $1 | $1 to $10 | Low |
| Urinary Catheter Anchoring Device, Leg Strap, Each | cardiac | $1 | $1 to $10 | Low |
| Endotrach Tube Oral Rae 7.0mm Cuff #76270 | other | $1 | $1 to $5 | Low |
| Feeding Set Kangaroo Omni W/flush Bag 1000ml #b10ff 30ea/case | other | $1 | $1 to $5 | Low |
| Feeding Set Kangaroo Omni W/flush Bag 500ml #b5ff 30ea/case | other | $1 | $1 to $5 | Low |
| Hydrocodone-chlorpheniramine ER Susp 5ml - Repackaged | other | $1 | $1 to $2 | Low |
| Nateglinide 60 Mg Tablet | other | $1 | $1 to $1 | Low |
| Tube Port Gientri 12fr Salem Sump #7771210 | other | $1 | $1 to $5 | Low |
| Tube Port Gientri 14fr Salem Sump #7771410 | other | $1 | $1 to $5 | Low |
| Tube Port Gientri 16fr Salem Sump #7771610 | other | $1 | $1 to $5 | Low |
| Voriconazole 100 Mg Half Tablet | other | $1 | $1 to $1 | Low |
| Voriconazole 200 Mg Tablet | other | $1 | $1 to $1 | Low |
| Aliskiren 150 Mg Tablet | other | $1 | $1 to $5 | 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 |
| Desitin 40% Paste | other | $1 | $1 to $5 | Low |
| Ethacrynic Acid 25 Mg Tablet | other | $1 | $1 to $2 | Low |
| Adhesive, Liquid OR Equal, Any Type, Per Oz | other | $1 | $1 to $5 | Low |
| Amox-clav 400-57 Mg/5 Ml Susp | other | $1 | $1 to $5 | Low |
| Orajel 3x Toothache-gum Gel | other | $1 | $1 to $5 | Low |
| Bacitracin 500 Unit/gm Ointmnt | other | $1 | $1 to $2 | Low |
| Flexinet Sz 5 Width 1-1/4"x25yds/bx #mto5a | other | $1 | $1 to $5 | Low |
| Toot Sweet Sub (glucose 25%) - 1 Ml - Repackaging | other | $1 | $1 to $2 | Low |
| Trazodone 100 Mg Tablet | other | $1 | $1 to $2 | Low |
| Trazodone Hcl 100 Mg Po Tabs | other | $1 | $1 to $2 | Low |
| Dressing Xtrasorb Classic 6"x9" #89569 | other | $1 | $1 to $5 | Low |
| Fluconazole 10 Mg/ml Susp | other | $1 | $1 to $2 | Low |
| Lanthanum Carb 500 Mg Tab Chew | other | $1 | $1 to $5 | Low |
| Lanthanum Carbonate 500 Mg Po Chew | other | $1 | $1 to $5 | Low |
| Wound Cleanser 12 Oz Safe Clens #159712 6/cs | other | $1 | $1 to $5 | Low |
| Clopidogrel 300 Mg Tablet | other | $1 | $1 to $5 | Low |
| Dish Scoop Round 8 Inch 1ea | other | $1 | $1 to $5 | Low |
| Dressing Foam Allevyn 7x7 Gntle Brdr 66800280 | other | $1 | $1 to $5 | Low |
| Glucose 40 % Po Gel | other | $1 | $1 to $2 | Low |
| Lidocaine Topical 2% 15 Ml Viscous Soln Ud - Repackaging | other | $1 | $1 to $2 | Low |
| Lubiprostone 24 Mcg Capsule | other | $1 | $1 to $2 | Low |
| Lubiprostone 24 Mcg Po Caps | other | $1 | $1 to $2 | Low |
| Montelukast Sod 5 Mg Tab Chew | other | $1 | $1 to $5 | Low |
| Montelukast Sodium 4 Mg Po Chew | other | $1 | $1 to $5 | Low |
| Montelukast Sodium 5 Mg Po Chew | other | $1 | $1 to $5 | Low |
| Splint Cool Blue Wrist Left #d5040 | other | $1 | $1 to $5 | Low |
| Splint Wrist Univ Rt Cool Blue #d5040 | other | $1 | $1 to $5 | Low |
| Tiagabine Hcl 4 Mg Tablet | other | $1 | $1 to $2 | Low |
| Allegra-d 24 Hour Tablet | other | $1 | $1 to $2 | Low |
| Doxycycline Hyclate 100 Mg Po Tabs | other | $1 | $1 to $2 | Low |
| Doxycycline Hyclate 100 Mg Tab | other | $1 | $1 to $2 | Low |
| Needle for Infusion Port Powerloc 20 Ga X 0.75in Injectable without Y Injecti... | surgery | $1 | $1 to $5 | Low |
| Pvc Drain Surgical 10 Fr Round Mid Perforation 100 Cc Reservoir Standard Leng... | surgery | $1 | $1 to $5 | Low |
| Valve Biopsy #maj-210 Endo/non-chrg | lab | $1 | $1 to $5 | Low |
| Brimonidine 0.2% Eye Drop | other | $1 | $1 to $5 | Low |
| Omega-3 Ethyl Esters 1 Gm Cap | other | $1 | $1 to $2 | Low |
| Rivastigmine 9.5 Mg/24hr Patch | other | $1 | $1 to $2 | Low |
| Tolterodine Tart ER 2 Mg Cap | other | $1 | $1 to $5 | Low |
| Weighted Spork 1ea | other | $1 | $1 to $5 | Low |
| Dressing Calcium Alginate 2x2 #31022 | other | $1 | $1 to $5 | Low |
| Electrode Ultra Clean Accessory | other | $1 | $1 to $5 | Low |
| Furosemide 10 Mg/ml Solution | other | $1 | $1 to $5 | Low |
| Magnesium Citrate Solution | other | $1 | $1 to $2 | Low |
| Olmesartan Medoxomil 40 Mg Po Tabs | other | $1 | $1 to $2 | Low |
| Skin Protectant Medline/remedy Specialized Extra Thick Zinc Oxide Paste 4oz #... | other | $1 | $1 to $5 | Low |
| Tramadol Hcl ER 100 Mg Tablet | other | $1 | $1 to $2 | Low |
| Anesthesia for Other Repair of Upper Abdomen Hernia | surgery | $1 | $1 to $750 | Low |
| Bactine Max 0.13% Solution | other | $1 | $1 to $5 | Low |
| Nafcillin 1 Gm/ 50 Ml Ns Mini-bag Plus - Compounded | other | $1 | $1 to $5 | Low |
| Nafcillin 2 Gm / 100 Ml Ns Mini-bag Plus - Compounded | other | $1 | $1 to $5 | Low |
| Teds Thigh 3x-large Regular Ultra Care Open Toe Purple Latex Free #868-06 Cas... | other | $1 | $1 to $5 | Low |
| Trazodone 50 Mg Tablet | other | $1 | $1 to $2 | Low |
| Trazodone Hcl 50 Mg Po Tabs | other | $1 | $1 to $2 | Low |
| Anesthesia for Procedure On Veins in Upper Leg | other | $1 | $1 to $1,260 | Low |
| Colchicine 0.6 Mg Po Tabs | other | $1 | $1 to $5 | Low |
| Colchicine 0.6 Mg Tablet | other | $1 | $1 to $5 | Low |
| Guaifenesin 200 Mg/10 Ml Cup | other | $1 | $1 to $2 | Low |
| Wrist Splint 6" W/stays Left Lg #5015 | other | $1 | $1 to $5 | Low |
| Wrist Splint 6" W/stays Left Md #5015 | other | $1 | $1 to $5 | Low |
| Wrist Splint 6" W/stays Right Lg #5015 | other | $1 | $1 to $5 | Low |
| Wrist Splint 6" W/stays Right Md #5015 | other | $1 | $1 to $5 | Low |
| Bss Eye Solution | other | $1 | $1 to $5 | Low |
| Injection, Topotecan, 0.1 Mg | other | $1 | $1 to $279 | Low |
| Mask Lma Unique Silicone W/cuff Pilot Size 1 | other | $1 | $1 to $6 | Low |
| Mask Lma Unique Silicone W/cuff Pilot Size 2 | other | $1 | $1 to $6 | Low |
| Mask Lma Unique Silicone W/cuff Pilot Sz 1.5 | other | $1 | $1 to $6 | Low |
| Mask Lma Unique Silicone W/cuff Pilot Sz 2.5 | other | $1 | $1 to $6 | Low |
| Propafenone Hcl ER 425 Mg Cap | other | $1 | $1 to $2 | Low |
| Propafenone Hcl ER 425 Mg Po Cp12 | other | $1 | $1 to $2 | Low |
| Theophylline ER 300 Mg Po Tb12 | other | $1 | $1 to $2 | Low |
| Theophylline ER 300 Mg Tablet | other | $1 | $1 to $2 | Low |
| Dextroamphetamine 10 Mg Tab | other | $1 | $1 to $2 | Low |
| Injection, Dexamethasone Sodium Phosphate, 1 Mg | imaging | $1 | $1 to $1 | Low |
| Injection, Fosphenytoin, 50 Mg Phenytoin Equivalent | other | $1 | $1 to $139 | Low |
| Loperamide 2 Mg/15 Ml Oral Soln - Repackaging | other | $1 | $1 to $2 | Low |
| Loperamide 2 Mg/15 Ml Soln Cup | other | $1 | $1 to $2 | Low |
| Tube Salem Sump 14fr W/filter&valve | other | $1 | $1 to $6 | Low |
| Tube Salem Sump 16fr W/filter&valve | other | $1 | $1 to $6 | Low |
| Daytrana 10 Mg/9 Hr Patch | other | $1 | $1 to $6 | Low |
| Daytrana 15 Mg/9 Hr Patch | other | $1 | $1 to $6 | Low |
| Daytrana 20 Mg/9 Hour Patch | other | $1 | $1 to $6 | Low |
| Daytrana 30 Mg/9 Hour Patch | other | $1 | $1 to $6 | Low |
| Filter Disp W/connector Tube Obgyn Berkeley | other | $1 | $1 to $6 | Low |
| Linezolid 600 Mg Tablet | other | $1 | $1 to $2 | Low |
| Menest 0.625 Mg Tablet | other | $1 | $1 to $2 | Low |
| Methotrexate; Oral, 2.5 Mg | other | $1 | $1 to $2 | Low |
| Methylprednisolone Oral, Per 4 Mg | other | $1 | $1 to $1 | Low |
| Bag Phlebotomy Set 25/bx #bk-64a | other | $1 | $1 to $6 | Low |
| Electrode Disposable Pre-gel Monitoring 25/bg | other | $1 | $1 to $6 | Low |
| Iontophoris Pad - Sp 6ea/1bx | other | $1 | $1 to $6 | Low |
| Mesalamine ER 250 Mg Po Cpcr | other | $1 | $1 to $6 | Low |
| Pentasa 250 Mg Capsule | other | $1 | $1 to $6 | Low |
| Triamcinolone 0.1% Cream | other | $1 | $1 to $2 | Low |
| Triamcinolone Acetonide 0.1 % Ex Crea | other | $1 | $1 to $2 | Low |
| Bandage Comprilan 6cm 20ea/1cs | other | $2 | $2 to $6 | Low |
| Desloratadine 5 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Diflunisal 500 Mg Po Tabs | other | $2 | $2 to $2 | Low |
| Dressing Biatain 5x5" Silicone Foam #33436 | other | $2 | $2 to $6 | Low |
| Forcep Surgical Adson Dressing Serrated 4.75 | surgery | $2 | $2 to $6 | Low |
| Glove Edema Compression Large Left 1ea | other | $2 | $2 to $6 | Low |
| Glove Edema Compression Lrg Right 1ea | other | $2 | $2 to $6 | Low |
| Glove Edema Compression Med Right 1ea | other | $2 | $2 to $6 | Low |
| Glove Edema Compression Medium Left 1ea | other | $2 | $2 to $6 | Low |
| Injection, Meropenem, 100 Mg | other | $2 | $2 to $2 | Low |
| Nitroglycerin 0.2 Mg / 5 Ml Syringe (for Radial Cocktail) - Compounded | other | $2 | $2 to $3 | Low |
| Yaz 28 Tablet | other | $2 | $2 to $6 | Low |
| Cuff Universal Lrg 3-1/2in #1489 | other | $2 | $2 to $6 | Low |
| Dermoplast Pain Relieving Spry | other | $2 | $2 to $6 | Low |
| Forcep Surgical Adson Tissue 1x2 4.75in | surgery | $2 | $2 to $6 | Low |
| Medroxyprogesterone Acetate 10 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Midazolam Hcl 10 Mg/5 Ml Cup | other | $2 | $2 to $6 | Low |
| Support Abducted Thumbspica Uni #79 | other | $2 | $2 to $6 | Low |
| Support Abducted Thumbspica Uni Lt #79 | other | $2 | $2 to $6 | Low |
| Acetaminophen 120 Mg Re Supp | other | $2 | $2 to $2 | Low |
| Aripiprazole 2 Mg Tablet | other | $2 | $2 to $6 | Low |
| Clotrimazole 10 Mg Troche | other | $2 | $2 to $3 | Low |
| Fleet Mineral Oil Enema | other | $2 | $2 to $3 | Low |
| Rivastigmine 1.5 Mg Capsule | other | $2 | $2 to $3 | Low |
| Tropicamide 0.5% Eye Drops | other | $2 | $2 to $6 | Low |
| Injection, Pantoprazole Sodium, 40 Mg | other | $2 | $2 to $3 | Low |
| Flexiseal Collect Bags W Fil 5ea/bx 6bx/cs #422291 | other | $2 | $2 to $6 | Low |
| Irrigation Tur Set 21" #2c4006 12ea/1ca | other | $2 | $2 to $6 | Low |
| Levetiracetam 500 Mg/5 Ml Cup | other | $2 | $2 to $3 | Low |
| Injection, Fondaparinux Sodium, 0.5 Mg | other | $2 | $2 to $6 | Low |
| Iontophoris Pad - 80 6ea/1bx | other | $2 | $2 to $6 | Low |
| Raloxifene Hcl 60 Mg Tablet | other | $2 | $2 to $3 | Low |
| Factor Ix, Complex, Per I.u. | other | $2 | $2 to $6,009 | Low |
| Montelukast Sod 10 Mg Tablet | other | $2 | $2 to $6 | Low |
| Nebivolol 10 Mg Tablet | other | $2 | $2 to $3 | Low |
| Nebivolol 2.5 Mg Tablet | other | $2 | $2 to $3 | Low |
| Nebivolol Hcl 10 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Spear Eye #10 Merocel 10ea/pk | other | $2 | $2 to $6 | 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 |
| Anesthesia for Extensive Removal of Prostate | surgery | $2 | $2 to $865 | Low |
| Anesthesia for Repair of Bulging (aneurysm) Defect in Knee Artery | surgery | $2 | $2 to $1,444 | Low |
| Cuff Universal Medium 3in #1487 | other | $2 | $2 to $6 | Low |
| Temazepam 7.5 Mg Capsule | other | $2 | $2 to $3 | Low |
| 1/2 Circle Rev Cut Richard Allen #209106 | other | $2 | $2 to $6 | Low |
| Dress Aquacel Advantage Hydrofbr Rope #422300 | other | $2 | $2 to $6 | Low |
| Glove Edema Compression Sm Left 1ea | other | $2 | $2 to $6 | Low |
| Ligaclip-lg Titanium Orange #004200 120ea/bx | other | $2 | $2 to $6 | Low |
| Thoracic Chest Tube 32fr 10ea/1cs | other | $2 | $2 to $6 | Low |
| Anesthesia for Other Procedures On Nerves, Muscles, Tendons, and Tissue of Up... | other | $2 | $2 to $1,710 | Low |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, and Tissue of Knee | other | $2 | $2 to $1,320 | Low |
| Anesthesia for Procedure On Saliva Gland | other | $2 | $2 to $100 | Low |
| Demeclocycline Hcl 150 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Extension Set W/controller 60ea/1cs | other | $2 | $2 to $6 | Low |
| Lavage Tray 34fr Argyle #88 | other | $2 | $2 to $6 | Low |
| Amoxicillin 400 Mg/5 Ml Susp | other | $2 | $2 to $6 | Low |
| Connector Straight 3/8 X 1/4" #050516000 | other | $2 | $2 to $6 | Low |
| Efavirenz 600 Mg Tablet | other | $2 | $2 to $3 | Low |
| Hc Remote Cardiac Monitoring-additional Hrs | cardiac | $2 | $2 to $6 | Low |
| Merit Medical K-50 Tube #08-01859 15/bx | other | $2 | $2 to $6 | Low |
| Nausea Aromatic Pk Disp/quease Ease 30ea/1ca | other | $2 | $2 to $6 | Low |
| Adaptic Toe Dressing 1-1/8" Size Lg #mad062u 10ea/bx | other | $2 | $2 to $6 | Low |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, Fascia, and Bursae of S... | other | $2 | $2 to $1,610 | Low |
| Cannula Vessel One Way Flow Bevd Tip #30000 | other | $2 | $2 to $6 | Low |
| Intermittent Urinary Catheter; Straight Tip, with OR without Coating (teflon,... | cardiac | $2 | $2 to $5 | Low |
| Rosuvastatin Calcium 10 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Rosuvastatin Calcium 10 Mg Tab | other | $2 | $2 to $6 | Low |
| Rosuvastatin Calcium 20 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Rosuvastatin Calcium 40 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Rosuvastatin Calcium 40 Mg Tab | other | $2 | $2 to $6 | Low |
| Rosuvastatin Calcium 5 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Rosuvastatin Calcium 5 Mg Tab | other | $2 | $2 to $6 | Low |
| Splint Wrist Lrg Right 1ea | other | $2 | $2 to $6 | Low |
| Splint Wrist Med Left 1ea | other | $2 | $2 to $6 | Low |
| Suction Cath-14fr-coude 20ea/1cs | other | $2 | $2 to $6 | Low |
| Varenicline 1 Mg Tablet | other | $2 | $2 to $6 | Low |
| Varenicline Tartrate 1 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Anesthesia for Other Procedure On Artery of Upper Leg | other | $2 | $2 to $1,270 | Low |
| Ezetimibe-simvastatin 10-40 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Ezetimibe-simvastatin 10-80 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Oxycontin ER 15 Mg Tablet | other | $2 | $2 to $6 | Low |
| Penicillin Vk 250 Mg/5 Ml Soln | 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 |
| Moxifloxacin Hcl 400 Mg Tablet | other | $2 | $2 to $3 | Low |
| Ortho-glass Splint W4xl15in Fiberglass Double Sided Padded Og-4pc 10ea/bx | other | $2 | $2 to $6 | Low |
| Splint Clavicle-adult/large #3004 | other | $2 | $2 to $6 | Low |
| Splint Clavicle-adult/x-lrg #3004 | other | $2 | $2 to $6 | Low |
| Splint Clavicle-medium #3004 | other | $2 | $2 to $6 | Low |
| Wilson Frame Headrest #1937dz 12/cs | other | $2 | $2 to $6 | Low |
| Anesthesia for Other Procedure On Upper Front Abdomen | other | $2 | $2 to $700 | Low |
| Carvedilol ER 10 Mg Capsule | other | $2 | $2 to $6 | Low |
| Carvedilol ER 20 Mg Capsule | other | $2 | $2 to $6 | Low |
| Carvedilol Phosphate ER 20 Mg Po Cp24 | other | $2 | $2 to $6 | Low |
| Cast Splint 3" X 12" Comformable 10ea/1csquick Step Splint Scotchcast 3" X 12" | other | $2 | $2 to $6 | Low |
| Imatinib Mesylate 100 Mg Tab | other | $2 | $2 to $3 | Low |
| Injection, Aprepitant, 1 Mg | other | $2 | $2 to $1,476 | Low |
| Nadolol 20 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Nadolol 20 Mg Tablet | other | $2 | $2 to $3 | Low |
| Repaglinide 1 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Repaglinide 1 Mg Tablet | other | $2 | $2 to $3 | Low |
| Venlafaxine Hcl ER 37.5 Mg Cap | other | $2 | $2 to $6 | Low |
| Venlafaxine Hcl ER 37.5 Mg Po Cp24 | other | $2 | $2 to $6 | Low |
| Alginate OR Other Fiber Gelling Dressing, Wound Filler, Sterile, Per 6 Inches | other | $2 | $2 to $8 | 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 |
| Calmoseptine Ointment | other | $2 | $2 to $6 | Low |
| Fluvastatin Sodium ER 80 Mg Po Tb24 | other | $2 | $2 to $6 | Low |
| Single Use Distal Cover #maj-2315 20ea/bx | other | $2 | $2 to $6 | Low |
| Anesthesia for Insertion of Penile Prosthesis | other | $2 | $2 to $938 | Low |
| Anesthesia for Other Procedure On Lower Abdomen Outside Abdominal Cavity | other | $2 | $2 to $860 | Low |
| Lidocaine 5% Patch | other | $2 | $2 to $3 | Low |
| Methylphenidate Hcl ER (cd) 10 Mg Po Cpcr | other | $2 | $2 to $6 | Low |
| Methylphenidate Hcl ER (cd) 20 Mg Po Cpcr | other | $2 | $2 to $6 | Low |
| Methylphenidate Hcl ER (cd) 30 Mg Po Cpcr | other | $2 | $2 to $6 | Low |
| Anesthesia for Removal of Testicle Through Groin | surgery | $2 | $2 to $926 | Low |
| Binder Abdominal 10" 27"-48" #ort21200 | other | $2 | $2 to $6 | Low |
| Fluconazole 150 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Fluconazole 150 Mg Tablet | other | $2 | $2 to $3 | Low |
| Resuscitator Bag W/mask Child Manual Spur Ii Ambu 531613000 Case/6ea | other | $2 | $2 to $6 | Low |
| Disposable Temperature Probe Sterile 400 Series Molex Esophageal OR Rectal Pr... | other | $2 | $2 to $6 | Low |
| Estrogens Conjugated 0.625 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Nasal Aspirator without Syringe #mad300 | other | $2 | $2 to $6 | Low |
| Premarin 0.3 Mg Tablet | other | $2 | $2 to $6 | Low |
| Premarin 0.625 Mg Tablet | other | $2 | $2 to $6 | Low |
| Anes Breathing Circuit Ped 2l W/mask B1557xx4 | other | $2 | $2 to $6 | Low |
| Anesthesia for Other Procedure On Lower Leg, Ankle, and Foot Bones | other | $2 | $2 to $1,480 | Low |
| Dibucaine 1% Ointment | other | $2 | $2 to $3 | Low |
| Jackson Rees Modification Circuit #3842-61z | other | $2 | $2 to $6 | Low |
| Lanolin Cream | other | $2 | $2 to $3 | Low |
| Nystatin 100,000 Unit/gm Oint | other | $2 | $2 to $3 | Low |
| Anesthesia for Other Procedure On Skin of Arms, Legs, and Front Body | other | $2 | $2 to $400 | Low |
| Fenofibrate 145 Mg Po Tabs | other | $2 | $2 to $6 | Low |
| Fenofibrate 145 Mg Tablet | other | $2 | $2 to $6 | Low |
| Brace Wrist/forearm Support Left #79 | other | $2 | $2 to $6 | Low |
| Endotrach Tube 5mm Micro Oral/nasal #86387 | other | $2 | $2 to $6 | Low |
| Endotrach Tube Oral/nasal Cuffed Murphy Eye 6mm 10ea/pk #86389 | other | $2 | $2 to $6 | Low |
| Anesthesia for Repair of Abdominal Wall Hernia | surgery | $2 | $2 to $832 | Low |
| Scopolamine 1 Mg/3days Td Pt72 | other | $2 | $2 to $7 | Low |
| Anesthesia for Other Procedure On Artery of Knee | other | $2 | $2 to $1,440 | Low |
| Biofreeze W/ilex 4oz Tube 1ea | other | $2 | $2 to $7 | Low |
| Chemotherapy Administration | other | $2 | $2 to $1,780 | High |
| Clotrimazole 1 % Ex Crea | other | $2 | $2 to $7 | Low |
| Dressing Port Chg Tegaderm #1665 | other | $2 | $2 to $7 | Low |
| Dronabinol, 2.5 Mg, Oral, Fda Approved Prescription Anti-emetic, for Use As a... | other | $2 | $2 to $7 | Low |
| Lacosamide 10 Mg/ml 20 Ml Ud Oral Soln - Repackaged | other | $2 | $2 to $3 | Low |
| Pressure Damping Device #r.o.s.e. 25ea/1bx | other | $2 | $2 to $7 | 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 |
| Anesthesia for Open Amputation Below the Knee | other | $2 | $2 to $1,482 | Low |
| Anesthesia for Other Procedure On Elbow | other | $2 | $2 to $1,740 | Low |
| Dextroamphetamine Sulfate ER 5 Mg Po Cp24 | other | $2 | $2 to $3 | Low |
| Flexinet Sz 10 Width 3"x25yds/bx #mt1oa | other | $2 | $2 to $7 | Low |
| Foam Dressing, Wound Cover, Sterile, Pad Size 16 Sq. In. OR Less, without Adh... | other | $2 | $2 to $11 | Low |
| Green Enternal Feeding Tube Declogger 20-22fr 39.5cm Item 913 | other | $2 | $2 to $7 | Low |
| Putty Exercise Progressive Purple 1ea | other | $2 | $2 to $7 | Low |
| Enulose 10 Gm/15 Ml Solution | other | $2 | $2 to $7 | Low |
| Selenium Sulfide 2.5% Lotion | other | $2 | $2 to $7 | 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 |
| Catheter Purewick Female External Ltx #pwf030 | cardiac | $2 | $2 to $7 | Low |
| Hydrodissector Cortical Clearing | other | $2 | $2 to $7 | Low |
| Amoxicillin 200 Mg/5 Ml Susp | other | $2 | $2 to $7 | Low |
| Anesthesia for Other Procedure On Neck Area | other | $2 | $2 to $320 | Low |
| Anesthesia for Other Procedure On Top of Arm Bone and Shoulder Joint | other | $2 | $2 to $1,630 | Low |
| Cocoa Butter Balm 1ea | other | $2 | $2 to $7 | Low |
| Dressing Restore Wound Care 4x4 #519930 5/bx | other | $2 | $2 to $7 | Low |
| Erythromycin 0.5% Eye Ointment | other | $2 | $2 to $7 | Low |
| Mycophenolic Acid, Oral, 180 Mg | other | $2 | $2 to $3 | Low |
| Anesthesia for Other Repair of Lower Abdomen Hernia | surgery | $2 | $2 to $834 | Low |
| Anesthesia for Removal of All OR Part of Breast | surgery | $2 | $2 to $404 | Low |
| Bandage Comprilan 8cm 20ea/1cs | other | $2 | $2 to $7 | Low |
| Isosorbide Mononit ER 30 Mg Tb | other | $2 | $2 to $3 | Low |
| Isosorbide Mononitrate ER 30 Mg Po Tb24 | other | $2 | $2 to $3 | Low |
| Pantoprazole Dr 40 Mg Susp Pkt | other | $2 | $2 to $7 | Low |
| Amoxicillin 125 Mg/5ml Po Susr | other | $2 | $2 to $3 | Low |
| Anesthesia for Procedure On Gallbladder, Pancreas, OR Liver Using an Endoscope | other | $2 | $2 to $732 | Low |
| Cefpodoxime 200 Mg Tablet | other | $2 | $2 to $3 | Low |
| Dilator Cook 5fr #g00972 | other | $2 | $2 to $7 | Low |
| Dilator Cook 6fr X 20cm Long #g00937 | other | $2 | $2 to $7 | Low |
| Drawtex Hydroconductive Dressing 18 Inch Strip 10/bx #00321 | other | $2 | $2 to $7 | Low |
| Fentanyl 25 Mcg/hr Patch | other | $2 | $2 to $7 | Low |
| Lactulose 10 Gm/15 Ml - 300 Ml (for Enemas) - Compounded | other | $2 | $2 to $3 | Low |
| Splint, Prefabricated, Digit | other | $2 | $2 to $6 | Low |
| Transparent Film, Sterile, 16 Sq. In. OR Less, Each Dressing | other | $2 | $2 to $6 | Low |
| Vitamin D3 10 Mcg/ml Liquid | other | $2 | $2 to $3 | Low |
| Anesthesia for Other Procedure On Collar Bone and Shoulder Blade | other | $2 | $2 to $450 | Low |
| Anesthesia for Procedure On Upper Urinary Tubes OR Removal of Kidney for Tran... | surgery | $2 | $2 to $862 | Low |
| Bandage Comprilan 10cm 20ea/1cs | other | $2 | $2 to $7 | Low |
| Dressing Aquacel Foam Sacral Lg 9.4"x8.4" | other | $2 | $2 to $7 | Low |
| Dressing Drawtex Tracheostomy 4x4 #00310 | other | $2 | $2 to $7 | Low |
| Forcep Surgical Fine 3.5in | surgery | $2 | $2 to $7 | Low |
| Lidocaine Hcl 2% Jelly Uro-jet | other | $2 | $2 to $7 | Low |
| Prevena V.a.c. Connector 10/pk Pre9090 | other | $2 | $2 to $3 | Low |
| Short Ballard Adapter Tracheostomy 12 in Od14 Fr T-piece Swivel Clear #220135... | other | $2 | $2 to $3 | Low |
| Wrist Brace Form Fit Lrg R #317077 | other | $2 | $2 to $7 | Low |
| Anesthesia for Other Procedure On Male Genitals | other | $2 | $2 to $920 | Low |
| Anesthesia for Procedure On Kneecap And/or Upper Part of Lower Leg Bones | other | $2 | $2 to $1,392 | Low |
| Eliquis 5 Mg Tablet | other | $2 | $2 to $7 | Low |
| Specialty Absorptive Dressing, Wound Cover, Sterile, Pad Size More Than 16 Sq... | other | $2 | $2 to $5 | Low |
| Anesthesia for Other Procedure On Lower Spine | other | $2 | $2 to $630 | Low |
| Elevator Foam Arm 20x20.5 Lf Non Ster | other | $2 | $2 to $7 | Low |
| Venlafaxine Hcl ER 75 Mg Cap | other | $2 | $2 to $7 | Low |
| Venlafaxine Hcl ER 75 Mg Po Cp24 | other | $2 | $2 to $7 | Low |
| Anesthesia for Other Procedure On Lower Abdomen | other | $2 | $2 to $840 | Low |
| Auryxia 210 Mg Tablet | other | $2 | $2 to $7 | Low |
| Brilinta 60 Mg Tablet | other | $2 | $2 to $7 | Low |
| Brilinta 90 Mg Tablet | other | $2 | $2 to $7 | Low |
| Injection, Promethazine Hcl, Up to 50 Mg | other | $2 | $2 to $3 | Low |
| Ticagrelor 90 Mg Po Tabs | other | $2 | $2 to $7 | Low |
| Tranexamic Acid 1000 Mg / 100 Ml Ns - Compounded | other | $2 | $2 to $7 | Low |
| Anes Breathing Circuit Ped 1l 20/cs B1554xx4 | other | $2 | $2 to $7 | Low |
| Eplerenone 25 Mg Tablet | other | $2 | $2 to $3 | Low |
| Niacin ER (antihyperlipidemic) 1000 Mg Po Tbcr | lab | $2 | $2 to $7 | Low |
| Anesthesia for Extensive Partial Removal of Rib | surgery | $2 | $2 to $474 | Low |
| Binder Abdominal 12" 27"-48" #ort21300 | other | $2 | $2 to $7 | Low |
| Carbamazepine ER 200 Mg Po Tb12 | other | $2 | $2 to $3 | Low |
| Carbamazepine ER 200 Mg Tablet | other | $2 | $2 to $3 | Low |
| Composite Dressing, Sterile, Pad Size More Than 16 Sq. In. But Less Than OR E... | other | $2 | $2 to $14 | Low |
| Ligaclip Medium St Titanium Blue 30pk/1bx | other | $2 | $2 to $3 | Low |
| Metaxalone 800 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Metaxalone 800 Mg Tablet | other | $2 | $2 to $3 | Low |
| Anesthesia for Exam of Knee Joint Using an Endoscope | other | $2 | $2 to $1,382 | Low |
| Anesthesia for Other Procedure On Nerves, Muscles, Tendons, and Tissue of Low... | other | $2 | $2 to $1,470 | Low |
| Sock and Stocking Aid W/notch #081007673 | other | $2 | $2 to $7 | Low |
| Anesthesia for Closed Procedure On Upper 2/3rd of Thigh Bone | other | $2 | $2 to $1,220 | Low |
| Closed Sys Female Ll Connector #fc-1 120ea/bx | other | $2 | $2 to $3 | Low |
| Filter Line Sampling Adult Pediatric 13ft Long Intubated Microstream Advance ... | other | $2 | $2 to $7 | Low |
| Scar Tissue Massage Tool #a8113 | other | $2 | $2 to $7 | Low |
| T-tube Drain 12fr | other | $2 | $2 to $7 | Low |
| T-tube Drain 14fr | other | $2 | $2 to $7 | Low |
| T-tube Drain 16fr | other | $2 | $2 to $7 | Low |
| T-tube Drain 18fr | other | $2 | $2 to $7 | Low |
| T-tube Drain 20fr | other | $2 | $2 to $7 | Low |
| **discontinued** Endotrach Tube 2.0 Uncuffed 10ea/1bx | other | $2 | $2 to $3 | Low |
| Anesthesia for Repair of Achilles Tendon | surgery | $2 | $2 to $1,472 | Low |
| Endotrach Tube 3.0 Uncuffed 10ea/1bx | other | $2 | $2 to $3 | Low |
| Endotrach Tube 3.5 Uncuffed 10ea/1bx | other | $2 | $2 to $3 | Low |
| Endotrach Tube 4.0 Uncuffed 10ea/1bx | other | $2 | $2 to $3 | Low |
| Endotrach Tube 4.5 Uncuffed | other | $2 | $2 to $3 | Low |
| Promethazine Hcl 25 Mg Re Supp #2 Dispense Pack | other | $2 | $2 to $7 | Low |
| Tube Endotracheal Rusch Slick-set 160mm Od 3.3mm Id 2.5mm Uncuffed Pre Stylet... | other | $2 | $2 to $3 | Low |
| Ursodiol 300 Mg Capsule | other | $2 | $2 to $3 | Low |
| Wrist Brace Form Fit Lrg. L #317087 | other | $2 | $2 to $7 | Low |
| Wrist Brace Form Fit Med L #317085 | other | $2 | $2 to $7 | Low |
| Wrist Brace Form Fit Med R #317075 | other | $2 | $2 to $7 | Low |
| Wrist Brace Form Fit Small L #317083 | other | $2 | $2 to $7 | Low |
| Wrist Brace Form Fit Small R #317073 | other | $2 | $2 to $7 | Low |
| Anesthesia for Closed Procedure On Top of Arm Bone and Shoulder Joint | other | $2 | $2 to $1,620 | Low |
| Anesthesia for Procedure On Tendon of Upper Arm Muscle | other | $2 | $2 to $1,716 | Low |
| Anesthesia for Vaginal Removal of Uterus | surgery | $2 | $2 to $944 | Low |
| Biotene Moisturizing Mouth Spr | other | $2 | $2 to $7 | Low |
| Cannula Inner Sz 6 Spare #6sic Shiley | other | $2 | $2 to $7 | Low |
| Cannula Inner Sz 8 Spare #8sic Shiley | other | $2 | $2 to $7 | Low |
| Entry Needle 21g X 7cm | other | $2 | $2 to $3 | Low |
| Needle Tuohy Epidural 20ga X 3.5" Lf 25ea/cs | other | $2 | $2 to $7 | Low |
| Tape Cast W5inxl4yd White Fiberglass Polyurethane Delta-lite Plus 7345804 10e... | other | $2 | $2 to $3 | Low |
| Anesthesia for Closed Procedure On Lower Leg, Ankle, and Foot | other | $2 | $2 to $1,462 | Low |
| Anesthesia for Other Procedure On Female Genitals | other | $2 | $2 to $940 | Low |
| Azithromycin 250 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Dressing Nugauze Iodoform 2 Inch | other | $2 | $2 to $3 | Low |
| Injection, Aprepitant, (aponvie), 1 Mg | other | $2 | $2 to $656 | Low |
| Metoclopramide 10 Mg/10 Ml Cup | other | $2 | $2 to $3 | Low |
| Nadolol 40 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Nadolol 40 Mg Tablet | other | $2 | $2 to $3 | Low |
| Skintegrity Wound Cleanser 8oz Bottles with Trigger Sprayer #msc6008 6bt/case | other | $2 | $2 to $3 | Low |
| Zithromax 250 Mg Tablet | other | $2 | $2 to $3 | Low |
| Anesthesia for Removal of Breast Bone Tissue | surgery | $2 | $2 to $550 | Low |
| Cath Coude Tiemann 12fr /rusch | other | $2 | $2 to $3 | Low |
| Catheter Foley 22fr 5cc Silver Coat 12ea/1dz | cardiac | $2 | $2 to $7 | Low |
| Catheter Foley 24fr 5cc Silver 12ea/1dz | cardiac | $2 | $2 to $7 | Low |
| Catheter Foley Peds 10fr 3cc Silvr 12ea/1cs | cardiac | $2 | $2 to $7 | Low |
| Catheter Foley Peds 8fr 3cc Silver 12ea/1cs | cardiac | $2 | $2 to $7 | Low |
| Flexinet Sz 6 Width 1-1/2"x25yds/bx #mto6a | other | $2 | $2 to $7 | Low |
| Stylet Glidescope Pediatric Disp #0270 | other | $2 | $2 to $7 | Low |
| Catheter Foley 18 Fr 5cc Silicone St | cardiac | $2 | $2 to $3 | Low |
| Sheath Probe Cover W/gel Site Rite #9001c0197 10ea/sp | other | $2 | $2 to $7 | Low |
| Splint Wrist W/thumb Left #a125107 | other | $2 | $2 to $7 | Low |
| Splint Wrist W/thumb Left Med #a125106 | other | $2 | $2 to $7 | Low |
| Splint Wrist W/thumb Left Sm #a125105 | other | $2 | $2 to $7 | Low |
| Splint Wrist W/thumb Right Lrg #a125207 | other | $2 | $2 to $7 | Low |
| Splint Wrist W/thumb Right Med #a125206 | other | $2 | $2 to $7 | Low |
| Splint Wrist W/thumb Right Sm #a125205 | other | $2 | $2 to $7 | Low |
| Thoracic Chest Tube 28fr 10ea/1cs | other | $2 | $2 to $7 | Low |
| Urethral Catheter Bardex 2-way Foley 16fr 5ml Balloon Silicone Sterile Latex ... | cardiac | $2 | $2 to $3 | Low |
| Anesthesia for Other Procedure On Large Bowel Using an Endoscope | other | $2 | $2 to $811 | Low |
| Anesthesia for Procedure On Lower 1/3rd of Thigh Bone | other | $2 | $2 to $1,360 | Low |
| Anesthesia for Procedure On Nerves, Muscles, Tendons, and Tissue of Upper Leg | other | $2 | $2 to $1,250 | Low |
| Brace Wrist Elastic Right Sm #79 | other | $2 | $2 to $3 | Low |
| Convamax Superabsorber 8 X 16 Dropship Only 10ea/bx 5bx/cs. #422574 | other | $2 | $2 to $7 | Low |
| Galantamine Hbr 4 Mg Tablet | other | $2 | $2 to $3 | Low |
| Teds Thigh Large Regular Novaplus #v8803r | other | $2 | $2 to $7 | Low |
| Anesthesia for Other Procedure On Upper Abdomen | other | $2 | $2 to $790 | Low |
| Anesthesia for Other Procedure On Urinary System Through Urethra | other | $2 | $2 to $910 | Low |
| Dressing Aquacel Ag Advantage 4 X 5in Hydrofiber #422299 | other | $2 | $2 to $7 | Low |
| Injection, Cisplatin, Powder OR Solution, 10 Mg | other | $2 | $2 to $269 | Low |
| Pin Ball Cover .035(.9mm) #wo35-db | other | $2 | $2 to $7 | Low |
| Pin Ball Cover .062(1.1mm) #wo62-gn | other | $2 | $2 to $7 | Low |
| Pin Ball Cover 5/64(2mm) #w564-bl | other | $2 | $2 to $7 | Low |
| Risperidone 0.5 Mg Odt | other | $2 | $2 to $3 | Low |
| Theo-24 ER 100 Mg Capsule | other | $2 | $2 to $3 | Low |
| Wilson Frame Pad #m60 | other | $2 | $2 to $7 | Low |
| Anesthesia for Relocation of Undescended Testicle Into Scrotum | other | $2 | $2 to $930 | Low |
| Catheter Sheath Introducer 5fr#504605x 5ea/bx | cardiac | $2 | $2 to $7 | Low |
| Catheter Sheath Introducer 6fr#504606x 5ea/bx | cardiac | $2 | $2 to $7 | Low |
| Catheter Sheath Introducer 8fr #504608x | cardiac | $2 | $2 to $7 | Low |
| Colchicine 0.3 Mg Half Tablet | other | $2 | $2 to $3 | Low |
| Collagen Dressing, Sterile, Size 16 Sq. In. OR Less, Each | other | $2 | $2 to $30 | Low |
| Cvvh Prisma 5l Effluent Bag #114423 50/cs | other | $2 | $2 to $7 | Low |
| Esenta Sting Free Adhesive Remover Spray 50ml Can #423289 12cn/case | other | $2 | $2 to $7 | Low |
| Needle Cook Entry 21 X 15 Echotip #g08700 | imaging | $2 | $2 to $3 | Low |
| Resuscitator Bag W/mask Adult Manual 12ea/cs | other | $2 | $2 to $7 | Low |
| Anesthesia for Other Procedure On Skin, Muscles, OR Nerves of Head, Neck, and... | other | $2 | $2 to $300 | Low |
| Entry Needle 21g X 15cm | other | $2 | $2 to $3 | Low |
| Pant Clips -white 1ea | other | $2 | $2 to $7 | Low |
| Tape-elastoplast-2 Inch 0294002 Latex 36ea/case | other | $2 | $2 to $3 | Low |
| Amoxicillin 250 Mg/5 Ml Susp | other | $2 | $2 to $3 | Low |
| Anesthesia for Other Procedure OR Exam of Knee Joint Using an Endoscope | other | $2 | $2 to $1,400 | Low |
| Capsaicin 0.025% Cream | other | $2 | $2 to $3 | Low |
| Feed Tube 12fr 43" Entriflex | other | $2 | $2 to $7 | Low |
| Tolterodine Tart ER 4 Mg Cap | other | $2 | $2 to $7 | Low |
| Tolterodine Tartrate ER 4 Mg Po Cp24 | other | $2 | $2 to $7 | Low |
| Anesthesia for Other Procedure On Nose and Sinuses | other | $2 | $2 to $160 | Low |
| Anesthesia for Removal of Tissue From Around Lung | surgery | $2 | $2 to $542 | 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 |
| Anesthesia for Open OR Endoscopic Total Shoulder Joint Replacement | surgery | $2 | $2 to $1,638 | Low |
| Anesthesia for Other Procedure On Hip Joint | other | $2 | $2 to $1,210 | Low |
| Anesthesia for Other Procedure On Lower Front Abdomen | other | $2 | $2 to $800 | Low |
| Aquacel Adhesive Foam Dressing 4 X 10 #421153 140ea/case | other | $2 | $2 to $3 | Low |
| Blade Beaver #bb365r Aesculap | other | $2 | $2 to $3 | Low |
| Super Sheath Introducer Guide Wire Not Included 10f/11cm M00115726b1 15-726b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 10f/25cm M00115735b1 15-735b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 11f/25cm M00115736b1 15-736b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 12f/11cm M00115728b1 15-728b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 12f/25cm M00115737b1 15-737b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 14f/11cm M00115740b1 15-740b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 14f/25cm M00115739b1 15-739b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 4f/11cm M00115720b1 15-720b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 5f/11cm M00115721b1 15-721b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 5f/25cm M00115730b1 15-730b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 6f/11cm M00115722b1 15-722b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 6f/25cm M00115731b1 15-731b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 7f/11cm M00115723b1 15-723b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 7f/25cm M00115732b1 15-732b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 8f/11cm M00115724b1 15-724b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 8f/25cm M00115733b1 15-733b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 9f/11cm M00115725b1 15-725b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer Guide Wire Not Included 9f/25cm M00115734b1 15-734b | other | $2 | $2 to $8 | Low |
| Venlafaxine Hcl ER 150 Mg Po Cp24 | other | $2 | $2 to $8 | Low |
| Anesthesia for Access to Central Vein | other | $2 | $2 to $532 | Low |
| Imipramine Hcl 25 Mg Po Tabs | other | $2 | $2 to $8 | Low |
| Anesthesia for Procedure On Tendon of Elbow to Shoulder | other | $2 | $2 to $1,712 | Low |
| Catheter Foley 18fr30cc 2way Silver 12ea/dz | cardiac | $2 | $2 to $8 | Low |
| Catheter Foley 20fr 30cc 2way Silver Coat | cardiac | $2 | $2 to $8 | Low |
| Catheter Foley 24fr 30cc 2way Silver 12ea/dz | cardiac | $2 | $2 to $8 | Low |
| Catheter Foley 26fr 30cc 2way 12ea/1cs | cardiac | $2 | $2 to $8 | Low |
| Catheter Foley 28fr 30cc 2way Silver Coated | cardiac | $2 | $2 to $8 | Low |
| Cavilon Adv Skin Protectant #5050 20ea/1cs | other | $2 | $2 to $8 | Low |
| Electrode Needle Tip #0013 12/bx | other | $2 | $2 to $3 | Low |
| Mask Lma Unique Evo W/cuff Pilot Size 3 | other | $2 | $2 to $8 | Low |
| Mask Lma Unique Evo W/cuff Pilot Size 4 | other | $2 | $2 to $8 | Low |
| Mask Lma Unique Evo W/cuff Pilot Size 5 | other | $2 | $2 to $8 | Low |
| Nisoldipine ER 8.5 Mg Tablet | other | $2 | $2 to $3 | Low |
| Procto-med Hc 2.5% Cream | other | $2 | $2 to $8 | Low |
| Valve-ambu Peep Disp #2k8082 10ea/cs | other | $2 | $2 to $3 | Low |
| Amox-clav 250-62.5 Mg/5 Ml Sus | other | $2 | $2 to $8 | Low |
| Catheter Bern 5fr/65cm/035 Angiograph #31 | imaging | $2 | $2 to $8 | Low |
| Injection, Mesna, 200 Mg | other | $2 | $2 to $87 | Low |
| Anesthesia for Procedure On Ankle OR Foot Using an Endoscope | other | $2 | $2 to $1,464 | Low |
| Cath Coude Tiemann 22fr Rusch 50ea/1bx | other | $2 | $2 to $8 | Low |
| Pin Ball Cover .045(.9mm) #wo45-yl | other | $2 | $2 to $8 | Low |
| Pin Ball Cover 3/32(2.5mm) #w332-cr | other | $2 | $2 to $8 | Low |
| Sucralfate 1 Gm/10 Ml Susp | other | $2 | $2 to $3 | Low |
| Sucralfate 1 Gm/10 Ml Susp - 10 Ml - Repackaging | other | $2 | $2 to $3 | Low |
| Addition to Ctlso OR Scoliosis Orthosis, Kyphosis Pad | other | $2 | $2 to $128 | Low |
| Anesthesia for Heart Artery Bypass Grafting On Heart-lung Machine | cardiac | $2 | $2 to $567 | Low |
| Duloxetine Hcl 20 Mg Po Cpep | other | $2 | $2 to $8 | Low |
| Duloxetine Hcl Dr 20 Mg Cap | other | $2 | $2 to $8 | Low |
| Gauze, Impregnated, Hydrogel, for Direct Wound Contact, Sterile, Pad Size 16 ... | other | $2 | $2 to $15 | Low |
| Memantine Hcl ER 14 Mg Po Cp24 | other | $2 | $2 to $3 | Low |
| Anesthesia for Closed Procedure On Lower 1/3rd of Thigh Bone | other | $2 | $2 to $1,340 | Low |
| Anesthesia for Procedure On Eye for Corneal Transplant | surgery | $2 | $2 to $144 | Low |
| Anesthesia for Procedure On Upper 2/3rd of Thigh Bone | other | $2 | $2 to $1,230 | Low |
| Cannula Inner Sz 4 Fen #4dicfen | other | $2 | $2 to $3 | Low |
| Cannula Inner Sz 6 Fen #6dicfen | other | $2 | $2 to $3 | Low |
| Cannula Inner Sz 8 Fen #8dicfen 10ea/bx | other | $2 | $2 to $3 | Low |
| Cannula Inner Sz10 Fen #10dicfen | other | $2 | $2 to $3 | Low |
| Electrode Est Thymapad Disposable 96ea/1cs | other | $2 | $2 to $3 | Low |
| Grounding Pad Split #cra-sgp 1cs/10ea | other | $2 | $2 to $8 | Low |
| Hcs Adhesive 2.8x2.8 Medihoney #31722 50/cs | other | $2 | $2 to $8 | Low |
| Mycophenolate Mofetil, Oral, 250 Mg | other | $2 | $2 to $8 | Low |
| Oxymetazoline Hcl 0.05 % Na Soln | other | $2 | $2 to $8 | Low |
| Refresh Tears 0.5% Eye Drop | other | $2 | $2 to $8 | Low |
| Tranexamic Acid 650 Mg Po Tabs | other | $2 | $2 to $3 | Low |
| Tranexamic Acid 650 Mg Tablet | other | $2 | $2 to $3 | Low |
| Anesthesia for Other Procedure On Large Blood Vessel of Neck | other | $2 | $2 to $350 | Low |
| Cath Purewick Female Ext Pwf030k 30ea/1cs | other | $2 | $2 to $8 | Low |
| Metronidazole 500 Mg Po Tabs | other | $2 | $2 to $8 | Low |
| Metronidazole 500 Mg Tablet | other | $2 | $2 to $8 | Low |
| Tropicamide 1% Eye Drops | other | $2 | $2 to $8 | Low |
| Bile Bag with Straps 0015850 12ea/case | other | $2 | $2 to $8 | Low |
| Cast Tape 5"x4yd White Scotchcast #82005 | other | $2 | $2 to $3 | Low |
| Precutaneous Entry Thinwall Needle 18g X 9cmsdn-18-9.0 G00273 | other | $2 | $2 to $3 | Low |
| Procare Wrist Adult Left Suede/flannel <5.5" X-small 7"#79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Left Suede/flannel 5.5-6.5" Small 7"#79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Left Suede/flannel 6.5-7.5" Medium 7" #79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Left Suede/flannel 7.5-8.5" Large 7" #79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Left Suede/flannel 8.5+" X-large 7" #79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Right Suede/flannel 5.5-6.5" Small 7"#79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Right Suede/flannel 5.5" X-small 7"#79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Right Suede/flannel 6.5-7.5" Large 7"#79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Right Suede/flannel 6.5-7.5" Medium 7" #79 | other | $2 | $2 to $8 | Low |
| Procare Wrist Adult Right Suede/flannel 8.5+" X-large 7" #79 | other | $2 | $2 to $8 | Low |
| Anesthesia for Exam of Shoulder Joint Using an Endoscope | other | $2 | $2 to $1,622 | Low |
| Anesthesia for Other Procedure On Esophagus, Stomach, OR Upper Small Bowel Us... | other | $2 | $2 to $731 | 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 |
| Diphenhydramine 12.5mg/5ml Cup | other | $2 | $2 to $4 | Low |
| Ferrous Sulf 15 Mg Iron/ml Drp | other | $2 | $2 to $4 | Low |
| Phenytoin 100 Mg/4 Ml Susp Cup | other | $2 | $2 to $4 | Low |
| Refresh P.m. Ointment | other | $2 | $2 to $8 | Low |
| Speculum Vaginal Med Disp Lighted #c020110 | other | $2 | $2 to $4 | Low |
| Cyclosporine 0.05% Eye Emuls | other | $2 | $2 to $4 | Low |
| Dilator 10fr #jcd10.0-38 | other | $2 | $2 to $8 | Low |
| Dilator 8fr 20cm | other | $2 | $2 to $8 | Low |
| Electrode Dysphagia Ped .68"x.87" #05a170 | other | $2 | $2 to $4 | Low |
| Azelastine 0.1% (137 Mcg) Spry | other | $2 | $2 to $8 | Low |
| Diag Catheter 6fr IM Merit #7511 | cardiac | $2 | $2 to $8 | Low |
| Sleeve Advanced Fixation 5x100mm #cfs02 | other | $2 | $2 to $8 | Low |
| Sleeve Z-thread 5x100mm #cts02 | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer with Guide Wire 10f/11cm .035 M00115716b1 15-716b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer with Guide Wire 11f/11cm .035 M00115717b1 15-717b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer with Guide Wire 4f/11cm .035 M00115710b1 15-710b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer with Guide Wire 5f/11cm .035 M00115711b1 15-711b | other | $2 | $2 to $8 | Low |
| Super Sheath Introducer with Guide Wire 9f/11cm .035 M00115715b1 15-715b | other | $2 | $2 to $8 | Low |
| Vashe Wound Solution 4 Oz Bottle #00312 24ea/case | other | $2 | $2 to $8 | Low |
| Heel and Elbow Protectors | other | $2 | $2 to $4 | Low |
| Lidocaine 2% Viscous 15 Ml Cup | other | $2 | $2 to $4 | Low |
| Prothrombin Complex Concentrate (human), Kcentra, Per I.u. of Factor Ix Activity | other | $2 | $2 to $5,949 | Low |
| Dotti 0.05 Mg Patch | other | $2 | $2 to $8 | Low |
| Dotti 0.1 Mg Patch | other | $2 | $2 to $8 | Low |
| Morphine Sulfate ER 20 Mg Cap | other | $2 | $2 to $4 | Low |
| Oxycodone Hcl 5 Mg/5 Ml Cup | other | $2 | $2 to $4 | Low |
| Quetiapine Fumarate 25 Mg Po Tabs | other | $2 | $2 to $4 | Low |
| Quetiapine Fumarate 25 Mg Tab | other | $2 | $2 to $4 | Low |
| Suture Surgilon 6-0 Bk 18 Pc-10 #sbs566g | other | $2 | $2 to $8 | Low |
| Catheter Foley 12fr 5ml Silicone Hydrogel Coating Lf 175812 12ea/case | cardiac | $2 | $2 to $4 | Low |
| Isentress 100 Mg Powder Packet | other | $2 | $2 to $8 | Low |
| Alaris Pump Module Admin Set 10942011 20ea/cs | other | $2 | $2 to $4 | Low |
| Ammonium Lactate 12% Lotion | other | $2 | $2 to $4 | Low |
| Benzoyl Peroxide 5 % Ex Gel | other | $2 | $2 to $4 | Low |
| Clarithromycin 500 Mg Po Tabs | other | $2 | $2 to $4 | Low |
| Clarithromycin 500 Mg Tablet | other | $2 | $2 to $4 | Low |
| Feed Tube 12fr 43" Dobbhoff Kangaroo 10ea/cs | other | $2 | $2 to $8 | Low |
| Feed Tube 8fr 43" Dobbhoff Kangaroo 10ea/1cs 8884710859e | other | $2 | $2 to $8 | Low |
| Dextroamphetamine Sulfate ER 10 Mg Po Cp24 | other | $2 | $2 to $4 | Low |
| Erythromycin 250 Mg Tablet | other | $2 | $2 to $4 | Low |
| Miconazole 2% Topical Cream | other | $2 | $2 to $4 | Low |
| Minerin Creme | other | $2 | $2 to $4 | Low |
| Sumatriptan 6 Mg/0.5 Ml Vial | other | $2 | $2 to $4 | Low |
| Anesthesia for Extensive Procedure On Perineum | other | $2 | $2 to $904 | Low |
| Grounding Pad Surgical Peds #425 | surgery | $2 | $2 to $4 | Low |
| Colostomy OR Set #416928 5ea/1bx | other | $2 | $2 to $4 | Low |
| Hcs Non-adhesive 2.4x2.4 Medihoney #31622 | other | $2 | $2 to $4 | Low |
| Prasugrel 10 Mg Tablet | other | $2 | $2 to $8 | Low |
| Prasugrel Hcl 10 Mg Po Tabs | other | $2 | $2 to $8 | Low |
| Prasugrel Hcl 5 Mg Po Tabs | other | $2 | $2 to $8 | Low |
| Restraints Wrist & Ankle #m20116 1pr/1ea | other | $2 | $2 to $4 | Low |
| Trap Tissue Berkeley Safetouch 10/bx | other | $2 | $2 to $8 | Low |
| Anesthesia for Insertion OR Replace of Pacing Heart Defibrillator | cardiac | $2 | $2 to $534 | Low |
| Anesthesia for Other Procedure On Mouth | other | $2 | $2 to $170 | Low |
| Anesthesia for Procedure to Control Urinary System Bleeding Including Use of ... | other | $2 | $2 to $916 | Low |
| Dex 5%/0.45% Sodium Chl Inj Usp 1000m 14ea/cs | other | $2 | $2 to $4 | Low |
| Gelfoam 12-7mm Sponge | other | $2 | $2 to $8 | Low |
| Laryngoscope Handle Dispoled #77700 | other | $2 | $2 to $8 | Low |
| Anesthesia for Insertion of Permanent Heart Pacemaker | cardiac | $2 | $2 to $530 | Low |
| Anesthesia for Procedure On Chest with 1 Lung Inflated | other | $2 | $2 to $541 | Low |
| Cane Standard Aluminum Adjustable 30"-38" 300lbs 6/cs #mds86415 | other | $2 | $2 to $4 | Low |
| Catheter Coude 12fr | cardiac | $2 | $2 to $4 | Low |
| Catheter Coude 16fr 12ea/1cs | cardiac | $2 | $2 to $4 | Low |
| Catheter Coude 18fr 12ea/1dz | cardiac | $2 | $2 to $4 | Low |
| Methylphenidate ER 27 Mg Tab | other | $2 | $2 to $4 | Low |
| Morphine Sulf 10 Mg/5 Ml Soln | other | $2 | $2 to $8 | Low |
| Phenytoin Susp - 100 Mg/4 Ml - Repackaging | other | $2 | $2 to $4 | Low |
| Cath IV 14ga X 3.25 Angiocath Spec. Prodce | other | $2 | $2 to $4 | Low |
| Centrum Adult Po Liqd | other | $2 | $2 to $4 | Low |
| Convafoam Border Multisite 7.8x5x5 #423267 5ea/box | other | $2 | $2 to $4 | Low |
| Feed Spike Set W/flush Bag #775100 1ea | other | $2 | $2 to $4 | Low |
| Mvi W/iron Liquid - 15 Ml - Adult Oral Ud - Repackaged | other | $2 | $2 to $4 | Low |
| Splint Wrist Lrg Left 1ea | other | $2 | $2 to $8 | Low |
| Splint Wrist Med Right 1ea | other | $2 | $2 to $8 | Low |
| Splint Wrist Sml Left 1ea | other | $2 | $2 to $8 | Low |
| Splint Wrist Sml Right 1ea | other | $2 | $2 to $8 | Low |
| Splint Wrist Xlg Left 1ea | other | $2 | $2 to $8 | Low |
| Splint Wrist Xlg Right 1ea | other | $2 | $2 to $8 | Low |
| Anesthesia for Procedure for Total Knee Joint Replacement | surgery | $2 | $2 to $1,402 | Low |
| Anesthesia for Removal of Prostate Including Use of an Endoscope | surgery | $2 | $2 to $914 | Low |
| Fecal Collector Sys Flexi Seal W/tail Closure | other | $2 | $2 to $4 | Low |
| Nexium Dr 40 Mg Capsule | other | $2 | $2 to $8 | Low |
| Securement Device Picc/cvc 3m #1877 | other | $2 | $2 to $8 | Low |
| Sodium Chloride 5% Eye Drop | other | $2 | $2 to $4 | Low |
| Anesthesia for Procedure On Lower Rear Abdomen | other | $2 | $2 to $820 | Low |
| Locking Device W/biopsy Cup #m00545261 | lab | $2 | $2 to $8 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 4f/11cm M00115960b1 15-960b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 4f/25cm M00115970b1 15-970b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 5f/11cm M00115961b1 15-961b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 5f/25cm M00115971b1 15-971b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 5f/7cm M00115956b1 15-956b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 6f/11cm M00115962b1 15-962b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 6f/25cm M00115965b1 15-965b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 7f/11cm M00115963b1 15-963b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 7f/25cm M00115966b1 15-966b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 8f/11cm M00115964b1 15-964b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 8f/25cm M00115967b1 15-967b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 9f/11cm M00115969b1 15-969b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 9f/25cm M00115968b1 15-968b | other | $2 | $2 to $9 | Low |
| Super Sheath Ro Introducer Guide Wire Not Included 9f/7cm M00115955b1 15-955b | other | $2 | $2 to $9 | Low |
| Anesthesia for Procedure On Anus and Rectum | other | $2 | $2 to $902 | Low |
| Anesthesia for Other Procedure On Face Bones OR Skull | other | $2 | $2 to $190 | Low |
| Methylphenidate Hcl ER (cd) 40 Mg Po Cpcr | other | $2 | $2 to $9 | Low |
| Catheter Single Lumen Infusion 25/cs | surgery | $2 | $2 to $9 | Low |
| Anesthesia for Heart Artery Bypass Grafting | cardiac | $2 | $2 to $566 | Low |
| Duloxetine Hcl 30 Mg Po Cpep | other | $2 | $2 to $9 | Low |
| Duloxetine Hcl Dr 30 Mg Cap | other | $2 | $2 to $9 | Low |
| Anesthesia for Lens Surgery | surgery | $2 | $2 to $142 | Low |
| Anesthesia for Removal of Urinary Bladder Tumors Including Use of an Endoscope | surgery | $2 | $2 to $912 | Low |
| Dressing Prisma 4.34 SQ in #ma028 | other | $2 | $2 to $9 | Low |
| Exsept Plus Skin and Wound Cleanser #15108 Angelini Pharma 24ea/case | other | $2 | $2 to $9 | Low |
| Factor Viia (antihemophilic Factor, Recombinant), (novoseven Rt), 1 Microgram | other | $2 | $2 to $35,290 | Low |
| Injection, Gadoteridol, (prohance Multipack), Per Ml | other | $2 | $2 to $9 | Low |
| Loestrin 21 1-20 Tablet | other | $2 | $2 to $9 | Low |
| Snare Medium Oval-flex 27mmx240cm #m00562673 | other | $2 | $2 to $9 | Low |
| Abdominal Support 9in 1ea | other | $2 | $2 to $9 | Low |
| Injection, Irinotecan, 20 Mg | other | $2 | $2 to $89 | Low |
| Nasal Tampon 4.5cm #400400 20ea/1pk | other | $2 | $2 to $9 | Low |
| Nortriptyline Hcl 25 Mg Cap | other | $2 | $2 to $9 | Low |
| Nortriptyline Hcl 25 Mg Po Caps | other | $2 | $2 to $9 | Low |
| Anesthesia for Amputation On Upper 2/3rd of Thigh Bone | other | $2 | $2 to $1,232 | Low |
| Catheter Tray Add-a-foley Silver 10ea/1cs | cardiac | $2 | $2 to $9 | Low |
| Dressing Tritec Silver 4x5 Precut 3000112331 | other | $2 | $2 to $9 | Low |
| Thoracic Cath 32f Angled/argyle | other | $2 | $2 to $9 | Low |
| Transducer Probe Cover X-large L/f #610 | other | $2 | $2 to $9 | Low |
| Gentamicin 0.1% Cream | other | $2 | $2 to $9 | Low |
| Resuscitator Bag W/mask Infant 12ea/1cs Ambu | other | $2 | $2 to $9 | Low |
| Anesthesia for Fragmenting, Manipulation And/or Removal of Kidney Stone Inclu... | surgery | $2 | $2 to $918 | Low |
| Blood Count, Hemoglobin | other | $2 | $2 to $85,018 | Low |
| Cast Splint 3" X 35" Comformable 10ea/1cs | other | $2 | $2 to $9 | Low |
| Lt200 Ligaclip Medium 36/bx | other | $2 | $2 to $9 | Low |
| Red Blood Cell Concentration Measurement | other | $2 | $2 to $85,014 | Low |
| Splint Wrist/forearm Left Small 1ea | other | $2 | $2 to $9 | Low |
| Splint Wrist/forearm Left Xlarge | other | $2 | $2 to $9 | Low |
| Splint Wrist/forearm Rt Large 1ea | other | $2 | $2 to $9 | Low |
| Splint Wrist/forearm Rt Small 1ea | other | $2 | $2 to $9 | 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 9in Small #79 | other | $2 | $2 to $9 | Low |
| Cerebrospinal Fluid, OR Amniotic Fluid Albumin (protein) Level | other | $2 | $2 to $82,042 | Low |
| Femoral Canal Suction/irrigation Tip 12ea/pk #0210-004 | other | $2 | $2 to $9 | Low |
| Mobility Glove Black Mesh Small #081173632 | other | $2 | $2 to $9 | Low |
| Wheelchair Gloves Large #660802 | other | $2 | $2 to $9 | Low |
| Wheelchair Gloves Medium #660801 | other | $2 | $2 to $9 | Low |
| Wheelchair Gloves Xlarge #660803 | other | $2 | $2 to $9 | Low |
| Anesthesia for Other Procedure On Arteries of Upper Arm and Elbow | other | $2 | $2 to $1,770 | Low |
| Anesthesia for Procedure to Correct Abnormal Heart Rhythm | cardiac | $2 | $2 to $410 | Low |
| Refresh Lacri-lube Ointment | other | $2 | $2 to $9 | Low |
| 6 Fr Ultimate 4-t40 | other | $2 | $2 to $9 | Low |
| Catheter Foley 14fr 5cc Lf Silver | cardiac | $2 | $2 to $9 | Low |
| Catheter Foley 18fr 5cc Latex Free Silver | cardiac | $2 | $2 to $9 | Low |
| Catheter Foley 20fr Lf 5cc #1758si20 | cardiac | $2 | $2 to $9 | Low |
| Catheter Foley 24fr 5cc Ltx Free Silver | cardiac | $2 | $2 to $9 | Low |
| Celexa 40 Mg Tablet | other | $2 | $2 to $9 | Low |
| Knife 2.75mm Angld Slit Dbl Bevel #ab-asl27db | other | $2 | $2 to $9 | Low |
| Suction Cauterizer 12fr X 6" Handswitch | other | $2 | $2 to $9 | Low |
| Brace Ankle Air Gel 8.5in Med #79 | other | $2 | $2 to $9 | Low |
| Sam Splint Standard Roll Gray #61109 | other | $2 | $2 to $9 | Low |
| 6 Fr Cas 1 | other | $2 | $2 to $9 | Low |
| Cannula Arteriotomy 2.3 X 2mm #31102 20/pk | other | $2 | $2 to $9 | Low |
| Cannula Arteriotomy 2.3 X 3mm #31103 20/pk | other | $2 | $2 to $9 | Low |
| Cannula Arteriotomy 2.3 X 4mm #31104 | other | $2 | $2 to $9 | Low |
| Cast Splint 4"x 30" Comformable 1ea | other | $2 | $2 to $9 | Low |
| Corlanor 5 Mg Tablet | other | $2 | $2 to $9 | Low |
| Diag Catheter 6fr 3drc #533676 3/bx | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Al1 #533-645 5/bx | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Al2 #533646 5/bx | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Al3 #533647 5/bx | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Angled Pigtail #532652s | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Ar Mod #533648 | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Ar1 Mod #533641 5ea/bx | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Arii Mod #533643 | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr IM #533660 5/bx | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Jl3.5 #533618 | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Jl4 #533 | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Jl5 #533 | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Jr3.5 #533619 | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Jr4 Classic #533 | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Lcb #533672 5/bx | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Mpb2 #533649 5/bx | cardiac | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Rbc #533 | cardiac | $2 | $2 to $9 | Low |
| Tip Bone Cleaning #210 | other | $2 | $2 to $9 | Low |
| Anesthesia for Other Procedure On Upper Spine | other | $2 | $2 to $600 | Low |
| Cast Stockinette Delta-net Tubular Synthetic 1inx25yd Black #7272300 2rl/case | other | $2 | $2 to $9 | Low |
| Fentanyl 12 Mcg/hr Patch | other | $2 | $2 to $9 | Low |
| Jackson Pratt 15fr Round Drain Sil 1ea | other | $2 | $2 to $9 | Low |
| Atomizer Mucosal Atomization Device | other | $2 | $2 to $9 | Low |
| Clobetasol 0.05% Cream | other | $2 | $2 to $9 | Low |
| Anesthesia for Exam of Uterus Using an Endoscope | other | $2 | $2 to $952 | Low |
| Ankle Gel Splint #79 | other | $2 | $2 to $9 | Low |
| Crutch Adult Tall 300lb 5'10"-6'6" 8pr/1cs | other | $2 | $2 to $9 | Low |
| Crutch Medium Adult 300lb 5'2"-5'10" 8pr/cs | other | $2 | $2 to $9 | Low |
| Crutch Youth 300lb 4'6"-5'2" 8pr/1cs | other | $2 | $2 to $9 | Low |
| Lyrica 100 Mg Capsule | other | $2 | $2 to $9 | Low |
| Lyrica 75 Mg Capsule | other | $2 | $2 to $9 | Low |
| Pregabalin 150 Mg Capsule | other | $2 | $2 to $9 | Low |
| Pregabalin 150 Mg Po Caps | other | $2 | $2 to $9 | Low |
| Pregabalin 25 Mg Capsule | other | $2 | $2 to $9 | Low |
| Pregabalin 25 Mg Po Caps | other | $2 | $2 to $9 | Low |
| Anesthesia for Other Procedure On External Middle and Inner Ear | other | $2 | $2 to $120 | Low |
| Hurricaine One 20% U-d Spray | other | $2 | $2 to $9 | Low |
| Diag Catheter 6fr Mpa1 #7513-b3 | cardiac | $3 | $3 to $9 | Low |
| Diag Catheter 6fr Mpb1 #7513-e3 | cardiac | $3 | $3 to $9 | Low |
| Light Compression Bandage, Elastic, Knitted/woven, Width Greater Than OR Equa... | other | $3 | $3 to $24 | Low |
| Nerve Conduction Study of Arm OR Leg Movement And/or Feeling with Review and ... | other | $3 | $3 to $95,905 | Low |
| Test to Measure Largest Amount of Air Breathed in an Out | other | $3 | $3 to $94,200 | Low |
| Budesonide, Inhalation Solution, Fda-approved Final Product, Non-compounded, ... | other | $3 | $3 to $9 | Low |
| Cannula Nomoline Lh Adt Gas Sampling Adult Nasal Oral with Oxygen #3824 25ea/box | other | $3 | $3 to $10 | Low |
| Professional Service for Preparation and Provision of 1 OR More Antigens | other | $3 | $3 to $95,165 | Low |
| Automated White Blood Cell Count | other | $3 | $3 to $85,048 | Low |
| Zzzquil 50 Mg/30 Ml Liquid | other | $3 | $3 to $10 | Low |
| Abdominal Support 10in 1ea | other | $3 | $3 to $10 | Low |
| Injection, Phytonadione (vitamin K), Per 1 Mg | other | $3 | $3 to $10 | Low |
| Mesalamine 4 Gm/60 Ml Enema | other | $3 | $3 to $10 | Low |
| Belt Gait W/buckle 48" 1ea | other | $3 | $3 to $10 | Low |
| Injection, Fluorouracil, 500 Mg | other | $3 | $3 to $187 | Low |
| Electrodes, (e.g., Apnea Monitor), Per Pair | other | $3 | $3 to $15 | Low |
| Knife 300 Micron Precision 6ea/bx | other | $3 | $3 to $10 | Low |
| Tetracycline Hcl 500 Mg Po Caps | other | $3 | $3 to $10 | Low |
| Lidocaine-prilocaine 2.5-2.5 % Ex Crea | other | $3 | $3 to $10 | Low |
| Lidocaine-prilocaine Cream | other | $3 | $3 to $10 | Low |
| Anesthesia for Procedure On Heart and Large Blood Vessels Using Heart-lung Ma... | cardiac | $3 | $3 to $563 | Low |
| Blm Mouthwash - 10 Ml - Compounded | other | $3 | $3 to $10 | Low |
| Dressing Foam Ultra Silver 4x5ster Mk30051018 | other | $3 | $3 to $10 | Low |
| First-mouthwash Blm Mt Susp | other | $3 | $3 to $10 | Low |
| Ketoconazole 2% Shampoo | other | $3 | $3 to $10 | Low |
| Nucynta 50 Mg Tablet | other | $3 | $3 to $10 | Low |
| Xifaxan 200 Mg Tablet | other | $3 | $3 to $10 | Low |
| Hook Single Stay 5mm Sharp #3311-1g | other | $3 | $3 to $10 | Low |
| Adaptive Mug Alimed #2970010571 Pk/20ea | other | $3 | $3 to $10 | Low |
| Forceps Cold Biopsy Radial Jaw #m00513334 | lab | $3 | $3 to $10 | Low |
| Ankle Brace-air/gel 10" Universal | other | $3 | $3 to $10 | Low |
| Cervical, Flexible, Non-adjustable, Prefabricated, Off-the-shelf | other | $3 | $3 to $35 | Low |
| Injection, Decitabine, 1 Mg | other | $3 | $3 to $626 | Low |
| Dorzolamide Hcl 2% Eye Drops | other | $3 | $3 to $10 | Low |
| Bandage Comprilan 12cm 20ea/1cs | other | $3 | $3 to $10 | Low |
| Lidocaine 5% Ointment | other | $3 | $3 to $10 | Low |
| Aspirin 1 Mg/1 Ml Po Suspension | other | $3 | $3 to $10 | Low |
| Belt Gait W/buckle 60" 1ea | other | $3 | $3 to $10 | Low |
| Cast Supplies, Long Arm Splint, Pediatric (0-10 Years), Fiberglass | other | $3 | $3 to $20 | Low |
| Cast Supplies, Short Arm Splint, Pediatric (0-10 Years), Fiberglass | other | $3 | $3 to $20 | Low |
| EKG (Electrocardiogram) | cardiac | $3 | $3 to $93,271 | High |
| Pedialyte Advanced Care Soln | other | $3 | $3 to $10 | Low |
| Pedialyte Solution | other | $3 | $3 to $10 | Low |
| Pr Supplies&materials Above/beyond Prov By Phys/qhp | other | $3 | $3 to $99,070 | Low |
| **discontinued** Filter Line H Set M1920a 25ea/1cs | other | $3 | $3 to $10 | Low |
| Anesthesia for Closed Procedure On Hip Joint | other | $3 | $3 to $1,200 | Low |
| Catheter Filiform W/olive Tip 3fr | cardiac | $3 | $3 to $10 | Low |
| Catheter Filiform W/olive Tip 5fr | cardiac | $3 | $3 to $10 | Low |
| Catheter Filiform W/olive Tip 6fr | cardiac | $3 | $3 to $10 | Low |
| Procare Wrist Adult Left Suede/flannel 5.5-6.5" Small 10"#79 | other | $3 | $3 to $10 | Low |
| Procare Wrist Adult Left Suede/flannel 6.5-7.5" Medium 10" #79 | other | $3 | $3 to $10 | Low |
| Procare Wrist Adult Right Suede/flannel 5.5-6.5" Small 10"#79 | other | $3 | $3 to $10 | Low |
| Procare Wrist Adult Right Suede/flannel 6.5-7.5" Medium 10" #79 | other | $3 | $3 to $10 | Low |
| Procare Wrist Adult Right Suede/flannel 7.5-8.5" Large 10" #79 | other | $3 | $3 to $10 | Low |
| Vent Tube Paparella Pair (100pr/pk) #1040019 | other | $3 | $3 to $10 | Low |
| Finger Splint, Static | other | $3 | $3 to $40 | Low |
| Wrap 2" Edema/pain Kinesio 6ea/1bx | other | $3 | $3 to $10 | Low |
| Red Blood Cell Sedimentation Rate, to Detect Inflammation, Automated | other | $3 | $3 to $85,652 | Low |
| Breast Comfort Gel Pads #17264 50ea/1cs | other | $3 | $3 to $10 | Low |
| Catheter Tray Sure Step Add a Foley Silver | cardiac | $3 | $3 to $10 | Low |
| Dilator Cook 4fr #g02366 | other | $3 | $3 to $10 | Low |
| Feed Tube Extension Rt Angle Mickey 5ea/1ca | other | $3 | $3 to $10 | Low |
| Feed Tube Extension Set Mickey Secure 5ea/1ca | other | $3 | $3 to $10 | Low |
| Knee Immobilizer-16" Med | other | $3 | $3 to $10 | Low |
| Nucynta ER 50 Mg Tablet | other | $3 | $3 to $10 | Low |
| Acuvail 0.45% Ophth Solution | other | $3 | $3 to $10 | Low |
| Injection, Carboplatin, 50 Mg | other | $3 | $3 to $280 | Low |
| Diclofenac Sodium 1% Gel | other | $3 | $3 to $10 | Low |
| Morphine Sulf 100 Mg/5 Ml Conc | other | $3 | $3 to $10 | Low |
| Elmiron 100 Mg Capsule | other | $3 | $3 to $10 | Low |
| Graft Sizer Disp Sz 24mm-38mm #m002363200211 | other | $3 | $3 to $10 | Low |
| Anesthesia for Closed Procedure On Knee Joint | other | $3 | $3 to $1,380 | Low |
| Fluticasone Prop 50 Mcg Spray | other | $3 | $3 to $10 | Low |
| Fluticasone Propionate 50 Mcg/act Na Susp | other | $3 | $3 to $10 | Low |
| Hemoclip Small Titan Cartridge 25ea/bx Yellow | other | $3 | $3 to $10 | Low |
| Ligating Clip Small 24/pkg #1205 Horizon | other | $3 | $3 to $10 | Low |
| Entresto 24 Mg-26 Mg Tablet | other | $3 | $3 to $10 | Low |
| Entresto 49 Mg-51 Mg Tablet | other | $3 | $3 to $10 | Low |
| Entresto 97 Mg-103 Mg Tablet | other | $3 | $3 to $10 | Low |
| Forcep Surgical Lucae Serrated Bayonet 5.5in | surgery | $3 | $3 to $11 | Low |
| Trap Polyp Endo Suction #h334 #bx00711099 | other | $3 | $3 to $11 | Low |
| Administration and Interpretation of Patient-focused Health Risk Assessment | other | $3 | $3 to $96,160 | Low |
| Transducer Kit-disposable | other | $3 | $3 to $11 | Low |
| Desvenlafaxine Succnt ER 25 Mg | other | $3 | $3 to $11 | Low |
| Methylphenidate Hcl ER (cd) 50 Mg Po Cpcr | other | $3 | $3 to $11 | Low |
| Methylphenidate Hcl ER (cd) 60 Mg Po Cpcr | other | $3 | $3 to $11 | Low |
| Wrist/thumb Brace with Thumb Spica Left Cotton/foam Large/x-large #79 | other | $3 | $3 to $11 | Low |
| Wrist/thumb Brace with Thumb Spica Right Cotton/foam Large/x-large #79 | other | $3 | $3 to $11 | Low |
| Fluid Warming Set Std Flow 3m Ranger 24240 | other | $3 | $3 to $11 | Low |
| Dressing Col-active Ag Plus 4x4 #10340000 | other | $3 | $3 to $11 | Low |
| Procare Super Knee Splint Adult Foam 14-16" Small #79 | other | $3 | $3 to $11 | Low |
| Procare Super Knee Splint Adult Foam 16-19" Medium 20" #79 | other | $3 | $3 to $11 | Low |
| Procare Super Knee Splint Adult Foam 19-22" Large #79 | other | $3 | $3 to $11 | Low |
| Anesthesia for Closed Exam of Chest Using an Endoscope with 1 Lung Inflated | other | $3 | $3 to $529 | Low |
| Anesthesia for Extensive Surgery On Spine | surgery | $3 | $3 to $670 | Low |
| Anesthesia for Procedure to Assess Heart Electrical Activity | cardiac | $3 | $3 to $537 | Low |
| Male External Catheter, with OR without Adhesive, Disposable, Each | cardiac | $3 | $3 to $12 | Low |
| Eszopiclone 2 Mg Po Tabs | other | $3 | $3 to $11 | Low |
| Forcep Surgical Tiss Del 4.75in Reuse 130 | surgery | $3 | $3 to $11 | Low |
| Tetracaine 0.5% Steri-unit Sol | other | $3 | $3 to $11 | Low |
| Anesthesia for Retinal Surgery | surgery | $3 | $3 to $145 | Low |
| Guaifen-codeine 100-10 Mg/5 Ml | other | $3 | $3 to $11 | Low |
| Marker Coronary Bypass Graft #40149 | cardiac | $3 | $3 to $11 | Low |
| Wheels Walker Guardian #7722 for Walker 1pr | other | $3 | $3 to $11 | Low |
| Anesthesia for Procedure On Eyelid | other | $3 | $3 to $103 | Low |
| Mepilex Ag Antimicrobial Foam Dressings with Safetac Technology 4" X 5" | other | $3 | $3 to $11 | Low |
| Wound Irrigation Cap System # Irig8 Centurion | other | $3 | $3 to $11 | Low |
| 12 Ga Sertera Introducer5ea/bx #sertera Intro | other | $3 | $3 to $11 | Low |
| Anesthesia for Other Procedure On Eye | other | $3 | $3 to $140 | Low |
| Cannula Nasal Adult 4m Co2/o2 Nomoline Lh #4624 25ea/box | other | $3 | $3 to $11 | Low |
| Catheterization for Collection of Specimen, Single Patient, All Places of Ser... | lab | $3 | $3 to $22 | Low |
| Clobetasol 0.05% Ointment | other | $3 | $3 to $11 | Low |
| Injection, Darbepoetin Alfa, 1 Microgram | other | $3 | $3 to $11,874 | Low |
| Knife 2.4mm Angld Slit Dbl Bevel #ab-asl24db | other | $3 | $3 to $11 | Low |
| Rd Sedline Eeg Sensor 25/box #4248 | other | $3 | $3 to $11 | Low |
| Splint Wrist 8" #b | other | $3 | $3 to $11 | Low |
| Introducer Bougie Coude Tip Adult 15fr X 70cm | other | $3 | $3 to $11 | Low |
| Introducer Bougie Coude Tip Peds 10fr X 70cm | other | $3 | $3 to $11 | Low |
| Univ Ankle Brace #79 | other | $3 | $3 to $11 | Low |
| Lopinavir-ritonavr 200-50mg Tb | other | $3 | $3 to $11 | Low |
| Tube Medihoney Gel 1.5 Oz #31815 | other | $3 | $3 to $11 | Low |
| Blood Group Typing | other | $3 | $3 to $86,900 | Low |
| Blood Typing for Rh (d) Antigen | other | $3 | $3 to $86,901 | Low |
| Exofin Precision Pen Skin Adhesive #ep70412 12ea/bx | other | $3 | $3 to $11 | Low |
| Lymphedema Tube Gauze Band Med Tg7 18ea/1cs | other | $3 | $3 to $11 | Low |
| Support Ankle Stabilizing Large #79 | other | $3 | $3 to $11 | Low |
| Support Ankle Stabilizing Medium #79 | other | $3 | $3 to $11 | Low |
| Support Ankle Stabilizing Small #79 | other | $3 | $3 to $11 | Low |
| Coban 2 #2094 1bx=1kit | other | $3 | $3 to $11 | Low |
| Coban 2 Lite #2794 1bx=1kit | other | $3 | $3 to $11 | Low |
| Doxycycline 25 Mg/5 Ml Susp | other | $3 | $3 to $11 | Low |
| Collar Button Vent Tube 60 Ea/bx 70241060 | other | $3 | $3 to $11 | Low |
| Nix 1% Creme Rinse Liquid | other | $3 | $3 to $11 | Low |
| Wheels Walker Heavy Duty Extn Set #g07725 1st | other | $3 | $3 to $11 | 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 |
| Red Blood Cell Count, Automated Test | other | $3 | $3 to $85,041 | Low |
| Splint Hand Mason Allen Small 1ea | other | $3 | $3 to $11 | Low |
| Nasal Tampon 8.0 Cm 20ea/1pk | other | $3 | $3 to $11 | Low |
| Cast Splint 5" X 30" Comformable 10ea/1cs | other | $3 | $3 to $11 | Low |
| Lymphedema Tube Gauze Band Lrg Tg9 12ea/1cs | other | $3 | $3 to $11 | Low |
| Urinalysis | lab | $3 | $3 to $81,015 | High |
| Catheter Malecot 14fr #086014 | cardiac | $3 | $3 to $12 | Low |
| Catheter Malecot 16fr #086016 | cardiac | $3 | $3 to $12 | Low |
| Catheter Malecot 20fr #086020 | cardiac | $3 | $3 to $12 | Low |
| Catheter Malecot 30fr #086030 | cardiac | $3 | $3 to $12 | Low |
| Anucort-hc 25 Mg Suppository | other | $3 | $3 to $12 | Low |
| Hydrocortisone Acetate 25 Mg Re Supp | other | $3 | $3 to $12 | Low |
| Trocar Natura Cannula 5mmx100mm #100-005 | other | $3 | $3 to $12 | Low |
| Needle Jamshidi Infant Disp | other | $3 | $3 to $12 | Low |
| Dilator 10fr 20cm G10207 | other | $3 | $3 to $12 | Low |
| Dilator 6fr 20cm #g10284 | other | $3 | $3 to $12 | Low |
| Diovan 320 Mg Tablet | other | $3 | $3 to $12 | Low |
| Ocular Device, Intraoperative, Detached Retina | other | $3 | $3 to $12 | Low |
| Set Airway Adapter Adult/pediatric Nomoline-o Lh #4630 25ea/box | other | $3 | $3 to $12 | Low |
| Ritalin La 10 Mg Capsule | other | $3 | $3 to $12 | Low |
| Ritalin La 20 Mg Capsule | other | $3 | $3 to $12 | Low |
| Trueplus Glucose 15 Gram Liq | other | $3 | $3 to $12 | Low |
| Administration and Interpretation of Caregiver-focused Health Risk Assessment | other | $3 | $3 to $96,161 | Low |
| Catheter Guard Cont Shield 25ea/1cs | cardiac | $3 | $3 to $12 | Low |
| Ortho-glass Splint W4xl30in Fiberglass Double Sided Padded #og-430pc 5ea/bx | other | $3 | $3 to $12 | Low |
| Cath Rim 5ea/bx | other | $3 | $3 to $12 | Low |
| Nasal Tampon 10.0 Cm 20ea/1pk #10115-c | other | $3 | $3 to $12 | Low |
| High Osmolar Contrast Material, 350-399 Mg/ml Iodine Concentration, Per Ml | other | $3 | $3 to $12 | Low |
| Injection, Doxorubicin Hydrochloride, 10 Mg | other | $3 | $3 to $1,162 | Low |
| Ritalin La 30 Mg Capsule | other | $3 | $3 to $12 | Low |
| Splint Knee Univ 18" Basic #79 | other | $3 | $3 to $12 | Low |
| Vyvanse 10 Mg Capsule | other | $3 | $3 to $12 | Low |
| Vyvanse 20 Mg Capsule | other | $3 | $3 to $12 | Low |
| Vyvanse 30 Mg Capsule | other | $3 | $3 to $12 | Low |
| Vyvanse 40 Mg Capsule | other | $3 | $3 to $12 | Low |
| Vyvanse 50 Mg Capsule | other | $3 | $3 to $12 | Low |
| Vyvanse 60 Mg Capsule | other | $3 | $3 to $12 | Low |
| Vyvanse 70 Mg Capsule | other | $3 | $3 to $12 | Low |
| Cath Foley 26fr 30cc 3-way 12ea/1dz | other | $3 | $3 to $12 | Low |
| Catheter Foley 16fr 30cc 3way Silver Coat | cardiac | $3 | $3 to $12 | Low |
| Catheter Foley 18fr 30cc 3way Silver Coat | cardiac | $3 | $3 to $12 | Low |
| Coagulator Foot Control Suction 10fr #130187 | other | $3 | $3 to $12 | Low |
| Crutch Youth 300lb 4'6"-5'2" 8pr/case | other | $3 | $3 to $12 | Low |
| Vimpat 50 Mg Tablet | other | $3 | $3 to $12 | Low |
| Angiocath 16ga 3-1/4 Bd #382258 | other | $3 | $3 to $12 | Low |
| Chiba Biopsy Needle 20ga L20cm Aspiration #g00810 | lab | $3 | $3 to $12 | Low |
| Chiba Biopsy Needle Dchn-20-15.0 #g00777 | lab | $3 | $3 to $12 | Low |
| Collection Trap System Safetouch OB Gyn | other | $3 | $3 to $12 | Low |
| Dressing Mepilex Border Sacrum 7.2x7.2 Foam | other | $3 | $3 to $12 | Low |
| Dressing Wound Drawtex Wrap 4"x11.5 Ft #00352 | other | $3 | $3 to $12 | Low |
| Guide Spring J-wire Curved 150cm | other | $3 | $3 to $12 | Low |
| Perfusion Set Y-type 20/bx #per-1006s | surgery | $3 | $3 to $12 | Low |
| Topical Skin Adhesive 2-octyl Lx6 6ea/1bx | other | $3 | $3 to $12 | Low |
| Urinary Drainage Bag, Leg OR Abdomen, Vinyl, with OR without Tube, with Strap... | other | $3 | $3 to $24 | Low |
| Dronedarone 200 Mg Half Tablet | other | $3 | $3 to $12 | Low |
| Fentanyl 50 Mcg/hr Patch | other | $3 | $3 to $12 | Low |
| Multaq 400 Mg Tablet | other | $3 | $3 to $12 | Low |
| Tracheal Suction Catheter, Any Type Other Than Closed System, Each | cardiac | $3 | $3 to $17 | Low |
| Alginate OR Other Fiber Gelling Dressing, Wound Cover, Sterile, Pad Size 16 S... | other | $3 | $3 to $24 | Low |
| Thoracic Chest Tube 24fr 10ea/1bx | other | $3 | $3 to $12 | Low |
| Strattera 18 Mg Capsule | other | $3 | $3 to $12 | Low |
| Boots Sta-dri Knee-hi #kh | other | $3 | $3 to $12 | Low |
| Forcep Surgical Dressing Serrated 4.5in | surgery | $3 | $3 to $12 | Low |
| Mirabegron ER 50 Mg Po Tb24 | other | $3 | $3 to $12 | Low |
| Mirabegron ER 50 Mg Tablet | other | $3 | $3 to $12 | Low |
| Bcg Live Intravesical Instillation, 1 Mg | other | $3 | $3 to $318 | Low |
| Dilator Syracuse Medic Vaginal Small 7/8 22mm #sm-vd-s | other | $3 | $3 to $12 | Low |
| Dilator Syracuse Medical Vaginal X-small Plus 1 1/16 18mm #sm-vd-xs Plus | other | $3 | $3 to $12 | Low |
| Dilator Vaginal Syracuse Med X-small 1/2 13mm #sm-vd-xs | other | $3 | $3 to $12 | Low |
| Ritalin La 40 Mg Capsule | other | $3 | $3 to $12 | Low |
| Valacyclovir Hcl 500 Mg Po Tabs | other | $3 | $3 to $12 | Low |
| Valacyclovir Hcl 500 Mg Tablet | other | $3 | $3 to $12 | Low |
| Sorbitol 70% Solution | other | $3 | $3 to $12 | Low |
| Splint Hand Mason Allen Large 1ea | other | $3 | $3 to $12 | Low |
| Ultrasound of Heart with Color-depicted Blood Flow, Rate and Valve Function | imaging | $3 | $3 to $93,325 | Low |
| Blood Glucose (sugar) Test Performed By Hand-held Instrument | other | $3 | $3 to $82,962 | Low |
| Specific Gravity (liquid Weight) Measurement | other | $3 | $3 to $84,315 | Low |
| Catheter Malecot 22fr #086022 | cardiac | $3 | $3 to $12 | Low |
| Catheter Malecot 24fr #086024 | cardiac | $3 | $3 to $12 | Low |
| Catheter Malecot 26fr #086026 | cardiac | $3 | $3 to $12 | Low |
| Catheter Malecot 28fr #086028 | cardiac | $3 | $3 to $12 | Low |
| Stylet Gliderite Single Use Large 0270 | other | $3 | $3 to $12 | Low |
| Injection, Hydromorphone, 0.1 Mg | other | $3 | $3 to $12 | Low |
| Knee Immobilizer-22" Long | other | $3 | $3 to $12 | Low |
| Splint Knee Univ 20" Basic #79 | other | $3 | $3 to $13 | Low |
| Tc-99m From Non-highly Enriched Uranium Source, Full Cost Recovery Add-on, Pe... | other | $3 | $3 to $13 | Low |
| Tube Vent Collar Button #70241014 | other | $3 | $3 to $13 | Low |
| Bard Foley Drainage Syestem #a304400a | other | $3 | $3 to $13 | Low |
| Test for Allergy Using Allergenic Extract | other | $3 | $3 to $95,004 | Low |
| Estradiol 0.05 Mg Patch | other | $3 | $3 to $13 | Low |
| Tube Salem Sump 10fr Ltx Fr W/reflux Filter | other | $3 | $3 to $13 | Low |
| Cast Stockinette Delta-net Tubular Synthetic 2inx25yd Black #7272301 2rl/case | other | $3 | $3 to $13 | Low |
| Roylan Wr Brace 6" Left-large | other | $3 | $3 to $13 | Low |
| Roylan Wr Brace 6" Left-medium | other | $3 | $3 to $13 | Low |
| Roylan Wr Brace 6" Left-small | other | $3 | $3 to $13 | Low |
| Roylan Wr Brace 6" Left-xlarge | other | $3 | $3 to $13 | Low |
| Roylan Wr Brace 6" Right Medium | other | $3 | $3 to $13 | Low |
| Roylan Wr Brace 6" Right-large | other | $3 | $3 to $13 | Low |
| Roylan Wr Brace 6" Right-xlarge | other | $3 | $3 to $13 | Low |
| Roylan Wr Brace 6" Rt-small | other | $3 | $3 to $13 | Low |
| Splint Knee Univ 22" Basic #79 | other | $3 | $3 to $13 | Low |
| Anesthesia for Exam of Colon Using an Endoscope | other | $3 | $3 to $812 | Low |
| Betamethasone Va 0.1% Cream | other | $3 | $3 to $13 | Low |
| Prevacid Dr 30 Mg Solutab | other | $3 | $3 to $13 | Low |
| Simple Syrup | other | $3 | $3 to $13 | Low |
| Walker Basket 1ea | other | $3 | $3 to $13 | Low |
| Collar Button Vent Tube 1.27mm Uncoated Silicon 6/pk #240014 | other | $3 | $3 to $13 | Low |
| Bone Wax 2.5 Gram Non-absorbable #bw25g | other | $3 | $3 to $13 | Low |
| Don-joy Knee Immoblizer 20" #79 | other | $3 | $3 to $13 | Low |
| Microscopic Examination for White Blood Cells | other | $3 | $3 to $85,008 | Low |
| Oxycontin ER 40 Mg Tablet | other | $3 | $3 to $13 | Low |
| Dilator Syracuse Med Vaginal Sm Plus 1" 25mm #sm-vd-s Plus | other | $3 | $3 to $13 | Low |
| Drain Btl W/o Drainln 1000m 12ea/1cs #sv1000s | other | $3 | $3 to $13 | Low |
| Dressing Gel Silvasorb 1.5oz #msc9301ep | other | $3 | $3 to $13 | Low |
| Hydrocolloid Dressing, Wound Cover, Sterile, Pad Size 16 Sq. In. OR Less, wit... | other | $3 | $3 to $26 | Low |
| Snare Loop Hexagonal #m00562341 | other | $3 | $3 to $13 | Low |
| Chiba 22g X 20cm Needle | other | $3 | $3 to $13 | Low |
| Chiba Biopsy Needle Dchn-22-15.0 #g00012 | lab | $3 | $3 to $13 | Low |
| Detector Co2 Easy Colorimetric Indicator Adult #562134 10ea/1cs | other | $3 | $3 to $13 | Low |
| Electrode Dysphagia Therapy 1.0" #05a160 | other | $3 | $3 to $13 | Low |
| Hospital Observation Service, Per Hour | other | $3 | $3 to $13 | Low |
| Needle Insufflation Laproscopic | other | $3 | $3 to $13 | Low |
| Sprotte 27g X 4'' (103mm) Needle with Introducer and Magnifying Hub Minimum O... | other | $3 | $3 to $13 | Low |
| Sump Intracardiac 12fr #12013 20/bx | cardiac | $3 | $3 to $13 | Low |
| Sleeve Scd Knee Lengthmed Comfrt#74022 5pr/cs | other | $3 | $3 to $13 | Low |
| Tube Vent Armstrong 1.14mm Short #10 | other | $3 | $3 to $13 | Low |
| Tube Inner Ear Myringotomy Ventilation Notched Flange with Tab 1.14 Mm Id Sil... | other | $3 | $3 to $13 | Low |
| Xarelto 10 Mg Tablet | other | $4 | $4 to $13 | Low |
| Hemoclip Medium Titan Cartridge #002204 24ea/pk/ 25pk/bx Blue | other | $4 | $4 to $13 | Low |
| Strattera 60 Mg Capsule | other | $4 | $4 to $13 | Low |
| Comfortform Left Wrist/thumb Adult Foam Laminate 5.5-6.5" Small 7.5" #79 | other | $4 | $4 to $13 | Low |
| Comfortform Left Wrist/thumb Adult Foam Laminate 6.5-7.5" Medium 8" #79 | other | $4 | $4 to $13 | Low |
| Comfortform Left Wrist/thumb Adult Foam Laminate 7.5-8.5" Large 8.5" #79 | other | $4 | $4 to $13 | Low |
| Comfortform Right Wrist/thumb Adult Foam Laminate 5.5-6.5" Small 7.5"#79 | other | $4 | $4 to $13 | Low |
| Comfortform Right Wrist/thumb Adult Foam Laminate 6.5-7.5" Medium 8"#79 | other | $4 | $4 to $13 | Low |
| Comfortform Right Wrist/thumb Adult Foam Laminate 7.5-8.5" Large 8.5"#79 | other | $4 | $4 to $13 | Low |
| Comfortform Right Wrist/thumb Adult Foam Laminate 8.5+" X-large 7.5"#79 | other | $4 | $4 to $13 | Low |
| Diovan Hct 320-12.5 Mg Tab | other | $4 | $4 to $13 | Low |
| Sodium Chloride Uromatic Irrigation .9% 3000ml Baxter Product Code #2b7127 4e... | other | $4 | $4 to $13 | 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 |
| Diag Catheter 5fr Jl4 #534520t | cardiac | $4 | $4 to $13 | Low |
| Diag Catheter 5fr Jr4 #534521t | cardiac | $4 | $4 to $13 | Low |
| Ortho-glass Splint W3xl35in Fiberglass Double Sided Padded #og-335pc 5ea/bx | other | $4 | $4 to $13 | Low |
| Thoracic Chest Tube 36fr 10ea/1cs | other | $4 | $4 to $13 | Low |
| Vashe Wound Therapy 250ml Bottle #00313 | other | $4 | $4 to $13 | Low |
| Kittner Lap Dual Tip 20/bx Kt | other | $4 | $4 to $13 | Low |
| Mask Procedural O2 Adult Elite 301-0318lt-msa | other | $4 | $4 to $13 | Low |
| Knife 1mm Angled Dual Bevel 6/bx | other | $4 | $4 to $13 | Low |
| Pantoprazole Sod Dr 40 Mg Tab | other | $4 | $4 to $13 | Low |
| Pantoprazole Sodium 40 Mg Po Tbec | other | $4 | $4 to $13 | Low |
| Stone Interceptor 12ea/1pk | other | $4 | $4 to $13 | Low |
| Digi-flex Exercisor Green 5.0lbs | other | $4 | $4 to $13 | Low |
| Digi-flex Exercisor Red 3.0lbs | other | $4 | $4 to $13 | Low |
| Foot Brush 1ea | other | $4 | $4 to $13 | Low |
| Body Fluid Ph Level | other | $4 | $4 to $83,986 | Low |
| Cyclopentolate 1% Eye Drops | other | $4 | $4 to $13 | Low |
| Donaldson Vent Tube 1.14 Mm I.d. Ultrasil Silicone 6 Ea/bx 70241015 | other | $4 | $4 to $13 | Low |
| Escitalopram 10 Mg Tablet | other | $4 | $4 to $14 | Low |
| Escitalopram Oxalate 10 Mg Po Tabs | other | $4 | $4 to $14 | Low |
| Cast Supplies, Short Arm Cast, Adult (11 Years +), Plaster | other | $4 | $4 to $27 | Low |
| Atovaquone 750 Mg/5ml Susp Cup | other | $4 | $4 to $14 | Low |
| Fluocinonide 0.05% Ointment | other | $4 | $4 to $14 | Low |
| Forcep Surgical Tissue Teeth 1x2 4.5in | surgery | $4 | $4 to $14 | Low |
| Dressing Acticoat Flex 7 4x5in Strl #66800405 | other | $4 | $4 to $14 | Low |
| Irrigation Tur Y Set 80" #2c4041 12ea/1ca | other | $4 | $4 to $14 | Low |
| Clobazam 5 Mg Half Tablet | other | $4 | $4 to $14 | Low |
| Dilator Syracuse Med Vaginal Medium 1 1/8 29mm #sm-vd-m | other | $4 | $4 to $14 | Low |
| Catheter Trocar 10fr 10ea/1bx | cardiac | $4 | $4 to $14 | Low |
| Catheter Trocar 20fr 10ea/1cs | cardiac | $4 | $4 to $14 | Low |
| Total Protein Level, Blood | other | $4 | $4 to $84,155 | Low |
| Total Protein Level, Urine | other | $4 | $4 to $84,156 | Low |
| Needle Cook 19x15 #g06275 | other | $4 | $4 to $14 | Low |
| Clotrimazole 1 % Ex Soln | other | $4 | $4 to $14 | Low |
| Bovie High Temp Fine Tip Cautery Surgical Disposable Aspen # Aa01 10ea/1bx | surgery | $4 | $4 to $14 | Low |
| Purastat Catheter 20ea/bxwp-18/2200 | cardiac | $4 | $4 to $14 | Low |
| Catheter, Ureteral | cardiac | $4 | $4 to $14 | Low |
| Nystatin 100,000 Unit/gm Cream | other | $4 | $4 to $14 | Low |
| Nystatin 100000 Unit/gm Ex Crea | other | $4 | $4 to $14 | Low |
| Promote Liquid | other | $4 | $4 to $14 | Low |
| Suction System Oral Swab Kit 20/cs #6464 | other | $4 | $4 to $14 | Low |
| Oseltamivir Phos 75 Mg Capsule | other | $4 | $4 to $14 | Low |
| Oseltamivir Phosphate 75 Mg Po Caps | other | $4 | $4 to $14 | Low |
| Lap 5mm Sump Cannula Gleeson Flovac | other | $4 | $4 to $14 | Low |
| Lexapro 20 Mg Tablet | other | $4 | $4 to $14 | Low |
| Opthalmic Burr 10ea/1bx | other | $4 | $4 to $14 | Low |
| Cannula Ima 1mm Tip #31001 | other | $4 | $4 to $14 | Low |
| Espocaná18 Ga. X 3+ In. Tuohy with Backeye Lumen Pencan Á27 Ga. X 5 In. Penci... | other | $4 | $4 to $14 | Low |
| Myrbetriq ER 25 Mg Tablet | other | $4 | $4 to $14 | Low |
| Cannula Hydroexpression (corydon) 10/sp | other | $4 | $4 to $14 | Low |
| Strattera 80 Mg Capsule | other | $4 | $4 to $14 | Low |
| Microscopic Examination for White Blood Cells with Manual Cell Count | other | $4 | $4 to $85,007 | Low |
| Sterilid Eyelid Cleanser Foam | other | $4 | $4 to $14 | Low |
| Sump Cardiac 20fr #12112 20/bx | cardiac | $4 | $4 to $14 | Low |
| Arch Support Medium #mdy10520 | other | $4 | $4 to $14 | Low |
| Probe Myocardial Temp 15mm 20/bx | other | $4 | $4 to $14 | Low |
| Blood Typing for Red Blood Cell Antigens | other | $4 | $4 to $86,905 | Low |
| Catheter Foley Coude 18fr 5cc Silver 12ea/1cs | cardiac | $4 | $4 to $14 | Low |
| Catheter Foley Coude 20fr 5cc Silver 12ea/1cs | cardiac | $4 | $4 to $14 | Low |
| Restraint Vest Medium 3350m | other | $4 | $4 to $14 | Low |
| Restraint Vest Small 3350s | other | $4 | $4 to $14 | Low |
| Restraint Vest Xlarge 3350xl | other | $4 | $4 to $14 | Low |
| Epidural Anes Kit-18ga Burron 10ea/1cs | other | $4 | $4 to $14 | Low |
| Knee Immobilizer 24" X-long | other | $4 | $4 to $14 | Low |
| Sleeve Foot Compression Regular #5897 10ea/cs | other | $4 | $4 to $14 | Low |
| Dilator Vaginal Syracuse Medical Med Plus 1 1/4 32mm #sm-vd-m Plus | other | $4 | $4 to $15 | Low |
| Tradjenta 5 Mg Tablet | other | $4 | $4 to $15 | Low |
| Abdominal Support 12in 1ea | other | $4 | $4 to $15 | Low |
| Catheter Mediastinal 10/bx #14409 | cardiac | $4 | $4 to $15 | Low |
| Ortho-glass Splint W5xl30in Fiberglass Double Sided Paddedog-5pc 5ea/bx | other | $4 | $4 to $15 | Low |
| Injection, Belatacept, 1 Mg | other | $4 | $4 to $5,092 | Low |
| Injection, Certolizumab Pegol, 1 Mg | other | $4 | $4 to $9,151 | Low |
| Blood Glucose (sugar) Tolerance Test, Each Additional Beyond 3 Specimens | lab | $4 | $4 to $82,952 | Low |
| Blood Glucose (sugar) Level | other | $4 | $4 to $82,947 | Low |
| Glucose (sugar) Level On Body Fluid | other | $4 | $4 to $82,945 | Low |
| Needle Weiss 18ga X 5" 10/bx | other | $4 | $4 to $15 | Low |
| Sleeve Foot Compression Large #5898 10ea/1cs | other | $4 | $4 to $15 | Low |
| Trap Digit Finger Large #9903 | other | $4 | $4 to $15 | Low |
| 25-40cc Iabp Adaptor#0684-00-0510-01 5ea/pk | other | $4 | $4 to $15 | Low |
| Probe Cover Civ-flex 5.5"x96"sterile 610 | other | $4 | $4 to $15 | Low |
| Urea Nitrogen Level to Assess Kidney Function, Quantitative | other | $4 | $4 to $84,520 | Low |
| Knife 2.75mm Angled Split | other | $4 | $4 to $15 | Low |
| Jardiance 10 Mg Tablet | other | $4 | $4 to $15 | Low |
| Jardiance 25 Mg Tablet | other | $4 | $4 to $15 | Low |
| Mirror Flexible #6220 1ea | other | $4 | $4 to $15 | Low |
| Trap Digit Finger Small .63 #9906 Bx/20ea | other | $4 | $4 to $15 | Low |
| Dilator Vaginal Syracuse Medical Large 1 3/8 35mm #sm-vd-l | other | $4 | $4 to $15 | Low |
| Application of Hot OR Cold Packs | other | $4 | $4 to $97,010 | 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 |
| Cast Supplies, Gauntlet Cast (includes Lower Forearm and Hand), Pediatric (0-... | other | $4 | $4 to $30 | Low |
| Cast Supplies, Long Arm Cast, Adult (11 Years +), Plaster | other | $4 | $4 to $30 | Low |
| Diovan Hct 320-25 Mg Tablet | other | $4 | $4 to $15 | Low |
| Guidewire W/ Trocar Tip 0.45" #ar-8737 | other | $4 | $4 to $15 | Low |
| Injection, Aztreonam, 500 Mg | other | $4 | $4 to $30 | Low |
| Needle Jamshidi Adult Disp | other | $4 | $4 to $15 | Low |
| Non-elastic Binder for Extremity | other | $4 | $4 to $30 | Low |
| Nystatin-triamcinolone 100000-0.1 Unit/gm-% Ex Crea | other | $4 | $4 to $15 | Low |
| Nystatin-triamcinolone Cream | other | $4 | $4 to $15 | Low |
| Osmolite 1.5 Cal Liquid | other | $4 | $4 to $15 | Low |
| Polyethylene Glycol 3350 17 Gm/scoop Po Powd | other | $4 | $4 to $15 | Low |
| Red Blood Count, Automated Test | other | $4 | $4 to $85,045 | Low |
| Smoke Elimination Device 15/cs | other | $4 | $4 to $15 | Low |
| Smoking and Tobacco Use Intermediate Counseling, 3-10 Minutes | therapy | $4 | $4 to $99,406 | Low |
| Total Protein Level, Body Fluid | other | $4 | $4 to $84,157 | Low |
| Knee Immobilizer-12" X-small | other | $4 | $4 to $15 | Low |
| Oxymorphone Hcl ER 20 Mg Tab | other | $4 | $4 to $15 | Low |
| Prosthetic Sock, Single Ply, Fitting, Below Knee, Each | other | $4 | $4 to $15 | Low |
| Trintellix 10 Mg Tablet | other | $4 | $4 to $15 | Low |
| Trintellix 5 Mg Tablet | other | $4 | $4 to $15 | Low |
| Vortioxetine Hbr 10 Mg Po Tabs | other | $4 | $4 to $15 | Low |
| CPAP Nasal Mask Large #niv042l | other | $4 | $4 to $15 | Low |
| Docusate Sodium 50 Mg/5 Ml Liq | other | $4 | $4 to $15 | Low |
| Dressing Contact Layer W6xl8in Silver Urgotul #509342 10ea/bx | other | $4 | $4 to $15 | Low |
| 4fr Simmons 1 | other | $4 | $4 to $15 | Low |
| 4fr Sos 1 | other | $4 | $4 to $15 | Low |
| 5fr Simmons 2 | other | $4 | $4 to $15 | Low |
| 5fr Sos 2 | other | $4 | $4 to $15 | Low |
| Binder Abdominal 12" 46-62" #13982000 | other | $4 | $4 to $15 | Low |
| Antithrombin Iii (human), Per I.u. | other | $4 | $4 to $6,748 | Low |
| Intubated Filter Lines Adult/pediatric Short Term Mfg# 989803204521 25ea/bx | other | $4 | $4 to $15 | Low |
| Snare Cold Captivator 10mm Rnd M00561103 | other | $4 | $4 to $15 | Low |
| Injection, Sodium Ferric Gluconate Complex in Sucrose Injection, 12.5 Mg | other | $4 | $4 to $367 | Low |
| Cannula Nasal Co2 Adult 10ea/1bx | other | $4 | $4 to $16 | Low |
| Co2 Sampling O2 Delivery Cannula #989803206641 10ea/pk | obstetric | $4 | $4 to $16 | Low |
| Dilating Mixture 0.5 Ml - Compounded | other | $4 | $4 to $16 | Low |
| Male Purewick External Catheter #pwm030 30ea/case | cardiac | $4 | $4 to $16 | Low |
| Tray Catheter 14fr Foley/bag #a300314a | cardiac | $4 | $4 to $16 | Low |
| Tray Catheter 16fr Foley/bag #a300316a | cardiac | $4 | $4 to $16 | Low |
| Tray Catheter 18fr Foley/bag #a300318a | cardiac | $4 | $4 to $16 | Low |
| Y-adapter Ureteroscope Gateway #m0067301501 | other | $4 | $4 to $16 | Low |
| Spiriva Handihaler 18 Mcg Cap | other | $4 | $4 to $16 | Low |
| Paparella Vent Tube #240044 6ea/1bx | other | $4 | $4 to $16 | Low |
| Tape Elastic 4" 6/bx #5177 | other | $4 | $4 to $16 | Low |
| Prosthetic Sock, Single Ply, Fitting, Above Knee, Each | other | $4 | $4 to $16 | Low |
| Seal 8mm Cannula Disp #400077 | other | $4 | $4 to $16 | Low |
| Tobramycin, Inhalation Solution, Fda-approved Final Product, Non-compounded, ... | other | $4 | $4 to $28 | Low |
| Catheter Foley Council 16fr 5cc Ribbed Silver | cardiac | $4 | $4 to $16 | Low |
| Catheter Foley Council 20fr 5cc Silver Coat | cardiac | $4 | $4 to $16 | Low |
| Suction Cauterizer 10fr X 6" Handswitch | other | $4 | $4 to $16 | Low |
| Cannula Shoulder 7cm #9718 | other | $4 | $4 to $16 | Low |
| Injection, Ceftaroline Fosamil, 10 Mg | other | $4 | $4 to $1,689 | Low |
| Sleeve Scd Knee Length Smcomfrt #74021 5pr/cs | other | $4 | $4 to $16 | Low |
| Stool Analysis for Blood, By Peroxidase Activity | other | $4 | $4 to $82,272 | Low |
| Detector Co2 Easy Colorimetric Indicator Pediatric Carbon Dioxide Detector #5... | other | $4 | $4 to $16 | Low |
| Dilator Vaginal Syracuse Med Large Plus 39mm Sm-vd-l+ | other | $4 | $4 to $16 | Low |
| Mitt Hand Peek-a-boo #2811 12pr/cs 1pr=1ea | other | $4 | $4 to $16 | Low |
| Neomyc-bacit-polymix Eye Oint | other | $4 | $4 to $16 | Low |
| Xodus Pillow Abduction Hip Large Disp #40410 4ea/case | other | $4 | $4 to $16 | Low |
| Trocar 18g X 15cm | other | $4 | $4 to $16 | Low |
| Composite Dressing, Sterile, Pad Size 16 Sq. In. OR Less, with Any Size Adhes... | other | $4 | $4 to $32 | Low |
| Indwelling Catheter; Foley Type, Two-way Latex with Coating (teflon, Silicone... | cardiac | $4 | $4 to $32 | Low |
| Jumpstart 2" X 5" Antimicrobial Wound Dressing Abs | other | $4 | $4 to $16 | Low |
| Needle Disp. 2-part Trocar 18gax15cm #g14461 | other | $4 | $4 to $16 | Low |
| Needle Disp. 2-part Trocar 18gax20cm #g14255 | other | $4 | $4 to $16 | Low |
| Needle, Sterile, Any Size, Each | other | $4 | $4 to $32 | Low |
| Pacemaker Lead End Kit #5867-3m | cardiac | $4 | $4 to $16 | Low |
| Pressurizer Large 6ea/pk 0206-547 | other | $4 | $4 to $16 | Low |
| Pressurizer Medium 6ea/pk #0206-546 | other | $4 | $4 to $16 | Low |
| Pinworm Test | other | $4 | $4 to $87,172 | Low |
| Special Gram OR Giemsa Stain for Microorganism | other | $4 | $4 to $87,205 | Low |
| Syphilis Detection Test | other | $4 | $4 to $86,592 | Low |
| Tissue Fungi OR Parasites | other | $4 | $4 to $87,220 | Low |
| Coagulation Time Measurement, Activated | other | $4 | $4 to $85,347 | Low |
| Dripline Ii Water Trap Adult 10ea/1bx | other | $4 | $4 to $16 | Low |
| Tube Vent Armstrong 1.14mm - Sc | other | $4 | $4 to $16 | Low |
| Reddie Wraparound Knee Brace Adult Neoprene 13.5-15.5" X-small #79 | other | $4 | $4 to $16 | Low |
| Reddie Wraparound Knee Brace Adult Neoprene 15.5-18" Small #79 | other | $4 | $4 to $16 | Low |
| Reddie Wraparound Knee Brace Adult Neoprene 18-20.5" Medium #79 | other | $4 | $4 to $16 | Low |
| Reddie Wraparound Knee Brace Adult Neoprene 20.5-23" Large #79 | other | $4 | $4 to $16 | Low |
| Breast Pump One-hand Manual #17161 | other | $4 | $4 to $16 | Low |
| Cast Supplies, Short Arm Splint, Pediatric (0-10 Years), Plaster | other | $4 | $4 to $80 | Low |
| Injection, Vinblastine Sulfate, 1 Mg | other | $4 | $4 to $567 | Low |
| Red Blood Count, Manual Test | other | $4 | $4 to $85,044 | Low |
| Lymphedema Tube Gauze Band X-lrg K1 10ea/1cs | other | $4 | $4 to $16 | Low |
| Sleeve Scd Knee Length Lg Comfrt#74023 5pr/cs | other | $4 | $4 to $16 | Low |
| Cholesterol Level | other | $4 | $4 to $82,465 | Low |
| Injection, Pemetrexed, Not Otherwise Specified, 10 Mg | other | $4 | $4 to $160 | Low |
| Electrode Vital Stim Adlt Julia Jones 12ea/pk | other | $4 | $4 to $16 | Low |
| Injection, Degarelix, 1 Mg | other | $4 | $4 to $644 | Low |
| Stool Analysis for Blood to Screen for Colon Tumors | other | $4 | $4 to $82,270 | Low |
| Reddie Wraparound Knee Brace Adult Neoprene 23-25.5" X-large #79 | other | $4 | $4 to $17 | Low |
| Crutch Steel Bariatric Adult 5'2"-5'10" 650lb #mds80335xw 1pr/case | other | $4 | $4 to $17 | Low |
| Dressing Shield Zip Ds Ps1241 5ea/pk | other | $4 | $4 to $17 | Low |
| Elastomer Vascular Loop #1041 (retract-o-tape | other | $4 | $4 to $17 | Low |
| Caffeine Citrate 10 Mg/ml D5w Syringe - Peds - Compounded | other | $4 | $4 to $17 | Low |
| Injection, Tocilizumab-aazg (tyenne), Biosimilar, 1 Mg | other | $4 | $4 to $3,743 | Low |
| Linaclotide 145 Mcg Po Caps | other | $4 | $4 to $17 | Low |
| Linzess 145 Mcg Capsule | other | $4 | $4 to $17 | Low |
| Linzess 72 Mcg Capsule | other | $4 | $4 to $17 | Low |
| Needle Biopsy Tru-cut Disp #2n2702x | lab | $4 | $4 to $17 | Low |
| Levofloxacin 250 Mg Po Tabs | other | $4 | $4 to $17 | Low |
| Levofloxacin 250 Mg Tablet | other | $4 | $4 to $15 | Low |
| Levofloxacin 500 Mg Po Tabs | other | $4 | $4 to $17 | Low |
| Levofloxacin 500 Mg Tablet | other | $4 | $4 to $17 | Low |
| Pad Spider Elbow Slv Xxxl Blk 11-0392-7 | other | $4 | $4 to $17 | Low |
| Pad-sensa Trac W/tube/clamp/conn #m8275057/10 | other | $4 | $4 to $17 | Low |
| Reddie Wraparound Knee Brace Adult Neoprene 25.5-28" 2x-large #79 | other | $4 | $4 to $17 | Low |
| Thera Tears Sterilid Cleanser | other | $4 | $4 to $17 | Low |
| Nasal Tampon W/tube 8.0 Cm #400410 20ea/1pk | other | $4 | $4 to $17 | Low |
| Platelet Count, Automated Test | other | $4 | $4 to $85,049 | Low |
| 5fr Sos 80cm | other | $5 | $5 to $17 | Low |
| Foam Dressing, Wound Cover, Sterile, Pad Size 16 Sq. In. OR Less, with Any Si... | other | $5 | $5 to $34 | Low |
| Needle Spinal Sterile 22gx20cm #dsn-22-20.0 | other | $5 | $5 to $17 | Low |
| Flow Cytometry Technique for Dna OR Cell Analysis, Each Additional Marker | other | $5 | $5 to $88,185 | Low |
| Guide Aiming 1.5mm Single Use Pdg-aim | other | $5 | $5 to $17 | Low |
| LASIK Eye Surgery | other | $5 | $5 to $17 | High |
| Lasik Flap Roller | other | $5 | $5 to $17 | Low |
| Male External Catheter with Integral Collection Chamber, Any Type, Each | cardiac | $5 | $5 to $34 | Low |
| Paracervical-pudenal Block Tray Includes 20g X 6" Spinal Needle Trumpet Needl... | other | $5 | $5 to $17 | Low |
| Punch Aortic 2.8mm #dp-28k | other | $5 | $5 to $17 | Low |
| Tubing Set Ext Compress System 4ft #9595 20ea/case | other | $5 | $5 to $17 | Low |
| Uric Acid Level, Blood | other | $5 | $5 to $84,550 | Low |
| Lap Spatula Elec 5mm X 32mm 60-5272 | 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 |
| Freestyle Lite Meter | other | $5 | $5 to $17 | Low |
| **discontinued** Catheter Imager Ii Cobra 5fr M0064003011 5/bx | cardiac | $5 | $5 to $17 | Low |
| Drain Catheter 12fr Pezzer #064012 6ea/1bx | cardiac | $5 | $5 to $17 | Low |
| Drain Catheter 14fr Pezzer #064014 6ea/1cs | cardiac | $5 | $5 to $17 | Low |
| Jackson Pratt Drain 19fr #su130 | other | $5 | $5 to $17 | Low |
| Immobilizer Knee 20" Black Elastic #bf7072 | other | $5 | $5 to $17 | Low |
| Blood Chloride Level | other | $5 | $5 to $82,435 | Low |
| Reddie Wraparound Knee Brace Adult Neoprene 28-31" 3x-large #79-82399 | other | $5 | $5 to $17 | Low |
| Splint Nasal Septal Small | other | $5 | $5 to $17 | Low |
| Dialator Cook 16fr #g03947 | other | $5 | $5 to $17 | Low |
| Dilator 12fr #jcd12.0-38-20-coons | other | $5 | $5 to $17 | Low |
| Dilator 14fr #jcd14.0-38-20-coons | other | $5 | $5 to $17 | Low |
| Cautery Hot Biopsy Polyp #m00515033 | lab | $5 | $5 to $17 | Low |
| Knee Immobilizer-19" Med" | other | $5 | $5 to $17 | Low |
| Lap Electrode L Hook 5 X 32mm | other | $5 | $5 to $17 | Low |
| M00561101 - Snare Vascular L240cm Loop W10mm Sheath Dia2.4mm Round Stiff Cold... | other | $5 | $5 to $17 | Low |
| Arch Support Large #mdy10530 | other | $5 | $5 to $17 | Low |
| Cannula Air Injection 27g | other | $5 | $5 to $18 | Low |
| Catheter Trocar 32fr | cardiac | $5 | $5 to $18 | Low |
| Catheter Kit Coude/foley Complete Care 16fr | cardiac | $5 | $5 to $18 | Low |
| Cephalexin 125 Mg/5 Ml Susp | other | $5 | $5 to $18 | Low |
| Body Fluid Cell Count | other | $5 | $5 to $89,050 | Low |
| Endostitch 2-0 Polysorb #170053 | other | $5 | $5 to $18 | Low |
| Needle Sonoplex Ii 20g X 6" (150mm) Echogenic Needle with Facet S Tip Nanolin... | imaging | $5 | $5 to $18 | Low |
| Urine Potassium Level | other | $5 | $5 to $84,133 | Low |
| Anesthesia for Incision of Ear Drum | other | $5 | $5 to $126 | Low |
| Resuscitator Bag Infant W/peep Mask 6ea/1cs | other | $5 | $5 to $18 | Low |
| Anesthesia for Exam of Ear Using an Endoscope | other | $5 | $5 to $124 | Low |
| Blood Glucose (sugar) Level After Receiving Dose of Glucose | other | $5 | $5 to $82,950 | Low |
| Desonide 0.05% Cream | other | $5 | $5 to $18 | Low |
| Blood Potassium Level | other | $5 | $5 to $84,132 | Low |
| Brace Elbow 11 Inch Adult #79 | other | $5 | $5 to $18 | Low |
| Knife 4.1mm Angled Shortcut | other | $5 | $5 to $18 | Low |
| Uterine Vac 5mm Flexible #505 Milex | other | $5 | $5 to $18 | Low |
| Dakin's 0.25% Solution | other | $5 | $5 to $18 | Low |
| Dakin's 0.5% Solution | other | $5 | $5 to $18 | Low |
| Cast Supplies, Short Arm Cast, Pediatric (0-10 Years), Fiberglass | other | $5 | $5 to $36 | Low |
| Cps Universal Ii Slitter Ds2a006 | other | $5 | $5 to $18 | Low |
| Desonide 0.05% Ointment | other | $5 | $5 to $18 | Low |
| Endotrach Tube Reinforced 6.0mm #86548 | other | $5 | $5 to $18 | Low |
| Endotrach Tube Reinforced 6.5mm #86549 | other | $5 | $5 to $18 | Low |
| Endotrach Tube Reinforced 7.0mm #86550 | other | $5 | $5 to $18 | Low |
| Endotrach Tube Reinforced 7.5mm #86551 | other | $5 | $5 to $18 | Low |
| Endotrach Tube Reinforced 8.0mm #86552 | other | $5 | $5 to $18 | Low |
| Quick-use Disposable Bone Cement Curette 10 Ea/bx 00504905300#5049 | other | $5 | $5 to $18 | Low |
| Blood Sodium Level | other | $5 | $5 to $84,295 | Low |
| Catheter Trocar 12fr 10ea/1cs | cardiac | $5 | $5 to $18 | Low |
| Pad Cold Therapy Univ Wrap On 11-0679-9 | other | $5 | $5 to $18 | Low |
| Pad Cold Therapy Univ Wrap Xl 11-0681-9 | other | $5 | $5 to $18 | Low |
| Bleeding Time | other | $5 | $5 to $85,002 | Low |
| Cannula Air Injection 30g | other | $5 | $5 to $18 | Low |
| Dressing Calcium Alginate 4x5 #31045 | other | $5 | $5 to $18 | Low |
| Pin Steinman 5/32" Threaded 9" | other | $5 | $5 to $18 | Low |
| Pin Steinman 5/64" Threaded 9" #262-07 | other | $5 | $5 to $18 | Low |
| Pin Steinman 7/64 X 229mm Threaded #262-05 | other | $5 | $5 to $18 | Low |
| Pin Steinman Threaded 1/8 X 229mm #262-06 | other | $5 | $5 to $18 | Low |
| Pin Steinman Threaded 7/64" X 229mm | other | $5 | $5 to $18 | Low |
| Steinman Pin Threaded 9/64 X 229mm #262-03 | other | $5 | $5 to $18 | Low |
| Cast Stockinette Delta-net Tubular Synthetic 3inx25yd Non-sterile #7272302 2r... | other | $5 | $5 to $18 | Low |
| Snare Rotatable 20mm #m00561831 | other | $5 | $5 to $18 | Low |
| Sodium Level | other | $5 | $5 to $84,302 | Low |
| Immobilizer Knee 18" W/elastc Straps #7071 | other | $5 | $5 to $18 | Low |
| Carbon Dioxide (bicarbonate) Level | other | $5 | $5 to $82,374 | Low |
| Tacrolimus, Immediate Release, Oral, 1 Mg | other | $5 | $5 to $18 | Low |
| Uterine Vac 6mm Flexible #506 Milex 10ea/1bx | other | $5 | $5 to $18 | Low |
| Muri-lube Mineral Oil Vial | other | $5 | $5 to $18 | Low |
| Nail Clipper W/file for One-handed Nail Care 1ea A85410 | other | $5 | $5 to $18 | Low |
| Endostitch 0 Surgidac #173024 | other | $5 | $5 to $18 | Low |
| Suspensory W/straps-large-adult Pfpfp02570lg | other | $5 | $5 to $18 | Low |
| Suspensory W/straps-xlarge-adult Pfp2570xl | other | $5 | $5 to $18 | Low |
| Moderate Sedation Services Provided By the Same Physician OR Other Qualified ... | other | $5 | $5 to $330 | Low |
| Perfusion Set Multiple #14000 | surgery | $5 | $5 to $19 | Low |
| Sleeve Scd Knee Length Xl Exprss #9790 5pr/cs | other | $5 | $5 to $19 | Low |
| Albumin (protein) Level | other | $5 | $5 to $82,040 | Low |
| Closed Injectate Delivery Sys (cardiac Output | cardiac | $5 | $5 to $19 | Low |
| Dorzolamide-timolol Eye Drops | other | $5 | $5 to $19 | Low |
| Ez-stabilizer 9066-vc-005 5ea/1bx | other | $5 | $5 to $19 | Low |
| Akten 3.5% Gel Drops | other | $5 | $5 to $19 | Low |
| Suspensory W/straps-medium-adult Pfp02570m | other | $5 | $5 to $19 | Low |
| Vimpat 100 Mg Tablet | other | $5 | $5 to $19 | Low |
| Forceps Radial Jaw 4 Jumbo 80/bx M00513374 | other | $5 | $5 to $19 | Low |
| Chloride Level | other | $5 | $5 to $82,438 | Low |
| Dressing Sorbson Wound Packing 12" | other | $5 | $5 to $19 | Low |
| Diag Catheter 6fr Uf #451-504v5 | cardiac | $5 | $5 to $19 | Low |
| Paparella-type Vent Tube 1.27 Mm I.d. Ultrasil Silicone 6 Ea/bx 70241046 | other | $5 | $5 to $19 | Low |
| Bilirubin Level, Direct | other | $5 | $5 to $82,248 | Low |
| Bilirubin Level, Total | other | $5 | $5 to $82,247 | Low |
| Measurement of Bilirubin | other | $5 | $5 to $88,720 | Low |
| Vashe Wound Vac Wash 8.5oz Antimicrobial Bottle Non-cytotoxic #00316 12ea/case | other | $5 | $5 to $19 | Low |
| Cannula Seal 5mm-8mm #470361 Intuitive Surgic | other | $5 | $5 to $19 | Low |
| Laryngoscope Blade - Gvl 3 Stat #0270 | other | $5 | $5 to $19 | Low |
| Laryngoscope Blade - Gvl 4 Stat #0270 | other | $5 | $5 to $19 | Low |
| Blood Glucose (sugar) Measurement Using Reagent Strip | other | $5 | $5 to $82,948 | Low |
| Lap 5mm/44cm Sump Cannula Gleeson Flovac | other | $5 | $5 to $19 | Low |
| Fentanyl 75 Mcg/hr Patch | other | $5 | $5 to $19 | Low |
| Fentanyl 75 Mcg/hr Td Pt72 | other | $5 | $5 to $19 | Low |
| Urine Sodium Level | other | $5 | $5 to $84,300 | Low |
| Urovac Bladder Evacuator #m0067301251 | other | $5 | $5 to $19 | Low |
| Uric Acid Level | other | $5 | $5 to $84,560 | Low |
| Dermatac Drape 10 Pack Dtac10ldp | other | $5 | $5 to $19 | Low |
| Monsel's Ferric Subsulfate Sol | other | $5 | $5 to $19 | Low |
| Stool Fat OR Lipids Analysis, Qualitative | lab | $5 | $5 to $82,705 | Low |
| Blood Creatinine Level | other | $5 | $5 to $82,565 | Low |
| Channel Drain Round Silicone with Trocar 15fr 3/16" Full Fluted #dynjwe2189 1... | other | $5 | $5 to $19 | Low |
| Valtrex 1 Gram Caplet | other | $5 | $5 to $19 | Low |
| Xodus Pillow Abduction Hip Small W/straps Disp #40408b 6ea/case | other | $5 | $5 to $19 | Low |
| Calcium Level, Total | other | $5 | $5 to $82,310 | Low |
| Derma Hook | other | $5 | $5 to $19 | Low |
| Quikclot 4x4 Topical Hemostatic #459 | other | $5 | $5 to $19 | Low |
| Creatinine Level to Test for Kidney Function OR Muscle Injury | other | $5 | $5 to $82,570 | Low |
| Liver Enzyme (sgot), Level | other | $5 | $5 to $84,450 | Low |
| Measurement C-reactive Protein for Detection of Infection OR Inflammation | other | $5 | $5 to $86,140 | Low |
| Phosphatase (enzyme) Level, Alkaline | other | $5 | $5 to $84,075 | Low |
| Screening Test for Mononucleosis | preventive | $5 | $5 to $86,308 | Low |
| Micropuncture 5fr Access Set #g53574 | other | $5 | $5 to $20 | Low |
| Catheter Phillips Follower 12fr Lf 10ea/bx | cardiac | $5 | $5 to $20 | Low |
| Catheter Philllips Folllower 18fr Lf 10ea/bx | cardiac | $5 | $5 to $20 | Low |
| Crutch Steel Bariatric Tall Adult 5'10"-6'6" 650lb 1pr/case #mds80334xw | other | $5 | $5 to $20 | Low |
| Measurement of Antibody (ige) to Allergic Substance, Crude Allergen Extract, ... | other | $5 | $5 to $86,003 | Low |
| Angiographic Catheter 5f (1.8mm) X 90cm Cobra 2 #10719711 5ea/bx | imaging | $5 | $5 to $20 | Low |
| Profile Extra Small Oval Flexible Single Use Snare 10ea/bx M00562531 | other | $5 | $5 to $20 | Low |
| Vincristine Sulfate, 1 Mg | other | $5 | $5 to $107 | Low |
| Forceps Radial Jaw 4 Jumbo #m00513372 40/1bx | other | $5 | $5 to $20 | Low |
| Knee Support Med Neoprene Hinged #302155blk | other | $5 | $5 to $20 | Low |
| Cpm Pads Synthetic Patient Kit 1ea | other | $5 | $5 to $20 | Low |
| Ambien 10 Mg Tablet | other | $5 | $5 to $20 | Low |
| Diphenhydramine Hydrochloride, 50 Mg, Oral, Fda Approved Prescription Anti-em... | other | $5 | $5 to $20 | 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 |
| Comfort Cool Thumb Cmc Left-large | other | $5 | $5 to $20 | Low |
| Comfort Cool Thumb Cmc Left-medium | other | $5 | $5 to $20 | Low |
| Comfort Cool Thumb Cmc Left-small | other | $5 | $5 to $20 | Low |
| Comfort Cool Thumb Cmc Left-xlarge | other | $5 | $5 to $20 | Low |
| Comfort Cool Thumb Cmc Right-large | other | $5 | $5 to $20 | Low |
| Comfort Cool Thumb Cmc Right-medium | other | $5 | $5 to $20 | Low |
| Comfort Cool Thumb Cmc Right-small | other | $5 | $5 to $20 | Low |
| Comfort Cool Thumb Cmc Right-xlarge | other | $5 | $5 to $20 | Low |
| Liver Enzyme (sgpt), Level | other | $5 | $5 to $84,460 | Low |
| Endotrach Tube Reinforced 6.0mm 5/bx #5 | other | $5 | $5 to $20 | Low |
| Endotrach Tube Reinforced 6.5mm 5/bx #5 | other | $5 | $5 to $20 | Low |
| Endotrach Tube Reinforced 7.0mm #5 | other | $5 | $5 to $20 | Low |
| Lap Electrode Ball 3mm Ext | other | $5 | $5 to $20 | Low |
| Lap Electrode Loop Medium 15x10mm | other | $5 | $5 to $20 | Low |
| Lap Electrode Loop Small 12x8mm | other | $5 | $5 to $20 | Low |
| Delflex with 1.5% Dextrose | other | $5 | $5 to $20 | Low |
| Delflex with 2.5% Dextrose | other | $5 | $5 to $20 | Low |
| Golytely Solution | other | $5 | $5 to $20 | Low |
| Hc Ehc Rev | other | $5 | $5 to $20 | Low |
| Indwelling Catheter, Foley Type, Two-way, All Silicone OR Polyurethane, Each | cardiac | $5 | $5 to $40 | Low |
| Injection, Metronidazole, 500 Mg | other | $5 | $5 to $40 | Low |
| Intuitive Da Vinci Xi Universal Seal 5mm-12mm10 Ea/bx 470500 | other | $5 | $5 to $20 | Low |
| Non-coring Needle OR Stylet with OR without Catheter | cardiac | $5 | $5 to $40 | Low |
| Orthopedic Shoe, Hightop with Supinator OR Pronator, Child | other | $5 | $5 to $40 | Low |
| Pom Mask #1001-msa 30ea/pk | other | $5 | $5 to $20 | Low |
| Spirometer, Non-electronic, Includes All Accessories | other | $5 | $5 to $40 | Low |
| Splint | other | $5 | $5 to $40 | Low |
| Tvi Tool #tvi-07 Medtronic 5/pk | other | $5 | $5 to $20 | Low |
| Gradient Compression Garment, Not Otherwise Specified | other | $5 | $5 to $20 | Low |
| Hydrocolloid Dressing, Wound Filler, Paste, Sterile, Per Ounce | other | $5 | $5 to $40 | Low |
| Suction Control Valve/am Omi Cardiac | cardiac | $5 | $5 to $20 | Low |
| Catheter Phillips Follower 22fr Lf 10ea/1bx | cardiac | $5 | $5 to $20 | Low |
| Splint Bucks Traction-xlarge #8106 | other | $5 | $5 to $20 | Low |
| Catheter Phillips Follower 10fr Lf 10ea/bx | cardiac | $5 | $5 to $20 | Low |
| Catheter Tray Urine Meter E/ Foley 350ml | cardiac | $5 | $5 to $20 | Low |
| Red Blood Cell Antibody Detection Test, Direct | other | $5 | $5 to $86,880 | Low |
| Special Fluorescent And/or Acid Fast Stain for Microorganism | other | $5 | $5 to $87,206 | Low |
| Walker Palm Relfoldguardian #g30756 4ea/1cs | other | $5 | $5 to $20 | Low |
| Crutch Child Small 4'-4'6" 300 Lb 1pr | other | $5 | $5 to $20 | Low |
| Glycerin Skin Protectant Liq | other | $5 | $5 to $20 | Low |
| Lindane 1 % Ex Sham | other | $5 | $5 to $20 | Low |
| Wire Breast Localization 10/bx #47720 | other | $5 | $5 to $20 | Low |
| Wire Breast Localization 20gx5cm | other | $5 | $5 to $20 | Low |
| Forceps Magill Child #792-9-3018 | other | $5 | $5 to $20 | Low |
| Thermax Blood Warmer Disposable #955516 Ca/ 24ea | other | $5 | $5 to $21 | Low |
| 4fr Sos Mini Omni 65cm - Must Be Ordered in Qty's of 5 Ea | other | $5 | $5 to $21 | Low |
| Anesthesia for Procedure On Small and Large Bowel Using an Endoscope | other | $5 | $5 to $813 | Low |
| Pillow Abduction Hip Small Disp #m60-076-s | other | $5 | $5 to $21 | Low |
| Phenylalanine, Pku (amino Acid) Level | other | $6 | $6 to $84,030 | Low |
| Tube Vent Armstrong 1.14mm Reg #10 | other | $6 | $6 to $21 | Low |
| Red Blood Cell Sickling Measurement | other | $6 | $6 to $85,660 | Low |
| Juzo Compress Hose Belo Knee 20-30mmhg Ad Iii | other | $6 | $6 to $21 | Low |
| Juzo Compress Hose Below Knee 20-30mmhg Ad I | other | $6 | $6 to $21 | Low |
| Juzo Compress Hose Below Knee 20-30mmhg Ad Ii | other | $6 | $6 to $21 | Low |
| Juzo Compress Hose Below Knee 20-30mmhg Ad IV | other | $6 | $6 to $21 | Low |
| Juzo Compress Hose Below Knee 20-30mmhg Ad V | other | $6 | $6 to $21 | Low |
| Dressing Ear Pediatric Glasscock #s | other | $6 | $6 to $21 | Low |
| Oasis Wound Matrix, Per Square Centimeter | other | $6 | $6 to $119 | Low |
| Electrode Eletrosurgical OR Electrocautery 5.12 Inch Length 20 Mm Diameter T ... | surgery | $6 | $6 to $21 | Low |
| Urea Nitrogen Level to Assess Kidney Function, Urine | other | $6 | $6 to $84,540 | Low |
| Lap Electrode Ball 5mm Ext | other | $6 | $6 to $21 | Low |
| Lap Electrode Loop Lrge 20x10mm | other | $6 | $6 to $21 | Low |
| Permethrin 5% Cream | other | $6 | $6 to $21 | Low |
| Chiba 19g X 20cm Needle | other | $6 | $6 to $21 | Low |
| Dressing Aquacel Ag Advantage 3.5x6" #422604 10ea/1bx | other | $6 | $6 to $21 | Low |
| Tip Cover Accessory Version 12 | other | $6 | $6 to $21 | Low |
| Spacer Sock-hole in Toe Med #6ss040hv | other | $6 | $6 to $21 | Low |
| Bacitracin-polymyxin Eye Oint | other | $6 | $6 to $21 | Low |
| Lap J-hook Elec 5mm X 32mm Plus #60-5274 | other | $6 | $6 to $21 | Low |
| Injection, Rho(d) Immune Globulin (human), (rhophylac), Intramuscular OR Intr... | other | $6 | $6 to $732 | Low |
| Abreva 10% Cream | other | $6 | $6 to $21 | Low |
| Catheter Trocar 8fr Chest Tube 10ea/1cs | cardiac | $6 | $6 to $21 | Low |
| Cephalexin 250 Mg/5 Ml Susp | other | $6 | $6 to $21 | Low |
| Application of Hot Wax Bath | other | $6 | $6 to $97,018 | Low |
| Knee Support Large Neoprene Hinged #302157blk | other | $6 | $6 to $21 | Low |
| Rheumatoid Factor Level | other | $6 | $6 to $86,431 | Low |
| Clozex Skin Closure 40mm X 50mm Cl1040l | other | $6 | $6 to $21 | Low |
| Encore 26 Inflation Device M001151062 15 | other | $6 | $6 to $21 | Low |
| Injection, Tocilizumab, 1 Mg | other | $6 | $6 to $5,312 | Low |
| Red Blood Cell Antibody Detection Test, Indirect | other | $6 | $6 to $86,885 | Low |
| Triglycerides Level | other | $6 | $6 to $84,478 | Low |
| Urine Chloride Level | other | $6 | $6 to $82,436 | Low |
| Dressing Mepilex 4x6 Post Op Ag 5/bx 498300 | other | $6 | $6 to $22 | Low |
| Urine Microalbumin (protein) Level | other | $6 | $6 to $82,043 | Low |
| Urine Phosphate Level | other | $6 | $6 to $84,105 | Low |
| Suction Canister Omnijug W/cap #5036 | other | $6 | $6 to $22 | Low |
| Pad Cold Therapy Shoulder Wrap11-1397-9 | other | $6 | $6 to $22 | Low |
| Catheter Trocar 28fr 10ea/1cs | cardiac | $6 | $6 to $22 | Low |
| Ultrasound Probe Cover Gel #610-833 12ea/1bx | imaging | $6 | $6 to $22 | 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 |
| Smear for Infectious Agents | other | $6 | $6 to $87,210 | Low |
| All Potassium Hydroxide (koh) Preparations | other | $6 | $6 to $62 | Low |
| Cast Supplies, Long Arm Cast, Adult (11 Years +), Fiberglass | other | $6 | $6 to $44 | Low |
| Cast Supplies, Long Arm Splint, Adult (11 Years +), Plaster | other | $6 | $6 to $44 | Low |
| Clozex Skin Closure 50mm X 50mm Cl1050l | other | $6 | $6 to $22 | Low |
| Trocar 21g X 15cm | other | $6 | $6 to $22 | Low |
| Tube Vent Sheehy #10-26145 Implant | surgery | $6 | $6 to $22 | Low |
| Chemet 100 Mg Capsule | other | $6 | $6 to $22 | Low |
| Injection, Penicillin G Potassium, Up to 600,000 Units | other | $6 | $6 to $22 | Low |
| Vas-q Ligation Clip Adler #an2232 14ea/bx | other | $6 | $6 to $22 | Low |
| Walker Folding - Guardianmust Order By Case/4each | other | $6 | $6 to $22 | Low |
| Endo Close Trocar Site Closure Device 173022 12ea/case | other | $6 | $6 to $22 | Low |
| Prosthetic Shrinker, Below Knee, Each | other | $6 | $6 to $64 | Low |
| Sps 15 Gm/60 Ml Suspension | other | $6 | $6 to $22 | Low |
| Clindamycin Ph 1% Solution | other | $6 | $6 to $22 | Low |
| Prevena Plus 150ml Canister #pre4095us | other | $6 | $6 to $22 | Low |
| Pledget Oval 4.5 X 6 Soft 10 Pk #vpg56se | other | $6 | $6 to $22 | Low |
| Vacuum Birth Cup 60mm/tender Touch 10ea/1bx | other | $6 | $6 to $23 | Low |
| Vacuum Birth Cup 65mm/tender Touch 10ea/1bx | other | $6 | $6 to $23 | Low |
| Epidural Tray Perifix Tuohy 17ga X 3.5 Drape/syringe Latex Free Sterile #3320... | other | $6 | $6 to $23 | Low |
| Forceps Magill Adult #792-9-3018 | other | $6 | $6 to $23 | Low |
| Tube Vent Otologic 1.14mm Paprella Vt-0300-01 10ea/bx | other | $6 | $6 to $23 | Low |
| Urine Calcium Level | other | $6 | $6 to $82,340 | Low |
| Lactate Dehydrogenase (enzyme) Level | other | $6 | $6 to $83,615 | Low |
| Spacer Sock-hole in Toe Wide #6ss045hv | other | $6 | $6 to $23 | Low |
| Cromolyn Sodium 4 % Op Soln | other | $6 | $6 to $23 | Low |
| Tube Vent Ultrasil #70241071 Implant | surgery | $6 | $6 to $23 | Low |
| Lap Electrode L-hook #04-500mb | other | $6 | $6 to $23 | Low |
| X-ray of Toe, Minimum of 2 Views | imaging | $6 | $6 to $73,660 | Low |
| Co-set Cold Injection System 10ea/1cs | other | $6 | $6 to $23 | Low |
| Famotidine 40 Mg/5 Ml Susp | other | $6 | $6 to $23 | Low |
| Healon Pro 0.55ml 10340011 | other | $6 | $6 to $23 | Low |
| Influenza Virus Vaccine, Split Virus, When Administered to Individuals 3 Year... | preventive | $6 | $6 to $46 | Low |
| Introducer/sheath, Other Than Guiding, Other Than Intracardiac Electrophysiol... | cardiac | $6 | $6 to $23 | Low |
| Kit Pacing Stylet 0.014in X 52cm Blue Knob Stainless Steel Ball Tip Straight ... | other | $6 | $6 to $23 | Low |
| Kit Stylet L52cm Dia0.014in Stainless Steel Blue Knob Extended Taper Ball Tip... | other | $6 | $6 to $23 | Low |
| Kit Stylet Lead Acc #6056m | other | $6 | $6 to $23 | Low |
| Stylet Kit #6094 | other | $6 | $6 to $23 | Low |
| Stylet Kit 0.014in X 58cm #6082 | other | $6 | $6 to $23 | Low |
| Catheter Filiform with Spiral Tip 4f Sterile 10ea/bx #343104 | cardiac | $6 | $6 to $23 | Low |
| Shield Corneal W/ Suction Cups Med #ssa-02 | other | $6 | $6 to $23 | Low |
| Suction Wand Intracardiac Rigid #su | cardiac | $6 | $6 to $23 | Low |
| Quikclot Hemostatic #467z 10/bx | other | $6 | $6 to $23 | Low |
| Econazole Nitrate 1 % Ex Crea | other | $6 | $6 to $23 | Low |
| Cannula Aortic Root 14ga Reg Tip #20014 | other | $6 | $6 to $23 | Low |
| Knife Straight Cresent | other | $6 | $6 to $23 | Low |
| Carrying Bag for Walker #6447 | other | $6 | $6 to $24 | Low |
| Pin Fixation L65mm Speed for Journey Ii Bcs Knee System 3ea/bx #74013480 | other | $6 | $6 to $24 | Low |
| Sling Sara Disposable #mfa3000 10/bx | other | $6 | $6 to $24 | Low |
| Injection, Fomepizole, 15 Mg | other | $6 | $6 to $4,491 | Low |
| Ertapenem (invanz) 1 Gm / 50 Ml Ns Mini-bag Plus - Compounded | other | $6 | $6 to $24 | Low |
| Tray Laceration Disp 12ea/1cs | other | $6 | $6 to $24 | Low |
| Amerigel Wound Dressing Gel | other | $6 | $6 to $24 | Low |
| Screening Test for Compatible Blood Unit, Using Reagent Serum | preventive | $6 | $6 to $86,902 | Low |
| Copilot #1003330 | other | $6 | $6 to $24 | Low |
| CPAP Mask Full Face Medium Disp #niv040m | other | $6 | $6 to $24 | Low |
| Crutches Underarm, Wood, Adjustable OR Fixed, Pair, with Pads, Tips and Handg... | other | $6 | $6 to $48 | Low |
| Laryngoscope Blade - Gvl 1 Stat #0270 | other | $6 | $6 to $24 | Low |
| Laryngoscope Blade - Gvl 2 Stat #0270 | other | $6 | $6 to $24 | Low |
| Splint, Prefabricated, Wrist OR Ankle | other | $6 | $6 to $48 | Low |
| Heart Left Vent Catheter 20fr | cardiac | $6 | $6 to $24 | Low |
| Splint Nasal Airway Doyle Ii | other | $6 | $6 to $24 | Low |
| Drive Walker Basket #563285 | other | $6 | $6 to $24 | Low |
| Oseltamivir 6 Mg/ml Suspension | other | $6 | $6 to $24 | Low |
| Pathology Examination of Tissue Using a Microscope | lab | $6 | $6 to $88,302 | Low |
| X-ray of Finger, Minimum of 2 Views | imaging | $6 | $6 to $73,140 | Low |
| CPAP Mask Full Face Small Disp #niv040s | other | $6 | $6 to $24 | Low |
| Complete Blood Cell Count (red Cells, White Blood Cell, Platelets), Automated... | other | $6 | $6 to $85,027 | Low |
| Cryoglobulin (protein) Measurement | other | $6 | $6 to $82,595 | Low |
| Iron Level | other | $6 | $6 to $83,540 | Low |
| Thyroid Hormone Evaluation | other | $6 | $6 to $84,479 | Low |
| White Blood Cell Count | other | $6 | $6 to $85,004 | Low |
| Amylase (enzyme) Level | other | $6 | $6 to $82,150 | Low |
| Diag Catheter 5fr Sim 1 #g08584 | cardiac | $7 | $7 to $24 | Low |
| Injection, Onabotulinumtoxina, 1 Unit | other | $7 | $7 to $4,748 | Low |
| Semen Analysis; Presence And/or Motility of Sperm Excluding Huhner | other | $7 | $7 to $90 | Low |
| Creatine Kinase (cardiac Enzyme) Level, Total | cardiac | $7 | $7 to $82,550 | Low |
| Trimming of Dystrophic Nails, Any Number | other | $7 | $7 to $120 | Low |
| Promethazine-codeine 6.25-10 Mg/5ml Po Syrp | other | $7 | $7 to $25 | Low |
| Promethazine-codeine Solution | other | $7 | $7 to $25 | Low |
| Ligating Clip Lrg Vesolock #61114v | other | $7 | $7 to $25 | Low |
| Knife V-lance Ophthalmic | other | $7 | $7 to $25 | Low |
| Arch Support Xlarge #mdy10540 | other | $7 | $7 to $25 | Low |
| Ketoconazole 2 % Ex Crea | other | $7 | $7 to $25 | Low |
| Gelfoam Sponge Sz 100 8cmx12.5cm Sterile | other | $7 | $7 to $25 | Low |
| Punch Aortic Rotating #rcb40 Sz 4.0 | other | $7 | $7 to $25 | Low |
| Punch Aortic Rotating #rcb45 Sz 4.5 | other | $7 | $7 to $25 | Low |
| Electrode Defib Pads Quik-combo Adult 1pk/1ea | other | $7 | $7 to $25 | Low |
| Scalpel Micro Feather 0.4mm | other | $7 | $7 to $25 | Low |
| Silver Sulfadiazine 1% Cream | other | $7 | $7 to $25 | Low |
| Blood Osmolality (concentration) Measurement | other | $7 | $7 to $83,930 | Low |
| Lithium Level | other | $7 | $7 to $80,178 | Low |
| Screening Test for Pathogenic Organisms | preventive | $7 | $7 to $87,081 | Low |
| Spinal/single Wall 20g X 15cm Needle | other | $7 | $7 to $25 | Low |
| Spinal/single Wall 22g X 15cm Needle | other | $7 | $7 to $25 | Low |
| Cannula Twist in 7x7mm Fully Threaded 5ea/1bx | other | $7 | $7 to $25 | Low |
| Cannula Twist-in 5.75mmx7cm | other | $7 | $7 to $25 | Low |
| Cannula Twist-in 6mm X 9cm | other | $7 | $7 to $25 | Low |
| Cannula Twist-in 7mm X 7 Partial Thread | other | $7 | $7 to $25 | Low |
| Cannula Twist-in 7mm X 7cm | other | $7 | $7 to $25 | Low |
| Cannula Twist-in 8.25mm X 7cm | other | $7 | $7 to $25 | Low |
| Cannula Twist-in 8.25mm X 9cm #ar | other | $7 | $7 to $25 | Low |
| Capella Coaxial Micro-introducer Kit Nitinol with Gold/tungsten Tip 5f Sheath... | other | $7 | $7 to $25 | Low |
| Cast Supplies, Long Arm Splint, Adult (11 Years +), Fiberglass | other | $7 | $7 to $50 | Low |
| Cast Supplies, Short Leg Splint, Adult (11 Years +), Fiberglass | other | $7 | $7 to $50 | Low |
| Finger Orthosis, Proximal Interphalangeal (pip)/distal Interphalangeal (dip),... | other | $7 | $7 to $50 | Low |
| Hdl Cholesterol Level | other | $7 | $7 to $83,718 | Low |
| Infusion, Albumin (human), 25%, 20 Ml | surgery | $7 | $7 to $50 | Low |
| Large Neurostimulator Fixation Belt #fp9000l | other | $7 | $7 to $25 | Low |
| Ocucoat 1ml 6/bx #cc065s | other | $7 | $7 to $25 | Low |
| Patient Programmer Case #casea10e | other | $7 | $7 to $25 | Low |
| Physician Review, Interpretation, and Patient Management of Home Inr Testing ... | other | $7 | $7 to $50 | Low |
| Preparation of Special Reports Beyond What Is Found in the Medical Record | other | $7 | $7 to $99,080 | Low |
| Purastat Adapter 10ea/bx#001 | other | $7 | $7 to $25 | Low |
| Rotation Tool Kit #6056 for Leads | other | $7 | $7 to $25 | Low |
| Splint Supplies, Miscellaneous | other | $7 | $7 to $50 | Low |
| Surgical Trays | surgery | $7 | $7 to $50 | Low |
| Uroseal Adjustable Endoscopic Valve 5ea/bx #bx00913410 | other | $7 | $7 to $25 | Low |
| Wrench Hex 7.6cm #sc-4276 Sc | other | $7 | $7 to $25 | Low |
| Adapter Tuohy-borst #g18813 | other | $7 | $7 to $25 | Low |
| Cath Soft Simplastic 20fr 3-way 30cc #570620 | other | $7 | $7 to $25 | Low |
| Cath Soft Simplastic 24fr 3way 30cc #570624 | other | $7 | $7 to $25 | Low |
| Sensica Uo Pt Ring ICU Sspk1025 25ea/1bx | other | $7 | $7 to $25 | Low |
| Sensica Uo Pt Ring OR Sror1025 25ea/1bx | other | $7 | $7 to $25 | Low |
| Vent Tube Venturi Reuter Bobbin #1070032 | other | $7 | $7 to $25 | Low |
| Concentration of Specimen for Infectious Agents | lab | $7 | $7 to $87,015 | Low |
| Terconazole 80 Mg Suppository | other | $7 | $7 to $25 | Low |
| Aztreonam 1 Gm/ Ns 50 Ml Mini Bag Plus - Compounded | other | $7 | $7 to $25 | Low |
| Magnesium Level | other | $7 | $7 to $83,735 | Low |
| Pin High Strength #9744 5ea/1bx | other | $7 | $7 to $25 | Low |
| Pin High Strength 3/32 X 9" 5ea/bx #9742 | other | $7 | $7 to $25 | Low |
| Fischer Cone Biopsy Excisor Medium Extended | lab | $7 | $7 to $25 | Low |
| Injection, Bortezomib, 0.1 Mg | other | $7 | $7 to $187 | Low |
| Cdm9801 10-0 Nylon 2xm1-160 (corneal Transpl | other | $7 | $7 to $25 | Low |
| Injection, Remdesivir, 1 Mg | other | $7 | $7 to $4,406 | Low |
| Eye-stream Solution | other | $7 | $7 to $25 | Low |
| Splint Nasal Reuter #15 | other | $7 | $7 to $25 | Low |
| Cortisone Shot (Joint Injection) | surgery | $7 | $7 to $1,984 | High |
| Hyaluronan OR Derivative, Durolane, for Intra-articular Injection, 1 Mg | other | $7 | $7 to $1,984 | Low |
| Tubing Irrigation Set #031229-10 10/pk | other | $7 | $7 to $25 | Low |
| Cannula Coronary Soft Tip Modified | cardiac | $7 | $7 to $26 | Low |
| Lidocaine Hcl 4% Solution | other | $7 | $7 to $26 | Low |
| M654g #6 Sternal Wire 4wires/pk 1pk=1ea | other | $7 | $7 to $26 | Low |
| Urine Osmolality (concentration) Measurement | other | $7 | $7 to $83,935 | Low |
| Haloperidol Lac 2 Mg/ml Conc | other | $7 | $7 to $26 | Low |
| Test of Car Seat OR Bed (1 Year OR Younger), Each Additional 30 Minutes | other | $7 | $7 to $94,781 | Low |
| Comfort Cool Thumb Cmc Left Small Plus | other | $7 | $7 to $26 | Low |
| Comfort Cool Thumb Cmc Left-large Plus | other | $7 | $7 to $26 | Low |
| Comfort Cool Thumb Cmc Left-medium Plus | other | $7 | $7 to $26 | Low |
| Comfort Cool Thumb Cmc Right Large Plus | other | $7 | $7 to $26 | Low |
| Comfort Cool Thumb Cmc Right Small Plus | other | $7 | $7 to $26 | Low |
| Comfort Cool Thumb Cmc Right-medium Plus | other | $7 | $7 to $26 | Low |
| Novolog 100 Unit/ml Flexpen | other | $7 | $7 to $26 | Low |
| Thyroxine (thyroid Chemical), Total | other | $7 | $7 to $84,436 | Low |
| CPAP Mask Full Face Large Disp #niv040l | other | $7 | $7 to $26 | Low |
| Coagulation Function Analysis, Agglutination Slide, Semiquantitative | other | $7 | $7 to $85,362 | Low |
| Lipase (fat Enzyme) Level | other | $7 | $7 to $83,690 | Low |
| Neupro 2 Mg/24 Hr Patch | other | $7 | $7 to $26 | Low |
| Adapter Connecting Ureteral Cath #uca5 | other | $7 | $7 to $26 | Low |
| Guidewire .045" Trocar Thrded #ar-8737 | other | $7 | $7 to $26 | Low |
| Insert Pad 61mm Surgical 15/bx | surgery | $7 | $7 to $26 | Low |
| Insert Pad 86mm/surg Clamp Fog | other | $7 | $7 to $26 | Low |
| Insert Pad Sz 5 10/bx #a0c04 | other | $7 | $7 to $26 | Low |
| Insertion Tray with Drainage Bag with Indwelling Catheter, Foley Type, Two-wa... | cardiac | $7 | $7 to $52 | Low |
| Insertion Tray without Drainage Bag with Indwelling Catheter, Foley Type, Two... | cardiac | $7 | $7 to $52 | Low |
| Molecular Pathology Procedure | lab | $7 | $7 to $81,479 | Low |
| Test for Allergy Using Allergenic Extract Injected Into Skin with Delayed Rea... | other | $7 | $7 to $95,028 | Low |
| Fentanyl 100 Mcg/hr Patch | other | $7 | $7 to $26 | Low |
| Pleur-evac Chest Drain System Single Collection Chamber 2500ml 16l/min Pleura... | other | $7 | $7 to $26 | Low |
| Measurement of Antibody to Infectious Organism | other | $7 | $7 to $86,000 | Low |
| Mini Enteral Extension Set Right Angle Connector with Y-port Adapter Amt Mini... | other | $7 | $7 to $26 | Low |
| Electrode Loop 15 X 12mm Electrosurgical OR Electrocautery 5.12 Inch Length 1... | surgery | $7 | $7 to $27 | Low |
| Moxifloxacin 0.5% Eye Drops | other | $7 | $7 to $27 | Low |
| CPAP Mask - Lge #73-1019480ea | other | $7 | $7 to $27 | Low |
| CPAP Mask - Med #73-1019479ea | other | $7 | $7 to $27 | Low |
| CPAP Mask - Small #73-1019478ea | other | $7 | $7 to $27 | Low |
| Hydrogel Dressing, Wound Filler, Gel, Per Fluid Ounce | other | $7 | $7 to $53 | Low |
| Ultrasound of Heart Blood Flow, Valves and Chambers, Follow-up | imaging | $7 | $7 to $93,321 | Low |
| X-ray of Shoulder, 1 View | imaging | $7 | $7 to $73,020 | Low |
| Tube Ultrasil Modified T-tube #70241072 | other | $7 | $7 to $27 | Low |
| Tube Vent Ultrasil Duravent #70241075 Implant | surgery | $7 | $7 to $27 | Low |
| Ball Electrode 3mm Vaginal #e1563 | other | $7 | $7 to $27 | Low |
| Electrode Loop 20x15mm Vag #e1562 | other | $7 | $7 to $27 | Low |
| Sleeve Scd Thigh Med Comfort #74012- 5pr/1cs | other | $7 | $7 to $27 | Low |
| Zinc Oxide 20 % Ex Oint | other | $7 | $7 to $27 | Low |
| Tray Jamshidi Bone Marrow Latex Free 1ea | other | $7 | $7 to $27 | Low |
| Dressing Mepilex 4x10 Post Op Ag 5/bx 498450 | other | $7 | $7 to $27 | Low |
| Kirschner Wire .045 Threaded #47-0262 | other | $7 | $7 to $27 | Low |
| Lead Cap 4033a | other | $7 | $7 to $27 | Low |
| Valve Hemostasis #hva | other | $7 | $7 to $27 | Low |
| Wet Mounts, Including Preparations of Vaginal, Cervical OR Skin Specimens | lab | $7 | $7 to $54 | Low |
| Cannula Soft Tip 25g | other | $7 | $7 to $27 | Low |
| Glutamyltransferase (liver Enzyme) Level | other | $7 | $7 to $82,977 | Low |
| Fluocinonide 0.05% Cream | other | $7 | $7 to $27 | Low |
| Diag Catheter 6fr Multipack #cp0255 5/bx | cardiac | $7 | $7 to $27 | Low |
| Injection, Aripiprazole (abilify Maintena), 1 Mg | other | $7 | $7 to $7,868 | Low |
| Interventional Kit K05-02131c | other | $7 | $7 to $27 | Low |
| Measurement for Strep Antibody | other | $7 | $7 to $86,060 | Low |
| Antimicrobial Study, Mycobacteria | other | $7 | $7 to $87,190 | Low |
| Crystal Identification From Tissue OR Body Fluid | other | $7 | $7 to $89,060 | Low |
| Medical Nutrition Therapy; Reassessment and Subsequent Intervention(s) Follow... | other | $7 | $7 to $55 | Low |
| Endovive Gastrostomy Tube with Enfit 24fr Straight5 Ea / Bx M00509941 | other | $7 | $7 to $28 | Low |
| G Tube 18fr Straight W/enfit M00509911 Bx/5ea | other | $7 | $7 to $28 | Low |
| G Tube 20fr Straight W/enfit M00509921 Bx/5ea | other | $7 | $7 to $28 | Low |
| Gastrostomy Tube Repl 16fr Straight M00582060 | other | $7 | $7 to $28 | Low |
| Gastrostomy Tube Repl 20fr Std Balloon Straig | other | $7 | $7 to $28 | Low |
| Gastrostomy Tube Repl 24fr Std Balloon Straig | other | $7 | $7 to $28 | Low |
| Gastrostomy/jejunostomy Tube, Standard, Any Material, Any Type, Each | other | $7 | $7 to $28 | Low |
| Proparacaine 0.5% Eye Drops | other | $7 | $7 to $28 | Low |
| Antivenin (latrodectus) Vial | other | $7 | $7 to $28 | Low |
| Ball Electrode 5mm Vaginal #e1564 | other | $7 | $7 to $28 | Low |
| Vardenafil Hcl 20 Mg Po Tabs | other | $7 | $7 to $28 | Low |
| X-ray of Heel, Minimum of 2 Views | imaging | $7 | $7 to $73,650 | Low |
| X-ray of Spine, 1 View | imaging | $7 | $7 to $72,020 | Low |
| Slitter Universal #6230uni Medtronic | other | $7 | $7 to $28 | Low |
| Special Stained Specimen Slides to Examine Tissue Including Interpretation an... | lab | $7 | $7 to $88,313 | Low |
| Logicut Disp Lap Coag Mp Scissor #120 | other | $7 | $7 to $28 | Low |
| Exam of Ear Using a Microscope | other | $7 | $7 to $92,504 | Low |
| Office OR Other Outpatient Visit for the Evaluation and Management of Establi... | other | $7 | $7 to $99,211 | Low |
| Outpatient Heart Rehabilitation, Qualified Health Care Professional Services | cardiac | $7 | $7 to $93,797 | Low |
| Red Blood Cell Fragility Measurement, Unincubated | other | $7 | $7 to $85,555 | Low |
| Tretinoin 0.025% Cream | other | $7 | $7 to $28 | Low |
| Wire Pass Drill #1608-002 | other | $7 | $7 to $28 | Low |
| Electrode Defib Pediatric Quick Combo 1ea | other | $7 | $7 to $28 | Low |
| Evaluation of Antimicrobial Drug | other | $7 | $7 to $87,184 | Low |
| Knee Pad-polar Wrap On Regular #04700 | other | $7 | $7 to $28 | Low |
| Nuclear Medicine Study of Remaining Urine in Bladder | imaging | $8 | $8 to $78,730 | Low |
| Gonadotropin (reproductive Hormone) Analysis | other | $8 | $8 to $84,703 | Low |
| Pacemaker Cable Adapter #adap-2000 | cardiac | $8 | $8 to $28 | Low |
| Anesthesia for Removal of Blood Clot From Upper Arm OR Elbow Artery | surgery | $8 | $8 to $8 | Low |
| Walker Extra Duty Folding Guardian 1ea | other | $8 | $8 to $28 | Low |
| Tunnelers-sheaths Disp On Q 11ga X 12" 5/bx | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Left-large | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Left-medium | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Left-small | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Left-xlarge | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Left-xsmall | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Rt-large | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Rt-medium | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Rt-small | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Rt-xlarge | other | $8 | $8 to $29 | Low |
| Roylan Wr&th Spica Rt-xsmall | other | $8 | $8 to $29 | Low |
| Lap Electrode L Hook 5 X 27mm | other | $8 | $8 to $29 | Low |
| Lap Spatula Tip Solid Shaft #60-5159 | other | $8 | $8 to $29 | Low |
| Dressing Aquacel Ag Advantage 3.5 X 10" #422605 10ea/bx | other | $8 | $8 to $29 | Low |
| Fungal Culture (mold OR Yeast) of Skin, Hair, OR Nail | lab | $8 | $8 to $87,101 | Low |
| Tube Trach 4.0 Ped Cuffless | other | $8 | $8 to $29 | Low |
| Tube Trach Ped 5.0 Cuffless | other | $8 | $8 to $29 | Low |
| Tube Trach Ped 5.5 Cuffless | other | $8 | $8 to $29 | Low |
| X-ray of Ankle, 2 Views | imaging | $8 | $8 to $73,600 | Low |
| X-ray of Elbow, 2 Views | imaging | $8 | $8 to $73,070 | Low |
| X-ray of Hand, 2 Views | imaging | $8 | $8 to $73,120 | Low |
| X-ray of Knee, 1-2 Views | imaging | $8 | $8 to $73,560 | Low |
| X-ray of Upper Arm, Minimum of 2 Views | imaging | $8 | $8 to $73,060 | Low |
| Blood Typing Rh Phenotyping | other | $8 | $8 to $86,906 | Low |
| Cefprozil 250 Mg/5ml Po Susr | other | $8 | $8 to $29 | Low |
| Catheter Phillips Follower 8fr Lf 10ea/bx | cardiac | $8 | $8 to $29 | Low |
| Closure Pilot Guide 15mm #pg-15s 5ea/bx | other | $8 | $8 to $29 | Low |
| Cyclomydril Eye Drops | other | $8 | $8 to $29 | Low |
| Cardioplegia Table Line #029463000 | other | $8 | $8 to $30 | Low |
| Interpulse Handpiece W/coaxial Highflo | other | $8 | $8 to $30 | Low |
| Short Cam Walker Lg #w0900blk | other | $8 | $8 to $30 | Low |
| Short Cam Walker Med #w0700blk | other | $8 | $8 to $30 | Low |
| Short Cam Walker Sm #w0500blk | other | $8 | $8 to $30 | Low |
| Veltassa 16.8 Gm Powder Packet | other | $8 | $8 to $30 | Low |
| Veltassa 8.4 Gm Powder Packet | other | $8 | $8 to $30 | Low |
| Catheter Phillips Follower 20fr Lf 10ea/bx | cardiac | $8 | $8 to $30 | Low |
| Lymphedema Foam 1/2" #cr-2-c 5ea/1cs | other | $8 | $8 to $30 | Low |
| Injection, Elotuzumab, 1 Mg | other | $8 | $8 to $9,370 | Low |
| Electrode Defib Preconnect Quik-combo 1st/1ea | other | $8 | $8 to $30 | Low |
| Mini Access Kit Stiff #s-mak501n | other | $8 | $8 to $30 | Low |
| Rybelsus 14 Mg Tablet | other | $8 | $8 to $30 | Low |
| Rybelsus 3 Mg Tablet | other | $8 | $8 to $30 | Low |
| Rybelsus 7 Mg Tablet | other | $8 | $8 to $30 | Low |
| Semaglutide 14 Mg Po Tabs | other | $8 | $8 to $30 | Low |
| Semaglutide 7 Mg Po Tabs | other | $8 | $8 to $30 | Low |
| Levemir Flexpen 100 Unit/ml | other | $8 | $8 to $30 | Low |
| Catheter H/s 5fr #ua61-5005 10/bx | cardiac | $8 | $8 to $30 | Low |
| Hyaluronan OR Derivative, Synvisc OR Synvisc-one, for Intra-articular Injecti... | other | $8 | $8 to $812 | Low |
| Tray Cath Surestep Urine Meter 14fr A319414am | other | $8 | $8 to $30 | Low |
| Tray Cath Surestep Urine Meter 18fr A319418am | other | $8 | $8 to $30 | Low |
| Vision Supply, Accessory And/or Service Component of Another Hcpcs Vision Code | other | $8 | $8 to $30 | Low |
| Cable PSA Disp #6651 | other | $8 | $8 to $30 | Low |
| Cane, Includes Canes of All Materials, Adjustable OR Fixed, with Tip | other | $8 | $8 to $60 | Low |
| Cast Supplies, Gauntlet Cast (includes Lower Forearm and Hand), Adult (11 Yea... | other | $8 | $8 to $60 | Low |
| Diag Catheter 6fr Jacky Radial 110cm #40 | cardiac | $8 | $8 to $30 | Low |
| Diag Catheter 6fr Radial Tig 110cm #40 | cardiac | $8 | $8 to $30 | Low |
| Diag Catheter 6fr Radial Tig 4.0 #40 | cardiac | $8 | $8 to $30 | Low |
| Electrical Stimulation, (unattended), to One OR More Areas, for Chronic Stage... | other | $8 | $8 to $60 | Low |
| Handling And/or Conveyance of Specimen for Transfer From Physician Office to ... | lab | $8 | $8 to $99,000 | Low |
| Indwelling Catheter; Specialty Type, (e.g., Coude, Mushroom, Wing, Etc.), Each | cardiac | $8 | $8 to $60 | Low |
| Iodine I-131 Sodium Iodide, Diagnostic, Per Microcurie | other | $8 | $8 to $60 | Low |
| Plastazote Sandal, Each | other | $8 | $8 to $60 | Low |
| Professional Service for Single Injection of Allergen | other | $8 | $8 to $95,115 | Low |
| Prostate Cancer Screening | other | $8 | $8 to $196 | High |
| Screening for Visual Sharpness | preventive | $8 | $8 to $99,173 | Low |
| Smoke Evac Pencil Push Button #0703-046 | other | $8 | $8 to $30 | Low |
| Cannula Aortic Root W/flow Guard 10/bx | other | $8 | $8 to $30 | Low |
| Gammaglobulin (immune System Protein) Measurement, Immunoglobulin Subclasses | other | $8 | $8 to $82,787 | Low |
| Injection, Vinorelbine Tartrate, 10 Mg | other | $8 | $8 to $368 | Low |
| X-ray of Both Knees While Standing | imaging | $8 | $8 to $73,565 | Low |
| X-ray of Wrist, 2 Views | imaging | $8 | $8 to $73,100 | Low |
| Algicell 4 X 4 #88044 4ea/1cs | other | $8 | $8 to $30 | Low |
| Measurement of Cold Agglutinin (protein) to Detect Infection OR Disease | other | $8 | $8 to $86,157 | Low |
| Bacterial Colony Count, Urine | other | $8 | $8 to $87,086 | Low |
| X-ray of Ankle, Minimum of 3 Views | imaging | $8 | $8 to $73,610 | Low |
| X-ray of Elbow, Minimum of 3 Views | imaging | $8 | $8 to $73,080 | Low |
| X-ray of Joint Between Lower Spine and Hip Bone, 1-2 Views | imaging | $8 | $8 to $72,200 | Low |
| X-ray of Nose Bones, Minimum of 3 Views | imaging | $8 | $8 to $70,160 | Low |
| X-ray of Paranasal Sinus, 1-2 Views | imaging | $8 | $8 to $70,210 | Low |
| X-ray of Pelvis, 1-2 Views | imaging | $8 | $8 to $72,170 | Low |
| X-ray of Sacrum and Tailbone, Minimum of 2 Views | imaging | $8 | $8 to $72,220 | Low |
| Urine Culture | lab | $8 | $8 to $87,088 | Low |
| Catheter Phillips Follower 14fr Lf 10ea/bx | cardiac | $8 | $8 to $31 | Low |
| Knife Orthopedic Hook Disp | other | $8 | $8 to $31 | Low |
| Dressing Ear Adult Glasscock #s | other | $8 | $8 to $31 | Low |
| Blood Test | lab | $8 | $8 to $80,047 | High |
| Ketone Bodies Analysis, Quantitative | other | $8 | $8 to $82,010 | Low |
| Short Can Walker Xl #w1100blk | other | $8 | $8 to $31 | Low |
| Dressing Mepilex 4x12 Post Op Ag 5/bx 498600 | other | $8 | $8 to $31 | Low |
| Transducer Trifucated Color Coded 10ea/1cs | other | $8 | $8 to $31 | 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 |
| Cannula 30ga 7mm | other | $8 | $8 to $31 | Low |
| Cast Supplies, Long Arm Cast, Pediatric (0-10 Years), Plaster | other | $8 | $8 to $132 | Low |
| Cast Supplies, Short Arm Splint, Adult (11 Years +), Plaster | other | $8 | $8 to $62 | Low |
| Clozex Skin Closure 60mm X 50mm Cl1060l | other | $8 | $8 to $31 | Low |
| Test for Ability to Detect and Repeat Spoken Words | other | $8 | $8 to $92,555 | Low |
| Wound Debridement Handpiece Vericare 6ea/1pk | other | $8 | $8 to $31 | Low |
| Wrench Kit #5873w | other | $8 | $8 to $31 | Low |
| Electronic Assessment of Bladder Emptying | other | $8 | $8 to $51,741 | Low |
| Pain Ease Mist Spray | other | $8 | $8 to $31 | Low |
| Lead Pacing Temp Myocardial #6500 | other | $8 | $8 to $31 | Low |
| Vent Tube Venturi Reuter Bobbin #1070031 | other | $8 | $8 to $31 | Low |
| Fluocinonide 0.05% Solution | other | $8 | $8 to $31 | Low |
| Tubes Micron Infant Titanium #145221 | other | $8 | $8 to $31 | Low |
| Boot Prevalon Heel Protector I #7305 8/cs | other | $8 | $8 to $31 | Low |
| Extended Exam Involving Color Vision Testing | other | $8 | $8 to $92,283 | Low |
| Kwire Marked 0.9mm L70mm #agk09070m | other | $8 | $8 to $32 | Low |
| Obturator Bladeless 8mm #470359 Intuitive Sur | other | $8 | $8 to $32 | Low |
| X-ray of Hand, Minimum of 3 Views | imaging | $8 | $8 to $73,130 | Low |
| X-ray of Wrist, Minimum of 3 Views | imaging | $8 | $8 to $73,110 | Low |
| Catheter Umbilical 3.5 Double Lumen 5ea/bx | cardiac | $8 | $8 to $32 | Low |
| Catheter Umbilical 5.0 Double Lumen 5ea/bx | cardiac | $8 | $8 to $32 | Low |
| Vac Pad Small Black 10ea/1ca | other | $8 | $8 to $32 | Low |
| X-ray of Jaw Joint On 1 Side of Mouth | imaging | $8 | $8 to $70,328 | Low |
| X-ray of Skull, 1-3 Views | imaging | $8 | $8 to $70,250 | Low |
| X-ray of Soft Tissue of Neck | imaging | $8 | $8 to $70,360 | Low |
| Irrigation Sys W/cleaning Tip & Suction Tb | other | $8 | $8 to $32 | Low |
| Nuclear Medicine Study of Thyroid Function | imaging | $8 | $8 to $78,012 | Low |
| Gastrostomy Tube Endovibe 20fr Rt Angle | other | $8 | $8 to $32 | Low |
| Gastrostomy Tube Repl 24fr Rt Angle | other | $8 | $8 to $32 | Low |
| Test to Assess Middle Ear Function | other | $8 | $8 to $92,567 | Low |
| Triamcinolone 0.1% Ointment | other | $8 | $8 to $32 | Low |
| Triamcinolone Acetonide 0.1 % Ex Oint | other | $8 | $8 to $32 | Low |
| Tube Vent .76mm Tiny Tylan Titanium Lf | other | $8 | $8 to $32 | Low |
| Administration of Nasal OR Oral Vaccine, Each Additional Vaccine | preventive | $9 | $9 to $90,474 | 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 |
| Calcium Gluconate (antidote) 2.5 % Ex Gel | other | $9 | $9 to $32 | Low |
| Cannula Passport Button 8 X 3cm 5ea/bx | other | $9 | $9 to $32 | Low |
| Cannula Passport Button 8 X 4cm 5ea/bx | other | $9 | $9 to $32 | Low |
| Cannula Passport Button 8x2cm Ar-6592-08 | other | $9 | $9 to $32 | Low |
| Lacosamide 10 Mg/ml Solution | other | $9 | $9 to $32 | Low |
| Nepro Carb Steady Liquid | other | $9 | $9 to $32 | Low |
| Pin Drill Guide 2.4mm 6ea/bx Ar-1250l | other | $9 | $9 to $32 | Low |
| Skin Test for Tuberculosis | other | $9 | $9 to $86,580 | Low |
| Test for Screening Hearing | preventive | $9 | $9 to $92,551 | Low |
| Sling Medium #mfa-1000m-m | other | $9 | $9 to $32 | Low |
| Sling Xl #mf-a1000m-xl | other | $9 | $9 to $32 | Low |
| Sling Xxlg #mf-a100m-xxlg | other | $9 | $9 to $32 | Low |
| Pillow Abduction Hip Large Disp #m60-031-l | other | $9 | $9 to $32 | Low |
| Injection, Epoetin Alfa, (for Non-esrd Use), 1000 Units | other | $9 | $9 to $563 | Low |
| Hydroxyzine Hcl 10 Mg/5ml Po Syrp | other | $9 | $9 to $32 | Low |
| Tray Cath Surstep Lf Urin Met 18fr #a319518am | other | $9 | $9 to $32 | Low |
| Floseal Applicator Curved #ads201815 | other | $9 | $9 to $32 | Low |
| Spiriva Respimat 2.5 Mcg Inh | other | $9 | $9 to $32 | Low |
| Stirrup Air Orth Left | other | $9 | $9 to $32 | Low |
| Stirrup Air Ortho. Right | other | $9 | $9 to $32 | Low |
| Urine Pregnancy Test | other | $9 | $9 to $81,025 | Low |
| Drainage Bag Aspira 1000ml#4992301 5ea/1bx | other | $9 | $9 to $32 | Low |
| Sleeve 0.9mm Microsmooth -eye | other | $9 | $9 to $32 | Low |
| Isentress 400 Mg Tablet | other | $9 | $9 to $32 | Low |
| Wrap Breast Sterile Comp Silverstein #sw001 Minimum Order 24 Each. Order Incr... | other | $9 | $9 to $32 | Low |
| Ortho Glass 2" X 15 #og-2l1 | other | $9 | $9 to $32 | Low |
| Evaluation of Antimicrobial Drug (antibiotic, Antifungal, Antiviral), Microdi... | other | $9 | $9 to $87,186 | Low |
| Wire Guide .025 X 40cm Fixed Core 10ea/1cs | other | $9 | $9 to $33 | Low |
| Dressing Aquacel Ag Advantage 3.5 X 14" #422607 10ea/bx | other | $9 | $9 to $33 | Low |
| Dressing Aquacel Ag Advantage 3.5 X 12" #420606 10ea/bx | other | $9 | $9 to $33 | Low |
| Snapsecure 1-layer Foley Catheter Tray Temp Sensing 100% Silicone Urine Meter... | cardiac | $9 | $9 to $33 | Low |
| Electrode Defib Radio-cmb#11996-000090 1st/1ea | other | $9 | $9 to $33 | Low |
| X-ray of Shoulder Blade | imaging | $9 | $9 to $73,010 | Low |
| X-ray of Part of Lower Jaw, 1-4 Views | imaging | $9 | $9 to $70,100 | Low |
| X-ray of Shoulder, Minimum of 2 Views | imaging | $9 | $9 to $73,030 | Low |
| Injection, Non-radioactive, Non-contrast, Visualization Adjunct (e.g., Methyl... | other | $9 | $9 to $1,066 | Low |
| Tube Trach 3.5 Ped Cuffless Shiley | other | $9 | $9 to $33 | Low |
| Iron Binding Capacity | other | $9 | $9 to $83,550 | Low |
| 0.054 Wire Ws-1407st | other | $9 | $9 to $33 | 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 |
| Cast Supplies, Long Arm Cast, Pediatric (0-10 Years), Fiberglass | other | $9 | $9 to $66 | Low |
| Wrench Kit St Jude #442 | other | $9 | $9 to $33 | Low |
| Catheter Trocar 16fr 10ea/1cs | cardiac | $9 | $9 to $33 | Low |
| Cannula Distal Rib Clr W/obturator 5.5mmx75mm | other | $9 | $9 to $33 | Low |
| Gentamicin 0.3% Eye Drop | other | $9 | $9 to $33 | Low |
| Zidovudine 50 Mg/5 Ml Syrup | other | $9 | $9 to $33 | Low |
| Smear for Parasites | other | $9 | $9 to $87,177 | Low |
| Micropuncture Kit 5fr #g43871 | other | $9 | $9 to $34 | Low |
| Terconazole 0.8% Cream | other | $9 | $9 to $34 | Low |
| Trach Tube Sz8 Lpc Non-fen Dct W/cannula | other | $9 | $9 to $34 | Low |
| Trach Tube Sz6 Lpc Non-fen Dct W/cannula | other | $9 | $9 to $34 | Low |
| Tube Trach Cuffless Sz 6 W/cannula #6cfs | other | $9 | $9 to $34 | Low |
| Tube Trach Cuffless Sz 8 W/cannula #8cfs | other | $9 | $9 to $34 | Low |
| Diag Catheter 6fr Barbeau 100cm #srd5897 5/bx | cardiac | $9 | $9 to $34 | Low |
| Thyroxine (thyroid Chemical), Free | other | $9 | $9 to $84,439 | Low |
| X-ray of Both Collar Bones Joints | imaging | $9 | $9 to $73,050 | Low |
| X-ray of Knee, 3 Views | imaging | $9 | $9 to $73,562 | Low |
| Influenza Vaccine, Trivalent, 0.25 Ml Dosage | preventive | $9 | $9 to $90,657 | Low |
| Skin Test for Candida | other | $9 | $9 to $86,485 | Low |
| Test to Examine How Well the Lungs Exchange Gases | other | $9 | $9 to $94,729 | Low |
| Tourniquet Emergency C-a-t 30 | emergency | $9 | $9 to $34 | Low |
| Injection, Ceftolozane 50 Mg and Tazobactam 25 Mg | other | $9 | $9 to $1,499 | Low |
| Bone Density Scan | imaging | $9 | $9 to $550 | High |
| Dxa Bone Density Measurement of Hip, Pelvis, Spine | other | $9 | $9 to $77,080 | Low |
| X-ray of Chest Bone, Minimum of 2 Views | imaging | $9 | $9 to $71,120 | Low |
| Forcep Biopsy Pediatric W/needle #m00513453 | lab | $9 | $9 to $34 | Low |
| Butorphanol 10 Mg/ml Spray | other | $9 | $9 to $34 | Low |
| Cannula Venous 24fr Malleable Single Stage | other | $9 | $9 to $34 | Low |
| Cannula Venous 26fr Malleable Single Stage | other | $9 | $9 to $34 | Low |
| Cannula Venous 28fr Malleable Single Stage | other | $9 | $9 to $34 | Low |
| Cannula Venous 30fr Malleable Single Stage | other | $9 | $9 to $34 | Low |
| Cannula Venous 32/40fr Two Stage #91263 | other | $9 | $9 to $34 | Low |
| Catheter Venous Return 34fr Malleable | cardiac | $9 | $9 to $34 | Low |
| Use of a Drug to Induce Depression of Consciousness By Physician Performing a... | other | $9 | $9 to $99,152 | Low |
| Collagen Dressing, Sterile, Size More Than 16 Sq. In. But Less Than OR Equal ... | other | $9 | $9 to $69 | Low |
| Clozex Skin Closure 80mm X 50mm Cl1080l | other | $9 | $9 to $35 | Low |
| Needle Accucore Biopsy 10/bx #640914 | lab | $9 | $9 to $35 | Low |
| Picc Introducer 4.5fr Micro Bard | other | $9 | $9 to $35 | Low |
| Picc Introducer 5.0fr Micro Bard | other | $9 | $9 to $35 | Low |
| Temno 18g X 6.0cm Biopsy Needle 5ea / Bx T186 | lab | $9 | $9 to $35 | Low |
| Interdry 10"x36"sheet Moist-wick Fabric 10/bx | other | $9 | $9 to $35 | Low |
| 6/7 Glidesheath Slender #50-1070 10ea/box | other | $9 | $9 to $35 | Low |
| Defib /electrode Peds Pd-2300 Zoll 6ea/1cs | other | $9 | $9 to $35 | Low |
| Gammaglobulin (immune System Protein) Measurement | other | $9 | $9 to $82,784 | Low |
| Cannula Viscoelastic Asp Ang 10mm 19g | other | $9 | $9 to $35 | Low |
| Cast Supplies, Short Arm Splint, Adult (11 Years +), Fiberglass | other | $9 | $9 to $70 | Low |
| Lead Pacing Temp Atrial Unipolar #6492-xf53 | other | $9 | $9 to $35 | Low |
| Lead Pacing Temp Pediatric #6491-xf53 | other | $9 | $9 to $35 | Low |
| Preparation of Tissue for Examination By Removing Any Calcium Present | other | $9 | $9 to $88,311 | Low |
| Professional Service for Multiple Injections of Allergen | other | $9 | $9 to $95,117 | Low |
| Repair of Orthotic Device, Labor Component, Per 15 Minutes | surgery | $9 | $9 to $70 | Low |
| Screening of Eye with Special Instrument Onsite Analysis | preventive | $9 | $9 to $99,177 | Low |
| See Sharp Temp Control Laparoscope Cleaning and Defogging with Long Trocar #3... | surgery | $9 | $9 to $35 | Low |
| Biopsy Inst Max-core Disposable Core #mc1820 | lab | $9 | $9 to $35 | Low |
| Fetal Hemoglobin OR Red Blood Cells Measurement for Assessment of Fetal-mater... | other | $9 | $9 to $85,461 | Low |
| Cefdinir 125 Mg/5 Ml Susp | other | $9 | $9 to $35 | Low |
| Defib /electrode Stat-pads Adult Zoll 12ea/cs | other | $9 | $9 to $35 | Low |
| X-ray of Middle Spine, 2 Views | imaging | $9 | $9 to $72,070 | Low |
| Stool Culture | lab | $9 | $9 to $87,045 | Low |
| Stool Culture, Additional Pathogens | lab | $9 | $9 to $87,046 | Low |
| Creatinine Clearance Measurement to Test for Kidney Function | other | $9 | $9 to $82,575 | Low |
| Bacterial Culture | lab | $9 | $9 to $87,075 | Low |
| Catheter Venous Return 36fr Malleable | cardiac | $9 | $9 to $36 | Low |
| Spinal Lumbar Puncture Adult 20gx3.5 #dynjts4301 10ea/case | other | $9 | $9 to $36 | Low |
| Dressing Mepilex 4x14 Post Op Ag 5/bx 498650 | other | $9 | $9 to $36 | Low |
| Caffeine Cit 60 Mg/3 Ml Oral | other | $10 | $10 to $36 | Low |
| Max-core Disposable Core Biopsy Instrument 16g X 16cm #mc1616 5ea/case | lab | $10 | $10 to $36 | Low |
| Spinal Tray-lumbar-infant 10ea/1cs | other | $10 | $10 to $36 | Low |
| Catheter Tray Foley Criticore 16fr Surestep | cardiac | $10 | $10 to $36 | Low |
| Interject Catheter #1836 25ga 7fr 240cm | cardiac | $10 | $10 to $36 | Low |
| Promethazine Hydrochloride, 12.5 Mg, Oral, Fda Approved Prescription Anti-eme... | other | $10 | $10 to $36 | Low |
| Tube Trach Cuffless Size 4cfn | other | $10 | $10 to $36 | Low |
| Tube Trach Cuffless Size 6cfn 1ea | other | $10 | $10 to $36 | Low |
| Tube Trach Cuffless Size 8cfn 1ea | other | $10 | $10 to $36 | 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 |
| Cast Supplies, Short Arm Cast, Adult (11 Years +), Fiberglass | other | $10 | $10 to $72 | Low |
| Clotting Factor X Assessment Test, Diluted | other | $10 | $10 to $85,613 | Low |
| Cannula Venous 34/46fr #91246 Two-stage | other | $10 | $10 to $36 | Low |
| Heart Muscle Strain Imaging | cardiac | $10 | $10 to $93,356 | Low |
| Breather/speech/rehab 1ea | other | $10 | $10 to $36 | Low |
| G6pd (enzyme) Level | other | $10 | $10 to $82,955 | Low |
| X-ray of Middle and Lower Spine, 2 Views | imaging | $10 | $10 to $72,080 | Low |
| Aldolase (enzyme) Level | other | $10 | $10 to $82,085 | Low |
| Hemoglobin A1C | lab | $10 | $10 to $83,036 | High |
| Fibrinogen (factor 1) Activity Measurement | other | $10 | $10 to $85,384 | Low |
| Irrigator Lap Suction Davol 12/cs #5102710 | other | $10 | $10 to $37 | Low |
| Thrombin-jmi 5,000 Units Vial | other | $10 | $10 to $37 | Low |
| Reuter-bobbin Vent Tube 1.27 Mm Lumen I.d. 1 Mm Interflange Stainless Steel 6... | other | $10 | $10 to $37 | Low |
| Rapid Rhino 5.5cm Rapid-pac Rr530 #rr 530 | other | $10 | $10 to $37 | Low |
| Softkit Black Univ Xsmall 283900010 | other | $10 | $10 to $37 | Low |
| Screening Test for Red Blood Cell Antibodies | preventive | $10 | $10 to $86,850 | Low |
| Trach Tube Sz4 Lpc Fen Disp Dfen W/cannula | other | $10 | $10 to $37 | Low |
| Trach Tube Sz6 Lpc Fen Disp Dfen W/cannula | other | $10 | $10 to $37 | Low |
| Trach Tube Sz8 Lpc Fen Disp Dfen W/cannula | other | $10 | $10 to $37 | Low |
| Hc Dressing Aquacel Extra | other | $10 | $10 to $37 | Low |
| Dressing Jumpstart Abs | other | $10 | $10 to $37 | Low |
| Cyclogyl 2% Eye Drops | other | $10 | $10 to $37 | Low |
| Phytonadione 5 Mg Po Tabs | other | $10 | $10 to $37 | Low |
| Phytonadione 5 Mg Tablet | other | $10 | $10 to $37 | Low |
| Aortical Surgical Flat 4.0 Punch #080-401 6ea/box | surgery | $10 | $10 to $37 | Low |
| Cervical OR Vaginal Cancer Screening; Pelvic and Clinical Breast Examination | preventive | $10 | $10 to $74 | Low |
| Semen Analysis Presence And/or Motility of Sperm | other | $10 | $10 to $89,300 | Low |
| Suction Coag Tips #ps300 | other | $10 | $10 to $37 | Low |
| Night Splint Lg #w | other | $10 | $10 to $37 | Low |
| Betamethasone Dp 0.05% Lot | other | $10 | $10 to $37 | Low |
| Softkit Black Univ Large/xlarge 283900013 | other | $10 | $10 to $37 | Low |
| Softkit Black Univ Medium 283900012 | other | $10 | $10 to $37 | Low |
| Softkit Black Univ Small 283900011 | other | $10 | $10 to $37 | Low |
| Ascorbic Acid (vitamin C) Level, Blood | other | $10 | $10 to $82,180 | Low |
| Perfusion Vavd W/specimen Trap 5/cs | surgery | $10 | $10 to $37 | Low |
| Staple Reload Ta 90mm Disposable Ta9048l 6/cs | other | $10 | $10 to $37 | Low |
| Hydrocolloid Dressing, Wound Cover, Sterile, Pad Size More Than 16 Sq. In. Bu... | other | $10 | $10 to $75 | Low |
| Shiley Tracheostomy Tube Uncuffed Id 6.5mm Od 9.4mm 62mm #4un65h | other | $10 | $10 to $38 | Low |
| Shiley Tracheostomy Tube Uncuffed Id 8.5mm Od 12.2mm 5mm | other | $10 | $10 to $38 | Low |
| Gatifloxacin 0.5 % Op Soln | other | $10 | $10 to $38 | Low |
| Insertion of Probe in Esophagus for Heart Ultrasound | imaging | $10 | $10 to $93,313 | Low |
| Pathology Examination of Tissue Using a Microscope, Moderately Low Complexity | lab | $10 | $10 to $88,304 | Low |
| X-ray of Joint Between Breast and Collar Bones, Minimum of 2 Views | imaging | $10 | $10 to $71,130 | Low |
| X-ray of Paranasal Sinus, Minimum of 3 Views | imaging | $10 | $10 to $70,220 | Low |
| X-ray of Upper Spine, 2-3 Views | imaging | $10 | $10 to $72,040 | Low |
| X-ray of Joint Between Lower Spine and Hip Bone, 3 OR More Views | imaging | $10 | $10 to $72,202 | Low |
| X-ray of Middle Spine, 3 Views | imaging | $10 | $10 to $72,072 | Low |
| Carnitor 100 Mg/ml Oral Soln | other | $10 | $10 to $38 | Low |
| Levocarnitine 1 Gm/10ml Po Soln | other | $10 | $10 to $38 | Low |
| Catheter Kumar Disp Ltx-free #cc | cardiac | $10 | $10 to $38 | Low |
| Clozex Skin Closure 100mm X 50mm Cl10100l | other | $10 | $10 to $38 | Low |
| Detection Test By Immunoassay Technique for Respiratory Syncytial Virus | other | $10 | $10 to $87,420 | Low |
| Endo Colon Spot Ex Tattoo #gis | other | $10 | $10 to $38 | Low |
| Drop Foot Splint Standard Sm Lt #pls-ff-100l | other | $10 | $10 to $38 | Low |
| Stiff Micropuncture Introducer #h787065971045 | other | $10 | $10 to $38 | 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 |
| Coagulation Function Measurement, D-dimer; Quantitative | other | $10 | $10 to $85,379 | Low |
| Stylet Glidescope Adult Single Use #0270 | other | $10 | $10 to $39 | Low |
| Wound Care Set, for Negative Pressure Wound Therapy Electrical Pump, Includes... | other | $10 | $10 to $77 | Low |
| Blood Culture | lab | $10 | $10 to $87,040 | Low |
| Fungal Culture, Yeast | lab | $10 | $10 to $87,106 | Low |
| Detection Test By Immunoassay Technique for Hepatitis B Surface Antigen | other | $10 | $10 to $87,340 | Low |
| X-ray of Lower and Sacral Spine, 2-3 Views | imaging | $10 | $10 to $72,100 | Low |
| Clindamycin (pedi) 75 Mg/5 Ml | other | $10 | $10 to $39 | Low |
| Clindamycin Palmitate Hcl 75 Mg/5ml Po Solr | other | $10 | $10 to $39 | Low |
| Expanula Port 8.25 X 7cm #ar | other | $10 | $10 to $39 | Low |
| Knee Stabilizer Pad #o-tksp-a | other | $10 | $10 to $39 | Low |
| Sleeve Scd Thigh Large Comfort #74013 3pr/1cs | other | $10 | $10 to $39 | Low |
| Lotronex 0.5 Mg Tablet | other | $10 | $10 to $39 | Low |
| Vac Pad Medium Black 10ea/1ca | other | $10 | $10 to $39 | Low |
| Temno 20g X 6.0cm Biopsy Needle 5ea / Bx T206 | lab | $10 | $10 to $39 | Low |
| Drop Foot Splint Standard Xlg Lt #pls-ff-400l | other | $10 | $10 to $39 | Low |
| Drop Foot Splint Standard Xlg Rt #pls-ff-400r | other | $10 | $10 to $39 | Low |
| Iodine I-131 Sodium Iodide Solution, Therapeutic, Per Millicurie | other | $10 | $10 to $78 | Low |
| Transfer Board W/slots 1ea | other | $10 | $10 to $39 | Low |
| Low Osmolar Contrast Material, 300-399 Mg/ml Iodine Concentration, Per Ml | other | $10 | $10 to $39 | Low |
| Commode Bedside 300lb Fixedarm Alum #cpat0002 | other | $10 | $10 to $39 | Low |
| Ldl Cholesterol Level | other | $11 | $11 to $83,721 | Low |
| Core Disposable Irrigation Cassette #5400-050 | other | $11 | $11 to $40 | Low |
| Flunisolide 0.025% Spray | other | $11 | $11 to $40 | Low |
| Injection, Paclitaxel Protein-bound Particles, 1 Mg | other | $11 | $11 to $4,977 | Low |
| Hem-o-lok Med/lrg #544230 6ea/cartidg 14ct/bx | other | $11 | $11 to $40 | Low |
| Ligating Clip Lrg Hemolok #544240 Teleflex | other | $11 | $11 to $40 | Low |
| Surgineedle 120mm #172015 | other | $11 | $11 to $40 | Low |
| Erythromycin 2 % Ex Soln | other | $11 | $11 to $40 | Low |
| Sulfamethoxazole-tmp Susp | other | $11 | $11 to $40 | Low |
| Needle Foramen 20ga 5.0 Parylene #041829 | other | $11 | $11 to $40 | Low |
| Infusion, Albumin (human), 5%, 50 Ml | surgery | $11 | $11 to $1,747 | Low |
| Application of Blood Vessel Compression Device | other | $11 | $11 to $97,016 | Low |
| Cast Supplies, Short Leg Cast, Adult (11 Years +), Fiberglass | other | $11 | $11 to $80 | Low |
| Cast Supplies, Short Leg Cast, Pediatric (0-10 Years), Fiberglass | other | $11 | $11 to $80 | Low |
| Drain Ep Sil 3/16" Zimmer #2540-007 | other | $11 | $11 to $40 | Low |
| Endocatch 10mm Gold Specimen Pouch #173050g | lab | $11 | $11 to $40 | Low |
| Hc Boot Cast Gelo Unna's-wch | other | $11 | $11 to $40 | Low |
| Inflation Device Encore 26 Vascular | other | $11 | $11 to $40 | Low |
| Orthotic and Prosthetic Supply, Accessory, And/or Service Component of Anothe... | other | $11 | $11 to $40 | Low |
| Stylet | other | $11 | $11 to $40 | Low |
| Stylet #6082-52cm | other | $11 | $11 to $40 | Low |
| Stylet 45cm Gray #6091-45cm | other | $11 | $11 to $40 | Low |
| Stylet Cap & Ring Sc-4395 | other | $11 | $11 to $40 | Low |
| Stylet Gray #6082-45cm | other | $11 | $11 to $40 | Low |
| Stylet Kit with Stylet Cap M365sc4385700 #sc-4385 | other | $11 | $11 to $40 | Low |
| Surgical Boot/shoe, Each | surgery | $11 | $11 to $80 | Low |
| Granufoam Thin Dressing #m8275081/10.s 10ea/case | other | $11 | $11 to $40 | Low |
| Drop Foot Splint Standard Med Lt #pls-ff-200l | other | $11 | $11 to $40 | Low |
| Gelfoam Size 100 Sponge | other | $11 | $11 to $40 | Low |
| For Diabetics Only, Multiple Density Insert, Direct Formed, Molded to Foot Af... | other | $11 | $11 to $40 | Low |
| Phenylephrine 10% Eye Drop | other | $11 | $11 to $40 | Low |
| Ceruloplasmin (protein) Level | other | $11 | $11 to $82,390 | Low |
| Hepatitis B Surface Antibody Measurement | other | $11 | $11 to $86,706 | Low |
| Protein Measurement, Serum | other | $11 | $11 to $84,165 | Low |
| Knife Retrograde Dyonics Disp | 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 |
| Culture for Acid-fast Bacilli | lab | $11 | $11 to $87,116 | Low |
| Reservoir Blood Collection Xres B #04259 6/cs | other | $11 | $11 to $41 | Low |
| Catheter 5fr Filiform W/spiral Tip V. Mueller Gu2075-105 10ea/bx | cardiac | $11 | $11 to $41 | Low |
| Nerve Locator/ Neuro Pulse 10/pk | other | $11 | $11 to $41 | Low |
| Cannula Venous T Flex Ds #trf2937o2 10ea/1cs | other | $11 | $11 to $41 | Low |
| Therapeutic Interventions That Focus On Cognitive Function (eg, Attention, Me... | other | $11 | $11 to $97,127 | Low |
| Velys Array Drill Pin 100mm X 4mm 4515-70-004 Minimum Order 10 Each | other | $11 | $11 to $41 | Low |
| **obsolete** Suture 0 Poly Prolene #833 | other | $11 | $11 to $41 | Low |
| Injection, Risperidone (risperdal Consta), 0.5 Mg | other | $11 | $11 to $4,517 | Low |
| Foley Cath 1.5cc 6fr #170003060 | other | $11 | $11 to $41 | Low |
| Injection, Romiplostim, 1 Microgram | other | $11 | $11 to $16,516 | Low |
| X-ray of Jaw Joints On Both Sides of Mouth | imaging | $11 | $11 to $70,330 | Low |
| X-ray of Middle Spine, Minimum of 4 Views | imaging | $11 | $11 to $72,074 | Low |
| Stiolto Respimat Inhaler | other | $11 | $11 to $42 | Low |
| Aminocaproic Acid 500 Mg Tab | other | $11 | $11 to $42 | Low |
| Cervical, Semi-rigid, Adjustable | other | $11 | $11 to $86 | Low |
| Foley Urinary Catheter 18fr 5ml Silicone Council Tip #0196si18 12ea/cs | cardiac | $11 | $11 to $42 | Low |
| Nucleotidase 5' (enzyme) Level | other | $11 | $11 to $83,915 | Low |
| Ultrasound Study of Arm and Leg Arteries | imaging | $11 | $11 to $93,922 | Low |
| Dermatac Drape W/granufoam Dressing Small10pk | other | $11 | $11 to $42 | Low |
| Imaging of Organ | other | $11 | $11 to $76,120 | Low |
| Tacrolimus Level | other | $11 | $11 to $80,197 | Low |
| Drop Foot Splint Standard Lg Lt #pls-ff-300l | other | $11 | $11 to $42 | Low |
| Drop Foot Splint Standard Lg Rt #pls-ff-300r | other | $11 | $11 to $42 | Low |
| Drop Foot Splint Standard Med Rt #pls-ff-200r | other | $11 | $11 to $42 | Low |
| Drop Foot Splint Standard Sm Rt #pls-ff-100r | other | $11 | $11 to $42 | Low |
| Trach Tube 6dct #6cn75h | other | $11 | $11 to $42 | Low |
| Clobetasol 0.05% Solution | other | $11 | $11 to $42 | Low |
| Trach Sz 8 Shiley Cuffed Trach Cann 8.5mm #8cn85h | other | $11 | $11 to $42 | Low |
| Trach Tube 4dct #4cn65h | other | $11 | $11 to $42 | Low |
| Drain Hemovac Replacement 5ea/1bx #00-2555-050 | surgery | $11 | $11 to $42 | Low |
| Splint Denver Nasal Thermoplastic Sm #10-4021-05ks 5/bx | other | $11 | $11 to $42 | Low |
| Measurement of Hepatitis a Antibody | other | $11 | $11 to $86,709 | Low |
| Pediatric Tracheostomy Tube Shiley Cuffless 4.0mm Id 6.0mm Od Medtronic 4.0pe... | other | $11 | $11 to $42 | Low |
| Butrans 5 Mcg/hr Patch | other | $11 | $11 to $42 | Low |
| Nasal 7.5 Epistaxis Ant/posterior 10ea/1bx | other | $11 | $11 to $43 | Low |
| X-ray of Lower Jaw, Minimum of 4 Views | imaging | $11 | $11 to $70,110 | Low |
| Immobilizer Shoulder Lg W/block Deroyal | other | $11 | $11 to $43 | Low |
| Immobilizer Shoulder Med W/block Deroyal | other | $11 | $11 to $43 | Low |
| Immobilizer Shoulder Small W/block Deroyal | other | $11 | $11 to $43 | Low |
| Zinc Level | other | $11 | $11 to $84,630 | Low |
| Tube Trach Cuff Size 8 Low Pressure | other | $11 | $11 to $43 | Low |
| Tube Trach Cuff Sz-6 Low Pressure | other | $11 | $11 to $43 | Low |
| Tube Trach Cuffless Sz 4 W/cannula #4cfs | other | $11 | $11 to $43 | Low |
| Laser Trach Tube 3.0 #86400 Uncuffed | other | $11 | $11 to $43 | Low |
| Laser Trach Tube 3.5 #86401 Uncuffed | other | $11 | $11 to $43 | Low |
| Laser Trach Tube 4.0 #86402 Uncuffed | other | $11 | $11 to $43 | Low |
| Insulin Measurement, Total | other | $11 | $11 to $83,525 | Low |
| Detection Test By Immunoassay with Direct Visual Observation for Streptococcu... | other | $11 | $11 to $87,880 | Low |
| Pin Guide 2.8 #ar | other | $11 | $11 to $43 | Low |
| Provisc #8065-18 | other | $11 | $11 to $43 | Low |
| Analysis for Antibody to Coccidioides | other | $11 | $11 to $86,635 | Low |
| Trach Sz 10 Shiley Cuffed Trach Cann 10.0mm 10cn10h | other | $11 | $11 to $43 | Low |
| Prosthetic Sock, Multiple Ply, Below Knee, Each | other | $12 | $12 to $43 | Low |
| Ultrasound Mak Kit #k12t-05493a **must Order Increments of 10 Each** | imaging | $12 | $12 to $43 | Low |
| Analysis of Substance Using Immunoassay Technique, Multiple Step Method | other | $12 | $12 to $83,516 | Low |
| Detection of Pancreatic Elastase (enzyme) in Stool | other | $12 | $12 to $82,656 | Low |
| Detection Test By Immunoassay Technique for Hepatitis Be Surface Antigen | other | $12 | $12 to $87,350 | Low |
| Screening Test for Presence of Antibody | preventive | $12 | $12 to $86,403 | Low |
| Creatine Kinase (cardiac Enzyme) Level, Mb Fraction Only | cardiac | $12 | $12 to $82,553 | Low |
| Cath Cholangiogram Orc-b | other | $12 | $12 to $44 | Low |
| Hepatitis Be Antibody Measurement | other | $12 | $12 to $86,707 | Low |
| Lactic Acid Level | other | $12 | $12 to $83,605 | Low |
| Clindamycin Ph 1% Gel | other | $12 | $12 to $44 | Low |
| Protein S (clotting Inhibitor) Level | other | $12 | $12 to $85,305 | Low |
| Single Action Pumping Sys #m0067201001 | other | $12 | $12 to $44 | Low |
| Vitamin a Level | other | $12 | $12 to $84,590 | Low |
| Prednisolone Oral, Per 5 Mg | other | $12 | $12 to $44 | Low |
| Splint Nasal Intranasal 15-24050 5ea/1bx | other | $12 | $12 to $44 | Low |
| Psychiatric Services Complicated By Communication Factor | therapy | $12 | $12 to $90,785 | Low |
| Blood Viscosity Measurement | other | $12 | $12 to $85,810 | Low |
| Pulmonary Biopsy Forcep Rj4 #m0515181 | lab | $12 | $12 to $44 | Low |
| Injection, Lincomycin Hcl, Up to 300 Mg | other | $12 | $12 to $44 | Low |
| Laser Flex Trach Tube 4.5mm #86397 Cuffed | other | $12 | $12 to $44 | Low |
| Laser Flex Trach Tube 5.5 #86395 Cuffed | other | $12 | $12 to $44 | Low |
| Laser Flex Tracheal Tube 6.0 Cuffed | other | $12 | $12 to $44 | Low |
| Test to Determine Lung Volumes Using Gas Dilution OR Washout | other | $12 | $12 to $94,727 | Low |
| Test to Determine Lung Volumes Using Sensors | other | $12 | $12 to $94,726 | Low |
| Influenza Vaccine, Trivalent, Split Virus, Preservative-free, 0.5 Ml Dosage | preventive | $12 | $12 to $90,656 | Low |
| Urethral Needle for Macroplastique | other | $12 | $12 to $44 | Low |
| Vac Soft White Foam Sys Sm 10"x 7.5" M8275068 | other | $12 | $12 to $44 | Low |
| Pleuravac - Infant #a-8020-08lf | other | $12 | $12 to $44 | Low |
| Hepatitis B Core Antibody (igm) Measurement | other | $12 | $12 to $86,705 | Low |
| Cannula Aortic Ez Glide 21fr X 35cm Ezs21ta | other | $12 | $12 to $44 | Low |
| Betamethasone Dp 0.05% Oint | other | $12 | $12 to $44 | Low |
| Cement Mix Bowl Quick Vac Vacuum | other | $12 | $12 to $45 | Low |
| Antithrombin Iii Antigen (clotting Inhibitor) Activity | other | $12 | $12 to $85,300 | Low |
| Immobilizer Shoulder Xlg W/block Deroyal | other | $12 | $12 to $45 | Low |
| Topiramate Level | other | $12 | $12 to $80,201 | Low |
| Cannula Endo 5fr Biliary ERCP 5-4-3 M00530880 | other | $12 | $12 to $45 | Low |
| Cor-knot Quick Load Singles #030850 | other | $12 | $12 to $45 | Low |
| Foot, Arch Support, Removable, Premolded, Metatarsal, Each | other | $12 | $12 to $90 | Low |
| Introducer Peritoneal Taut #pi | other | $12 | $12 to $45 | Low |
| Presto Inflation High Pressure Device with 30cc Barrel 5ea/ca Id4030 | other | $12 | $12 to $45 | Low |
| Screening of Eye with Special Instrument with Remote Analysis | preventive | $12 | $12 to $99,174 | Low |
| Splint, Prefabricated, Elbow | other | $12 | $12 to $90 | Low |
| Detection Test By Immunoassay Technique for Aspergillus | other | $12 | $12 to $87,305 | Low |
| Detection Test By Immunoassay Technique for Clostridium Difficile Toxins | other | $12 | $12 to $87,324 | Low |
| Detection Test By Immunoassay Technique for Giardia | other | $12 | $12 to $87,329 | Low |
| Detection Test By Immunoassay Technique for Other Organism | other | $12 | $12 to $87,449 | Low |
| Detection Test By Immunoassay Technique for Rotavirus | other | $12 | $12 to $87,425 | Low |
| Tray Epidural #182221 Ballard | other | $12 | $12 to $45 | Low |
| X-ray of Face Bones, Minimum of 3 Views | imaging | $12 | $12 to $70,150 | Low |
| Measurement of Complement (immune System Proteins), Antigen | other | $12 | $12 to $86,160 | Low |
| Protein C, (clotting Inhibitor) Activity | other | $12 | $12 to $85,302 | Low |
| Pentam 300 Mg Vial | other | $12 | $12 to $45 | Low |
| Brexpiprazole 2 Mg Po Tabs | other | $12 | $12 to $45 | Low |
| Rexulti 1 Mg Tablet | other | $12 | $12 to $45 | Low |
| Rexulti 2 Mg Tablet | other | $12 | $12 to $45 | Low |
| Hepatitis B Core Antibody Measurement | other | $12 | $12 to $86,704 | Low |
| Marker Scar Spee-d-line 3d Digital Breast | other | $12 | $12 to $45 | Low |
| Screening Test for Antibody to Noninfectious Agent | preventive | $12 | $12 to $86,255 | Low |
| Screening Test for Autoimmune Disorder | preventive | $12 | $12 to $86,038 | Low |
| Shiley Pediatric Tracheostomy Tube Cuffless 3.0mm Id 4.8mm Od 39mm 3.0 Pef #3... | other | $12 | $12 to $46 | Low |
| Shiley Pediatric Tracheostomy Tube Cuffless 4.5mm Id 6.7mm Od 42mm 4.5 Pef #4... | other | $12 | $12 to $46 | Low |
| Lead Level | other | $12 | $12 to $83,655 | Low |
| Infusion Set Rapid #d-60hl Smith Med.10ea/1cs | surgery | $12 | $12 to $46 | Low |
| Catheter Duplocath Application 35cm #1506166 Be-10-01-106 for Billing Reference | cardiac | $12 | $12 to $46 | Low |
| Shiley Tracheostomy Tube Twist Lock Ic Size 10.0 Adult #10fen | other | $12 | $12 to $46 | Low |
| Tube Trach Cuff Size 6fen 1ea | other | $12 | $12 to $46 | Low |
| Tube Trach Cuff Size 8fen 1ea | other | $12 | $12 to $46 | Low |
| X-ray of Ribs On Side of Body, Minimum of 3 Views | imaging | $12 | $12 to $71,101 | 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 |
| Assessment of Emotional OR Behavioral Problems | other | $12 | $12 to $96,127 | Low |
| Trocar 15mm X 100 6/bx #c0r37 | other | $12 | $12 to $46 | Low |
| Cannula 15fr Coronary Ostial Perfusion | surgery | $12 | $12 to $46 | Low |
| Cannula 17fr Coronary Ostial Perfusion | surgery | $12 | $12 to $46 | Low |
| Cannula 20fr Coronary Ostial Perfusion | surgery | $12 | $12 to $46 | Low |
| Lumbar Support Basic Xlrg #10155 | other | $12 | $12 to $46 | Low |
| Sheath Storz/xomed 4mm/30" #1912010 Sc | other | $12 | $12 to $46 | Low |
| Sheath Storz/xomed 4mm/45" #1912013 Sc | other | $12 | $12 to $46 | Low |
| Carboxyhemoglobin (protein) Level | other | $12 | $12 to $82,375 | Low |
| Injection, Inclisiran, 1 Mg | other | $12 | $12 to $6,763 | Low |
| Test to Assess Middle Ear Muscle Reflex | other | $12 | $12 to $92,568 | Low |
| Copper Level | other | $12 | $12 to $82,525 | Low |
| Review By Radiologist of Bile And/or Pancreatic Duct Image During Surgery | surgery | $12 | $12 to $74,300 | Low |
| Troponin (protein) Analysis, Quantitative | other | $12 | $12 to $84,484 | Low |
| Evaluation of Use of Breathing Device | other | $13 | $13 to $94,664 | Low |
| Stylet S 53-j | other | $13 | $13 to $47 | Low |
| Stylet S 53-jl | other | $13 | $13 to $47 | Low |
| Stylet S 53-s | other | $13 | $13 to $47 | Low |
| Stylet S53-k | other | $13 | $13 to $47 | Low |
| Torque Wrench | other | $13 | $13 to $47 | Low |
| Tobramycin-dexameth Ophth Susp | imaging | $13 | $13 to $47 | Low |
| Tobramycin-dexamethasone 0.3-0.1 % Op Susp | imaging | $13 | $13 to $47 | Low |
| Deluxe Paring Board 1ea | other | $13 | $13 to $47 | Low |
| X-ray for Bone Length Assessment | imaging | $13 | $13 to $77,073 | Low |
| Neomyc-polym-gramicid Eye Drop | other | $13 | $13 to $47 | Low |
| X-ray of Upper Spine, 4-5 Views | imaging | $13 | $13 to $72,050 | Low |
| Cath Word Bartholin Gland 10fr 6ea/1bx | other | $13 | $13 to $47 | Low |
| Haptoglobin (serum Protein) Level | other | $13 | $13 to $83,010 | Low |
| Cannula Arterial 18fr Eopa Elongated One Piec | other | $13 | $13 to $47 | Low |
| Cannula Arterial 20fr Eopa Elongated One Piec | other | $13 | $13 to $47 | Low |
| Cannula Arterial 22fr Eopa Elongated One Piec | other | $13 | $13 to $47 | Low |
| Boot Prevalon Iii W/wedge #7355 8ea/cs | other | $13 | $13 to $48 | Low |
| Injection, Insulin, Per 5 Units | other | $13 | $13 to $48 | Low |
| Insulin for Administration Through DME (i.e., Insulin Pump) Per 50 Units | other | $13 | $13 to $48 | Low |
| Prosthetic Sock, Multiple Ply, Above Knee, Each | other | $13 | $13 to $48 | Low |
| X-ray of Skull, Minimum of 4 Views | imaging | $13 | $13 to $70,260 | Low |
| Iodosorb Gel | other | $13 | $13 to $48 | Low |
| Muscle Biopsy Clamp Rayport 12mm #su130 | lab | $13 | $13 to $48 | Low |
| Tube Endobronchial 35fr Left #125035 | other | $13 | $13 to $48 | Low |
| Tube Endobronchial 37fr Left #125037 | other | $13 | $13 to $48 | Low |
| Tube Endobronchial 39fr Left #125039 | other | $13 | $13 to $48 | Low |
| Tube Endobronchial 41fr Left #125041 | other | $13 | $13 to $48 | Low |
| Surgiclip Lrg 13.0 #134048 | other | $13 | $13 to $48 | Low |
| Surgiclip Sm 9.0 #133650 | other | $13 | $13 to $48 | Low |
| Tube Trach Metal Jackson Sz 7 #pm1034317 | other | $13 | $13 to $48 | Low |
| Transferrin (iron Binding Protein) Level | other | $13 | $13 to $84,466 | Low |
| Haemophilus Influenzae Type B Vaccine, Prp-omp Conjugate | preventive | $13 | $13 to $90,647 | Low |
| Ligaclip Medium 11.5 6/bx #134053 | other | $13 | $13 to $48 | Low |
| Sensor Rectal Pressure #pg | other | $13 | $13 to $48 | Low |
| Sensor Vaginal Emg #pg | other | $13 | $13 to $48 | Low |
| Surgiclip Med 9.75 6 Ea/bx #134051 | other | $13 | $13 to $48 | Low |
| Vac Pad Large Black 10ea/1ca | other | $13 | $13 to $48 | Low |
| X-ray of Hip, Minimum of 4 Views | imaging | $13 | $13 to $73,503 | Low |
| Irrigation Sys Bard Assist #160130 | other | $13 | $13 to $48 | Low |
| Blood Glucose (sugar) Tolerance Test, 3 Specimens | lab | $13 | $13 to $82,951 | Low |
| Chemical Analysis of Stone | other | $13 | $13 to $82,360 | Low |
| Hemoglobin Analysis and Measurement, Electrophoresis | other | $13 | $13 to $83,020 | 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 |
| Analysis for Antibody to Blastomyces | other | $13 | $13 to $86,612 | Low |
| Avitene Ultrafoam Collagen Sponge 100 SQ Cm 8cm X 12.5cm 3-1/18" X 5" 1050040 | other | $13 | $13 to $49 | Low |
| Catheter Kit 5.0" Pain On Q Silversoaker 5/bx | cardiac | $13 | $13 to $48 | Low |
| Hydroxyindolacetic Acid (product of Metabolism) Level | other | $13 | $13 to $83,497 | Low |
| Infrared Analysis of Stone | other | $13 | $13 to $82,365 | Low |
| Myoglobin (muscle Protein) Level | other | $13 | $13 to $83,874 | Low |
| Tube Trach Metal Jackson Sz 5 #pm1034915 | other | $13 | $13 to $49 | Low |
| Measurement C-reactive Protein for Detection of Infection OR Inflammation, Hi... | other | $13 | $13 to $86,141 | Low |
| Measurement of Antibody for Rheumatoid Arthritis Assessment | other | $13 | $13 to $86,200 | Low |
| Clotting Factor Ii Prothrombin, Measurement | other | $13 | $13 to $85,210 | Low |
| Rbn-114 Bone Marrow Biopsy Needle 11 Gauge X 4" Snarecoil Box/10each | lab | $13 | $13 to $49 | Low |
| Rbn-116 Bone Marrow Biopsy Needle 11 Gauge X 6" Snarecoil Box/10each | lab | $13 | $13 to $49 | Low |
| Ustekinumab, for Intravenous Injection, 1 Mg | other | $13 | $13 to $4,047 | 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 Enterovirus | other | $13 | $13 to $86,658 | Low |
| Hydro-surg Plus Laparoscopic Irrigator with Nezhat-dorsey Smokevac Trumpet Va... | surgery | $13 | $13 to $49 | Low |
| Immobilizer Arm/shoulder Atlas#00052 Breg | other | $13 | $13 to $49 | Low |
| Safety Amniocentesis 20gx3.5 29-am1sfa 10ea/case | other | $13 | $13 to $49 | Low |
| Analysis for Antibody to Mumps Virus | other | $13 | $13 to $86,735 | Low |
| Buprenorphine 10 Mcg/hr Patch | other | $13 | $13 to $49 | Low |
| Heparin Assay | other | $13 | $13 to $85,520 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Early Antigen | other | $13 | $13 to $86,663 | Low |
| Ultrasonic Guidance for Blood Vessel Access | other | $13 | $13 to $76,937 | Low |
| Immobilizer Sling Shot Sz Large Breg | other | $13 | $13 to $49 | Low |
| Immobilizer Sling Shot Sz Medium | other | $13 | $13 to $49 | Low |
| Immobilizer Sling Shot Sz Small | other | $13 | $13 to $49 | Low |
| Immobilizer Sling Shot Sz Xlarge Breg | other | $13 | $13 to $49 | Low |
| Lap Probe Monopolar J Hook Tip | other | $13 | $13 to $49 | Low |
| Viscera Retainer-medium Hs3204-1 Bx/10 | other | $13 | $13 to $50 | Low |
| Analysis for Antibody to Mycoplasma | other | $13 | $13 to $86,738 | Low |
| Tube Ear Ventilation Richards T 1.14mm 240071 | other | $13 | $13 to $50 | Low |
| Lamotrigine Level | other | $13 | $13 to $80,175 | Low |
| Levetiracetam Level | other | $13 | $13 to $80,177 | Low |
| Oxcarbazepine Level | other | $13 | $13 to $80,183 | Low |
| Phenytoin Level, Total | other | $13 | $13 to $80,185 | Low |
| Zonisamide Level | other | $13 | $13 to $80,203 | Low |
| Nasal 4.5 Epistaxis Anterior 10ea/1bx | other | $13 | $13 to $50 | Low |
| Nasal 5.5 Epistaxis Anterior 10ea/1bx | other | $13 | $13 to $50 | Low |
| Cannula Endo 1.83mm X 210cm Tandem M00545820 | other | $13 | $13 to $50 | Low |
| Nystatin-triamcinolone 100000-0.1 Unit/gm-% Ex Oint | other | $13 | $13 to $50 | Low |
| Nystatin-triamcinolone Ointm | other | $13 | $13 to $50 | Low |
| Digoxin Level, Total | other | $13 | $13 to $80,162 | Low |
| Guardian Ii Hemostasis Valve #8211 | other | $13 | $13 to $50 | Low |
| Polymyxin B-trimethoprim 10000-0.1 Unit/ml-% Op Soln | other | $13 | $13 to $50 | 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 |
| Bacteriostatic Saline Vial | other | $13 | $13 to $50 | Low |
| Bupivacaine-epinephrine (pf) 0.5% -1:200000 Ij Soln | other | $13 | $13 to $50 | Low |
| Caffeine Cit 60 Mg/3 Ml Vial | other | $13 | $13 to $50 | Low |
| Cefazolin 5 Mg/ml + Heparin 2500 Units/ml Antibiotic Catheter Mixture - Compo... | cardiac | $13 | $13 to $50 | Low |
| Detection Test By Nucleic Acid for Strep (streptococcus, Group A), Amplified ... | other | $13 | $13 to $87,651 | Low |
| Dextrose 2.5%-0.45% Nacl IV | other | $13 | $13 to $50 | Low |
| Dextrose 5%-0.2% Nacl IV Soln | other | $13 | $13 to $50 | Low |
| Dextrose 5%-0.45% Nacl IV Soln | other | $13 | $13 to $50 | Low |
| Diltiazem 25 Mg/5 Ml Vial | other | $13 | $13 to $50 | Low |
| Encore 40 Inflation Device M001394472540 | other | $13 | $13 to $50 | Low |
| Etomidate 2 Mg/ml IV Soln | other | $13 | $13 to $50 | Low |
| Evoke Epidural Needle 6.5' #3014 | other | $13 | $13 to $50 | Low |
| Flu Vaccination | preventive | $13 | $13 to $100 | High |
| Haemophilus Influenzae Type B Vaccine, Prp-t Conjugate | preventive | $13 | $13 to $90,648 | Low |
| Hc Dress Duoderm 5.5 X 5.5 Signal | other | $13 | $13 to $50 | Low |
| Influenza Vaccine, Quadrivalent for Nasal Administration | preventive | $13 | $13 to $90,672 | Low |
| Infusion, Normal Saline Solution, 250 Cc | surgery | $13 | $13 to $50 | Low |
| Injection Fluconazole, 200 Mg | other | $13 | $13 to $50 | Low |
| Injection, Acetaminophen (fresenius Kabi), Not Therapeutically Equivalent to ... | other | $13 | $13 to $50 | Low |
| Injection, Acetylcysteine, 100 Mg | other | $13 | $13 to $50 | Low |
| Injection, Amikacin Sulfate, 100 Mg | other | $13 | $13 to $50 | Low |
| Injection, Amiodarone Hydrochloride, 30 Mg | other | $13 | $13 to $50 | Low |
| Injection, Ampicillin Sodium, 500 Mg | other | $13 | $13 to $50 | Low |
| Injection, Ampicillin Sodium/sulbactam Sodium, Per 1.5 Gm | other | $13 | $13 to $50 | Low |
| Injection, Atropine Sulfate, 0.01 Mg | other | $13 | $13 to $50 | Low |
| Injection, Bumetanide, 0.5 Mg | other | $13 | $13 to $50 | Low |
| Injection, Butorphanol Tartrate, 1 Mg | other | $13 | $13 to $50 | Low |
| Injection, Calcium Gluconate, Not Otherwise Specified, 10 Mg | other | $13 | $13 to $50 | Low |
| Injection, Ceftazidime, Per 500 Mg | other | $13 | $13 to $50 | Low |
| Injection, Ciprofloxacin for Intravenous Infusion, 200 Mg | surgery | $13 | $13 to $50 | Low |
| Injection, Clindamycin Phosphate, 300 Mg | other | $13 | $13 to $50 | Low |
| Injection, Dicyclomine Hcl, Up to 20 Mg | other | $13 | $13 to $50 | Low |
| Injection, Digoxin, Up to 0.5 Mg | other | $13 | $13 to $50 | Low |
| Injection, Diphenhydramine Hcl, Up to 50 Mg | other | $13 | $13 to $50 | Low |
| Injection, Dopamine Hcl, 40 Mg | other | $13 | $13 to $50 | Low |
| Injection, Famotidine, 0.25 Mg | other | $13 | $13 to $50 | Low |
| Injection, Fluphenazine Decanoate, Up to 25 Mg | other | $13 | $13 to $50 | Low |
| Injection, Folic Acid, 0.1 Mg | other | $13 | $13 to $50 | Low |
| Injection, Furosemide, 1 Mg | other | $13 | $13 to $50 | Low |
| Injection, Garamycin, Gentamicin, Up to 80 Mg | other | $13 | $13 to $50 | Low |
| Injection, Granisetron Hydrochloride, 100 Mcg | other | $13 | $13 to $50 | Low |
| Injection, Haloperidol, Up to 5 Mg | other | $13 | $13 to $50 | Low |
| Injection, Heparin Sodium, (heparin Lock Flush), Per 10 Units | other | $13 | $13 to $50 | Low |
| Injection, Hydralazine Hcl, Up to 20 Mg | other | $13 | $13 to $50 | Low |
| Injection, Levofloxacin, 250 Mg | other | $13 | $13 to $50 | Low |
| Injection, Lidocaine Hydrochloride, 1 Mg | other | $13 | $13 to $50 | Low |
| Injection, Lorazepam, 2 Mg | other | $13 | $13 to $50 | Low |
| Injection, Magnesium Sulfate, Per 500 Mg | other | $13 | $13 to $50 | Low |
| Injection, Mannitol, 25% in 50 Ml | other | $13 | $13 to $50 | Low |
| Injection, Meperidine Hydrochloride, Per 100 Mg | other | $13 | $13 to $50 | Low |
| Injection, Methocarbamol, Up to 10 Ml | other | $13 | $13 to $50 | Low |
| Injection, Metoclopramide Hcl, Up to 10 Mg | other | $13 | $13 to $50 | Low |
| Injection, Midazolam Hydrochloride, Per 1 Mg | other | $13 | $13 to $50 | Low |
| Injection, Milrinone Lactate, 5 Mg | other | $13 | $13 to $50 | Low |
| Injection, Nalbuphine Hydrochloride, Per 10 Mg | other | $13 | $13 to $50 | Low |
| Injection, Paricalcitol, 1 Mcg | other | $13 | $13 to $50 | Low |
| Injection, Phenylephrine Hydrochloride (biorphen), 20 Micrograms | other | $13 | $13 to $50 | Low |
| Injection, Phenytoin Sodium, Per 50 Mg | other | $13 | $13 to $50 | Low |
| Injection, Piperacillin Sodium/tazobactam Sodium, 1 Gram/0.125 Grams | other | $13 | $13 to $50 | Low |
| Injection, Potassium Chloride, Per 2 Meq | other | $13 | $13 to $50 | Low |
| Injection, Sterile Cefuroxime Sodium, Per 750 Mg | other | $13 | $13 to $50 | Low |
| Injection, Terbutaline Sulfate, Up to 1 Mg | other | $13 | $13 to $50 | Low |
| Injection, Thiamine Hcl, 100 Mg | other | $13 | $13 to $50 | Low |
| Injection, Triamcinolone Acetonide, Not Otherwise Specified, 10 Mg | other | $13 | $13 to $50 | Low |
| Injection, Vitamin B-12 Cyanocobalamin, Up to 1000 Mcg | other | $13 | $13 to $50 | Low |
| Intraocular Vancomycin 10 Mg/ Ml- 3 Ml (for Dr. Ouano) - Compounded | other | $13 | $13 to $50 | Low |
| Kcl 20 Meq/l-d5w-0.45% Nacl | other | $13 | $13 to $50 | Low |
| Lactated Ringers Injection | other | $13 | $13 to $50 | Low |
| Lidocaine / Bicarb 1 Ml Syringe - Compounded | other | $13 | $13 to $50 | Low |
| Lidocaine / Sodium Bicarb 0.09 Meq/ Ml Vial - Compounded | other | $13 | $13 to $50 | Low |
| Lidocaine 0.5%-epi 1:200,000 | other | $13 | $13 to $50 | Low |
| Lidocaine-epinephrine 2 %-1:100000 Ij Soln | other | $13 | $13 to $50 | Low |
| Metoprolol Tartrate 5 Mg/5ml IV Soln | other | $13 | $13 to $50 | Low |
| Morphine 0.1 Mg/ml Peds Oral Solution - Compounded | other | $13 | $13 to $50 | Low |
| Moxifloxacin Intracameral 600 Mcg / 0.4 Ml Syringe-surgery Center - Compounded | surgery | $13 | $13 to $50 | Low |
| Neostigmine 10 Mg/10 Ml Vial | other | $13 | $13 to $50 | Low |
| Norepinephrine Bitartrate 1 Mg/ml IV Soln | other | $13 | $13 to $50 | Low |
| Removal of Sutures; By a Physician Other Than the Physician Who Originally Cl... | surgery | $13 | $13 to $100 | Low |
| Ringers Lactate Infusion, Up to 1000 Cc | surgery | $13 | $13 to $50 | Low |
| Rocuronium Bromide 50 Mg/5ml IV Soln | other | $13 | $13 to $50 | Low |
| Slitter Catheter for Agilis Hispro Steerable Catheter#ds3a001 | cardiac | $13 | $13 to $50 | Low |
| Sodium Acetate 40 Meq/20 Ml Vl | other | $13 | $13 to $50 | Low |
| Sodium Chloride 0.45% Soln | other | $13 | $13 to $50 | Low |
| Sterile Water for Irrigation | other | $13 | $13 to $50 | Low |
| Test for Ability to Detect and Repeat Spoken Words with Speech Recognition | other | $13 | $13 to $92,556 | Low |
| Tool Locking Helix for Tendril Sts Pacing Lead#a001helx | other | $13 | $13 to $50 | Low |
| Tranexamic Acid 1000 Mg/10ml IV Soln | other | $13 | $13 to $50 | Low |
| Ultrasharp Scleral Knife | other | $13 | $13 to $50 | Low |
| Valproate Sod 500 Mg/5 Ml Vl | other | $13 | $13 to $50 | Low |
| Vancomycin 2.5 Mg/ml + Heparin 2500 Units/ml Antibiotic Catheter Mixture - Co... | cardiac | $13 | $13 to $50 | Low |
| Vancomycin Retention Enema 500 Mg/ns 100 Ml - Compounded | other | $13 | $13 to $50 | Low |
| Verapamil 2.5 Mg/5 Ml Syringe (for Radial Cocktail) - Compounded | other | $13 | $13 to $50 | Low |
| Xylocaine 1%-epi 1:100,000 | other | $13 | $13 to $50 | Low |
| Xifaxan 550 Mg Tablet | other | $13 | $13 to $50 | Low |
| Harvest of Vein Using an Endoscope | other | $13 | $13 to $33,508 | Low |
| Hydrocolloid Dressing, Wound Cover, Sterile, Pad Size More Than 48 Sq. In., w... | other | $13 | $13 to $101 | Low |
| Geo Matt Chair 6ea/1cs | other | $13 | $13 to $51 | Low |
| Needle Angiody. Ministick Max 5f 10cm #h965457561 | other | $13 | $13 to $51 | Low |
| Analysis for Antibody to Hiv-2 Virus | other | $14 | $14 to $86,702 | Low |
| Vac Soft White Foam Sys Lrg 10"x 15" M8275067 | other | $14 | $14 to $51 | Low |
| Valproic Acid Level, Total | other | $14 | $14 to $80,164 | Low |
| Vancomycin (antibiotic) Level | other | $14 | $14 to $80,202 | Low |
| Fosfomycin 3 Gm Sachet | other | $14 | $14 to $51 | Low |
| Caplyta 42 Mg Capsule | other | $14 | $14 to $51 | Low |
| Injection, Methotrexate Sodium, 50 Mg | other | $14 | $14 to $51 | Low |
| Nephelometry, Test Method Using Light | other | $14 | $14 to $83,883 | Low |
| Ferritin (blood Protein) Level | other | $14 | $14 to $82,728 | Low |
| Benzoyl Peroxide-erythromycin 5-3 % Ex Gel | other | $14 | $14 to $51 | Low |
| Calcium Level, Ionized | other | $14 | $14 to $82,330 | Low |
| Boot Prevalon Heel Protector Petite #7310 | other | $14 | $14 to $52 | Low |
| Sheath Storz/xomed 4mm/0" #1912000 Sc | other | $14 | $14 to $52 | Low |
| Surgiflo Endo Applicator 34cm #ms1995 | other | $14 | $14 to $52 | Low |
| Tube Endobronchial 35fr Left #116100350 | other | $14 | $14 to $52 | Low |
| Tube Endobronchial 37fr Left #5 | other | $14 | $14 to $52 | Low |
| Tube Endobronchial 39fr Left #116100390 | other | $14 | $14 to $52 | Low |
| Tube Endobronchial 41fr Left #5 | other | $14 | $14 to $52 | Low |
| Sirolimus Level | other | $14 | $14 to $80,195 | Low |
| Measurement of Dna Antibody, Native OR Double Stranded | other | $14 | $14 to $86,225 | Low |
| Analysis for Antibody to Histoplasma | other | $14 | $14 to $86,698 | Low |
| Cialis 10 Mg Tablet | other | $14 | $14 to $52 | Low |
| Cialis 20 Mg Tablet | other | $14 | $14 to $52 | Low |
| Tube Gastrostomy Kangaroo 16fr #8884720163e 5ea/case | other | $14 | $14 to $52 | Low |
| Healon5 Pro 0.60 Ml 10340015 Dr. Ouano | other | $14 | $14 to $52 | Low |
| Test for Hearing Various Pitches Using Earphone | other | $14 | $14 to $92,552 | Low |
| Dxa Bone Density Measurement of Hip, Pelvis, Spine Including Spine Fracture A... | other | $14 | $14 to $77,085 | Low |
| Irrigator Lap Suction W/pistol Grip/conmed | other | $14 | $14 to $52 | Low |
| X-ray Lower and Sacral Spine, Minimum of 6 Views | imaging | $14 | $14 to $72,114 | Low |
| X-ray of Upper Spine, 6 OR More Views | imaging | $14 | $14 to $72,052 | Low |
| Physostigmine 1 Mg/ml Ampul | other | $14 | $14 to $52 | Low |
| Visit Complexity Inherent to Evaluation and Management Associated with Medica... | other | $14 | $14 to $120 | Low |
| Programming of Single, Dual, OR Multiple Lead OR Leadless Pacemaker System Be... | cardiac | $14 | $14 to $93,286 | Low |
| Splint System Bsn Dynacast Fiberglass Padded Roll Form 4inx15ft #7449804 1ea/... | other | $14 | $14 to $52 | Low |
| Dermatac Drape W/granufoam Dressing Med 10pk | other | $14 | $14 to $53 | Low |
| Kyphon Cement Mixer Only #a07a | other | $14 | $14 to $53 | Low |
| Immunologic Analysis Technique, Unspecified | other | $14 | $14 to $86,329 | Low |
| Pushr Stent for 4/5fr Pancreatic Rx M00535010 | cardiac | $14 | $14 to $53 | Low |
| Analysis Using Chemiluminescent Technique (light and Chemical )reaction | other | $14 | $14 to $82,397 | Low |
| Coagulator Bipolar .5mm Tip Non-insul#20 | other | $14 | $14 to $53 | Low |
| Theophylline Level | other | $14 | $14 to $80,198 | Low |
| Addition to Lower Extremity Orthosis, Drop Lock Retainer, Each | other | $14 | $14 to $53 | Low |
| Ephedrine Sulfate (pressors) 50 Mg/ml Soln Wrapper | other | $14 | $14 to $53 | Low |
| Thyroid Hormone, T3 Measurement, Total | other | $14 | $14 to $84,480 | Low |
| Vitamin E Level | other | $14 | $14 to $84,446 | Low |
| Injection, Succinylcholine Chloride, Up to 20 Mg | other | $14 | $14 to $53 | Low |
| X-ray of Both Hips, Minimum of 5 Views | imaging | $14 | $14 to $73,523 | Low |
| X-ray of Surgical Specimen | imaging | $14 | $14 to $76,098 | Low |
| Ortho Glass 3" X 15 #og-3l22 Rolls/case | other | $14 | $14 to $53 | Low |
| Sole Wedge, Outside Sole | other | $14 | $14 to $54 | Low |
| Hepatitis C Antibody Measurement | other | $14 | $14 to $86,803 | Low |
| Irrigation Tubeset for Bone Scalpel Mxb-t 5/b | other | $14 | $14 to $54 | Low |
| Injection, Tafasitamab-cxix, 2 Mg | other | $14 | $14 to $4,247 | Low |
| Neomycin-polymyxin-hc Ear Soln | other | $14 | $14 to $54 | Low |
| Lipoprotein (a) Level | other | $14 | $14 to $83,695 | Low |
| Vac Veraflo Veralink Cassette #ultlnk0500 | other | $14 | $14 to $54 | Low |
| Bowl Cement Smart Mix #5401-76 | other | $14 | $14 to $54 | Low |
| Hydrocortisone 2.5 % Ex Crea | other | $14 | $14 to $54 | Low |
| Hydrocortisone 2.5% Cream | other | $14 | $14 to $54 | Low |
| Nipple Prosthesis, Prefabricated, Reusable, Any Type, Each | other | $14 | $14 to $54 | Low |
| Pin Fixation Pk #07.00656.002 | other | $14 | $14 to $54 | Low |
| Special Casting Material | other | $14 | $14 to $108 | Low |
| Trocar Cannula Alcon 25g #8065751448 | other | $14 | $14 to $54 | Low |
| Detection Test By Immunoassay Technique for Helicobacter Pylori (gi Tract Bac... | other | $14 | $14 to $87,338 | 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 Rubella | other | $14 | $14 to $86,762 | Low |
| Analysis for Antibody to Toxoplasma | other | $14 | $14 to $86,777 | Low |
| Analysis for Antibody to Cryptococcus | other | $14 | $14 to $86,641 | Low |
| Mask CPAP O2-resq Sys Sz Adult Med | other | $14 | $14 to $54 | Low |
| Addition to Upper Extremity Orthosis, Sock, Fracture OR Equal, Each | other | $14 | $14 to $54 | Low |
| Mammary Support Medium W/cups | other | $14 | $14 to $54 | Low |
| Levalbuterol Tar Hfa 45mcg Inh | other | $14 | $14 to $54 | Low |
| Review By Radiologist of Urinary Bladder Image | other | $15 | $15 to $74,430 | Low |
| X-ray of Ribs On Both Sides of Body, Minimum of 4 Views | imaging | $15 | $15 to $71,111 | Low |
| X-ray Series of Abdomen with Single X-ray of Chest | imaging | $15 | $15 to $74,022 | Low |
| Microsomal Antibodies (autoantibody) Measurement | other | $15 | $15 to $86,376 | Low |
| Geo Matt-foam Pressure Air 34x72x3.5 4ea/1cs | other | $15 | $15 to $55 | Low |
| Ammonia Level | other | $15 | $15 to $82,140 | Low |
| Carbamazepine Level, Total | other | $15 | $15 to $80,156 | Low |
| Prealbumin (protein) Level | other | $15 | $15 to $84,134 | Low |
| Angiotensin L - Converting Enzyme (ace) Level | other | $15 | $15 to $82,164 | Low |
| Carbamazepine 100 Mg/5ml Po Susp | other | $15 | $15 to $55 | Low |
| 4fr Pigtail | other | $15 | $15 to $55 | Low |
| Blower Mister Kit Clearview #22150 | other | $15 | $15 to $55 | Low |
| Crutches Underarm, Other Than Wood, Adjustable OR Fixed, Pair, with Pads, Tip... | other | $15 | $15 to $110 | Low |
| Detection Test By Immunoassay with Direct Visual Observation for Influenza Virus | other | $15 | $15 to $87,804 | Low |
| Inflation Device Sphere 20cc #g31027 | other | $15 | $15 to $55 | Low |
| Plate Tack Acumed #pl-ptack | other | $15 | $15 to $55 | Low |
| Test for Screening Hearing Using a Probe | preventive | $15 | $15 to $92,558 | Low |
| Lidocaine Level | other | $15 | $15 to $80,176 | Low |
| Folic Acid Level, Serum | other | $15 | $15 to $82,746 | Low |
| Imaging Guidance for Procedure, 60 Minutes OR Less | other | $15 | $15 to $76,000 | Low |
| Urine Porphyrins (metabolism Substance) Measurement | other | $15 | $15 to $84,120 | Low |
| Hydrocortisone 2.5% Ointment | other | $15 | $15 to $55 | Low |
| Tolvaptan 15 Mg Tablet | other | $15 | $15 to $55 | Low |
| Phosphatase (enzyme) Measurement, Alkaline, Isoenzymes | other | $15 | $15 to $84,080 | Low |
| Coag Bipolar Bayonet Non-insulated Tip1.5mm | other | $15 | $15 to $56 | Low |
| Desmopressin 10 Mcg/0.1 Ml Spr | other | $15 | $15 to $56 | Low |
| Tall Air Walker Lg #b | other | $15 | $15 to $56 | Low |
| Tall Air Walker Med #b | other | $15 | $15 to $56 | Low |
| Tall Air Walker Sm #b | other | $15 | $15 to $56 | Low |
| Tall Air Walker Xs #b | other | $15 | $15 to $56 | Low |
| Review By Radiologist of Urinary Bladder and Urethra Images with Contrast | other | $15 | $15 to $74,450 | Low |
| Fitting/orientation/checking of Hearing Aid | other | $15 | $15 to $2,690 | Low |
| Tru-pull Lite Left Knee Adult 15.5-18.5" Small #11-0261 | other | $15 | $15 to $56 | Low |
| Tru-pull Lite Left Knee Adult 18.5-21" Medium #11-0261 | other | $15 | $15 to $56 | Low |
| Tru-pull Lite Left Knee Adult 21-23.5" Large #11-0261 | other | $15 | $15 to $56 | Low |
| Tru-pull Lite Left Knee Adult 23.5-26.5" X-large #11-0261 | other | $15 | $15 to $56 | Low |
| Tru-pull Lite Right Knee Adult 18.5-21" Medium #11-0260 | other | $15 | $15 to $56 | Low |
| Tru-pull Lite Right Knee Adult 21-23.5" Large #11-0260 | other | $15 | $15 to $56 | Low |
| Tru-pull Lite Right Knee Adult 23.5-26.5" X-large #11-0260 | other | $15 | $15 to $56 | Low |
| Placement of Strapping to Ankle OR Foot | other | $15 | $15 to $29,540 | Low |
| Test to Assess Balance During Warm OR Cool Irrigation in Both Ears | other | $15 | $15 to $92,538 | Low |
| Drill Solid Side Cutting 2x40 Drll-ssc | other | $15 | $15 to $56 | Low |
| Pressure Guard 12cm #82050 10ea/1bx | other | $15 | $15 to $56 | Low |
| Grasper Babcock 533-005-925 8ea/1bx | other | $15 | $15 to $56 | Low |
| Tube Endobronchial 35fr Right #126035 | other | $15 | $15 to $56 | Low |
| Tube Endobronchial 37fr Right #126037 | other | $15 | $15 to $56 | Low |
| Tube Endobroncial 39fr Right #126039 | other | $15 | $15 to $56 | Low |
| Examination of Archival Tissue for Genetic Analysis | other | $15 | $15 to $88,363 | Low |
| Detection of Infectious Agent Antibody, Quantitative | other | $15 | $15 to $86,317 | Low |
| Temno Evolution Biopsy Needles Ctt1811 | lab | $15 | $15 to $56 | Low |
| Temno Evolution Biopsy Needles Ctt1815 | lab | $15 | $15 to $56 | Low |
| Temno Evolution Biopsy Needles Ctt1820 | lab | $15 | $15 to $56 | Low |
| Analysis for Antibody to Aspergillus | other | $15 | $15 to $86,606 | Low |
| Gonadotropin, Chorionic (reproductive Hormone) Level | other | $15 | $15 to $84,702 | Low |
| Lantus 100 Unit/ml Vial | other | $15 | $15 to $57 | Low |
| Amikacin (antibiotic) Level | other | $15 | $15 to $80,150 | Low |
| Cyanocobalamin (vitamin B-12) Level | other | $15 | $15 to $82,607 | Low |
| Injection, Esmolol Hydrochloride, 10 Mg | other | $15 | $15 to $57 | Low |
| For Diabetics Only, Multiple Density Insert, Made By Direct Carving with Cam ... | other | $15 | $15 to $57 | Low |
| Ethyl Chloride Spray | other | $15 | $15 to $57 | Low |
| Albuterol, Up to 2.5 Mg and Ipratropium Bromide, Up to 0.5 Mg, Fda-approved F... | other | $15 | $15 to $29 | Low |
| Drill Solid Side Cuttin 2.5x40 Drll-ssc | other | $15 | $15 to $57 | Low |
| Inflation Device Stonemaster V #maj | other | $15 | $15 to $57 | Low |
| Screening Papanicolaou Smear; Obtaining, Preparing and Conveyance of Cervical... | preventive | $15 | $15 to $150 | Low |
| Stool Analysis for Blood, By Fecal Hemoglobin Determination By Immunoassay | other | $15 | $15 to $82,274 | Low |
| Stylet Kit 58cm Ds06003/58 Ds06003 | other | $15 | $15 to $57 | Low |
| Review By Radiologist of Urinary Bladder and Urethra Images with Contrast and... | other | $15 | $15 to $74,455 | Low |
| Exam of Visual Field with Limited Testing | other | $15 | $15 to $92,081 | Low |
| Lidocaine Hcl 2% Syringe | other | $15 | $15 to $57 | Low |
| Pin Skull Disp | other | $15 | $15 to $57 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Nuclear An... | imaging | $15 | $15 to $86,664 | Low |
| Injection, Pertuzumab, 1 Mg | other | $15 | $15 to $20,559 | Low |
| Analysis for Antibody to Legionella | other | $15 | $15 to $86,713 | Low |
| Gradient Compression Gauntlet, Each | other | $15 | $15 to $58 | Low |
| Phenobarbital Level | other | $15 | $15 to $80,184 | Low |
| Tray Umbilical Vessel Insertion #43201 | other | $15 | $15 to $58 | Low |
| Protein S (clotting Inhibitor) Measurement | other | $15 | $15 to $85,306 | Low |
| Diag Catheter 4fr Vert #srd6108 | cardiac | $15 | $15 to $58 | Low |
| Radial Cocktail 10 Ml Kit (2-5 Ml Syringes)-compounded | other | $15 | $15 to $58 | Low |
| Shoulder Suspension Kit 72200195 | other | $15 | $15 to $58 | Low |
| Sodium Chloride 3% IV Soln | other | $15 | $15 to $58 | Low |
| Marcaine 0.25%-epi 1:200,000 | other | $15 | $15 to $58 | Low |
| Mycoplasma Culture | lab | $15 | $15 to $87,109 | Low |
| Resting Hand Orthosis Large Left 29rho-l-l | other | $15 | $15 to $58 | Low |
| Resting Hand Orthosis Large Right 29rho-l-r | other | $15 | $15 to $58 | Low |
| Resting Hand Orthosis Medium Right 29rho-m-r | other | $15 | $15 to $58 | Low |
| Resting Hand Orthosis Small Left 29rho-s-l | other | $15 | $15 to $58 | Low |
| Resting Hand Orthosis Small Right 29rho-s-r | other | $15 | $15 to $58 | Low |
| Resting Hand Orthosis X-large Left 29rho-xl-l | other | $15 | $15 to $58 | Low |
| Resting Hand Orthosis X-large Right 29rho-xl-r | other | $15 | $15 to $58 | Low |
| Resting Hand Othosis Medium Left 29rho-m-l | other | $15 | $15 to $58 | Low |
| Brachytherapy Source, Non-stranded, Iodine-125, Per Source | other | $15 | $15 to $58 | Low |
| Hc Epidural Anesthesia Time - Each Incremental 15 Minute | other | $15 | $15 to $58 | Low |
| Hc Spinal Anes Ea Addl 15 Min | other | $15 | $15 to $58 | Low |
| Stylet Kit 52cm Ds06001-52 Ds06001/52 | other | $15 | $15 to $58 | Low |
| Tall Air Walker Xl #b | other | $15 | $15 to $58 | Low |
| Pleur-evac Sahara Chest Drain #s-1100-08lf 6ea/case | other | $15 | $15 to $58 | Low |
| Brachytherapy Needle | other | $15 | $15 to $58 | Low |
| Confirmation Test for Antibody to Borrelia Burgdorferi | other | $15 | $15 to $86,617 | Low |
| Confirmation Test for Hepatitis C Antibody | other | $15 | $15 to $86,804 | Low |
| Semen Evaluation Volume, Sperm Count, Motility and Analysis | other | $16 | $16 to $89,322 | Low |
| Urine Vanillylmandelic Acid | other | $16 | $16 to $84,585 | Low |
| X-ray of Bone Behind the Ear, Minimum of 3 Views Per Side | imaging | $16 | $16 to $70,130 | Low |
| Monoka Mini #s1-1500u | other | $16 | $16 to $58 | Low |
| Vascular Sheath A/v Small Yellow | other | $16 | $16 to $58 | Low |
| Needle/sheath Injector #nm-221c-0427 1ea/1bx | other | $16 | $16 to $59 | Low |
| Picc Introducer 6.0fr Micro Bard | other | $16 | $16 to $59 | Low |
| Detection Test By Immunofluorescent Technique for Legionella Pneumophila | other | $16 | $16 to $87,278 | Low |
| Injection, Dalbavancin, 5 Mg | other | $16 | $16 to $4,912 | Low |
| Ped Trach Tapershape Cuff 5.0mm Id 7.3mm Od 5.0pcf 1ea | other | $16 | $16 to $59 | Low |
| Ped Trach Tapershape Cuff 5.5mm Id 7.9mm Od 5.5pcf 1ea | other | $16 | $16 to $59 | Low |
| Shiley Pediatric Tracheostomy Tubes with Taperguard Cuff 3.5pcf | other | $16 | $16 to $59 | Low |
| Shiley Pediatric Tracheostomy Tubes with Taperguard Cuff 4.0pcf | other | $16 | $16 to $59 | Low |
| Tube Trach Pediatric 4.5 Cuff Medtronic #4.5pcf | other | $16 | $16 to $59 | Low |
| Kcl 40 Meq/l-d5w-0.9% Nacl | other | $16 | $16 to $59 | Low |
| Potassium Cl 20 Meq-0.45% Nacl | other | $16 | $16 to $59 | Low |
| Cannula Tandem Xl Triple Lumen ERCP M00535700 | other | $16 | $16 to $59 | Low |
| Cannula Eopa Arterial 22fr 77622 10ea/1pk | other | $16 | $16 to $59 | Low |
| Loop Cutting 24fr #m0068802611 | other | $16 | $16 to $59 | Low |
| Dilation of Stomach And/or Small Bowel Using Long Gastrointestinal Tube | other | $16 | $16 to $44,500 | Low |
| Thyroid Hormone, T3 Measurement, Reverse | other | $16 | $16 to $84,482 | Low |
| Removal of Impacted Ear Wax By Washing | surgery | $16 | $16 to $69,209 | Low |
| Repair Prosthetic Device, Labor Component, Per 15 Minutes | surgery | $16 | $16 to $60 | Low |
| Gabapentin 250 Mg/5 Ml Soln | other | $16 | $16 to $60 | Low |
| 10.0mm Shiley Flex Cuffless Reus Trach 10un10r | other | $16 | $16 to $60 | Low |
| Orthopedic Footwear, Ladies Shoe, Depth Inlay, Each | other | $16 | $16 to $60 | Low |
| Trach 4cfs 6.5mm Adt Flex Trach Cuffless 4un65r | other | $16 | $16 to $60 | Low |
| Trach Tube 6cfs #6un75r | other | $16 | $16 to $60 | Low |
| Trach Tube 8cfs #8un85r | other | $16 | $16 to $60 | Low |
| Verapamil 10 Mg/4 Ml Vial | other | $16 | $16 to $60 | Low |
| Thyroglobulin (thyroid Protein) Antibody Measurement | other | $16 | $16 to $86,800 | Low |
| Viscoat #8065-18 | other | $16 | $16 to $60 | Low |
| Shiley Xlt Extended -length Tracheostomy Tube Distal Extension Size 6 Uncuffe... | other | $16 | $16 to $60 | Low |
| Trach Cuff Xlt 7.0mm #70xltcp | other | $16 | $16 to $60 | Low |
| Tracheostomy Tube Shiley Uncuffed Id 8.0mm 105mm #80xltud | other | $16 | $16 to $60 | Low |
| Tracheostomy Tube Shiley Uncuffed Size 6 Id 6mm 95mm 60xltup | other | $16 | $16 to $60 | Low |
| Tube Trach Cuff 6.0mm Xlt Prox | other | $16 | $16 to $60 | Low |
| Tube Trach Xlt 6.0 Distal Ext Cuffed | other | $16 | $16 to $60 | Low |
| Tube Trach Xlt 7.0 Distal Ext Cuffed | other | $16 | $16 to $60 | Low |
| Tube Trach Xlt 7.0 Uncuffed Proximal #70xltup | other | $16 | $16 to $60 | Low |
| Tube Trach Xlt 8.0 Distal Ext Cuffed | other | $16 | $16 to $60 | Low |
| Tube Trach Xlt 8.0 Proximal Ext Cuffed | other | $16 | $16 to $60 | Low |
| Tube Trach Xlt 8.0 Uncuff Proximal #80xltup | 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 |
| Aveta Waste Management Accessory 3.0 #205-2036 6ea/ct | other | $16 | $16 to $60 | Low |
| Breast Prosthesis, Mastectomy Bra, without Integrated Breast Prosthesis Form,... | other | $16 | $16 to $60 | Low |
| Cast Supplies, Long Leg Cast, Pediatric (0-10 Years), Fiberglass | other | $16 | $16 to $120 | Low |
| Gastrostomy 24fr Peg Kit/gastrodome #6824 | other | $16 | $16 to $60 | Low |
| Influenza Vaccine, Trivalent, Derived From Cell Cultures, Antibiotic Free, 0.... | lab | $16 | $16 to $90,661 | Low |
| Lap Gas Conditioning Device Vessel Guardian | other | $16 | $16 to $60 | Low |
| Passport 12 X 3 #ar-6592-12 | other | $16 | $16 to $60 | Low |
| Pessary, Reusable, Rubber, Any Type | other | $16 | $16 to $60 | Low |
| Poliovirus Vaccine | preventive | $16 | $16 to $90,713 | Low |
| Service Provided in an Office During Regularly Scheduled Office Hours, Evenin... | other | $16 | $16 to $99,051 | Low |
| Thyroglobulin (thyroid Related Hormone) Level | other | $16 | $16 to $84,432 | Low |
| Detection Test By Immunoassay with Direct Visual Observation for Other Organism | other | $16 | $16 to $87,899 | Low |
| Tobramycin (antibiotic) Level | other | $16 | $16 to $80,200 | Low |
| Anesthesia for Electroshock Therapy | other | $16 | $16 to $148 | Low |
| Vecuronium 10 Mg Vial | other | $16 | $16 to $61 | Low |
| Vecuronium Bromide 10 Mg IV Solr | other | $16 | $16 to $61 | Low |
| Beta-2 Microglobulin (protein) Level | other | $16 | $16 to $82,232 | Low |
| Nuclear Medicine Study of Thyroid | imaging | $16 | $16 to $78,013 | Low |
| Pelvic Exam | other | $16 | $16 to $99,459 | Low |
| Catheter Endo 5.5fr Ercp-1-cramer #g21765 | cardiac | $16 | $16 to $61 | Low |
| Metatarsal Bar Wedge, Rocker | other | $16 | $16 to $61 | Low |
| Mercury Level | other | $16 | $16 to $83,825 | Low |
| Tube Endobronchial 37fr Right #116200370 | other | $16 | $16 to $61 | Low |
| Cortisol (hormone) Measurement, Total | other | $16 | $16 to $82,533 | Low |
| Purstring 65 Instrument Medtronic #020242 Case/3ea | other | $16 | $16 to $61 | Low |
| Gentamicin (antibiotic) Level | other | $16 | $16 to $80,170 | Low |
| Splint Nasal Denver Aluminum Sm/md #10-1500-05ks | other | $16 | $16 to $62 | Low |
| Temno Evolution Biopsy Needle Ctt2011 | lab | $16 | $16 to $62 | Low |
| Temno Evolution Biopsy Needles Ctt2015 | lab | $16 | $16 to $62 | Low |
| Aminolevulinic Acid (protein) Level | other | $16 | $16 to $82,135 | Low |
| Ige (immune System Protein) Level | other | $16 | $16 to $82,785 | Low |
| Catheter, Guiding | cardiac | $16 | $16 to $62 | Low |
| Dermagraft, Per Square Centimeter | other | $16 | $16 to $124 | Low |
| Hc Regional Anesthesia Time - Each Incremental 15 Minutes | other | $16 | $16 to $62 | Low |
| Influenza Vaccine, Trivalent for Nasal Administration | preventive | $16 | $16 to $90,660 | Low |
| Safeguard 24cm #82000 10ea/1bx | other | $16 | $16 to $62 | Low |
| Primidone Level | other | $17 | $17 to $80,188 | Low |
| Addition to Lower Extremity, Below Knee, Fork Strap | other | $17 | $17 to $63 | Low |
| Human Growth Hormone Level | other | $17 | $17 to $83,003 | Low |
| Cns Monitor Icp Drain Bag 1ea | other | $17 | $17 to $63 | Low |
| Cortisol (hormone) Measurement, Free | other | $17 | $17 to $82,530 | Low |
| Catheter Jet Ventilation Adult 30-02-013 | cardiac | $17 | $17 to $63 | Low |
| Catheter Jet Ventilation Child 30-02-014 | cardiac | $17 | $17 to $63 | Low |
| Catheter Jet Ventilation Infant 30-02-018 | cardiac | $17 | $17 to $63 | Low |
| Detection Test By Immunoassay Technique for Streptococcus, Group a | other | $17 | $17 to $87,430 | Low |
| Glycated Protein Level | other | $17 | $17 to $82,985 | Low |
| Alpha-fetoprotein (afp) Level, Serum | other | $17 | $17 to $82,105 | Low |
| Starchmark Ultracore Marker Ss 14g #stmk14gss | other | $17 | $17 to $63 | Low |
| Ultra Clip Dual Trigger Marker #862017d | other | $17 | $17 to $63 | Low |
| Ultra Clip Dual Trigger Marker Ribb #863017d | other | $17 | $17 to $63 | Low |
| Ultraclip Dual Trigger Marker 108 Coil | other | $17 | $17 to $63 | Low |
| Ultraclip Dual Trigger Marker 108 Venus | other | $17 | $17 to $63 | Low |
| Ultraclip Dual Trigger Marker Titanium Heart | cardiac | $17 | $17 to $63 | Low |
| Stool Fat OR Lipids Analysis, Quantitative | lab | $17 | $17 to $82,710 | Low |
| Injection, Testosterone Cypionate, 1 Mg | other | $17 | $17 to $63 | Low |
| Analysis for Antibody | other | $17 | $17 to $86,645 | Low |
| Analysis for Antibody to Helicobacter Pylori | other | $17 | $17 to $86,677 | Low |
| Carnitine Level | other | $17 | $17 to $82,379 | Low |
| Aprepitant, Oral, 5 Mg | other | $17 | $17 to $63 | Low |
| Evaluation of Cardiac Rhythm Monitor System | cardiac | $17 | $17 to $93,291 | Low |
| Ultrasound of Heart Blood Flow, Valves and Chambers | imaging | $17 | $17 to $93,320 | Low |
| Metanephrines Level | other | $17 | $17 to $83,835 | Low |
| Thyroid Hormone, T3 Measurement, Free | other | $17 | $17 to $84,481 | Low |
| Fluoroscopic Guidance for Insertion OR Removal of Central Vein Access Device | surgery | $17 | $17 to $77,001 | Low |
| Pump Cold Therapy Polar Care Cube | other | $17 | $17 to $64 | Low |
| Smark Atec-2s-13 | other | $17 | $17 to $64 | Low |
| Catheter Ph Internal 10cm Disp Dual Versaflex | cardiac | $17 | $17 to $64 | Low |
| Education and Training for Patient Self-management, Each 30 Minutes | other | $17 | $17 to $98,960 | Low |
| Piercing of Ear | other | $17 | $17 to $69,090 | Low |
| Analysis for Antibody Borrelia Burgdorferi | other | $17 | $17 to $86,618 | Low |
| Injection, Epoprostenol, 0.5 Mg | other | $17 | $17 to $218 | Low |
| Restraint Vest Xxlrg #m227b-xl | other | $17 | $17 to $64 | Low |
| Splint Ortho-glass 4"x15' 2rl/cs #og-4l2 | other | $17 | $17 to $64 | Low |
| Vascular Sheath Blue #9009 | other | $17 | $17 to $64 | Low |
| Bile Acids Level, Total | other | $17 | $17 to $82,239 | Low |
| Testing for Presence of Drug, Read By Instrument Assisted Observation | other | $17 | $17 to $80,306 | Low |
| Analysis for Antibody to Hepatitis D Virus | other | $17 | $17 to $86,692 | Low |
| Miami Slim Lumbar 2xl #lmbsl | other | $17 | $17 to $65 | Low |
| Injection, Pyridoxine Hcl, 100 Mg | other | $17 | $17 to $65 | Low |
| Potassium Alum Powder | other | $17 | $17 to $65 | Low |
| Crown Fistula Wound 00860013000301 | other | $17 | $17 to $65 | Low |
| Myelin Basic Protein (nerve Protein) Level, Spinal Fluid | other | $17 | $17 to $83,873 | Low |
| Measurement of Substance Using Immunoassay Technique | other | $17 | $17 to $83,520 | 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 |
| Wound Retractor/protector Medium | other | $17 | $17 to $65 | Low |
| Wound Retractor/protector Small 5 Ea/bx #c8401 | other | $17 | $17 to $65 | Low |
| Trimark Eviva 2s | other | $17 | $17 to $65 | Low |
| Trimark Td 1309 | other | $17 | $17 to $65 | Low |
| Electrode-bugbee Fulgurating 5frx58cm #be | other | $17 | $17 to $65 | Low |
| Infusion Supplies for External Drug Infusion Pump, Per Cassette OR Bag | surgery | $17 | $17 to $131 | Low |
| Surgicel 1/2 X 2 #1955s 12ea/cs | other | $17 | $17 to $65 | Low |
| Valved Entry System 23ga 4mm #8065751585 | other | $17 | $17 to $65 | Low |
| Miami Slim Lumbar 6xl #lmbsl | other | $17 | $17 to $66 | Low |
| Tcc-ez Regular Boot Tcc21100 1 Each | other | $17 | $17 to $66 | Low |
| Dermatac Drape W/granufoam Dressing Lg 10pk | other | $18 | $18 to $66 | Low |
| Injection, Phenylephrine Hydrochloride, 20 Micrograms | 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 |
| Blood Pressure Monitoring | other | $18 | $18 to $93,790 | High |
| Pap Test, Slides, Manual Screening | preventive | $18 | $18 to $88,164 | Low |
| Protein Test for Diagnosis and Monitoring of Bladder Cancer | other | $18 | $18 to $86,386 | Low |
| Rom Elbow Orthosis Right #w | other | $18 | $18 to $66 | Low |
| Gastrin (gi Tract Hormone) Level | other | $18 | $18 to $82,941 | Low |
| Folic Acid Level, Rbc | other | $18 | $18 to $82,747 | Low |
| 10.0mm Shiley Flex Cuffed Reus Trach 10cn10r | other | $18 | $18 to $66 | Low |
| 6.5mm Shiley Flex Cuffed Reus Trach 4cn65r | other | $18 | $18 to $66 | Low |
| 8.5mm S Shiley Flex Cuffed Reus Trach 8cn85r | other | $18 | $18 to $66 | Low |
| Trach Tube Shiley Cuffed 7mm Id 10.1mm Od 68mm Reusable 5cn70r 1ea | other | $18 | $18 to $66 | Low |
| Fogarty Insert Safe Jaw 33mm Safehy33 | other | $18 | $18 to $67 | Low |
| Packing Silverstein #14 | other | $18 | $18 to $66 | Low |
| Tray Snarecoil Bone Marrow 11x4 W/rbn-114 Needle No Aspiration Needle Include... | other | $18 | $18 to $67 | Low |
| Vascular Sheath Large Orange #9009 | other | $18 | $18 to $67 | Low |
| Cement Mixer Smart Mix Mini #5401-39 | other | $18 | $18 to $67 | Low |
| Check of Hearing Aid, 1 Ear | other | $18 | $18 to $92,592 | Low |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, Limited Study | other | $18 | $18 to $95,885 | Low |
| Breast Biopsy | other | $18 | $18 to $2,510 | High |
| Marker Biopsy Site Stainless Steel Stoplight Shape for Securmark MRI #smark-m... | imaging | $18 | $18 to $67 | Low |
| Marker Breast Biopsy Clip 9 Gauge Stainless Steel Securmark Atec #smark-m-ss2... | lab | $18 | $18 to $67 | Low |
| Marker Breast Biopsy Clip Stainless Steel Securmark Atec #smark-m-ss1 10ea/box | lab | $18 | $18 to $67 | Low |
| Placement of Ear Probe for Computerized Measurement of Sound with Interpretat... | other | $18 | $18 to $92,587 | Low |
| Special Stained Specimen Slides to Identify Organisms Including Interpretatio... | lab | $18 | $18 to $88,312 | Low |
| Cold Therapy Unit Donjoy Iceman Clear 11 | other | $18 | $18 to $67 | Low |
| Injection, Secukinumab, Intravenous, 1 Mg | other | $18 | $18 to $4,251 | Low |
| Injection, Lidocaine Hcl in 5% Dextrose, 1 Mg | other | $18 | $18 to $67 | Low |
| Kcl 10 Meq/l-d5w-0.45% Nacl | other | $18 | $18 to $67 | Low |
| Kcl 20 Meq/l-d5w-0.9% Nacl | other | $18 | $18 to $67 | Low |
| Kcl 40 Meq/l-d5w-0.45% Nacl | other | $18 | $18 to $67 | Low |
| Clotting Factor Viii (ahg) Measurement | other | $18 | $18 to $85,240 | Low |
| Measurement of Antibody for Assessment of Autoimmune Disorder, Any Method | other | $18 | $18 to $86,235 | Low |
| Loop Cutting 24fr .012 #g46209 | other | $18 | $18 to $68 | Low |
| Compass Lumbar Puncture #clph2o001-5 5ea/case | other | $18 | $18 to $68 | Low |
| Aztreonam 2 Gm/ Ns 50 Ml Mini Bag Plus - Compounded | other | $18 | $18 to $68 | Low |
| Immunologic Analysis Technique On Serum | other | $18 | $18 to $86,334 | Low |
| Cyclosporine Level | other | $18 | $18 to $80,158 | Low |
| Mycophenolate (mycophenolic Acid) Level | other | $18 | $18 to $80,180 | Low |
| Cefdinir 250 Mg/5 Ml Susp | other | $18 | $18 to $68 | Low |
| Cefdinir 250 Mg/5ml Po Susr | other | $18 | $18 to $68 | Low |
| Injection, Anifrolumab-fnia, 1 Mg | other | $18 | $18 to $10,459 | Low |
| 14fr Entuit Gastrostomy Tube #g35615 | other | $18 | $18 to $68 | Low |
| Entuit Gastrostomy Tube | other | $18 | $18 to $68 | Low |
| Gastrostomy/jejunostomy Tube, Low-profile, Any Material, Any Type, Each | other | $18 | $18 to $68 | Low |
| Physician OR Allowed Practitioner Re-certification for Medicare-covered Home ... | other | $18 | $18 to $136 | Low |
| Rom Elbow Orthosis Left #w | other | $18 | $18 to $68 | Low |
| Test to Measure the Total Volume of Air That Can Be Exhaled After Inhaling | other | $18 | $18 to $94,150 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Viral Capsid | other | $18 | $18 to $86,665 | Low |
| Cystotome Kelman Sharp 22g #e01412s | other | $18 | $18 to $68 | Low |
| Auto Effluent Set #115370 Ca/ 8ea | other | $18 | $18 to $69 | Low |
| Injection, Triamcinolone Acetonide, Preservative-free, Extended-release, Micr... | other | $18 | $18 to $1,088 | Low |
| Vascular Sheath Sm Green | other | $18 | $18 to $69 | Low |
| 7.5mm Shiley Flex Cuffed Reus Trach 6cn75r | other | $18 | $18 to $69 | Low |
| Cefpodoxime Proxetil 100 Mg/5ml Po Susr | other | $18 | $18 to $69 | Low |
| Pap Smear | preventive | $18 | $18 to $138 | High |
| Pap Test, Evaluation of Fine Needle Aspirate, Immediate, Each Additional Eval... | other | $18 | $18 to $88,177 | Low |
| Test for Abnormal Eye Movement without Stimulus | other | $18 | $18 to $92,531 | Low |
| Antibody Identification Test, Platelet Antibodies | other | $18 | $18 to $86,022 | Low |
| PSA (prostate Specific Antigen) Measurement, Free | other | $18 | $18 to $84,154 | Low |
| PSA (prostate Specific Antigen) Measurement, Total | other | $18 | $18 to $84,153 | Low |
| Measurement of Substance Using Immunoassay Technique, By Radioimmunoassay | other | $18 | $18 to $83,519 | Low |
| For Diabetics Only, Multiple Density Insert, Custom Molded From Model of Pati... | other | $18 | $18 to $69 | Low |
| Injection, Methylprednisolone Acetate, 1 Mg | other | $18 | $18 to $69 | Low |
| Soft-flow Angled Tip Arterial Cannula with Suture Bulb 21fr X 14" ( 7.0mm ) 5761 | other | $18 | $18 to $69 | Low |
| Gonadotropin, Luteinizing (reproductive Hormone) Level | other | $19 | $19 to $83,002 | Low |
| Tray Paracentesis Quick Tap 15x3-1/4 4ea/1cs | other | $19 | $19 to $70 | Low |
| Blood Smear Interpretation By Physician with Written Report | other | $19 | $19 to $85,060 | Low |
| Tumark Pro X for Brevara Std Tumark-brev-s-x | other | $19 | $19 to $70 | Low |
| Tumark Profess Q for Eviva Std Tumark-e13-s-q | other | $19 | $19 to $70 | Low |
| Tumark Professional Q Shape 10cm 351220 Bx/10ea | other | $19 | $19 to $70 | Low |
| Tumark Professional X Shape 10cm 351210 Bx/10ea | other | $19 | $19 to $70 | Low |
| Tumark Vq for Brevera Standard 127.5mm 18g Tumark-brev-s-q-02 10/bx | other | $19 | $19 to $70 | Low |
| Gonadotropin, Follicle Stimulating (reproductive Hormone) Level | other | $19 | $19 to $83,001 | Low |
| Endoclip Ii Ml 10mm #176657 | other | $19 | $19 to $70 | Low |
| Eric Arch Bar/6" Per Chrge | other | $19 | $19 to $70 | Low |
| Exofin Fusion Skin Closure 22cm #ef70401 | surgery | $19 | $19 to $70 | Low |
| Influenza Vaccine, Quadrivalent Derived From Cell Cultures, Preservative and ... | lab | $19 | $19 to $90,674 | Low |
| Manta 14f Depth Locator 5 Ea/bx 114f | other | $19 | $19 to $70 | Low |
| Shoulder Orthosis, Figure of Eight Design Abduction Restrainer, Prefabricated... | other | $19 | $19 to $140 | Low |
| Stylet for Peritoneal Cath #sst | other | $19 | $19 to $70 | Low |
| Wrist Hand Orthosis, Wrist Extension Control Cock-up, Non Molded, Prefabricat... | other | $19 | $19 to $140 | Low |
| 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 |
| Measurement of Amiodarone | other | $19 | $19 to $80,151 | Low |
| Quantitation of Therapeutic Drug | other | $19 | $19 to $80,299 | Low |
| Bivona Uncuffed Tracheostomy Tube Flextend Size 8.0 Pediatric #60pfs55 | other | $19 | $19 to $70 | Low |
| White Blood Cell Enzyme Activity Measurement | other | $19 | $19 to $85,549 | Low |
| Tretinoin 0.025 % Ex Gel | other | $19 | $19 to $71 | Low |
| Erythropoietin (protein) Level | other | $19 | $19 to $82,668 | Low |
| Duovisc Viscoelastic System | other | $19 | $19 to $71 | Low |
| Swan Ganz Catheter #131f7p 5/cs | cardiac | $19 | $19 to $71 | Low |
| Hydromorphone 6 Mg/30 Ml-ns | other | $19 | $19 to $71 | Low |
| Injection, Procainamide Hcl, Up to 1 Gm | other | $19 | $19 to $295 | Low |
| Carcinoembryonic Antigen (cea) Protein Level | other | $19 | $19 to $82,378 | Low |
| Arsenic Level | other | $19 | $19 to $82,175 | Low |
| Sodium Chloride 120 Meq/30 Ml | other | $19 | $19 to $71 | Low |
| Fluorometholone 0.1% Eye Drop | other | $19 | $19 to $71 | Low |
| Needle Measurement of Electrical Activity in Arm, Leg, Trunk OR Head Muscles,... | other | $19 | $19 to $95,870 | Low |
| Foot, Molded Shoe Plastazote (or Similar) Custom Fitted, Each | other | $19 | $19 to $72 | Low |
| Orthopedic Footwear, Custom Shoe, Depth Inlay, Each | other | $19 | $19 to $72 | Low |
| Orthopedic Footwear, Mens Shoe, Depth Inlay, Each | other | $19 | $19 to $72 | Low |
| Vascular Occluder 30mm 1.50 5ea/bx | other | $19 | $19 to $72 | Low |
| Vascular Occluders 1.25mm | other | $19 | $19 to $72 | Low |
| X-ray of Entire Middle and Lower Spine, Minimum of 6 Views | imaging | $19 | $19 to $72,084 | Low |
| Drill Flexible 25mm 71362925 S&n | other | $19 | $19 to $72 | Low |
| Needle Measurement of Electrical Activity in Muscle with Injection of Chemica... | other | $19 | $19 to $95,874 | Low |
| Osteopathic Manipulative Treatment, 1-2 Body Regions | other | $19 | $19 to $98,925 | Low |
| Retrograde Cardioplegia Cannula Self Inflating Balloon 18mm and Sure Touch Ha... | other | $19 | $19 to $72 | Low |
| Barron Vacuum Punch 9.0mm | other | $19 | $19 to $72 | Low |
| Healon Gv Pro 0.85ml 10340014 | other | $19 | $19 to $72 | Low |
| Test for Allergy Using Allergenic Extract Injected Into Skin | other | $19 | $19 to $95,024 | Low |
| Elite Irrigation Sleeve 7cm #5407-010 | other | $19 | $19 to $72 | Low |
| Analysis for Antibody to Rickettsia | other | $19 | $19 to $86,757 | Low |
| Prolactin (milk Producing Hormone) Level | other | $19 | $19 to $84,146 | Low |
| Obgyn Vacuum Palm Delivery Pump Mini Vac-6000m 5ea/1bx | obstetric | $19 | $19 to $73 | Low |
| Obgyn Vacuum Palm Delivery Small Pump Vac-6000s 5ea/1bx | obstetric | $19 | $19 to $73 | Low |
| Counseling for Genetic Testing Provided By a Genetic Counselor, Each 30 Minut... | therapy | $19 | $19 to $96,041 | Low |
| Tip Wet-field Bipolar Hemostatic Eraser 25g | other | $20 | $20 to $73 | Low |
| Injection, Penicillin G Benzathine and Penicillin G Procaine, 100,000 Units | other | $20 | $20 to $2,120 | Low |
| Evaluation of Single, Dual, Multiple Lead OR Leadless Pacemaker System | cardiac | $20 | $20 to $93,288 | Low |
| Speed Pins 3.2x110 #74013401 3ea/bx | other | $20 | $20 to $74 | Low |
| Virus Isolation, Centrifuge Enhanced | other | $20 | $20 to $87,254 | Low |
| Valve Speaking Passy-muir Trach #pmv | other | $20 | $20 to $74 | Low |
| Stool Lactoferrin (immune System Protein) Level | other | $20 | $20 to $83,631 | Low |
| Vascular Occluders 1.75mm | other | $20 | $20 to $74 | Low |
| Vessel Occluder Coronary 12mm 2.50 | cardiac | $20 | $20 to $74 | Low |
| Vessel Occluders 1.50mm | other | $20 | $20 to $74 | Low |
| Vessel Occuluder 2.0mm #50200 | other | $20 | $20 to $74 | Low |
| Blake Drain 19fr R/f #2230 Case/10ea | other | $20 | $20 to $74 | Low |
| Bowl and Spatula Bone Cement Mixing Universal System Vacuum Rotor without Noz... | other | $20 | $20 to $74 | Low |
| Shunt Javid Carotid 10frx27cm #007714 | other | $20 | $20 to $74 | Low |
| Single Contrast X-ray of Esophagus | imaging | $20 | $20 to $74,220 | Low |
| Injection, Labetalol Hydrochloride, 5 Mg | other | $20 | $20 to $74 | Low |
| Lap Sac Tissue Pouch 4" X 6" #g16495 | other | $20 | $20 to $74 | Low |
| Lap Sac Tissue Pouch 8" X 10" #g16497 | other | $20 | $20 to $74 | Low |
| Electrode Pacing Bipolar 4fr 5ea/1bx | other | $20 | $20 to $74 | Low |
| Electrode Pacing Bipolar 5fr 5ea/1bx | other | $20 | $20 to $74 | Low |
| Electrode Pacing Bipolar 6fr - 5ea/1bx | other | $20 | $20 to $74 | Low |
| Test for Abnormal Eye Movement with Recording | other | $20 | $20 to $92,541 | Low |
| Test of Car Seat OR Bed (1 Year OR Younger), 1 Hour | other | $20 | $20 to $94,780 | Low |
| Injection, Nafcillin Sodium, 20 Mg | other | $20 | $20 to $75 | Low |
| Outflare Wedge | other | $20 | $20 to $75 | Low |
| Relpax 20 Mg Tablet | other | $20 | $20 to $75 | Low |
| Relpax 40 Mg Tablet | other | $20 | $20 to $75 | Low |
| Bone Hemostasis 2.5gm #bw012 Ostene | other | $20 | $20 to $75 | Low |
| Evaluation of Implantable Heart and Blood Vessel Monitoring System | surgery | $20 | $20 to $93,290 | Low |
| Ketamine 500 Mg/5 Ml Vial | other | $20 | $20 to $75 | Low |
| Abdominal Ultrasound | imaging | $20 | $20 to $75 | High |
| Injection, Eptinezumab-jjmr, 1 Mg | other | $20 | $20 to $5,758 | Low |
| Aerotech I Aerosol Unit Ca-1124 | other | $20 | $20 to $75 | Low |
| Flow Cytometry Technique for Dna OR Cell Analysis, 16 OR More Markers | other | $20 | $20 to $88,189 | Low |
| Influenza Vaccine, Trivalent, 0.5 Ml Dosage | preventive | $20 | $20 to $90,658 | Low |
| Inserter Tip for Tibial Tray #00584305201 | other | $20 | $20 to $75 | Low |
| Insertion Needle 6" #acck1015 | other | $20 | $20 to $75 | Low |
| Interrogation Device Evaluation(s), (remote) Up to 30 Days; Implantable Cardi... | surgery | $20 | $20 to $150 | Low |
| Needle Epimed 4" #epmd1040 | other | $20 | $20 to $75 | Low |
| Omo Neurexa Plus Left Small 5065n=l-s | other | $20 | $20 to $75 | Low |
| Omo Neurexa Plus Right Small 5065n=r-s | other | $20 | $20 to $75 | Low |
| Omo Neurexa Plus Right Xlarge 5065n=r-xl | other | $20 | $20 to $75 | Low |
| Optetrak (4) Holding Pins Mni Head Sharp Point Mini Length Diameter 3.2mm #20... | other | $20 | $20 to $75 | Low |
| Optetrak (4) Short Head Pins 1.125in (28.575mm) Diameter 3.175mm Item # 201-78 | other | $20 | $20 to $75 | Low |
| Optetrak Quick Release Pins with Collar 40mm #201-78 | other | $20 | $20 to $75 | Low |
| Orthopedic Shoe, Oxford with Supinator OR Pronator, Infant | other | $20 | $20 to $150 | Low |
| Pin Fixation 2.3in Threaded Collared #521-78 | other | $20 | $20 to $75 | Low |
| Sensa Ii Ipg Template #acck7200 | other | $20 | $20 to $75 | Low |
| Smoking and Tobacco Use Intensive Counseling, More Than 10 Minutes | therapy | $20 | $20 to $99,407 | Low |
| Therapy Procedure for Nutrition Management, Each 15 Minutes | other | $20 | $20 to $97,802 | Low |
| Torque Wrench Kit #acck6006 | other | $20 | $20 to $75 | Low |
| Hook Blunt 5mm #3316-8g 8ea/pk | other | $20 | $20 to $75 | Low |
| Retractor Ring Plastic Single Use #3304-g | other | $20 | $20 to $75 | Low |
| Injection, Cangrelor, 1 Mg | other | $20 | $20 to $4,614 | Low |
| Limited X-ray of Body Bones | imaging | $20 | $20 to $77,074 | Low |
| 3d Ultrasound Imaging of Heart for Evaluation of Heart Structure Performed Du... | imaging | $20 | $20 to $93,319 | Low |
| Marker Breast MRI Compatible Senomark#smuc13c | imaging | $20 | $20 to $76 | Low |
| Potassium Cl 40 Meq/1,000ml-ns | other | $20 | $20 to $76 | Low |
| Brace Knee Post Op Warrior Kb9000 | other | $20 | $20 to $76 | Low |
| Tube Inner Ear Myringotomy Ventilation Reuter Bobbin without Flange Holes 1 M... | other | $20 | $20 to $76 | Low |
| Clozapine Level | other | $20 | $20 to $80,159 | Low |
| Drill for Bi-cortical Post #ar-1365d | other | $20 | $20 to $76 | Low |
| Influenza Vaccine, Trivalent, Split Virus, Preservative-free, 0.25 Ml Dosage | preventive | $20 | $20 to $90,655 | Low |
| Post Op Knee Brace Regular #423100 | other | $20 | $20 to $76 | Low |
| Vessel Occluder 1.75mm #50175 | other | $20 | $20 to $76 | Low |
| Vitamin B-2 (riboflavin) Level | other | $20 | $20 to $84,252 | Low |
| Pap Test, Manual Screening | preventive | $20 | $20 to $88,142 | Low |
| Orthopedic Shoe Addition, Sole, Full | other | $20 | $20 to $76 | Low |
| Measurement of Complement (immune System Proteins), Total Hemolytic | other | $20 | $20 to $86,162 | Low |
| Complete Ultrasound Study of Arm and Leg Arteries | imaging | $20 | $20 to $93,923 | Low |
| Methacholine Chloride Administered As Inhalation Solution Through a Nebulizer... | other | $20 | $20 to $77 | Low |
| Provocholine (methacholine) Dilutions (vials a -e) - Compounded | other | $20 | $20 to $77 | Low |
| Globo Ped Mobil Gr Lg #36628000030000eu | other | $20 | $20 to $77 | Low |
| Globo Ped Mobil Gr Shoe Med 36628000020000 | other | $20 | $20 to $77 | Low |
| Midline Indicator Pdl | other | $20 | $20 to $77 | Low |
| Injection, Infliximab-axxq, Biosimilar, (avsola), 10 Mg | other | $20 | $20 to $956 | Low |
| Clotting Factor Viii Related Antigen Measurement | other | $20 | $20 to $85,244 | Low |
| Cath Airway Exchange Cook 14fr Dbl #g57628 | other | $20 | $20 to $77 | Low |
| Mupirocin Calcium 2 % Ex Crea | other | $20 | $20 to $77 | Low |
| Transfer Set 6" Mini Cap 6ea/cs | other | $20 | $20 to $77 | Low |
| Addition to Lower Extremity, Limited Ankle Motion, Each Joint | other | $20 | $20 to $77 | Low |
| Mammogram | preventive | $20 | $15 to $77,052 | High |
| Therapy Procedure Using Massage, Each 15 Minutes | other | $20 | $20 to $97,124 | Low |
| Electronic Analysis of Spinal Canal Drug Infusion Pump | surgery | $21 | $21 to $62,367 | Low |
| C-reamer 9mm #8772a 4/bx | other | $21 | $21 to $77 | Low |
| Gelfoam Powder | other | $21 | $21 to $77 | Low |
| Lap Sac Tissue Pouch 5" X 8" #g16496 | other | $21 | $21 to $78 | Low |
| 45 Degree Kelman Mini-flare Tip | other | $21 | $21 to $78 | Low |
| Beta 2 Glycoprotein 1 Antibody (autoantibody) Measurement | other | $21 | $21 to $86,146 | Low |
| Marker Breast Stereotactic Senomark #smev9c | other | $21 | $21 to $78 | Low |
| Removal of Tissue From Wound, Each Additional 20.0 SQ Cm | surgery | $21 | $21 to $97,598 | Low |
| Tcc-ez Large Boot Tcc21114 1 Each | other | $21 | $21 to $78 | Low |
| Omo Neurexa Plus Left Xlarge 5065n=l-xl | other | $21 | $21 to $78 | Low |
| Analysis for Detection of Tumor Marker | other | $21 | $21 to $86,316 | Low |
| C-peptide (protein) Level | other | $21 | $21 to $84,681 | Low |
| Cell Examination of Specimen, Concentration Technique | lab | $21 | $21 to $88,108 | Low |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 125 | other | $21 | $21 to $86,304 | Low |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 15 | other | $21 | $21 to $86,300 | Low |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 19 | other | $21 | $21 to $86,301 | Low |
| Lift, Elevation, Heel, Tapered to Metatarsals, Per Inch | other | $21 | $21 to $78 | Low |
| Acclarent Balloon Inflation Device 5 Ea/bxdib30 | other | $21 | $21 to $78 | Low |
| Inflation Device Acclarent Se #seid Order By Bx/5ea | other | $21 | $21 to $78 | Low |
| Funnel Fistula 00860013000325 | other | $21 | $21 to $78 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Multiple Rib Nerves for Reg... | other | $21 | $21 to $64,421 | Low |
| Progesterone (reproductive Hormone) Level | other | $21 | $21 to $84,144 | Low |
| Xomed Nasal Postpac #15-26800 5/pk | other | $21 | $21 to $78 | Low |
| Uterine Manipulator Dx Vcare | other | $21 | $21 to $79 | Low |
| Test for Eardrum and Muscle Function | other | $21 | $21 to $92,550 | Low |
| Removal of Skin and Tissue, Each Additional 20.0 SQ Cm OR Less | surgery | $21 | $21 to $11,045 | Low |
| Flumazenil 0.5 Mg/5ml IV Soln | 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 |
| Diphtheria, Tetanus, and Acellular Pertussis Vaccine | preventive | $21 | $21 to $90,715 | Low |
| Programming of Single, Dual OR Multiple Lead Implantable Defibrillator System... | surgery | $21 | $21 to $93,287 | Low |
| Water for Injection Vial | other | $21 | $21 to $79 | Low |
| Bio-medicus Venous Insertion Kit 5 Ea/pk 96551 | other | $21 | $21 to $79 | Low |
| Addition to Lower Extremity, Below Knee, Waist Belt, Webbing | other | $21 | $21 to $79 | Low |
| Interstim Therapy Antenna #3709 | other | $21 | $21 to $80 | Low |
| Injection, Vancomycin Hcl, 500 Mg | other | $21 | $21 to $80 | Low |
| Injection for Imaging of Right Heart Chambers with Review By Radiologist | cardiac | $21 | $21 to $93,566 | Low |
| Tranexamic 1,000 Mg/100ml-nacl | other | $21 | $21 to $80 | Low |
| Organic Acid Level | other | $21 | $21 to $83,921 | Low |
| Ephedrine Sulfate (pressors) 5 Mg/ml IV Soln | other | $21 | $21 to $80 | Low |
| Vitamin B-1 (thiamine) Level | other | $21 | $21 to $84,425 | Low |
| Somatomedin (growth Factor) Level | other | $21 | $21 to $84,305 | Low |
| Cath Cholangiogram #lap-13 6each/1box | other | $21 | $21 to $80 | Low |
| Drill 3.0mm Step #ar-1250lt | other | $21 | $21 to $80 | Low |
| Genetic Sequencing Localization, Initial Procedure | other | $21 | $21 to $88,365 | Low |
| Group Psychotherapy | therapy | $21 | $21 to $90,853 | Low |
| Pathology Examination of Specimen During Surgery, Each Additional Tissue Block | surgery | $21 | $21 to $88,332 | Low |
| Screening 3d Breast Mammography | imaging | $21 | $21 to $77,063 | Low |
| Injection, Vedolizumab, Intravenous, 1 Mg | other | $21 | $21 to $17,333 | Low |
| Tissue Orientation Correct Clip #lcc6 | other | $21 | $21 to $80 | Low |
| Insulin Antibody Measurement | other | $21 | $21 to $86,337 | Low |
| Cyclogyl 0.5% Eye Drops | other | $21 | $21 to $81 | Low |
| Shunt Coronary Coil 1.5mm X 18mm Cts Flo | cardiac | $21 | $21 to $81 | Low |
| Shunt Coronary Coil 2.5mm X 18mm #ft | cardiac | $21 | $21 to $81 | Low |
| Viagra 100 Mg Tablet | other | $21 | $21 to $81 | Low |
| Viagra 50 Mg Tablet | other | $21 | $21 to $81 | Low |
| Injection, Amphotericin B Liposome, 10 Mg | other | $21 | $21 to $1,101 | Low |
| Small Parts Kit 23g Cannl&plugset #8065752149 | other | $22 | $22 to $81 | Low |
| Tube Trach Hyperflex Sz 7 Cuffed #67fhxl70 | other | $22 | $22 to $81 | Low |
| Wellbutrin Xl 300 Mg Tablet | other | $22 | $22 to $81 | Low |
| Nuclear Medicine Study of Lung Ventilation | imaging | $22 | $22 to $78,579 | Low |
| Gabapentin Level | other | $22 | $22 to $80,171 | Low |
| Estrogen Analysis, Total | other | $22 | $22 to $82,672 | Low |
| Sex Hormone Binding Globulin (protein) Level | other | $22 | $22 to $84,270 | Low |
| Counseling Visit to Discuss Need for Lung Cancer Screening Using Low Dose CT ... | preventive | $22 | $22 to $170 | Low |
| Cath 7fr Navilflex Rx Delivery Sys M00533560 | obstetric | $22 | $22 to $82 | Low |
| Delivery System Rx 10fr Biliary M00533580 | obstetric | $22 | $22 to $82 | Low |
| Delivery System Rx 7fr Biliary M00533560 | obstetric | $22 | $22 to $82 | Low |
| Tcc-ez Extra Large Boot Tcc21124 1 Each | other | $22 | $22 to $82 | Low |
| Ultrasound of One Arm Arteries OR Artery Grafts | imaging | $22 | $22 to $93,931 | Low |
| Full Sole and Heel Wedge, Between Sole | other | $22 | $22 to $82 | Low |
| Superficial And/or Low Voltage Radiation Treatment Delivery | obstetric | $22 | $22 to $77,401 | Low |
| Nuclear Medicine Study of Liver and Spleen | imaging | $22 | $22 to $78,215 | Low |
| Nuclear Medicine Study of Thyroid and Thyroid Function | imaging | $22 | $22 to $78,014 | Low |
| Renin (kidney Enzyme) Level | other | $22 | $22 to $84,244 | Low |
| Cath Fogarty Biliary 5fr 23cm 410235fp 5ea/case | other | $22 | $22 to $83 | Low |
| Cath Fogarty Biliary 6fr 23cm 410236fp 5ea/case | other | $22 | $22 to $83 | Low |
| External Breast Prosthesis Garment, with Mastectomy Form, Post Mastectomy | other | $22 | $22 to $83 | Low |
| Ultrasound of Aorta, Vena Cava, Groin Vessels OR Bypass Grafts | imaging | $22 | $22 to $93,979 | Low |
| 4.2mm Trocar 210mm 03.010.070 | other | $22 | $22 to $83 | Low |
| Strip Fistula Isolator 00860013000318 | other | $22 | $22 to $83 | Low |
| Dehydroepiandrosterone (dhea-s) Hormone Level | other | $22 | $22 to $82,627 | Low |
| Eleview Submucosal Injectable Composition 10ml Ampoule 5ea/bx #9000020 | other | $22 | $22 to $84 | Low |
| Addition to Lower Extremity, Extended Steel Shank | other | $22 | $22 to $84 | Low |
| Needle Transbronchial 19ga Aspiration W/syr | other | $22 | $22 to $84 | Low |
| Needle Transbronchial 20ga Aspiration W/syr | other | $22 | $22 to $84 | Low |
| Needle Transbronchial 21ga Aspiration W/syr | other | $22 | $22 to $84 | Low |
| Ultrasound of One Side of Head and Neck Blood Flow | imaging | $22 | $22 to $93,882 | Low |
| Fresh Frozen Plasma (single Donor), Frozen Within 8 Hours of Collection, Each... | other | $22 | $22 to $86 | Low |
| Pap Test | other | $22 | $22 to $88,141 | Low |
| Endopath Electrosurgery Probe Plus Ii 5mm Hook 34cm Length Eps01 | surgery | $22 | $22 to $84 | Low |
| Endopath Electrosurgery Probe Plus Ii 5mm Hook 29cm Length Eps05 | surgery | $22 | $22 to $84 | Low |
| Review By Radiologist of Previous Placed Shunt Image | other | $22 | $22 to $75,809 | Low |
| Review By Radiologist of Chest Aorta Image | other | $23 | $23 to $75,600 | Low |
| Shunt Coronary Coil 2.0mm X 18mm Cts Flo | cardiac | $23 | $23 to $85 | Low |
| Barron Vacuum Punch 7.5mm | other | $23 | $23 to $85 | Low |
| Barron Vacuum Punch 8.0mm | other | $23 | $23 to $85 | Low |
| Dihydroxyvitamin D, 1, 25 Level | other | $23 | $23 to $82,652 | Low |
| Endoscopic Clip Applier 5mm M/l Port Universal Epix #ca500 3ea/box | other | $23 | $23 to $85 | Low |
| Punch Barron Donor 7.75 K20 | other | $23 | $23 to $85 | Low |
| Rd Rainbow Set 2 Adult Adhesive Sensor 4026 Box/10ea | other | $23 | $23 to $85 | Low |
| Rd Rainbow Set 2 Neo Adhesive Sensor 4029 Box/10ea | other | $23 | $23 to $85 | Low |
| Sensor Large Foresight Elite #fsesl Bx/20 | other | $23 | $23 to $85 | Low |
| Service Provided On an Emergency Basis in the Office | emergency | $23 | $23 to $99,058 | Low |
| Stylet Faller for Pd Cath #fs | other | $23 | $23 to $85 | Low |
| Test for Detecting Genes Associated with Blood Cancer | other | $23 | $23 to $81,246 | Low |
| Tube Fastrach Combo Sz 3 #135130 5ea/1case | other | $23 | $23 to $85 | Low |
| Tube Fastrach Combo Sz 4 | other | $23 | $23 to $85 | Low |
| Tube Fastrach Combo Sz 5 | other | $23 | $23 to $85 | Low |
| Brush Biopsy Deflection 3.2frx115cm #g15045 | lab | $23 | $23 to $85 | Low |
| Ultrasound of Leg Arteries At Rest and After Exercise | imaging | $23 | $23 to $93,924 | Low |
| Injection, Aminocaproic Acid, 1 Gram | other | $23 | $23 to $85 | Low |
| Reaming Rod 3.0 W/offset Ball Tip 950mm Nonst | other | $23 | $23 to $85 | Low |
| Reaming Rod 3.0mm X 950mm #351.76 | other | $23 | $23 to $85 | Low |
| Application of Vein Wound Compression Bandages On Lower Leg, Ankle, and Foot | other | $23 | $23 to $29,581 | Low |
| Centurion 45 Fms Cassette Only | other | $23 | $23 to $85 | Low |
| Cook Chest Drain Valve #g36370 | other | $23 | $23 to $86 | Low |
| Injection, Aminophyllin, Up to 250 Mg | other | $23 | $23 to $85 | Low |
| Fogarty Insert Dbl Hydrajaw 33mm | other | $23 | $23 to $86 | Low |
| Design and Construction of Simple Radiation Treatment Device | other | $23 | $23 to $77,332 | Low |
| Closure Surgical Skin 16cm Zip16 Ps1160 10/pk | surgery | $23 | $23 to $86 | Low |
| Clotting Factor Viii (vw Factor) Antigen | other | $23 | $23 to $85,246 | Low |
| Gradient Compression Glove, Each | other | $23 | $23 to $86 | Low |
| Amino Acid Analysis, Quantitative, Each Specimen | lab | $23 | $23 to $82,131 | Low |
| Grasping Forceps Rescue Combo #m00538351 | other | $23 | $23 to $86 | Low |
| Retractor Ring Lone Star Disposable 3307g | other | $23 | $23 to $86 | Low |
| Retrieval Net 30mm Rescue Net #dgn-538 | other | $23 | $23 to $86 | Low |
| Sodium Bicarbonate 8.4 % IV Soln | other | $23 | $23 to $87 | Low |
| Globo Ped Mobil Gr Small #36628000010000eu | other | $23 | $23 to $87 | Low |
| Globo Ped Mobil Gr X-large #36628000040000 | other | $23 | $23 to $87 | Low |
| Micro Nester .018 3mm X 14cm | other | $23 | $23 to $87 | Low |
| Micro Nester .018 4mm X 14cm | other | $23 | $23 to $87 | Low |
| Micro Nester .018 6mm X 14cn | other | $23 | $23 to $87 | Low |
| Micro Nester .018 8mm X 7cm | other | $23 | $23 to $87 | Low |
| Nester .035 16mm X 14cm | other | $23 | $23 to $87 | Low |
| Nester .035 20mm X 14cm | other | $23 | $23 to $87 | Low |
| Nester .035 3mm X 7cm | other | $23 | $23 to $87 | Low |
| Nester .035 4mm X 14cm | other | $23 | $23 to $87 | Low |
| Nester .035 6mm X 14cm | other | $23 | $23 to $87 | Low |
| Addition to Lower Extremity, Varus/valgus Correction ('t') Strap, Padded/line... | other | $23 | $23 to $87 | Low |
| Tcc-ez Transmet Boot Tcc21131 1 Each | other | $23 | $23 to $87 | Low |
| Electrode Hf Needle 45deg 24-28fr #a22255c | other | $23 | $23 to $87 | Low |
| Electrode Monopolar Roller Ball24-28f A22251c | other | $23 | $23 to $87 | Low |
| Single Sensor W/lumen 7fr Catheter | cardiac | $23 | $23 to $87 | Low |
| Cannula Grundy Retrograde 15fr #94115t | other | $23 | $23 to $87 | Low |
| Cannula Perfusion Retrograde 15 Fr 32 Cm Length Stopcock Wirewound Body #9462... | surgery | $23 | $23 to $87 | Low |
| Immunologic Analysis Technique On Body Fluid | other | $23 | $23 to $86,325 | Low |
| Microscopic Genetic Analysis of Tumor, Using Computer-assisted Technology | other | $23 | $23 to $88,361 | Low |
| Levemir 100 Unit/ml Vial | other | $23 | $23 to $87 | Low |
| Brace Knee T-scope Post Op #08814 | other | $23 | $23 to $87 | Low |
| Neomycin-polymyxin-hc Ear Susp | other | $23 | $23 to $87 | Low |
| Uterine Manipulator Lrge Vcare | other | $23 | $23 to $87 | Low |
| Uterine Manipulator Medium Vcare | other | $23 | $23 to $87 | Low |
| Uterine Manipulator Small Vcare | other | $23 | $23 to $87 | Low |
| Cement Mixer Sys Acm Stryker(used for Hip Rar | other | $23 | $23 to $87 | Low |
| Comprehensive Hearing Test | other | $23 | $23 to $92,570 | Low |
| Electrode Monopolar Loop A22205c | other | $23 | $23 to $88 | 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 |
| Barron Vacuum Punch 8.25mm | other | $23 | $23 to $88 | Low |
| Catheter Dilation Soehendra Biliary G21571 | cardiac | $23 | $23 to $88 | Low |
| Punch Cornea 8.5mm Barron Vacuum | other | $23 | $23 to $88 | Low |
| Pigazzi Pad Pink Xl #40583 4ea/1cs | other | $23 | $23 to $88 | Low |
| Snare System Lariat 30mm10mm6mm Port 2.5mm | other | $24 | $24 to $89 | Low |
| Pessary, Reusable, Non Rubber, Any Type | other | $24 | $24 to $178 | Low |
| Physician OR Allowed Practitioner Certification for Medicare-covered Home Hea... | other | $24 | $24 to $178 | Low |
| Service Provided in the Office When the Office Is Normally Closed | other | $24 | $24 to $99,050 | Low |
| Sulfacetamide 10% Eye Drops | other | $24 | $24 to $89 | Low |
| Sulfacetamide Sodium 10 % Op Soln | other | $24 | $24 to $89 | Low |
| Evaluation of Cardiac Rhythm Monitor System, Remote Up to 30 Days | cardiac | $24 | $24 to $93,298 | Low |
| Evaluation of Implantable Heart and Blood Vessel Monitoring System, Remote Up... | surgery | $24 | $24 to $93,297 | Low |
| Test for Abnormal Eye Movement Using 3 Positions with Recording | other | $24 | $24 to $92,542 | Low |
| Tcc-ez Large Charcot Boot Tcc21116 1 Each | other | $24 | $24 to $90 | Low |
| Endovive Soft Peg Pull 20f 2/bx M00509001 | other | $24 | $24 to $90 | Low |
| Gastrostomy Safety Peg 24fr Kit Pull | other | $24 | $24 to $90 | Low |
| Gastrostomy Safety Peg Set 20fr W/xylocaine | other | $24 | $24 to $90 | Low |
| Olumiant 1 Mg Tablet | other | $24 | $24 to $90 | Low |
| 3d Radiographic Procedure | imaging | $24 | $24 to $76,376 | Low |
| Bra Cardiac Surgery Sz-40b-52dd 1ea | surgery | $24 | $24 to $90 | Low |
| Cath Cholangiogram Aerostat Rigid Tip #c1002 | other | $24 | $24 to $90 | Low |
| Prolonged Office OR Other Outpatient Evaluation and Management Service(s) Bey... | other | $24 | $24 to $180 | Low |
| Retractor Alexis O Lg C-section 9-14cm #g6313 | obstetric | $24 | $24 to $90 | Low |
| Wound Retractor/protector Large #c8403 | other | $24 | $24 to $90 | 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 |
| Injection, Morphine Sulfate (fresenius Kabi), Not Therapeutically Equivalent ... | other | $24 | $24 to $90 | Low |
| Injection, Natalizumab, 1 Mg | other | $24 | $24 to $25,859 | Low |
| Zomig 5 Mg Nasal Spray | other | $24 | $24 to $90 | Low |
| Imaging of Urinary Tract Following Injection of a Contrast Agent | other | $24 | $24 to $74,420 | Low |
| Omo Neurexa Plus Left Medium 5065n=l-m | other | $24 | $24 to $90 | Low |
| Ultrasound of Heart, Follow-up | imaging | $24 | $24 to $93,308 | Low |
| Detection Test By Immunoassay Technique for Hiv-1 Antigen and Hiv-1 and Hiv-2... | other | $24 | $24 to $87,389 | Low |
| Chemical Analysis Using Chromatography Technique | other | $24 | $24 to $82,542 | Low |
| Addition to Lower Extremity, Below Knee, Cuff Suspension | other | $24 | $24 to $91 | Low |
| Preventive Medicine Counseling, Typically 15 Minutes | therapy | $24 | $24 to $99,401 | Low |
| Humeral Splint Ext Length Medium 37-2162 | other | $24 | $24 to $91 | Low |
| Humeral Splint Ext. Length Lg | other | $24 | $24 to $91 | Low |
| Humeral Splint Ext. Length Xlg | other | $24 | $24 to $91 | Low |
| Humeral Splint Mid Length Lg | other | $24 | $24 to $91 | Low |
| Humeral Splint Mid Length Med. | other | $24 | $24 to $91 | Low |
| Humeral Splint Mid Length Small | other | $24 | $24 to $91 | Low |
| Application of Nonmoveable Finger Splint | other | $24 | $24 to $29,130 | Low |
| Programming of Cardiac Rhythm Monitor System | cardiac | $24 | $24 to $93,285 | Low |
| Rally Vacuum Mixing Bowl7127 | other | $24 | $24 to $92 | Low |
| Bard Single Lumen Picc 5fr #3195335 | other | $24 | $24 to $92 | Low |
| Loop 3mm 12 Deg for Small Tur Set #wa47050c | other | $24 | $24 to $92 | 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 |
| Dressing Nasal Foam Stammberger Sinus #rr650 | other | $24 | $24 to $92 | Low |
| G Tube Entuit #g35618 | other | $24 | $24 to $92 | Low |
| Compass Compartment #cmps001 | other | $25 | $25 to $92 | Low |
| Injection, Triamcinolone Acetonide, Preservative Free, 1 Mg | other | $25 | $25 to $114 | Low |
| Nasal Packing Epostat 1ea | other | $25 | $25 to $92 | Low |
| Nitroglycerin 400 Mcg Spray | other | $25 | $25 to $92 | Low |
| Cath Nasal Posterior Epistaxis Rapid Rhino | other | $25 | $25 to $93 | Low |
| Nasogastric/nasointestinal Feeding Tube Retention System 12fr White Corgrip S... | other | $25 | $25 to $93 | Low |
| Nasogastric/nasointestinal Feeding Tube Retention System 14fr Yellow Corgrip ... | other | $25 | $25 to $93 | Low |
| Nasogastric/nasointestinal Feeding Tube Retention System Corgrip Sr 10fr Pink... | other | $25 | $25 to $93 | Low |
| Nasogastric/nasointestinal Feeding Tube Retention System Corgrip Sr 16fr Oran... | other | $25 | $25 to $93 | Low |
| Nasogastric/nasointestinal Feeding Tube Retention System Corgrip Sr 18fr Tan ... | other | $25 | $25 to $93 | Low |
| Removal of Impacted Cerumen (one OR Both Ears) By Physician On Same Date of S... | surgery | $25 | $25 to $186 | Low |
| Ultrasound Scan of Abdominal Aorta | imaging | $25 | $25 to $76,706 | Low |
| Complete X-ray of Body Bones | imaging | $25 | $25 to $77,075 | Low |
| Insertion of Lower Leg Neurostimulator Electrode | other | $25 | $25 to $64,566 | Low |
| Simple Bladder Irrigation And/or Instillation | other | $25 | $25 to $51,700 | Low |
| Omo Neurexa Plus Left Large 5065n=l-l | other | $25 | $25 to $94 | Low |
| Omo Neurexa Plus Right Large 5065n=r-l | other | $25 | $25 to $94 | Low |
| Omo Neurexa Plus Right Medium 5065n=r-m | other | $25 | $25 to $94 | Low |
| Basket Retrieval 2.5x230cm Disp Roth 00711050 | other | $25 | $25 to $94 | Low |
| Gradient Compression Arm Sleeve, Each | other | $25 | $25 to $94 | Low |
| Guide Wire | other | $25 | $25 to $94 | Low |
| Roth Net Retrieval Basket #bx00711150 | other | $25 | $25 to $94 | Low |
| Adapter/extension, Pacing Lead OR Neurostimulator Lead | other | $25 | $25 to $94 | Low |
| X-ray of Bone At Base of Skull | imaging | $25 | $25 to $70,240 | Low |
| X-ray of Infant Leg, Minimum of 2 Views | imaging | $25 | $25 to $73,592 | Low |
| Tcc-ez Extra Large Charcot Boot Tcc21126 1 Each | other | $25 | $25 to $94 | Low |
| Hc Medihoney Alginate Dressing | other | $25 | $25 to $95 | Low |
| Aplisol 5t Unit/0.1 Ml Vial | other | $25 | $25 to $95 | Low |
| Duovisc Large #8065183150 | other | $25 | $25 to $95 | Low |
| Comprehensive Hearing and Speech Recognition Test | other | $25 | $25 to $92,557 | Low |
| Catecholamines (organic Nitrogen) Level | imaging | $25 | $25 to $82,384 | Low |
| 5.5x85mm Rod Ti Alloy Curved Vitality #07.02015.014 | other | $25 | $25 to $95 | Low |
| Cast Supplies | other | $25 | $25 to $190 | Low |
| Dehydroepiandrosterone (dhea) Hormone Level | other | $25 | $25 to $82,626 | Low |
| Home Sleep Test (hst) with Type IV Portable Monitor, Unattended; Minimum of 3... | other | $25 | $25 to $190 | Low |
| Lineum 3.5mm X 80mm Ti Rod #14 | other | $25 | $25 to $95 | Low |
| Other Allergy OR Clinical Immunology Service OR Procedure | other | $25 | $25 to $95,199 | Low |
| Presbyopia Correcting Function of Intraocular Lens | other | $25 | $25 to $95 | Low |
| Tornado .018 8mm X 4mm | other | $25 | $25 to $95 | Low |
| Tornado .035 10mm X 5mm | other | $25 | $25 to $95 | Low |
| Tornado Coil .035 10mm X 4mm | other | $25 | $25 to $95 | Low |
| Vitality 5.5x300mm Rod Ti Alloy Straight #07.02013.001 | other | $25 | $25 to $95 | Low |
| X-ray From Nose to Rectum | imaging | $25 | $25 to $76,010 | Low |
| Foot Drop Splint, Recumbent Positioning Device, Prefabricated, Off-the-shelf | other | $25 | $25 to $95 | Low |
| Orthopedic Footwear, Woman's Shoe, Oxford, Used As an Integral Part of a Brace | other | $25 | $25 to $95 | Low |
| Hc Dress Aquacl Ag Xtr | other | $25 | $25 to $96 | Low |
| Instrument Tracker 9733533xom ENT | other | $25 | $25 to $96 | Low |
| Cell Examination of Specimen, Selective Cellular Enhancement Technique | lab | $25 | $25 to $88,112 | Low |
| Cardiolipin Antibody (tissue Antibody) Measurement | other | $25 | $25 to $86,147 | Low |
| Injection, Rho D Immune Globulin, Intravenous, Human, Solvent Detergent, 100 Iu | other | $25 | $25 to $13,063 | Low |
| Testosterone (hormone) Level, Free | other | $25 | $25 to $84,402 | Low |
| Oxcarbazepine 300 Mg/5 Ml Susp | other | $26 | $26 to $96 | Low |
| Kit Mickey Gastrostomy Feeding Tube 14fr2.3cm | other | $26 | $26 to $96 | Low |
| Kit Mickey Gastrostomy Feeding Tube 16fr2.3cm | other | $26 | $26 to $96 | Low |
| Tube Inner Ear Myringotomy Ventilation Notched Flange with Tab 1.14 Mm Id Sof... | other | $26 | $26 to $96 | Low |
| Pillow Intubating Positioner Including Disposable Head Cradle #10-910-00 3/bx | other | $26 | $26 to $96 | Low |
| Tri-lumen Filtered Tube Set 6ea/cs | other | $26 | $26 to $96 | Low |
| Foot, Arch Support, Removable, Premolded, Longitudinal/ Metatarsal, Each | other | $26 | $26 to $97 | Low |
| Injection, Bevacizumab-bvzr, Biosimilar, (zirabev), 10 Mg | other | $26 | $26 to $6,239 | Low |
| Immunologic Analysis for Autoimmune Disease, A, B, OR C, Single Antigen | other | $26 | $26 to $86,812 | Low |
| Testosterone (hormone) Level, Total | other | $26 | $26 to $84,403 | Low |
| Removal of Impacted Ear Wax | surgery | $26 | $26 to $69,210 | Low |
| CT Scan of Heart with Evaluation of Blood Vessel Calcium | imaging | $26 | $26 to $75,571 | Low |
| Check of Hearing Aid, Both Ears | other | $26 | $26 to $92,593 | Low |
| Humeral Splint Mid Length 2xl #37-2185 | other | $26 | $26 to $98 | Low |
| Adhesion Barrier | other | $26 | $26 to $98 | Low |
| Cell Examination of Body Fluid, Smears | other | $26 | $26 to $88,104 | Low |
| Blood Gases Measurement | other | $26 | $26 to $82,803 | Low |
| Smart Ablate Irrigation Tubing #sat001 | other | $26 | $26 to $98 | Low |
| Special Stained Specimen Slides to Examine Tissue, Initial Procedure | lab | $26 | $26 to $88,342 | Low |
| Tissue Culture Inoculation for Virus Isolation | lab | $26 | $26 to $87,252 | Low |
| Catheter, Occlusion | cardiac | $26 | $26 to $98 | Low |
| Cement Mixer Smart Mix Tower #5401-98 | other | $26 | $26 to $98 | Low |
| Fluoroscopic Guidance for Needle Placement | other | $26 | $26 to $77,002 | Low |
| Injection, Gemcitabine Hydrochloride (accord), Not Therapeutically Equivalent... | other | $26 | $26 to $98 | Low |
| Addition to Lower Extremity Orthosis, Knee Control, Full Kneecap | other | $26 | $26 to $99 | Low |
| Injection, Methylnaltrexone, 0.1 Mg | other | $26 | $26 to $99 | Low |
| C-reamer 10mm Linvatec #8773a 4/bx | other | $26 | $26 to $99 | Low |
| Injection of Radioactive Material for X-ray Identification of Lymph Node | imaging | $26 | $26 to $38,792 | Low |
| Anticoagulant Management for an Outpatient Taking Warfarin, Physician Review ... | other | $26 | $26 to $99,364 | Low |
| Diabetes Outpatient Self-management Training Services, Individual, Per 30 Min... | other | $26 | $26 to $198 | Low |
| Influenza Vaccine Split Virus, Preservative Free | preventive | $26 | $26 to $90,662 | Low |
| Kyphon Bone Biopsy Device #3 #f05a | lab | $26 | $26 to $99 | Low |
| Preparation of Report of Patient's Psychiatric Status | therapy | $26 | $26 to $90,889 | Low |
| Sternal Zipfix with Needle Pk/20ea #08.501.001.20s | other | $26 | $26 to $99 | Low |
| Transfer of an Orthosis From One Shoe to Another, Caliper Plate, Existing | other | $26 | $26 to $99 | Low |
| Bone Marrow Asp Sys Dstl Hole 11g 710.150.97s | other | $26 | $26 to $99 | Low |
| Hearing Service, Miscellaneous | other | $27 | $27 to $199 | Low |
| Limited Ultrasound Scan of Abdomen | imaging | $27 | $27 to $76,705 | Low |
| Indocin 50 Mg Suppository | other | $27 | $27 to $100 | Low |
| Balloon Wedge Pressure Catheter 5fr 110cm | cardiac | $27 | $27 to $100 | Low |
| Entrada Needle 11cm $sc-4220 | other | $27 | $27 to $100 | Low |
| Entrada Needle 15cm #sc-4220 | other | $27 | $27 to $100 | Low |
| Hand Finger Orthosis, without Joints, May Include Soft Interface, Straps, Pre... | other | $27 | $27 to $200 | Low |
| Hepatitis a Vaccine Pediatric OR Adolescent Dosage | preventive | $27 | $27 to $90,633 | Low |
| Irrigation Tubing #rob10031 | other | $27 | $27 to $100 | Low |
| Pin Plug #6725 Medtronic | other | $27 | $27 to $100 | Low |
| Repositioning Exercises of Head for Treatment of Dizziness, Each Day | other | $27 | $27 to $95,992 | Low |
| Stent Introducer Set G22684 | cardiac | $27 | $27 to $100 | Low |
| Test to Assess Hearing Sensitivity Using Visual Aids | other | $27 | $27 to $92,579 | Low |
| Sheath Uropass 11/13 Fr X 38cm #61138bx | other | $27 | $27 to $100 | Low |
| Addition to Lower Extremity Orthosis, Femoral Length Sock, Fracture OR Equal,... | other | $27 | $27 to $100 | Low |
| Needle Ebus 22g #na-201sx-4022-a | other | $27 | $27 to $100 | Low |
| Proinsulin (pancreatic Hormone) Level | other | $27 | $27 to $84,206 | Low |
| Nasal Tube Bridal Pro System 12-14 Fr Dark Blue5ea/box #4 | other | $27 | $27 to $101 | Low |
| Nasal Tube Bridle Pro System 16-18fr Yellow 5ea/box #4 | other | $27 | $27 to $101 | Low |
| Nasal Tube Bridle Pro System 5-6 Fr Purple 5ea/box#4 | other | $27 | $27 to $101 | Low |
| Nasal Tube Bridle Pro System 8-10 Fr Teal 5ea/box# 4 | other | $27 | $27 to $101 | Low |
| Coil Embolization Nester 8mmx7cm #g52744 | other | $27 | $27 to $101 | Low |
| Calcitonin (hormone) Level | other | $27 | $27 to $82,308 | Low |
| Review By Radiologist of Image From Tube Placement Into Bile and Pancreatic D... | other | $27 | $27 to $74,330 | Low |
| Alkaloids Levels | other | $27 | $27 to $80,323 | Low |
| Cook Catheter Willis Oglesby Tube #g09892 | cardiac | $27 | $27 to $101 | Low |
| Medical Management Interactions On the Patient's Behalf with Agencies, Employ... | other | $27 | $27 to $90,882 | Low |
| Incision of Tissue Joining Lip and Gum | other | $27 | $27 to $40,806 | Low |
| Common Carotid Intima-media Thickness (imt) Study for Evaluation of Atheroscl... | other | $27 | $27 to $246 | Low |
| Calcium Chloride 10 % IV Soln | other | $27 | $27 to $101 | Low |
| Albendazole 200 Mg Po Tabs | other | $27 | $27 to $102 | Low |
| Collection of Blood Sample From Central Venous Tube | other | $27 | $27 to $36,592 | Low |
| Guide Pin D1.5 Lg 300mm Gleno #230796000 | other | $27 | $27 to $102 | Low |
| Guide Pin Metaglene 2.5 #2307-87 | other | $27 | $27 to $102 | Low |
| Procalcitonin (hormone) Level | other | $27 | $27 to $84,145 | Low |
| Nuclear Medicine Study of Bone And/or Joint Limited Area | imaging | $27 | $27 to $78,300 | Low |
| Pathology Examination of Specimen During Surgery | surgery | $27 | $27 to $88,329 | Low |
| Technetium Tc 99m Pentetate Diagnostic 25 Mci | other | $27 | $27 to $102 | Low |
| Belt, Strap, Sleeve, Garment, OR Covering, Any Type | other | $27 | $27 to $103 | Low |
| Cath Cholangiogram/taut 4fr X 18in | other | $27 | $27 to $103 | Low |
| Fulgurating Endo Electrode 2fr 105cm #be | other | $27 | $27 to $103 | Low |
| Measurement of Immune Substance | other | $27 | $27 to $83,916 | Low |
| Injection, Bleomycin Sulfate, 15 Units | other | $27 | $27 to $265 | 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 |
| Cement Bone Mixing System #414702 1pk/10ea | other | $28 | $28 to $104 | Low |
| Knee Brace Recover Neo Long Large #00364 | other | $28 | $28 to $104 | Low |
| Knee Brace Recover Neo Long Medium #00363 | other | $28 | $28 to $104 | Low |
| Knee Brace Recover Neo Long Small #00362 | other | $28 | $28 to $104 | Low |
| Knee Brace Recover Neo Long Xlarge #00365 | other | $28 | $28 to $104 | Low |
| Knee Brace Recover Neo Long Xxl #00366 | other | $28 | $28 to $104 | Low |
| Endostitch Device 10mm #173016 | other | $28 | $28 to $104 | Low |
| I&a Tip Straight | other | $28 | $28 to $104 | Low |
| Diltiazem 100 Mg/100 Ml - Compounded | other | $28 | $28 to $104 | Low |
| Potassium Acet 100 Meq/50 Ml | other | $28 | $28 to $104 | Low |
| Diltiazem 100 Mg Add-van Vial | other | $28 | $28 to $104 | Low |
| Therapeutic Procedures to Improve Respiratory Function, Other Than Described ... | other | $28 | $28 to $112 | Low |
| Therapeutic Procedures to Increase Strength OR Endurance of Respiratory Muscl... | other | $28 | $28 to $143 | Low |
| Removal of Blood Flow Assist Device in Aorta | surgery | $28 | $28 to $33,968 | Low |
| Citrate Level | other | $28 | $28 to $82,507 | Low |
| 2.2mm Match Head 5820-107 | other | $28 | $28 to $105 | Low |
| Test to Measure Lung Airway Sensitivity | other | $28 | $28 to $94,070 | Low |
| Injection, Rituximab-pvvr, Biosimilar, (ruxience), 10 Mg | other | $28 | $28 to $8,783 | Low |
| Hydrocort-pramoxine 1%-1% Crm | other | $28 | $28 to $105 | Low |
| Food Bolus 4cmx2.5mmx160cm Rothnet Bx00711155 | other | $28 | $28 to $105 | Low |
| Placement of Ear Probe for Computerized Measurement of Repeated Sounds with I... | other | $28 | $28 to $92,588 | Low |
| Residence Visit for Established Patient with Straightforward Medical Decision... | other | $28 | $28 to $99,347 | Low |
| Measurement of Total Estradiol | other | $28 | $28 to $82,670 | Low |
| Injection, Trastuzumab-qyyp, Biosimilar, (trazimera), 10 Mg | other | $28 | $28 to $6,579 | Low |
| Coil Vascular Loop Shape Standard Stretch 8 Mm Dia 10 Cm Length Pushable 0.03... | other | $28 | $28 to $106 | Low |
| Mreye .035 10mm X 10cm | other | $28 | $28 to $106 | Low |
| Mreye .035 10mm X 15cm | other | $28 | $28 to $106 | Low |
| Mreye .035 10mm X 8cm | other | $28 | $28 to $106 | Low |
| Mreye .035 15mm X 15cm | other | $28 | $28 to $106 | Low |
| Mreye .035 20mm X 15cm | other | $28 | $28 to $106 | Low |
| Mreye .035 4mm X 4cm | other | $28 | $28 to $106 | Low |
| Mreye .035 5mm X 3cm | other | $28 | $28 to $106 | Low |
| Mreye .035 5mm X 5cm | other | $28 | $28 to $106 | Low |
| Mreye .035 5mm X 8cm | other | $28 | $28 to $106 | Low |
| Mreye .035 6mm X 5cm | other | $28 | $28 to $106 | Low |
| Mreye .035 8mm X 8cm | other | $28 | $28 to $106 | Low |
| Vitamin B-6 Level | other | $28 | $28 to $84,207 | Low |
| Lumbar Orthosis, Sagittal Control, with Rigid Posterior Panel(s), Posterior E... | lab | $28 | $28 to $106 | Low |
| Probe Vascular 2.0-2.5mm 45cm 5/bx | other | $28 | $28 to $106 | Low |
| Rasp #5100-037-114 Stryker (bone Shaver | other | $28 | $28 to $106 | Low |
| Rasp Large Tear #5100-037 | other | $28 | $28 to $106 | Low |
| Rasp Small Tear #5100-37 | other | $28 | $28 to $106 | Low |
| Electronic Analysis and Reprogramming of Spinal Canal Drug Infusion Pump | surgery | $28 | $28 to $62,368 | Low |
| Evaluation of Fine Needle Aspirate | other | $28 | $28 to $88,172 | Low |
| Injection, Leucovorin Calcium, Per 50 Mg | other | $28 | $28 to $106 | Low |
| Introducer/sheath, Guiding, Intracardiac Electrophysiological, Fixed-curve, O... | cardiac | $28 | $28 to $106 | Low |
| Introducer/sheath, Guiding, Intracardiac Electrophysiological, Steerable, Oth... | cardiac | $28 | $28 to $106 | Low |
| Cannula I&a Simcoe | other | $28 | $28 to $106 | Low |
| Collection of Blood Sample From Implanted Device | surgery | $28 | $28 to $36,591 | Low |
| Evaluation of Single, Dual, Multiple Lead OR Leadless Pacemaker System, Remot... | cardiac | $28 | $28 to $93,294 | Low |
| Addition to Lower Extremity Fracture Orthosis, Drop Lock Knee Joint | other | $28 | $28 to $107 | Low |
| Gastrointestinal Suture Anchor Kit #g04474 | other | $28 | $28 to $107 | Low |
| Other Evaluation and Management Service | other | $28 | $28 to $99,499 | Low |
| Reaming Rod 2.5mm X 850mm Ti Cannulated | other | $28 | $28 to $107 | Low |
| Injection, Nitroglycerin, 5 Mg | other | $28 | $28 to $107 | Low |
| Electronic Analysis Reprogramming and Refill of Spinal Canal Drug Infusion Pump | surgery | $29 | $29 to $62,369 | Low |
| Detractor Guhl Ankle 6ea/bx | other | $29 | $29 to $108 | Low |
| Mental Health Evaluation | therapy | $29 | $29 to $430 | High |
| Psychiatric Evaluation of Hospital Records, Reports, Testing, OR Data for Dia... | therapy | $29 | $29 to $90,885 | Low |
| Repair Arterial Blockage | surgery | $29 | $29 to $75,962 | Low |
| Injection, Adrenalin, Epinephrine, 0.1 Mg | other | $29 | $29 to $109 | Low |
| Tretinoin 0.05 % Ex Crea | other | $29 | $29 to $109 | Low |
| Precedex 200 Mcg/50 Ml Bottle | other | $29 | $29 to $109 | Low |
| Osteopathic Manipulative Treatment, 3-4 Body Regions | other | $29 | $29 to $98,926 | Low |
| Injection of Anesthetic And/or Steroid Drug Into Foot Nerve | other | $29 | $29 to $64,455 | Low |
| Probe Bio Vascular 1.0-1.5mm 5/bx | other | $29 | $29 to $109 | Low |
| Cuffed Tracheostomy Tube Bivona Fome-cuf Disposable Ic Size 6.0 Adult 850160 | other | $29 | $29 to $109 | Low |
| Cuffed Tracheostomy Tube Bivona Fome-cuf Disposable Ic Size 7.0 Adult 850170 | other | $29 | $29 to $109 | Low |
| Tray Pneumothorax Infant 5ea/1cs | other | $29 | $29 to $109 | Low |
| Centurion 30 Fms Cassette Only #8065000138 6ea/bx | other | $29 | $29 to $109 | Low |
| Removal of Foreign Body From External Eye | surgery | $29 | $29 to $65,210 | Low |
| Orthopedic Footwear, Man's Shoe, Oxford, Used As an Integral Part of a Brace | other | $29 | $29 to $110 | Low |
| Nail Nippers 4" #881302 | other | $29 | $29 to $110 | Low |
| Tretinoin 0.1 % Ex Crea | other | $29 | $29 to $110 | Low |
| Cement Mixer 00-4501-090-00 00450109000 | other | $29 | $29 to $110 | Low |
| Clip Avalon Filshie #avm-851j | other | $29 | $29 to $110 | Low |
| Established Patient Office OR Other Outpatient Visit with Straightforward Med... | other | $29 | $29 to $99,212 | Low |
| Group Preventive Medicine Counseling, Typically 1 Hour | therapy | $29 | $29 to $99,412 | Low |
| Pathology Cytologic Examination of Specimen During Surgery, Each Additional Site | surgery | $29 | $29 to $88,334 | Low |
| Resure Sealant Ocular #rs-1004-us-10 10/bx | other | $29 | $29 to $110 | Low |
| 7fr Single Sensor W/lumen/coude Tip | other | $29 | $29 to $110 | Low |
| Immunologic Analysis Technique On Body Fluid, Other Fluids with Concentration | other | $29 | $29 to $86,335 | Low |
| Nuclear Medicine Study, 1 Area | imaging | $29 | $29 to $78,800 | Low |
| Injection, Rituximab-abbs, Biosimilar, (truxima), 10 Mg | other | $29 | $29 to $8,440 | Low |
| Hc Dress Aquacl Ag Hydrofiber | other | $29 | $29 to $111 | Low |
| Lift, Elevation, Inside Shoe, Tapered, Up to One-half Inch | other | $29 | $29 to $111 | Low |
| Application of Hinged Finger Splint | other | $29 | $29 to $29,131 | Low |
| Closure Pilot Guides 5mm & 10/12mm Set | other | $29 | $29 to $111 | Low |
| 2.3mm Tapered Router5407-fa2 | other | $30 | $30 to $111 | Low |
| 3.0mm Tapered Router5407-fa3 | other | $30 | $30 to $111 | Low |
| Electrode Emg 18mm Needle 2 Channel 1m Cable Muscle Specific Prass Paired Ins... | other | $30 | $30 to $111 | Low |
| Evaluation of Single, Dual, Multiple Lead OR Leadless Pacemaker System OR Imp... | cardiac | $30 | $30 to $93,296 | Low |
| Development of Cognitive Skills to Improve Attention, Memory, Problem Solving... | other | $30 | $30 to $111 | Low |
| Test to Assess Balance During Warm and Cool Irrigation in Both Ears | other | $30 | $30 to $92,537 | Low |
| Vitamin D-3 Level | other | $30 | $30 to $82,306 | Low |
| Nester .035 4mm X 7cm #g47372 | other | $30 | $30 to $111 | Low |
| Dexmedetomidine Hcl in Nacl 80 Mcg/20ml IV Soln | other | $30 | $30 to $112 | Low |
| Zimmer Compact Vacuum Cement Mixing System #00-5049-035 | other | $30 | $30 to $112 | Low |
| Side-by-side Bipolar Stimulating Probe 5ea/pk #8225401 | other | $30 | $30 to $112 | Low |
| Injection, Lanreotide, (cipla), 1 Mg | other | $30 | $30 to $30,120 | Low |
| Programming of Single Lead Pacemaker System | cardiac | $30 | $30 to $93,279 | Low |
| Handle Sizer for Inhance Shoulder System #720530301 #7205-30 | other | $30 | $30 to $113 | Low |
| Repair/modification of a Hearing Aid | surgery | $30 | $30 to $632 | Low |
| Dificid 200 Mg Tablet | other | $30 | $30 to $113 | Low |
| Injection, Fam-trastuzumab Deruxtecan-nxki, 1 Mg | other | $30 | $30 to $8,846 | Low |
| Vac Veraflo Dress Sys-medium #ultvfl05md | other | $30 | $30 to $113 | Low |
| Injection, Ketorolac Tromethamine, Per 15 Mg | other | $30 | $30 to $50 | Low |
| Sterile Water, Saline And/or Dextrose, Diluent/flush, 10 Ml | other | $30 | $30 to $50 | Low |
| Ankle Orthosis, Ankle Gauntlet OR Similar, with OR without Joints, Prefabrica... | other | $30 | $30 to $226 | Low |
| X-ray of Bone Behind the Ear, 1-2 Views Per Side | imaging | $30 | $30 to $70,120 | Low |
| Digoxin 0.05 Mg/ml Solution | other | $30 | $30 to $114 | Low |
| Injection, Cilastatin Sodium; Imipenem, Per 250 Mg | other | $30 | $30 to $114 | Low |
| Injection, Trastuzumab-anns, Biosimilar, (kanjinti), 10 Mg | other | $30 | $30 to $4,094 | Low |
| Antibody Evaluation, Each Additional Single Antibody Stain Procedure | other | $30 | $30 to $88,350 | Low |
| Cryoprecipitate, Each Unit | other | $30 | $30 to $114 | Low |
| Injection, Pegfilgrastim-bmez (ziextenzo), Biosimilar, 0.5 Mg | other | $30 | $30 to $6,183 | Low |
| Pathology Examination of Tissue Using a Microscope, Intermediate Complexity | lab | $30 | $30 to $88,305 | Low |
| X-ray of Infant Arm, Minimum of 2 Views | imaging | $30 | $30 to $73,092 | Low |
| Ultrasonic Guidance for Needle Placement | other | $30 | $30 to $76,942 | Low |
| Surgicel Original Hemostat 2in X 3in 1953s | other | $31 | $31 to $115 | Low |
| Ear Mold/insert, Not Disposable, Any Type | other | $31 | $31 to $300 | Low |
| Nanoneedle Diagnostic Sheath Kit 125 Mm #ar-3210 | other | $31 | $31 to $115 | Low |
| Needle Osteo-site Bn Bx M2 #g36211 Dbbn-11-10.0-m2s | other | $31 | $31 to $115 | Low |
| Needle Osteo-site Long #g36406 | other | $31 | $31 to $115 | Low |
| Polyloop Ligating Device #hx-400u | other | $31 | $31 to $115 | Low |
| Testosterone Pellet, 75 Mg | other | $31 | $31 to $230 | Low |
| Endoclip 5mm #176630 | other | $31 | $31 to $115 | Low |
| Reaming Rod 3.0mm X 950mm W/balltip Sterile | other | $31 | $31 to $115 | Low |
| Reaming Rod 3.0mm X950mm W/offset Tip | other | $31 | $31 to $115 | Low |
| Patient Tracker Noninvasive #9734887xom | other | $31 | $31 to $116 | Low |
| Ultrasound Study of Arm OR Leg Veins with Compression and Maneuvers | imaging | $31 | $31 to $93,970 | Low |
| Test to Assess Hearing Using Pictures | other | $31 | $31 to $92,583 | Low |
| Ultrasound Scan of Pelvic Region Through Rectum | imaging | $31 | $31 to $76,872 | Low |
| Wound Retractor/protector Xlrg #c8404 | other | $31 | $31 to $116 | Low |
| Injection of Contrast Through Abdominal Cavity Tube for X-ray Study | imaging | $31 | $31 to $49,424 | Low |
| Injection, Protamine Sulfate, Per 10 Mg | other | $31 | $31 to $116 | Low |
| Tornade Embolization Coil 10 X 4 #g09217 | other | $31 | $31 to $116 | Low |
| Addition to Lower Extremity Orthosis, Non-corrosive Finish, Per Bar | other | $31 | $31 to $116 | Low |
| Serotonin (hormone) Level | other | $31 | $31 to $84,260 | 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 |
| Limited Ultrasound Scan of Joint OR Other Extremity Structure Except Blood Ve... | imaging | $31 | $31 to $76,882 | Low |
| Injection, Infliximab, Excludes Biosimilar, 10 Mg | other | $31 | $31 to $2,276 | Low |
| Injection, Mepolizumab, 1 Mg | other | $31 | $31 to $5,991 | Low |
| Plasma-lyte a Ph 7.4 Soln. | other | $31 | $31 to $118 | Low |
| Pin Steinmann 3.2mm 9" #110003484 | other | $31 | $31 to $118 | Low |
| Complete Ultrasound Scan of Pelvis | imaging | $31 | $31 to $76,856 | Low |
| Sheath Navigator 11/13frx36cm #250-222 Bossci | other | $31 | $31 to $118 | Low |
| X-ray of Infant Body Bones | imaging | $31 | $31 to $77,076 | Low |
| Removal of Tissue From Wound Gradually | surgery | $31 | $31 to $97,602 | Low |
| Gastro Anchor Set Saf-t-pexy T-fastener | other | $31 | $31 to $118 | Low |
| Exam of the Nose and Throat Using an Endoscope | other | $31 | $31 to $92,511 | Low |
| Commode Patient Bariatric (800lbs) Cpat0008d | other | $32 | $32 to $119 | Low |
| Meniscal Knot Pusher/cutter #72201537 | other | $32 | $32 to $119 | Low |
| Codman Disposable Catheter Passer #82 | cardiac | $32 | $32 to $119 | Low |
| Avitene Microfibril Collagen Hemostat 1010020 | other | $32 | $32 to $119 | Low |
| Resolution Clips 2.8mmx235cm 20ea/1bx | other | $32 | $32 to $120 | Low |
| Occluder Colpo Pneumo Occluder | other | $32 | $32 to $120 | Low |
| Dornase Alfa, Inhalation Solution, Fda-approved Final Product, Non-compounded... | other | $32 | $32 to $120 | 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 |
| Gastrostomy Tube 24fr 3.4cm Kit Replacement | surgery | $32 | $32 to $120 | Low |
| Hard-bone Drill 1.5 Mm Ar-9938 | other | $32 | $32 to $120 | Low |
| Hard-bone Drill 1.7 Mm Ar-9938 | other | $32 | $32 to $120 | Low |
| Inner Vision Fiber Optic Tip 56fr 1465 | other | $32 | $32 to $120 | Low |
| Tip Detachable 40fr Transillumination #1465 | other | $32 | $32 to $120 | Low |
| Fluticasone Furoate 27.5 Mcg/spray Na Susp | other | $32 | $32 to $120 | Low |
| Pigazzi Pad #40595 3/cs | other | $32 | $32 to $120 | Low |
| Neomy-polymyxin B 40 Mg/ml Amp | other | $32 | $32 to $120 | Low |
| Basket Roth Net Pedia Foreign Body Bx00711057 | other | $32 | $32 to $121 | Low |
| Subsequent Hospital Care with Straightforward OR Low Level of Medical Decisio... | other | $32 | $32 to $99,231 | Low |
| Potassium Phosph 15 Mmol/5 Ml | other | $32 | $32 to $121 | Low |
| Hetastarch 6%-0.9% Nacl Bag | other | $32 | $32 to $122 | Low |
| Catheter Kit 7.5" Pain On Q Silversoaker 5/bx | cardiac | $32 | $32 to $122 | Low |
| Follow-up Hospital Care of Newborn Per Day | obstetric | $32 | $32 to $99,462 | Low |
| Influenza Vaccine, Inactivated | preventive | $32 | $32 to $90,653 | Low |
| Lift, Elevation, Heel and Sole, Neoprene, Per Inch | other | $32 | $32 to $122 | Low |
| Ofloxacin 0.3% Ear Drops | other | $32 | $32 to $122 | Low |
| Injection of Contrast for Imaging of Knee Joint | other | $33 | $33 to $27,369 | Low |
| Nuclear Medicine Study of Liver and Bile Duct System | imaging | $33 | $33 to $78,226 | Low |
| Nuclear Medicine Study of Lung Circulation | imaging | $33 | $33 to $78,580 | Low |
| Steinmann Pin 9" Shoulder #405800 | other | $33 | $33 to $123 | Low |
| Sensor Arterial Cdi #cdi510h | other | $33 | $33 to $123 | Low |
| Evaluation of Lower Heart Chamber Assist Device | cardiac | $33 | $33 to $93,750 | Low |
| Addition to Lower Extremity Orthosis, Rocker Bottom for Total Contact Ankle F... | other | $33 | $33 to $124 | Low |
| Dextrose 50%-water Abboject | other | $33 | $33 to $123 | Low |
| Injection, Nivolumab, 1 Mg | other | $33 | $33 to $24,049 | Low |
| Complete Ultrasound Scan Behind Abdominal Cavity | imaging | $33 | $33 to $76,770 | Low |
| Addition to Lower Extremity, Split Flat Caliper Stirrups and Plate Attachment | other | $33 | $33 to $124 | Low |
| Injection, Infliximab-abda, Biosimilar, (renflexis), 10 Mg | other | $33 | $33 to $249 | Low |
| 2.0mm Round Diamond 5820-012-020d | other | $33 | $33 to $125 | Low |
| Electronic Analysis of Implanted Neurostimulator Generator with Simple Spinal... | surgery | $33 | $33 to $95,971 | Low |
| Ligator Band 7 Speedband 4ea/1bx M00542253 | other | $33 | $33 to $125 | Low |
| Addition to Lower Extremity, Dorsiflexion Assist (plantar Flexion Resist), Ea... | other | $33 | $33 to $125 | Low |
| Ankle Control Orthosis, Stirrup Style, Rigid, Includes Any Type Interface (e.... | other | $33 | $33 to $250 | Low |
| Caloric Vestibular Test | other | $33 | $33 to $92,543 | Low |
| Catheter Venogram Balloon #6215 Mdt | cardiac | $33 | $33 to $125 | Low |
| Corneal Vacuum Punch 8.00mm #17200d800 | other | $33 | $33 to $125 | Low |
| Diphtheria, Tetanus, Acellular Pertussis, Hepatitis B, and Polio Vaccine | preventive | $33 | $33 to $90,723 | Low |
| Extension Titanium for Pd Catheter #ta | cardiac | $33 | $33 to $125 | Low |
| Hc Monitored Anesthesia Care Anesthesia Time - Each Incremental 15 Minutes | other | $33 | $33 to $125 | Low |
| Hydrocortisone-acetic Ear Drop | other | $33 | $33 to $125 | Low |
| Influenza Virus Vaccine, Quadrivalent (iiv4), Split Virus, Preservative Free,... | preventive | $33 | $33 to $90,630 | Low |
| Preventive Medicine Counseling, Typically 30 Minutes | therapy | $33 | $33 to $99,402 | Low |
| Punch Cornea Vacuum 7.75mm #17200d775 | other | $33 | $33 to $125 | Low |
| Punch Corneal Vacuum 7.50mm #17200d750 | other | $33 | $33 to $125 | Low |
| Loop 12 Degree for Long Tur Set #wa22037c | other | $33 | $33 to $125 | Low |
| Neomycin-poly-hc Eye Drops | other | $33 | $33 to $126 | Low |
| Screw Hex Female 2.5mm #42-5099-025 | other | $33 | $33 to $126 | Low |
| Dacarbazine, 100 Mg | other | $33 | $33 to $126 | Low |
| Prosthetic Shrinker, Above Knee, Each | other | $33 | $33 to $126 | Low |
| Hepatitis a Vaccine Adult Dosage | preventive | $34 | $34 to $90,632 | Low |
| Hepatitis B Vaccine, Adult Dosage | preventive | $34 | $34 to $90,746 | Low |
| Test for Abnormal Eye Movement Using 3 Positions | other | $34 | $34 to $92,532 | Low |
| Training in the Use of Artificial Arm And/or Leg, Each 15 Minutes | other | $34 | $34 to $97,761 | Low |
| Hc Coban 2 #2094 1bx=1kit | other | $34 | $34 to $126 | Low |
| Hc Coban 2 Lite #2794 1bx=1kit | other | $34 | $34 to $126 | Low |
| Needle Ebus 21g #na-201sx | other | $34 | $34 to $126 | Low |
| Sizing Catheter Sf #g47308 5ea/1bx | cardiac | $34 | $34 to $127 | Low |
| Super-dimension Premarked Biopsy Forceps #sdbf1000 5/ct | lab | $34 | $34 to $127 | Low |
| Cannula Retrograde 14fr Research Med | other | $34 | $34 to $127 | Low |
| Catheter, Drainage | cardiac | $34 | $34 to $127 | Low |
| Post Op Knee Brace Xlg #423101 | other | $34 | $34 to $127 | Low |
| Electronic Analysis of Implanted Neurostimulator Generator with Complex Spina... | surgery | $34 | $34 to $95,972 | Low |
| Ultrasound of Heart for Congenital Defect, Follow-up | imaging | $34 | $34 to $93,304 | Low |
| Adh (antidiuretic Hormone) Level | other | $34 | $34 to $84,588 | Low |
| Rotavirus Vaccine, Pentavalent | preventive | $34 | $34 to $90,680 | Low |
| Addition to Knee Joint, Lift Loop for Drop Lock Ring | other | $34 | $34 to $129 | Low |
| Irradiation of Blood Product, Each Unit | other | $34 | $34 to $86,945 | Low |
| Evaluation of Implantable Defibrillator System | surgery | $34 | $34 to $93,261 | Low |
| Vac Veraflo Cleanse Dress Sys Med #ultvcl05md | other | $34 | $34 to $129 | Low |
| Biktarvy 50-200-25 Mg Tablet | other | $34 | $34 to $129 | Low |
| Stone Extractor Perc Ncircle #g32862 | other | $34 | $34 to $129 | Low |
| Pad Electrode Adult One Piece for Auto External Defibrillator Cpr-d-padz 8900... | other | $34 | $34 to $130 | Low |
| Injection, Trastuzumab-pkrb, Biosimilar, (herzuma), 10 Mg | other | $35 | $35 to $12,061 | Low |
| Electrode Barrie Bar 3mm Storz #27050nx-s | other | $35 | $35 to $130 | Low |
| Chest Tube Tray #cht2085 20ea/case6-8 Week Lead Time | 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 |
| Aveta Fluid Management Accessory #205-212 3/ctn | other | $35 | $35 to $130 | Low |
| Endo Clip Applier 5mm #ae05ml 3 Ea/1bx | other | $35 | $35 to $130 | Low |
| Fecal Collector Flexi Seal Sys #418000 1ea/bx | other | $35 | $35 to $130 | Low |
| Knee Orthosis, Immobilizer, Canvas Longitudinal, Prefabricated, Off-the-shelf | other | $35 | $35 to $260 | Low |
| Insertion of Probe in Esophagus for Recording Electrical Impulses to Upper an... | other | $35 | $35 to $93,615 | Low |
| Nuclear Medicine Study of Stomach to Assess Emptying | imaging | $35 | $35 to $78,264 | Low |
| Alvimopan 12 Mg Capsule | other | $35 | $35 to $130 | Low |
| Stopcock Universal #75u | other | $35 | $35 to $131 | Low |
| Opticath High Flow Cath Lfr 8fr 110cm 6/cs | other | $35 | $35 to $131 | Low |
| Evaluation of Single, Dual, OR Multiple Lead Implantable Defibrillator System | surgery | $35 | $35 to $93,295 | Low |
| Pneumothorax Cath Tray Disp Arrow 5ea/1bx | other | $35 | $35 to $131 | Low |
| Injection, Tobramycin Sulfate, Up to 80 Mg | other | $35 | $35 to $132 | Low |
| Addition to Lower Extremity, Torsion Control, Ankle Joint and Half Solid Stirrup | other | $35 | $35 to $132 | Low |
| Knot Pusher/suture Cutter and Slotted Cannula Set 72202674 | other | $35 | $35 to $132 | Low |
| Closure Surgical Skin 24cm Zip24 Ps1240 5/pk | surgery | $35 | $35 to $132 | Low |
| Detection Test By Nucleic Acid for Chlamydia Trachomatis, Amplified Probe Tec... | other | $35 | $35 to $87,491 | Low |
| Detection Test By Nucleic Acid for Hepatitis C Virus, Amplified Probe Technique | other | $35 | $35 to $87,521 | Low |
| Detection Test By Nucleic Acid for Herpes Simplex Virus, Amplified Probe Tech... | other | $35 | $35 to $87,529 | Low |
| Detection Test By Nucleic Acid for Human Papillomavirus (hpv), High-risk Types | other | $35 | $35 to $87,624 | Low |
| Detection Test By Nucleic Acid for Mycoplasma Pneumoniae (bacteria), Amplifie... | other | $35 | $35 to $87,581 | Low |
| Detection Test By Nucleic Acid for Neisseria Gonorrhoeae (gonorrhoeae Bacteri... | other | $35 | $35 to $87,591 | Low |
| Detection Test By Nucleic Acid for Organism, Amplified Probe Technique | other | $35 | $35 to $87,798 | Low |
| Detection Test By Nucleic Acid for Staphylococcus Aureus, Methicillin Resista... | other | $35 | $35 to $87,641 | Low |
| Identification of Organisms By Genetic Analysis, Amplified Probe Technique | other | $35 | $35 to $87,150 | Low |
| Chemistry Procedures | other | $35 | $35 to $84,999 | Low |
| Grasping Device-endo Raptor Disp #bx00711177 | other | $35 | $35 to $132 | Low |
| Imaging Guidance for Localization of Radiation Treatment | other | $35 | $35 to $77,387 | Low |
| Norepinephrine 4 Mg / 250 Ml Ns Bag - Compounded | other | $35 | $35 to $132 | Low |
| Pressure Monitor Set/stryker Quick | other | $35 | $35 to $133 | Low |
| Application of Lower and Upper Arm Splint | other | $35 | $35 to $29,105 | Low |
| Nuclear Medicine Study of Parathyroid | imaging | $35 | $35 to $78,070 | Low |
| Declotting of Central Venous Tube | other | $35 | $35 to $36,593 | Low |
| Vasoactive Intestinal Peptide (intestinal Hormone) Level | other | $35 | $35 to $84,586 | Low |
| Ultrasound of Leg Arteries OR Artery Grafts | imaging | $35 | $35 to $93,925 | Low |
| Measles, Mumps, and Rubella Vaccine | preventive | $35 | $35 to $90,707 | Low |
| Test for Hearing Various Pitches Using Earphone and Device Placed Against the... | other | $35 | $35 to $92,553 | Low |
| Injection, Nicardipine, 0.1 Mg | other | $35 | $35 to $133 | Low |
| Hemostatic Sealant Floseal Matrix Recothrom 5ml 6/cs | other | $35 | $35 to $133 | Low |
| Complete Ultrasound of Aorta, Vena Cava, Groin Vessels OR Bypass Grafts | imaging | $36 | $36 to $93,978 | Low |
| Injection, Ziprasidone Mesylate, 10 Mg | other | $36 | $36 to $134 | Low |
| Residence Visit for New Patient with Straightforward Medical Decision Making,... | other | $36 | $36 to $99,341 | Low |
| Typhoid Vaccine for Injection Into Muscle | preventive | $36 | $36 to $90,691 | Low |
| Ultrasound of Arm Arteries OR Artery Grafts | imaging | $36 | $36 to $93,930 | Low |
| Programming of Dual Lead Pacemaker System | cardiac | $36 | $36 to $93,280 | Low |
| Electrodes-4 Channel Paired Subdermal Ea=set | other | $36 | $36 to $134 | Low |
| Injection, Oxytocin, Up to 10 Units | other | $36 | $36 to $134 | Low |
| Oxytocin 20 Unit/1,000 Ml-ns | other | $36 | $36 to $134 | Low |
| Obtaining Data Needed to Develop the Optimal Radiation Treatment, 1 Treatment... | other | $36 | $36 to $77,280 | Low |
| Needle Measurement of Electrical Activity in Trunk OR Head Muscles | other | $36 | $36 to $95,887 | Low |
| Ultrasound of Abdomen and Pelvis Artery and Vein Blood Flow | imaging | $36 | $36 to $93,976 | Low |
| Removal of Foreign Body in Cornea | surgery | $36 | $36 to $65,220 | Low |
| Bonopty Biopsy Set 16cm #10 | lab | $36 | $36 to $135 | Low |
| Bonopty Penetration Set 9.5cms #10 | other | $36 | $36 to $135 | Low |
| Detection Test By Immunoassay Technique for Severe Acute Respiratory Syndrome... | other | $36 | $36 to $87,428 | Low |
| Drill Twist Trimed #drill-2.30l | other | $36 | $36 to $135 | Low |
| Laser Fiber 200 Rnd Tip #dfs-200-rtsb | other | $36 | $36 to $135 | Low |
| Laser Fiber 272mic #dfs-272sb | other | $36 | $36 to $135 | Low |
| Shoulder Gps Threaded Pin Kit(1) Shoulder Gps Coracoid Pin Long(1) Shoulder G... | other | $36 | $36 to $135 | Low |
| Injection Procedure for Imaging of Bladder During Voiding | other | $36 | $36 to $51,600 | Low |
| Ultrasound of Both Sides of Head and Neck Blood Flow | imaging | $36 | $36 to $93,880 | Low |
| Vac Veraflo Cleanse Choice Medium Ultvcc05md | other | $36 | $36 to $135 | Low |
| Biopsy of Ear | lab | $36 | $36 to $69,100 | Low |
| Conformity Evaluation | other | $36 | $36 to $271 | Low |
| Exam for Hearing Aid, Both Ears | other | $36 | $36 to $92,591 | Low |
| Loop 24fr Monopolar Angled 27050g-s Cysview | other | $36 | $36 to $136 | Low |
| Technetium Tc 99m Pyrophosphate | other | $36 | $36 to $136 | Low |
| Feeding Tube Mic Jejunal #0200-12lv | other | $36 | $36 to $136 | 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 |
| Complete Ultrasound Scan of Abdomen | imaging | $36 | $36 to $76,700 | Low |
| Injection, Sacituzumab Govitecan-hziy, 2.5 Mg | other | $36 | $36 to $7,761 | Low |
| Scraper Membrane Stiff 25g | other | $36 | $36 to $137 | Low |
| Instillation of Anti-cancer Drug Into Bladder | other | $36 | $36 to $51,720 | Low |
| Test to Measure Lung Function At High Altitude | other | $36 | $36 to $94,452 | Low |
| Replace Leather Cuff Kafo-afo, Calf OR Distal Thigh | other | $37 | $37 to $137 | Low |
| Skin Substitute Graft to Wound 100.0 SQ Cm OR More of Trunk, Arms, OR Legs, E... | other | $37 | $37 to $15,274 | Low |
| Chemical Receptor Analysis | other | $37 | $37 to $84,238 | Low |
| Ball 24fr Monopolar Coag 3mm 27050n-s Cysview | other | $37 | $37 to $138 | Low |
| Cath Laparoscopic Chole Arrow | surgery | $37 | $37 to $138 | Low |
| Injection, Rituximab 10 Mg and Hyaluronidase | other | $37 | $37 to $20,716 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Vagus Nerve | other | $37 | $37 to $64,408 | Low |
| Injection, Enfortumab Vedotin-ejfv, 0.25 Mg | other | $37 | $37 to $13,273 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Other Nerve OR Branch | other | $37 | $37 to $64,450 | Low |
| Feeding Tube Endovive Jejunal 12fr #m00566340 | other | $37 | $37 to $138 | Low |
| Stone Extractor Tipless 4.5frx65cm #g17520 | other | $37 | $37 to $139 | Low |
| Cement Mixer | other | $37 | $37 to $139 | Low |
| Transfer of an Orthosis From One Shoe to Another, Solid Stirrup, New | other | $37 | $37 to $140 | Low |
| Uterine Manipulator X-large Vcare | other | $37 | $37 to $140 | Low |
| Nevirapine 50 Mg/5 Ml Susp | other | $37 | $37 to $140 | Low |
| Catheter, Suprapubic/cystoscopic | cardiac | $37 | $37 to $140 | Low |
| Diphtheria, Tetanus, Acellular Pertussis, Polio, and Haemophilus Influenzae T... | other | $37 | $37 to $90,698 | Low |
| Kit Fecal Management Flexi-seal Protect Plus Enfit Connection Bag Nonsterile ... | other | $37 | $37 to $140 | Low |
| Osteopathic Manipulative Treatment, 5-6 Body Regions | other | $37 | $37 to $98,927 | Low |
| Training in the Use of Orthopedic Device for Arm, Leg And/or Trunk, Each 15 M... | other | $37 | $37 to $97,760 | Low |
| Detection Test By Nucleic Acid for Clostridium Difficile, Amplified Probe Tec... | other | $37 | $37 to $87,493 | Low |
| Drain Ethicon Blake Silicon Surg 15fr #2229 | other | $37 | $37 to $140 | Low |
| Addition to Lower Extremity Orthosis, Soft Interface for Molded Plastic, Belo... | other | $37 | $37 to $141 | Low |
| Needle Ez Io Ld 15ga 45mm #9079 | other | $38 | $38 to $141 | Low |
| Needle-ez Io Ld 15g Io Set 25mm #9001 Vidacre | other | $38 | $38 to $141 | Low |
| Needle-ez Io Pd 15g Io Set 15mm #9018 Vidacre | other | $38 | $38 to $141 | Low |
| Removal of Foreign Body in Nose | surgery | $38 | $38 to $30,300 | Low |
| Maxgrip Revolution Disp Forceps 23g #706.13 | other | $38 | $38 to $141 | Low |
| Sleep Study (Polysomnography) | diagnostic | $38 | $38 to $95,800 | High |
| Nuclear Medicine Study of Bone And/or Joint Whole Body | imaging | $38 | $38 to $78,306 | Low |
| T Cells Count, Total | other | $38 | $38 to $86,359 | Low |
| Cath Single Lumen 6.6fr | other | $38 | $38 to $142 | Low |
| Elbow Orthosis, Rigid, without Joints, Includes Soft Interface Material, Pref... | other | $38 | $38 to $284 | Low |
| Review By Radiologist of Ultrasound of Digestive Tract Using an Endoscope | imaging | $38 | $38 to $76,975 | Low |
| Design and Construction of Intermediate Radiation Treatment Device | other | $38 | $38 to $77,333 | Low |
| Injection for Nonselective Imaging of Pulmonary Artery During Heart Catheteri... | cardiac | $38 | $38 to $93,568 | Low |
| Aspiration And/or Injection of Fluid From Small Joint Using Ultrasound Guidance | imaging | $38 | $38 to $20,604 | Low |
| Electronic Analysis Reprogramming and Refill of Spinal Canal Drug Infusion Pu... | surgery | $38 | $38 to $62,370 | Low |
| Tube Inner Ear Myringotomy Ventilation Flange 4.8 Mm Length 1.32 Mm Id Silico... | other | $38 | $38 to $143 | Low |
| Bone Marrow, Smear Interpretation | other | $38 | $38 to $85,097 | Low |
| 1203105 9.0 Uniblocker 1/ea | other | $38 | $38 to $143 | Low |
| Irrigation of Implanted Venous Access Drug Delivery Device | surgery | $38 | $38 to $96,523 | Low |
| Test to Assess Hearing Sensitivity Using Activity Related Feedback | other | $38 | $38 to $92,582 | Low |
| X-ray for Estimating Bone Age | imaging | $38 | $38 to $77,072 | Low |
| Smog Enema - Compounded | other | $38 | $38 to $143 | Low |
| Addition to Lower Extremity, Dorsiflexion and Plantar Flexion Assist/resist, ... | other | $38 | $38 to $143 | Low |
| Diagnostic Exam of Anus Using an Endoscope | other | $38 | $38 to $46,600 | Low |
| CT Scan Head OR Brain without Contrast | imaging | $38 | $38 to $70,450 | Low |
| Addition to Lower Extremity, Torsion Control, Straight Knee Joint, Each Joint | other | $38 | $38 to $144 | Low |
| Curved Knot Pusher/suture Cutter #72202675 | other | $38 | $38 to $144 | Low |
| Needle Measurement of Electrical Activity in Muscles On Side of Body | other | $38 | $38 to $95,867 | Low |
| Prolonged Outpatient Service, Each 15 Minutes of Total Time Beyond Required T... | other | $38 | $38 to $99,417 | Low |
| Psychotherapy, 30 Minutes | therapy | $38 | $38 to $90,832 | Low |
| Timolol 0.5% Gfs Gel-solution | other | $38 | $38 to $144 | Low |
| Forcep Micro Holding 23g #dfh | other | $38 | $38 to $144 | Low |
| Tube Blakemore Ng 20fr | other | $38 | $38 to $144 | Low |
| CT Scan of Face without Contrast | imaging | $38 | $38 to $70,486 | Low |
| Extractor Balloon 15-18mm Rx Pro #4702 | other | $38 | $38 to $145 | Low |
| Extractor Pro Rx Below Injection 12-15 M00547040 | other | $38 | $38 to $145 | Low |
| Extractor Pro Rx Below Injection 15-18 M00547050 | other | $38 | $38 to $145 | Low |
| Extractor Pro Rx Below Injection 9-12 M00547030 | other | $38 | $38 to $145 | Low |
| Extractor Retrieval Balloon 12.0-15mm Rx Pro | other | $38 | $38 to $145 | Low |
| Extractor Retrieval Balloon 9-12mm Rx Pro | other | $38 | $38 to $145 | Low |
| Electronic Analysis of Implanted Gastric Neurostimulator Generator During Sur... | surgery | $39 | $39 to $95,980 | Low |
| Injection, Sulfamethoxazole 5 Mg and Trimethoprim 1 Mg | other | $39 | $39 to $145 | Low |
| Measurement of Infliximab | other | $39 | $39 to $80,230 | Low |
| Injection, Secretin, Synthetic, Human, 1 Microgram | other | $39 | $39 to $4,723 | 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 |
| Olopatadine Hcl 0.1 % Op Soln | other | $39 | $39 to $146 | Low |
| Sodium Ferric Gluconate (ferrlecit) 125 Mg/ Ns 100 Mls - Compounded | other | $39 | $39 to $146 | Low |
| Malyugin Ring 6.25mm Disp #mal-0001-d | other | $39 | $39 to $146 | Low |
| Malyugin Ring 7.00mm Disp #mal-0002-d | other | $39 | $39 to $146 | Low |
| D Stat Flowable #4000 | other | $39 | $39 to $146 | Low |
| Gia Endo 30 2.5 Roticular Load #030451 | other | $39 | $39 to $147 | Low |
| Gia Endo 30 3.5 Roticular Load #030452 | other | $39 | $39 to $147 | Low |
| Gradient Compression Stocking, Below Knee, 30-40 Mmhg, Used As a Surgical Dre... | surgery | $39 | $39 to $147 | Low |
| Mannitol 20% | other | $39 | $39 to $147 | Low |
| Catheter Passer Disposable 38cm #8591 | cardiac | $39 | $39 to $147 | Low |
| Catheter Passer Disposable 4.8mm X 3.3mm X 38cm #48407 | cardiac | $39 | $39 to $147 | Low |
| Natriuretic Peptide (heart and Blood Vessel Protein) Level | cardiac | $39 | $39 to $83,880 | Low |
| Programming of Single Lead Implantable Defibrillator System | surgery | $39 | $39 to $93,282 | Low |
| Nail Nippers 6" #881862 | other | $39 | $39 to $148 | Low |
| Tissue Culture for Tumor Disorders of Bone Marrow and Blood Cells | lab | $39 | $39 to $88,237 | Low |
| Severe Acute Respiratory Syndrome Coronavirus 2 (covid-19) Vaccine, Recombina... | preventive | $39 | $39 to $91,304 | Low |
| Injection for X-ray Imaging Procedure Into Vein of Arm OR Leg | imaging | $39 | $39 to $36,005 | Low |
| Budesonide 32 Mcg/act Na Susp | other | $40 | $40 to $149 | Low |
| Removal of Foreign Body in Ear Canal | surgery | $40 | $40 to $69,200 | Low |
| Puncture of Windpipe for Aspiration And/or Injection | other | $40 | $40 to $31,612 | Low |
| Programming of Implantable Defibrillator System | surgery | $40 | $40 to $93,260 | Low |
| Programming of Multiple Lead Pacemaker System | cardiac | $40 | $40 to $93,281 | Low |
| New Patient Office OR Other Outpatient Visit with Straightforward Medical Dec... | other | $40 | $40 to $99,202 | Low |
| Laser Fiber 365mic #dfs-365sb | other | $40 | $40 to $149 | Low |
| Nuclear Medicine Study of Liver and Bile Duct System with Use of Drugs | imaging | $40 | $40 to $78,227 | Low |
| Injection, Bezlotoxumab, 10 Mg | other | $40 | $40 to $11,970 | Low |
| Diphtheria, Tetanus, Acellular Pertussis, and Polio Vaccine | preventive | $40 | $40 to $90,696 | Low |
| Family Psychotherapy without Patient, 50 Minutes | therapy | $40 | $40 to $90,846 | Low |
| Guide Sheath Kit Endo Sz 2mm 105cm #k | other | $40 | $40 to $150 | Low |
| Needle Entrada #sc-4200 | other | $40 | $40 to $150 | Low |
| Profile Drill 3.5mm Beveled Ft #ar-8741 | other | $40 | $40 to $150 | Low |
| Profile Drill for Micro Compression Ft #ar-8737 | other | $40 | $40 to $150 | Low |
| Aspiration And/or Injection of Cyst of Thyroid | other | $40 | $40 to $60,300 | Low |
| Placement of Locating Device in Breast Using Imaging Guidance, Each Additiona... | other | $40 | $40 to $19,282 | Low |
| Knee Orthosis, Elastic with Joints, Prefabricated, Off-the-shelf | other | $40 | $40 to $151 | Low |
| Transfer of an Orthosis From One Shoe to Another, Caliper Plate, New | other | $40 | $40 to $151 | Low |
| Diag Catheter 6fr Langston #5540 5/pk | cardiac | $40 | $40 to $151 | Low |
| Alcohols Levels, 1 OR 2 | other | $40 | $40 to $80,321 | Low |
| Barbiturates Levels | other | $40 | $40 to $80,345 | Low |
| Cannabinoids Levels, Natural | other | $40 | $40 to $80,349 | Low |
| Cocaine Level | other | $40 | $40 to $80,353 | Low |
| Dextrose 70%-water IV Soln | other | $40 | $40 to $151 | Low |
| Opiates Levels | other | $40 | $40 to $80,361 | Low |
| Injection, Trastuzumab-dkst, Biosimilar, (ogivri), 10 Mg | other | $40 | $40 to $4,418 | Low |
| Injection, Chloramphenicol Sodium Succinate, Up to 1 Gm | other | $40 | $40 to $152 | Low |
| Addition to Knee Joint, Drop Lock, Each | other | $40 | $40 to $152 | Low |
| Catheter Bernstein 4fr 140cm #h787107227085 | cardiac | $40 | $40 to $152 | Low |
| Removal of Foreign Body in Cornea Using Slit Lamp | surgery | $40 | $40 to $65,222 | Low |
| Evaluation of Hearing Ringing in Ear | other | $40 | $40 to $92,625 | Low |
| Injection of Contrast for Imaging of Shoulder Joint | other | $41 | $41 to $23,350 | Low |
| Dissecting Tool Disp #14mh30 Midas | other | $41 | $41 to $153 | Low |
| Femoral Bone Cementing Prep Kit W/o Cement 00-5049-055-00 00504905500 | other | $41 | $41 to $153 | Low |
| Ibandronate Sodium 150 Mg Po Tabs | other | $41 | $41 to $153 | Low |
| Intralipid 20% IV Fat Emul | lab | $41 | $41 to $153 | Low |
| Aldosterone Hormone Level | other | $41 | $41 to $82,088 | Low |
| Injection, Voriconazole, 10 Mg | other | $41 | $41 to $153 | Low |
| Coil Pusher 16 | other | $41 | $41 to $155 | Low |
| Drill Cann Plyaxial Lck Screw 2mm Drll-pls | other | $41 | $41 to $155 | Low |
| Knee Orthosis, Elastic with Condylar Pads and Joints, with OR without Patella... | other | $41 | $41 to $310 | Low |
| Osteopathic Manipulative Treatment, 7-8 Body Regions | other | $41 | $41 to $98,928 | Low |
| Parathormone (parathyroid Hormone) Level | other | $41 | $41 to $83,970 | Low |
| Anesthesia for Procedure to Drain Brain and Spinal Cord Fluid | other | $41 | $41 to $378 | Low |
| Complete Ultrasound Scan of Joint | imaging | $41 | $41 to $76,881 | Low |
| Pack Robotic Rf | other | $41 | $41 to $156 | Low |
| Sodium Citrate 4% Soln | other | $41 | $41 to $156 | Low |
| Blood Unit Compatibility Test, Antiglobulin Technique | other | $42 | $42 to $86,922 | Low |
| Microscopic Genetic Analysis of Tumor, Manual | other | $42 | $42 to $88,360 | Low |
| Addition to Lower Extremity, Straight Knee Joint, Heavy Duty, Each Joint | other | $42 | $42 to $156 | Low |
| Sumatriptan 6 Mg/0.5ml Autoinj | other | $42 | $42 to $156 | Low |
| Biopsy of Lobe of Lung Using an Endoscope, Each Additional Lobe | lab | $42 | $42 to $31,632 | Low |
| Seprafilm #508602 6ea/pk & 5pk/bx | other | $42 | $42 to $157 | Low |
| Probe Incrementing Nerve Stim W/std Prasstip #8225825x | other | $42 | $42 to $157 | Low |
| Cyclosporine, Oral, 100 Mg | other | $42 | $42 to $157 | Low |
| Grasping Device/endo Talon #00711175 | other | $42 | $42 to $157 | Low |
| Prep Kit W/restrictors #5461-01 | other | $42 | $42 to $158 | Low |
| Ultrasound of Heart | imaging | $42 | $42 to $93,307 | Low |
| Injection, Luspatercept-aamt, 0.25 Mg | other | $42 | $42 to $37,360 | Low |
| Addition to Lower Extremity Orthosis, Soft Interface for Molded Plastic, Abov... | other | $42 | $42 to $158 | Low |
| Oats 70 Degree Measure Probe #ar-4070-70s | other | $42 | $42 to $158 | Low |
| Insertion of Implant in Urethra Within Prostate Gland Using an Endoscope, Eac... | surgery | $42 | $42 to $52,442 | Low |
| Intubation Set Cook Retrograde | other | $42 | $42 to $158 | Low |
| Simple Removal of Skin Debris and Drainage of Mastoid Cavity | surgery | $42 | $42 to $69,220 | Low |
| Mometasone Furoate 50 Mcg/act Na Susp | other | $42 | $42 to $158 | Low |
| Nuclear Medicine Study of Kidney, Blood Flow, and Function | imaging | $42 | $42 to $78,707 | Low |
| Injection, Ado-trastuzumab Emtansine, 1 Mg | other | $42 | $42 to $19,811 | Low |
| Antipsychotics Levels, 1 | other | $42 | $42 to $80,342 | Low |
| Written Consultation Report On X-ray | imaging | $42 | $42 to $76,140 | Low |
| Flulaval Trivalent 2024-25 Syr | other | $42 | $42 to $159 | Low |
| Heel, New Rubber, Standard | other | $42 | $42 to $600 | Low |
| Diagnostic Exam of Rectum and Lower Large Bowel Using an Endoscope | other | $43 | $43 to $45,300 | 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 |
| Bonopty Biopsy Set 16.5cm #12 | lab | $43 | $43 to $160 | Low |
| Bonopty Penetration Set 10cm #12 | other | $43 | $43 to $160 | Low |
| Crescent Quick Pass Lasso #ar-6068c | other | $43 | $43 to $160 | Low |
| Initial Preventive Physical Examination; Face-to-face Visit, Services Limited... | preventive | $43 | $43 to $320 | Low |
| Pathology Examination of Specimen During Surgery, First Tissue Block | surgery | $43 | $43 to $88,331 | Low |
| Detection Test By Nucleic Acid for Cytomegalovirus, Quantification | other | $43 | $43 to $87,497 | Low |
| Detection Test By Nucleic Acid for Hepatitis B Virus, Quantification | other | $43 | $43 to $87,517 | Low |
| Detection Test By Nucleic Acid for Hepatitis C Virus, Quantification | other | $43 | $43 to $87,522 | Low |
| Detection Test By Nucleic Acid for Organism, Quantification | other | $43 | $43 to $87,799 | Low |
| Endopath Electrosurgery Probe Plus Ii Pistol Hand Control Eph02 | surgery | $43 | $43 to $161 | Low |
| Inflator Kit Balloon ENT #18infkit | other | $43 | $43 to $161 | Low |
| Review By Radiologist of Additional Artery Image | other | $43 | $43 to $75,774 | Low |
| Application of Moveable OR Hinged Forearm to Hand Splint | other | $43 | $43 to $29,126 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Upper Neck and Back of Head... | other | $43 | $43 to $64,405 | Low |
| Peripheral Arterial Disease Rehabilitation, Each Session | therapy | $43 | $43 to $93,668 | Low |
| Rod Carbon Fiber 11.0mm X 200mm External | other | $43 | $43 to $162 | Low |
| Extractor Foreign Body 5/cs #fb 5000 5ea/1cs | other | $43 | $43 to $162 | Low |
| Limited OR Follow-up CT Scan | imaging | $43 | $43 to $76,380 | Low |
| Tray Disp Exchange Transfusion 1ea #275.00 | surgery | $43 | $43 to $163 | Low |
| Pathology Cytologic Examination of Specimen During Surgery, Initial Site | surgery | $43 | $43 to $88,333 | Low |
| Insertion of Tube Into Chest OR Arm Artery, Additional Second, Third Order an... | other | $43 | $43 to $36,218 | Low |
| Progel Extended Applicator Spray Tip 16cm | other | $44 | $44 to $164 | Low |
| Nuclear Medicine Study of Heart Pumping Function By Labeling Red Blood Cells ... | imaging | $44 | $44 to $78,472 | Low |
| Psychotherapy for Crisis, Each Additional 30 Minutes | therapy | $44 | $44 to $90,840 | Low |
| Test to Measure Lung Function At High Altitude with Evaluation of Oxygen Need... | other | $44 | $44 to $94,453 | Low |
| Pericardiocentesis Kit Latex Free 3ea/1bx#m00443151 | other | $44 | $44 to $165 | Low |
| Reaming Rod/3.8mm Ball Tip 950mm Sterile #03.233.010s | other | $44 | $44 to $165 | Low |
| Addition to Knee Lock with Integrated Release Mechanism (bail, Cable, OR Equa... | other | $44 | $44 to $165 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Face Nerve | other | $44 | $44 to $64,400 | Low |
| Application of Finger Cast | other | $44 | $44 to $29,086 | Low |
| Cervical, Collar, Semi-rigid Thermoplastic Foam, Two-piece, Prefabricated, Of... | other | $44 | $44 to $330 | Low |
| Needle Transeptal Adult #tsnc-18-71.0 | other | $44 | $44 to $165 | Low |
| Needle Transseptal Brk 18ga 71cm #407200 | other | $44 | $44 to $165 | Low |
| Shoulder Orthosis, Acromio/clavicular (canvas and Webbing Type), Prefabricate... | other | $44 | $44 to $330 | Low |
| Removal of Kidney Drainage Tube Using Fluoroscopic Guidance | surgery | $44 | $44 to $50,389 | Low |
| Sheath Access 12/14fr X38cm #61238bx | other | $44 | $44 to $165 | Low |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, Complete Study | other | $44 | $44 to $95,886 | Low |
| Injection, Abatacept, 10 Mg | other | $44 | $44 to $2,852 | Low |
| Observation Care Discharge Day Management | other | $44 | $44 to $99,217 | Low |
| Wand 3.0mm 45 Degree Turbo | other | $44 | $44 to $167 | Low |
| Wand Arthro 2.5mm 60deg Dome #ac3525 | other | $44 | $44 to $167 | Low |
| Wand Arthro 3.5mm 90deg Rt Angle #ac1340 | other | $44 | $44 to $167 | Low |
| Wand Ortho Super Multivac 50 | other | $44 | $44 to $167 | Low |
| Wand Saber 30 W/cable Arthrocare #ac4330 | other | $44 | $44 to $167 | Low |
| Gradient Compression Wrap, Non-elastic, Below Knee, 30-50 Mmhg, Used As a Sur... | other | $44 | $44 to $333 | Low |
| Testing of Autonomic (sympathetic) Nervous System Function, Heart Rate Respon... | cardiac | $44 | $44 to $95,922 | Low |
| Kit Carotid Rf 2ea/1cs #dynj906961f | other | $45 | $45 to $167 | Low |
| Hip Orthosis, Abduction Control of Hip Joints, Flexible, (pavlik Harness), Pr... | other | $45 | $45 to $168 | Low |
| Epidisc Patch Kit #1417151 Xomed | other | $45 | $45 to $168 | Low |
| Alpena Contour Lso Universal Fits Waist Circumference: 25-60inch (64-152cm) #... | other | $45 | $45 to $168 | Low |
| Aspiration Tubing Kit #72-00114 | other | $45 | $45 to $168 | Low |
| Review By Radiologist of 1 Arm OR Leg Vein of 1 Arm OR Leg Image | other | $45 | $45 to $75,820 | Low |
| Nuclear Medicine Study of Bone Taken At Different Times | imaging | $45 | $45 to $78,315 | Low |
| Application of On-body Injector for Under Skin Injection | other | $45 | $45 to $96,377 | Low |
| CT Scan of Leg without Contrast | imaging | $45 | $45 to $73,700 | Low |
| CT Scan of Lower Spine without Contrast | imaging | $45 | $45 to $72,131 | Low |
| CT Scan of Middle Spine without Contrast | imaging | $45 | $45 to $72,128 | Low |
| CT Scan of Upper Spine without Contrast | imaging | $45 | $45 to $72,125 | Low |
| Removal of Muscle And/or Tissue, Each Additional 20.0 SQ Cm OR Less | surgery | $45 | $45 to $11,046 | Low |
| Wand Arthro 3.5x90deg Suc Foot #asc4250 | other | $45 | $45 to $169 | Low |
| Wand Arthrocare 90deg W/suct & Finger Switch | other | $45 | $45 to $169 | Low |
| Contact Layer, Sterile, More Than 48 Sq. In., Each Dressing | other | $45 | $45 to $339 | Low |
| Injection, Phenobarbital Sodium, Up to 120 Mg | other | $45 | $45 to $170 | Low |
| Gene Analysis (fms-related Tyrosine Kinase 3) Internal Tandem Duplication Var... | other | $45 | $45 to $81,245 | Low |
| Residence Visit for Established Patient with Low Level of Medical Decision Ma... | other | $45 | $45 to $99,348 | Low |
| Stone Extractor Basket 3.0frx120cm #390 | other | $45 | $45 to $170 | Low |
| Tisseel Vhsd 2 Ml Kit | other | $45 | $45 to $171 | Low |
| Insulin (novolin) R 100 Units / 100 Ml Ns - Compounded | other | $45 | $45 to $171 | Low |
| Myxredlin 100 Unit/100 Ml Bag | other | $45 | $45 to $171 | Low |
| Clinical Pathology Consultation; Limited, without Review of Patient's History... | lab | $45 | $45 to $80,500 | Low |
| Skin Substitute Graft to Wound 100.0 SQ Cm OR More of Face, Scalp, Eyelids, M... | other | $46 | $46 to $15,278 | Low |
| Tissue Marker, Implantable, Any Type, Each | surgery | $46 | $46 to $172 | Low |
| Ultrasonic Guidance During Surgery | surgery | $46 | $46 to $76,998 | Low |
| Residence Visit for New Patient with Low Level of Medical Decision Making, Pe... | other | $46 | $46 to $99,342 | Low |
| Tvt70100as - Tube Endotracheal L312mm Od10mm Id7mm Pvc Single Lumen Visualize... | other | $46 | $46 to $173 | Low |
| Tvt75105as - Tube Endotracheal L323mm Od10.5mm Id7.5mm Pvc Single Lumen Visua... | other | $46 | $46 to $173 | Low |
| Tvt80110as - Tube Endotracheal L323mm Od11mm Id8mm Pvc Single Lumen Visualize... | other | $46 | $46 to $173 | Low |
| Dextrose 25%-water Syringe | other | $46 | $46 to $173 | Low |
| Breast Prosthesis, Mastectomy Bra, with Integrated Breast Prosthesis Form, Un... | other | $46 | $46 to $173 | Low |
| Imaging of Esophagus Done From the Inside of the Esophagus | other | $46 | $46 to $91,111 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Suprascapular Shoulder Nerve | other | $46 | $46 to $64,418 | Low |
| Rod Carbon Fiber 11.0mm X 250mm External | other | $46 | $46 to $174 | Low |
| Rod Carbon Fiber 11.0mm X 300mm External | other | $46 | $46 to $174 | Low |
| Rod Carbon Fiber 11.0mm X 350mm External | other | $46 | $46 to $174 | Low |
| Flovent Hfa 44 Mcg Inhaler | other | $46 | $46 to $174 | Low |
| Hydromorphone Pca 1 Mg/ml *high Concentration* Cemc Batched Compounded | other | $46 | $46 to $175 | Low |
| Carbojet Co2 Tube Set #25-100 | other | $47 | $47 to $175 | Low |
| Family Psychotherapy with Patient, 50 Minutes | therapy | $47 | $47 to $90,847 | Low |
| Mini Bio-anchor Disp Kit | other | $47 | $47 to $175 | Low |
| Pushlock Kit for 2.9mm Shrt Pshlck #ar-2923ds | other | $47 | $47 to $175 | Low |
| Rotavirus Vaccine, Human, Attenuated | preventive | $47 | $47 to $90,681 | Low |
| Sheath Access 12/14fr X24cm #61224bx | other | $47 | $47 to $175 | Low |
| Sheath Access 12/14fr X54cm #61254bx | other | $47 | $47 to $175 | Low |
| Dissecting Tool 3.0 Matchstick Long #10mh30l | other | $47 | $47 to $175 | Low |
| Gallium Citrate Ga 67 | other | $47 | $47 to $175 | Low |
| Wand Artho 3.0mm 50deg Suction #asc2530 | other | $47 | $47 to $176 | Low |
| Doxycycline 100 Mg/100 Ml Ns Mini-bag Plus - Compounded | other | $47 | $47 to $176 | Low |
| Doxy 100 Mg Vial | other | $47 | $47 to $176 | Low |
| Injection, Immune Globulin, (octagam), Intravenous, Non-lyophilized (e.g., Li... | other | $47 | $47 to $22,851 | Low |
| Injection of Local Anesthetic for Abdominal Wall Pain Control On Side Using I... | other | $47 | $47 to $64,486 | Low |
| Nuclear Medicine Study of Lung Ventilation and Circulation | imaging | $47 | $47 to $78,582 | Low |
| Simple Control of Nose Bleed | other | $47 | $47 to $30,901 | Low |
| T Cell Count and Ratio, Including Ratio | other | $47 | $47 to $86,360 | Low |
| Psychotherapy with Evaluation and Management Visit, 30 Minutes | therapy | $47 | $47 to $90,833 | Low |
| Cath Reddick Cystic Duct 2401-52 *min Order 5 | other | $47 | $47 to $177 | Low |
| Papaverine 60 Mg/2 Ml Vial | other | $47 | $47 to $177 | Low |
| Barone Jejunostomy Set | other | $47 | $47 to $178 | Low |
| Detection Test By Nucleic Acid for Multiple Types Influenza Virus | other | $47 | $47 to $87,502 | Low |
| Psychotherapy with Evaluation and Management Visit, 45 Minutes | therapy | $48 | $48 to $90,836 | Low |
| Psychotherapy, 45 Minutes | therapy | $48 | $48 to $90,834 | Low |
| Subsequent Hospital Inpatient OR Observation Care with Moderate Level of Medi... | other | $48 | $48 to $99,232 | Low |
| Acute Hepatitis Panel | lab | $48 | $48 to $80,074 | Low |
| Nuclear Medicine Study, SPECT Imaging, 1 Area OR Single Acquisition, Single D... | imaging | $48 | $48 to $78,803 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Lower Abdomen and Groin Nerve | other | $48 | $48 to $64,425 | Low |
| CT Scan of Chest without Contrast | imaging | $48 | $48 to $71,250 | Low |
| Low Dose CT Scan of Chest for Lung Cancer Screening | imaging | $48 | $48 to $71,271 | Low |
| Velys Array Drill Pin 125mm X 4mm 4515-70-005 Minimum Order 10 Each | other | $48 | $48 to $180 | Low |
| Velys Array Drill Pin 175mm X 4mm 4515-70-006 Minimum Order 10 Each | other | $48 | $48 to $180 | Low |
| 2.5mm Mtch Hd 16cm Stryker #8470-107 | other | $48 | $48 to $180 | Low |
| Dilator Healicoil Rg 4.75mm #72203951 | other | $48 | $48 to $181 | Low |
| Dilator Healicoil Rg 5.5mm #72203952 | other | $48 | $48 to $181 | Low |
| Rasp Small Riordan #5100-037 | other | $48 | $48 to $181 | Low |
| Advance Care Planning, Each Additional 30 Minutes | other | $48 | $48 to $99,498 | Low |
| Gene Analysis | other | $48 | $48 to $81,210 | Low |
| CT Scan of Pelvis without Contrast | imaging | $48 | $48 to $72,192 | Low |
| Injection, Ibuprofen, 100 Mg | other | $48 | $48 to $181 | Low |
| Flovent Hfa 110 Mcg Inhaler | other | $48 | $48 to $182 | Low |
| Clinolipid 20% | lab | $48 | $48 to $182 | Low |
| Kyphon Bone Biopsy Device #2 #f07a | lab | $48 | $48 to $182 | Low |
| Meningococcal Vaccine, Serogroups A, C, W, Y, Diphtheria Toxoid Carrier Vaccine | preventive | $48 | $48 to $90,734 | Low |
| Wound Retractor/protector Xxlrg #c8405 | other | $48 | $48 to $182 | Low |
| Application of Walking Cast Covering Below Knee to Toe | other | $49 | $49 to $29,425 | Low |
| Cxi .014 X 90cm | other | $49 | $49 to $183 | Low |
| Margin Marker #mms6 | other | $49 | $49 to $183 | Low |
| Injection, Carfilzomib, 1 Mg | other | $49 | $49 to $4,012 | Low |
| Injection, Immune Globulin, (gamunex-c/gammaked), Non-lyophilized (e.g., Liqu... | other | $49 | $49 to $36,661 | Low |
| Application of Elbow to Finger Cast | other | $49 | $49 to $29,075 | Low |
| Established Patient Office OR Other Outpatient Visit with Low Level of Decisi... | other | $49 | $49 to $99,213 | Low |
| Genetic Sequencing Localization, Each Additional Procedure | other | $49 | $49 to $88,364 | Low |
| Other Ultrasound Procedure | imaging | $49 | $49 to $76,999 | Low |
| Programming of Heart Rhythm Stimulation After Drug Infusion | surgery | $49 | $49 to $93,623 | Low |
| Overtube Guardus Endo 3/bx #bx00711147 | other | $49 | $49 to $186 | Low |
| Grieshaber Revolution Dsp Ilm Forceps 25g | other | $50 | $50 to $186 | Low |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, 1 Extremity | other | $50 | $50 to $95,860 | Low |
| Review By Radiologist of Major Lower Body Vein Image | other | $50 | $50 to $75,825 | Low |
| Review By Radiologist of Chest Aorta Serial Images | other | $50 | $50 to $75,605 | Low |
| Scissors Ophthalmic 23ga Vertical Grieshaber | other | $50 | $50 to $188 | Low |
| Vemp Testing of Upper and Lower Branches of Inner Ear Nerve with Interpretati... | other | $50 | $50 to $92,519 | Low |
| Evaluation of Fine Needle Aspirate with Interpretation and Report | other | $50 | $50 to $88,173 | Low |
| Initial Therapy Service to Facilitate Lung Function | other | $50 | $50 to $94,667 | Low |
| Symbicort 80-4.5 Mcg Inhaler | other | $50 | $50 to $189 | Low |
| Kit for 1.8mm Q-fix Implant #25 | surgery | $50 | $50 to $189 | Low |
| CT Head | imaging | $50 | $50 to $2,518 | High |
| CT Scan Head OR Brain with Contrast | imaging | $50 | $50 to $70,460 | Low |
| CT Scan of Cranial Cavity with Contrast | imaging | $50 | $50 to $70,481 | Low |
| CT Scan of Face with Contrast | imaging | $50 | $50 to $70,487 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Rib Nerve | other | $50 | $50 to $64,420 | Low |
| Addition to Lower Extremity Fracture Orthosis, Plastic Shoe Insert with Ankle... | other | $50 | $50 to $190 | Low |
| Insertion of Probe to Widen Saliva Gland Duct | other | $50 | $50 to $42,650 | Low |
| Blood Unit Compatibility Test, Immediate Spin Technique | other | $51 | $51 to $86,920 | Low |
| Addition to Lower Extremity, Long Tongue Stirrup | other | $51 | $51 to $191 | Low |
| Dexmedetomidin 400mcg/100ml-ns | other | $51 | $51 to $191 | Low |
| Injection, Immune Globulin (privigen), Intravenous, Non-lyophilized (e.g., Li... | other | $51 | $51 to $4,423 | Low |
| Probe Laser Illuminated Directional 55.47.25p | other | $51 | $51 to $191 | Low |
| Hospital Inpatient OR Observation Discharge Day Management, 30 Minutes OR Less | other | $51 | $51 to $99,238 | Low |
| Diagnostic Exam of Lower Portion of Large Bowel Using a Flexible Endoscope | other | $51 | $51 to $45,330 | Low |
| Rod Carbon Fiber 11.0mm X 400mm External | other | $51 | $51 to $191 | Low |
| Vital-vue Urol/gen #8280-06 Extended Yank | other | $51 | $51 to $191 | Low |
| Antidepressants Levels, 1 OR 2 | other | $51 | $51 to $80,335 | Low |
| Osteopathic Manipulative Treatment, 9-10 Body Regions | other | $51 | $51 to $98,929 | Low |
| Injection of Medication Into Nasal Air Passage | other | $51 | $51 to $30,200 | Low |
| Injection, Ganciclovir Sodium, 500 Mg | other | $51 | $51 to $336 | Low |
| Complete Ultrasound of Abdomen and Pelvis Artery and Vein Blood Flow | imaging | $51 | $51 to $93,975 | Low |
| Addition to Lower Extremity Prosthesis, Below Knee, Suspension/sealing Sleeve... | other | $51 | $51 to $193 | Low |
| Review By Radiologist of Head OR Neck Vein System Image | other | $51 | $51 to $75,860 | Low |
| Pretreatment of Red Blood Cells for Use in Red Blood Cells Antibody Analysis ... | other | $51 | $51 to $86,972 | Low |
| Wrist Hand Finger Orthosis, without Joint(s), Prefabricated Item That Has Bee... | other | $51 | $51 to $386 | Low |
| Falope-ring Band Disp 8ea/bx | other | $51 | $51 to $193 | Low |
| Super Multivac 50 Wand-amblient | other | $51 | $51 to $194 | Low |
| Wand 90 Degree Superturbovac Amb Fingerswitch | other | $51 | $51 to $194 | Low |
| Injection, Meropenem (b. Braun), Not Therapeutically Equivalent to J2185, 100 Mg | other | $52 | $52 to $194 | Low |
| Hepatitis a and Hepatitis B Vaccine | preventive | $52 | $52 to $90,636 | Low |
| Subsequent Instillation of Agent Onto Lung Lining Using Chest Tube | other | $52 | $52 to $32,562 | Low |
| Nerve Conduction, 1-2 Studies | other | $52 | $52 to $95,907 | Low |
| CT Scan of Pelvis with Contrast | imaging | $52 | $52 to $72,193 | Low |
| Addition to Lower Extremity, Below Knee, Molded Distal Cushion | other | $52 | $52 to $195 | Low |
| Sodium Bicarb 4.2% Abboject | other | $52 | $52 to $195 | Low |
| Syringe Orise Twnpk23g Intej Needle M00519211 | other | $52 | $52 to $195 | Low |
| Raltegravir Potassium 400 Mg Po Tabs #6 Dispense Pack | other | $52 | $52 to $195 | Low |
| Review By Radiologist of Breast Artery of Breast Image | other | $52 | $52 to $75,756 | Low |
| Sodium Phosphate 45 Mmol/15 Ml | other | $52 | $52 to $195 | Low |
| Basket Nitinol 1.9 #390 | other | $52 | $52 to $195 | Low |
| Application of Hand and Lower Forearm Cast | other | $52 | $52 to $29,085 | Low |
| Chg Us, Breast(s), Real Time | other | $52 | $52 to $76,645 | Low |
| Decompression Set 14fr #cdsg-14 | other | $52 | $52 to $195 | Low |
| Needle Scorpion W/megaloader #ar-13999hdn 5ea/bx | other | $52 | $52 to $195 | Low |
| Placement of Proximal OR Distal Extension Prosthesis for Endovascular Repair ... | surgery | $52 | $52 to $75,953 | Low |
| Nuclear Medicine Study of Lymphatic System | imaging | $52 | $52 to $78,195 | Low |
| Injection, Alprostadil, 1.25 Mcg | other | $52 | $52 to $195 | Low |
| CT Scan of Chest with Contrast | imaging | $52 | $52 to $71,260 | Low |
| Arc Smart Argon Probe 2.3/220 G1140001 | other | $52 | $52 to $196 | Low |
| X-ray of Voice Box OR Throat | imaging | $52 | $52 to $70,370 | Low |
| Injection, Belinostat, 10 Mg | other | $52 | $52 to $7,566 | Low |
| Preventive Medicine Counseling, Typically 45 Minutes | therapy | $52 | $52 to $99,403 | Low |
| Retractor Dexterity 9-14cm #100301 | other | $52 | $52 to $197 | Low |
| Injection, Margetuximab-cmkb, 5 Mg | other | $52 | $52 to $7,440 | Low |
| Application of Short Leg Cast | other | $53 | $53 to $29,405 | Low |
| Nuclear Medicine Study of Kidney, Blood, Flow, and Function with Drug Adminis... | imaging | $53 | $53 to $78,708 | Low |
| Knee Orthosis, Elastic with Joints, Prefabricated Item That Has Been Trimmed,... | other | $53 | $53 to $396 | Low |
| Ligasure Xtd Disp #ls3112 | other | $53 | $53 to $198 | Low |
| Removal of Implanted Eardrum Tube Under Anesthesia | surgery | $53 | $53 to $69,424 | Low |
| Dilator Urethral Set 14f to 26f #g14893 | other | $53 | $53 to $199 | Low |
| Urethral S-curve Dilator Set 8fr-20fr #g32789 | other | $53 | $53 to $199 | Low |
| Injection, Midazolam in 0.9% Sodium Chloride, Intravenous, Not Therapeuticall... | other | $53 | $53 to $199 | Low |
| Programming of Dual Lead Implantable Defibrillator System | surgery | $53 | $53 to $93,283 | Low |
| Stent, Non-coronary, Temporary, without Delivery System | cardiac | $53 | $53 to $199 | Low |
| X-ray of Joints, Multiple | imaging | $53 | $53 to $77,077 | Low |
| CT Scan of Abdomen without Contrast | imaging | $53 | $53 to $74,150 | Low |
| Infusion, Albumin (human), 25%, 50 Ml | surgery | $53 | $53 to $246 | Low |
| Cannulated Hex Driver 3.5 Ar-8967d | other | $53 | $53 to $200 | Low |
| Carbonaid C02 Diffuser #carbonaid | other | $53 | $53 to $200 | Low |
| Ear Impression, Each | other | $53 | $53 to $400 | Low |
| Equinoxe Torque Defining Square Drive Screw Kit #300-20 | other | $53 | $53 to $200 | Low |
| Hex Driver 2.0 70mm Ao Marked Cannulated #dvhx-2.0/070mc Ao | other | $53 | $53 to $200 | Low |
| Laser Fiber 200micron Disp #clt1020fl | other | $53 | $53 to $200 | Low |
| Shoulder Gps Reverse Shoulder Drill Kit (1) 2mm Drill (1) 3.2mm Drill #531-20 | other | $53 | $53 to $200 | Low |
| Shoulder Orthosis, Vest Type Abduction Restrainer, Canvas Webbing Type OR Equ... | other | $53 | $53 to $400 | Low |
| Spacer 36+6mm #ar-9555 | other | $53 | $53 to $200 | Low |
| Sputum Specimen Collection | lab | $53 | $53 to $89,220 | Low |
| Fentanyl 2 Mcg/ml, Bupivacaine 0.125% Epidural | other | $53 | $53 to $200 | Low |
| Fentanyl 2 Mcg/ml, Bupivacaine 0.125% Epidural Pca - Compounded | other | $53 | $53 to $200 | Low |
| Wand Arthro 3.0mm Capsure Low Temperature | other | $53 | $53 to $201 | Low |
| Office OR Other Outpatient Consultation with Straightforward Medical Decision... | other | $54 | $54 to $99,242 | Low |
| Translocation Analysis (bcr/abl1) Major Breakpoint | other | $54 | $54 to $81,206 | Low |
| Biopsy of Lip | lab | $54 | $54 to $40,490 | Low |
| Alcohol And/or Substance Abuse Screening and Intervention, More Than 30 Minutes | preventive | $54 | $54 to $99,409 | Low |
| Exam for Hearing Aid, 1 Ear | other | $54 | $54 to $92,590 | Low |
| Hyaluronan OR Derivative, Euflexxa, for Intra-articular Injection, Per Dose | other | $54 | $54 to $203 | Low |
| Needle Biopsy of Lobe of Lung Using an Endoscope, Each Additional Lobe | lab | $54 | $54 to $31,633 | Low |
| Injection, Belimumab, 10 Mg | other | $54 | $54 to $4,148 | Low |
| Muscle Testing, Manual (separate Procedure) with Report; Total Evaluation of ... | other | $54 | $54 to $95,833 | Low |
| CT Scan of Lower Spine with Contrast | imaging | $54 | $54 to $72,132 | Low |
| CT Scan of Middle Spine with Contrast | imaging | $54 | $54 to $72,129 | Low |
| CT Scan of Pelvis Before and After Contrast | imaging | $54 | $54 to $72,194 | Low |
| CT Scan of Upper Spine with Contrast | imaging | $54 | $54 to $72,126 | Low |
| Biopsy of Ear Canal | lab | $54 | $54 to $69,105 | Low |
| Resolution 360 Clip 235cm X 2.8mm #m00521232 | other | $54 | $54 to $204 | Low |
| Measurement of Brain Wave Activity (eeg), Awake and Drowsy | other | $55 | $55 to $95,816 | Low |
| Arista Surgical Hemostatic Powder 5 Gm Polysaccharide Hemospheres Absorbable ... | surgery | $55 | $55 to $205 | Low |
| Electrode Pacing Bipolar 5fr-usci 5ea/1ca | other | $55 | $55 to $205 | Low |
| Occupational Therapy | therapy | $55 | $55 to $97,168 | High |
| Physical Therapy | therapy | $55 | $55 to $97,164 | High |
| Reamer Coring 10mm #ar-1224s W/collared Pin | other | $55 | $55 to $205 | Low |
| Reamer Coring 11mm #ar-1226s | other | $55 | $55 to $205 | Low |
| Reamer Coring 12mm Cannulated | other | $55 | $55 to $205 | Low |
| Reamer Coring 8mm Cannulated W/collared Pin | other | $55 | $55 to $205 | Low |
| Reamer Coring 9mm #ar-1223s W/collarded Pin | other | $55 | $55 to $205 | Low |
| IUD Insertion | other | $55 | $55 to $712 | High |
| Application of Stress By Physician for Joint Imaging | other | $55 | $55 to $77,071 | Low |
| Measurement of Brain Wave Activity (eeg), Awake and Asleep | other | $55 | $55 to $95,819 | Low |
| Measurement of Brain Wave Activity (eeg), in Coma OR Asleep | other | $55 | $55 to $95,822 | Low |
| Injection of Local Anesthetic for Abdominal Wall Pain Control On Both Sides U... | other | $55 | $55 to $64,488 | Low |
| Injection of Medication Into Palm | other | $55 | $55 to $20,527 | Low |
| Sodium Phosphate 15 Mmol/5 Ml | other | $55 | $55 to $207 | Low |
| Injection Procedure Through Bladder and Urethra for X-ray Imaging | imaging | $55 | $55 to $51,610 | Low |
| Paragon T2 Wand | other | $55 | $55 to $207 | Low |
| Physician Supervision of Patient Home Health Agency Services Per Month, 15-29... | other | $55 | $55 to $99,374 | Low |
| Injection of Contrast for Imaging of Hip Joint | other | $55 | $55 to $27,093 | Low |
| Sodium Chloride 0.9% Irrig. | other | $55 | $55 to $208 | Low |
| Prolonged Monitoring and Recording of Esophageal Function Through Nasal Tube ... | other | $55 | $55 to $91,038 | Low |
| Injection, Daratumumab, 10 Mg and Hyaluronidase-fihj | other | $56 | $56 to $31,413 | Low |
| CT Scan of Chest Before and After Contrast | imaging | $56 | $56 to $71,270 | Low |
| Hip Knee Ankle Foot Orthosis, Torsion Control, Bilateral Rotation Straps, Pel... | other | $56 | $56 to $210 | Low |
| Eviva Trocar 9g 10cm Length 12mm Aperture | other | $56 | $56 to $209 | Low |
| Eviva_0913-20 9ga 13cm Length 20mm Aperture | other | $56 | $56 to $209 | Low |
| Expect Slimline 25g Eus Needle #m00555521 Bx/5ea | other | $56 | $56 to $209 | Low |
| Needle Eus 19ga Expect Slimline #m00555501 | other | $56 | $56 to $209 | Low |
| Needle Eus 22ga Expect Slimline #m00555511 | other | $56 | $56 to $209 | Low |
| Surgicel 4 X 8 #1952s 12ea/case | other | $56 | $56 to $210 | Low |
| Pin Threaded Tip 1/8 X 2.5in #406669 | other | $56 | $56 to $210 | Low |
| Annual Wellness Visit; Includes a Personalized Prevention Plan of Service (pp... | preventive | $56 | $56 to $420 | Low |
| Gene Analysis (janus Kinase 2) Targeted Sequence Analysis | other | $56 | $56 to $81,279 | Low |
| Inpatient OR Observation Consultation with Straightforward Medical Decision M... | other | $56 | $56 to $99,252 | Low |
| Hydrocodone-chlorphen ER Susp | other | $56 | $56 to $210 | Low |
| Acu-dispo-cautery2 Fine Tip-s #dcft2 | other | $56 | $56 to $211 | Low |
| Carbojet Xf Handpiece Set with 40" Nozzle (10-unit Multi-pack) #27-100 | other | $56 | $56 to $211 | Low |
| Supervision of Interfacility Transport Care of Critical Patient, Each Additio... | other | $56 | $56 to $99,486 | Low |
| Telephone Evaluation and Management Service By a Physician OR Other Qualified... | other | $56 | $56 to $99,443 | Low |
| Stone Extractor Tipless 2.2frx115cm Ncircle | other | $56 | $56 to $211 | Low |
| Stone Extractor Tipless 3.0frx115cm Ncircle | other | $56 | $56 to $211 | Low |
| Addition to Lower Extremity, Varus/valgus Correction, Plastic Modification, P... | other | $56 | $56 to $212 | Low |
| CT Scan of Cranial Cavity Before and After Contrast | imaging | $56 | $56 to $70,482 | Low |
| Measurement of Brain Wave Activity (eeg), 41-60 Minutes | other | $56 | $56 to $95,812 | Low |
| Septal Button Nasal 2 Part #1524110 | other | $57 | $57 to $213 | Low |
| CT Scan of Abdomen with Contrast | imaging | $57 | $57 to $74,160 | Low |
| CT Scan of Face Before and After Contrast | imaging | $57 | $57 to $70,488 | Low |
| CT Scan of Head OR Brain Before and After Contrast | imaging | $57 | $57 to $70,470 | Low |
| Injection, Cosyntropin, 0.25 Mg | other | $57 | $57 to $213 | Low |
| Gold Probe Injection 10fr #6016 | other | $57 | $57 to $214 | Low |
| Gold Probe W/injector 7fr/210cm #6015 | other | $57 | $57 to $214 | Low |
| M00521231 - Clip Internal L235cm Channel 2.8mm with Ergonomic Handle Braided ... | other | $57 | $57 to $214 | Low |
| Advance Care Planning, First 30 Minutes | other | $57 | $57 to $99,497 | Low |
| Psychotherapy, 1 Hour | therapy | $57 | $57 to $90,837 | Low |
| Reamer Cann Head 6.5mm #ar-1406.5 | other | $57 | $57 to $215 | Low |
| Reamer Cann Head 6mm #ar | other | $57 | $57 to $215 | Low |
| Reamer Cann Head 7.5mm #ar-1407.5 | other | $57 | $57 to $215 | Low |
| Reamer Cann Head 7mm #ar | other | $57 | $57 to $215 | Low |
| Reamer Cann Head 8mm #ar | other | $57 | $57 to $215 | Low |
| CT Scan of Cranial Cavity without Contrast | imaging | $57 | $57 to $70,480 | Low |
| CT Scan of Soft Tissue of Neck without Contrast | imaging | $57 | $57 to $70,490 | Low |
| Ultrasound Scan of Growth for Measuring Elasticity, Each Additional Growth | imaging | $57 | $57 to $76,983 | Low |
| Symbicort 160-4.5 Mcg Inhaler | other | $57 | $57 to $216 | Low |
| Meningococcal Vaccine, Serogroups A, C, Y, W | preventive | $57 | $57 to $90,733 | Low |
| Programming of Multiple Lead Implantable Defibrillator System | surgery | $58 | $58 to $93,284 | Low |
| Amplatz Grad Renal Dilation Set | other | $58 | $58 to $217 | Low |
| Initial Instillation of Agent Onto Lung Lining Using Chest Tube | other | $58 | $58 to $32,561 | Low |
| Blade Shave Biopsy Flex Dermablade 8ea/1cs | lab | $58 | $58 to $217 | Low |
| Removal of Antibodies From Surface of Red Blood Cell | surgery | $58 | $58 to $86,860 | Low |
| Biopsy of Lining of Nose | lab | $58 | $58 to $30,100 | Low |
| Needle Eus 22g Expect Slimline #m00555510 | other | $58 | $58 to $218 | Low |
| Arc Smart Argon Probe 2.3/330 G1140002 | other | $58 | $58 to $218 | Low |
| Design and Construction of Complex Radiation Treatment Device | other | $58 | $58 to $77,334 | Low |
| Picc Cath 4fr Single Lumen Sapiens | other | $58 | $58 to $219 | Low |
| A-scope 4 Rhinolaryngo Slim 510001000 5ea/1bx | other | $59 | $59 to $220 | Low |
| Catheter Oximetry Nonheparin Swan-ganz782f75m | cardiac | $59 | $59 to $220 | Low |
| Helmet, Protective, Hard, Prefabricated, Includes All Components and Accessories | other | $59 | $59 to $220 | Low |
| Knot Pusher Suture Cutter #ar | other | $59 | $59 to $220 | Low |
| Microspheres 700-900 S820gh 5ea/box | other | $59 | $59 to $220 | Low |
| Robotic Suction Irrigator #410299 | other | $59 | $59 to $220 | Low |
| Subsequent Observation Care, Per Day, for the Evaluation and Management of a ... | other | $59 | $59 to $99,226 | Low |
| Ultrasound of Heart for Congenital Defect | imaging | $59 | $59 to $93,303 | Low |
| Addition, Endoskeletal System, Above Knee OR Hip Disarticulation, Knee Extens... | other | $59 | $59 to $221 | Low |
| Carbojet Xf Handpiece Set with 40" Nozzle Individual Handpiece #27-100 | other | $59 | $59 to $221 | Low |
| Evaluation of Hearing Function Related to Surgically Implanted Hearing Device... | surgery | $59 | $59 to $92,626 | Low |
| Injection of Contrast for Imaging of Wrist | other | $59 | $59 to $25,246 | Low |
| Injection Beneath Lining of Lower Large Bowel Using a Flexible Endoscope | other | $59 | $59 to $45,335 | Low |
| Injection, Hydroxyzine Hcl, Up to 25 Mg | other | $59 | $59 to $223 | Low |
| Cannula Simcoe | other | $59 | $59 to $223 | Low |
| Injection, Ocrelizumab, 1 Mg | other | $59 | $59 to $39,429 | Low |
| 2.5mm Prcsn Mtch Hd 13cm8450-107 | other | $60 | $60 to $224 | Low |
| Tretinoin 0.01 % Ex Gel | other | $60 | $60 to $224 | Low |
| Lap Grasper 5mm 6ea/bx #5dsg | other | $60 | $60 to $225 | Low |
| Urethral Dilator Set 8fr-24fr #g14185 | other | $60 | $60 to $225 | Low |
| 2.0 Mm Drive Shaft for Quickfix Screw System Ar-8930d | other | $60 | $60 to $225 | Low |
| 3.0 Drive Shft for Quickfix Screw System Ar-8930d | other | $60 | $60 to $225 | Low |
| Clip Resolution 360 Ultra17mm M00521402 20/bx | other | $60 | $60 to $225 | Low |
| Erythromycin 200 Mg/5 Ml Susp | other | $60 | $60 to $225 | Low |
| Pinning System #2544-00 | other | $60 | $60 to $225 | Low |
| Ruby Coil Detachment Handle | other | $60 | $60 to $225 | Low |
| Tube Nasal Moss Feed 18fr 44" Min Order of 2 | other | $60 | $60 to $225 | Low |
| 2.0mm Carbide Round 5820-110-020c | 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 |
| Injection, Gadolinium-based Magnetic Resonance Contrast Agent, Not Otherwise ... | other | $60 | $60 to $225 | Low |
| Varicella Vaccine | preventive | $60 | $60 to $90,716 | Low |
| Injection, Pembrolizumab, 1 Mg | other | $60 | $60 to $18,214 | 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 |
| Static OR Dynamic Ankle Foot Orthosis, Including Soft Interface Material, Adj... | 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 |
| Hepatitis B Vaccine (hepb), Cpg-adjuvanted, Adult Dosage, 2 Dose OR 4 Dose Sc... | preventive | $61 | $61 to $90,739 | Low |
| Power Picc Solo Catheter 4f Sl 3cg #ck001030 3kits/1 Case | cardiac | $61 | $61 to $229 | Low |
| Epinephrine Hcl (nasal) 0.1 % Na Soln | other | $61 | $61 to $230 | Low |
| Gradient Compression Arm Sleeve, Custom, Medium Weight, Each | other | $61 | $61 to $231 | Low |
| Nuclear Medicine Study of Heart Muscle At Rest and with Stress and SPECT | imaging | $61 | $61 to $78,451 | Low |
| Physician Attendance At Delivery and Stabilization of Newborn | obstetric | $61 | $61 to $99,464 | Low |
| CT Scan of Soft Tissue of Neck with Contrast | imaging | $62 | $62 to $70,491 | Low |
| Tuberculosis Test, Gamma Interferon | other | $62 | $62 to $86,480 | Low |
| Injection, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf, Per 10 Mg | other | $62 | $62 to $38,342 | Low |
| Injection, Desmopressin Acetate, Per 1 Mcg | other | $62 | $62 to $234 | Low |
| Testing for Presence of Drug, By Chemistry Analyzers | other | $62 | $62 to $80,307 | Low |
| Mic Tube Feeding Jejunal 18fr 30cm #0250-18 | other | $62 | $62 to $234 | Low |
| CT Scan of Abdomen Before and After Contrast | imaging | $62 | $62 to $74,170 | Low |
| Electrode Pacing Non-heparin 5frx110cm 5ea/ca | other | $62 | $62 to $234 | Low |
| 2.0 Cann Driver Tip Ht | other | $62 | $62 to $234 | Low |
| Human Papillomavirus Vaccine, Types 6, 11, 16, 18, Quadrivalent | preventive | $62 | $62 to $90,649 | Low |
| Walking Boot, Non-pneumatic, with OR without Joints, with OR without Interfac... | other | $62 | $62 to $468 | Low |
| Arndt Endobronchial Blocker Set 7fr G44114 | other | $62 | $62 to $235 | Low |
| Tobrex 0.3% Eye Ointment | other | $63 | $63 to $235 | Low |
| Optisphere 700-1000 #osl271 5ea/1bx | other | $63 | $63 to $235 | Low |
| Medtronic Percutaneous Extention Kit 3560022 | other | $63 | $63 to $236 | 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 |
| Evaluation of Brain Response to Sound for Diagnosis of Nervous System Disorde... | other | $63 | $63 to $92,653 | Low |
| Needle Biopsy of Thyroid Through Skin | lab | $63 | $63 to $60,100 | Low |
| Desonide 0.05 % Ex Lotn | other | $63 | $63 to $237 | Low |
| Home Visit for the Evaluation and Management of a New Patient, Which Requires... | other | $63 | $63 to $99,343 | Low |
| Evaluation of Hearing Function Brain Responses, First Hour | other | $63 | $63 to $92,620 | Low |
| Chg Stereotactic Guidance Breast Bx/ Needle Place | other | $63 | $63 to $77,031 | Low |
| Hc General Anesthesia Time - Each Incremental 15 Minutes | other | $63 | $63 to $238 | Low |
| Preventive Medicine Counseling, Typically 1 Hour | therapy | $63 | $63 to $99,404 | Low |
| Pulmonary Needle Arcpoint 21g #ils-2100-pn 5/pk | other | $63 | $63 to $238 | Low |
| Biopsy of Lower Large Bowel Using a Flexible Endoscope | lab | $63 | $63 to $45,331 | Low |
| Pneumothorax Cath Set 10.2fr #c-tpt-200 1ea | other | $63 | $63 to $239 | Low |
| Coblator Evac 70 Xtra W/cable | other | $64 | $64 to $240 | Low |
| Hc Epidural Anesthesia Time - Initial Base Charge | other | $64 | $64 to $240 | Low |
| Hc Spinal Anes 1st 30 | other | $64 | $64 to $240 | Low |
| Diagnostic Exam of Surgically Created Pouch of Small Bowel Using an Endoscope | surgery | $64 | $64 to $44,385 | Low |
| Injection, Acyclovir, 5 Mg | other | $64 | $64 to $240 | Low |
| Injection, Ertapenem Sodium, 500 Mg | other | $64 | $64 to $241 | Low |
| Evaluation of Brain Response to Sound for Determination of Hearing Status wit... | other | $64 | $64 to $92,651 | Low |
| Pathology Examination of Tissue Using a Microscope, Moderately High Complexity | lab | $64 | $64 to $88,307 | Low |
| Fetal Fibronectin (protein) Analysis | other | $64 | $64 to $82,731 | Low |
| Fiapc Probe W/ Filter 2200 a Od 2.3 Mm / 6.9 Fr; L 2.2 M / 7.2 Ft - #20132-21... | other | $65 | $65 to $243 | Low |
| Biopsy of Small Bowel Using an Endoscope Inserted Through Surgically Created ... | surgery | $65 | $65 to $44,382 | Low |
| Fiapc Probe W/ Filter 2200 Cod 2.3 Mm / 6.9 Fr; L 2.2 M / 7.2 Ftno. #20132-21... | other | $65 | $65 to $243 | Low |
| Embospheres 500-700 #s620gh 5ea/bx | other | $65 | $65 to $243 | Low |
| Lacosamide 200 Mg/20 Ml Vial | other | $65 | $65 to $243 | Low |
| Microspheres 300-500 #s420gh 5ea/box | other | $65 | $65 to $243 | Low |
| Nerve Conduction, 3-4 Studies | other | $65 | $65 to $95,908 | Low |
| Review By Radiologist of Both Arms and Legs Veins of Both Arms OR Legs Image | other | $65 | $65 to $75,822 | Low |
| Forcep Long Kleppinger 45cm 5mm #910010pk | other | $65 | $65 to $244 | Low |
| Hemostatic Sealant Floseal Matrix 10ml 6/ca | other | $65 | $65 to $244 | Low |
| Instillation of Agent Onto Lung Surface Using Chest Tube | other | $65 | $65 to $32,560 | Low |
| Biopsies of Rectum And/or Lower Large Bowel Using a Rigid Endoscope | other | $65 | $65 to $45,305 | Low |
| Ergo Gps Drill 3.2mm #531-55 | other | $65 | $65 to $245 | Low |
| Twist Drill 1.0mm X 20mm L76mm Ao Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.0mm X 20mml82mm Dental Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.0mm X 20mml82mm Stryker Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.2mm X 10mm L66mm Ao Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.2mm X 10mm L72mm Dental Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.2mm X 10mm L72mm Stryker Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.2mm X 25mm L81mm Ao Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.2mm X 25mm L87mm Dental Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.2mm X 25mm L87mm Stryker Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.6mm X 10mm L66mm Ao Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.6mm X 10mm L72mm Dental Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.6mm X 10mm L72mm Stryker Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.6mm X 25mm L81mm Ao Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.6mm X 25mm L87mm Dental Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.6mm X 25mm L87mm Stryker Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.9mm X 35mm L91mm Ao Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.9mm X 35mm L97mm Dental Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 1.9mm X 35mm L97mm Stryker Fixation #a | other | $65 | $65 to $245 | Low |
| Twist Drill 2.1mm X 10mm L66mm Ao Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 2.1mm X 10mm L72 Stryker Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 2.1mm X 10mm L72mm Dental Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 2.35mm X 10mm L66mm Ao Lag #a | other | $65 | $65 to $245 | Low |
| Twist Drill 2.35mm X 10mm L72mm Dental Lag #a | other | $65 | $65 to $245 | Low |
| Gene Analysis (hemochromatosis) Common Variants | other | $65 | $65 to $81,256 | Low |
| Study of Esophagus to Assess Movement | other | $65 | $65 to $91,010 | Low |
| Balloon Oval Kidney Shape Str #omspdbs2 | other | $65 | $65 to $246 | Low |
| Injection, C-1 Esterase Inhibitor (human), Cinryze, 10 Units | other | $66 | $66 to $10,428 | Low |
| Ultrasound of Heart During Rest, Exercise And/or Drug-induced Stress with Report | imaging | $66 | $66 to $93,350 | Low |
| Ultrasound of Heart with Color-depicted Blood Flow, Rate, Direction and Valve... | imaging | $66 | $66 to $93,306 | Low |
| Gene Analysis (prothrombin, Coagulation Factor Ii) a Variant | other | $66 | $66 to $81,240 | Low |
| Hc Regional Anesthesia Time - Initial Base Charge | other | $66 | $66 to $247 | Low |
| Injection, Chlorpromazine Hcl, Up to 50 Mg | other | $66 | $66 to $247 | Low |
| Complex Control of Nose Bleed | other | $66 | $66 to $30,903 | Low |
| Test for Exercise-induced Heart and Lung Stress | cardiac | $66 | $66 to $94,621 | Low |
| Tralement Vial | other | $66 | $66 to $247 | Low |
| Adapalene 0.3% Gel | other | $66 | $66 to $248 | Low |
| Review By Radiologist of Image for Repair of Descending Aorta and Subclavian ... | surgery | $66 | $66 to $75,956 | Low |
| Sensors Starling W/leadwires 25pk/1bx #cms25 | other | $66 | $66 to $248 | Low |
| Injection, Irinotecan Liposome, 1 Mg | other | $66 | $66 to $8,930 | Low |
| Injection, Erythromycin Lactobionate, Per 500 Mg | other | $66 | $66 to $249 | Low |
| Reaming Rod Push Rod with Ball Handle 03.010.093 | other | $66 | $66 to $249 | Low |
| Centurion Anterior Vitrectomy Probe | other | $66 | $66 to $249 | Low |
| Initial Hospital Care with Straightforward OR Low Level of Medical Decision M... | other | $66 | $66 to $99,221 | Low |
| Dilation of Saliva Gland Duct and Insertion of Tube | other | $66 | $66 to $42,660 | Low |
| Administration of Hormonal Anti-neoplastic Chemotherapy Under Skin OR Into Mu... | other | $67 | $67 to $96,402 | 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 |
| Cables Ensite X Extension for Magnet #a-ens-magext-cbl | other | $67 | $67 to $250 | Low |
| Custom Peg Board Kit #1 #pbk10001 | other | $67 | $67 to $250 | Low |
| Ensnare 18-30mm #en2007030 Elgx | other | $67 | $67 to $250 | Low |
| Exam of Neurobehavioral Status, First Hour | other | $67 | $67 to $96,116 | Low |
| Hearing Aid OR Assistive Listening Device/supplies/accessories, Not Otherwise... | other | $67 | $67 to $500 | Low |
| Pins 4x127 #rob10010 4ea/bx | other | $67 | $67 to $250 | Low |
| Pins 4x152 #rob10011 2ea/bx | other | $67 | $67 to $250 | Low |
| Screwdriver Bit Headless 3.0mm 212-40 | other | $67 | $67 to $250 | Low |
| Bypass of Diseased OR Blocked Artery with Prosthetic and Vein | other | $67 | $67 to $35,681 | Low |
| Tobradex Eye Ointment | other | $67 | $67 to $250 | Low |
| Ingrezza 40 Mg Capsule | other | $67 | $67 to $250 | Low |
| Powerpicc Solo Provena Catheter 4f Dl 3cg #ck001031 3kt/cs | cardiac | $67 | $67 to $251 | Low |
| Extracorp Shock Wv Tx Ms Nos | other | $67 | $67 to $610 | Low |
| Catheter Angiographic Coronary OR Peripheral Guiding W/o Sideholes Right C315... | imaging | $67 | $67 to $251 | Low |
| New Patient Office OR Other Outpatient Visit with Low Level of Medical Decisi... | other | $67 | $67 to $99,203 | Low |
| Diphtheria and Tetanus Vaccine | preventive | $67 | $67 to $90,714 | Low |
| Biopsy of Anus Using an Endoscope | lab | $67 | $67 to $46,606 | Low |
| Alvarado Traction Boot #00132021000 | other | $67 | $67 to $252 | Low |
| Prevena Dressing 13cm #pre1155us 5/cs | other | $67 | $67 to $254 | Low |
| Prevena Dressing 20cm #pre1055us 5/cs | other | $67 | $67 to $254 | Low |
| Administration of Non-hormonal Anti-neoplastic Chemotherapy Under Skin OR Int... | other | $68 | $68 to $96,401 | Low |
| Dressing Neg Press Veraflo Lg 5pk Ultvcc05lg | other | $68 | $68 to $254 | Low |
| Drill Tip Set-acl Patella Tendon Reusable | other | $68 | $68 to $254 | Low |
| Back Brace Aspen Summit 637 X-large 992380 | other | $68 | $68 to $255 | Low |
| Ligator Six Bander #mbl-6-ov Implant | surgery | $68 | $68 to $255 | Low |
| 8813e Suture Kit Dr Dumicz Oh Only 5kt/bx | other | $68 | $68 to $256 | Low |
| Ultrasound Scan of Fetal Umbilical Artery Blood Flow Rate | imaging | $68 | $68 to $76,820 | Low |
| Insertion of Tube Into Windpipe and Airways of Lung for Aspiration of Secreti... | other | $68 | $68 to $31,725 | Low |
| Use of a Drug to Induce Depression of Consciousness By Physician Not Performi... | other | $68 | $68 to $99,156 | Low |
| Antibody Evaluation, Initial Single Antibody Stain Procedure | other | $68 | $68 to $88,346 | Low |
| Subsequent Hospital Inpatient OR Observation Care with High Level of Medical ... | other | $68 | $68 to $99,233 | Low |
| Needle Biopsy of Growth of Abdominal Cavity | lab | $68 | $68 to $49,180 | Low |
| Amnioexcel, Amnioexcel Plus OR Biodexcel, Per Square Centimeter | other | $68 | $68 to $257 | Low |
| Manipulation of Finger for Connective Tissue Release Following Enzyme Injection | other | $69 | $69 to $26,341 | Low |
| Injection, Levocarnitine, Per 1 Gm | other | $69 | $69 to $258 | Low |
| Gene Rearrangement Analysis Detection Abnormal Clonal Population | other | $69 | $69 to $81,342 | Low |
| Candin Skin Test | other | $69 | $69 to $258 | 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 |
| **discontinued 2/19/2021** Percut Kit 19fr X 18cm Femoral Arterial | other | $69 | $69 to $259 | Low |
| Percut Kit 21fr 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 |
| CABG (Heart Bypass Surgery) | other | $69 | $69 to $2,578 | High |
| Cvvh Prisma Dilution Set #106697 4ea/cs | other | $69 | $69 to $259 | Low |
| Nuclear Medicine Study of Heart Muscle with Metabolic Evaluation | imaging | $69 | $69 to $78,459 | 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 |
| Hti Regulator Kit H80215901011 15901 | other | $69 | $69 to $260 | Low |
| Residence Visit for Established Patient with Moderate Level of Medical Decisi... | other | $69 | $69 to $99,349 | Low |
| Tube Endobronchial 35 Vivasight-dl #dlvt35las | other | $69 | $69 to $260 | Low |
| Tube Endobronchial 37 Vivasight-dl #dlvt37las | other | $69 | $69 to $260 | Low |
| Tube Endobronchial 39 Vivasight-dl #dlvt39las | other | $69 | $69 to $260 | Low |
| Tube Endobronchial 41 Vivasight-dl #dlvt41las | other | $69 | $69 to $260 | Low |
| Closed Treatment of Dislocated Joint Between Toe and Foot | other | $69 | $69 to $28,630 | Low |
| Santyl Ointment | other | $69 | $69 to $261 | Low |
| Hemostat Surgicel Snow 2x4 Absrb Ster #2082 | other | $69 | $69 to $261 | Low |
| Laser Probe 25g Vekt Illum Directl8065 | other | $69 | $69 to $261 | Low |
| Percut Kit 15fr X 18cm Femoral Arterial | other | $70 | $70 to $262 | Low |
| Removal of Appendix During Other Major Procedure | surgery | $70 | $70 to $44,955 | Low |
| Ligator Band 7 Band Speed | other | $70 | $70 to $262 | Low |
| Assessment for Hearing Aid | other | $70 | $70 to $8,400 | Low |
| Established Patient Office OR Other Outpatient Visit with Moderate Level of D... | other | $70 | $70 to $99,214 | Low |
| Retrieval Device, Insertable | other | $70 | $70 to $263 | Low |
| Laryngectomy Tubes: Provox Larytube Laryngectomy Tube 9/27 Inner Diameter 10.... | other | $70 | $70 to $263 | Low |
| Laryngectomy Tubes: Provox Larytube Laryngectomy Tube 9/36 Inner Diameter 13.... | other | $70 | $70 to $263 | Low |
| Injection, Collagenase, Clostridium Histolyticum, 0.01 Mg | other | $70 | $70 to $13,169 | Low |
| Pcp Drug Level | other | $70 | $70 to $83,992 | Low |
| Laproscopic Alligator Grasper | other | $70 | $70 to $265 | Low |
| Waveguide 12fr #1911273 | other | $70 | $70 to $265 | Low |
| Injection of Anesthetic OR Steroid Into Joint Between Lower Spine and Hip Bon... | other | $71 | $71 to $27,096 | Low |
| Rev - Ihs-moa Clinic Visit | other | $71 | $71 to $19,250 | Low |
| Injection, Benztropine Mesylate, Per 1 Mg | other | $71 | $71 to $266 | Low |
| Injection, Acetazolamide Sodium, Up to 500 Mg | other | $71 | $71 to $266 | Low |
| Disposable Distal Attachment D-201 | other | $71 | $71 to $267 | Low |
| Injection, Daratumumab, 10 Mg | other | $71 | $71 to $9,219 | Low |
| Silicone Elastomer T-tube 10fr Su130 | other | $71 | $71 to $268 | Low |
| Silicone Elastomer T-tube 12fr Su130 | other | $71 | $71 to $268 | Low |
| Silicone Elastomer T-tube 14fr Su130 | other | $71 | $71 to $268 | Low |
| Silicone Elastomer T-tube 16fr Su130 | other | $71 | $71 to $268 | Low |
| Ultrasound Scan of Infant Hip | imaging | $71 | $71 to $76,886 | Low |
| Ultrasound Scan of Infant Hip During Movement | imaging | $71 | $71 to $76,885 | Low |
| Stonetome 5.5fr 20mm #3511 | other | $71 | $71 to $268 | Low |
| Bflex 2 Slim 3.8 Single-use Bronchoscope 0570-0448 Bx=pk/5ea | other | $71 | $71 to $269 | Low |
| Non-canulated Non-sterile Torque Driver #00-8401-080 | other | $72 | $72 to $269 | Low |
| Removal of Anal Polyps OR Growths Using an Endoscope with Electrical Cautery | surgery | $72 | $72 to $46,610 | Low |
| CT Scan of Soft Tissue of Neck Before and After Contrast | imaging | $72 | $72 to $70,492 | Low |
| Electrode Hf Loop 24fr .2 Wire #a22201d | other | $72 | $72 to $269 | Low |
| Addition to Knee Joint, Disc OR Dial Lock for Adjustable Knee Flexion, Each J... | other | $72 | $72 to $270 | Low |
| Review By Radiologist of Arm OR Leg Artery Image | other | $72 | $72 to $75,710 | Low |
| Wand Arthro 2.3mm 35 Deg Short Bevel Sm Joint | other | $72 | $72 to $270 | Low |
| Individual Physician Supervision of a Patient (patient Not Present) in Home, ... | other | $72 | $72 to $99,340 | Low |
| Closed Treatment of 2 Broken Lower Leg Bones At Ankle | other | $72 | $72 to $27,808 | Low |
| Closed Treatment of Broken End of Finger OR Thumb | other | $72 | $72 to $26,750 | Low |
| Closed Treatment of Broken Finger OR Hand At Base of Finger | other | $72 | $72 to $26,740 | Low |
| Closed Treatment of Broken Hand Bone | other | $72 | $72 to $26,600 | Low |
| Closed Treatment of Broken Outside Lower Leg Bone At Ankle | other | $72 | $72 to $27,786 | Low |
| Closed Treatment of Broken Outside Lower Leg Bone At Ankle with Manipulation | other | $72 | $72 to $27,788 | Low |
| Closed Treatment of Broken Toe | other | $72 | $72 to $28,510 | Low |
| Closed Treatment of Broken Toe with Manipulation | other | $72 | $72 to $28,515 | Low |
| Closed Treatment of Inside Portion of Shin Bone At Ankle | other | $72 | $72 to $27,760 | Low |
| Overtube Guardus Endo 50cm 3ea/bx #bx00711149 | other | $72 | $72 to $272 | Low |
| Nuclear Medicine Studies of Heart Muscle At Rest and with Stress and SPECT | imaging | $72 | $72 to $78,452 | Low |
| Guidepin Resection 3mm X 100mm for Inhance Shoulder System #700030100 #7000-30 | other | $73 | $73 to $273 | Low |
| Evaluation and Testing for Balance with Recording | other | $73 | $73 to $92,540 | Low |
| Biopsy of Breast and Placement of Locating Device Using Mri, Each Additional ... | imaging | $73 | $73 to $19,086 | Low |
| Technetium Tc 99m Labeled Red Blood Cell Diagnostic 30 Mci | other | $73 | $73 to $274 | Low |
| Percut Kit 23fr X 18cm Femoral Venous | other | $73 | $73 to $275 | Low |
| Acp Max Prp System W/acda Abs | other | $73 | $73 to $275 | Low |
| Driver Surgical T8 Solid Ao for Colink Screw P04s0051 #p04 S0051 | surgery | $73 | $73 to $275 | Low |
| Knot Pusher #kp1 Cardiac Surg Only | cardiac | $73 | $73 to $275 | Low |
| Lag Screw Driver T8 Cannulated Sterile Single Use #p06 S0411 | other | $73 | $73 to $275 | Low |
| Office OR Other Outpatient Consultation with Low Level of Medical Decision Ma... | other | $73 | $73 to $99,243 | Low |
| Psychotherapy for Crisis, First Hour | therapy | $73 | $73 to $90,839 | Low |
| Radioactive Drug Therapy Through a Tube Inserted in an Artery | other | $73 | $73 to $79,445 | Low |
| Respiratory Syncytial Virus Vaccine, Pref, Recombinant, Subunit, Adjuvanted, ... | preventive | $73 | $73 to $90,679 | Low |
| Tube Feed Gastrostomy 18fr Moss | other | $73 | $73 to $275 | Low |
| Injection, Bevacizumab, 10 Mg | other | $73 | $73 to $10,041 | Low |
| Clevercut Tome 7mm Tip 20mm Wire | other | $73 | $73 to $275 | Low |
| Needle Biopsy of Liver Through Skin | lab | $73 | $73 to $47,000 | Low |
| Gene Analysis (coagulation Factor V) Leiden Variant | other | $73 | $73 to $81,241 | Low |
| Gene Analysis (interferon, Lambda 3) for Rs12979860 Variant | other | $73 | $73 to $81,283 | Low |
| Anesthesia for Tying OR Incision of Fallopian Tubes Using an Endoscope | other | $73 | $73 to $851 | Low |
| Dilation of Esophagus with a Guide Wire | other | $74 | $74 to $43,453 | Low |
| Initial Control of Nose Bleed and Insertion of Packing | other | $74 | $74 to $30,905 | Low |
| Kyphon Bevel Osteo Introducer #t15k | other | $74 | $74 to $277 | Low |
| Insertion of Needle OR Tube Into Artery of Arm OR Leg | other | $74 | $74 to $36,140 | Low |
| Endowrist Suction Irrigator #480299 6ea/1bx | other | $74 | $74 to $278 | Low |
| Injection, Ramucirumab, 5 Mg | other | $74 | $74 to $22,944 | Low |
| Injection, Obinutuzumab, 10 Mg | other | $74 | $74 to $25,962 | Low |
| Ibs 2in1 Drill 2.2 Diam / Lg22mm Ao Sterile Cannulated Lg65mm G01 00721 | other | $74 | $74 to $280 | Low |
| Initial Evaluation and Management of Newborn Per Day | obstetric | $74 | $74 to $99,460 | Low |
| Tool Delivery Large Cps Locator 3d#ds2c300 | obstetric | $74 | $74 to $280 | Low |
| Tool Delivery Large Xlong Cps Locator 3d#ds2c300 | obstetric | $74 | $74 to $280 | Low |
| Tool Delivery Medium Cps Locator 3d#ds2c200 | obstetric | $74 | $74 to $280 | Low |
| Tool Delivery Medium Xlong Cps Locator 3d#ds2c200 | obstetric | $74 | $74 to $280 | Low |
| Tool Delivery Small Cps Locator 3d#ds2c100 | obstetric | $74 | $74 to $280 | Low |
| 3d Radiographic Procedure with Computerized Image Postprocessing | imaging | $75 | $75 to $76,377 | Low |
| Hc Dressing Aquacel Ag 3.5x6 | other | $75 | $75 to $281 | Low |
| Benzodiazepines Levels, 1 | other | $75 | $75 to $80,346 | Low |
| Established Patient Periodic Preventive Medicine Examination | preventive | $75 | $75 to $99,397 | Low |
| Injection, Trastuzumab, Excludes Biosimilar, 10 Mg | other | $75 | $75 to $4,909 | Low |
| Flovent Hfa 220 Mcg Inhaler | other | $75 | $75 to $282 | Low |
| Injection, Rituximab, 10 Mg | other | $75 | $75 to $14,797 | Low |
| Foot, Insert, Removable, Molded to Patient Model, Longitudinal Arch Support, ... | other | $75 | $75 to $283 | Low |
| 11mm Mcglamry Metatarsal Elevator Ar-8930m | other | $76 | $76 to $285 | Low |
| Connecting Tube #maj | other | $76 | $76 to $285 | Low |
| Removal of Blood Clot in Heart Artery | surgery | $76 | $76 to $92,973 | Low |
| Removal of Drain (seton) From Anus | surgery | $76 | $76 to $46,030 | Low |
| Hospital Inpatient OR Observation Discharge Day Management, More Than 30 Minutes | other | $76 | $76 to $99,239 | Low |
| Splinting Tube 11mm X 13.2mm for Enteroscopy | other | $76 | $76 to $287 | Low |
| Injection, Cetuximab, 10 Mg | other | $76 | $76 to $5,762 | Low |
| Needle Ultrafast Fix Straight | other | $77 | $77 to $288 | Low |
| Pack Arthroscopic 1.2 Disposable Rap-pac B #72202797 | surgery | $77 | $77 to $288 | Low |
| For Diabetics Only, Fitting (including Follow-up), Custom Preparation and Sup... | other | $77 | $77 to $289 | Low |
| Gene Analysis (mpl Proto-oncogene, Thrombopoietin Receptor) Sequence Analysis... | other | $77 | $77 to $81,339 | Low |
| Laryngectomy Tubes: Provox Larytube Laryngectomy Tube 8/27 Standard Inner Dia... | other | $77 | $77 to $289 | Low |
| Bone Mill #bm210 Fine | other | $77 | $77 to $290 | 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 |
| Placement of Expandable Tube in Breast for Radiation Treatment Using Imaging ... | other | $77 | $77 to $19,297 | Low |
| CT Scan of Abdomen and Pelvis without Contrast | imaging | $77 | $77 to $74,176 | Low |
| Nerve Conduction, 5-6 Studies | other | $77 | $77 to $95,909 | Low |
| S1294108d5 - Power Picc 4fr Dual 3ea/case | other | $78 | $78 to $292 | Low |
| Powerpicc Solo Catheter 5f Tl Hf 3cg #ck001032 3kt/1cs | cardiac | $78 | $78 to $292 | Low |
| CT Scan of Blood Vessels of Head with Contrast | imaging | $78 | $78 to $70,496 | Low |
| CT Scan of Blood Vessels of Neck with Contrast | imaging | $78 | $78 to $70,498 | Low |
| Laryngectomy Tubes: Provox Larytube Laryngectomy Tube 8/36 Nonsterile Single-... | other | $78 | $78 to $292 | Low |
| Gore Smoother 7.9mm Disp | other | $78 | $78 to $293 | Low |
| Gore Smoother 9.5mm Disp | other | $78 | $78 to $293 | Low |
| Biopsy of Mouth | lab | $78 | $78 to $40,808 | Low |
| CT Scan of Heart Structure with Contrast | imaging | $78 | $78 to $75,572 | Low |
| Balloon Cre Rx Biliary 10-11-12mm #m00558930 | other | $78 | $78 to $294 | Low |
| Hyaluronan OR Derivative, Hyalgan, Supartz OR Visco-3, for Intra-articular In... | other | $78 | $78 to $438 | Low |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, 2 Extremities | other | $78 | $78 to $95,861 | 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 |
| Inpatient OR Observation Consultation with Low Level of Medical Decision Maki... | other | $78 | $78 to $99,253 | Low |
| Insertion of Tube in Pulmonary Artery for Monitoring | other | $79 | $79 to $93,503 | Low |
| Addition to Lower Extremity Fracture Orthosis, Adjustable Motion Knee Joint, ... | other | $79 | $79 to $296 | Low |
| Test to Assess Electrical Potentials Generated in the Inner Ear As a Result o... | other | $79 | $79 to $92,584 | Low |
| Obtaining Data Needed to Develop the Optimal Radiation Treatment, 3 OR More T... | other | $79 | $79 to $77,290 | Low |
| Cns Drainage System /latex Free #10-110 1ea | other | $79 | $79 to $298 | Low |
| Special Stained Specimen Slides to Examine Tissue, Each Additional Procedure | lab | $79 | $79 to $88,341 | Low |
| Evaluation of Sleep-disordered Breathing By Examination of Upper Airway Using... | other | $79 | $79 to $42,975 | Low |
| Radioactive Drug Therapy By Mouth | other | $79 | $79 to $79,005 | Low |
| Biopsy of Floor of Mouth | lab | $79 | $79 to $41,108 | Low |
| Physician Supervision of Patient Home Health Agency Services Per Month, 30 Mi... | other | $80 | $80 to $99,375 | Low |
| Injection, Olanzapine, 0.5 Mg | other | $80 | $80 to $299 | Low |
| Cables Ensite X Inquiry Quad #d-ens-inq-q-cbl | other | $80 | $80 to $300 | Low |
| Cables Ensite X Supreme Quad #d-ens-sup-q-cbl | other | $80 | $80 to $300 | Low |
| Catheter, Balloon Dilatation, Non-vascular | cardiac | $80 | $80 to $300 | Low |
| Ocular Implant | surgery | $80 | $80 to $784 | Low |
| Work-related OR Medical Disability Examination By the Treating Physician | other | $80 | $80 to $99,455 | Low |
| CT Scan of Blood Vessels of Pelvis with Contrast | imaging | $80 | $80 to $72,191 | Low |
| Removal of Polyp OR Growth of Rectum and Large Bowel Using an Endoscope with ... | surgery | $80 | $80 to $45,309 | Low |
| Nim Trivantage Emg Endotracheal Tube 5.0 #8229705 | other | $80 | $80 to $301 | Low |
| Tube Emg Trivantage 6mm #8229706 | other | $80 | $80 to $301 | Low |
| Tube Emg Trivantage 7mm #8229707 | other | $80 | $80 to $301 | Low |
| Tube Emg Trivantage 8mm #8229708 | other | $80 | $80 to $301 | Low |
| Removal of Bone, Each Additional 20.0 SQ Cm OR Less | surgery | $80 | $80 to $11,047 | Low |
| Balloon Seeker 6x17mm Em Sphn #1830617sph | other | $80 | $80 to $301 | Low |
| Destination Slender Seath Guide 6fr 85cm Gs-r6st1c85w | other | $80 | $80 to $302 | Low |
| Pedvaxhib Vaccine Vial | preventive | $80 | $80 to $302 | Low |
| CT Scan of Blood Vessels of Abdomen with Contrast | imaging | $80 | $80 to $74,175 | Low |
| Electrode Hf Roller Lg 24-28fr 12/30deg | other | $81 | $81 to $303 | Low |
| CT Scan of Blood Vessels of Chest with Contrast | imaging | $81 | $81 to $71,275 | Low |
| Rod Attacment for Lrg Multi-pin Clamp Externa | other | $81 | $81 to $304 | Low |
| Reflex Ultra 45 Coblator Ii #eica4845 | other | $81 | $81 to $304 | Low |
| CT Scan of Abdomen and Pelvis with Contrast | imaging | $81 | $81 to $74,177 | Low |
| Extended Physician Standby Service, Each 30 Minutes | other | $81 | $81 to $99,360 | Low |
| Meningococcal Recombinant Protein and Outer Membrane Vesicle Vaccine, Serogro... | preventive | $81 | $81 to $90,620 | Low |
| Microscopic Genetic Analysis of Tissue, Computer-assisted Technology, Initial... | other | $81 | $81 to $88,374 | Low |
| Microscopic Genetic Analysis of Tissue, Manual, Each Additional Multiplex Sta... | other | $81 | $81 to $88,377 | Low |
| Fusion of Finger Joint, Each Additional Joint | surgery | $81 | $81 to $26,861 | Low |
| Placement of External Device to Assist Circulation | other | $81 | $81 to $92,971 | Low |
| X-ray of Thigh Bone, 1 View | imaging | $82 | $82 to $73,551 | Low |
| Mtp Cup Reamer 22mm Gen #58890122 | other | $82 | $82 to $307 | Low |
| Vital-vue/ob Gyn #8281-06 Slender Tip | other | $82 | $82 to $307 | Low |
| Forceps Biopsy Piranha #m0065051600 | lab | $82 | $82 to $308 | Low |
| Injection, Isatuximab-irfc, 10 Mg | other | $82 | $82 to $12,466 | Low |
| Pneumococcal Vaccine, 13-valent | preventive | $82 | $82 to $90,670 | Low |
| Wrist Hand Finger Orthosis, without Joint(s), Prefabricated, Off-the-shelf, A... | other | $82 | $82 to $309 | Low |
| Evaluation of Brain Response to Sound for Determination of Hearing Threshold ... | other | $82 | $82 to $92,652 | Low |
| Temno Biopsy Needle 20x20 Ctt2020 | lab | $82 | $82 to $309 | Low |
| Removal of Foreign Body in Ear Canal Under Anesthesia | surgery | $83 | $83 to $69,205 | Low |
| Injection, Doxorubicin Hydrochloride, Liposomal, Not Otherwise Specified, 10 Mg | other | $83 | $83 to $1,526 | Low |
| Breast Prosthesis, Mastectomy Form | other | $83 | $83 to $312 | Low |
| Exam of Head, Neck, Including Ears, Nose and Throat Under General Anesthesia | other | $83 | $83 to $92,502 | Low |
| Methohexital 10 Mg/ml Injection - Compounded | other | $83 | $83 to $312 | Low |
| Photon Guide #104015 | other | $83 | $83 to $313 | Low |
| Limited Ultrasound Scan of 1 Breast | imaging | $83 | $83 to $76,642 | Low |
| Other MRI Scan | imaging | $83 | $83 to $76,498 | Low |
| X-ray of Chest, 1 View | imaging | $83 | $83 to $71,045 | Low |
| X-ray of Chest, 2 Views | imaging | $83 | $83 to $71,046 | Low |
| X-ray of Chest, 3 Views | imaging | $83 | $83 to $71,047 | Low |
| X-ray of Collar Bone | imaging | $83 | $83 to $73,000 | Low |
| X-ray of Entire Middle and Lower Spine, 1 View | imaging | $83 | $83 to $72,081 | Low |
| X-ray of Face Bones, 1-2 Views | imaging | $83 | $83 to $70,140 | Low |
| X-ray of Foot, 2 Views | imaging | $83 | $83 to $73,620 | Low |
| X-ray of Foot, Minimum of 3 Views | imaging | $83 | $83 to $73,630 | Low |
| X-ray of Hip, 1 View | imaging | $83 | $83 to $73,501 | Low |
| X-ray of Hip, 2-3 Views | imaging | $83 | $83 to $73,502 | Low |
| X-ray of Lower Jaws, Upper Jaws and Teeth | imaging | $83 | $83 to $70,355 | Low |
| X-ray of Thigh Bone, Minimum 2 Views | imaging | $83 | $83 to $73,552 | Low |
| Firstpass Mini Suture Passer - Left Curved 72290129 | other | $84 | $84 to $315 | Low |
| Firstpass Mini Suture Passer - Right Curved 72290130 | other | $84 | $84 to $315 | Low |
| Firstpass Mini Suture Passer - Straight 72290128 | other | $84 | $84 to $315 | Low |
| C-reamer 11mm Linvatec #8774a 4/bx | other | $84 | $84 to $315 | Low |
| Injection of Chemical for Paralysis of Nerve Muscles On Side of Face | other | $84 | $84 to $64,612 | Low |
| CT Scan of Blood Vessels of Lower Leg with Contrast | imaging | $84 | $84 to $73,706 | Low |
| Repositioning of Oral OR Nasal Feeding Tube in Small Bowel | other | $84 | $84 to $43,761 | Low |
| Prismaflex St150 Set Us #107640us | other | $84 | $84 to $317 | Low |
| Wand Turbinator Arthrocare #eica6895 | other | $84 | $84 to $317 | Low |
| Gene Analysis (calreticulin), Common Variants | other | $85 | $85 to $81,219 | Low |
| Estradiol 0.01% Cream | other | $85 | $85 to $318 | Low |
| Photonblade Rf Cautery #pb1 | other | $85 | $85 to $319 | Low |
| Coblator Probe ENT Reflex #eica4835 | other | $85 | $85 to $319 | Low |
| Drug Infusion OR Exercise for Heart Stimulation During Diagnostic Study | surgery | $85 | $85 to $93,464 | Low |
| Detection Test By Nucleic Acid for Hiv-1 Virus, Quantification | other | $85 | $85 to $87,536 | Low |
| Brav0 Cf Capsule Delivery Dev 5-pk #fgs | obstetric | $85 | $85 to $320 | Low |
| Initial Inpatient Hospital OR Birthing Center Same Date Care and Discharge of... | other | $85 | $85 to $99,463 | Low |
| Injection, Durvalumab, 10 Mg | other | $85 | $85 to $13,003 | Low |
| Interpretation and Report of Ultrasound of Heart | imaging | $85 | $85 to $93,314 | Low |
| Measurement of Brain Wave Activity (eeg), 61-119 Minutes | other | $85 | $85 to $95,813 | Low |
| Simple Drainage of Abscess of Finger | other | $85 | $85 to $26,010 | Low |
| Drill Staple Comp Charlotte #43112032 | other | $86 | $86 to $322 | Low |
| Bflex 2 Ultraslim 2.8 Single-use Bronchoscope 0570-0447 Bx=pk/5ea | other | $86 | $86 to $322 | Low |
| Foot, Insert, Removable, Molded to Patient Model, Longitudinal/ Metatarsal Su... | other | $86 | $86 to $323 | Low |
| Needle Biopsy of Liver | lab | $86 | $86 to $47,001 | Low |
| Application of Long Leg Cast From Thigh to Toe | other | $86 | $86 to $29,345 | Low |
| Review By Radiologist of Both Arms OR Legs Arteries Image | other | $86 | $86 to $75,716 | Low |
| 10.5mm Short Flipcutter #ar-1204as | other | $86 | $86 to $325 | Low |
| Flipcutter Ii Short 8.5mm #ar-1204as | other | $86 | $86 to $325 | Low |
| Flipcutter Ii Short 8mm #ar-1204as | other | $86 | $86 to $325 | Low |
| Flipcutter Ii Short 9.5mm #ar-1204as | other | $86 | $86 to $325 | Low |
| Flipcutter Ii Short 9mm #ar-1204as | other | $86 | $86 to $325 | Low |
| Flipcutter Short 10mm #ar-1204as | other | $86 | $86 to $325 | Low |
| Flipcutter Short 7.5mm #ar-1204as | other | $86 | $86 to $325 | Low |
| Flipcutter Short 7mm #ar-1204as | other | $86 | $86 to $325 | Low |
| Flat Markers #pfsdv0016 18ea/bx | other | $86 | $86 to $325 | Low |
| Prevena Plus Dressing #pre4055us 5/cs | other | $87 | $87 to $326 | Low |
| Caffeine-sod Benzoat 250 Mg/ml | other | $87 | $87 to $326 | Low |
| Flow Cytometry Technique for Dna OR Cell Analysis, First Marker | other | $87 | $87 to $88,184 | Low |
| Home Sleep Test (hst) with Type Iii Portable Monitor, Unattended; Minimum of ... | other | $87 | $87 to $654 | Low |
| Identification of Red Blood Cell Antibodies | other | $87 | $87 to $86,870 | Low |
| Aspiration And/or Injection of Fluid Large Joint Using Ultrasound Guidance | imaging | $87 | $87 to $20,611 | Low |
| Micro Acutrak 2 Extended Long Drill Acumed #80 | other | $87 | $87 to $328 | Low |
| Hand Orthosis, without Joints, May Include Soft Interface, Straps, Custom Fab... | other | $87 | $87 to $328 | Low |
| Evaluation of Heart Function Using Tilt Table | cardiac | $87 | $87 to $93,660 | Low |
| Review By Radiologist of Abdominal Aorta and Both Leg Arteries Image | other | $87 | $87 to $75,630 | Low |
| Gene Analysis (myeloid Differentiation Primary Response 88) for P.leu265pro V... | other | $88 | $88 to $81,305 | Low |
| Patch Vascular 1cm X 10cm Xenosure E1p10 | other | $88 | $88 to $329 | Low |
| Captivator Emr Large Scope Single #m00561610 | other | $88 | $88 to $329 | Low |
| Captivator Emr Standard Scope Single #m00561600 | other | $88 | $88 to $329 | Low |
| Review By Radiologist of Abdominal Artery Image | other | $88 | $88 to $75,726 | Low |
| Norepinephrine 16 Mg/250ml-d5w | other | $88 | $88 to $330 | Low |
| Percut Kit 17fr X 18cm Femoral Arterial | other | $88 | $88 to $330 | Low |
| Extended Patient Service without Direct Patient Contact, First Hour | other | $88 | $88 to $99,358 | Low |
| Ensnare 7fr 45mm #en2007045 | other | $88 | $88 to $331 | Low |
| Acyclovir 200 Mg/5 Ml Susp | other | $88 | $88 to $331 | Low |
| Dressing Dermabond Prineo (2/bx) #clr222us | other | $88 | $88 to $331 | Low |
| Shingles Vaccine for Injection Under Skin | preventive | $88 | $88 to $90,736 | Low |
| Injection, Mepivacaine Hydrochloride, Per 10 Ml | other | $88 | $88 to $88 | Low |
| Cervicovaginal Secretion of Placenta Protein | other | $89 | $89 to $84,112 | Low |
| Review By Radiologist of Image for Replacement of Stomach OR Large Bowel Tube | surgery | $89 | $89 to $75,984 | Low |
| Mitomycin 1.5 Ml (0.4 Mg/ Ml) - for Ophthalmic Use Only - Compounded | other | $89 | $89 to $334 | Low |
| Injection, Ropivacaine Hydrochloride, 1 Mg | other | $89 | $89 to $334 | Low |
| Ultrasound Guided Compression Repair of Blood Vessel | imaging | $89 | $89 to $76,936 | Low |
| Mtp Cone Reamer 22mm Gen #58890222 | other | $89 | $89 to $334 | Low |
| ACL Reconstruction | surgery | $89 | $89 to $9,920 | High |
| Arthrex Acl Fibertag Tightrope Abs Implant #ar-1588tnt | surgery | $89 | $89 to $335 | Low |
| Psychiatric Diagnostic Evaluation | therapy | $89 | $89 to $90,792 | Low |
| Forcep Biopsy Oval Cup 3.3frx15cm #g15054 | lab | $89 | $89 to $335 | Low |
| Injection, Pegfilgrastim, Excludes Biosimilar, 0.5 Mg | other | $89 | $89 to $13,206 | Low |
| Insertion of Tube Into Vena Cava | other | $90 | $90 to $36,010 | Low |
| Injection, Chlorothiazide Sodium, Per 500 Mg | other | $90 | $90 to $337 | Low |
| Initial Hospital Inpatient OR Observation Care with Moderate Level of Medical... | other | $90 | $90 to $99,222 | Low |
| Other Procedure On Skin, Mucous Membrane, and Tissue | other | $90 | $90 to $17,999 | Low |
| CT Scan of Abdomen and Pelvis Before and After Contrast | imaging | $90 | $90 to $74,178 | Low |
| Gene Analysis (v-kit Hardy-zuckerman 4 Feline Sarcoma Viral Oncogene Homolog)... | other | $90 | $90 to $81,272 | Low |
| Residence Visit for Established Patient with High Level of Medical Decision M... | other | $90 | $90 to $99,350 | Low |
| Injection of Anesthetic Agent, Trigeminal Nerve Bundle | other | $90 | $90 to $64,505 | Low |
| Dissector Ultrasonic 13cm #scd13 Sonicision | other | $90 | $90 to $340 | Low |
| Dissector Ultrasonic 26cm #scd26 Sonicision | other | $90 | $90 to $340 | Low |
| Injection, Adenosine, 1 Mg | other | $91 | $91 to $340 | Low |
| Wand ENT Procise Max W/cable #eica8898 | other | $91 | $91 to $341 | 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 |
| Injection, Moxifloxacin, 100 Mg | other | $91 | $91 to $342 | Low |
| Removal of Foreign Bodies in Lower Portion of Large Bowel Using a Flexible En... | surgery | $91 | $91 to $45,332 | Low |
| Injection, Linezolid, 200 Mg | other | $91 | $91 to $343 | Low |
| Revision OR Removal of Sacral Integrated Nerve Stimulating System with Electr... | surgery | $91 | $91 to $686 | Low |
| OB Cath System Bakri Balloon #g24237 | other | $91 | $91 to $344 | Low |
| Gene Analysis (janus Kinase 2) Variant | other | $92 | $92 to $81,270 | Low |
| Initial New Patient Preventive Medicine Evaluation | preventive | $92 | $92 to $99,387 | Low |
| Cervical, Collar, Semi-rigid, Thermoplastic Foam, Two Piece with Thoracic Ext... | other | $92 | $92 to $347 | Low |
| Biopsy of Front 2/3 of Tongue | lab | $92 | $92 to $41,100 | Low |
| Hemostat Surgicel Snow 4x4 Absrb Ster #2083 | other | $92 | $92 to $347 | Low |
| Insertion of Needle OR Tube Into Vein | other | $93 | $93 to $36,000 | Low |
| Ultrasound Scan of Spinal Canal | imaging | $93 | $93 to $76,800 | Low |
| Cables Ensite X Livewire Deca #d-ens-l/r-hod-cbl | other | $93 | $93 to $350 | Low |
| Concave Cone Reamer 21mm P04 N0033 | other | $93 | $93 to $350 | Low |
| Cone Reamer 23mm Non-sterile P04 N0034 | other | $93 | $93 to $350 | Low |
| Convex Cup Reamer 21mm P04 N0023 | other | $93 | $93 to $350 | Low |
| Cup Reamer 23mm Non-sterile P04 N0024 | other | $93 | $93 to $350 | Low |
| Human Papillomavirus Vaccine Types 6, 11, 16, 18, 31, 33, 45, 52, 58, Nonavalent | preventive | $93 | $93 to $90,651 | Low |
| Irrigation of Nasal Sinus | other | $93 | $93 to $31,000 | Low |
| Diagnostic Exam of Anus and Rectum Under Anesthesia | other | $93 | $93 to $45,990 | Low |
| Mic-key Gastric Jejunal Feeding Tube K 1 Ea/ca 0270-18-2.3 | other | $93 | $93 to $351 | Low |
| Drainage of Abscess of Roof of Mouth | other | $94 | $94 to $42,000 | Low |
| Screening Evaluation of Brain Response to Sound with Automated Analysis | preventive | $94 | $94 to $92,650 | Low |
| Ipol Vial | other | $94 | $94 to $354 | Low |
| Angiojet Power Pulse Kit #104834 | other | $94 | $94 to $354 | Low |
| Initial Observation Care, Per Day, for the Evaluation and Management of a Pat... | other | $94 | $94 to $99,220 | Low |
| Needle Biopsy Fine Endobronchial Ultrasound Acquire Pulmonary M00552350 | imaging | $94 | $94 to $354 | Low |
| Forcep Bipolar Non Stick with Stop Insulated 0.5mm Tip 8 1/2in Buzz Hardy #nh05 | other | $94 | $94 to $354 | Low |
| Incision and Drainage of Abscess of Female Genital Gland | other | $94 | $94 to $56,420 | Low |
| Biocomposite Corkscrew Ft Suture Anchor 4.75 Mm X 14 Mm W/two 1.3 Mm Sutureta... | other | $94 | $94 to $355 | Low |
| Kit-interstim Neurostimulator Extern #353101 | other | $94 | $94 to $355 | Low |
| Upper Extremity Fracture Orthosis, Humeral, Prefabricated, Includes Fitting a... | other | $94 | $94 to $710 | Low |
| Contrast Injection for X-ray Imaging Through Existing Tube in Stomach, Small ... | imaging | $95 | $95 to $49,465 | Low |
| Replacement of Stomach-to-small Bowel Tube Using Fluoroscopic Guidance with C... | surgery | $95 | $95 to $49,452 | Low |
| Drawing of Blood for a Medical Problem | other | $95 | $95 to $99,195 | Low |
| Biopsy of Back 1/3 of Tongue | lab | $95 | $95 to $41,105 | Low |
| Endovascular Repair of Iliac Artery Aneurysm, Pseudoaneurysm, Arteriovenous M... | surgery | $95 | $95 to $75,954 | Low |
| Screening Mammography | imaging | $95 | $95 to $77,067 | Low |
| Brachytherapy Source, Non-stranded, Non-high Dose Rate Iridium-192, Per Source | other | $95 | $95 to $909 | Low |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, 3 Extremities | other | $96 | $96 to $95,863 | Low |
| External Counterpulsation, Per Treatment Session | other | $96 | $96 to $1,060 | Low |
| Injection, Vasopressin, 1 Unit | other | $96 | $96 to $360 | Low |
| Removal of Embedded Foreign Body in Eyelid | surgery | $96 | $96 to $67,938 | Low |
| Biopsy of Roof of Mouth | lab | $96 | $96 to $42,100 | Low |
| Nitirol Tipped Stone Extractor G36250 | other | $96 | $96 to $361 | Low |
| Residence Visit for New Patient with Moderate Level of Medical Decision Makin... | other | $96 | $96 to $99,344 | Low |
| Supervision of Interfacility Transport Care of Critical Patient, First 30 Min... | other | $96 | $96 to $99,485 | Low |
| Injection, Micafungin Sodium, 1 Mg | other | $96 | $96 to $362 | Low |
| Injection, Oxaliplatin, 0.5 Mg | other | $96 | $96 to $161 | Low |
| Incision of Tissue Connecting Tongue and Floor of Mouth | other | $97 | $97 to $41,010 | Low |
| Sodium Floride F 18 Diagnostic 30 Mci | other | $97 | $97 to $363 | Low |
| Gradient Compression Garment, Arm, Padded, for Nighttime Use, Each | other | $97 | $97 to $363 | Low |
| Osteocool Bone Access Kit 10g | other | $97 | $97 to $364 | Low |
| Control of Bleeding of Lower Large Bowel Using an Endoscope | other | $97 | $97 to $45,317 | Low |
| Dissector Ultrasonic 39cm #scd396 Sonicision | other | $97 | $97 to $365 | Low |
| Penumbra Max Canister | other | $97 | $97 to $365 | Low |
| Drainage of Abscess, Cyst, OR Blood Accumulation of Side of Tongue From Insid... | other | $97 | $97 to $41,000 | Low |
| Laser Fiber 150 Micron Tfl Single Use Tfl-fbx150s 5/box | other | $97 | $97 to $366 | Low |
| Laser Fiber 200 Micron Tfl Single Use Tfl-fbx200s 5/box | other | $97 | $97 to $366 | Low |
| Established Patient Synchronous Audio-only Visit with High Medical Decision M... | other | $97 | $97 to $98,015 | Low |
| Laser Fiber 365 Micron Tfl Single Use Tfl-fbx365s 5/box | other | $97 | $97 to $366 | Low |
| Arterial Cannula 19fr 96530 | other | $97 | $97 to $366 | Low |
| CT Scan of Blood Vessels of Abdomen and Pelvis with Contrast | imaging | $98 | $98 to $74,174 | Low |
| Injection of Blood OR Blood Clot Into Spinal Canal | other | $98 | $98 to $62,273 | Low |
| Staple Boyd Fixation Medium Short #128724 | other | $98 | $98 to $369 | Low |
| MRI Scan of Pelvis Before and After Contrast | imaging | $98 | $98 to $72,197 | Low |
| Clinimix 8%-10% Solution | other | $98 | $98 to $370 | Low |
| Injection, Amiodarone Hydrochloride (nexterone), 30 Mg | other | $98 | $98 to $370 | Low |
| Follow-up Intensive Care of Recovering Medium Birth Weight Infant Per Day | other | $98 | $98 to $99,480 | Low |
| Fluoroscopic Guidance for Spine OR Back Muscle Injection | other | $98 | $98 to $77,003 | Low |
| Ultrasound of Heart with Probe in Esophagus to Assess Heart Pump Function | imaging | $98 | $98 to $93,318 | Low |
| Biopsy of Voice Box Using a Flexible Endoscope | lab | $98 | $98 to $31,576 | Low |
| Exam to Assess Movement of Vocal Cord Flaps Using an Endoscope | other | $99 | $99 to $31,579 | Low |
| Continuous Monitoring of Blood Sugar Level in Tissue Fluid Using Sensor Under... | other | $99 | $99 to $95,250 | Low |
| Hc Monitored Anesthesia Care Anesthesia Time - Initial Base Charge | other | $99 | $99 to $372 | Low |
| Insertion of Tube Into External Neck Artery for Diagnosis OR Treatment with R... | other | $99 | $99 to $36,227 | Low |
| Low Osmolar Contrast Material, 200-299 Mg/ml Iodine Concentration, Per Ml | other | $99 | $99 to $373 | Low |
| Ligasure 5mm #ls1500 | other | $99 | $99 to $373 | Low |
| Injection of Chemical for Paralysis of Salivary Glands On Both Sides of Mouth | other | $99 | $99 to $64,611 | Low |
| Basket Memory 2x4cm Eight Wire ERCP G21538 | other | $99 | $99 to $374 | Low |
| ERCP (Gallstone Removal) | other | $99 | $99 to $5,821 | High |
| Established Patient Office OR Other Outpatient Visit with High Level of Medic... | other | $100 | $100 to $99,215 | Low |
| Release of Large Bowel From Spleen and Abdominal Wall with Partial Removal of... | surgery | $100 | $100 to $44,139 | Low |
| Injection of Chemical for Paralysis of Facial and Neck Nerve Muscles On Both ... | other | $100 | $100 to $64,615 | Low |
| Complex Measurement of Pressure of Urine Flow in Bladder with Voiding Pressur... | other | $100 | $100 to $51,728 | Low |
| Injection of Radioactive Contrast Into a Vein for Non-imaging Gamma Probe | other | $100 | $100 to $78,808 | Low |
| Injection, Avelumab, 10 Mg | other | $100 | $100 to $6,099 | Low |
| Knife Bayonet Disc Non Pt Charge | other | $100 | $100 to $376 | Low |
| Biopsy of Back of Throat | lab | $100 | $100 to $42,800 | Low |
| Complete Ultrasound Scan of 1 Breast | imaging | $100 | $100 to $76,641 | Low |
| Follow-up Ultrasound Scan of Pregnant Uterus | imaging | $100 | $100 to $76,816 | Low |
| Ultrasound and Monitoring of Heart of Fetus | imaging | $100 | $100 to $76,818 | Low |
| Ultrasound Scan of Brain | imaging | $100 | $100 to $76,506 | Low |
| X-ray of Both Hips, 2 Views | imaging | $100 | $100 to $73,521 | Low |
| X-ray of Both Hips, 3-4 Views | imaging | $100 | $100 to $73,522 | Low |
| X-ray of Entire Middle and Lower Spine, 2-3 Views | imaging | $100 | $100 to $72,082 | Low |
| X-ray of Eye Socket, Minimum of 4 Views | imaging | $100 | $100 to $70,200 | Low |
| X-ray of Knee, 4 OR More Views | imaging | $100 | $100 to $73,564 | Low |
| X-ray of Lower and Sacral Spine, Minimum of 4 Views | imaging | $100 | $100 to $72,110 | Low |
| 3d Breast Mammography of Both Breasts | imaging | $100 | $100 to $77,062 | Low |
| Red Blood Cells, Leukocytes Reduced, Each Unit | other | $101 | $101 to $378 | Low |
| Balloon Seeker 6x7mm Em Maxl #1830607max | other | $101 | $101 to $378 | Low |
| Injection, Dihydroergotamine Mesylate, Per 1 Mg | other | $101 | $101 to $378 | 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 |
| Removal of Tube Into Artery OR Vein with Review By Radiologist | surgery | $101 | $101 to $37,214 | Low |
| Control of Bleeding of Lower Large Bowel Using a Flexible Endoscope | other | $101 | $101 to $45,334 | Low |
| Other Procedure On Tongue OR Floor of Mouth | other | $101 | $101 to $41,599 | Low |
| Needle Measurement of Electrical Activity in Arm OR Leg Muscles, 4 Extremities | other | $101 | $101 to $95,864 | Low |
| Ligasure Small Jaw Open #lf1212a | other | $101 | $101 to $381 | 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 |
| Methohexital 100 Mg/10ml-water | other | $102 | $102 to $382 | Low |
| Potassium Phosp 45 Mmol/15 Ml | other | $102 | $102 to $383 | Low |
| Ankle Foot Orthosis, Plastic OR Other Material, Prefabricated, Includes Fitti... | other | $102 | $102 to $383 | Low |
| Tisseel Vhsd Frozen Prima 10ml #1506080 | other | $102 | $102 to $383 | Low |
| Radiation Treatment Management, 1-2 Treatment Sessions | other | $102 | $102 to $77,431 | Low |
| Combivent Respimat 20-100 Mcg | other | $102 | $102 to $384 | Low |
| Shingrix Vial Kit | other | $102 | $102 to $384 | Low |
| Catheter, Electrophysiology, Diagnostic, Other Than 3d Mapping | cardiac | $102 | $102 to $384 | Low |
| Immediate Post Surgical OR Early Fitting, Application of Non-weight Bearing R... | surgery | $102 | $102 to $501 | Low |
| Aztreonam 1 G/3ml Ij | other | $102 | $102 to $385 | Low |
| Aztreonam 1 Gm Vial | other | $102 | $102 to $385 | Low |
| Follow-up Intensive Care of Recovering Low Birth Weight Infant Per Day | other | $102 | $102 to $99,479 | Low |
| Alexis Extraction System #gtk17 | other | $102 | $102 to $385 | Low |
| Bacillus Calmette-guerin Vaccine for Bladder Cancer | preventive | $102 | $102 to $90,586 | Low |
| Exposure of Groin Artery for Delivery of Graft | obstetric | $102 | $102 to $34,713 | Low |
| Ultrasound of Heart with Probe in Esophagus, with Report | imaging | $102 | $102 to $93,312 | Low |
| Simple Drainage of Abscess OR Blood Accumulation of External Ear | other | $103 | $103 to $69,000 | Low |
| Therapeutic Fracture of Nasal Passages | other | $103 | $103 to $30,930 | Low |
| Fiber Laser 365um 6j 80hz 120w D/f/l for Lithotripsy Moses Ac | other | $103 | $103 to $386 | Low |
| Special Radiation Treatment | other | $103 | $103 to $77,470 | Low |
| Nerve Conduction, 7-8 Studies | other | $103 | $103 to $95,910 | Low |
| Pneumococcal Conjugate Vaccine, 15 Valent (pcv15), for Intramuscular Use | preventive | $103 | $103 to $90,671 | Low |
| Topaz Ifs Microdebrider Wand Ez #ach4041 | other | $103 | $103 to $387 | Low |
| Forcep Bipolar Non Stick Insulated 1.2mm Tip 7 1/2in Buzz Cushing #n19c12 | other | $103 | $103 to $387 | Low |
| Tumor Markers 1 Inteliq 6x2ml #12008289 | other | $103 | $103 to $388 | Low |
| Tumor Markers 2 Inteliq 6x2ml #12008290 | other | $103 | $103 to $388 | Low |
| Drainage of Deep Abscess OR Blood Accumulation of Leg OR Ankle | other | $103 | $103 to $27,603 | Low |
| Removal of Polyps OR Growths of Lower Large Bowel Using a Flexible Endoscope ... | surgery | $104 | $104 to $45,338 | Low |
| Loop Cysview Bipolar 24/26fr Longitudinal | other | $104 | $104 to $390 | Low |
| Insertion of Drain (seton) Into Anus | other | $104 | $104 to $46,020 | Low |
| Ambulatory Infusion Pump, Single OR Multiple Channels, Electric OR Battery Op... | surgery | $104 | $104 to $782 | Low |
| Transitional Care Management Services for Problem of At Least Moderate Comple... | other | $104 | $104 to $99,495 | Low |
| Laser Fiber 1000mic #dfs-1000sb | other | $104 | $104 to $391 | Low |
| Incision, Aspiration, And/or Inflation of Eardrum | other | $104 | $104 to $69,420 | Low |
| Management of Oxygen Chamber Therapy | other | $104 | $104 to $99,183 | Low |
| Drainage of Abscess OR Blood Accumulation of Nose | other | $104 | $104 to $30,000 | Low |
| Electrode Hf Band 30deg #wa22623s | other | $104 | $104 to $392 | Low |
| Electrode Hf Loop Med 30deg #wa22606s | other | $104 | $104 to $392 | Low |
| Lumbar Drainage Kit #10 | other | $105 | $105 to $393 | Low |
| Clamp Lrg Open Adjustable External Mr Safe | other | $105 | $105 to $393 | Low |
| Injection, Ceftazidime and Avibactam, 0.5 G/0.125 G | other | $105 | $105 to $3,448 | Low |
| Removal of Dental Bone Growth | surgery | $105 | $105 to $41,825 | Low |
| Needle Acquire Fnb 22 Ga #m00555540 1ea/1bx | other | $105 | $105 to $394 | Low |
| Injection, Betamethasone Acetate 3 Mg and Betamethasone Sodium Phosphate 3 Mg | other | $105 | $105 to $395 | Low |
| Recording of Upper Heart Chamber Rhythm | cardiac | $105 | $105 to $93,602 | Low |
| Drainage of Abscess OR Blood Accumulation of Nasal Cartilage | other | $105 | $105 to $30,020 | Low |
| Injection, Glucagon Hydrochloride (fresenius Kabi), Not Therapeutically Equiv... | other | $106 | $106 to $397 | Low |
| CT Scan of Abdominal Aorta and Both Leg Arteries with Contrast | imaging | $106 | $106 to $75,635 | Low |
| Graft Hemashield 15cm 18mm #m00202175118p0 | other | $106 | $106 to $399 | Low |
| Graft Oh Hemashield 15cm 24mm #175124p | other | $106 | $106 to $399 | Low |
| New Patient Office OR Other Outpatient Visit with Moderate Level of Medical D... | other | $106 | $106 to $99,204 | Low |
| Norepinephrine 16 Mg / 250 Ml Ns Bag (quad Concentrate) - Compounded | other | $106 | $106 to $399 | Low |
| Drainage of Fluid From Chest Cavity with Insertion of Indwelling Tube | other | $106 | $106 to $32,556 | Low |
| Destruction of Peripheral Nerve OR Branch | other | $106 | $106 to $64,640 | Low |
| Recording of Upper Heart Rhythm | cardiac | $106 | $106 to $93,600 | Low |
| Insertion of Tube Into Right Heart OR Main Pulmonary Artery | cardiac | $106 | $106 to $36,013 | Low |
| Simple Biopsy of Growth of Throat Behind Nose | lab | $106 | $106 to $42,804 | Low |
| 3d Breast Mammography of 1 Breast | imaging | $106 | $106 to $77,061 | Low |
| Cables Ensite X Inquiry Deca #d-ens-inq-od-cbl | other | $106 | $106 to $400 | Low |
| Carpal Tunnel Release | surgery | $106 | $106 to $400 | High |
| Colonoscopy | preventive | $106 | $106 to $45,383 | High |
| Ensite X Duo Deca X Cable #d-ens-l/r-ddy-cbl | other | $106 | $106 to $400 | Low |
| Port, Indwelling | other | $106 | $106 to $400 | Low |
| Psychotherapy with Evaluation and Management Visit, 1 Hour | therapy | $106 | $106 to $90,838 | Low |
| Vitality Polyaxial 7.0x55mm #701m7055 | other | $106 | $106 to $400 | Low |
| Review By Radiologist of Image for Drainage of Fluid | other | $107 | $107 to $75,989 | Low |
| All Lower Extremity Prostheses, Foot, Single Axis Ankle/foot | other | $107 | $107 to $402 | Low |
| CT Scan of Blood Vessels and Grafts of Heart with Contrast | imaging | $107 | $107 to $75,574 | Low |
| Needle Del Sys 360 Curved 72202468 | other | $107 | $107 to $404 | Low |
| Needle Del Sys 360 Reverse Curved #72202469 | other | $107 | $107 to $404 | Low |
| Placement and Subsequent Removal of Device to Protect Brain From Embolism Thr... | surgery | $108 | $108 to $33,370 | Low |
| Exposure of Arm Artery for Insertion of Prosthesis | other | $108 | $108 to $34,834 | Low |
| Removal of Growth of Tissue of Mouth | surgery | $108 | $108 to $40,810 | Low |
| Hydratome Rx44 450cm X .035" 20mm Cut Wire | other | $109 | $109 to $408 | Low |
| Electrode Plasmabutton 12/30deg #wa22657s | other | $109 | $109 to $408 | Low |
| Simple Removal of Embedded Foreign Body in Mouth | surgery | $109 | $109 to $40,804 | Low |
| Exclusion of Appendage of Left Upper Chamber of Heart Performed During Other ... | cardiac | $109 | $109 to $33,268 | Low |
| Cellutome Harvester 5cm X 5cm #ct-h50 | other | $109 | $109 to $410 | Low |
| Closed Treatment of Broken Great Toe | other | $109 | $109 to $28,490 | Low |
| Graft Oh Hemashield 15cm 22mm #m00202175122p0 | other | $109 | $109 to $410 | Low |
| Foot, Insert, Removable, Molded to Patient Model, 'ucb' Type, Berkeley Shell,... | other | $109 | $109 to $411 | Low |
| Adult Venous Cannula 25fr 96600 | other | $109 | $109 to $411 | Low |
| Adult Venous Cannula 96600 | other | $109 | $109 to $411 | Low |
| Percut Kit 21fr X 60cm Femoral Venous | other | $109 | $109 to $411 | Low |
| Percut Kit 25fr X 60cm Femoral Venous | other | $109 | $109 to $411 | Low |
| Insertion of Implant to Close Nasal Passage | surgery | $109 | $109 to $30,220 | Low |
| Office OR Other Outpatient Consultation with Moderate Level of Medical Decisi... | other | $110 | $110 to $99,244 | Low |
| Destruction of Subsequent Incompetent Veins of Arm OR Leg Using Radiofrequenc... | other | $110 | $110 to $36,476 | Low |
| Loop Cysview 24/26 Fr Bipolar Std27040gp130-s | other | $110 | $110 to $413 | Low |
| Walking Boot, Pneumatic And/or Vacuum, with OR without Joints, with OR withou... | other | $110 | $110 to $828 | Low |
| Adapalene 0.1 % Ex Gel | other | $111 | $111 to $417 | Low |
| Dialysis | other | $111 | $13 to $75,791 | High |
| Guide Precision Bipolar Clear 6ea/bx | other | $112 | $112 to $419 | Low |
| Addition to Lower Extremity Fracture Orthosis, Hip Joint, Pelvic Band, Thigh ... | other | $112 | $112 to $421 | Low |
| Removal of Single External Noncancer Growth of Anus | surgery | $112 | $112 to $46,220 | Low |
| Removal of Growth of Tongue without Closure | surgery | $112 | $112 to $41,110 | Low |
| Assistant W/stable Soft 3l #401-209s | other | $112 | $112 to $422 | Low |
| Removal of Foreign Body in Voice Box Using a Flexible Endoscope | surgery | $112 | $112 to $31,577 | Low |
| Closed Treatment of Broken Forearm (radius) Bone At the Wrist Area On the Thu... | other | $113 | $113 to $25,600 | Low |
| Closed Treatment of Broken Midpart of Forearm Bone On Small Finger Side | other | $113 | $113 to $25,530 | Low |
| Closed Treatment of Broken Midpart of Forearm Bone On Thumb Side | other | $113 | $113 to $25,500 | Low |
| Closed Treatment of Broken OR Growth Plate Separate of Forearm Bone At Wrist ... | other | $113 | $113 to $25,605 | Low |
| Intermediate Repair of Wound of Face, Ears, Eyelids, Nose, Lips, OR Mouth, 20... | surgery | $113 | $113 to $12,056 | Low |
| Intermediate Repair of Wound of Face, Ears, Eyelids, Nose, Lips, OR Mouth, Mo... | surgery | $113 | $113 to $12,057 | Low |
| Follow-up Intensive Care of Recovering Very Low Birth Weight Infant Per Day | other | $113 | $113 to $99,478 | Low |
| Incision of Eardrum with Insertion of Eardrum Tube Under Local OR Topical Ane... | other | $113 | $113 to $69,433 | Low |
| Graft Hemashield 15cm 28mm #175128p | other | $113 | $113 to $425 | Low |
| Graft Hemashield 15cm 30mm #175130p | other | $113 | $113 to $425 | Low |
| Graft Hemashield 15cm 32mm #175132p | other | $113 | $113 to $425 | Low |
| Graft Hemashield 15cmx38mm #175138p | other | $113 | $113 to $425 | Low |
| Removal of Polyp of Outer Ear | surgery | $113 | $113 to $69,540 | Low |
| Simple Removal of Nasal Polyp | surgery | $113 | $113 to $30,110 | Low |
| Pad Temp Arctic Sun Universal #317-00 | other | $113 | $113 to $426 | Low |
| Tetracaine 1% (20 Mg/2 Ml) Vl | other | $113 | $113 to $426 | Low |
| Inpatient OR Observation Consultation with Moderate Level of Medical Decision... | other | $114 | $114 to $99,254 | Low |
| Electrode Electrosurgical 24fr Angled Needle 12-30deg Hf Resection Plasma Nee... | surgery | $114 | $114 to $429 | Low |
| Electrode Electrosurgical 24fr Standard Band 12-30deg Hf Resection Plasma Ban... | surgery | $114 | $114 to $429 | Low |
| Esg Plasmaloop - Long Medium Wa22737s Bx/5ea | other | $114 | $114 to $429 | Low |
| Generator Electrosurgical M Plasmaloop #wa22706s | surgery | $114 | $114 to $429 | Low |
| Imaging of Digestive Tract Done From the Inside of the Digestive Tract | other | $114 | $114 to $91,110 | Low |
| Loop TURP Plasmakinetic Superpuls #784415 | other | $114 | $114 to $430 | Low |
| Imaging of Lymph Nodes During Surgery | surgery | $114 | $114 to $38,900 | Low |
| Hyaluronan OR Derivative, Orthovisc, for Intra-articular Injection, Per Dose | other | $115 | $115 to $882 | Low |
| Proximal Reamer Headless 2.0mm Non-sterile #cd-fx | other | $115 | $115 to $432 | Low |
| Proximal Reamer Headless 2.0mm Sterile #cd-fx-2520-s | other | $115 | $115 to $432 | Low |
| Proximal Reamer Headless 3.0mm #cd-fx | other | $115 | $115 to $432 | Low |
| Ligasure Maryland Short Jaw #lf1923 | other | $116 | $116 to $435 | Low |
| Prostate Biopsy | other | $116 | $116 to $870 | High |
| Surgical Pathology | lab | $116 | $116 to $88,321 | Low |
| Upper Extremity Fracture Orthosis, Radius/ulnar, Prefabricated, Includes Fitt... | other | $116 | $116 to $870 | Low |
| Atrovent 17 Mcg Hfa Inhaler | other | $116 | $116 to $436 | Low |
| Removal of Growth of Roof of Mouth | surgery | $116 | $116 to $42,104 | Low |
| Computer-assisted, Fluoroscopic Image-guided Musculoskeletal Surgical Navigat... | surgery | $116 | $116 to $1,060 | Low |
| Computer-assisted Surgery for Muscle and Bone Procedure | surgery | $116 | $116 to $20,985 | Low |
| **discontinued**laser Fiber 200 Ball Tip #m0068403961 | other | $116 | $116 to $438 | Low |
| Review By Radiologist of Placement of Long Small Bowel Tube | other | $117 | $117 to $74,340 | Low |
| Residence Visit for New Patient with High Level of Medical Decision Making, P... | other | $117 | $117 to $99,345 | Low |
| Closed Treatment of Dislocated Joint Between Toe and Foot Under Anesthesia | other | $117 | $117 to $28,635 | Low |
| Review By Radiologist of CT Guidance for Needle Placement | other | $117 | $117 to $77,012 | Low |
| Dilation of Sphenoid Nasal Sinus Using an Endoscope | other | $117 | $117 to $31,297 | Low |
| Refilling and Maintenance of Portable Pump | other | $117 | $117 to $96,521 | Low |
| Pronto Lp #5010 | other | $118 | $118 to $442 | Low |
| Insertion of Feeding Tube OR Tube Into Upper Small Bowel | other | $118 | $118 to $44,015 | Low |
| Centered Nano Alto Partial #651 1/bx | other | $118 | $118 to $443 | Low |
| Centered Nano Alton Total #611 1/bx | other | $118 | $118 to $443 | Low |
| Bss Plus Eye Irrig Solution | other | $118 | $118 to $445 | Low |
| Shockwave Destruction of Calcified Plaque in Coronary Artery Accessed Through... | cardiac | $118 | $118 to $92,972 | Low |
| Complex Removal of Skin Debris and Drainage of Mastoid Cavity | surgery | $119 | $119 to $69,222 | Low |
| Snare Kit 18-30mm #382007030 | other | $119 | $119 to $446 | Low |
| Arthroflex, Per Square Centimeter | other | $119 | $119 to $3,889 | Low |
| Dermacell, Dermacell Awm OR Dermacell Awm Porous, Per Square Centimeter | other | $119 | $119 to $9,995 | Low |
| Epifix, Per Square Centimeter | other | $119 | $119 to $1,495 | Low |
| Grafix Core and Grafixpl Core, Per Square Centimeter | other | $119 | $119 to $1,256 | Low |
| Grafix Prime, Grafixpl Prime, Stravix and Stravixpl, Per Square Centimeter | other | $119 | $119 to $915 | Low |
| Integra Bilayer Matrix Wound Dressing (bmwd), Per Square Centimeter | other | $119 | $119 to $9,776 | Low |
| Primatrix, Per Square Centimeter | other | $119 | $119 to $544 | Low |
| Strattice Tm, Per Square Centimeter | other | $119 | $119 to $12,553 | Low |
| Theraskin, Per Square Centimeter | other | $119 | $119 to $3,595 | Low |
| Flexiva Pulse Id Tractip M006l8406960 | other | $119 | $119 to $447 | Low |
| Enema Using Air OR Contrast | other | $119 | $119 to $74,283 | Low |
| Electrode Plasma Button Front Loading | other | $119 | $119 to $448 | Low |
| Allograft Mis Dispenser Bl-1900-gun | other | $120 | $120 to $450 | Low |
| Cables Ensite X Advisor/grid #d-ens-avse-6-cbl | other | $120 | $120 to $450 | Low |
| Ligasure Maryland Jaw #lf1937 6/cs | other | $120 | $120 to $450 | Low |
| Metatarsal Reamer 16 Mm #ar-8944mr | other | $120 | $120 to $450 | Low |
| Metatarsal Reamer 18 Mm #ar-8944mr | other | $120 | $120 to $450 | Low |
| Metatarsal Reamer 20 Mm #ar-8944mr | other | $120 | $120 to $450 | Low |
| Metatarsal Reamer 22 Mm #ar-8944mr | other | $120 | $120 to $450 | Low |
| Phalangeal Reamer 14 Mm #ar-8944pr | other | $120 | $120 to $450 | Low |
| Phalangeal Reamer 16 Mm #ar-8944pr | other | $120 | $120 to $450 | Low |
| Phalangeal Reamer 18 Mm #ar-8944pr | other | $120 | $120 to $450 | Low |
| Phalangeal Reamer 20 Mm #ar-8944pr | other | $120 | $120 to $450 | Low |
| Phalangeal Reamer 22 Mm #ar-8944pr | other | $120 | $120 to $450 | 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 |
| Reviving Newborn At Delivery | obstetric | $120 | $120 to $99,465 | Low |
| Aspiration of Bladder with Insertion of Bladder Tube to Skin | other | $120 | $120 to $51,102 | Low |
| Complex Measurement of Pressure of Urine Flow in Bladder with Urethra Pressur... | other | $120 | $120 to $51,729 | Low |
| Ultrasonic Guidance for Pericardiocentesis, Imaging Supervision and Interpret... | other | $120 | $120 to $76,930 | Low |
| Children's Tylenol 160 Mg/5 Ml | other | $121 | $121 to $454 | Low |
| Balloon Dilation of Vein with Review By Radiologist, Each Additional Vein | other | $121 | $121 to $37,249 | Low |
| Graft Hemashield 15cm 34mm #175134p M00202175134po | other | $121 | $121 to $455 | Low |
| Complex Biopsy of Growth of Throat Behind Nose | lab | $121 | $121 to $42,806 | Low |
| Tlso Flexible, Provides Trunk Support, Extends From Sacrococcygeal Junction t... | other | $122 | $122 to $458 | Low |
| Destruction of Growth OR Soft Tissue of Roof of Mouth | other | $122 | $122 to $42,160 | Low |
| Retinal Tamponade Device, Silicone Oil | other | $122 | $122 to $460 | Low |
| Wrist Hand Finger Orthosis, Rigid without Joints, May Include Soft Interface ... | other | $122 | $122 to $920 | Low |
| Removal of Growth of Voice Box Using an Endoscope | surgery | $122 | $122 to $31,578 | Low |
| Simple Destruction of Growth of Anus | other | $122 | $122 to $46,910 | Low |
| Strapping, Unna Boot | other | $123 | $123 to $29,580 | Low |
| Wilson Retractor System Tlc-5042-m | other | $123 | $123 to $461 | Low |
| Aspiration of Subsequent Secretions of Lung Airway Using an Endoscope During ... | other | $124 | $124 to $31,646 | Low |
| Liver Access/ Biopsy Needle Set | lab | $124 | $124 to $466 | Low |
| Porous Purified Collagen Matrix Bone Void Filler (integra Mozaik Osteoconduct... | other | $124 | $124 to $466 | Low |
| Drainage of Fluid From Chest Cavity with Insertion of Indwelling Tube Using I... | other | $124 | $124 to $32,557 | Low |
| Tunneler #402 Vns Cyberonics | other | $124 | $124 to $468 | Low |
| All Lower Extremity Prostheses, Foot, Flexible Keel | other | $125 | $125 to $468 | Low |
| Dressing Ab Thera Sensa Trac #m8275026/5 | other | $125 | $125 to $469 | Low |
| Simple Chemical Destruction of Growth of Anus | other | $125 | $125 to $46,900 | Low |
| Loop TURP Plasmakinetic Supersect #784515 | other | $126 | $126 to $472 | Low |
| Removal of Tissue Connecting Tongue and Floor of Mouth | surgery | $126 | $126 to $41,115 | Low |
| Simple Removal of Growth of Anus | surgery | $126 | $126 to $46,922 | Low |
| New Patient Office OR Other Outpatient Visit with a High Level of Medical Dec... | other | $126 | $126 to $99,205 | Low |
| Bypass of Upper OR Lower Leg Artery Reoperation More Than 1 Month After Origi... | other | $127 | $127 to $35,700 | Low |
| Clamp Lrg Combination #390.005 External | other | $127 | $127 to $478 | Low |
| Addition to Lower Extremity, Test Socket, Below Knee | other | $127 | $127 to $479 | Low |
| Nipride Rtu 50 Mg/100 Ml Vial | other | $128 | $128 to $479 | Low |
| Destruction of Nasal Nerve By Heat Using an Endoscope | other | $128 | $128 to $31,242 | Low |
| Dilation of Nasal Sinus Using an Endoscope | other | $128 | $128 to $31,295 | Low |
| Diagnostic Exam of Voice Box Using an Endoscope with Operating Microscope OR ... | other | $128 | $128 to $31,526 | Low |
| Nerve Conduction, 9-10 Studies | other | $128 | $128 to $95,911 | Low |
| Revision of Peripheral Neurostimulator Electrodes | other | $129 | $129 to $64,585 | Low |
| Addition to Lower Extremity, Socket Insert, Below Knee | other | $129 | $129 to $485 | Low |
| Insertion of Tube Into Vein, First Order Branch | other | $129 | $129 to $36,011 | Low |
| Lead, Neurostimulator Test Kit | other | $129 | $129 to $485 | Low |
| Patch Pericardial W/encap 9x14cm #c0914 | other | $129 | $129 to $485 | Low |
| Snare Kit 27-45mm #382007045 | other | $129 | $129 to $485 | Low |
| Wrist Hand Finger Orthosis, Includes One OR More Nontorsion Joint(s), Turnbuc... | other | $129 | $129 to $970 | Low |
| Initial Repair of Anal Tear with Dilation of Anal Muscle | surgery | $129 | $129 to $46,940 | Low |
| Cardene-nacl 40 Mg/200 Ml IV | other | $130 | $130 to $487 | Low |
| Clinimix 4.25%-10% Solution | other | $130 | $130 to $487 | Low |
| Clinimix 4.25%-5% Solution | other | $130 | $130 to $487 | Low |
| Fiber Laser 200um 2j 80hz 60w D/f/l for Lithotripsy Moses Ac | other | $130 | $130 to $488 | Low |
| Measurement of Brain Wave Activity (eeg) to Evaluate Brain Death | other | $130 | $130 to $95,824 | Low |
| Transitional Care Management Services for Problem of High Complexity | other | $130 | $130 to $99,496 | Low |
| Differin 0.1% Cream | other | $130 | $130 to $488 | Low |
| Incision, Aspiration, and Inflation of Eardrum Under Anesthesia | other | $130 | $130 to $69,421 | Low |
| Bone Dowel Revision Kit 10 Mm #abs-2850 | other | $130 | $130 to $490 | Low |
| Mantis 235cm Closure Clip #m00521422 Bx/20 | other | $130 | $130 to $490 | Low |
| Diagnostic Exam of Voice Box Using an Endoscope | other | $130 | $130 to $31,525 | Low |
| Insertion of Stent Into Lower Large Bowel Using a Flexible Endoscope | cardiac | $130 | $130 to $45,347 | Low |
| Repair of Lacerated Mouth, 2.5 Cm OR Less | surgery | $131 | $131 to $40,830 | Low |
| Injection, Pegfilgrastim-apgf (nyvepria), Biosimilar, 0.5 Mg | other | $131 | $131 to $6,296 | Low |
| Release of Nasal Scar Tissue | other | $131 | $131 to $30,560 | Low |
| Removal of Lung Tissue Wedge for Diagnosis | surgery | $131 | $131 to $32,507 | Low |
| Removal of Lung Tissue Wedge Through Chest, Each Additional Removal | surgery | $131 | $131 to $32,506 | Low |
| Forcep Spybite Biopsy #moo546270 | lab | $131 | $131 to $494 | Low |
| Spybite Max Biopsy Forceps #m00546470 | lab | $131 | $131 to $494 | Low |
| Simple Drainage of Abscess of Saliva Gland | other | $131 | $131 to $42,300 | Low |
| Test to Measure Rate of Airflow | other | $131 | $131 to $94,375 | Low |
| Removal of Wedge of Tissue of Lung Using an Endoscope, Each Additional Removal | surgery | $132 | $132 to $32,667 | Low |
| Addition to Lower Extremity, Lacer Molded to Patient Model, for Custom Fabric... | other | $132 | $132 to $495 | Low |
| Blade Kahook Dual#kdb Glide | other | $132 | $132 to $495 | Low |
| Lengthening of Esophagus Using an Endoscope | other | $132 | $132 to $43,283 | Low |
| Destruction of Soft Tissue of Nasal Passages | other | $132 | $132 to $30,801 | Low |
| Biopsy of Wedge of Lung Tissue Followed By Partial Removal of Lung | surgery | $132 | $132 to $32,668 | Low |
| Ligasure Exact Dissector Lf2019 6ea/1cs | other | $132 | $132 to $496 | Low |
| Hyperbaric Oxygen Under Pressure, Full Body Chamber, Per 30 Minute Interval | other | $132 | $132 to $698 | Low |
| Ultrasound Exam of Esophagus Using a Flexible Endoscope | imaging | $132 | $132 to $43,231 | Low |
| Addition to Lower Extremity, Below Knee, Total Contact | other | $132 | $132 to $498 | Low |
| Initial Hospital Inpatient OR Observation Care with High Level of Medical Dec... | other | $133 | $133 to $99,223 | Low |
| Removal of Blood Clot and Portion of Neck Artery Following Previous Surgery | surgery | $133 | $133 to $35,390 | 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 |
| Harvest and Injections of Platelet Rich Plasma Using Imaging Guidance | other | $133 | $133 to $1,000 | Low |
| Lead, Pacemaker, Other Than Transvenous Vdd Single Pass | cardiac | $133 | $133 to $500 | Low |
| Primary Removal and Dissolving of Blood Clot From Artery OR Artery Graft Usin... | surgery | $133 | $133 to $37,185 | Low |
| Hith Kit #inshith | other | $133 | $133 to $502 | Low |
| X-ray of Inside of Ear Canal | imaging | $134 | $134 to $70,134 | Low |
| Repositioning of Blood Flow Assist Device in Lower Heart Chamber Using Imagin... | cardiac | $134 | $134 to $33,993 | Low |
| Therapy Procedure Using a Special Bandage and Vacuum Pump, Surface Area 50.0 ... | other | $135 | $135 to $97,605 | Low |
| Exam of Bile Duct During Surgery Using an Endoscope | surgery | $135 | $135 to $47,550 | Low |
| Delivery of Complex Radiation Treatment | obstetric | $135 | $135 to $77,412 | Low |
| Detection Test By Nucleic Acid for Digestive Tract Pathogen, Multiple Types O... | other | $135 | $135 to $87,507 | 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 |
| Otsc 11/6a Bear Claw System Set #100.09 | other | $135 | $135 to $509 | Low |
| Dissector Spacemaker Pro 10mm-12mm #smsbtovlx | cardiac | $136 | $136 to $510 | Low |
| Insertion of Temporary Pacemaker Lead in Upper and Lower Heart Chambers | cardiac | $136 | $136 to $33,211 | Low |
| Office OR Other Outpatient Consultation with High Level of Medical Decision M... | other | $136 | $136 to $99,245 | Low |
| Prog Eval Inper Leadls Pm | other | $136 | $136 to $1,024 | Low |
| Destruction of Polyp OR Growth of Lower Large Bowel Using a Flexible Endoscope | other | $136 | $136 to $45,346 | Low |
| Incision of Eardrum with Placement of Eardrum Tube Under General Anesthesia | other | $137 | $137 to $69,436 | Low |
| Spy Bite Basket Retrieval Working L286cm Channel 1.2mm Cable Dia 1mm for Dire... | other | $137 | $137 to $515 | Low |
| Computer-assisted Procedure Outside Membrane Covering Brain | other | $137 | $137 to $61,782 | Low |
| Sonicone OR Sharpvac Mxc-c2-vac 5ea/1bx | other | $137 | $137 to $516 | Low |
| Sonicvac Kit Mxc-x2-vac 5ea/bx | other | $137 | $137 to $516 | Low |
| Simple Control of Bleeding of Throat | other | $137 | $137 to $42,960 | Low |
| Microsatellite Instability Analysis | other | $138 | $138 to $81,301 | Low |
| Graft Hemashield 30cm X 6mm #175206p | other | $138 | $138 to $518 | Low |
| Graft Hemashield 30cm X 8mm #175208p | other | $138 | $138 to $518 | Low |
| Complicated Drainage of External Ear Abscess OR Blood Accumulation | other | $138 | $138 to $69,005 | Low |
| Repair of Collapsed Nostril Using Implant in Side of Nose | surgery | $138 | $138 to $30,468 | Low |
| Repair of Nerve Using Nerve Graft, Each Additional Strand | surgery | $138 | $138 to $64,913 | Low |
| Stapler Hemorrhoid Ph #ppho3 3/bx | other | $138 | $138 to $519 | Low |
| Diagnostic Exam of Voice Box Using a Flexible Endoscope | other | $138 | $138 to $31,575 | Low |
| Inpatient OR Observation Consultation with High Level of Medical Decision Mak... | other | $138 | $138 to $99,255 | Low |
| Hernia Tacker #abstack30 | other | $138 | $138 to $521 | Low |
| Nerve Conduction, 11-12 Studies | other | $139 | $139 to $95,912 | Low |
| Shaving of Part of Shoulder Bone and Repair of Ligament Using an Endoscope | surgery | $139 | $139 to $29,826 | Low |
| Electrode Electrosurgical Resection with Hf Cable Plasma Oval Button | surgery | $139 | $139 to $521 | Low |
| Tlso, Triplanar Control, Hyperextension, Rigid Anterior and Lateral Frame Ext... | other | $139 | $139 to $529 | Low |
| Drug Delivery Using a Drug-coated Balloon for Male Treatment of Urethral Stri... | obstetric | $139 | $139 to $52,284 | Low |
| Review By Radiologist of Ankle Joint Image | other | $139 | $139 to $73,615 | Low |
| Review By Radiologist of Hinged Joint of Upper and Lower Jaw Bones Image | other | $139 | $139 to $70,332 | Low |
| Arexvy Vial Kit | other | $139 | $139 to $523 | Low |
| Fiber Laser 550um 6j 80hz 120w D/f/l for Lithotripsy Moses Ac | other | $140 | $140 to $525 | 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 |
| Nano Swivelock Suture Anchor #ar-8998t | other | $140 | $140 to $525 | Low |
| Nanoneedle Scope 125 Mm #ar-3210 | other | $140 | $140 to $525 | Low |
| Removal of Indwelling Tube in Lining of Lung | surgery | $140 | $140 to $32,552 | Low |
| Control of Bleeding in Esophagus Using a Flexible Endoscope | other | $140 | $140 to $43,227 | Low |
| Removal OR Destruction of Growth of Throat | surgery | $140 | $140 to $42,808 | Low |
| Manipulation of Knee Joint Under Anesthesia | other | $140 | $140 to $27,570 | Low |
| Clamp Large Multi-pin 4position External | other | $140 | $140 to $528 | Low |
| Mantis Closure Clip Box 10 #m00521421 | other | $140 | $140 to $528 | Low |
| Incision of Sphincter of Anus | other | $141 | $141 to $46,080 | Low |
| Dilation of Canal Between Middle Ear and Throat (eustachian Tube) On One Side... | other | $141 | $141 to $69,705 | Low |
| Versajet Ii Plus Handset 45deg/14mm #66800044 | other | $141 | $141 to $529 | Low |
| Versajet Ii Plus Handset 45deg/8mm #66800045 | other | $141 | $141 to $529 | Low |
| Autoinjector Endologix #tv-a101-n | other | $141 | $141 to $530 | Low |
| Radioactive Drug Therapy of Radiolabeled Monoclonal Antibody Through a Vein | other | $141 | $141 to $79,403 | Low |
| Exam with Injections of Chemical for Destruction of Bladder Using an Endoscope | other | $142 | $142 to $52,287 | Low |
| Removal of Growth of Roof of Mouth with Simple Closure | surgery | $142 | $142 to $42,106 | Low |
| Ventriculostomy Kit - Ghajar Guide | other | $143 | $143 to $538 | Low |
| Removal of Soft Tissue of Roof of Mouth | surgery | $143 | $143 to $42,140 | Low |
| Balloon Dilation of Artery with Review By Radiologist, Each Additional Artery | other | $143 | $143 to $37,247 | Low |
| Clamp Large Multi-pin External Fix 6 Position | other | $144 | $144 to $543 | Low |
| Destruction of Growth OR Scar of Mouth | other | $145 | $145 to $40,820 | Low |
| Dilation of Frontal Nasal Sinus Using an Endoscope | other | $145 | $145 to $31,296 | Low |
| Biopsy of Prostate Gland | lab | $145 | $145 to $55,700 | Low |
| Insertion of Tube Into Vein, Second Order Branch | other | $145 | $145 to $36,012 | Low |
| Epifix OR Epicord | other | $145 | $145 to $1,090 | Low |
| Mesh Fixation Device 5mm W/25 Absorb Straps | other | $145 | $145 to $546 | Low |
| Laser Fiber 150 Micron Tfl Ball Tip Single Use Tfl-fbx150bs 5/box | other | $145 | $145 to $546 | Low |
| Laser Fiber 200 Micron Tfl Ball Tip Single Use Tfl-fbx200bs 5/box | other | $145 | $145 to $546 | Low |
| Removal of Nasal Air Passage Under Lining Tissue | surgery | $145 | $145 to $30,140 | Low |
| Addition to Lower Extremity, Below Knee, Acrylic Socket | other | $146 | $146 to $548 | Low |
| Needle Acquire Fnb 19 Ga #m00555580 1ea/1bx | other | $146 | $146 to $549 | Low |
| Endoclip Cartridge M/l-#1112 Microline Clip Titanium K2 Single Use 19/clip 10/bx | other | $146 | $146 to $549 | Low |
| Injection, Icatibant, 1 Mg | other | $146 | $146 to $7,577 | Low |
| Fetal Test | other | $146 | $146 to $59,025 | Low |
| Obturator 24 Fr #a22081a | other | $146 | $146 to $549 | Low |
| Drg Tunneling Tool #mn15000 | other | $146 | $146 to $550 | Low |
| Flexcath Cross Ag 61cm # 900300 | other | $146 | $146 to $550 | Low |
| Flexcath Cross Ag 71cm# 900301 | other | $146 | $146 to $550 | Low |
| Flexcath Cross Fc 65cm# 900304 | other | $146 | $146 to $550 | Low |
| Flexcath Cross Sl 63cm# 900302 | other | $146 | $146 to $550 | Low |
| Flexcath Cross Sl 81cm# 900309 | other | $146 | $146 to $550 | Low |
| Flexcath Cross Vz 71cm# 900303 | other | $146 | $146 to $550 | Low |
| Flexcath Cross Wt 75cm# 900308 | other | $146 | $146 to $550 | Low |
| Jeti Non-sterile Cannister Set Wv1500a | other | $146 | $146 to $550 | Low |
| Reference Patch Carto 3 (6pack) #crefp6 | other | $146 | $146 to $550 | Low |
| Cisatracurium 200 Mg/20 Ml Vl | other | $146 | $146 to $550 | Low |
| Review By Radiologist of Salivary Structure Image | other | $147 | $147 to $70,390 | Low |
| Repair of Prosthetic Device, Repair OR Replace Minor Parts | surgery | $147 | $147 to $551 | Low |
| Harvest of Artery From Arm for Heart Bypass Graft Using an Endoscope | cardiac | $147 | $147 to $33,509 | Low |
| Insertion of Temporary Pacemaker Electrode for Diagnostic Upper Heart Pacing | cardiac | $147 | $147 to $93,610 | Low |
| Nuclear Medicine Study of Limited Area for Thyroid Cancer | imaging | $148 | $148 to $78,015 | Low |
| Insertion of Temporary Pacemaker Electrode for Diagnostic Lower Heart Pacing | cardiac | $148 | $148 to $93,612 | Low |
| Atrial Depressor W/quick Connect Clearview Mv | other | $148 | $148 to $557 | Low |
| Hip Knee Ankle Foot Orthosis, Torsion Control, Bilateral Torsion Cables, Hip ... | other | $148 | $148 to $559 | Low |
| Acutrak 2 Drill Acumed #at2-m1813 | other | $148 | $148 to $558 | Low |
| Destruction of Internal Hemorrhoids Using Heat | other | $148 | $148 to $46,930 | Low |
| Prevena Plus System Kit #pre4001us | other | $149 | $149 to $559 | Low |
| Sensor Persona Cr Zimmer Bio Cd39-l Zbh-psncr | other | $149 | $149 to $559 | Low |
| Sensor Persona Cr Zimmer Bio Cd39-r Zbh-psncr | other | $149 | $149 to $559 | Low |
| Sensor Persona Cr Zimmer Bio Ef311l Zbh-psncr | other | $149 | $149 to $559 | Low |
| Sensor Persona Cr Zimmer Bio Ef311r Zbh-psncr | other | $149 | $149 to $559 | Low |
| Sensor Persona Cr Zimmer Bio Gh712l Zbh-psncr | other | $149 | $149 to $559 | Low |
| Sensor Persona Cr Zimmer Bio Gh712r Zbh-psncr | other | $149 | $149 to $559 | Low |
| Verasense Journey Bcs 1-2 Lt #snn-jrnybcs12-l | other | $149 | $149 to $559 | Low |
| Verasense Journey Bcs 1-2 Rt #snn-jrnybcs12-r | other | $149 | $149 to $559 | Low |
| Verasense Journey Bcs 3-4 Lt #snn-jrnybcs34-l | other | $149 | $149 to $559 | Low |
| Verasense Journey Bcs 3-4 Rt #snn-jrnybcs34-r | other | $149 | $149 to $559 | Low |
| Verasense Journey Bcs 5-6 Lt #snn-jrnybcs56-l | other | $149 | $149 to $559 | Low |
| Verasense Journey Bcs 5-6 Rt #snn-jrnybcs56-r | other | $149 | $149 to $559 | Low |
| Verasense Journey Bcs 7-8 Lt #snn-jrnybcs78-l | other | $149 | $149 to $559 | Low |
| Verasense Journey Bcs 7-8 Rt #snn-jrnybcs78-r | other | $149 | $149 to $559 | Low |
| Verasense Legion Ps 1-2 #snn-lgnps12 | other | $149 | $149 to $559 | Low |
| Verasense Legion Ps 3-4 #snn-lgnps34 | other | $149 | $149 to $559 | Low |
| Verasense Legion Ps 5-6 #snn-lgnps56 | other | $149 | $149 to $559 | Low |
| Verasense Legion Ps 7-8 #snn-lgnps78 | other | $149 | $149 to $559 | Low |
| Graft Accessory Component Kit #hero 1003 | other | $149 | $149 to $560 | Low |
| Progreat 2.8fr Microcatheter Mc*pe28151yv 1ea/1box | cardiac | $149 | $149 to $560 | Low |
| Scrotal Retraction System Skw Deep #72403867 | other | $149 | $149 to $560 | Low |
| Balloon Dilation Treatment of Stricture of Ureter Using Imaging Guidance with... | other | $149 | $149 to $50,706 | Low |
| Amputation of Toe At Toe Joint | other | $149 | $149 to $28,825 | Low |
| Laser Fiber 550 Micron Tfl Single Use Tfl-fbx550s 5/box | other | $150 | $150 to $562 | Low |
| Bipolar Sealer 2.3 Neuro Aquamantys | other | $150 | $150 to $563 | Low |
| Surgical Supply; Miscellaneous | surgery | $150 | $150 to $565 | Low |
| Retractor-reddick Saye Screw #e2504 | other | $150 | $150 to $566 | Low |
| Chord-x Pre-measured Loops for Mitral Chordal Replacement 2-0 U.s.p 16mm Cxl-... | surgery | $151 | $151 to $566 | Low |
| Mantis Clip L235cm 2.8mm Minimum Working Channel #m00521420 | other | $151 | $151 to $567 | Low |
| Elbow Orthosis (eo), with Adjustable Position Locking Joint(s), Prefabricated... | other | $152 | $152 to $1,140 | Low |
| Dispensing Fee, Monaural Hearing Aid, Any Type | other | $152 | $152 to $1,143 | Low |
| Laser Fiber Sidefire 600 #ftir600 | other | $152 | $152 to $572 | Low |
| Harmonic Ace Curved Shears Xi #480275 6ea/1bx | other | $152 | $152 to $572 | Low |
| Clamp 4.0 Adj for Distal Radius Fixatr Extern | other | $153 | $153 to $573 | Low |
| Gps User Kit for Gps Station V2 Ref# A10012 | other | $153 | $153 to $575 | Low |
| Biopsy of Voice Box Using an Endoscope | lab | $154 | $154 to $31,535 | Low |
| Intraocular Vancomycin 10 Mg/ Ml- **10ml** (for Dr. Ouano) - Compounded | other | $154 | $154 to $578 | Low |
| Removal of Blood Flow Assist Device in Left Lower Heart Chamber Through the Skin | surgery | $154 | $154 to $33,992 | Low |
| 8mm Blunt Xi #470008 | other | $154 | $154 to $578 | Low |
| Injection, Panitumumab, 10 Mg | other | $154 | $154 to $21,194 | Low |
| Closed Treatment of Broken Finger OR Thumb At Midportion OR Part Near Hand | other | $154 | $154 to $26,720 | Low |
| Amputation of Toe At Joint Between Forefoot and Toes | other | $154 | $154 to $28,820 | Low |
| Partial Release of Large Bowel and Partial Removal of Large Bowel Using an En... | surgery | $155 | $155 to $44,213 | Low |
| Addition to Lower Extremity, Suction Suspension, Above Knee OR Knee Disarticu... | other | $156 | $156 to $586 | Low |
| Ligasure Impact #lf4418 | other | $156 | $156 to $586 | Low |
| Removal of Multiple External Noncancer Growths of Anus | surgery | $156 | $156 to $46,230 | Low |
| Cannula 8mm #420002 | other | $156 | $156 to $588 | Low |
| Clinimix 5%-15% Solution | other | $156 | $156 to $588 | Low |
| Diagnostic Exam of Large Bowel Using a Flexible Endoscope | other | $157 | $157 to $45,378 | Low |
| Fluzone High-dose Triv 2024 | other | $157 | $157 to $589 | Low |
| Suture of Internal Abdominal Lining Using an Endoscope | other | $157 | $157 to $49,326 | Low |
| Harvest of Arm Artery Segment for Heart Byplass Procedure | cardiac | $157 | $157 to $35,600 | Low |
| Gradient Compression Garment, Glove, Padded, for Nighttime Use, Custom, Each | other | $158 | $158 to $593 | Low |
| Dilation of Sphincter of Anus Under Anesthesia | other | $158 | $158 to $45,905 | Low |
| Astigmatism Correcting Function of Intraocular Lens | other | $158 | $158 to $595 | Low |
| Coronary Artery Bypass Using Vein OR Artery Graft, 1 Graft | cardiac | $158 | $158 to $33,517 | Low |
| Vessel Sealer (6/bx) #410322 | other | $158 | $158 to $595 | Low |
| Vessel Sealer # 480322 Intuitive Surgical | surgery | $158 | $158 to $595 | Low |
| Obturator Deflecting Tip 24 Fr #a22085 | other | $159 | $159 to $596 | Low |
| Proximal Reamer Cannulated 3.0mm #cd-fx | other | $159 | $159 to $598 | Low |
| Removal of Growth of Mouth with Simple Repair | surgery | $159 | $159 to $40,812 | Low |
| Repair of Lacerated Roof of Mouth, 2.0 Cm OR Less | surgery | $159 | $159 to $42,180 | Low |
| Aveta Smol Disposable Resecting Device 2.9mm #210-100 3/ctn | other | $160 | $160 to $600 | Low |
| Dispensing Fee, Binaural | other | $160 | $160 to $1,200 | Low |
| Laser Fiber Sidefire 550 | other | $160 | $160 to $600 | Low |
| Auto-id Quad Cable; Vizigo Cable #cy1212ct | other | $161 | $161 to $604 | Low |
| Carto 3 Ablation Cable Irrigated #cr3434ct | other | $161 | $161 to $604 | Low |
| Carto 3 Dx Cable Vizigo #cb3412ct | other | $161 | $161 to $604 | Low |
| Decanav Cable #cb3434ct | other | $161 | $161 to $604 | Low |
| Nerve Conduction, 13 OR More Studies | other | $161 | $161 to $95,913 | Low |
| Pentaray and Lasso Cable #d134401 | other | $161 | $161 to $604 | Low |
| Ligasure Retractable L-hook 37cm Lf5637 6/cs | other | $161 | $161 to $605 | Low |
| Evaluation of Single OR Dual Chamber Pacing Cardioverter-defibrillator At Tim... | other | $162 | $162 to $93,640 | Low |
| Dressing Kit Open Abdomen Abthera Advance | other | $162 | $162 to $609 | Low |
| Removal of Foreign Bodies From Small Bowel Using an Endoscope | surgery | $162 | $162 to $44,363 | Low |
| Conversion of Stomach Tube to Tube in Middle Small Bowel Using an Endoscope | other | $162 | $162 to $44,373 | Low |
| Viscoat Syringe | other | $162 | $162 to $610 | Low |
| Therapy Procedure Using a Special Bandage and Vacuum Pump, Surface Area More ... | other | $162 | $162 to $97,606 | Low |
| Extensive Destruction of Growth of Anus | other | $162 | $162 to $46,924 | Low |
| Injection, Siltuximab, 10 Mg | other | $163 | $163 to $18,918 | Low |
| Removal of Foreign Body in Voice Box Using an Endoscope | surgery | $164 | $164 to $31,530 | Low |
| Obturator Optical 24 Fr #a22071a | other | $164 | $164 to $616 | Low |
| Injection, Benralizumab, 1 Mg | other | $165 | $165 to $10,048 | Low |
| Insertion of Tube in Left Heart Chamber Through Heart Septum | cardiac | $165 | $165 to $93,462 | Low |
| Repair Device, Urinary, Incontinence, without Sling Graft | surgery | $165 | $165 to $620 | Low |
| Imaging for Evaluation of Swallowing Function | other | $165 | $165 to $74,230 | Low |
| Incision of Achilles Tendon Using Local Anesthetic | other | $165 | $165 to $27,605 | Low |
| Insertion of Vein Patch At Lowest Portion of Bypass Graft | other | $166 | $166 to $35,685 | Low |
| Insertion of Tube Into Chest Aorta for Diagnosis OR Treatment with Review By ... | other | $166 | $166 to $36,221 | Low |
| Addition, Endoskeletal System, Below Knee, Alignable System | other | $166 | $166 to $624 | Low |
| Radiation Treatment Management, 5 Treatment Sessions | other | $167 | $167 to $77,427 | Low |
| Addition to Lower Extremity, Test Socket, Above Knee | other | $167 | $167 to $627 | Low |
| Cervical, Multiple Post Collar, Occipital/mandibular Supports, Adjustable Cer... | other | $167 | $167 to $629 | Low |
| Injection of Implant Material Beneath Lining of Bladder And/or Urethra Using ... | surgery | $167 | $167 to $51,715 | Low |
| Cannula 8 Mm Size Reusable for Da Vinci X/xi Endoscopic System #470002 | other | $168 | $168 to $630 | Low |
| Review By Radiologist of Image for Repair of Descending Aorta with Insertion ... | surgery | $168 | $168 to $75,957 | Low |
| CT Scan of Arm Before and After Contrast | imaging | $168 | $168 to $73,202 | Low |
| CT Scan of Leg Before and After Contrast | imaging | $168 | $168 to $73,702 | Low |
| CT Scan of Leg with Contrast Material | imaging | $168 | $168 to $73,701 | Low |
| CT Scan of Lower Spine Before and After Contrast | imaging | $168 | $168 to $72,133 | Low |
| CT Scan of Middle Spine Before and After Contrast | imaging | $168 | $168 to $72,130 | Low |
| CT Scan of Upper Spine Before and After Contrast | imaging | $168 | $168 to $72,127 | Low |
| Double Contrast X-ray of Large Intestine | imaging | $168 | $168 to $74,280 | Low |
| Double Contrast X-ray of Small Intestine | imaging | $168 | $168 to $74,251 | Low |
| Double Contrast X-ray of Upper Digestive Tract | imaging | $168 | $168 to $74,246 | Low |
| Imaging of Urinary Tract with Injection of Contrast Into a Vein | other | $168 | $168 to $74,400 | Low |
| Single Contrast X-ray of Large Intestine | imaging | $168 | $168 to $74,270 | Low |
| Single Contrast X-ray of Small Intestine | imaging | $168 | $168 to $74,250 | Low |
| Single Contrast X-ray of Upper Digestive Tract | imaging | $168 | $168 to $74,240 | Low |
| Insertion of Device to Block Groin Artery | other | $168 | $168 to $34,808 | Low |
| Azactam 2 Gm Vial | other | $169 | $169 to $634 | Low |
| Injection, Aztreonam, 100 Mg | other | $169 | $169 to $634 | Low |
| Gene Analysis (t Cell Antigen Receptor Beta) Amplification Methodology | other | $169 | $169 to $81,340 | Low |
| Biopsy of Large Bowel Using a Flexible Endoscope | lab | $169 | $169 to $45,380 | Low |
| Injection Beneath Lining of Large Bowel Using a Flexible Endoscope | other | $169 | $169 to $45,381 | Low |
| Removal of Dental Bone Growth with Simple Repair | surgery | $169 | $169 to $41,826 | Low |
| Biopsy of Voice Box Using an Endoscope with Operating Microscope OR Telescope | lab | $170 | $170 to $31,536 | Low |
| Cup Removal System 52mm #00705305220 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Full 48mm #00705304820 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Full 50mm #00705305020 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Full 54mm #00705305420 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Full 56mm #00705305620 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Full 58mm #00705305820 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Full 60mm #00705306020 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Truncatd 50mm #00705305010 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Truncatd 52mm #00705305210 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Truncatd 54mm #00705305410 | surgery | $170 | $170 to $640 | Low |
| Cup Removal System Truncatd 58mm #00705305810 | surgery | $170 | $170 to $640 | Low |
| Hernia Repair | surgery | $171 | $171 to $49,623 | High |
| Exposure of Thigh Artery for Insertion of Prosthesis | other | $171 | $171 to $34,812 | Low |
| Implantation of Biologic Implant to Soft Tissue | surgery | $172 | $172 to $15,777 | Low |
| Repair of Wound By Transferring Skin, Each Additional 30.0 SQ Cm | surgery | $172 | $172 to $14,302 | Low |
| Injection, Tenecteplase, 1 Mg | other | $172 | $172 to $22,751 | Low |
| Injection, Ibutilide Fumarate, 1 Mg | other | $172 | $172 to $953 | Low |
| Removal of Small Bowel Polyps OR Growths Using an Endoscope with Mechanical S... | surgery | $172 | $172 to $44,364 | Low |
| Removal of Foreign Body in Voice Box Using an Endoscope with Operating Micros... | surgery | $172 | $172 to $31,531 | Low |
| Nicardipin 40mg/200ml-0.9%nacl | other | $173 | $173 to $649 | Low |
| Insertion of Indwelling Tube for Drainage of Lung Fluid | other | $173 | $173 to $32,550 | Low |
| Destruction of Surface Soft Tissue of Nasal Passages | other | $173 | $173 to $30,802 | Low |
| Ankle Foot Orthosis, Plastic OR Other Material with Ankle Joint, Prefabricate... | other | $173 | $173 to $650 | Low |
| Catheter Angiographic Coronary OR Peripheral Delivery 45 Degree Angled Tip 15... | imaging | $173 | $173 to $650 | Low |
| Respiratory Syncytial Virus Antibody, 0.5 Ml Dosage for Injection Into Muscle | other | $173 | $173 to $90,380 | Low |
| Respiratory Syncytial Virus Antibody, 1.0 Ml Dosage for Injection Into Muscle | other | $173 | $173 to $90,381 | Low |
| Cyberwand Probe Set #cw-rbpbx | other | $173 | $173 to $650 | Low |
| Injection, Methylprednisolone Sodium Succinate, Up to 125 Mg | other | $173 | $173 to $652 | Low |
| Vessel Xi Sealer Extnd #480422 Intuitive Surg | other | $175 | $175 to $656 | Low |
| Forcep Flexo Grasping #fg53s-x | other | $175 | $175 to $657 | Low |
| Complicated Removal of Embedded Foreign Body in Mouth | surgery | $175 | $175 to $40,805 | Low |
| Unclassified Biologics | other | $175 | $175 to $658 | Low |
| Nanoscope Handpiece #ar-3210 | other | $175 | $175 to $659 | Low |
| Insertion of Implant in Urethra Within Prostate Gland Using an Endoscope, 1 I... | surgery | $176 | $176 to $52,441 | Low |
| Electronic Analysis of Pacemaker to Correct Rapid Heart Rate | cardiac | $176 | $176 to $93,724 | Low |
| Visual Obturator 22.5 Fr #a20924a | other | $176 | $176 to $663 | Low |
| Leuprolide Acetate (for Depot Suspension), 7.5 Mg | other | $176 | $176 to $4,145 | Low |
| Laser Fiber 940 Micron Tfl Single Use Tfl-fbx940s 5/box | other | $177 | $177 to $665 | Low |
| Dilation of Narrowing of Rectum Under Anesthesia | other | $177 | $177 to $45,910 | Low |
| Incision of Artery for Creation of Channel for Ecmo External Blood Circulatio... | other | $177 | $177 to $33,987 | Low |
| Removal of Tissue At Dental Edge and Cheek | surgery | $177 | $177 to $40,819 | Low |
| Treatment of Broken Spine Bone with Stabilizing Device, Each Additional Segment | other | $177 | $177 to $22,515 | Low |
| Hospital Inpatient OR Observation Care with Admission and Discharge On the Sa... | other | $177 | $177 to $99,236 | Low |
| Wrist Hand Orthosis, without Joints, May Include Soft Interface, Straps, Cust... | other | $178 | $178 to $668 | Low |
| Injection, Ipilimumab, 1 Mg | other | $179 | $179 to $109,659 | Low |
| Balloon Dilation of Large Bowel Using a Flexible Endoscope | other | $179 | $179 to $45,386 | Low |
| Complicated Drainage of Abscess, Cyst, OR Blood Accumulation of Mouth | other | $179 | $179 to $40,801 | Low |
| Removal of Foreign Body in Nose Under Anesthesia | surgery | $179 | $179 to $30,310 | Low |
| Analysis Test By Nucleic Acid for Hepatitis C Virus | other | $179 | $179 to $87,902 | Low |
| Control of Bleeding of Esophagus | other | $179 | $179 to $43,460 | Low |
| Addition to Lower Extremity, Pelvic Control, Hip Joint, Adjustable Flexion, E... | other | $179 | $179 to $675 | Low |
| Insertion of Expandable Tube in Breast for Radiation Treatment Using Imaging ... | other | $180 | $180 to $32,334 | Low |
| Removal of Embedded Foreign Body in Soft Tissue of Tooth Bearing Bone | surgery | $180 | $180 to $41,805 | Low |
| Red Blood Cells, Washed, Each Unit | other | $180 | $180 to $678 | Low |
| Trimark Td 13mr Breast Biopsy Site Marker MRI | imaging | $181 | $181 to $680 | Low |
| Injection, Baclofen, 10 Mg | other | $181 | $181 to $1,320 | Low |
| Removal of Lymph Nodes of Chest Cavity and Breast Bone | surgery | $181 | $181 to $38,746 | Low |
| Removal of Lymph Nodes of Chest Cavity Using an Endoscope | surgery | $181 | $181 to $32,674 | Low |
| Biomed Fiber Optic Probe Assembly Pteye | other | $182 | $182 to $683 | Low |
| Cannula Long 8mm #470004 | other | $182 | $182 to $683 | Low |
| All Lower Extremity Prostheses, Energy Storing Foot | other | $184 | $184 to $692 | Low |
| Pr Rom Rad Therapy Bone Mets, Pc | other | $185 | $185 to $1,388 | Low |
| Fetal Pillow #fp-010 6ea/bx | other | $185 | $185 to $695 | Low |
| Stabilizer Enclose #en240 | other | $185 | $185 to $695 | Low |
| Injection Into Vocal Cords Using an Endoscope | other | $186 | $186 to $31,570 | Low |
| Ultrasound of Heart with Probe in Esophagus During Surgery On Heart OR Great ... | imaging | $186 | $186 to $93,355 | Low |
| Intracept Access Instruments Additional Level #rlv 0075 | other | $186 | $186 to $700 | Low |
| Placement of Occlusive Device Into Either a Venous OR Arterial Access Site, P... | other | $186 | $186 to $1,400 | Low |
| Removal of Abdominal Cavity Tube | surgery | $188 | $188 to $49,422 | Low |
| Suture of Recent Wound of Eyelid | other | $188 | $188 to $67,930 | Low |
| Harmonic Lap Dissector 9cm #har9f 6ea/bx | other | $189 | $189 to $710 | Low |
| Room & Board - Private (one Bed) - Pediatric | other | $189 | $189 to $710 | Low |
| Removal of Growth of Floor of Mouth | surgery | $190 | $190 to $41,116 | Low |
| Gelport Laparoscopic Colectomy 120mm | surgery | $190 | $190 to $715 | Low |
| Medical Testimony | other | $190 | $190 to $99,075 | Low |
| Insertion of Tube Into Artery OR Vein for Drug Infusion for Blood Clot with R... | surgery | $191 | $191 to $37,213 | Low |
| Biopsy of Saliva Gland | lab | $191 | $191 to $42,405 | Low |
| Implantation of Nerve End Into Bone OR Muscle | surgery | $192 | $192 to $64,787 | Low |
| Removal of Polyps OR Growths of Large Bowel Using a Flexible Endoscope with E... | surgery | $193 | $193 to $45,384 | Low |
| Needle Biopsy of Prostate Gland Using Image Guidance | lab | $194 | $194 to $55,706 | Low |
| Removal of Plaque From Heart Artery At Time of Coronary Artery Bypass | surgery | $195 | $195 to $33,572 | Low |
| Room & Board - Private (one Bed) - General Classification | other | $195 | $195 to $733 | Low |
| Removal of Growth of Throat And/or Stripping of Vocal Cords Using an Endoscope | surgery | $195 | $195 to $31,540 | Low |
| Dilation of Canal Between Middle Ear and Throat (eustachian Tube) On Both Sid... | other | $195 | $195 to $69,706 | Low |
| Material for Vocal Cord Medialization, Synthetic | other | $196 | $196 to $735 | Low |
| Ankle Orthosis, Supramalleolar with Straps, with OR without Interface/pads, C... | other | $196 | $196 to $738 | Low |
| Twin Grasper Otsc 220cm #200.45 | other | $197 | $197 to $739 | Low |
| Daily Management of Ecmo External Vein to Artery Blood Circulation in Heart a... | cardiac | $198 | $198 to $33,949 | Low |
| Fluciclovine F-18, Diagnostic, 1 Millicurie | other | $198 | $198 to $746 | Low |
| Needle Biopsy of Saliva Gland | lab | $198 | $198 to $42,400 | Low |
| Induction of Abnormal Heart Rhythm By Electrical Pacing | cardiac | $199 | $199 to $93,618 | Low |
| Removal OR Revision of a Peripheral, Sacral, OR Gastric Neurostimulator Pulse... | surgery | $199 | $199 to $64,595 | Low |
| Removal of Growth of Front 2/3 of Tongue with Switches | surgery | $199 | $199 to $41,112 | Low |
| Injection of Dilated Vein of Stomach And/or Esophagus Using a Flexible Endoscope | other | $199 | $199 to $43,243 | Low |
| Bactisure Wound Lavage #00888700200(qtys of 6 | other | $200 | $200 to $750 | Low |
| Coil Vascular 2mm X 1cm Ruby #rby4c0201 | other | $200 | $200 to $750 | Low |
| Coil Vascular 2mm X 2cm Ruby #rby4c0202 | other | $200 | $200 to $750 | Low |
| Coil Vascular 2mm X 4cm Ruby #rby4c0204 | other | $200 | $200 to $750 | Low |
| Coil Vascular 3mm X 5cm Ruby #rby4c0305 | other | $200 | $200 to $750 | Low |
| Cooled Radiofrequency Kit #crk-17-75 | other | $200 | $200 to $750 | Low |
| Cooled Rf Probe Kit #crk-17-50 | other | $200 | $200 to $750 | Low |
| Gelpoint Mini Advanced Access Platform | other | $200 | $200 to $750 | Low |
| Hemostatic Agent, Gastrointestinal, Topical | other | $200 | $200 to $750 | Low |
| Pars Suture Implant Ar-8860ds | surgery | $200 | $200 to $750 | Low |
| Ruby Complex Soft 3 Mm X 15 Cm | other | $200 | $200 to $750 | Low |
| Ruby Complex Soft 4 Mm X 6 Cm | other | $200 | $200 to $750 | Low |
| Ruby Complex Standard 3mm X 5cm | other | $200 | $200 to $750 | Low |
| Vas-q-clip Applier 10mm - 45cm #an1462-l | other | $200 | $200 to $750 | Low |
| All Endoskeletal Lower Extremity Prosthesis, Axial Rotation Unit, with OR wit... | other | $200 | $200 to $752 | Low |
| Removal of Impacted Stool OR Foreign Body in Rectum Under Anesthesia | surgery | $201 | $201 to $45,915 | Low |
| Injection Into Vocal Cords Using an Endoscope with Operating Microscope OR Te... | other | $201 | $201 to $31,571 | Low |
| Primary Removal of Adenoids | surgery | $201 | $201 to $42,831 | Low |
| Internal Shock to Heart to Regulate Heart Beat | cardiac | $201 | $201 to $92,961 | Low |
| Partial Removal and Reconnection of Small Bowel, Each Additional Removal and ... | surgery | $201 | $201 to $44,121 | Low |
| Addition to Lower Extremity, Above Knee OR Knee Disarticulation, Acrylic Socket | other | $202 | $202 to $758 | Low |
| Insertion of Tube Into Middle Small Bowel Using an Endoscope | other | $202 | $202 to $44,372 | Low |
| Reamer 40/44 Depuy Low Profile #2230-00 | other | $202 | $202 to $760 | Low |
| Reamer 48/52/56 Depuy #2230-00-031 Low Profil | other | $202 | $202 to $760 | Low |
| Reamer Shoulder 40mm Depuy #223600008 | other | $202 | $202 to $760 | Low |
| Reamer Shoulder 48mm #223000010 Depuy | other | $202 | $202 to $760 | Low |
| Injection, Calcitonin Salmon, Up to 400 Units | other | $202 | $202 to $761 | 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 |
| Cor-knot Mini Device Kit W/ Loads #031350 | other | $203 | $203 to $765 | Low |
| Secondary Removal and Dissolving of Blood Clot From Artery OR Artery Graft Us... | surgery | $204 | $204 to $37,186 | Low |
| Injection, Octreotide, Depot Form for Intramuscular Injection, 1 Mg | other | $204 | $204 to $19,890 | Low |
| Destruction of Growth OR Polyp of Large Bowel Using an Endoscope Inserted Thr... | other | $204 | $204 to $44,401 | Low |
| Contrast Injection for Imaging to Evaluate Central Venous Access Device | other | $204 | $204 to $36,598 | Low |
| Refilling and Maintenance of Implantable Pump OR Reservoir for Drug Delivery | surgery | $204 | $204 to $96,522 | Low |
| Carboprost 250 Mcg/ml Vial | other | $204 | $204 to $767 | Low |
| Repair of Lung Airway and Removal of Segment of Lung | surgery | $205 | $205 to $32,501 | Low |
| Dilation of Sphenoid and Frontal Nasal Sinus Using an Endoscope | other | $205 | $205 to $31,298 | Low |
| Aortic Balloon Pump Cath 7.5fr 34cc 0684-00-0479-01u | other | $205 | $205 to $771 | Low |
| Nursery - Newborn - Level I | obstetric | $206 | $206 to $774 | Low |
| Detection Test By Nucleic Acid for Multiple Types of Respiratory Virus, Multi... | other | $207 | $207 to $87,633 | Low |
| Fibrin Sealant Patch Large Tachosil #1144922 | other | $207 | $207 to $777 | Low |
| Balloon Seeker 70dg Frt 6x17 #1830617frt0 | other | $207 | $207 to $778 | Low |
| Injection, Lurbinectedin, 0.1 Mg | other | $207 | $207 to $25,295 | Low |
| Positioner Heart Urchin Evo #hp3500 | cardiac | $207 | $207 to $779 | Low |
| Decompression of Twisted OR Abnormally Dilated Large Bowel Using a Flexible E... | other | $209 | $209 to $45,393 | Low |
| Insertion of Blood Flow Assist Device in Aorta Through Skin | other | $210 | $210 to $33,967 | Low |
| Reamer / + 5.5mm 03.045.029 | other | $210 | $210 to $789 | Low |
| Lap Harmonic Shear Curved 36cm 6/bx #har36 | other | $210 | $210 to $789 | Low |
| Removal of Growth of Lung Airways Using an Endoscope | surgery | $210 | $210 to $31,640 | Low |
| Room & Board - Private (one Bed) - Rehabilitation | therapy | $210 | $210 to $790 | Low |
| Room & Board - Semi-private (two Beds) - General Classification | other | $210 | $210 to $790 | Low |
| Secondary Removal of Adenoids | surgery | $210 | $210 to $42,836 | Low |
| Destruction of First Division of Face Nerve Branch | other | $210 | $210 to $64,600 | Low |
| Pr Rom Rad Therapy Brain Mets, Pc | other | $211 | $211 to $1,584 | Low |
| Kyphon Osteo Introducer Size 2 #t34a | other | $211 | $211 to $792 | Low |
| Kyphon Osteo Introducer Size 3 #t15j | other | $211 | $211 to $792 | Low |
| Tying of Single Internal Hemorrhoid Group | other | $211 | $211 to $46,945 | Low |
| Insertion of Tube Into First Order Main and Accessory Arteries of Kidney for ... | other | $211 | $211 to $36,251 | Low |
| Prosthesis, Breast | other | $211 | $211 to $795 | Low |
| Rts Instruments Size 1-2 M03 S0002 | other | $211 | $211 to $795 | Low |
| Removal of Growth of Tongue And/or Stripping of Vocal Cord Using an Endoscope... | surgery | $212 | $212 to $31,541 | Low |
| Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm OR Dissection, Ra... | surgery | $212 | $212 to $75,952 | Low |
| Olm Intracranial Pressure Monitor Kit 1ea | other | $212 | $212 to $799 | Low |
| Aveta Flex Disposable Resecting Device 2.9mm #210-080 3/ctn | other | $213 | $213 to $800 | Low |
| Fixate Suture Device Band Pk=2ea Fb-201-01 Sc | other | $213 | $213 to $800 | Low |
| Orthoalign Plus Unit #403001 | other | $213 | $213 to $800 | Low |
| Review By Radiologist of Uterine Tube and Ovary Image | other | $213 | $213 to $74,740 | Low |
| Removal of Polyps OR Growths of Large Bowel Using an Endoscope with Mechanica... | surgery | $213 | $213 to $45,385 | Low |
| Tying of Multiple Internal Hemorrhoid Groups | other | $214 | $214 to $46,946 | Low |
| Removal of Connective Tissue of Palm and Release of Finger, Each Additional D... | surgery | $214 | $214 to $26,125 | Low |
| Echelon Contour Curved Cutter Stapler Blue 2.0 Gcs40g Bx/3ea | other | $215 | $215 to $809 | Low |
| Amniotic Membrane for Surgical Reconstruction, Per Procedure | surgery | $215 | $215 to $810 | Low |
| Waterjet Destruction of Prostrate Accessed Through the Urethra | other | $215 | $215 to $1,620 | Low |
| Destruction of Growth OR Narrowing of Lung Airway Using an Endoscope | other | $216 | $216 to $31,641 | Low |
| Repair of Lacerated Roof of Mouth, More Than 2.0 Cm | surgery | $216 | $216 to $42,182 | Low |
| Ultrasound Exam of Large Bowel Using a Flexible Endoscope | imaging | $216 | $216 to $45,391 | Low |
| Review By Radiologist of Abscess OR Sinus Cavity Study | other | $217 | $217 to $76,080 | Low |
| Control of Bleeding of Upper Large Bowel Using a Flexible Endoscope | other | $217 | $217 to $45,382 | Low |
| Repair of Tissue Connecting Tongue to Floor of Mouth | surgery | $217 | $217 to $41,520 | Low |
| Work-related OR Medical Disability Examination By Other Than the Treating Phy... | other | $217 | $217 to $99,456 | Low |
| Preparation of Skin Graft Site of Face, Scalp, Eyelids, Mouth, Neck, Ears, Ar... | other | $217 | $217 to $15,004 | Low |
| Delivery of Placenta | obstetric | $218 | $218 to $59,414 | Low |
| Review By Radiologist of Elbow Image | other | $218 | $218 to $73,085 | Low |
| Removal of Tonsils | surgery | $219 | $219 to $42,826 | Low |
| Injection to Cause Blood Clot in Diseased OR Pseudoaneurysm of Arm OR Leg | other | $219 | $219 to $36,002 | Low |
| Ultrasound Guided Needle Aspiration OR Biopsy of Esophagus, Stomach, And/or U... | imaging | $220 | $220 to $43,242 | Low |
| Rom Rad Therapy Lymphoma, Pc | other | $220 | $220 to $1,655 | Low |
| Hc an Epidural Block Charge | other | $220 | $220 to $828 | Low |
| Dmsa Injection Kit | other | $222 | $222 to $834 | Low |
| Addition, Endoskeletal System, Below Knee, Flexible Protective Outer Surface ... | other | $223 | $223 to $837 | Low |
| Removal of Growth in Soft Tissue of Ear Canal | surgery | $223 | $223 to $69,145 | Low |
| Biopsy of Lung Lining Using an Endoscope | lab | $223 | $223 to $32,609 | Low |
| Closed Treatment of Broken Middle OR Upper End of Outside Lower Leg Bone | other | $224 | $224 to $27,780 | Low |
| Radioactive Drug Therapy Through a Vein | other | $224 | $224 to $79,101 | Low |
| Additions to Lower Extremity, Total Contact, Above Knee OR Knee Disarticulati... | other | $224 | $224 to $842 | Low |
| Inceptiv Programming Handset and Communicator #th91scsr | other | $224 | $224 to $842 | Low |
| Spinal Pt Programmer #97740 Restoresensor | other | $224 | $224 to $842 | Low |
| Injection of Agent to Destroy Nerve to Internal Sphincter of Anus | other | $225 | $225 to $46,505 | Low |
| Complicated Removal of Saliva Gland Stone From Inside Mouth | surgery | $226 | $226 to $42,335 | Low |
| Removal of Infected Artificial Material OR Mesh From Abdomen | surgery | $227 | $227 to $11,008 | Low |
| Exposure of Major Groin Artery with Creation of Conduit | other | $228 | $228 to $34,714 | Low |
| Biopsy OR Removal of Lymph Nodes | surgery | $228 | $228 to $38,500 | Low |
| MRI Scan of 1 Breast without Contrast | imaging | $229 | $229 to $77,046 | Low |
| MRI Scan of Abdomen without Contrast | imaging | $229 | $229 to $74,181 | Low |
| MRI Scan of Arm without Contrast | imaging | $229 | $229 to $73,218 | Low |
| MRI Scan of Blood Vessels of Head without Contrast | imaging | $229 | $229 to $70,544 | Low |
| MRI Scan of Blood Vessels of Neck without Contrast | imaging | $229 | $229 to $70,547 | Low |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck without Contrast | imaging | $229 | $229 to $70,540 | Low |
| MRI Scan of Both Breasts without Contrast | imaging | $229 | $229 to $77,047 | Low |
| MRI Scan of Brain without Contrast | imaging | $229 | $229 to $70,551 | Low |
| MRI Scan of Chest without Contrast | imaging | $229 | $229 to $71,550 | Low |
| MRI Scan of Jaw Joint | imaging | $229 | $229 to $70,336 | Low |
| MRI Scan of Leg Joint without Contrast | imaging | $229 | $229 to $73,721 | Low |
| MRI Scan of Leg without Contrast | imaging | $229 | $229 to $73,718 | Low |
| MRI Scan of Lower Spinal Canal without Contrast | imaging | $229 | $229 to $72,148 | Low |
| MRI Scan of Middle Spinal Canal without Contrast | imaging | $229 | $229 to $72,146 | Low |
| MRI Scan of Pelvis without Contrast | imaging | $229 | $229 to $72,195 | Low |
| MRI Scan of Upper Spinal Canal without Contrast | imaging | $229 | $229 to $72,141 | Low |
| Review By Radiologist of Breast Duct Image, 1 Duct | other | $229 | $229 to $77,053 | Low |
| Ultrasound Scan of Pregnant Uterus with Detailed Fetal Anatomic Examination, ... | imaging | $229 | $229 to $76,811 | Low |
| Ultrasound Scan of Uterus and Uterine Cavity | imaging | $229 | $229 to $76,831 | Low |
| Gradient Compression Garment, Arm, Padded, for Nighttime Use, Custom, Each | other | $229 | $229 to $861 | Low |
| X-ray of Lower Leg, 2 Views | imaging | $230 | $230 to $73,590 | 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 |
| Injection, Azacitidine, 1 Mg | other | $230 | $230 to $384 | Low |
| Destruction of First Incompetent Vein of Arm OR Leg Using Radiofrequency and ... | other | $230 | $230 to $36,475 | Low |
| Insertion of Tube for 3d Mapping of Electrical Impulses to Heart Muscle | cardiac | $231 | $231 to $93,613 | Low |
| Injection, Brentuximab Vedotin, 1 Mg | other | $231 | $231 to $36,987 | Low |
| Programming of Pacing Cardioverter-defibrillator | other | $231 | $231 to $93,642 | Low |
| Drainage of Abscess, Cyst, OR Blood Accumulation Under Jaw Bone From Inside M... | other | $231 | $231 to $41,008 | Low |
| Removal of Growth of Back 1/3 of Tongue with Suturing | surgery | $231 | $231 to $41,113 | Low |
| Nuclear Medicine Study of Brain and Blood Flow | imaging | $232 | $232 to $78,601 | Low |
| Room & Board - Private | other | $233 | $233 to $875 | Low |
| Review By Radiologist of Wrist Joint Image | other | $233 | $233 to $73,115 | Low |
| Insertion of Tube Into Extracranial Artery for Diagnosis OR Treatment with Re... | other | $234 | $234 to $36,222 | Low |
| Addition to Lower Extremity, Pre-tibial Shell, Molded to Patient Model | other | $235 | $235 to $882 | Low |
| Removal of Growth Under Skin of Face OR Scalp, Less Than 2.0 Cm | surgery | $235 | $235 to $21,011 | Low |
| Administration of Chemotherapy Into Vein, 1 Hour OR Less | other | $235 | $235 to $96,413 | Low |
| Repair of Eardrum | surgery | $236 | $236 to $69,610 | Low |
| Heart Rhythm Recording for More Than 7 Days Up to 15 Days By Continuous Rhyth... | cardiac | $237 | $237 to $93,245 | Low |
| Diagnostic Exam of Small Bowel (including Lower Small Intestine) Using an End... | other | $238 | $238 to $44,376 | Low |
| Anchor/screw for Opposing Bone-to-bone OR Soft Tissue-to-bone | other | $238 | $238 to $895 | Low |
| Coring Reamer Cannulated 6 Mm #ar-8900cr | other | $238 | $238 to $895 | Low |
| Coring Reamer Cannulated 8 Mm #ar-8901cr | other | $238 | $238 to $895 | Low |
| Endoblade Plantar Fascia Release Ar-8856ds | other | $238 | $238 to $895 | Low |
| Ankle Foot Orthosis, Posterior Solid Ankle, Plastic, Custom Fabricated | other | $239 | $239 to $897 | Low |
| Leadless C Pm Ins/rpl Ventr | other | $239 | $239 to $1,794 | Low |
| Removal of Tube for Ecmo External Blood Circulation in Heart and Lungs Using ... | surgery | $240 | $240 to $33,984 | Low |
| Wand Laryngeal Procise Mlw #eica7071 | other | $241 | $241 to $908 | Low |
| Wand Procise Lw Arthrocare #eica7070 | other | $241 | $241 to $908 | Low |
| Insertion of Stent in Large Bowel Using a Flexible Endoscope | cardiac | $242 | $242 to $45,389 | Low |
| Partial Foot, Shoe Insert with Longitudinal Arch, Toe Filler | other | $243 | $243 to $912 | Low |
| Gradient Compression Garment, Lower Leg and Foot, Padded, for Nighttime Use, ... | other | $243 | $243 to $915 | Low |
| Addition, Endoskeletal System, Above Knee OR Hip Disarticulation, Alignable S... | other | $243 | $243 to $915 | Low |
| Removal of Congenital Skin and Tissue Cyst of Neck | surgery | $243 | $243 to $42,810 | Low |
| Injection, Dostarlimab-gxly, 10 Mg | other | $244 | $244 to $11,563 | Low |
| Periprosthetic Wire Guide 03.233.000 | other | $244 | $244 to $918 | Low |
| Delayed Insertion of Prosthesis for Repair of Abdominal OR Groin Artery with ... | surgery | $245 | $245 to $34,711 | Low |
| Microcatheter Canaloplasty Itrack 250a | cardiac | $245 | $245 to $922 | Low |
| Review By Radiologist of Abdominal Cavity Lining Image | other | $246 | $246 to $74,190 | Low |
| Custom Shaped Protective Cover, Below Knee | other | $246 | $246 to $924 | Low |
| Protopam Chloride 1 Gm Vial | other | $246 | $246 to $924 | Low |
| Exam of Kidney Using an Endoscope Inserted Through Surgically Created Opening... | surgery | $247 | $247 to $50,551 | Low |
| Biopsy of Small Bowel Using an Endoscope | lab | $249 | $249 to $44,377 | Low |
| Retrieval of Foreign Body in Blood Vessel with Review By Radiologist | other | $250 | $250 to $37,197 | Low |
| Closed Treatment of Broken Wrist Bone Near Base of Thumb | other | $250 | $250 to $25,622 | Low |
| Exposure of Underarm OR Upper Chest Artery for Delivery of Prosthesis | obstetric | $250 | $250 to $34,715 | Low |
| Vena Cava Filter | other | $250 | $250 to $940 | Low |
| Removal of Growth of Mouth with Complicated Repair | surgery | $250 | $250 to $40,814 | Low |
| Removal of Growth of Dental Bone Growth with Complex Repair | surgery | $250 | $250 to $41,827 | Low |
| Shoulder Elbow Wrist Hand Orthosis, Abduction Positioning, Airplane Design, P... | other | $250 | $250 to $941 | Low |
| Injection Procedure for Imaging of Kidney and Ureter Through Already Existing... | other | $252 | $252 to $50,431 | Low |
| Platelets, Pheresis, Leukocytes Reduced, Each Unit | other | $253 | $253 to $950 | Low |
| Ruby Complex Soft 4 Mm X 15 Cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Soft 6 Mm X 20 Cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 3mm X 12cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 3mm X 20cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 4mm X 10cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 4mm X 15cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 4mm X 20cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 5mm X 12cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 6mm X 20cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 7mm X 25cm | other | $253 | $253 to $950 | Low |
| Ruby Complex Standard 8mm X 25cm | other | $253 | $253 to $950 | Low |
| Insertion OR Replacement of Peripheral, Sacral, OR Gastric Neurostimulator Ge... | surgery | $253 | $253 to $64,590 | Low |
| Fine Needle Aspiration And/or Biopsy of Large Bowel with Ultrasound Guidance ... | imaging | $254 | $254 to $45,392 | Low |
| Placement of Tubes in Breast for Radiation Treatment Using Imaging Guidance D... | other | $254 | $254 to $19,298 | Low |
| Bupivacaine, Collagen-matrix Implant, 1 Mg | surgery | $255 | $255 to $959 | Low |
| Pr Sigmoidoscopy,ablate Lesn | other | $256 | $256 to $45,339 | Low |
| Incision of Windpipe for Insertion of Breathing Tube | other | $257 | $257 to $31,600 | Low |
| Test for Detecting Nucleic Acid of Organism Causing Infection of Central Nerv... | other | $257 | $257 to $87,483 | Low |
| Removal of Biliary Drainage Tube Using Imaging Guidance with Review By Radiol... | surgery | $257 | $257 to $47,537 | Low |
| Complex Removal of Tissue and Muscle Growth of Mouth | surgery | $257 | $257 to $40,816 | Low |
| Removal of Tonsils and Adenoid Glands | surgery | $258 | $258 to $42,821 | Low |
| Insertion of Sacral Nerve Neurostimulator Electrode Array | other | $258 | $258 to $64,561 | Low |
| Stent, Non-coronary, Temporary, with Delivery System | cardiac | $259 | $259 to $973 | Low |
| Incision of Bladder with Drainage | other | $259 | $259 to $51,040 | Low |
| Addition, Endoskeletal Knee-shin System, Single Axis, Friction Swing and Stan... | other | $259 | $259 to $975 | Low |
| Implant System Achillies Midsubstance Speedbridge Ar-8929bc-cp | surgery | $259 | $259 to $975 | Low |
| Vein Harvest Dumicz Endovascular #vsp550ex | other | $261 | $261 to $981 | Low |
| Nuclear Medicine Study of Lung Ventilation and Blood Flow to Lung | imaging | $261 | $261 to $78,597 | Low |
| Initiation of Ecmo External Vein to Vein Blood Circulation in Heart and Lungs... | cardiac | $262 | $262 to $33,946 | Low |
| Emergent Incision of Windpipe Through Neck for Insertion of Breathing Tube | other | $262 | $262 to $31,603 | Low |
| Closed Treatment of Broken Kneecap | other | $263 | $263 to $27,520 | Low |
| Hc General Anesthesia Time - Initial Base Charge | other | $263 | $263 to $989 | Low |
| Pr Rom Rad Therapy Breast, Pc | other | $263 | $263 to $1,978 | Low |
| Aveta Wave+ Disposable Resecting Device 3.9mm #210-2005 3/ctn | other | $263 | $263 to $990 | Low |
| Ruby Complex Standard 5mm X 20cm | other | $263 | $263 to $990 | Low |
| Ruby Complex Standard 6mm X 12cm | other | $263 | $263 to $990 | Low |
| Addition to Lower Extremity, Below Knee / Above Knee Suspension Locking Mecha... | other | $264 | $264 to $991 | Low |
| Insertion of Tube Into Ureter Using an Endoscope Inserted Through Surgically ... | surgery | $264 | $264 to $50,553 | Low |
| Scleral Tutoplast Processed | other | $264 | $264 to $992 | Low |
| Brevital Sodium 500 Mg Vial | other | $265 | $265 to $995 | Low |
| Spiration Deployment Catheter and Loader Hudhus-c26n | cardiac | $266 | $266 to $1,000 | Low |
| Watchman Fxd Access System Double Curve Tu8002 | other | $266 | $266 to $1,000 | Low |
| Watchman Trueseal Access System Anterior Curve Tu7004 | other | $266 | $266 to $1,000 | Low |
| Removal of Foreign Body OR Stone in Kidney OR Ureter Using an Endoscope Inser... | surgery | $266 | $266 to $50,961 | Low |
| Biopsy of Anal And/or Rectal Wall Through Anus | lab | $268 | $268 to $45,100 | Low |
| Repair of Abdominal OR Groin Artery with Prosthesis with Review By Radiologist | surgery | $268 | $268 to $34,709 | Low |
| Diagnostic Exam of Lungs, Heart Sac, Chest Cavity, OR Lung Lining Using an En... | cardiac | $268 | $268 to $32,601 | Low |
| Application of Walking Cast Covering Foot, Ankle, and Lower Leg | other | $268 | $268 to $29,445 | Low |
| Biopsy of Fluid Collection of Lung Using an Endoscope | lab | $269 | $269 to $32,607 | Low |
| Incision of Tendon Covering of Finger | other | $269 | $269 to $26,055 | Low |
| Insertion of Tube Into Chest Artery for Diagnosis OR Treatment with Review By... | other | $271 | $271 to $36,225 | Low |
| Control of Bleeding of Large Bowel Using an Endoscope Inserted Through Surgic... | other | $271 | $271 to $44,391 | Low |
| Removal of Growths OR Polyps of Large Bowel By Electrical Cautery Using an En... | surgery | $271 | $271 to $44,392 | Low |
| Injectable Bulking Agent, Collagen Implant, Urinary Tract, 2.5 Ml Syringe, In... | surgery | $271 | $271 to $1,019 | Low |
| Gene Analysis (tumor Protein 53) Targeted Sequence Analysis | other | $272 | $272 to $81,352 | Low |
| Addition to Lower Extremity, Below Knee/above Knee, Custom Fabricated From Ex... | other | $272 | $272 to $1,022 | Low |
| Removal of Voice Box Cartilage Using an Endoscope with Operating Microscope O... | surgery | $273 | $273 to $31,561 | Low |
| Graft, Vascular | other | $273 | $273 to $1,028 | Low |
| All Lower Extremity Prostheses, Multi-axial Rotation Unit | other | $274 | $274 to $1,031 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Arm Nerve Bundle | other | $275 | $275 to $64,415 | Low |
| Injection of Anesthetic Agent And/or Steroid Into Upper Arm and Shoulder Nerve | other | $275 | $275 to $64,417 | Low |
| Review By Radiologist of Knee Joint Image | other | $276 | $276 to $73,580 | Low |
| Closed Treatment of Dislocated Finger Joint with Manipulation Under Anesthesia | other | $276 | $276 to $26,775 | Low |
| Insertion of Tube Into Vein for Drug Infusion for Blood Clot with Review By R... | surgery | $278 | $278 to $37,212 | Low |
| Pr Renal Angio, Cardiac Cath | cardiac | $278 | $278 to $2,090 | Low |
| Removal of Nasal Air Passage | surgery | $278 | $278 to $30,130 | Low |
| Removal of Growth Under Skin of Leg OR Ankle, Less Than 3.0 Cm | surgery | $279 | $279 to $27,618 | Low |
| Ensite X Surface Electrodes #ensite-sek-5-01 5ea/bx | other | $279 | $279 to $1,050 | Low |
| Ankle Foot Orthosis, Spiral, (institute of Rehabilitative Medicine Type), Pla... | other | $280 | $280 to $1,051 | Low |
| Injection of Anesthetic Agent Into Abdominal Sympathetic Nerve Bundle | other | $280 | $280 to $64,530 | Low |
| Removal and Replacement of Single Lead Permanent Pacemaker | surgery | $281 | $281 to $33,227 | Low |
| Closed Treatment of Broken Shin Bone | other | $281 | $281 to $27,530 | Low |
| Injectable Bulking Agent, Synthetic Implant, Urinary Tract, 1 Ml Syringe, Inc... | surgery | $282 | $282 to $1,150 | Low |
| Custom Seal Kit Endologix #tv-cs14-g | other | $282 | $282 to $1,060 | Low |
| Evaluation of Single OR Dual Chamber Pacing Cardioverter-defibrillator and Ge... | other | $282 | $282 to $93,641 | Low |
| Emergent Incision of Windpipe for Insertion of Breathing Tube | other | $283 | $283 to $31,605 | Low |
| Partial Removal of External Ear with Simple Repair | surgery | $283 | $283 to $69,110 | Low |
| Closure of Permanent Windpipe Opening OR Abnormal Drainage Tract | other | $284 | $284 to $31,820 | Low |
| Mesh | other | $284 | $284 to $1,068 | Low |
| Addition to Lower Extremity, Below Knee Suction Socket | other | $284 | $284 to $1,069 | Low |
| Harvest of Upper Leg to Thigh Vein Segment | other | $285 | $285 to $35,572 | Low |
| Injection, Imipenem 4 Mg, Cilastatin 4 Mg and Relebactam 2 Mg | other | $285 | $285 to $1,071 | Low |
| Incision and Drainage of Abscess Within Wall of Rectum Under Anesthesia | other | $285 | $285 to $46,045 | Low |
| Rom Rad Therapy Lung, Pc | other | $285 | $285 to $2,142 | Low |
| Review By Radiologist of Upper Urinary Tract Image | other | $285 | $285 to $74,425 | Low |
| Glucagon Kit - Compounded | other | $286 | $286 to $1,076 | Low |
| Removal of Vena Cava Filter with Review By Radiologist | surgery | $287 | $287 to $37,193 | Low |
| Initial Intensive Care of Newborn Per Day | obstetric | $287 | $287 to $99,477 | Low |
| Hem-o-lok Medium/large 5mm Endo Applier # 544965 | other | $287 | $287 to $1,079 | Low |
| Initiation of Ecmo External Vein to Artery Blood Circulation in Heart and Lun... | cardiac | $288 | $288 to $33,947 | Low |
| Progel Pleural Air Leak Sealant 4ml 4ea/capgps002 | other | $288 | $288 to $1,084 | Low |
| Pegasys 180 Mcg/ml Vial | other | $289 | $289 to $1,086 | Low |
| Insertion of Tube Into First Order Main and Accessory Arteries of Both Kidney... | other | $289 | $289 to $36,252 | Low |
| Removal of Growth of Tendon Finger OR Hand | surgery | $289 | $289 to $26,160 | Low |
| Release of Tissue of Palm | other | $289 | $289 to $26,040 | Low |
| Destruction And/or Removal of Growth of Kidney Using an Endoscope Inserted Th... | surgery | $290 | $290 to $50,557 | Low |
| Removal of Vocal Cord Growths and Reconstruction with Local Tissue Flap Using... | surgery | $290 | $290 to $31,545 | Low |
| Review By Radiologist of Shoulder Joint Image | other | $291 | $291 to $73,040 | Low |
| Implantable Breast Prosthesis, Silicone OR Equal | surgery | $291 | $291 to $1,095 | Low |
| Insertion of Tube Into Second OR Third Order Branches of Arteries of Kidney f... | other | $292 | $292 to $36,253 | Low |
| Resecting Device Symphion #fg | other | $292 | $292 to $1,099 | Low |
| Insertion of Blood Flow Assist Device in Aorta Through Upper Leg Artery | other | $293 | $293 to $33,970 | Low |
| Afo, Rigid Anterior Tibial Section, Total Carbon Fiber OR Equal Material, Pre... | other | $293 | $293 to $1,103 | Low |
| Joint Device | other | $293 | $293 to $1,100 | Low |
| Repair of Abdomen Using Abdominal Lining Graft | surgery | $294 | $294 to $49,905 | Low |
| Removal and Replacement of Dual Lead Permanent Pacemaker | surgery | $294 | $294 to $33,228 | Low |
| Diagnostic Exam of Abdomen Using an Endoscope | other | $294 | $294 to $49,320 | Low |
| Review By Radiologist of Image for Insertion of Material to Block Blood Flow | other | $295 | $295 to $75,894 | Low |
| Simple Repair of Salivary Duct | surgery | $296 | $296 to $42,500 | Low |
| Knee Orthosis, Adjustable Knee Joints (unicentric OR Polycentric), Positional... | other | $297 | $297 to $2,230 | Low |
| Alexis Ces W/gel Point Mini #gtm14 | other | $297 | $297 to $1,115 | Low |
| Destino Catheter (steerable Sheath 55cm 7mm Curve) #dst0655507d2 | cardiac | $297 | $297 to $1,115 | Low |
| Insertion of Pacemaker Pulse Generator with Existing Multiple Leads | cardiac | $297 | $297 to $33,221 | Low |
| Removal of Growth Under Skin of Face OR Scalp, 2.0 Cm OR More | surgery | $297 | $297 to $21,012 | Low |
| Knee Orthosis (ko), Single Upright, Thigh and Calf, with Adjustable Flexion a... | other | $297 | $297 to $1,118 | Low |
| Sodium Nitrite 300 Mg/10 Ml Vl | other | $298 | $298 to $1,120 | Low |
| Sodium Thiosulfat 12.5 G/50 Ml | other | $298 | $298 to $1,120 | Low |
| Removal of Multiple External Hemorrhoids | surgery | $298 | $298 to $46,250 | Low |
| Accessory Kit Ams 700 #72401850 | other | $299 | $299 to $1,125 | Low |
| Knee Orthosis, Single Upright, Thigh and Calf, with Adjustable Flexion and Ex... | other | $299 | $299 to $1,126 | Low |
| Removal of Wedge of Lip Tissue with Closure | surgery | $300 | $300 to $40,510 | Low |
| Signature One Alliance Glenoid Shoulder Guide and Bone Model Left 20-8090-008 | other | $300 | $300 to $1,128 | Low |
| Removal (1.5 Centimeters OR Greater) Tissue Growth Beneath the Skin of Foot O... | surgery | $300 | $300 to $28,039 | Low |
| Removal of Chronic Tear of Anus | surgery | $300 | $300 to $46,200 | Low |
| Bridion 200 Mg/2 Ml Vial | other | $301 | $301 to $1,131 | Low |
| Removal (less Than 1.5 Centimeters) Tissue Beneath the Skin Growth of Hand OR... | surgery | $301 | $301 to $26,115 | Low |
| Nuclear Medicine Study of Bone Marrow Limited Area | imaging | $301 | $301 to $78,102 | Low |
| Review By Radiologist of Hip Joint Image | other | $301 | $301 to $73,525 | Low |
| Ultraflex Intra-aortic Ballon 7.5fr 40cc Iab-06840-u | other | $303 | $303 to $1,140 | Low |
| Endobronchial Us Add-on | other | $304 | $304 to $31,620 | Low |
| Prostin Vr Pedi 500 Mcg/ml Amp | other | $305 | $305 to $1,147 | Low |
| Shunt Carotid Pruitt W/t-port(outlying)*min 3 | other | $306 | $306 to $1,149 | Low |
| Removal of Salivary Cyst Under Tongue | surgery | $306 | $306 to $42,408 | Low |
| Speed Compression Implant Kit #se | surgery | $306 | $306 to $1,152 | Low |
| Biopsy of Abdomen Using an Endoscope | lab | $307 | $307 to $49,321 | Low |
| Removal and Replacement of Single Lead Defibrillator | surgery | $307 | $307 to $33,262 | Low |
| Repair Umbilical Hernia, Younger Than Age 5 Years; Reducible | surgery | $307 | $307 to $49,580 | Low |
| Removal and Replacement of Multiple Lead Permanent Pacemaker | surgery | $307 | $307 to $33,229 | Low |
| Tactiflex Radiofrequency Cable #tsq-rf-tfse-cbl | other | $307 | $307 to $1,155 | Low |
| Incision of Nasal Sinus Through Nose | other | $308 | $308 to $31,020 | Low |
| Removal of Growth of Soft Tissue of Abdominal Wall, Less Than 3.0 Cm | surgery | $308 | $308 to $22,902 | Low |
| V-shaped Removal of Lip Tissue | surgery | $308 | $308 to $40,520 | Low |
| Nursery - Newborn - Level Ii | obstetric | $309 | $309 to $1,160 | Low |
| Dilation of Esophagus | other | $309 | $309 to $43,450 | Low |
| Incision of Lower Finger Joint for Exploration, Fluid Drainage, OR Removal of... | surgery | $309 | $309 to $26,075 | Low |
| Insertion of Defibrillator with Existing Dual Leads | other | $310 | $310 to $33,230 | Low |
| Knee Orthosis (ko), Double Upright, Thigh and Calf, with Adjustable Flexion a... | other | $310 | $310 to $1,167 | Low |
| Removal of Saliva Gland Under Tongue | surgery | $311 | $311 to $42,450 | Low |
| Revision of Permanent Windpipe Opening Scar | other | $313 | $313 to $31,830 | Low |
| Cardioplegia Del Nido Formula | other | $313 | $313 to $1,176 | Low |
| Repair Device, Urinary, Incontinence, with Sling Graft | surgery | $313 | $313 to $1,176 | Low |
| Replacement of Stomach OR Large Bowel Tube Using Fluoroscopic Guidance with C... | surgery | $313 | $313 to $49,450 | Low |
| Rabies Vaccine for Injection Into Muscle | preventive | $314 | $314 to $90,675 | Low |
| Exposure of Underarm OR Upper Chest Artery with Creation of Conduit | other | $314 | $314 to $34,716 | Low |
| Removal of Border of Lip | surgery | $315 | $315 to $40,500 | Low |
| Bone And/or Joint Imaging; Tomographic | other | $315 | $315 to $78,320 | Low |
| Drainage of Abscess of Throat From Inside Mouth | other | $316 | $316 to $42,720 | Low |
| Patient Programmer, Neurostimulator | other | $317 | $317 to $1,190 | Low |
| Rom Rad Therapy Pancreas, Pc | other | $317 | $317 to $2,382 | Low |
| Stapling of Internal Hemorrhoid | other | $317 | $317 to $46,947 | Low |
| Insertion of Tube Into Artery for Drug Infusion for Blood Clot with Review By... | surgery | $318 | $318 to $37,211 | Low |
| Removal and Replacement of Dual Lead Defibrillator | surgery | $319 | $319 to $33,263 | Low |
| Room & Board - Private (one Bed) - Psychiatric | therapy | $319 | $319 to $1,200 | Low |
| Right Angled Slimline Cryoprobe #pcs | other | $319 | $319 to $1,200 | Low |
| Pr Rom Rad Therapy Colorectal, Pc | other | $320 | $320 to $2,408 | Low |
| Control of Bleeding of Small Bowel Using an Endoscope | other | $320 | $320 to $44,378 | Low |
| Primary Repair of Tendon On Front of Leg | surgery | $324 | $324 to $27,664 | Low |
| Duraseal Exact 5ml Spine Sealant Sys #206520 | other | $325 | $325 to $1,220 | Low |
| Mediastinoscopy Incl Biopsy | lab | $325 | $325 to $39,400 | Low |
| Repair Epigastric Hernia | surgery | $325 | $325 to $49,570 | Low |
| Control of Bleeding of Throat Requiring Hospitalization | other | $326 | $326 to $42,961 | Low |
| Pr Rom Rad Therapy Cns, Pc | other | $327 | $327 to $2,455 | Low |
| Removal of Growth of Leg And/or Ankle Tendon Lining OR Capsule | surgery | $327 | $327 to $27,630 | Low |
| Follow-up Inpatient Hospital Critical Care of Newborn Per Day | obstetric | $327 | $327 to $99,469 | Low |
| Removal of Growth Under Skin of Pelvis and Hip, Less Than 3.0 Cm | surgery | $328 | $328 to $27,047 | Low |
| Biopsy of Growth of Lung Using an Endoscope | lab | $328 | $328 to $32,608 | Low |
| Catheter Frontrunner Xp Ctd #fbp39140 | cardiac | $328 | $328 to $1,234 | Low |
| Monitoring and Recording of Esophageal Function Through a Capsule Attached to... | other | $328 | $328 to $91,035 | Low |
| Injection, Hyaluronidase, Recombinant, 1 Usp Unit | other | $328 | $328 to $547 | Low |
| Injection, Dactinomycin, 0.5 Mg | other | $328 | $328 to $3,052 | Low |
| Removal of Single External and Internal Hemorrhoid Group | surgery | $329 | $329 to $46,255 | Low |
| Tlso, Flexible, Provides Trunk Support, Thoracic Region, Rigid Posterior Pane... | other | $330 | $330 to $1,239 | Low |
| Extensive Removal of Nasal Polyp | surgery | $330 | $330 to $30,115 | Low |
| Removal of Foreign Body OR Stone in Kidney Using an Endoscope Inserted Throug... | surgery | $330 | $330 to $50,561 | Low |
| Insertion of Defibrillator with Existing Multiple Leads | other | $331 | $331 to $33,231 | Low |
| Removal and Replacement of Multiple Lead Defibrillator | surgery | $331 | $331 to $33,264 | Low |
| Other Procedure On Voice Box | other | $332 | $332 to $31,599 | Low |
| Jada System 2.0 Vacuum Induced Hemorrhage Control System Blue Seal Valve Gree... | other | $333 | $333 to $1,250 | Low |
| Packing Coil 45cm Rbypodj45 | other | $333 | $333 to $1,250 | Low |
| Pod J-soft Packing Coil 60cm Rbypodj60 | other | $333 | $333 to $1,250 | Low |
| Ruby Coil Standard 10 Mm X 35 Cm Rby2c1035 | other | $333 | $333 to $1,250 | Low |
| Ruby Coil Standard 12 Mm X 60 Cm Rby2c1260 | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Soft 16 Mm X 50 Cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Soft 20 Mm X 60 Cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Soft 6 Mm X 30 Cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Soft 8 Mm X 35 Cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Soft 8 Mm X 60 Cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 14mm X 60cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 16mm X 60cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 18mm X 57cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 20mm X 60cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 24mm X 57cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 28mm X 60cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 32mm X 60cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 4mm X 35cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 5mm X 30cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 6mm X 30cm | other | $333 | $333 to $1,250 | Low |
| Ruby Complex Standard 8mm X 40cm | other | $333 | $333 to $1,250 | Low |
| Repositioning of Defibrillator Electrode | other | $334 | $334 to $33,273 | Low |
| CT Scan of Arm with Contrast | imaging | $335 | $335 to $73,201 | Low |
| MRI Scan of Abdomen Before and After Contrast | imaging | $335 | $335 to $74,183 | Low |
| MRI Scan of Abdomen with Contrast | imaging | $335 | $335 to $74,182 | Low |
| MRI Scan of Arm Before and After Contrast | imaging | $335 | $335 to $73,220 | Low |
| MRI Scan of Arm Joint Before and After Contrast | imaging | $335 | $335 to $73,223 | Low |
| MRI Scan of Arm with Contrast | imaging | $335 | $335 to $73,219 | Low |
| MRI Scan of Blood Vessels of Neck Before and After Contrast | imaging | $335 | $335 to $70,549 | Low |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck Before and After Contrast | imaging | $335 | $335 to $70,543 | Low |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck with Contrast | imaging | $335 | $335 to $70,542 | Low |
| MRI Scan of Brain Before and After Contrast | imaging | $335 | $335 to $70,553 | Low |
| MRI Scan of Brain with Contrast | imaging | $335 | $335 to $70,552 | Low |
| MRI Scan of Chest Before and After Contrast | imaging | $335 | $335 to $71,552 | Low |
| MRI Scan of Leg Before and After Contrast | imaging | $335 | $335 to $73,720 | Low |
| MRI Scan of Leg Joint Before and After Contrast | imaging | $335 | $335 to $73,723 | Low |
| MRI Scan of Leg with Contrast | imaging | $335 | $335 to $73,719 | Low |
| MRI Scan of Lower Spinal Canal Before and After Contrast | imaging | $335 | $335 to $72,158 | Low |
| MRI Scan of Lower Spinal Canal with Contrast | imaging | $335 | $335 to $72,149 | Low |
| MRI Scan of Middle Spinal Canal Before and After Contrast | imaging | $335 | $335 to $72,157 | Low |
| MRI Scan of Middle Spinal Canal with Contrast | imaging | $335 | $335 to $72,147 | Low |
| MRI Scan of Pelvis with Contrast | imaging | $335 | $335 to $72,196 | Low |
| MRI Scan of Upper Spinal Canal Before and After Contrast | imaging | $335 | $335 to $72,156 | Low |
| MRI Scan of Upper Spinal Canal with Contrast | imaging | $335 | $335 to $72,142 | Low |
| Matristem Micromatrix, 1 Mg | other | $335 | $335 to $1,258 | Low |
| Second Stage Repair of Abnormal Anal Drainage Tract | surgery | $336 | $336 to $46,285 | Low |
| Tying, Incision, and Stripping of Short Leg Vein | other | $337 | $337 to $37,718 | Low |
| Nuclear Medicine Study to Assess Blood Loss | imaging | $337 | $337 to $78,278 | Low |
| Graft Hemashield 28x10x50 | other | $337 | $337 to $1,267 | Low |
| Graft Hemashield 30x10x50 | other | $337 | $337 to $1,267 | Low |
| Insertion of Abdominal Cavity Tube Using an Endoscope | other | $340 | $340 to $49,324 | Low |
| Destruction of Tongue Tissue, Per Session | other | $340 | $340 to $41,530 | Low |
| Accessory Kit Ams 800 #720066 | other | $340 | $340 to $1,280 | Low |
| Rom Rad Therapy Gi, Pc | other | $341 | $341 to $2,561 | Low |
| Spacemaker Pro Trocar Endoscoic Blunt Tip W/oval Dissection Balloon #smbttovlx | cardiac | $342 | $342 to $1,285 | Low |
| Ruby Complex Soft 10 Mm X 35 Cm | other | $343 | $343 to $1,290 | Low |
| Ruby Complex Soft 12 Mm X 40 Cm | other | $343 | $343 to $1,290 | Low |
| Ruby Complex Standard 12mm X 40cm | other | $343 | $343 to $1,290 | Low |
| Ruby Complex Standard 14mm X 40cm | other | $343 | $343 to $1,290 | Low |
| Ruby Complex Standard 4mm X 30cm | other | $343 | $343 to $1,290 | Low |
| Ruby Complex Standard 7mm X 40cm | other | $343 | $343 to $1,290 | Low |
| Ruby Complex Standard 9mm X 30cm | other | $343 | $343 to $1,290 | Low |
| Removal of Single External and Internal Hemorrhoid Group and Chronic Tear in ... | surgery | $344 | $344 to $46,257 | Low |
| Osteogenesis Stimulator, Electrical, Surgically Implanted | surgery | $344 | $344 to $5,476 | Low |
| Shunt Carotid Flexcel Inlying #2020 | other | $344 | $344 to $1,295 | Low |
| Shunt Carotid Pruitt F3 T-port 8f #e2013 | other | $346 | $346 to $1,299 | Low |
| Shunt Carotid Pruitt Inahara 2012-11 Min. 3 | other | $346 | $346 to $1,299 | Low |
| Skin Substitute, Not Otherwise Specified | other | $346 | $346 to $1,299 | Low |
| Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Cast Orthosis, Custom... | other | $346 | $346 to $1,301 | Low |
| Repair of Abnormal Anal Drainage Tract | surgery | $346 | $346 to $46,270 | Low |
| Coronary Artery Bypass Using Vein OR Artery Graft, 2 Grafts | cardiac | $347 | $347 to $33,518 | Low |
| Nuclear Medicine Study of Liver | imaging | $347 | $347 to $78,201 | Low |
| Removal of Growth of Muscle of Face OR Scalp, Less Than 2.0 Cm | surgery | $349 | $349 to $21,013 | Low |
| Removal of Growth Under Skin of Leg OR Ankle, 3.0 Cm OR More | surgery | $350 | $350 to $27,632 | Low |
| Graft Hemashield 32x10x50 | other | $350 | $350 to $1,314 | Low |
| Rom Rad Therapy Uterus, Pc | other | $350 | $350 to $2,629 | Low |
| Exam of Windpipe and Lung Airways Through Permanent Windpipe Opening Using an... | other | $350 | $350 to $31,615 | Low |
| Removal of Saliva Gland Under Floor of Mouth | surgery | $350 | $350 to $42,440 | Low |
| Removal of Growth Under Skin of Upper Arm OR Elbow, 3.0 Cm OR More | surgery | $351 | $351 to $24,071 | Low |
| Exam of Chest with Biopsy of Lymph Node Using an Endoscope | lab | $351 | $351 to $39,402 | Low |
| Monitoring and Recording of Esophageal Function Through Nasal Tube | other | $351 | $351 to $91,034 | Low |
| Incision of Connective Tissue of Front OR Side of Lower Leg to Relieve Pressure | other | $352 | $352 to $27,600 | Low |
| Repair of Wound of Eyelid Margin | surgery | $352 | $352 to $67,935 | Low |
| Twist Drill U44-645 | other | $352 | $352 to $1,325 | Low |
| Removal OR Destruction of Growth of Nose Through Nose | surgery | $352 | $352 to $30,117 | Low |
| Removal of Growth of Finger OR Toe Nerve, Same Digit | surgery | $353 | $353 to $64,776 | Low |
| Ankle Foot Orthosis, Plastic with Ankle Joint, Custom Fabricated | other | $353 | $353 to $1,327 | Low |
| Insertion of Catheters for Recording and Pacing of Right Heart Chambers Rhythm | cardiac | $353 | $353 to $93,619 | Low |
| Removal OR Scraping of Skin On Nose | surgery | $354 | $354 to $30,120 | Low |
| Tying of Sphenopalatine Artery Using an Endoscope | other | $354 | $354 to $31,241 | Low |
| Vh-4000 - System Vein Harvest Connical Dissector Tip with Insulated Jaw Short... | other | $354 | $354 to $1,333 | Low |
| Biopsy OR Removal of Deep Lymph Nodes of Neck | surgery | $355 | $355 to $38,510 | Low |
| Removal of Growth Under Skin of Thigh OR Knee, Less Than 3.0 Cm | surgery | $355 | $355 to $27,337 | Low |
| Pr Rom Rad Therapy Bladder, Pc | other | $356 | $356 to $2,677 | Low |
| Nursery - Newborn - Level Iii | obstetric | $356 | $356 to $1,339 | Low |
| Exam of Nose and Sinus with Removal of Nasal Sinus Using an Endoscope | surgery | $356 | $356 to $31,257 | Low |
| Removal of Growth of Muscle of Foot OR Toe, 1.5 Cm OR More | surgery | $358 | $358 to $28,041 | Low |
| Study of Stomach to Assess Movement | other | $358 | $358 to $91,020 | Low |
| Insertion of Tube Through the Skin for Ecmo External Blood Circulation in Hea... | other | $359 | $359 to $33,952 | Low |
| Biopsy OR Removal of Deep Lymph Nodes of Underarm | surgery | $359 | $359 to $38,525 | Low |
| Fuzeright Peg and Hole Reaming Kit Sterile #ht-60-8000-s | other | $359 | $359 to $1,350 | Low |
| Addition, Endoskeletal System, Above Knee, Ultra-light Material | other | $360 | $360 to $1,352 | Low |
| Cath Intra-aortic Balloon 30cc #iab-05830-lws | other | $360 | $360 to $1,355 | Low |
| Cath Intra-aortic Balloon 40cc #iab-05840-lws | other | $360 | $360 to $1,355 | Low |
| Menquadfi Vial | other | $361 | $361 to $1,355 | Low |
| Revision of Abdominal Cavity Tube Using an Endoscope | other | $361 | $361 to $49,325 | Low |
| Removal of Growth of Soft Tissue Under Skin of Neck OR Front of Chest, 3.0 Cm... | surgery | $361 | $361 to $21,552 | Low |
| Exploration of Neck Artery | other | $361 | $361 to $35,701 | Low |
| Fusion of Big Toe Between Toe Joints | surgery | $362 | $362 to $28,755 | Low |
| Removal of Growth Under Skin of Shoulder Area, 3.0 Cm OR More | surgery | $362 | $362 to $23,071 | Low |
| Release And/or Relocation of Wrist Nerve | other | $363 | $363 to $64,719 | Low |
| Incision of Finger Joint for Exploration, Fluid Drainage, OR Removal of Forei... | surgery | $363 | $363 to $26,080 | Low |
| Stabilizer Tissue Octopus 4.3 #ts2000 | other | $364 | $364 to $1,367 | Low |
| Complicated Drainage of Abscess of Saliva Gland | other | $364 | $364 to $42,305 | Low |
| Removal of Plaque with Balloon Dilation of Coronary Artery OR Branch, Each Ad... | surgery | $365 | $365 to $92,925 | Low |
| Rotalink Plus Burr 1.25mm #23631 | other | $366 | $366 to $1,374 | Low |
| Low Osmolar Contrast Material, 100-199 Mg/ml Iodine Concentration, Per Ml | other | $366 | $366 to $1,375 | Low |
| Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis, Rigid, Prefabricated... | other | $366 | $366 to $1,376 | Low |
| Removal of Growth of Soft Tissue of Abdominal Wall, 3.0 Cm OR More | surgery | $366 | $366 to $22,903 | Low |
| Removal OR Destruction of Growth of Tongue Lymph Node | surgery | $366 | $366 to $42,870 | Low |
| Banding of Hemorrhoids Using a Flexible Endoscope | other | $367 | $367 to $45,350 | Low |
| Destruction of Polyp OR Growth of Large Bowel Using a Flexible Endoscope | other | $367 | $367 to $45,388 | Low |
| Insertion of Left Lower Heart Electrode for Pacemaker OR Defibrillator | cardiac | $367 | $367 to $33,225 | Low |
| Removal (1.5 Centimeters OR Greater) Tissue Beneath the Skin Growth of Hand O... | surgery | $368 | $368 to $26,111 | Low |
| Injection, Rasburicase, 0.5 Mg | other | $370 | $370 to $16,924 | Low |
| Repair of Abnormal Anal Drainage Tract with Implanted Plug | surgery | $372 | $372 to $46,707 | Low |
| Simple Revision of Permanent Opening of Windpipe for Breathing | other | $373 | $373 to $31,613 | Low |
| Removal of Blood Clot and Portion of Tibial OR Peroneal Artery, Each Addition... | surgery | $373 | $373 to $35,306 | Low |
| Inceptiv Recharger #rs7230 | other | $373 | $373 to $1,404 | Low |
| Recharger 97755 Intellis Rtm #97755 | other | $373 | $373 to $1,404 | Low |
| Removal of Growth Under Skin of Forearm OR Wrist, 3.0 Cm OR More | surgery | $374 | $374 to $25,071 | Low |
| Diagnostic Exam of Knee Using an Endoscope | other | $374 | $374 to $29,870 | Low |
| Pad Temp Arctic Sun Large Kit #317-09 | other | $375 | $375 to $1,409 | Low |
| Pad Temp Arctic Sun Sml Kit #3170502 2ea/1cs | other | $375 | $375 to $1,409 | Low |
| Amputation of Toe and Midfoot Bone | other | $375 | $375 to $28,810 | Low |
| Removal of Plaque, Insertion of Stent and Balloon Dilation of Coronary Artery... | surgery | $375 | $375 to $92,934 | Low |
| Removal of Tissue From Sphenoid Sinus Using an Endoscope | surgery | $377 | $377 to $31,259 | Low |
| Replacement of Small Bowel Tube Using Fluoroscopic Guidance with Contrast | surgery | $378 | $378 to $49,451 | Low |
| Incision and Drainage of Abscess Above Pelvic Floor OR Behind Rectum | other | $378 | $378 to $45,020 | Low |
| Injection, Paclitaxel, 1 Mg | other | $378 | $378 to $631 | Low |
| Injection of Substance Into Lower Spine Canal Using Imaging Guidance | other | $380 | $380 to $62,323 | Low |
| Octaray Mapping Cable #d-1344 | other | $381 | $381 to $1,433 | Low |
| Nuclear Medicine Study of Intestine | imaging | $383 | $383 to $78,290 | Low |
| Nuclear Medicine Study, Multiple Areas | imaging | $383 | $383 to $78,801 | Low |
| Removal OR Partial Removal of Lower End of Forearm Bone On Small Finger Side ... | surgery | $385 | $385 to $25,240 | Low |
| Primary Repair of Tendon OR Muscle of Palm Side of Forearm OR Wrist | surgery | $385 | $385 to $25,260 | Low |
| Destruction of Second and Third Division of Face Nerve Branch | other | $385 | $385 to $64,605 | Low |
| Inner 24 Fr for 26 Fr Outer #a22040a | other | $386 | $386 to $1,453 | Low |
| Placement of Stabilizing Device for Broken End of Finger OR Thumb | other | $387 | $387 to $26,756 | Low |
| Removal of Cerebrospinal Fluid with Lower Back Spinal Tap for Diagnostic Test | surgery | $387 | $387 to $62,270 | Low |
| Partial Removal of Wrist Bone Near Thumb | surgery | $388 | $388 to $25,230 | Low |
| Complicated Plastic Repair of Salivary Duct | surgery | $388 | $388 to $42,505 | Low |
| Rom Rad Therapy Cervical, Pc | other | $388 | $388 to $2,916 | Low |
| Incision of Tendon of Forearm And/or Wrist, Open Procedure | other | $389 | $389 to $25,290 | Low |
| Removal of Growth Under Skin of Back OR Lower Sides, 3.0 Cm OR More | surgery | $389 | $389 to $21,931 | Low |
| Large Clip Applier #470230 | other | $391 | $391 to $1,470 | Low |
| Injection, Mycophenolate Mofetil, 10 Mg | other | $392 | $392 to $1,473 | Low |
| Injection, Estrogen Conjugated, Per 25 Mg | other | $392 | $392 to $3,209 | Low |
| Addition, Endoskeletal Knee-shin System, Polycentric, Mechanical Stance Phase... | other | $392 | $392 to $1,475 | Low |
| Incision of Connective Tissue of Back of Lower Leg to Relieve Pressure | other | $392 | $392 to $27,601 | Low |
| Injection, Iron Sucrose, 1 Mg | other | $393 | $393 to $655 | Low |
| Tying, Incision, and Stripping of Long Leg Vein | other | $394 | $394 to $37,722 | Low |
| Repair of Groin Hernia Using an Endoscope | surgery | $394 | $394 to $49,650 | Low |
| Elastomeric Pump Reservoir 8 Ml/hr | other | $395 | $395 to $1,485 | Low |
| Tissueblue 0.025% Syringe | other | $396 | $396 to $1,487 | Low |
| Release And/or Relocation of Hand Nerve | other | $396 | $396 to $64,721 | Low |
| Rom Rad Therapy Anal, Pc | other | $396 | $396 to $2,980 | Low |
| Rom Rad Ther Head/neck, Pc | other | $397 | $397 to $2,984 | Low |
| Removal of Extra Breast Tissue in Male | surgery | $397 | $397 to $19,300 | Low |
| Biopsy of Tissue of Chest Using an Endoscope | lab | $398 | $398 to $32,606 | Low |
| Repair of Fibrous Tissue of Arch of Foot Using an Endoscope | surgery | $398 | $398 to $29,893 | Low |
| Repair of Abnormal Drainage Tract Between Nasal Sinuses | surgery | $398 | $398 to $30,580 | Low |
| Repair of Abnormal Drainage Tract in Anal Sphincter | surgery | $399 | $399 to $46,275 | Low |
| Clip Flex 35mm Atriclip #ach235 | other | $399 | $399 to $1,500 | Low |
| Clip Flex 40mm Atriclip #ach240 | other | $399 | $399 to $1,500 | Low |
| Clip Flex 45mm Atriclip #ach245 | other | $399 | $399 to $1,500 | Low |
| Endoscope, Single-use | other | $399 | $399 to $1,500 | Low |
| Laa Exclusion Sys Flex 50mm Clip #a000919 | other | $399 | $399 to $1,500 | Low |
| Stent, Non-coated/non-covered, with Delivery System | cardiac | $399 | $399 to $1,500 | Low |
| Complete Exam of Nose and Sinuses Using an Endoscope | other | $399 | $399 to $31,253 | Low |
| Complex Application of Radiation Source | other | $400 | $400 to $77,778 | Low |
| Gradient Compression Garment, Full Leg and Foot, Padded, for Nighttime Use, C... | other | $401 | $401 to $1,506 | Low |
| Review By Radiologist of MRI Guidance for Needle Placement | imaging | $401 | $401 to $77,021 | Low |
| Bexsero Prefilled Syringe | other | $401 | $401 to $1,508 | Low |
| Removal of Growth Under Skin of Pelvis and Hip, 3.0 Cm OR More | surgery | $401 | $401 to $27,043 | Low |
| Programmer Kit Interstim Smart #th90q01 | other | $402 | $402 to $1,510 | Low |
| Insertion of Tube for Ecmo External Blood Circulation in Heart and Lungs Usin... | cardiac | $402 | $402 to $33,954 | Low |
| Repair Umbilical Hernia, Age 5 Years OR Older; Incarcerated OR Strangulated | surgery | $404 | $404 to $49,587 | Low |
| Removal of Cyst OR Growth of Wrist Bone | surgery | $404 | $404 to $25,130 | Low |
| Removal of Fluid-filled Sac (bursa) OR Calcium Deposit of Pelvis | surgery | $405 | $405 to $27,062 | Low |
| Biopsy OR Removal of Lymph Nodes of Neck with Removal of Fat Pad | surgery | $406 | $406 to $38,520 | Low |
| Closure of Permanent Windpipe Opening OR Abnormal Drainage Tract with Plastic... | other | $407 | $407 to $31,825 | Low |
| Management of Complete Single Session Course of Stereotactic Radiation Treatm... | other | $407 | $407 to $77,432 | Low |
| Removal of Infected Neck Graft | surgery | $407 | $407 to $35,901 | Low |
| Aspiration of Initial Secretion of Lung Airway Using an Endoscope | other | $408 | $408 to $31,645 | Low |
| Repair Epigastric Hernia (eg, Preperitoneal Fat); Incarcerated OR Strangulated | surgery | $409 | $409 to $49,572 | Low |
| Knee Orthosis, without Knee Joint, Rigid, Custom Fabricated | other | $410 | $410 to $1,543 | Low |
| Lumbar-sacral Orthosis, Sagittal-coronal Control, Rigid Shell(s)/panel(s), Po... | lab | $411 | $411 to $1,544 | Low |
| Removal of Growth of Muscle of Leg OR Ankle, Less Than 5.0 Cm | surgery | $411 | $411 to $27,619 | Low |
| Incision of Bladder with Removal of Bladder Stone | surgery | $412 | $412 to $51,050 | Low |
| Diagnostic Exam of Wrist Using an Endoscope | other | $412 | $412 to $29,840 | Low |
| Incision of Connective Tissue of Front And/or Side and Back of Lower Leg to R... | other | $413 | $413 to $27,602 | Low |
| Repair of Brow Paralysis | surgery | $413 | $413 to $67,900 | Low |
| Closed Treatment of Back Portion of Shin Bone At Ankle with Manipulation | other | $413 | $413 to $27,768 | Low |
| Implantation of Cochlear Stimulating System Into Skull with Attachment Throug... | surgery | $413 | $413 to $69,714 | Low |
| Release of Ligaments of Knee Joint | other | $414 | $414 to $27,425 | Low |
| Complicated Control of Bleeding of Throat | other | $417 | $417 to $42,962 | Low |
| Lengthening OR Shortening of Tendon of Leg OR Ankle | other | $419 | $419 to $27,685 | Low |
| Diagnostic Exam of Shoulder Using an Endoscope | other | $420 | $420 to $29,805 | Low |
| Partial Removal of Breast | surgery | $423 | $423 to $19,301 | Low |
| Revision of Prosthetic Vaginal Graft | other | $423 | $423 to $57,295 | Low |
| Correction of Rigid Deformity of First Joint of Big Toe Using Implant | surgery | $424 | $424 to $28,291 | Low |
| Microporous Collagen Implantable Tube (neuragen Nerve Guide), Per Centimeter ... | surgery | $426 | $426 to $1,600 | Low |
| Repair of Defect OR Tear of Eardrum | surgery | $426 | $426 to $69,620 | Low |
| Placement of Stabilizing Device for Broken Finger OR Thumb At Midportion OR P... | other | $428 | $428 to $26,727 | Low |
| Repair Spigelian Hernia | surgery | $428 | $428 to $49,590 | Low |
| Delivery of Single Session of Intraoperative Radiation Treatment with X-ray | imaging | $428 | $428 to $77,424 | Low |
| Radiation Therapy | other | $428 | $122 to $3,220 | High |
| Hip Orthosis, Abduction Control of Hip Joint, Postoperative Hip Abduction Typ... | other | $429 | $429 to $1,612 | Low |
| Incision of Bladder with Insertion of Tube OR Stent in Ureter | cardiac | $431 | $431 to $51,045 | Low |
| Rom Rad Therapy Prostate, Pc | other | $432 | $432 to $3,246 | Low |
| Removal of Navel and Surrounding Tissue | surgery | $432 | $432 to $49,250 | Low |
| Injection, Phentolamine Mesylate, Up to 5 Mg | other | $432 | $432 to $4,059 | Low |
| Removal of Lining of Large Bowel Using an Endoscope Inserted Through Surgical... | surgery | $434 | $434 to $44,403 | Low |
| Treatment of Broken Finger Bone with Stabilizing Device Accessed Through Skin | other | $435 | $435 to $26,608 | Low |
| Removal of Multiple Hemorrhoid Groups and Chronic Tear in Anus | surgery | $437 | $437 to $46,261 | Low |
| Removal of Plaque with Balloon Dilation of Single Coronary Artery OR Branch | surgery | $437 | $437 to $92,924 | Low |
| Mometasone Furoate Sinus Implant, 370 Micrograms | surgery | $438 | $438 to $3,290 | Low |
| Removal of Wrist Bone | surgery | $438 | $438 to $25,210 | Low |
| Closed Treatment of Broken Hand Bone with Manipulation and Placement of Exter... | other | $439 | $439 to $26,607 | Low |
| Release of Arm OR Leg Nerve | other | $439 | $439 to $64,708 | Low |
| Custom Shaped Protective Cover, Above Knee | other | $439 | $439 to $1,651 | Low |
| Primary Repair of Tendon OR Muscle of Top Side of Forearm OR Wrist | surgery | $441 | $441 to $25,270 | Low |
| Partial Removal of Wrist Joint Lining Using an Endoscope | surgery | $441 | $441 to $29,844 | Low |
| Stent, Non-coated/non-covered, without Delivery System | cardiac | $442 | $442 to $1,662 | Low |
| Release And/or Relocation of Cranial Nerve | other | $442 | $442 to $64,716 | Low |
| Removal of Deep Lymph Nodes of Neck | surgery | $442 | $442 to $38,542 | Low |
| Coronary Artery Bypass OR Valve Procedure Reoperation More Than 1 Month After... | cardiac | $444 | $444 to $33,530 | Low |
| Partial Removal of Knee Joint Lining Using an Endoscope | surgery | $444 | $444 to $29,875 | Low |
| Graft Hemashield 30x10x8x8x10mm #175930p | other | $444 | $444 to $1,670 | Low |
| Secondary Closure OR Revision of Scar At Previous Thigh Amputation | other | $445 | $445 to $27,594 | Low |
| Repair Umbilical Hernia, Age 5 Years OR Older; Reducible | surgery | $449 | $449 to $49,585 | Low |
| Removal of Multiple Hemorrhoid Groups | surgery | $449 | $449 to $46,260 | Low |
| Aspiration And/or Injection of Cyst of Kidney | other | $449 | $449 to $50,390 | Low |
| Pod 12mm X 60cm Coil Rbypod12 | other | $450 | $450 to $1,690 | Low |
| Biopsy and Removal of Lymph Nodes of Abdominal Cavity Using an Endoscope | surgery | $450 | $450 to $38,570 | Low |
| Exploration, Drainage, Biopsy, OR Removal of Foreign Body in Chest Cavity Thr... | surgery | $450 | $450 to $39,000 | Low |
| Removal of Joint Lining and Repair of Tendon On the Topside of Finger | surgery | $451 | $451 to $26,140 | Low |
| Removal of Growth of Muscle of Face OR Scalp, 2.0 Cm OR More | surgery | $451 | $451 to $21,014 | Low |
| Removal of Congenital Cyst OR Abnormal Drainage Tract of Neck And/or Throat | surgery | $452 | $452 to $42,815 | Low |
| Treatment of Broken Midportion of Foot | other | $452 | $452 to $28,485 | Low |
| Repair of Abnormal Drainage Tract Around Anal Sphincter | surgery | $453 | $453 to $46,280 | Low |
| Removal of Defect in Wall of Esophagus Using a Rigid Endoscope | surgery | $454 | $454 to $43,180 | Low |
| Bydureon Bcise 2 Mg Autoinject | other | $456 | $456 to $1,714 | Low |
| Placement of Locating Device in Breast Using Imaging Guidance, First Growth | other | $456 | $456 to $19,281 | Low |
| Cranial Access W/subdural Port Medtronic | other | $457 | $457 to $1,716 | Low |
| Repair of Tendon, Finger, And/or Palm of Hand | surgery | $457 | $457 to $26,145 | Low |
| Intensive Care Unit - Intermediate ICU | other | $458 | $458 to $1,720 | Low |
| Removal OR Repair of Wrist Cartilage Using an Endoscope | surgery | $458 | $458 to $29,846 | Low |
| Placement of Stabilizing Device for Dislocated Hand Bone At Wrist Joint with ... | other | $458 | $458 to $26,676 | Low |
| Procedure Kit Illumisite 180 #ils-1800-kt | other | $459 | $459 to $1,724 | Low |
| Release of Finger Nerve | other | $459 | $459 to $64,702 | Low |
| Coronary Artery Bypass Using Vein OR Artery Graft, 3 Grafts | cardiac | $459 | $459 to $33,519 | Low |
| Repair of Hand Muscle | surgery | $461 | $461 to $26,591 | Low |
| Biopsy of Esophagus Using a Flexible Endoscope Through Mouth | lab | $461 | $461 to $43,202 | Low |
| Injection Into Esophagus Using a Flexible Endoscope | other | $461 | $461 to $43,201 | Low |
| Drainage of Tendon of Finger And/or Palm | other | $462 | $462 to $26,020 | Low |
| Creation of Opening of Windpipe and Insertion of Speech Prosthesis | other | $463 | $463 to $31,611 | Low |
| Destruction of Heart Conduction Tissue to Create Heart Block | cardiac | $463 | $463 to $93,650 | Low |
| Diagnostic Exam of Esophagus Using a Flexible Endoscope Through Mouth | other | $463 | $463 to $43,200 | Low |
| Removal of Growth of Muscle of Hand OR Finger, Less Than 1.5 Cm | surgery | $463 | $463 to $26,116 | Low |
| Balloon Dilation of Esophagus Using a Flexible Endoscope, Less Than 3.0 Cm | other | $464 | $464 to $43,220 | Low |
| Dilation of Esophagus with Insertion of Guide Wire Using a Flexible Endoscope | other | $464 | $464 to $43,226 | Low |
| Needle Biopsy OR Removal of Surface Lymph Nodes | surgery | $464 | $464 to $38,505 | Low |
| Removal of Foreign Bodies in Esophagus Using a Flexible Endoscope | surgery | $464 | $464 to $43,215 | Low |
| Removal of Scar Tissue to Release Tendon of Forearm OR Wrist | surgery | $466 | $466 to $25,295 | Low |
| Incision of Ear Canal with Release of Scar Tissue | other | $468 | $468 to $69,450 | Low |
| Incision of Elbow Tendon with Removal of Tissue | surgery | $468 | $468 to $24,358 | Low |
| Removal of Infected Skin, Tissue OR Muscle of Genitals | surgery | $470 | $470 to $11,004 | Low |
| Partial Removal of Shoulder Joint Lining Using an Endoscope | surgery | $471 | $471 to $29,820 | Low |
| Repair of Groin Hernia | surgery | $471 | $471 to $49,505 | Low |
| Therapy Using Electrical Currents | other | $471 | $471 to $90,870 | Low |
| Biopsy of Lung Airway Using an Endoscope | lab | $473 | $473 to $31,625 | Low |
| Diagnostic Exam of Lung Airway Using an Endoscope | other | $473 | $473 to $31,622 | Low |
| Exam of Lung Airways Using an Endoscope | other | $473 | $473 to $31,623 | Low |
| Irrigation and Suction of Lung Airways to Obtain Cells Using an Endoscope | other | $473 | $473 to $31,624 | Low |
| Needle Biopsy of Windpipe Cartilage, Airway, And/or Lung Using an Endoscope | lab | $473 | $473 to $31,629 | Low |
| Removal of Foreign Body in Lung Airways Using an Endoscope | surgery | $473 | $473 to $31,635 | Low |
| Removal of Loose OR Foreign Body in Knee Joint Using an Endoscope | surgery | $474 | $474 to $29,874 | Low |
| Removal of Tendon of Forearm And/or Wrist | surgery | $475 | $475 to $25,109 | Low |
| Removal of Growth of Muscle of Forearm OR Wrist, 3.0 Cm OR More | surgery | $475 | $475 to $25,073 | Low |
| Addition to Lower Extremity, Below Knee/above Knee, Custom Fabricated Socket ... | other | $475 | $475 to $1,787 | Low |
| Diagnostic Exam of Jaw Joint Using an Endoscope | other | $476 | $476 to $29,800 | Low |
| Vivigen Mis Delivery System Bl-1900 | obstetric | $476 | $476 to $1,791 | Low |
| Amniomatrix OR Biodmatrix, Injectable, 1 Cc | other | $479 | $479 to $1,799 | Low |
| Hip Extraction System S9-hip S9hip | other | $479 | $479 to $1,800 | Low |
| Universal Knee Implant Extraction System #s9kne #s9knee | surgery | $479 | $479 to $1,800 | Low |
| Removal of Growth of Muscle of Hand OR Finger, 1.5 Cm OR More | surgery | $480 | $480 to $26,113 | Low |
| Removal of Infected Graft of Arm OR Leg | surgery | $481 | $481 to $35,903 | Low |
| Diagnostic Exam of Small Bowel Using an Endoscope Inserted Through Surgically... | surgery | $481 | $481 to $44,380 | Low |
| Replacement of Peripherally Inserted Central Venous Tube (picc) with Review B... | surgery | $481 | $481 to $36,584 | Low |
| Removal of Knee Cartilage Using an Endoscope | surgery | $483 | $483 to $29,881 | Low |
| Limited Removal of Abnormal Shoulder Joint Tissue Using Endoscope | surgery | $483 | $483 to $29,822 | Low |
| Repair of Abnormal Anal Drainage Tract with Rectal Tissue Flap | surgery | $484 | $484 to $46,288 | Low |
| Incision OR Removal of Spinal Nerve | surgery | $485 | $485 to $64,772 | Low |
| Needle Biopsy of Lining of Lung | lab | $487 | $487 to $32,400 | Low |
| Needle Biopsy of Pancreas | lab | $487 | $487 to $48,102 | Low |
| Release of Ligaments At Outer Side of Knee Joint Using an Endoscope | other | $487 | $487 to $29,873 | Low |
| Graft Hemashield 32x12x10x10x10mm #175732p | other | $488 | $488 to $1,836 | Low |
| Lumbar-sacral Orthosis, Sagittal-coronal Control, with Rigid Anterior and Pos... | other | $491 | $491 to $1,846 | Low |
| Exploration (not Followed By Surgical Repair), with OR without Lysis of Arter... | surgery | $491 | $491 to $35,761 | Low |
| Nuclear Medicine Study of Parathyroid with SPECT and CT Scan | imaging | $492 | $492 to $78,072 | Low |
| Clip Flexv Dvice W/vclp 50mm Atriclip Achv50 | other | $492 | $492 to $1,850 | Low |
| Dissector Articlating Instrument #mid1 | other | $492 | $492 to $1,850 | Low |
| Tlso, Triplanar Control, Modular Segmented Spinal System, Four Rigid Plastic ... | other | $493 | $493 to $1,852 | Low |
| Complications of Treatment without Cc/mcc | other | $493 | $493 to $14,849 | Low |
| Incision of Hand OR Finger Bone | other | $493 | $493 to $26,034 | Low |
| Cable Torch Grip 5 X 115mm 71340004 | other | $493 | $493 to $1,855 | Low |
| Injection, Etanercept, 25 Mg | other | $494 | $494 to $1,858 | Low |
| Shock Wave Crushing of Kidney Stones | other | $495 | $495 to $50,590 | Low |
| Biopsy OR Removal of Lymph Nodes of Breast | surgery | $496 | $496 to $38,530 | Low |
| Lengthening OR Shortening of Tendon of Forearm And/or Wrist | other | $499 | $499 to $25,280 | Low |
| Removal of Both Knee Cartilages Using an Endoscope | surgery | $499 | $499 to $29,880 | Low |
| Removal of Growth of Rectum Through Anus | surgery | $499 | $499 to $45,171 | Low |
| Removal of Blood Clot of Artery OR Vein Graft | surgery | $500 | $500 to $35,875 | Low |
| Intracept Access Instruments #rlv 0045 | other | $500 | $500 to $1,880 | Low |
| Repair of Femoral Groin Hernia | surgery | $500 | $500 to $49,550 | Low |
| Removal of Diseased Part of Forearm Bone On Small Finger Side | surgery | $501 | $501 to $25,150 | Low |
| Ocular Implant, Aqueous Drainage Assist Device | surgery | $502 | $502 to $1,887 | Low |
| Knee Ankle Foot Orthosis, Double Upright, Free Ankle, Solid Stirrup, Thigh an... | other | $503 | $503 to $1,889 | Low |
| Spinal Cs Charging Sys Restoresensor #97754 | other | $504 | $504 to $1,895 | Low |
| Removal of Blood Clot in Artery of Upper Arm | surgery | $504 | $504 to $34,101 | Low |
| Removal of Blood Clot in Artery of Lower Arm | surgery | $505 | $505 to $34,111 | 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 |
| Connective Tissue, Human | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 4x100mm #lx1813041004f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 4x40mm #lx181304404f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 4x60mm #lx181304604f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 4x80mm #lx181304804f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 5x100mm #lx1813051005f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 5x40mm #lx181305405f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 5x60mm #lx181305605f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 5x80mm #lx181305805f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 6x100mm #lx1813061005f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 6x40mm #lx181306405f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 6x60mm #lx181306605f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 7x100mm #lx1813071005f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 7x40mm #lx181307405f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 7x60mm #lx181307605f | other | $505 | $505 to $1,900 | Low |
| Lutonix .018" Dcb 130cm 7x80mm #lx181307805f | other | $505 | $505 to $1,900 | Low |
| Removal of Growth of Soft Tissue of Pelvis and Hip, Less Than 5.0 Cm | surgery | $505 | $505 to $27,048 | Low |
| Vbr-s Dev 26mm X 11mm X 14mm #06-115 | other | $505 | $505 to $1,900 | Low |
| Vbr-s Dev 29mm X 11mm X 14mm #06-115 | other | $505 | $505 to $1,900 | Low |
| Removal of Cyst OR Growth of Wrist Bone with Self Bone Graft | surgery | $506 | $506 to $25,135 | Low |
| CT Guidance for Tissue Removal | surgery | $508 | $508 to $77,013 | Low |
| Other Circulatory System Diagnoses without Cc/mcc | other | $509 | $509 to $22,167 | Low |
| Secondary Closure OR Revision of Scar of Lower Leg Bone Amputation | other | $510 | $510 to $2,072 | Low |
| Tying of Ethmoidal Artery Ethmoidal for Control of Nose Bleed | other | $510 | $510 to $30,915 | Low |
| Repair of Recurrent Groin Hernia Using an Endoscope | surgery | $510 | $510 to $49,651 | Low |
| External Shock to Heart to Regulate Heart Beat | cardiac | $510 | $510 to $92,960 | Low |
| Removal of Cyst OR Growth of Lower Leg Bone | surgery | $513 | $513 to $27,635 | Low |
| Treatment of Broken Finger At Midportion OR Part Near Hand | other | $513 | $513 to $26,735 | Low |
| Treatment of Broken Midhand Bone | other | $513 | $513 to $26,615 | Low |
| Balloon Dilation of Pulmonary Artery, Single Vessel | other | $514 | $514 to $92,997 | Low |
| Repair of Sliding Groin Hernia | surgery | $514 | $514 to $49,525 | Low |
| Removal of Loose OR Foreign Body in Shoulder Joint Using an Endoscope | surgery | $516 | $516 to $29,819 | Low |
| Removal of Plaque, Insertion of Stent and Balloon Dilation of Single Coronary... | surgery | $516 | $516 to $92,933 | Low |
| Removal of Plaque, Insertion of Stent And/or Balloon Dilation of Coronary Ves... | surgery | $516 | $516 to $92,938 | Low |
| Immediate Post Surgical OR Early Fitting, Application of Initial Rigid Dressi... | surgery | $517 | $517 to $1,945 | Low |
| Removal of Shoulder Scar Tissue Using an Endoscope | surgery | $518 | $518 to $29,825 | Low |
| Nuclear Medicine Study of Cerebrospinal Fluid Flow After Injection of Contras... | imaging | $521 | $521 to $78,630 | Low |
| Nuclear Medicine Study of Whole Body for Thyroid Cancer | imaging | $521 | $521 to $78,018 | Low |
| Nuclear Medicine Study, Whole Body Requiring Multiple Imaging Days | imaging | $521 | $521 to $78,804 | Low |
| Repair of Bulging of Rectum Into Vagina | surgery | $522 | $522 to $45,560 | Low |
| Removal of Extensive Shoulder Joint Tissue Using an Endoscope | surgery | $523 | $523 to $29,823 | Low |
| Creation of Surgical Opening From Stomach to Skin Using an Endoscope | surgery | $525 | $525 to $43,653 | Low |
| Insertion of Small Bowel Tube Using Fluoroscopic Guidance with Contrast | other | $526 | $526 to $49,441 | Low |
| Insertion of Stomach Tube Using Fluoroscopic Guidance with Contrast | other | $526 | $526 to $49,440 | Low |
| Removal of Growth of Saliva Gland OR Saliva Gland, Lateral Lobe | surgery | $526 | $526 to $42,410 | Low |
| Removal of Connective Tissue of Palm | surgery | $527 | $527 to $26,121 | Low |
| Repair of Trapped Groin Hernia | surgery | $527 | $527 to $49,507 | Low |
| Drainage of Abscess of Throat From Outside Mouth | other | $528 | $528 to $42,725 | Low |
| Removal of Growth of Muscle of Abdomen, 5.0 Cm OR More | surgery | $528 | $528 to $22,901 | Low |
| Tlso, Triplanar Control, One Piece Rigid Plastic Shell with Interface Liner, ... | other | $529 | $529 to $1,988 | Low |
| Addition to Lower Extremity, Endoskeletal System, Above Knee - Knee Disarticu... | other | $529 | $529 to $1,989 | Low |
| Partial Destruction and Reconstruction of Right Upper Heart Chamber | cardiac | $529 | $529 to $33,257 | Low |
| Removal of Large Bowel Tissue Using a Flexible Endoscope | surgery | $536 | $536 to $45,390 | Low |
| Removal of Appendix Using an Endoscope | surgery | $537 | $537 to $44,970 | Low |
| Ankle Foot Orthosis, Walking Boot Type, Varus/valgus Correction, Rocker Botto... | other | $538 | $538 to $2,023 | Low |
| Release And/or Relocation of Elbow Nerve | other | $538 | $538 to $64,718 | Low |
| Ultrasound Evaluation of Heart Blood Vessel During Diagnosis OR Treatment, Ea... | imaging | $539 | $539 to $93,572 | Low |
| Repair of Recurrent Femoral Groin Hernia | surgery | $541 | $541 to $49,555 | Low |
| Removal of Multiple Wrist Bones | surgery | $542 | $542 to $25,215 | Low |
| Treatment of Dislocated Wrist Bones | other | $542 | $542 to $25,670 | Low |
| Knee Orthosis, Double Upright, Thigh and Calf, with Adjustable Flexion and Ex... | other | $543 | $543 to $2,043 | Low |
| Treatment of Broken Thumb At Wrist | other | $543 | $543 to $26,665 | Low |
| Removal of Scar Tissue From Knee Using an Endoscope | surgery | $549 | $549 to $29,884 | Low |
| Removal OR Shaving of Knee Joint Cartilage Using an Endoscope | surgery | $549 | $549 to $29,877 | Low |
| Repair Recurrent Incisional OR Ventral Hernia; Reducible | surgery | $550 | $550 to $49,565 | 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 |
| Coronary Artery Bypass Using Vein OR Artery Graft, 4 Grafts | cardiac | $551 | $551 to $33,521 | Low |
| Delivery of Fixation Device to Graft with Review By Radiologist | obstetric | $552 | $552 to $34,712 | Low |
| Repair of Joint Between Hand and Finger Bones with Prosthesis | surgery | $552 | $552 to $26,531 | Low |
| Repair of Congenital Defect of Bladder | surgery | $552 | $552 to $51,500 | Low |
| Removal of Growth of Muscle of Back OR Lower Sides, Less Than 5.0 Cm | surgery | $553 | $553 to $21,932 | Low |
| Complicated Treatment of Dislocated Midhand Bone At Wrist | other | $554 | $554 to $26,686 | Low |
| Partial Removal of Lymph Nodes of Underarm | surgery | $555 | $555 to $38,740 | Low |
| Interfyl, 1 Mg | other | $556 | $556 to $2,090 | Low |
| Removal of Growth Under Nasal Bone OR Cartilage | surgery | $557 | $557 to $30,125 | Low |
| Fusion of Finger Joint, Initial Joint | surgery | $557 | $557 to $26,860 | Low |
| Insertion of Sacral Nerve Neurostimulator Electrode | other | $558 | $558 to $64,581 | Low |
| Reshaping of Nasal Cartilage | other | $559 | $559 to $30,520 | Low |
| Repair Initial Incisional OR Ventral Hernia; Reducible | surgery | $559 | $559 to $49,560 | Low |
| Repair of Trapped Femoral Groin Hernia | surgery | $559 | $559 to $49,553 | Low |
| Diagnostic Exam of Small Bowel (excluding Lower Small Intestine) Using an End... | other | $559 | $559 to $44,360 | Low |
| Biopsy of Small Bowel (except Ileum) Using an Endoscope | lab | $561 | $561 to $44,361 | Low |
| Removal of Appendix | surgery | $563 | $563 to $44,950 | Low |
| Drainage of Lymph Fluid to Abdominal Cavity Using an Endoscope | other | $563 | $563 to $49,323 | Low |
| Repair of Groin Hernia That Is Not Trapped | surgery | $564 | $564 to $49,520 | Low |
| Removal of Plaque, Insertion of Stent And/or Balloon Dilation, Each Additiona... | surgery | $566 | $566 to $92,944 | Low |
| Removal of Lymph Nodes of Both Sides of Pelvis Using an Endoscope | surgery | $566 | $566 to $38,571 | Low |
| Connective Tissue, Non-human | other | $569 | $569 to $2,140 | Low |
| Treatment of Broken Outer Lower Leg Bone At Ankle | other | $570 | $570 to $27,792 | Low |
| 8x21x32mm 7 Degree Tm-400 Dev #06-131 | other | $572 | $572 to $2,150 | Low |
| Repair of Openings of Nasal Cartilage | surgery | $573 | $573 to $30,630 | Low |
| Velys Puresight Array Set Knee 4515-70-011 Minimum Order 5 Each | other | $573 | $573 to $2,155 | Low |
| Amputation of Foot Across Instep | other | $574 | $574 to $28,805 | Low |
| Complex Removal of Soft Tissue of Roof of Mouth | surgery | $575 | $575 to $42,145 | Low |
| Removal of Joint Lining From Multiple Knee Joint Compartments Using an Endoscope | surgery | $576 | $576 to $29,876 | Low |
| Repair of Left Upper Heart Chamber with Implant with Review By Radiologist | surgery | $576 | $576 to $37,347 | Low |
| Biopsy of Large Bowel Using an Endoscope Inserted Through Surgically Created ... | surgery | $578 | $578 to $44,389 | Low |
| Repair of Tendon OR Muscle On Top Side of Forearm OR Wrist with Graft | surgery | $578 | $578 to $25,274 | Low |
| Incision and Repair of Elbow Tendon with Removal of Tissue OR Bone | surgery | $578 | $578 to $24,359 | Low |
| Other Procedure On Appendix Using an Endoscope | other | $580 | $580 to $44,979 | Low |
| Tying of Dilated Veins of Stomach And/or Esophagus Using a Flexible Endoscope | other | $580 | $580 to $43,244 | Low |
| Creation of Opening From Small Bowel to Skin with Insertion of a Tube for Dec... | other | $580 | $580 to $44,186 | Low |
| Pneumococcal Conjugate Vaccine, 20 Valent (pcv20), for Intramuscular Use | preventive | $583 | $583 to $90,677 | Low |
| Removal of Infected Skin, Tissue OR Muscle of Genitals, Perineum, OR Abdomen | surgery | $583 | $583 to $11,006 | Low |
| Repair of Knee Joint with Drilling and OR Scraping of Joint Using an Endoscope | surgery | $583 | $583 to $29,879 | Low |
| Multiple Incisions of Connective Tissue of Thigh And/or Knee to Relieve Pressure | other | $584 | $584 to $27,498 | Low |
| Amputation of Thigh Through Thigh Bone Leaving Wound | other | $585 | $585 to $27,592 | Low |
| Closure Device, Vascular | other | $585 | $585 to $2,200 | Low |
| Lutonix .018" Dcb 130cm 5x150mm #lx1813051505f | other | $585 | $585 to $2,200 | Low |
| Lutonix .018" Dcb 130cm 6x150mm #lx1813061505f | other | $585 | $585 to $2,200 | Low |
| Lutonix .018" Dcb 130cm 7x150mm #lx1813071505f | other | $585 | $585 to $2,200 | Low |
| Microporous Collagen Implantable Slit Tube (neurawrap Nerve Protector), Per C... | surgery | $585 | $585 to $2,200 | Low |
| Repair of Forearm And/or Wrist Tendon Covering with Graft | surgery | $585 | $585 to $25,275 | Low |
| Removal of Gallbladder Using an Endoscope | surgery | $586 | $586 to $47,562 | Low |
| Injection of Esophagus, Stomach, And/or Upper Small Bowel Using a Flexible En... | other | $588 | $588 to $43,236 | Low |
| Repair of Ruptured Achilles Tendon | surgery | $588 | $588 to $27,650 | Low |
| Repair of Penis | surgery | $589 | $589 to $54,437 | Low |
| Dilation of Stomach Outlet Using a Flexible Endoscope | other | $590 | $590 to $43,245 | Low |
| Exploration of Stomach OR Removal of Foreign Body in Stomach | surgery | $593 | $593 to $43,500 | Low |
| Injection, Tetanus Immune Globulin, Human, Up to 250 Units | other | $593 | $593 to $3,854 | Low |
| Treatment of Broken Midpart of Forearm Bone On Thumb Side | other | $594 | $594 to $25,515 | Low |
| Placement of Stabilizing Device for Broken Forearm Bone On Thumb Side At Wrist | other | $595 | $595 to $25,606 | Low |
| Release of Hand Muscle | other | $595 | $595 to $26,593 | Low |
| Primary Repair of Torn Ligament OR Joint Capsule At Outside Part of Knee | surgery | $597 | $597 to $27,405 | Low |
| Repair of Abdominal Muscle Hernia | surgery | $597 | $597 to $49,540 | Low |
| Injection, Regadenoson, 0.1 Mg | other | $598 | $598 to $2,248 | Low |
| Simple Surgical Treatment of Kidney Stone with Imaging Guidance | surgery | $598 | $598 to $50,080 | Low |
| Partial Removal of Collar Bone At Shoulder Using an Endoscope | surgery | $598 | $598 to $29,824 | Low |
| Incision of Mastoid Bone | other | $600 | $600 to $69,501 | Low |
| Removal of Leg At Knee Joint | surgery | $600 | $600 to $27,598 | Low |
| Repair of Inside OR Outside Knee Joint Cartilage Using an Endoscope | surgery | $602 | $602 to $29,882 | Low |
| Suture of Hand OR Foot Digital Nerve, First Digital Nerve | other | $604 | $604 to $64,831 | Low |
| Adhesion of Linings of Lung Using an Endoscope | other | $605 | $605 to $32,650 | Low |
| Removal of Growth of Muscle of Neck OR Front of Chest, 5.0 Cm OR More | surgery | $606 | $606 to $21,554 | Low |
| Revision of Permanent Opening of Windpipe for Breathing with Flap Rotation | other | $606 | $606 to $31,614 | Low |
| Removal of Growth of Muscle of Upper Arm OR Elbow, 5.0 Cm OR More | surgery | $609 | $609 to $24,073 | Low |
| Needle Biopsy of Kidney | lab | $610 | $610 to $50,200 | Low |
| Other Procedure On Stomach Using an Endoscope | other | $612 | $612 to $43,659 | Low |
| Anchoring of Flexing Tendon of Fingers to Wrist Bone | other | $614 | $614 to $25,300 | Low |
| Removal of Growth of Muscle of Shoulder, 5.0 Cm OR More | surgery | $614 | $614 to $23,073 | Low |
| Forcep - Prograsp | other | $614 | $614 to $2,310 | Low |
| Forceps Tenaculum for Davinci Xi/x 8mm Instrument #470207 | other | $614 | $614 to $2,310 | Low |
| Re-amputation of Thigh Through Thigh Bone | other | $615 | $615 to $27,596 | Low |
| Technetium Tc 99m Exametazime Diagnostic 25 Mci | other | $615 | $615 to $2,310 | Low |
| Drainage of Deep Abscess OR Blood Accumulation of Pelvis OR Hip Near Joint | other | $617 | $617 to $26,990 | Low |
| Treatment of Ligament Tear At Ankle Joint | other | $618 | $618 to $27,829 | Low |
| Coronary Artery Bypass Using Vein OR Artery Graft, 5 Grafts | cardiac | $618 | $618 to $33,522 | Low |
| Removal of Lining Covering Abdominal Organs | surgery | $619 | $619 to $49,255 | Low |
| Amputation of Finger OR Thumb with Direct Closure | other | $620 | $620 to $26,951 | Low |
| Exploration of Neck for Bleeding, Blood Clot, OR Infection After Surgery | surgery | $620 | $620 to $35,800 | Low |
| Reconstruction of Ligaments Outside Knee Joint | other | $621 | $621 to $27,427 | Low |
| Cranial Neurostim Complex | other | $622 | $622 to $1,036 | Low |
| Removal of Blood Flow Assist Device in Aorta with Repair of Upper Leg Artery | surgery | $625 | $625 to $33,971 | Low |
| Drainage of Fluid Collection By Tube Through Skin Using Imaging Guidance | other | $626 | $626 to $49,405 | Low |
| Closure of Surgically Created Opening From Stomach to Skin | surgery | $627 | $627 to $43,870 | Low |
| Relocation of Tendon of Forearm And/or Wrist | other | $627 | $627 to $25,310 | Low |
| Partial Removal of Pelvic and Aortic Lymph Nodes | surgery | $627 | $627 to $38,562 | Low |
| Treatment of Broken Wrist Bone Located Near Base of Thumb | other | $628 | $628 to $25,628 | Low |
| Insertion of Stomach Feeding Tube | other | $628 | $628 to $43,830 | Low |
| Removal of Growth of Muscle of Back OR Lower Sides, 5.0 Cm OR More | surgery | $628 | $628 to $21,933 | Low |
| Goserelin Acetate Implant, Per 3.6 Mg | surgery | $629 | $629 to $8,768 | Low |
| Insertion of Tube in Peripheral Blood Vessel for Heart-lung Machine Support | cardiac | $630 | $630 to $33,368 | Low |
| Victoza 3-pak 18 Mg/3 Ml Pen | other | $630 | $630 to $2,370 | Low |
| Removal of Growth of Peripheral Nerve | surgery | $631 | $631 to $64,784 | Low |
| Severing of Muscle At Stomach Outlet to Upper Small Bowel | other | $631 | $631 to $43,520 | Low |
| Repair of Nasal Passage Through Nose | surgery | $634 | $634 to $30,540 | Low |
| Removal of Heart Artery Blood Clot By Dissolving Using Imaging Guidance | surgery | $634 | $634 to $92,975 | Low |
| Removal of Gallbladder with X-ray Study of Bile Ducts Using an Endoscope | imaging | $635 | $635 to $47,563 | Low |
| Repair of Trapped OR Strangulated Groin Hernia | surgery | $636 | $636 to $49,521 | Low |
| Destruction of Growth of Rectum | other | $636 | $636 to $45,190 | Low |
| Repair of Ligament of Finger OR Hand and Finger Joint | surgery | $636 | $636 to $26,540 | Low |
| Repair of Abnormal Artery-vein Connection in Arm OR Leg | surgery | $637 | $637 to $35,190 | Low |
| Aspiration of Bone Marrow Sample for Diagnosis | other | $637 | $637 to $38,220 | 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 |
| Secondary Repair of Ruptured Achilles Tendon | surgery | $638 | $638 to $27,654 | Low |
| Lead, Cardioverter-defibrillator, Endocardial Dual Coil | other | $638 | $638 to $2,400 | Low |
| Lead, Left Ventricular Coronary Venous System | cardiac | $638 | $638 to $2,400 | Low |
| Repair Recurrent Incisional OR Ventral Hernia; Incarcerated OR Strangulated | surgery | $639 | $639 to $49,566 | Low |
| Review By Radiologist of Image for Biopsy of Blood Vessel with Tube | lab | $640 | $640 to $75,970 | Low |
| Removal of Growth Plate of Both Lower Leg Bones | surgery | $643 | $643 to $27,477 | Low |
| Removal of Infected Skin, Tissue OR Muscle of Abdomen | surgery | $644 | $644 to $11,005 | Low |
| Preparatory, Below Knee 'ptb' Type Socket, Non-alignable System, No Cover, Sa... | other | $644 | $644 to $2,422 | Low |
| Treatment of Broken Finger OR Hand At Base of Finger | other | $646 | $646 to $26,746 | Low |
| Removal of Growth of Muscle of Pelvis and Hip, 5.0 Cm OR More | surgery | $646 | $646 to $27,045 | Low |
| Removal of Polyps OR Growths of Esophagus, Stomach, And/or Upper Small Bowel ... | surgery | $648 | $648 to $43,251 | Low |
| Repair of Ligament of Hand to Finger Joint with Local Tissue | surgery | $652 | $652 to $26,542 | Low |
| Removal of Foreign Body in Abdominal Cavity | surgery | $653 | $653 to $49,402 | Low |
| Repair of Dislocating Kneecap with Realignment | surgery | $654 | $654 to $27,422 | Low |
| Partial Removal of Finger Bone | surgery | $655 | $655 to $26,567 | Low |
| Repair of Nerve with Graft | surgery | $656 | $656 to $64,910 | Low |
| Reconstruction of Dislocating Kneecap with Removal | surgery | $658 | $658 to $27,424 | Low |
| Repair of Dislocating Kneecap | surgery | $659 | $659 to $27,420 | Low |
| Treatment of Broken Kneecap with Placement of Stabilizing Device And/or Remov... | other | $660 | $660 to $27,524 | Low |
| Nuclear Medicine Study Limited Area with CT Scan | imaging | $661 | $661 to $78,814 | Low |
| Transfer of Deep Tendon of Foot with Muscle Rerouting | other | $661 | $661 to $27,691 | Low |
| Repair of Non-healed Wrist Bone, Scaphoid OR Navicular At the Base of the Thumb | surgery | $661 | $661 to $25,440 | Low |
| Shortening of One of the Forearm Bones | other | $661 | $661 to $25,390 | Low |
| Fusion of Joint Between Finger and Hand | surgery | $662 | $662 to $26,850 | Low |
| Laparoscopy, Surgical, Repair, Ventral, Umbilical, Spigelian OR Epigastric He... | surgery | $664 | $664 to $49,653 | Low |
| Repair of Knee Joint with Bone Graft and Internal Stabilizing Device Using an... | surgery | $664 | $664 to $29,887 | Low |
| Laparoscopy, Surgical, Repair, Incisional Hernia (includes Mesh Insertion, Wh... | surgery | $665 | $665 to $49,655 | Low |
| Laparoscopy, Surgical, Repair, Recurrent Incisional Hernia (includes Mesh Ins... | surgery | $665 | $665 to $49,657 | Low |
| Probe 10cm Malleable A000683 | other | $665 | $665 to $2,500 | Low |
| Removal of Growth of Muscle of Thigh OR Knee, 5.0 Cm OR More | surgery | $666 | $666 to $27,339 | Low |
| Repair of Knee Joint with Bone Graft Using an Endoscope | surgery | $666 | $666 to $29,885 | Low |
| Injection, Etoposide, 10 Mg | other | $667 | $667 to $1,111 | Low |
| Repair Initial Incisional OR Ventral Hernia; Incarcerated OR Strangulated | surgery | $668 | $668 to $49,561 | Low |
| Addition to Lower Limb Prosthesis, Vertical Shock Reducing Pylon Feature | other | $668 | $668 to $2,512 | Low |
| Treatment of Both Broken Lower Leg Bones At Ankle | other | $670 | $670 to $27,814 | Low |
| Amputation of Thigh Through Thigh Bone | other | $670 | $670 to $27,590 | Low |
| Flotufolastat F 18, Diagnostic, 1 Millicurie | other | $671 | $671 to $8,296 | Low |
| Biopsy of Lung Lining | lab | $671 | $671 to $32,098 | Low |
| Removal of Lymph Nodes From Chin to Thyroid Cartilage | surgery | $672 | $672 to $38,700 | Low |
| Repair of Joint Capsule of Hand and Palm, 1 Finger | surgery | $672 | $672 to $26,516 | Low |
| Exchange of Abdominal Cavity Drainage Tube Using Imaging Guidance | other | $672 | $672 to $49,423 | Low |
| Removal of Defect in Wall of Esophagus Through Neck | surgery | $672 | $672 to $43,130 | Low |
| Removal and Replacement of Stent in Kidney and Ureter Using Fluoroscopic Guid... | surgery | $672 | $672 to $50,387 | Low |
| Deep Biopsy of Bone Using Needle OR Trocar | lab | $674 | $674 to $20,225 | Low |
| Repair of Blood Vessel of Arm | surgery | $675 | $675 to $35,206 | Low |
| Instillation, Bupivacaine and Meloxicam, 1 Mg/0.03 Mg | other | $677 | $677 to $2,546 | Low |
| Insertion of Tube Into Small Bowel | other | $677 | $677 to $44,300 | Low |
| Exploration of Abdominal Cavity | other | $678 | $678 to $49,000 | Low |
| Creation of Permanent Opening of Windpipe for Breathing | other | $678 | $678 to $31,610 | Low |
| Catheter, Transluminal Angioplasty, Drug-coated, Non-laser | cardiac | $678 | $678 to $2,550 | Low |
| Vascular Graft Material, Synthetic, Implant | surgery | $681 | $681 to $2,909 | Low |
| Core Needle Biopsy of Lung OR Center Cavity of Chest (mediastinum), Accessed ... | lab | $682 | $682 to $32,408 | Low |
| Biopsy of Esophagus, Stomach, And/or Upper Small Bowel Using a Flexible Endos... | lab | $684 | $684 to $43,239 | Low |
| Control of Bleeding of Esophagus, Stomach, And/or Upper Small Bowel Using a F... | other | $684 | $684 to $43,255 | Low |
| Insertion of Guide Wire with Dilation of Esophagus Using a Flexible Endoscope | other | $684 | $684 to $43,248 | Low |
| Insertion of Stomach Tube Using a Flexible Endoscope | other | $684 | $684 to $43,246 | Low |
| Insertion of Hypoglossal Nerve Neurostimulator Electrode and Generator and Br... | other | $685 | $685 to $64,582 | Low |
| Intracept Access Instrument Rlv 0055 | other | $686 | $686 to $2,580 | Low |
| Removal of Blood Clot and Portion of Upper Thigh Artery | surgery | $686 | $686 to $35,371 | Low |
| Repair of Congenital Bowel Defect | surgery | $688 | $688 to $44,800 | Low |
| Removal of Bony Growths of Ear Canal | surgery | $688 | $688 to $69,140 | Low |
| Express Tray 15/2 First Fracture with Kyphx | other | $689 | $689 to $2,591 | Low |
| Insertion of Electrode to Outer Layer of Heart | cardiac | $689 | $689 to $33,202 | Low |
| Plastic OR Reconstructive Repair of Throat | surgery | $690 | $690 to $42,950 | Low |
| Repair Non-healed Fracture of Forearm Bone | surgery | $691 | $691 to $25,400 | Low |
| Clamp Long Jaw A000362 | other | $692 | $692 to $2,600 | Low |
| Clamp Short Jaw A000432 | other | $692 | $692 to $2,600 | Low |
| Endovascular Repair of Iliac Artery (eg, Aneurysm, Pseudoaneurysm, Arterioven... | surgery | $692 | $692 to $34,900 | Low |
| Balloon Dilation of Groin Artery, Each Additional Vessel | other | $692 | $692 to $37,222 | Low |
| Other Antepartum Diagnoses without O.r. Procedures without Cc/mcc | other | $693 | $693 to $14,072 | Low |
| Amputation of Finger OR Thumb | other | $693 | $693 to $26,910 | Low |
| Release of Major Arm OR Leg Nerve | other | $695 | $695 to $64,713 | Low |
| Fusion of Part of Wrist Joint with Patient-derived Bone Graft | surgery | $698 | $698 to $25,825 | Low |
| Replacement of Joint Between Wrist and Fingers Using Tissue | surgery | $698 | $698 to $25,447 | Low |
| Repair of Torn Ligament And/or Joint Capsule At Front of Knee | surgery | $700 | $700 to $27,407 | Low |
| Repair of Blood Vessel of Leg | surgery | $702 | $702 to $35,226 | Low |
| Removal of Growth of Rectum Through Anus with Removal of a Portion of Muscle | surgery | $703 | $703 to $45,172 | Low |
| Insertion of Tube Through the Chest for Ecmo External Blood Circulation in He... | other | $704 | $704 to $33,956 | Low |
| Coronary Artery Bypass Using Vein OR Artery Graft, 6 OR More Grafts | cardiac | $704 | $704 to $33,523 | Low |
| Catheter, Intravascular Ultrasound | imaging | $705 | $705 to $2,650 | Low |
| Suture of Hand Median Motor Nerve | other | $706 | $706 to $64,835 | Low |
| Revision OR Replacement of Hypoglossal Nerve Neurostimulator Electrode and Br... | surgery | $707 | $707 to $64,583 | Low |
| Exploration, Drainage, Biopsy, OR Removal of Foreign Body in Chest Cavity | surgery | $709 | $709 to $39,010 | Low |
| Biopsy of Fluid Collection of Lung | lab | $710 | $710 to $32,096 | Low |
| Diagnostic Exam of Large Bowel Using an Endoscope Inserted Through Surgically... | surgery | $711 | $711 to $44,388 | Low |
| Removal of Growths OR Polyps of Large Bowel By Mechanical Snare Using an Endo... | surgery | $711 | $711 to $44,394 | Low |
| Stress Test | cardiac | $711 | $70 to $2,674 | High |
| Incision OR Partial Removal of Middle Portion of Thigh Bone | surgery | $713 | $713 to $27,448 | Low |
| Treatment of Broken Shin Bone At Knee | other | $713 | $713 to $27,540 | Low |
| Repair of Upper End of Shin Bone At Knee Joint | surgery | $715 | $715 to $27,418 | Low |
| Biopsy of Growth of Lung | lab | $716 | $716 to $32,097 | Low |
| Insertion of Electrode to Outer Layer of Heart Using an Endoscope | cardiac | $716 | $716 to $33,203 | Low |
| Repair of Joint Between Finger and Palm | surgery | $717 | $717 to $26,548 | Low |
| Delivery of Simple High Precision Radiation Treatment | obstetric | $720 | $720 to $77,385 | Low |
| Creation of Open Flap Tract for Drainage of Infected Material From Lining Aro... | other | $720 | $720 to $32,036 | Low |
| Incision of Corner of Eye At Eyelid | other | $720 | $720 to $67,715 | Low |
| Exploration of Arm OR Leg for Bleeding, Blood Clot, OR Infection After Surgery | surgery | $721 | $721 to $35,860 | Low |
| Incision and Exploration of Chest Cavity | other | $723 | $723 to $32,100 | Low |
| Treatment of 2 Broken Lower Forearm Bone Pieces On Thumb Side Inside Wrist Jo... | other | $723 | $723 to $25,608 | Low |
| Repair of Wound By Transferring Skin, 30.1-60.0 SQ Cm | surgery | $724 | $724 to $14,301 | Low |
| Suture Repair of Ureter | surgery | $725 | $725 to $50,900 | Low |
| Repair of Wrist Joint | surgery | $727 | $727 to $25,332 | Low |
| Removal of Lymph Nodes of Groin | surgery | $729 | $729 to $38,760 | Low |
| Catheter Spyscope Ds #m00546600 | cardiac | $730 | $730 to $2,743 | Low |
| Spyscope Ds Ii Access & Delivery Catheter M00546610 | cardiac | $730 | $730 to $2,743 | Low |
| Repair of Blood Vessel of Arm with Graft | surgery | $731 | $731 to $35,266 | Low |
| Clip Pro 35mm Atriclip #a000824 | other | $732 | $732 to $2,750 | Low |
| Clip Pro 40mm Atriclip #a000825 | other | $732 | $732 to $2,750 | Low |
| Clip Pro 50mm Atriclip #a000827 | other | $732 | $732 to $2,750 | Low |
| Hearing Aid, Digital, Monaural, Bte | other | $732 | $732 to $5,500 | Low |
| Scp Foot & Ankle Kit #514.315 | other | $732 | $732 to $2,750 | Low |
| Drainage of Fluid Collection of Abdominal Cavity By Tube Using Imaging Guidance | other | $732 | $732 to $49,406 | Low |
| X-ray of Lower Spinal Canal with Review By Radiologist | imaging | $732 | $732 to $62,304 | Low |
| Removal of Connective Tissue of Palm and Release of Finger, First Digit | surgery | $733 | $733 to $26,123 | Low |
| Partial Removal of Liver Tissue | surgery | $734 | $734 to $47,100 | Low |
| X-ray of Middle Spinal Canal with Review By Radiologist | imaging | $734 | $734 to $62,303 | Low |
| X-ray of Upper Spinal Canal with Review By Radiologist | imaging | $734 | $734 to $62,302 | Low |
| Repair of Ruptured Bowel Into Bladder | surgery | $735 | $735 to $51,525 | Low |
| Ultrasound Guided Needle Aspiration OR Biopsy of Esophagus Using a Flexible E... | imaging | $735 | $735 to $43,238 | Low |
| Knee Ankle Foot Orthosis, Fracture Orthosis, Femoral Fracture Cast Orthosis, ... | other | $738 | $738 to $2,775 | Low |
| Exclusion of Appendage of Left Upper Chamber of Heart Using an Endoscope | cardiac | $740 | $740 to $33,269 | Low |
| Lutonix .018" Dcb 130cm 4x220mm # Lx1813042204f | other | $745 | $745 to $2,800 | Low |
| Lutonix .018" Dcb 130cm 5x220mm #lx1813052205f | other | $745 | $745 to $2,800 | Low |
| Lutonix .018" Dcb 130cm 6x220mm #lx1813062205f | other | $745 | $745 to $2,800 | Low |
| Lutonix .018" Dcb 130cm 7x220mm #lx1813072205f | other | $745 | $745 to $2,800 | Low |
| Fusion of Wrist Joint with Graft From Hip OR Other Bone | surgery | $745 | $745 to $25,810 | Low |
| Reshaping of Tip of Nose | other | $747 | $747 to $30,400 | Low |
| Injection, Dmso, Dimethyl Sulfoxide, 50%, 50 Ml | other | $749 | $749 to $5,387 | Low |
| Simple Complete Removal of Breast | surgery | $751 | $751 to $19,303 | Low |
| MRI Scan of Arm Joint with Contrast | imaging | $752 | $752 to $73,222 | Low |
| MRI Scan of Chest with Contrast | imaging | $752 | $752 to $71,551 | Low |
| MRI Scan of Leg Joint with Contrast | imaging | $752 | $752 to $73,722 | Low |
| X-ray of Multiple Regions of Spinal Canal with Review By Radiologist | imaging | $752 | $752 to $62,305 | Low |
| Byfavo 20 Mg Vial | other | $752 | $752 to $2,826 | Low |
| Remimazolam Besylate 20 Mg IV Solr | other | $752 | $752 to $2,826 | Low |
| Closure of Surgically Created Large OR Small Bowel Opening | surgery | $752 | $752 to $44,620 | Low |
| Repair of Eardrum and Ear Canal with Opening to Ear Bones | surgery | $754 | $754 to $69,631 | Low |
| Prosthetic Implant, Not Otherwise Specified | surgery | $754 | $754 to $2,833 | Low |
| Forcep - Fenestrated Bipolar | other | $754 | $754 to $2,835 | Low |
| Forcep Maryland Bipolar | other | $754 | $754 to $2,835 | Low |
| Forceps Cadiere #471049 | other | $754 | $754 to $2,835 | Low |
| Forceps Prograsp #471093 | other | $754 | $754 to $2,835 | Low |
| Intensive Care Unit - General Classification | other | $754 | $754 to $2,835 | Low |
| Initial Inpatient Hospital Critical Care of Newborn Per Day | obstetric | $757 | $757 to $99,468 | Low |
| Conversion of Kidney Tube to Nephroureteral Tube Using Imaging Guidance and S... | other | $757 | $757 to $50,434 | Low |
| Kyphon 10/2 #kex102eb | other | $758 | $758 to $2,850 | Low |
| Kyphon Kit 15/2 #kex152eb | other | $758 | $758 to $2,850 | Low |
| Stent, Coated/covered, with Delivery System | cardiac | $758 | $758 to $2,850 | Low |
| Kyphon 15/3 Expender Ii Tray #kpx153pb | other | $758 | $758 to $2,851 | Low |
| Genomic Sequence Analysis Panel of Dna OR Combined Dna and Rna of 5-50 Genes ... | lab | $760 | $760 to $81,450 | Low |
| Fusion of Thumb At Wrist with Bone Graft | surgery | $763 | $763 to $26,842 | Low |
| Repair of Muscle of Stomach Outlet Into Upper Small Bowel | surgery | $763 | $763 to $43,800 | Low |
| Extensive Destruction and Reconstruction of Right Upper Heart Chamber On Hear... | cardiac | $764 | $764 to $33,259 | Low |
| Amputation of Both Lower Leg Bones | other | $765 | $765 to $27,880 | Low |
| Ca15l2 15cm Reinforced Percutaneous Antenna X1 | other | $767 | $767 to $2,885 | Low |
| Ca20l2 Reinforced Percutaneous Antenna Emprint X1 | other | $767 | $767 to $2,885 | Low |
| Repair of Nerve Using Nerve Graft, First Strand | surgery | $768 | $768 to $64,912 | Low |
| Replacement of Joint Between Wrist and Fingers Using Tendon OR Stitches | surgery | $769 | $769 to $25,448 | Low |
| Control of Bleeding of First OR Second Part of Small Bowel Using an Endoscope | other | $769 | $769 to $44,366 | Low |
| Cardiac Congenital and Valvular Disorders without Mcc | cardiac | $770 | $770 to $21,359 | Low |
| Injection, Ferumoxytol, for Treatment of Iron Deficiency Anemia, 1 Mg | other | $770 | $770 to $1,283 | Low |
| Biopsy and Aspiration of Bone Marrow Sample for Diagnosis | lab | $772 | $772 to $38,222 | Low |
| Removal of Cyst Below Breast Bone | surgery | $773 | $773 to $39,200 | Low |
| Removal of Blood Clot in Neck to Chest Artery | surgery | $774 | $774 to $34,001 | Low |
| Treatment of 3 Broken Lower Leg Bones At Ankle | other | $774 | $774 to $27,822 | Low |
| Repair of Tendons of Outer Forearm At Wrist Joint | surgery | $777 | $777 to $25,337 | Low |
| Initial Removal of Wedge of Lung Tissue Using an Endoscope | surgery | $780 | $780 to $32,666 | Low |
| Revision of Leg Artery Bypass with Vein Patch | other | $780 | $780 to $35,879 | Low |
| Removal of Lymph Nodes of Underarm | surgery | $781 | $781 to $38,745 | Low |
| Repair of Blood Vessel of Leg with Graft | surgery | $781 | $781 to $35,286 | Low |
| Destruction of Cyst of Kidney Using an Endoscope | other | $782 | $782 to $50,541 | Low |
| Small Clip Applier Xi #470401 Intuitive Surgical | surgery | $782 | $782 to $2,940 | Low |
| Repair of Blood Vessel of Neck | surgery | $787 | $787 to $35,201 | Low |
| Destruction of Polyp OR Growth of Small Bowel Using an Endoscope | other | $787 | $787 to $44,369 | Low |
| Incision of Chest Cavity for Complications After Surgery | surgery | $789 | $789 to $32,120 | Low |
| Release of Tendon Connecting Biceps Muscle and Shoulder Using an Endoscope | other | $791 | $791 to $29,828 | Low |
| Preparatory, Below Knee 'ptb' Type Socket, Non-alignable System, Pylon, No Co... | other | $792 | $792 to $2,978 | Low |
| Catheter, Intracardiac Echocardiography | imaging | $792 | $792 to $2,979 | Low |
| Echocardiogram | imaging | $792 | $66 to $3,400 | High |
| Removal of Middle Ear (mastoid) Bone | surgery | $794 | $794 to $69,502 | Low |
| Removal of Blood Clot and Revision of Artery OR Vein Graft | surgery | $795 | $795 to $35,876 | Low |
| Release of Small Bowel Scar Tissue Using an Endoscope | other | $796 | $796 to $44,180 | Low |
| Knee Ankle Foot Orthosis, Full Plastic, Double Upright, with OR without Free ... | other | $799 | $799 to $3,002 | Low |
| Removal of Cyst OR Growth of Chest Cavity Using an Endoscope | surgery | $800 | $800 to $32,662 | Low |
| Removal of Blood Clot in Artery of Lower Leg | surgery | $800 | $800 to $34,203 | Low |
| Exploration of Ureter | other | $800 | $800 to $50,600 | Low |
| Exploration Behind Abdominal Cavity | other | $803 | $803 to $49,010 | Low |
| Replacement of Kidney Drainage Tube Using Imaging Guidance with Review By Rad... | surgery | $805 | $805 to $50,435 | Low |
| Partial Removal of Breast and Underarm Lymph Nodes | surgery | $805 | $805 to $19,302 | Low |
| Treatment of 3 OR More Broken Lower Forearm Bone Pieces On Thumb Side Inside ... | other | $807 | $807 to $25,609 | Low |
| Balloon Dilation of Artery of Leg, Each Additional Vessel | other | $807 | $807 to $37,232 | Low |
| Repair of Aneurysm OR Forearm Artery with Graft | surgery | $809 | $809 to $35,045 | Low |
| Partial Removal of Roof of Mouth | surgery | $809 | $809 to $42,120 | Low |
| Hearing Aid, Digital, Binaural, Bte | other | $811 | $811 to $9,320 | Low |
| Tlso, Triplanar Control, Two Piece Rigid Plastic Shell with Interface Liner, ... | other | $812 | $812 to $3,051 | Low |
| Review By Radiologist of Major Upper Body Vein Image | other | $817 | $817 to $75,827 | Low |
| Repair of Twisted OR Herniated Small Bowel | surgery | $818 | $818 to $44,050 | Low |
| Treatment of Broken Side of Lower End of Thigh Bone | other | $819 | $819 to $27,514 | Low |
| Removal and Replacement of Stent in Ureter with Review By Radiologist | surgery | $819 | $819 to $50,382 | Low |
| Removal of Blood Clot and Portion of Deep Upper Thigh Artery | surgery | $821 | $821 to $35,372 | Low |
| Insertion of Stent and Blood Clot Protection Device in Neck Artery with Revie... | cardiac | $823 | $823 to $37,215 | Low |
| Repair of Chronic Injury to Muscle Separating Chest and Abdominal Cavities | surgery | $824 | $824 to $39,541 | Low |
| Simple Partial Removal of Bladder | surgery | $826 | $826 to $51,550 | Low |
| Creation of Flap Graft to Nose, Forehead, Temple, OR Scalp | other | $829 | $829 to $15,731 | Low |
| Relocation of Nerve and Muscle to Restore Voice Box Function | other | $829 | $829 to $31,590 | Low |
| Addition, Endoskeletal, Knee-shin System, Stance Flexion Feature, Adjustable | other | $831 | $831 to $3,125 | Low |
| Initial Removal of Wedge of Lung Tissue | surgery | $832 | $832 to $32,505 | Low |
| Repair of Blood Vessel of Neck with Graft | surgery | $832 | $832 to $35,261 | Low |
| Repair of Anterior Cruciate Ligament of Knee Using an Endoscope | surgery | $834 | $834 to $29,888 | Low |
| Transfer of Nerve to Injured Nerve, Stage 1 of 2 | other | $835 | $835 to $64,905 | Low |
| Incision OR Partial Removal of Upper Portion of Lower Leg Bone to Repair Defo... | surgery | $835 | $835 to $27,455 | Low |
| Ca30l2 Reinforced Percutaneous Antenna Emprint X1 | other | $837 | $837 to $3,148 | Low |
| Cath Ensite Cath Array #ec1000-204 5/bx | other | $838 | $838 to $3,150 | Low |
| Repair of Throat At Esophagus | surgery | $841 | $841 to $42,953 | Low |
| Ropivacaine/ Ketorolac 400 Ml On-q Pump (greenlaw) - Compounded | other | $842 | $842 to $3,167 | Low |
| Implantation of Self Cartilage Cells Into Knee Bone | surgery | $844 | $844 to $27,416 | Low |
| Extensive Removal of Growth of Face OR Scalp, 2.0 Cm OR More | surgery | $847 | $847 to $21,016 | Low |
| Repair of Aneurysm OR Arm Artery with Graft | surgery | $847 | $847 to $35,011 | Low |
| Removal of Growth of Ear Canal | surgery | $849 | $849 to $69,150 | Low |
| Insertion of Brain Neurostimulator Pulse Device with Connection to 2 OR More ... | other | $851 | $851 to $61,886 | Low |
| Removal of Air Sac of Lung Using an Endoscope | surgery | $851 | $851 to $32,655 | Low |
| Lead, Neurostimulator | other | $851 | $851 to $3,200 | Low |
| Repair of Blood Vessel of Arm with Vein Graft | surgery | $854 | $854 to $35,236 | Low |
| Removal of Stomach Ulcer OR Growth | surgery | $854 | $854 to $43,610 | Low |
| Reopening of Recent Abdominal Incision | other | $854 | $854 to $49,002 | Low |
| Insertion of Stents with Balloon Dilation of Coronary Artery OR Branch, Each ... | cardiac | $855 | $855 to $92,929 | Low |
| Biopsy OR Removal of Foreign Body in Large Bowel | surgery | $855 | $855 to $44,025 | Low |
| Insertion of Stent in Arteries of Leg | cardiac | $856 | $856 to $37,226 | Low |
| Suture and Relocation of Arm OR Leg Peripheral Nerve | other | $857 | $857 to $64,856 | Low |
| Extensive Removal of Tonsils, Tissue, Muscle, and Bone | surgery | $859 | $859 to $42,842 | Low |
| Tonsillectomy | surgery | $859 | $859 to $6,828 | High |
| Recording of Right Lower Heart Chamber Rhythm | cardiac | $859 | $859 to $93,603 | Low |
| Removal of Blood Clot in Artery of Groin and Leg | surgery | $860 | $860 to $34,201 | Low |
| Removal of Gallbladder | surgery | $862 | $862 to $47,600 | Low |
| Repair of Blood Vessel of Leg with Vein Graft | surgery | $863 | $863 to $35,256 | Low |
| Relocation of Defibrillator Skin Pocket | other | $865 | $865 to $33,223 | Low |
| Relocation of Pacemaker Skin Pocket | cardiac | $865 | $865 to $33,222 | Low |
| Removal of Blood Clot and Portion of Artery of Upper Thigh | surgery | $865 | $865 to $35,355 | Low |
| Removal of Gallbladder with Exploration of Common Bile Duct Using an Endoscope | surgery | $865 | $865 to $47,564 | Low |
| Repair of Shoulder Rotator Cuff Using an Endoscope | surgery | $866 | $866 to $29,827 | Low |
| Relocation And/or Reimplantation of Neck Artery to Chest Artery | surgery | $867 | $867 to $35,695 | Low |
| Revision of Leg Artery Bypass with Placement of Relocated Vein | other | $867 | $867 to $35,881 | Low |
| Reconstruction of Wrist Joint | other | $870 | $870 to $25,320 | Low |
| Repair of Shoulder Joint Capsule Using an Endoscope | surgery | $870 | $870 to $29,806 | Low |
| Repair of Nasal Passage | surgery | $870 | $870 to $30,465 | Low |
| Removal of Growth of Saliva Gland with Release of Facial Nerve | surgery | $871 | $871 to $42,415 | Low |
| Removal of Growth of Windpipe Cartilage | surgery | $872 | $872 to $31,785 | Low |
| Insertion of Stent in Ureter | cardiac | $872 | $872 to $50,605 | Low |
| Reconstruction of Opening From Small Bowel to Skin | other | $874 | $874 to $44,314 | Low |
| Complex Repair of Eardrum and Ear Canal with Removal of Mastoid Bone | surgery | $876 | $876 to $69,641 | Low |
| Valvulotome 1.8 Expandable #1009 | other | $878 | $878 to $3,299 | Low |
| Catheter, Transluminal Atherectomy, Rotational | cardiac | $879 | $879 to $3,306 | Low |
| Balloon Dilation of Coronary Artery OR Branch, Each Additional Artery OR Branch | cardiac | $880 | $880 to $92,921 | Low |
| Repair Non-healed Fracture of Forearm Bone with Patient-derived Bone Graft | surgery | $881 | $881 to $25,405 | Low |
| Release of Intestinal Scar Tissue | other | $884 | $884 to $44,005 | Low |
| Bypass of Diseased OR Blocked Chest to Opposite Chest Artery with Other Than ... | other | $884 | $884 to $35,612 | Low |
| Indium-111 Pentetate | other | $885 | $885 to $3,326 | Low |
| Catheter, Extravascular Tissue Ablation, Any Modality | cardiac | $885 | $885 to $3,328 | Low |
| Removal of Ureter and Partial Removal of Bladder | surgery | $885 | $885 to $50,650 | Low |
| Skin Graft Except for Skin Ulcer OR Cellulitis without Cc/mcc | other | $886 | $886 to $26,372 | Low |
| Thyroidectomy | surgery | $888 | $888 to $8,140 | High |
| Repair of Eardrum, Ear Canal, and Bones with Insertion of Prosthesis | surgery | $889 | $889 to $69,633 | Low |
| Review By Radiologist of Liver Vein Image with Assessment of Blood Flow | other | $891 | $891 to $75,889 | Low |
| Repair of Shoulder Socket Using an Endoscope | surgery | $891 | $891 to $29,807 | Low |
| Repair of Descending Aorta, Initial Extension | surgery | $894 | $894 to $33,883 | Low |
| Removal of Growth of Esophagus Through Chest OR Abdomen | surgery | $900 | $900 to $43,101 | Low |
| Removal of Growth OR Cyst of From Heart Sac | surgery | $900 | $900 to $33,050 | Low |
| Complicated Reconstruction of Opening From Large Bowel to Skin | other | $901 | $901 to $44,345 | Low |
| Bypass of Diseased OR Blocked Upper Leg to Lower Thigh Artery with Other Than... | other | $902 | $902 to $35,656 | Low |
| Csi Burr 1.5 Classic | other | $903 | $903 to $3,395 | Low |
| Csi Burr 2.0 Classic | other | $903 | $903 to $3,395 | Low |
| Stealth 1.5 Classic Crown #dbp-150classic145 | other | $903 | $903 to $3,395 | Low |
| Stealth 2.0 #dbp-200classic145 | other | $903 | $903 to $3,395 | Low |
| Stealth Th 1.5 Solid Crown #dbp-150solid145 | other | $903 | $903 to $3,395 | Low |
| Suture of Tear OR Hole in Large Bowel | other | $903 | $903 to $44,604 | Low |
| Creation of Opening From Small Bowel to Skin | other | $903 | $903 to $44,310 | Low |
| Removal of Extra Finger | surgery | $908 | $908 to $26,587 | Low |
| Bypass of Diseased OR Blocked Upper Leg to Opposite Upper Leg Artery with Oth... | other | $911 | $911 to $35,661 | Low |
| Creation of Opening From Large Bowel to Skin with Multiple Bowel Biopsies | other | $913 | $913 to $44,322 | Low |
| Repair of Eardrum, Ear Canal, and Bones | surgery | $914 | $914 to $69,632 | Low |
| Repair of Knee Cartilage and Bone with Patient-derived Healthy Cartilage Tran... | surgery | $916 | $916 to $29,866 | Low |
| Catheter, Transluminal Intravascular Lithotripsy, Coronary | cardiac | $918 | $918 to $3,450 | Low |
| Implantable/insertable Device, Not Otherwise Classified | surgery | $918 | $918 to $3,450 | Low |
| Bypass of Diseased OR Blocked Arm to Chest Artery with Other Than Vein | other | $919 | $919 to $35,621 | Low |
| Forceps Maryland Bipolar #471172 | other | $919 | $919 to $3,455 | Low |
| Repair of Aneurysm OR Upper Thigh Artery with Graft | surgery | $919 | $919 to $35,141 | Low |
| Exclusion of Appendage of Left Upper Chamber of Heart | cardiac | $919 | $919 to $33,267 | Low |
| Respiratory Syncytial Virus Antibody for Injection Into Tissue OR Muscle | other | $920 | $920 to $90,378 | Low |
| Removal of Less Than Half of Tongue | surgery | $921 | $921 to $41,120 | Low |
| Bypass of Diseased OR Blocked Upper Arm to Opposite Arm Artery with Vein | other | $928 | $928 to $35,525 | Low |
| Probe, Image-guided, Robotic, Waterjet Ablation | other | $928 | $928 to $3,490 | Low |
| Dupixent 200 Mg/1.14 Ml Syring | other | $933 | $933 to $3,509 | Low |
| Dupixent 300 Mg/2 Ml Syringe | other | $933 | $933 to $3,509 | Low |
| Technetium Tc-99m Exametazime Labeled Autologous White Blood Cells, Diagnosti... | other | $934 | $934 to $5,776 | Low |
| Repair of Aneurysm OR Neck OR Upper Chest Artery with Graft | surgery | $934 | $934 to $35,001 | Low |
| Pacemaker, Single Chamber, Rate-responsive | cardiac | $936 | $936 to $3,518 | Low |
| Replacement of Tunneled Central Venous Tube | surgery | $936 | $936 to $36,581 | Low |
| Repositioning of Left Lower Heart Electrode | cardiac | $936 | $936 to $33,226 | Low |
| Removal of Foreign Body in Lining of Chest Cavity Using an Endoscope | surgery | $937 | $937 to $32,653 | Low |
| Delivery of Complex High Precision Radiation Treatment | obstetric | $937 | $937 to $77,386 | Low |
| Strengthening of Muscle Between Esophagus and Stomach By Wrapping Part of Sto... | other | $939 | $939 to $43,280 | Low |
| Removal of Blood Clot and Portion of Superficial Femoral Artery | surgery | $939 | $939 to $35,302 | Low |
| Creation of Opening From Large Bowel to Skin | other | $942 | $942 to $44,320 | Low |
| Repair of Side of Voice Box By Moving Vocal Cord to Middle | surgery | $943 | $943 to $31,591 | Low |
| Repair of Aorta OR Great Vessels with Sutures | surgery | $945 | $945 to $33,320 | Low |
| Repair of Prolapsed Rectum Through Anus | surgery | $946 | $946 to $45,130 | Low |
| Removal of Gallbladder with X-ray Study of Bile Ducts | imaging | $947 | $947 to $47,605 | Low |
| Balloon Viabahn Bx 7mmx59mm 7fr Bxa075902a | other | $948 | $948 to $3,563 | Low |
| Removal of Blood Clot and Portion of Chest, Neck, OR Brain Artery | surgery | $951 | $951 to $35,301 | Low |
| Connection of Ureter to Bladder | other | $953 | $953 to $50,780 | Low |
| Bypass of Diseased OR Blocked Knee to Lower Leg Arteries with Other Than Vein | other | $954 | $954 to $35,671 | Low |
| Complex Surgical Treatment of Kidney Stone with Imaging Guidance | surgery | $955 | $955 to $50,081 | Low |
| Infasurf 35 Mg/ml Vial | other | $957 | $957 to $3,598 | Low |
| Removal of Gallbladder with Exploration of Common Bile Duct | surgery | $960 | $960 to $47,610 | Low |
| Creation of Opening From Small Bowel to Skin Using an Endoscope | other | $961 | $961 to $44,187 | Low |
| Partial Removal of Chest Cavity Lining and Lung Lining Using an Endoscope | surgery | $966 | $966 to $32,651 | Low |
| Stabilization of Thigh Bone with Device | other | $969 | $969 to $27,495 | Low |
| Partial Replacement of Thigh Bone At Hip Joint with Prosthesis | surgery | $969 | $969 to $27,125 | Low |
| Removal of Kidney Stone | surgery | $971 | $971 to $50,060 | Low |
| Division of Extra Arch of Aorta | other | $971 | $971 to $33,802 | Low |
| Removal of Growth of Saliva Gland OR Saliva Gland with Release of Facial Nerve | surgery | $972 | $972 to $42,420 | Low |
| Reconstruction Ligaments Inside Knee Joint | other | $973 | $973 to $27,428 | Low |
| Limb Ext Iliac Cuff Left #is20-25/c55 Sa | other | $974 | $974 to $3,660 | Low |
| Limb Extension Cuff #is20-25/c65 Sa | other | $974 | $974 to $3,660 | Low |
| Limb Extensions Cuff #i16-16/c55f Sa | other | $974 | $974 to $3,660 | Low |
| Limb Extensions Cuff #i20-13/c88f Sa | other | $974 | $974 to $3,660 | Low |
| Limb Extensions Cuff #i20-20/c55f Sa | other | $974 | $974 to $3,660 | Low |
| Reconstruction of Ear Canal | other | $976 | $976 to $69,310 | Low |
| Repair of Groin Artery with Graft for Other Than Rupture with Review By Radio... | surgery | $976 | $976 to $34,707 | Low |
| Suture of Perforated Ulcer, Wound, OR Injury of Stomach OR Upper Small Bowel | other | $976 | $976 to $43,840 | Low |
| Revision of Opening From Large Bowel to Skin with Repair of Hernia | surgery | $978 | $978 to $44,346 | Low |
| Gore Excluder Endorosthesis Iliac Branch Comp #hgb161007a | other | $980 | $980 to $3,684 | Low |
| Replacement of Knee Joint On Side of Knee | surgery | $980 | $980 to $27,446 | Low |
| Repair of Rectal Prolapse Using an Endoscope | surgery | $984 | $984 to $45,400 | 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 |
| Injection of Bile Duct for X-ray Through Already Existing Skin Access Using I... | imaging | $995 | $995 to $47,531 | Low |
| Removal of Growth Below Breast Bone | surgery | $995 | $995 to $39,220 | Low |
| Mechanical Heart Valve Aortic Size 27mm 27agn | cardiac | $998 | $998 to $3,750 | Low |
| Suture of Bleeding Stomach Ulcer | other | $998 | $998 to $43,501 | Low |
| Gore Excluder Aaa Endoprosthesis 12fr Pll161207 | other | $998 | $998 to $3,753 | Low |
| Gore Excluder Aaa Endoprosthesis 16mm X 14.5mm Pll161407 | other | $998 | $998 to $3,753 | Low |
| Removal of Extra Skin and Tissue of Abdomen | surgery | $1,000 | $1,000 to $15,830 | Low |
| Repair of Paraesophageal Hernia Through Abdomen | surgery | $1,001 | $1,001 to $43,332 | Low |
| Repair of Ruptured Aneurysm of Arm Artery with Graft | surgery | $1,001 | $1,001 to $35,013 | Low |
| Dilation of Windpipe Cartilage OR Treatment of Broken Windpipe Cartilage Usin... | other | $1,003 | $1,003 to $31,630 | Low |
| Replacement of Aortic Valve Through the Skin and Femoral Artery | surgery | $1,004 | $1,004 to $33,361 | Low |
| Revision of Groin Artery Bypass with Patch Graft | other | $1,005 | $1,005 to $35,883 | Low |
| Extensive Removal of Growth of Forearm OR Wrist, 3.0 Cm OR More | surgery | $1,010 | $1,010 to $25,078 | Low |
| Hearing Aid, Digital, Binaural, Ite | other | $1,011 | $1,011 to $7,600 | Low |
| Reshaping of Bone, Cartilage, And/or Tip of Nose | other | $1,011 | $1,011 to $30,410 | Low |
| Removal of Blood Clot and Portion of Tibial OR Peroneal Artery, Initial Artery | surgery | $1,021 | $1,021 to $35,305 | Low |
| Partial Removal of Small Bowel with Creation of Opening to Skin | surgery | $1,022 | $1,022 to $44,125 | Low |
| Suture of Tear of Hole in Small Bowel | other | $1,023 | $1,023 to $44,602 | Low |
| Bypass of Diseased OR Blocked Upper Leg to Opposite Upper Leg Artery with Vein | other | $1,024 | $1,024 to $35,558 | Low |
| Partial Removal of Small Bowel with Reconnection | surgery | $1,024 | $1,024 to $44,120 | Low |
| Removal of Kidney and Partial Removal of Ureter Using an Endoscope | surgery | $1,026 | $1,026 to $50,546 | Low |
| Repair of Eardrum and Ear Canal with Removal of Middle Ear Bone | surgery | $1,026 | $1,026 to $69,643 | Low |
| Isoproterenol 1 Mg/5 Ml Vial | other | $1,028 | $1,028 to $3,866 | Low |
| Removal OR Destruction of Growth(s) in the Abdomen, 5.0 Cm OR Less | surgery | $1,028 | $1,028 to $49,186 | Low |
| Removal of Total Knee Joint Prosthesis | surgery | $1,029 | $1,029 to $27,488 | Low |
| Revision to Reshape Nasal Bones After Previous Repair | surgery | $1,030 | $1,030 to $30,435 | Low |
| Gore Excluder Aortic Extender Endoprosthesis 28.5mm X 3.3cm #pla280300 | other | $1,031 | $1,031 to $3,877 | Low |
| Repositioning of Ureter with Creation of Bladder OR Muscle Flap | other | $1,032 | $1,032 to $50,785 | Low |
| Removal of Blood Clot and Portion of Popliteal Artery | surgery | $1,033 | $1,033 to $35,303 | Low |
| Removal of Bone Cavity Behind Eye for Decompression | surgery | $1,035 | $1,035 to $67,414 | Low |
| Repair of Aorta with Graft for Other Than Rupture with Review By Radiologist | surgery | $1,036 | $1,036 to $34,701 | Low |
| Hysterectomy (Laparoscopic) | surgery | $1,037 | $1,037 to $8,908 | High |
| Removal of Uterus, Tubes, And/or Ovaries Through Abdomen Using an Endoscope, ... | surgery | $1,037 | $1,037 to $58,573 | Low |
| Catheter, Electrophysiology, Diagnostic/ablation, Other Than 3d OR Vector Map... | cardiac | $1,037 | $1,037 to $3,900 | Low |
| Lead, Cardioverter-defibrillator, Endocardial Single Coil | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 19mm #esp100-19-00 Epic Supra | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 21mm #e100-21a-00 Epic | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 21mm #esp100-21-00 Epic Supra | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 23mm #e100-23a-00 Epic | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 23mm #esp100-23-00 Epic Supra | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 25mm #e100-25a-00 Epic | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 25mm #esp100-25-00 Epic Supra | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 27mm #e100-27a-00 Epic | other | $1,037 | $1,037 to $3,900 | Low |
| Valve Aortic 27mm #esp100-27-00 Epic Supra | other | $1,037 | $1,037 to $3,900 | Low |
| Bypass of Diseased OR Blocked Upper Arm to Arm Artery with Vein | other | $1,038 | $1,038 to $35,523 | Low |
| Repair of Aneurysm OR Lower Leg Artery with Graft | surgery | $1,042 | $1,042 to $35,151 | Low |
| Exploration of Abdomen for Bleeding, Blood Clot, OR Infection After Surgery | surgery | $1,044 | $1,044 to $35,840 | Low |
| Revision of Groin Artery Bypass with Vein Patch Graft | other | $1,045 | $1,045 to $35,884 | Low |
| Repositioning of Pacemaker OR Defibrillator Electrode | cardiac | $1,046 | $1,046 to $33,215 | Low |
| Removal of Breast and Underarm Lymph Nodes | surgery | $1,046 | $1,046 to $19,307 | Low |
| Release of Scar Tissue At Ureter | other | $1,048 | $1,048 to $50,715 | Low |
| Injection of Bile Duct for X-ray Through New Skin Access Using Imaging Guidan... | imaging | $1,049 | $1,049 to $47,532 | Low |
| Placement of External Drainage Tube of Biliary Duct Using Imaging Guidance wi... | other | $1,049 | $1,049 to $47,533 | Low |
| Placement of Internal-external Drainage Tube of Biliary Duct Using Imaging Gu... | other | $1,049 | $1,049 to $47,534 | Low |
| Replacement of Liver Duct Drainage Tube Using Imaging Guidance with Review By... | surgery | $1,049 | $1,049 to $47,536 | Low |
| Repair of Kidney Using an Endoscope | surgery | $1,051 | $1,051 to $50,544 | Low |
| Incision and Exploration of Heart | cardiac | $1,052 | $1,052 to $33,310 | Low |
| Creation of Window Into Nasal Sinus | other | $1,054 | $1,054 to $1,757 | Low |
| Removal of Stone OR Debris From Bile OR Pancreatic Duct Using a Flexible Endo... | surgery | $1,054 | $1,054 to $43,264 | Low |
| Dissector Curved Bipolar #471344 | other | $1,056 | $1,056 to $3,969 | Low |
| Drainage of Abscess OR Cyst of Liver | other | $1,061 | $1,061 to $47,010 | Low |
| **obsolete** Valve Mitral 25mm Bicor #b100-25m | other | $1,064 | $1,064 to $4,000 | Low |
| Valve Mitral 25mm #e100-25m-00 Epic | other | $1,064 | $1,064 to $4,000 | Low |
| Valve Mitral 27mm #b100-27m Bicor | other | $1,064 | $1,064 to $4,000 | Low |
| Valve Mitral 27mm #e100-27m-00 Epic | other | $1,064 | $1,064 to $4,000 | Low |
| Valve Mitral 29mm #b100-29m Bicor | other | $1,064 | $1,064 to $4,000 | Low |
| Valve Mitral 29mm #e100-29m-00 Epic | other | $1,064 | $1,064 to $4,000 | Low |
| Valve Mitral 31mm #e100-31m-00 Epic | other | $1,064 | $1,064 to $4,000 | Low |
| Valve Mitral 33mm #e100-33m-00 Epic | other | $1,064 | $1,064 to $4,000 | Low |
| Creation of Large Bowel Opening Using an Endoscope | other | $1,064 | $1,064 to $44,188 | Low |
| Repair of Aorta OR Great Vessels with Sutures Using a Shunt Bypass | surgery | $1,065 | $1,065 to $33,321 | Low |
| Removal of Malignant Growth of Stomach | surgery | $1,068 | $1,068 to $43,611 | Low |
| Removal of Thymus Gland Using an Endoscope | surgery | $1,069 | $1,069 to $32,673 | Low |
| Removal of Lymph Nodes of Neck | surgery | $1,070 | $1,070 to $38,720 | Low |
| Removal of Blood Clot and Portion of Tibioperoneal Trunk Artery | surgery | $1,071 | $1,071 to $35,304 | Low |
| Injection, Crotalidae Polyvalent Immune Fab (ovine), Up to 1 Gram | other | $1,072 | $1,072 to $4,029 | Low |
| Complicated Partial Removal of Bladder | surgery | $1,074 | $1,074 to $51,555 | Low |
| Repositioning of Ureter Using an Endoscope | other | $1,078 | $1,078 to $50,948 | Low |
| Normal Newborn | other | $1,080 | $1,080 to $5,975 | Low |
| Repair of Nonhealed Broken Thigh Bone with Self Bone Graft | surgery | $1,081 | $1,081 to $27,472 | 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 |
| Repair of Paraesophageal Hernia Through Chest | surgery | $1,083 | $1,083 to $43,334 | Low |
| Partial Removal of Large Bowel with Connection | surgery | $1,083 | $1,083 to $44,140 | Low |
| Removal of Blood Clot and Portion of Artery of Groin | surgery | $1,085 | $1,085 to $35,351 | Low |
| Replacement of Knee Joint, Both Sides of Knee | surgery | $1,085 | $1,085 to $27,447 | Low |
| Removal of Kidney, Lymph Nodes, And/or Blood Clot From Major Vein with Partia... | surgery | $1,086 | $1,086 to $50,230 | Low |
| Replacement of Thigh Bone and Hip Joint with Prosthesis | surgery | $1,087 | $1,087 to $27,130 | Low |
| Repair of Paraesophageal Hernia with Mesh Implant Through Abdomen | surgery | $1,091 | $1,091 to $43,333 | Low |
| Replacement of Aortic Valve By Through Femoral Artery | surgery | $1,093 | $1,093 to $33,362 | Low |
| Removal of Lower Part of Stomach with Reattachment of Remaining Stomach to Fi... | surgery | $1,094 | $1,094 to $43,631 | Low |
| Addition to Lower Extremity, Ischial Containment/narrow M-l Socket | other | $1,094 | $1,094 to $4,113 | Low |
| Repair of Knee Cartilage and Bone with Donor Cartilage Graft Using an Endoscope | surgery | $1,102 | $1,102 to $29,867 | Low |
| Removal of Growth of Saliva Gland OR Saliva Gland, and Surrounding Lymph Node... | surgery | $1,103 | $1,103 to $42,426 | Low |
| Removal of Gallbladder and Creation of Bile Duct Drainage to Bowel | surgery | $1,104 | $1,104 to $47,612 | Low |
| Removal of Kidney and Ureter with Partial Removal of Bladder Through Same Inc... | surgery | $1,104 | $1,104 to $50,234 | Low |
| Probe/needle, Cryoablation | other | $1,105 | $1,105 to $4,155 | Low |
| Endograft Iliac Limb 14x12x160 | other | $1,107 | $1,107 to $4,160 | Low |
| Repair of Ruptured Aneurysm of Upper Thigh Artery with Graft | surgery | $1,108 | $1,108 to $35,142 | Low |
| Removal of Defibrillator | surgery | $1,109 | $1,109 to $33,241 | Low |
| Removal of Single Electrode From Right Heart | surgery | $1,109 | $1,109 to $33,234 | Low |
| Repair of Muscle At Lower Esophagus and Stomach Using an Endoscope | surgery | $1,113 | $1,113 to $43,279 | Low |
| Bypass of Diseased OR Blocked Lower Leg to Lower Leg Artery with Vein | other | $1,113 | $1,113 to $35,571 | Low |
| Repair of Aneurysm OR Upper Chest OR Neck Artery with Graft | surgery | $1,126 | $1,126 to $35,021 | Low |
| Removal of Kidney and Lymph Nodes Using an Endoscope | surgery | $1,130 | $1,130 to $50,545 | Low |
| Partial Removal of Kidney | surgery | $1,133 | $1,133 to $50,240 | Low |
| Repair of Prolapsed Rectum Through Abdomen and Anus | surgery | $1,134 | $1,134 to $45,135 | Low |
| Biopsy of Gallbladder, Pancreatic, Liver, and Bile Ducts Using a Flexible End... | lab | $1,134 | $1,134 to $43,261 | Low |
| Removal of Kidney and Ureter Using an Endoscope | surgery | $1,135 | $1,135 to $50,548 | Low |
| Replacement of Aortic Valve Through Axillary Artery | surgery | $1,136 | $1,136 to $33,363 | Low |
| Review By Radiologist of Abdominal Aorta Image | other | $1,137 | $1,137 to $75,625 | Low |
| Extensive Removal of Growth of Neck OR Front of Chest, 5.0 Cm OR More | surgery | $1,143 | $1,143 to $21,558 | Low |
| Bypass of Diseased OR Blocked Arm to Both Lower Thigh Arteries with Other Tha... | other | $1,147 | $1,147 to $35,654 | Low |
| Biopsy of Lobe of Lung Using an Endoscope, 1 Lobe | lab | $1,147 | $1,147 to $31,628 | Low |
| Partial Removal of Small and Large Bowel with Attachment of Small and Large B... | surgery | $1,147 | $1,147 to $44,205 | Low |
| Insertion of Tube Into Gallbladder Using Imaging Guidance with Review By Radi... | other | $1,153 | $1,153 to $47,490 | Low |
| Removal of Blood Clot and Portion of Artery of Abdominal Organ | surgery | $1,154 | $1,154 to $35,341 | Low |
| Repair of Lung Airway with Graft | surgery | $1,164 | $1,164 to $31,770 | Low |
| Incision of Pancreatic Outlet Using a Flexible Endoscope | other | $1,166 | $1,166 to $43,262 | Low |
| Partial Removal of Stomach with Attachment of Stomach to Small Bowel | surgery | $1,167 | $1,167 to $43,820 | Low |
| Repair of Aneurysm OR Groin Artery with Graft | surgery | $1,168 | $1,168 to $35,131 | Low |
| Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm OR Dissection; Us... | surgery | $1,171 | $1,171 to $34,804 | Low |
| Bypass of Diseased OR Blocked Upper to Lower Leg Artery with Vein | other | $1,171 | $1,171 to $35,556 | Low |
| Removal of Blood Clot in Artery of Abdominal Organs | surgery | $1,172 | $1,172 to $34,151 | Low |
| Veklury 100 Mg Vial | other | $1,172 | $1,172 to $4,406 | Low |
| Removal of Defibrillator Electrodes Through Vein | surgery | $1,172 | $1,172 to $33,244 | Low |
| Removal of Dual Electrodes From Right Heart | surgery | $1,172 | $1,172 to $33,235 | Low |
| Endograft Iliac Limb 14x10x100 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x10x160 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x12x100 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x12x120 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x12x140 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x14x100 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x14x120 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x14x140 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x14x160 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x14x80 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x16x100 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x16x120 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x16x140 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x16x160 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x18x120 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x18x140 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x22x140 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x22x160 | other | $1,173 | $1,173 to $4,410 | Low |
| Endograft Iliac Limb 14x28x140 | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Ext System Ovation Ix Pma 10-10-45 #tv-ex101045-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Ext System Ovation Ix Pma 12-12-45 #tv-ex121245-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Ext System Ovation Ix Pma 14-14-45 #tv-ex141445-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Ext System Ovation Ix Pma 16-16-45 #tv-ex161645-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Ext System Ovation Ix Pma 18-18-45 #tv-ex181845-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Ext System Ovation Ix Pma 28-28-45 #tv-ex282845-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-10-120 #tv-il1410120-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-10-80 #tv-il141080-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-12-80 #tv-il141280-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-16-80 #tv-il141680-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-18-100 #tv-il1418100-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-18-160 #tv-il1418160-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-18-80 #tv-il141880-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-22-100 #tv-il1422100-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-22-120 #tv-il1422120-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-22-80 #tv-il142280-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-28-100 #tv-il1428100-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-28-120 #tv-il1428120-j | other | $1,173 | $1,173 to $4,410 | Low |
| Iliac Limb System Ovation Ix Pma 14-28-80 #tv-il142880-j | other | $1,173 | $1,173 to $4,410 | Low |
| Ovation Ix Iliac Stent Graft Tv-il1428160-j | cardiac | $1,173 | $1,173 to $4,410 | Low |
| Placement of Tube of Kidney Using Imaging Guidance with Review By Radiologist | other | $1,174 | $1,174 to $50,432 | Low |
| Insertion of Stent in Groin Artery, Additional Vessel | cardiac | $1,174 | $1,174 to $37,223 | Low |
| Repositioning of Ureter and Insertion of Stent Using an Endoscope | cardiac | $1,175 | $1,175 to $50,947 | Low |
| Implantation of Donor Cartilage Cells Into Knee Joint | surgery | $1,177 | $1,177 to $27,415 | Low |
| Injection, Cyclophosphamide (dr. Reddy's), 5 Mg | other | $1,177 | $1,177 to $1,962 | Low |
| Removal of Segment of Lung Tissue Using an Endoscope | surgery | $1,177 | $1,177 to $32,669 | Low |
| Repair of Ruptured Aneurysm of Lower Leg Artery with Graft | surgery | $1,179 | $1,179 to $35,152 | Low |
| Extreme Immaturity OR Respiratory Distress Syndrome, Neonate | other | $1,179 | $1,179 to $218,115 | Low |
| Drainage OR Removal of Bile Duct Stone with Redirection of Bile Flow and Inci... | surgery | $1,190 | $1,190 to $47,425 | Low |
| Bypass of Diseased OR Blocked Neck to Opposite Neck Artery with Vein | other | $1,191 | $1,191 to $35,509 | Low |
| Revision of Component of Total Knee Joint Prosthesis | other | $1,193 | $1,193 to $27,486 | Low |
| Removal of Lymph Nodes, Muscle, and Tissue of Neck | surgery | $1,194 | $1,194 to $38,724 | Low |
| Repair of Descending Aorta and Subclavian Artery with Insertion of Graft and ... | surgery | $1,195 | $1,195 to $33,880 | Low |
| Partial Removal and Reconnection of Small Bowel Using an Endoscope | surgery | $1,199 | $1,199 to $44,202 | Low |
| Closure of Abnormal Drainage Tract From Small Bowel to Urinary Bladder with R... | other | $1,200 | $1,200 to $44,661 | Low |
| Angiojet Solent Dista Set #111303 | other | $1,202 | $1,202 to $4,520 | Low |
| Suture of Injured Bile Duct | other | $1,203 | $1,203 to $47,900 | Low |
| Partial Destruction and Reconstruction of Upper Heart Chamber | cardiac | $1,203 | $1,203 to $33,254 | Low |
| Limited Reconstruction of Upper Heart Chamber and Alteration of Electrical Pa... | cardiac | $1,203 | $1,203 to $33,265 | Low |
| Bypass of Diseased OR Blocked Thigh to Knee Artery with Vein Graft | other | $1,208 | $1,208 to $35,583 | Low |
| Extensive Removal of Growth of Pelvis and Hip, Less Than 5.0 Cm | surgery | $1,209 | $1,209 to $27,049 | Low |
| Transfer of Chest Artery to Neck Artery and Repair of Descending Aorta | surgery | $1,210 | $1,210 to $33,889 | Low |
| Repair of Eardrum, Ear Canal, and Bones with Placement of Implant and Opening... | surgery | $1,211 | $1,211 to $69,637 | Low |
| Ultrasound Evaluation of Heart Blood Vessel During Diagnosis OR Treatment, In... | imaging | $1,216 | $1,216 to $93,571 | Low |
| Repair of Tear of Lung And/or Control of Traumatic Bleeding Through Chest | surgery | $1,217 | $1,217 to $32,110 | Low |
| Extensive Removal of Growth of Back OR Lower Side, 5.0 Cm OR More | surgery | $1,218 | $1,218 to $21,936 | Low |
| Insertion of Abdominal Tube Using Imaging Guidance with Review By Radiologist | other | $1,223 | $1,223 to $49,418 | Low |
| Addition to Lower Limb Prosthesis, Multiaxial Ankle with Swing Phase Active D... | other | $1,229 | $1,229 to $4,619 | Low |
| Revision of Hip Socket Part of Hip Prosthesis | other | $1,233 | $1,233 to $27,137 | Low |
| Repair of Rectal Prolapse with Partial Removal of Lower Large Bowel Using an ... | surgery | $1,233 | $1,233 to $45,402 | Low |
| Repair of Aorta OR Great Vessels with Sutures On Heart-lung Machine | surgery | $1,234 | $1,234 to $33,322 | Low |
| Closure of Abnormal Drainage Tract Within Small Bowel OR Small to Large Bowel | other | $1,235 | $1,235 to $44,650 | Low |
| Event Recorder, Cardiac | cardiac | $1,236 | $1,236 to $4,645 | Low |
| Reshaping of Bony Cartilage Dividing Nasal Passages | other | $1,237 | $1,237 to $30,420 | Low |
| Processing, Preserving and Transporting Corneal Tissue | other | $1,237 | $1,237 to $4,650 | Low |
| Partial Removal of Large Bowel Using an Endoscope | surgery | $1,248 | $1,248 to $44,204 | Low |
| Catheter, Transluminal Angioplasty, Non-laser | cardiac | $1,250 | $1,250 to $4,700 | Low |
| Ethacrynate Sodium 50 Mg Vial | other | $1,252 | $1,252 to $4,709 | Low |
| Destruction of Stone of Bile OR Pancreatic Duct Using a Flexible Endoscope | other | $1,253 | $1,253 to $43,265 | Low |
| Endurant Ii Contralateral Limb 16mm X 16mm X 124mm #etlw1616c124e | other | $1,258 | $1,258 to $4,728 | 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 |
| Catheter, Electrophysiology, Diagnostic/ablation, 3d OR Vector Mapping | cardiac | $1,262 | $1,262 to $4,743 | Low |
| Kidney and Urinary Tract Neoplasms without Cc/mcc | other | $1,265 | $1,265 to $30,404 | Low |
| Pacemaker, Dual Chamber, Rate-responsive | cardiac | $1,266 | $1,266 to $4,760 | Low |
| Partial Removal of Kidney Using an Endoscope | surgery | $1,266 | $1,266 to $50,543 | Low |
| Repair of Aorta OR Great Vessels with Graft | surgery | $1,269 | $1,269 to $33,330 | Low |
| Extensive Repair of Eardrum and Ear Canal with Removal of Middle Ear Bone | surgery | $1,273 | $1,273 to $69,645 | Low |
| Partial Removal of Large Bowel with Creation of Opening From Large Bowel to Skin | surgery | $1,274 | $1,274 to $44,143 | Low |
| Repair of Blood Vessel of Chest with Vein Graft On Heart-lung Machine | surgery | $1,275 | $1,275 to $35,241 | Low |
| Repair of Infrarenal Aorta and Groin Artery with Graft for Other Than Rupture... | surgery | $1,276 | $1,276 to $34,705 | Low |
| Revision of Thigh Bone Prosthesis | other | $1,279 | $1,279 to $27,138 | Low |
| Correction of Abnormal Rotation of Small Bowel | other | $1,279 | $1,279 to $44,055 | Low |
| Removal of Blood Clot and Portion of Abdominal Aorta and Groin Artery | surgery | $1,283 | $1,283 to $35,361 | Low |
| Neonate with Other Significant Problems | other | $1,283 | $1,283 to $12,894 | Low |
| Partial Removal of Large Bowel with Creation of Opening From Large Bowel to S... | surgery | $1,285 | $1,285 to $44,206 | Low |
| Closure of Surgically Created Large OR Small Bowel Opening with Bowel Removal... | surgery | $1,286 | $1,286 to $44,626 | Low |
| Removal of Defect in Wall of Esophagus Through Chest | surgery | $1,289 | $1,289 to $43,135 | 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 |
| Repair of Eardrum, Ear Canal, and Bones with Removal of Mastoid Bone, with In... | surgery | $1,293 | $1,293 to $69,644 | Low |
| Addition, Endoskeletal Knee-shin System, Single Axis, Fluid Swing and Stance ... | other | $1,295 | $1,295 to $4,868 | Low |
| Diagnostic Exam of Gallbladder and Pancreatic, Liver, and Bile Ducts Using an... | other | $1,296 | $1,296 to $43,260 | Low |
| Removal of Lobe of Lung | surgery | $1,303 | $1,303 to $32,480 | Low |
| Removal of Lung Segment to Reduce Lung Volume Through Chest | surgery | $1,307 | $1,307 to $32,491 | Low |
| Closure of Opening From Large OR Small Bowel to Skin Using an Endoscope | other | $1,309 | $1,309 to $44,227 | Low |
| Replacement, Socket, Below Knee, Molded to Patient Model | surgery | $1,314 | $1,314 to $4,939 | Low |
| Repair of Hernia of Muscle At Esophagus and Stomach Using an Endoscope | surgery | $1,321 | $1,321 to $43,281 | Low |
| Epic Plus Aortic Valve 29mm E200-29a | other | $1,323 | $1,323 to $4,972 | Low |
| Epic Supra Plus Aortic Valve 19mm Esp200 | other | $1,323 | $1,323 to $4,972 | Low |
| Epic Supra Plus Aortic Valve 21mm Esp200 | other | $1,323 | $1,323 to $4,972 | Low |
| Epic Supra Plus Aortic Valve 23mm Esp200 | other | $1,323 | $1,323 to $4,972 | Low |
| Epic Supra Plus Aortic Valve 25mm Esp200 | other | $1,323 | $1,323 to $4,972 | Low |
| Epic Supra Plus Aortic Valve 27mm Esp200 | other | $1,323 | $1,323 to $4,972 | Low |
| Other Procedure On Stomach | other | $1,330 | $1,330 to $43,999 | Low |
| Removal of Air Sac of Lung Through Chest | surgery | $1,332 | $1,332 to $32,141 | Low |
| Extensive Removal of Growth of Thigh OR Knee, 5.0 Cm OR More | surgery | $1,336 | $1,336 to $27,364 | Low |
| Endograft Vela Infrarenal #a25-25/c75v | other | $1,337 | $1,337 to $5,025 | Low |
| Endograft Vela Infrarenal #a28-28/c95v | other | $1,337 | $1,337 to $5,025 | Low |
| Endograft Vela Infrarenal #a34-34/c100v | other | $1,337 | $1,337 to $5,025 | Low |
| Endograft Vela Infrarenal #a34-34/c80v | other | $1,337 | $1,337 to $5,025 | Low |
| Vela Suprarenal Endograft 25mm X 25mm / 75mm X 20mm #a25-25/c75-o20v | other | $1,337 | $1,337 to $5,025 | Low |
| Addition, Endoskeletal Knee-shin System, Polycentric, Hydraulic Swing Phase C... | other | $1,342 | $1,342 to $5,045 | Low |
| Custom Breast Prosthesis, Post Mastectomy, Molded to Patient Model | other | $1,346 | $1,346 to $5,062 | Low |
| Extensive Repair and Reconstruction of Eardrum and Ear Canal with Removal of ... | surgery | $1,349 | $1,349 to $69,646 | Low |
| Partial Removal of Pancreas | surgery | $1,353 | $1,353 to $48,140 | Low |
| 25mj-501 Valve Mitral Size 25 Mm Rotatable Standard Cuff Mechanical | other | $1,357 | $1,357 to $5,100 | Low |
| Valve Aortic Mechanical 21mm #21aj | other | $1,357 | $1,357 to $5,100 | Low |
| Valve Mitral 27mm St Jude Cuffed #27mj | other | $1,357 | $1,357 to $5,100 | Low |
| Valve Mitral 29mm St Jude Cuffed #29mj | other | $1,357 | $1,357 to $5,100 | Low |
| Valve Mitral 31mm St Jude Cuffed #31mj | other | $1,357 | $1,357 to $5,100 | Low |
| Valve Mitral 33mm St Jude Cuffed #33mj | 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 |
| Partial Removal of Large Bowel and Reattachment to Rectum | surgery | $1,357 | $1,357 to $44,145 | Low |
| Repair of Aneurysm Above Heart Valve to Lung On Heart-lung Machine | surgery | $1,361 | $1,361 to $33,720 | Low |
| Removal of Blood Clot and Portion of Chest OR Neck Artery | surgery | $1,361 | $1,361 to $35,311 | Low |
| Partial Removal of Large Bowel with Creation of Opening to Skin | surgery | $1,371 | $1,371 to $44,141 | Low |
| Nuclear Medicine Study From Skull Base to Mid-thigh with CT Scan | imaging | $1,371 | $1,371 to $78,815 | Low |
| Nuclear Medicine Study Whole Body with CT Scan | imaging | $1,371 | $1,371 to $78,816 | Low |
| All Lower Extremity Prostheses, Flex-walk System OR Equal | other | $1,373 | $1,373 to $5,164 | Low |
| Review By Radiologist of Imaging Guidance for Removal of Blood Sample | surgery | $1,376 | $1,376 to $75,893 | 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 |
| Repair of Ruptured Aneurysm of Groin Artery with Graft | surgery | $1,377 | $1,377 to $35,132 | Low |
| Valve Aortic 19mm Mech #19agn | other | $1,383 | $1,383 to $5,200 | Low |
| Valve Aortic 21mm Mech #21agn | other | $1,383 | $1,383 to $5,200 | Low |
| Valve Aortic 23mm Mech #23agn | other | $1,383 | $1,383 to $5,200 | Low |
| Valve Aortic 25mm Mech #25agn | other | $1,383 | $1,383 to $5,200 | Low |
| Removal of Lung | surgery | $1,384 | $1,384 to $32,440 | Low |
| Removal of Rectum for Congenital Defect Through Abdomen and Region Between Th... | surgery | $1,388 | $1,388 to $45,120 | Low |
| Review By Radiologist of Arteries of Both Lungs Image | other | $1,391 | $1,391 to $75,743 | Low |
| Bypass of Diseased OR Blocked Major Upper to Lower Leg Artery with Vein | other | $1,393 | $1,393 to $35,566 | Low |
| Removal of 2 Lobes of Lung Using an Endoscope | surgery | $1,394 | $1,394 to $32,670 | Low |
| Removal of 2 Lobes of Lung | surgery | $1,397 | $1,397 to $32,482 | 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 |
| Insertion OR Replacement of Ear Bone Hearing Device | surgery | $1,403 | $1,403 to $69,710 | Low |
| Placement of Stent of Ureter and Separate Tube in Kidney Through New Skin Acc... | cardiac | $1,409 | $1,409 to $50,695 | Low |
| Epic Mitral Plus Mitral Valve 29mm E200-29m | other | $1,410 | $1,410 to $5,300 | Low |
| Epic Mitral Plus Mitral Valve 31mm E200-31m | other | $1,410 | $1,410 to $5,300 | Low |
| Epic Mitral Plus Mitral Valve 33mm E200-33m | other | $1,410 | $1,410 to $5,300 | Low |
| Partial Removal of Large Bowel with Creation of 2 Openings From Small OR Larg... | surgery | $1,414 | $1,414 to $44,144 | Low |
| Repair of Knee Cartilage with Donor Cartilage Graft Using an Endoscope | surgery | $1,415 | $1,415 to $29,868 | Low |
| Removal of Infected Chest Graft | surgery | $1,415 | $1,415 to $35,905 | Low |
| Gore Excluder Aaa Endoprosthesis 12fr Plc121000 | other | $1,419 | $1,419 to $5,335 | Low |
| Gore Excluder Aaa Endoprosthesis Plc141000 | other | $1,419 | $1,419 to $5,335 | Low |
| Gore Excluder Aaa Endoprosthesis Plc141200 | other | $1,419 | $1,419 to $5,335 | Low |
| Gore Excluder Aaa Endoprosthesis 16mm X 1105cm Plc161200 | other | $1,420 | $1,420 to $5,339 | Low |
| Repair of Congenital Defect Between Upper Heart Chambers On Heart-lung Machine | surgery | $1,424 | $1,424 to $33,641 | 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 |
| Dental and Oral Diseases without Cc/mcc | other | $1,431 | $1,431 to $14,905 | Low |
| Atricure Isolator Synergy Encompass Long #olh | other | $1,436 | $1,436 to $5,400 | Low |
| Extensive Destruction and Reconstruction of Upper Heart Chamber | cardiac | $1,443 | $1,443 to $33,255 | Low |
| Addition to Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume Manageme... | other | $1,446 | $1,446 to $5,436 | Low |
| Revision of Total Shoulder Repair, Total Shoulder | surgery | $1,455 | $1,455 to $23,474 | Low |
| Shoulder Surgery | surgery | $1,455 | $1,455 to $14,656 | High |
| Removal of Chest Cavity Lining and Lung Lining Using an Endoscope | surgery | $1,458 | $1,458 to $32,652 | Low |
| Repair of Aneurysm OR Abdominal Aorta with Graft | surgery | $1,460 | $1,460 to $35,081 | 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 |
| Repair of Aorta At Heart | surgery | $1,467 | $1,467 to $33,417 | Low |
| Revision of Thigh and Lower Leg Bone Components of Total Knee Joint Prosthesis | other | $1,473 | $1,473 to $27,487 | Low |
| Placement of Stent of Ureter Through Existing Skin Access Using Imaging Guida... | cardiac | $1,482 | $1,482 to $50,693 | Low |
| Repair of Hernia of Muscle At Esophagus and Stomach with Implantation of Mesh... | surgery | $1,485 | $1,485 to $43,282 | Low |
| Byetta 5 Mcg Dose Pen Inj | other | $1,487 | $1,487 to $5,591 | Low |
| Byetta 10 Mcg Dose Pen Inj | other | $1,487 | $1,487 to $5,591 | Low |
| Gore Excluder Aaa Endoproshesis Contralateral Leg 16mm X 20mm X 13.5cm 12fr P... | other | $1,490 | $1,490 to $5,602 | Low |
| Gore Excluder Aaa Endoprosthesis Plc201200 | other | $1,490 | $1,490 to $5,602 | Low |
| Gore Excluder Aaa Endoprosthesis Plc271400 | other | $1,490 | $1,490 to $5,602 | Low |
| Gore Excluder Aortic Extender Endoprosthesis 23mm X 10cm #plc231000 | other | $1,490 | $1,490 to $5,602 | Low |
| Gore Excluder Endoprosthesis Aaa #plc181200 | other | $1,490 | $1,490 to $5,602 | Low |
| Gore Excluder Endoprosthesis Aaa #plc271200 | other | $1,490 | $1,490 to $5,602 | Low |
| Acute Myocardial Infarction, Expired without Cc/mcc | other | $1,497 | $1,497 to $25,738 | Low |
| Removal of Defibrillator Electrode | surgery | $1,502 | $1,502 to $33,272 | Low |
| Indium in 111 Labeled Autologous White Blood Cells | other | $1,508 | $1,508 to $5,670 | Low |
| Repair of Ruptured Aorta with Graft with Review By Radiologist | surgery | $1,509 | $1,509 to $34,702 | Low |
| Repair of 2 Electrodes for Permanent Pacemaker OR Defibrillator | surgery | $1,510 | $1,510 to $33,220 | Low |
| Removal OR Destruction of Growth(s) in the Abdomen, 10.1 to 20.0 Cm | surgery | $1,517 | $1,517 to $49,188 | Low |
| Removal and Dissolving of Blood Clot From Vein Using Fluoroscopic Guidance, R... | surgery | $1,527 | $1,527 to $37,188 | Low |
| Partial Removal of Large Bowel and Reattachment to Rectum Using an Endoscope | surgery | $1,528 | $1,528 to $44,207 | Low |
| Repair of Groin Artery with Graft for Rupture with Review By Radiologist | surgery | $1,529 | $1,529 to $34,708 | Low |
| Removal of Large Bowel with Attachment of Small Bowel to Rectum OR Creation o... | surgery | $1,530 | $1,530 to $44,210 | Low |
| Revision to Reshape Nasal Bones and Tip of Nose After Previous Repair | surgery | $1,539 | $1,539 to $30,450 | Low |
| Viral Meningitis without Cc/mcc | other | $1,541 | $1,541 to $13,163 | Low |
| Bypass of Diseased OR Blocked Artery Aorta to Abdominal OR Kidney Artery with... | other | $1,553 | $1,553 to $35,631 | Low |
| Neonates, Died OR Transferred to Another Acute Care Facility | other | $1,566 | $1,566 to $47,576 | Low |
| Catheter, Transluminal Atherectomy, Directional | cardiac | $1,567 | $1,567 to $5,890 | Low |
| Removal of Rectum with Creation of Opening From Large Bowel to Skin Through A... | surgery | $1,573 | $1,573 to $45,110 | Low |
| Replacement, Socket, Above Knee/knee Disarticulation, Including Attachment Pl... | surgery | $1,578 | $1,578 to $5,932 | Low |
| Full Term Neonate with Major Problems | other | $1,580 | $1,580 to $36,427 | Low |
| Revision of Thigh Bone and Hip Joint Prosthesis | other | $1,586 | $1,586 to $27,134 | Low |
| Injection, Leuprolide Acetate (for Depot Suspension), Per 3.75 Mg | other | $1,599 | $1,599 to $14,957 | Low |
| Image-guided Robotic Linear Accelerator-based Stereotactic Radiosurgery, Deli... | surgery | $1,606 | $1,606 to $12,072 | Low |
| Addition, Endoskeletal Knee/shin System, 4-bar Linkage OR Multiaxial, Pneumat... | other | $1,609 | $1,609 to $6,048 | Low |
| Injection, Zolbetuximab-clzb, 1 Mg | other | $1,609 | $1,609 to $6,048 | Low |
| Vyloy 100 Mg Vial | other | $1,609 | $1,609 to $6,048 | Low |
| Extensive Reconstruction of Upper Heart Chamber and Alteration of Electrical ... | cardiac | $1,618 | $1,618 to $33,266 | Low |
| Coronary Artery Bypass Using Artery Graft, 1 Graft | cardiac | $1,634 | $1,634 to $33,533 | Low |
| Endurant Ii Contralateral Limb 16mm X 13mm X 146mm Etlw1613c146e | other | $1,634 | $1,634 to $6,144 | Low |
| Repair of Aorta OR Great Vessels with Graft On Heart-lung Machine | surgery | $1,647 | $1,647 to $33,335 | Low |
| Removal of Lower Portion of Stomach with Reattachment of Upper Portion of Rem... | surgery | $1,649 | $1,649 to $43,633 | Low |
| Removal of Rectum with Creation of Opening From Large Bowel to Skin Using an ... | surgery | $1,652 | $1,652 to $45,395 | Low |
| Postpartum and Post Abortion Diagnoses without O.r. Procedures | obstetric | $1,655 | $1,655 to $12,888 | Low |
| Injection, Thyrotropin Alpha, 0.9 Mg, Provided in 1.1 Mg Vial | other | $1,657 | $1,657 to $6,228 | Low |
| Placement of Stent of Ureter Through New Skin Access Using Imaging Guidance w... | cardiac | $1,661 | $1,661 to $50,694 | Low |
| Indium In-111 Pentetreotide IV Diagnostic | other | $1,665 | $1,665 to $6,259 | Low |
| Injection, Tbo-filgrastim, 1 Microgram | other | $1,680 | $1,680 to $2,800 | Low |
| Insertion of Vena Cava Filter with Review By Radiologist | other | $1,681 | $1,681 to $37,191 | Low |
| Coronary Artery Bypass Using Vein Graft, 1 Graft | cardiac | $1,687 | $1,687 to $33,510 | Low |
| Balloon Dilation of Groin Artery, Initial Vessel | other | $1,687 | $1,687 to $37,220 | Low |
| Ultrasound Evaluation of Heart Blood Vessel OR Graft with Review By Radiologi... | imaging | $1,688 | $1,688 to $92,978 | Low |
| Partial Removal of Large Bowel and Reattachment to Rectum and Creation of Ope... | surgery | $1,690 | $1,690 to $44,208 | Low |
| All Lower Extremity Prostheses, Flex Foot System | other | $1,700 | $1,700 to $6,392 | Low |
| Depressive Neuroses | other | $1,700 | $1,700 to $8,220 | Low |
| Extensive Destruction and Reconstruction of Upper Heart Chamber On Heart-lung... | cardiac | $1,701 | $1,701 to $33,256 | Low |
| Review By Radiologist of Pelvis Artery Image | other | $1,703 | $1,703 to $75,736 | Low |
| Other Multiple Significant Trauma with Cc | emergency | $1,710 | $1,710 to $40,352 | Low |
| Ultrasound Evaluation of Heart Blood Vessel with Review By Radiologist | imaging | $1,711 | $1,711 to $93,662 | Low |
| Papaverine 30 Mg in 100 Ml 0.9% Sodium Chloride - Irrigation - Compounded | other | $1,714 | $1,714 to $6,443 | Low |
| Anesthesia for Procedure On Esophagus | other | $1,722 | $500 to $15,746 | Low |
| Ryanodex 250 Mg Vial | other | $1,729 | $1,729 to $6,501 | Low |
| Exploration of Chest for Bleeding, Blood Clot, OR Infection After Surgery | surgery | $1,739 | $1,739 to $35,820 | Low |
| Major Hematological and Immunological Diagnoses Except Sickle Cell Crisis and... | other | $1,742 | $1,742 to $17,447 | Low |
| Prematurity without Major Problems | other | $1,751 | $1,751 to $25,411 | Low |
| Removal of Thickened Heart Muscle At Left Lower Heart Chamber | surgery | $1,768 | $1,768 to $35,284 | Low |
| Incision OR Removal of Tissue Below Aortic Valve | surgery | $1,770 | $1,770 to $33,415 | Low |
| Repair of Blood Vessel of Chest | surgery | $1,775 | $1,775 to $35,216 | Low |
| Removal of Growth of Lung and Reconstruction of Chest Wall | surgery | $1,782 | $1,782 to $32,504 | Low |
| Balloon Dilation of Artery of Leg | other | $1,786 | $1,786 to $37,224 | Low |
| Injection, Filgrastim-sndz, Biosimilar, (zarxio), 1 Microgram | other | $1,808 | $1,808 to $3,013 | Low |
| Partial Removal of Large Bowel and Reattachment to Rectum and Creation of Lar... | surgery | $1,811 | $1,811 to $44,146 | Low |
| Partial Removal of Tongue and Surrounding Lymph Nodes On Side of Neck | surgery | $1,811 | $1,811 to $41,135 | Low |
| Removal of Growth of Heart On Heart-lung Machine | surgery | $1,814 | $1,814 to $33,120 | Low |
| Insertion of Tube in Upper And/or Lower Heart Chambers to Record and Identify... | cardiac | $1,820 | $1,820 to $93,609 | Low |
| Above Knee, Molded Socket, Open End, Sach Foot, Endoskeletal System, Single A... | other | $1,828 | $1,828 to $6,873 | Low |
| Placement of Tube of Kidney and Urinary Tube Through New Skin Access Using Im... | other | $1,830 | $1,830 to $50,433 | Low |
| Traumatic Injury without Mcc | emergency | $1,831 | $1,831 to $20,348 | Low |
| Repair of Electrode for Permanent Pacemaker OR Defibrillator | surgery | $1,837 | $1,837 to $33,218 | Low |
| Graft Conduit 21mm Aortic Valved 21cavgj | other | $1,849 | $1,849 to $6,950 | Low |
| Graft Conduit 23mm Aortic Valved 23cavgj | other | $1,849 | $1,849 to $6,950 | Low |
| Graft Conduit 27mm Aortic Valved 27cavgj | other | $1,849 | $1,849 to $6,950 | Low |
| Graft Conduit 29mm Aortic Valved 29cavgj | other | $1,849 | $1,849 to $6,950 | Low |
| Graft Conduit 31mm Aortic Valved 31cavgj | other | $1,849 | $1,849 to $6,950 | Low |
| Coronary Artery Bypass Using Vein Graft, 2 Grafts | cardiac | $1,854 | $1,854 to $33,511 | Low |
| Pacemaker, Other Than Single OR Dual Chamber | cardiac | $1,861 | $1,861 to $6,995 | Low |
| Repair of Infrarenal Aorta and Groin Artery with Graft for Rupture with Revie... | surgery | $1,872 | $1,872 to $34,704 | Low |
| Insertion of Catheters for Recording, Pacing, and Induction of Abnormal Heart... | cardiac | $1,887 | $1,887 to $93,624 | Low |
| Repair of Infrarenal Aorta and Groin Artery with Graft for Rupture On Both Si... | surgery | $1,903 | $1,903 to $34,706 | Low |
| Septal Defect Implant System, Intracardiac | surgery | $1,904 | $1,904 to $7,156 | Low |
| Coronary Artery Bypass Using Artery Graft, 2 Grafts | cardiac | $1,916 | $1,916 to $33,534 | Low |
| Repair of Aortic Arch with Graft On Heart-lung Machine | surgery | $1,957 | $1,957 to $33,871 | Low |
| Replacement of Aortic Valve On Heart-lung Machine | surgery | $1,976 | $1,976 to $33,405 | Low |
| Pericardial Tissue Heart Valve All Sizes #3300tfx | cardiac | $1,995 | $1,995 to $7,500 | Low |
| Insertion of Stent in Groin Artery, Initial Vessel | cardiac | $2,000 | $2,000 to $37,221 | Low |
| Prosthesis, Urinary Sphincter | other | $2,000 | $2,000 to $7,520 | Low |
| Implant Pat-active Ht Record | surgery | $2,060 | $2,060 to $33,282 | Low |
| Otitis Media and Uri without Mcc | other | $2,071 | $2,071 to $13,756 | Low |
| Repair of Mitral Valve with Artificial Valve On Heart-lung Machine | surgery | $2,074 | $2,074 to $33,426 | Low |
| Removal of Remaining Lung After Previous Partial Removal of Lung | surgery | $2,079 | $2,079 to $32,488 | Low |
| Coronary Artery Bypass Using Vein Graft, 3 Grafts | cardiac | $2,100 | $2,100 to $33,512 | Low |
| Balloon Dilation of Artery with Review By Radiologist, Initial Artery | other | $2,101 | $2,101 to $37,246 | Low |
| Repair of Wound to Heart | surgery | $2,108 | $2,108 to $33,300 | Low |
| Repositioning of Tricuspid Valve | other | $2,109 | $2,109 to $40,276 | Low |
| Repair of Tricuspid Valve with Ring Insertion | surgery | $2,115 | $2,115 to $33,464 | Low |
| Radical Reconstruction of Mitral Valve On Heart-lung Machine | cardiac | $2,116 | $2,116 to $33,427 | Low |
| Coronary Artery Bypass Using Artery Graft, 3 Grafts | cardiac | $2,125 | $2,125 to $44,822 | Low |
| Coronary Artery Bypass Using Vein Graft, 4 Grafts | cardiac | $2,143 | $2,143 to $33,513 | Low |
| Removal of Heart Sac On Heart-lung Machine | surgery | $2,148 | $2,148 to $33,031 | Low |
| Other Antepartum Diagnoses without O.r. Procedures with Cc | other | $2,158 | $2,158 to $17,088 | Low |
| Balloon Dilation of Artery of Leg, Initial Vessel | other | $2,179 | $2,179 to $37,228 | Low |
| Inspira Resilian Aortic Valve 19mm #11500a19 | other | $2,181 | $2,181 to $8,200 | Low |
| Inspira Resilian Aortic Valve 21mmá #11500a21 | other | $2,181 | $2,181 to $8,200 | Low |
| Inspira Resilian Aortic Valve 23mmá #11500a23 | other | $2,181 | $2,181 to $8,200 | Low |
| Inspira Resilian Aortic Valve 25mmá #11500a25 | other | $2,181 | $2,181 to $8,200 | Low |
| Inspira Resilian Aortic Valve 27mmá #11500a27 | other | $2,181 | $2,181 to $8,200 | Low |
| Inspira Resilian Aortic Valve 29mmá #11500a29 | other | $2,181 | $2,181 to $8,200 | Low |
| Image-guided Robotic Linear Accelerator-based Stereotactic Radiosurgery, Comp... | surgery | $2,185 | $2,185 to $16,430 | Low |
| Anesthesia for Closed Drainage of Lung Fluid | other | $2,245 | $524 to $20,528 | Low |
| Coronary Artery Bypass Using Vein Graft, 5 Grafts | cardiac | $2,282 | $2,282 to $33,514 | Low |
| Removal of Blood Clot in Pulmonary Artery On Heart-lung Machine | surgery | $2,284 | $2,284 to $33,910 | Low |
| Coronary Artery Bypass Using Artery Graft, 4 Grafts | cardiac | $2,287 | $2,287 to $33,536 | Low |
| Other Kidney and Urinary Tract Diagnoses without Cc/mcc | other | $2,301 | $2,301 to $16,861 | Low |
| Iodine I-123 Iobenguane, Diagnostic, Per Study Dose, Up to 15 Millicuries | other | $2,318 | $2,318 to $9,342 | Low |
| Insertion of Catheters for Recording and Pacing of Left Lower Heart Chamber R... | cardiac | $2,319 | $2,319 to $93,622 | Low |
| Non-needle Measurement and Recording of Electrical Activity of Muscles At Bla... | other | $2,330 | $2,330 to $2,330 | Low |
| Vaginal Delivery | obstetric | $2,336 | $2,336 to $17,093 | High |
| Removal of Large Bowel, Rectum, Bladder and Ureter | surgery | $2,342 | $2,342 to $45,126 | Low |
| Coronary Artery Bypass Using Vein Graft, 6 OR More Grafts | cardiac | $2,364 | $2,364 to $36,658 | Low |
| Repair of Mitral Valve On Heart-lung Machine | surgery | $2,370 | $2,370 to $39,342 | Low |
| Insertion of Stent in Artery of Leg, Each Additional Vessel | cardiac | $2,374 | $2,374 to $37,234 | Low |
| Replacement of Tricuspid Valve On Heart-lung Machine | surgery | $2,384 | $2,384 to $33,465 | Low |
| Other Skin, Subcutaneous Tissue and Breast Procedures without Cc/mcc | other | $2,409 | $2,409 to $31,226 | Low |
| Treatment of Broken Lower Spine Bone with Placement of Stabilizing Device | other | $2,410 | $2,410 to $22,514 | Low |
| Treatment of Broken Middle Spine Bone with Placement of Stabilizing Device Us... | other | $2,410 | $2,410 to $22,513 | Low |
| Replacement of Mitral Valve On Heart-lung Machine | surgery | $2,438 | $2,438 to $33,664 | Low |
| Partial Removal of Lower Esophagus | surgery | $2,441 | $2,441 to $43,117 | Low |
| Endocrine Disorders with Cc | other | $2,452 | $2,452 to $25,065 | Low |
| Interspinous Process Distraction Device | other | $2,461 | $2,461 to $9,250 | Low |
| Balloon Dilation of Vein with Review By Radiologist, Initial Vein | other | $2,481 | $2,481 to $37,248 | Low |
| Uncomplicated Peptic Ulcer with Mcc | other | $2,485 | $2,485 to $22,735 | Low |
| Dilation of Bile Ducts with Stent Insertion Using an Endoscope | cardiac | $2,494 | $2,494 to $47,556 | Low |
| Insertion of Temporary Pacemaker Lead in Single Heart Chamber | cardiac | $2,498 | $2,498 to $33,210 | Low |
| Insertion of Pacemaker Pulse Generator with Existing Single Lead | cardiac | $2,541 | $2,541 to $33,212 | Low |
| Insertion of 1 Electrode for Permanent Pacemaker OR Defibrillator | cardiac | $2,545 | $2,545 to $33,216 | Low |
| Stent Endograft Endurant Iis Bifurcated 28mm X 14mm X 103mm #esbf2814c103e | cardiac | $2,547 | $2,547 to $9,576 | Low |
| Dental and Oral Diseases with Cc | other | $2,550 | $2,550 to $22,875 | Low |
| Catheter, Thrombectomy/embolectomy | cardiac | $2,567 | $2,567 to $9,650 | Low |
| Ascending Aorta Graft, with Cardiopulmonary Bypass, Includes Valve Suspension... | other | $2,568 | $2,568 to $33,860 | Low |
| Removal of Plaque in Artery of Leg, Each Additional Vessel | surgery | $2,576 | $2,576 to $37,233 | Low |
| Removal of Permanent Pacemaker Pulse Generator | surgery | $2,623 | $2,623 to $33,233 | Low |
| Iris Prosthesis | other | $2,633 | $2,633 to $9,900 | Low |
| Prematurity with Major Problems | other | $2,662 | $2,662 to $65,748 | Low |
| Repair of Tricuspid Valve | surgery | $2,665 | $2,665 to $43,034 | Low |
| Repair of Lower Heart Chamber Following Heart Attack | surgery | $2,669 | $2,669 to $41,546 | Low |
| Peripheral Vascular Disorders without Cc/mcc | other | $2,728 | $2,728 to $20,524 | Low |
| Insertion of Stent in Artery of Leg, Initial Vessel | cardiac | $2,752 | $2,752 to $37,230 | Low |
| Repair of Ascending Aorta with Graft On Heart-lung Machine with Aortic Root R... | surgery | $2,757 | $2,757 to $43,576 | Low |
| Injection, Glofitamab-gxbm, 2.5 Mg | other | $2,768 | $2,768 to $33,155 | Low |
| Psychoses | therapy | $2,788 | $2,788 to $21,896 | Low |
| Skin Ulcers with Cc | other | $2,867 | $2,867 to $32,350 | Low |
| Allergic Reactions without Mcc | other | $2,868 | $2,868 to $16,652 | Low |
| Other Respiratory System Diagnoses without Mcc | other | $2,870 | $2,870 to $21,706 | Low |
| Other Kidney and Urinary Tract Procedures without Cc/mcc | other | $2,890 | $2,890 to $47,927 | Low |
| Replacement of Aortic Valve with Aorta Enlargement | surgery | $2,897 | $2,897 to $37,022 | Low |
| Major Skin Disorders with Mcc | other | $2,912 | $2,912 to $50,036 | Low |
| Acute Myocardial Infarction, Expired with Cc | other | $2,933 | $2,933 to $25,738 | Low |
| Insertion of 2 Electrodes for Permanent Pacemaker OR Defibrillator | cardiac | $2,936 | $2,936 to $33,217 | Low |
| Abortion without D&c | other | $3,038 | $3,038 to $15,891 | Low |
| Epi-sense Guided 6130 Device #cdp-4330 | other | $3,059 | $3,059 to $11,500 | Low |
| Testes Procedures without Cc/mcc | other | $3,072 | $3,072 to $31,224 | Low |
| Graft Bifurcated Stent #ba28-100/i16 | cardiac | $3,080 | $3,080 to $11,580 | Low |
| Respiratory Neoplasms without Cc/mcc | other | $3,083 | $3,083 to $31,399 | Low |
| Viral Illness without Mcc | other | $3,099 | $3,099 to $16,207 | Low |
| Otitis Media and Uri with Mcc | other | $3,118 | $3,118 to $27,658 | Low |
| Other Factors Influencing Health Status | other | $3,129 | $3,129 to $11,765 | Low |
| Postpartum and Post Abortion Diagnoses with O.r. Procedures | obstetric | $3,157 | $3,157 to $38,052 | Low |
| Destruction of Growth of Kidney By Freezing | other | $3,195 | $3,195 to $50,593 | Low |
| Alloderm 1518320 | other | $3,248 | $3,248 to $12,210 | Low |
| Endograft Aortic Body 23mm Tv-ab2380-j | other | $3,273 | $3,273 to $12,305 | Low |
| Endograft Aortic Body 26mm Tv-ab2680-n | other | $3,273 | $3,273 to $12,305 | Low |
| Endograft Aortic Body 29mm Tv-ab2980-n | other | $3,273 | $3,273 to $12,305 | Low |
| Endograft Aortic Body 34mm Tv-ab3480-n | other | $3,273 | $3,273 to $12,305 | Low |
| Insertion of Pacemaker Pulse Generator with Existing Dual Leads | cardiac | $3,333 | $3,333 to $33,213 | Low |
| All Lower Extremity Prosthesis, Shank Foot System with Vertical Loading Pylon | other | $3,336 | $3,336 to $12,541 | Low |
| Vaginal Delivery with OR Procedure except Sterilization/D&C | obstetric | $3,364 | $3,364 to $22,892 | Low |
| Cardioverter-defibrillator, Dual Chamber | other | $3,378 | $3,378 to $12,700 | Low |
| Removal and Dissolving of Blood Clot From Vein Using Fluoroscopic Guidance, I... | surgery | $3,437 | $3,437 to $37,187 | Low |
| Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy w... | other | $3,456 | $3,456 to $22,966 | Low |
| Injection, Pegloticase, 1 Mg | other | $3,457 | $3,457 to $58,638 | Low |
| Infections, Female Reproductive System without Cc/mcc | other | $3,461 | $3,461 to $14,813 | Low |
| Gore Excluder Aaa Endoprosthesis 26mm X 14.5mm Rlt261414 | other | $3,461 | $3,461 to $13,012 | Low |
| Hand OR Wrist Procedures, Except Major Thumb OR Joint Procedures without Cc/mcc | other | $3,482 | $3,482 to $23,277 | Low |
| Cardioverter-defibrillator, Single Chamber | other | $3,486 | $3,486 to $13,104 | Low |
| Repair of Wound to Heart On Heart-lung Machine | surgery | $3,500 | $3,500 to $36,510 | Low |
| Insertion of Left Lower Heart Electrode and Attachment to Pacemaker OR Defibr... | cardiac | $3,500 | $3,500 to $33,224 | Low |
| Insertion of Pacemaker and Lower Heart Chamber Electrode | cardiac | $3,500 | $3,500 to $33,207 | Low |
| Gore Excluder Endoporsthesis Iliac Branch Comp #ceb231010a | other | $3,511 | $3,511 to $13,199 | Low |
| Gore Excluder Iliac Branch Endoprosthesis Iliac Branch Component 14.35mm X 10... | other | $3,511 | $3,511 to $13,199 | Low |
| Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes wit... | other | $3,518 | $3,518 to $21,657 | Low |
| Insertion of 2 Chamber Pacemaker System | cardiac | $3,518 | $3,518 to $33,214 | Low |
| Aftercare without Cc/mcc | other | $3,522 | $3,522 to $39,155 | Low |
| Other Ear, Nose, Mouth and Throat O.r. Procedures with Mcc | other | $3,558 | $3,558 to $84,423 | Low |
| Insertion of Catheters for Recording and Pacing of Left Upper Heart Chamber R... | cardiac | $3,572 | $3,572 to $93,621 | Low |
| Other Cerebrovascular Disorders without Cc/mcc | other | $3,572 | $3,572 to $18,397 | Low |
| Gore Excluder Ipsilateral Leg Endoprosthesis 28.5mm X 14.5mm X 12cm #rlt281412 | other | $3,575 | $3,575 to $13,441 | Low |
| Renal Failure without CC/MCC | other | $3,612 | $3,612 to $19,373 | Low |
| Wound Debridements for Injuries without Cc/mcc | other | $3,619 | $3,619 to $36,578 | Low |
| Disorders of Pancreas Except Malignancy without Cc/mcc | other | $3,653 | $3,653 to $18,435 | Low |
| Other O.r. Procedures of the Blood and Blood Forming Organs without Cc/mcc | other | $3,676 | $3,676 to $60,519 | Low |
| Skin Debridement without Cc/mcc | other | $3,687 | $3,687 to $26,843 | Low |
| Major Chest Trauma without Cc/mcc | emergency | $3,698 | $3,698 to $25,457 | Low |
| Injection, Digoxin Immune Fab (ovine), Per Vial | other | $3,698 | $3,698 to $13,902 | Low |
| Insertion of Pacemaker and Upper and Lower Heart Chamber Electrode | cardiac | $3,714 | $3,714 to $33,208 | Low |
| Hepatobiliary Diagnostic Procedures with Cc | other | $3,721 | $3,721 to $58,553 | Low |
| Multiple Sclerosis and Cerebellar Ataxia with Cc | other | $3,721 | $3,721 to $30,345 | Low |
| Major Gastrointestinal Disorders and Peritoneal Infections without Cc/mcc | other | $3,811 | $3,811 to $16,685 | Low |
| Cardiac Arrhythmia and Conduction Disorders without Cc/mcc | cardiac | $3,816 | $3,816 to $17,027 | 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 |
| Graft Bifurcated Afx2 #bea25-100/i16 | other | $3,818 | $3,818 to $14,355 | Low |
| Graft Bifurcated Afx2 #bea25-100/i20 | other | $3,818 | $3,818 to $14,355 | Low |
| Graft Bifurcated Afx2 #bea25-90/i16 | other | $3,818 | $3,818 to $14,355 | Low |
| Graft Bifurcated Afx2 #bea28-100/i16 | other | $3,818 | $3,818 to $14,355 | Low |
| Graft Bifurcated Afx2 #bea28-70/i16 | other | $3,818 | $3,818 to $14,355 | Low |
| Graft Bifurcated Afx2 #bea28-80/i16 | other | $3,818 | $3,818 to $14,355 | Low |
| Graft Bifurcated Afx2 #bea28-80/i20 | other | $3,818 | $3,818 to $14,355 | Low |
| Graft Bifurcated Stent #ba25-100/i20 | cardiac | $3,818 | $3,818 to $14,355 | Low |
| Graft Bifurcated Stent #bea25-90/i20 | 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 |
| Gore Excluder Conformable Aaa Endoprosthesis 18fr Cxt321414 | other | $3,996 | $3,996 to $15,022 | Low |
| Gore Excluder Conformable Aaa Endoprosthesis Cxt281412 | other | $3,996 | $3,996 to $15,022 | Low |
| Principal Diagnosis Invalid As Discharge Diagnosis | other | $3,996 | $3,996 to $15,024 | Low |
| Destruction of Growths and Adjacent Soft Tissue | other | $4,003 | $4,003 to $20,982 | Low |
| Spinal Fusion | surgery | $4,026 | $4,026 to $72,042 | High |
| Other O.r. Procedures for Injuries without Cc/mcc | other | $4,063 | $4,063 to $29,097 | Low |
| Hand Procedures for Injuries | other | $4,088 | $4,088 to $63,296 | Low |
| Pulmonary Embolism without MCC | other | $4,115 | $4,115 to $24,006 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue without Cc/mcc | other | $4,124 | $4,124 to $33,389 | Low |
| Infections, Female Reproductive System with Mcc | other | $4,126 | $4,126 to $37,637 | Low |
| Gore Excluder Endoprosthesis Aaa Conformable Endo #cxt261412 | other | $4,128 | $4,128 to $15,518 | Low |
| Insertion of Catheters for Recording and Pacing of Right Heart Chambers Rhyth... | cardiac | $4,163 | $4,163 to $93,620 | Low |
| Hypertension without Mcc | other | $4,167 | $4,167 to $22,215 | Low |
| Local Excision and Removal of Internal Fixation Devices Except Hip and Femur ... | surgery | $4,184 | $4,184 to $34,278 | Low |
| Occlusion of Growths OR Obstructed Vessels with Review By Radiologist | other | $4,190 | $4,190 to $37,243 | Low |
| Occlusion of Vein with Review By Radiologist | other | $4,190 | $4,190 to $37,241 | Low |
| Other Disorders of Nervous System without Cc/mcc | other | $4,232 | $4,232 to $21,683 | Low |
| Diabetes with Cc | other | $4,234 | $4,234 to $21,948 | Low |
| Gastrointestinal Obstruction without Cc/mcc | other | $4,244 | $4,244 to $15,954 | Low |
| Major Skin Disorders without Mcc | other | $4,244 | $4,244 to $18,389 | Low |
| Peripheral Vascular Disorders with Cc | other | $4,251 | $4,251 to $25,572 | Low |
| Insertion of Pacemaker and Upper Heart Chamber Electrode | cardiac | $4,255 | $4,255 to $33,206 | Low |
| Cirrhosis and Alcoholic Hepatitis without Cc/mcc | other | $4,288 | $4,288 to $18,896 | Low |
| Kidney and Urinary Tract Infections without MCC | other | $4,317 | $4,317 to $19,309 | Low |
| Cardioverter-defibrillator, Other Than Single OR Dual Chamber | other | $4,319 | $4,319 to $16,237 | Low |
| Chest Pain | other | $4,321 | $4,321 to $20,845 | Low |
| Acute Major Eye Infections with Cc/mcc | other | $4,350 | $4,350 to $23,264 | Low |
| Other Digestive System Diagnoses without Cc/mcc | other | $4,366 | $4,366 to $18,076 | Low |
| Red Blood Cell Disorders without Mcc | other | $4,425 | $4,425 to $24,538 | Low |
| Other Antepartum Diagnoses without O.r. Procedures with Mcc | other | $4,438 | $4,438 to $22,673 | Low |
| Other Musculoskeletal System and Connective Tissue Diagnoses without Cc/mcc | other | $4,442 | $4,442 to $24,624 | Low |
| Cellulitis without Mcc | other | $4,448 | $4,448 to $20,593 | Low |
| Prosthesis, Penile, Inflatable | other | $4,461 | $4,461 to $16,770 | Low |
| Pneumothorax without Cc/mcc | other | $4,463 | $4,463 to $17,750 | Low |
| Skin Grafts for Injuries with Cc/mcc | other | $4,467 | $4,467 to $126,176 | Low |
| Non-malignant Breast Disorders without Cc/mcc | other | $4,471 | $4,471 to $16,810 | Low |
| Urinary Stones without Mcc | other | $4,501 | $4,501 to $17,243 | Low |
| Septic Arthritis with Cc | other | $4,517 | $4,517 to $30,381 | Low |
| Watchman Flex Device 20mm Wu5020 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flex Device 24mm Wu5024 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flex Device 27mm Wu5027 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flex Device 31mm Wu5031 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flx Pro Laa Closure 20mm Wu6020 M635wu60200 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flx Pro Laa Closure 24mm Wu6024 M635wu60240 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flx Pro Laa Closure 27mm Wu6027 M635wu60270 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flx Pro Laa Closure 31mm Wu6031 M635wu60310 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flx Pro Laa Closure 35mm Wu6035 M635wu60350 | other | $4,522 | $4,522 to $17,000 | Low |
| Watchman Flx Pro Laa Closure 40mm Wu6040 M635wu60400 | other | $4,522 | $4,522 to $17,000 | Low |
| Skin Debridement with Mcc | other | $4,566 | $4,566 to $78,203 | Low |
| Cardiac Arrhythmia and Conduction Disorders with Cc | cardiac | $4,576 | $4,576 to $23,738 | Low |
| Simple Pneumonia with CC | other | $4,608 | $4,608 to $21,349 | Low |
| Mouth Procedures without Cc/mcc | other | $4,610 | $4,610 to $28,779 | Low |
| Insertion of Stent in Vein with Review By Radiologist, Initial Vein | cardiac | $4,611 | $4,611 to $37,238 | Low |
| Reticuloendothelial and Immunity Disorders with Cc | other | $4,622 | $4,622 to $20,190 | Low |
| Nervous System Neoplasms without Mcc | other | $4,669 | $4,669 to $22,169 | Low |
| Tendonitis, Myositis and Bursitis without Mcc | other | $4,698 | $4,698 to $18,053 | Low |
| Hypertension with Mcc | other | $4,699 | $4,699 to $33,353 | Low |
| Renal Failure with CC | other | $4,716 | $4,716 to $22,653 | Low |
| Kidney and Urinary Tract Signs and Symptoms without Mcc | other | $4,741 | $4,741 to $18,285 | Low |
| COPD with CC | other | $4,742 | $4,742 to $23,539 | Low |
| Traumatic Stupor and Coma >1 Hour with Cc | emergency | $4,760 | $4,760 to $28,335 | 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 |
| Watchman Device 27mm | other | $4,788 | $4,788 to $18,000 | Low |
| Watchman Device 30mm | other | $4,788 | $4,788 to $18,000 | Low |
| Watchman Device 33mm | other | $4,788 | $4,788 to $18,000 | Low |
| Watchman Flex Device 35mm Wu5035 | other | $4,788 | $4,788 to $18,000 | Low |
| Esophagitis and GI Disorders with MCC | other | $4,788 | $4,788 to $18,838 | Low |
| Anal and Stomal Procedures with Cc | other | $4,811 | $4,811 to $26,525 | Low |
| Cranial and Peripheral Nerve Disorders without Mcc | other | $4,813 | $4,813 to $27,227 | Low |
| Valiant Thoracic Stent Graft W/ Captivia Delivery System 38mm X 34mm X 150mm ... | cardiac | $4,821 | $4,821 to $18,125 | Low |
| Pneumothorax with Cc | other | $4,841 | $4,841 to $23,562 | Low |
| Uncomplicated Peptic Ulcer without Mcc | other | $4,894 | $4,894 to $22,735 | Low |
| Trauma to the Skin, Subcutaneous Tissue and Breast without Mcc | emergency | $4,911 | $4,911 to $22,999 | Low |
| Fractures of Hip and Pelvis without Mcc | other | $4,933 | $4,933 to $31,152 | Low |
| Heart Failure and Shock without CC/MCC | cardiac | $4,945 | $4,945 to $21,970 | Low |
| Myeloproliferative Disorders OR Poorly Differentiated Neoplasms with Other Pr... | other | $4,962 | $4,962 to $59,078 | Low |
| Minor Bladder Procedures without Cc/mcc | other | $4,970 | $4,970 to $32,940 | Low |
| Menstrual and Other Female Reproductive System Disorders without Cc/mcc | other | $4,976 | $4,976 to $20,388 | Low |
| Gastrointestinal Hemorrhage without Cc/mcc | other | $5,014 | $5,014 to $19,586 | Low |
| Foot Procedures with Cc | other | $5,019 | $5,019 to $48,587 | Low |
| Skin Graft for Skin Ulcer OR Cellulitis without Cc/mcc | other | $5,021 | $5,021 to $80,203 | Low |
| Peripheral, Cranial Nerve and Other Nervous System Procedures without Cc/mcc | other | $5,032 | $5,032 to $33,671 | Low |
| Acute and Subacute Endocarditis with Cc | other | $5,035 | $5,035 to $58,749 | Low |
| Respiratory Infections and Inflammations with Cc | other | $5,052 | $5,052 to $29,066 | Low |
| Generator, Neurostimulator (implantable), with Rechargeable Battery and Charg... | surgery | $5,054 | $5,054 to $19,000 | Low |
| Osteomyelitis with Cc | other | $5,061 | $5,061 to $36,542 | Low |
| Valiant Thoracic Stent Graft with the Captivia Delivery System Vamf3838c200tu | cardiac | $5,082 | $5,082 to $19,105 | Low |
| Extracranial Procedures with Cc | other | $5,111 | $5,111 to $54,422 | Low |
| Graft Thoracic 10cmx21mmx21mm Tgm212110 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 10cmx28mmx28mm Tgm282810 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 10cmx31mmx26mm Tgmr312610 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 10cmx31mmx31mm Tgmr313110 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 15cmx31mmx31mm Tgmr313115 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 15cmx34mmx34mm Tgm343415 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 15cmx37mmx37mm Tgmr373715 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 15cmx40mmx40mm Tgmr404015 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 15cmx45mmx45mm Tgm454515 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 20cmx31mmx31mm Tgmr313120 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 20cmx37mmx37mm Tgmr373720 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 20cmx40mmx40mm Tgmr404020 | other | $5,163 | $5,163 to $19,411 | Low |
| Graft Thoracic 20cmx45mmx45mm Tgm454520 | other | $5,163 | $5,163 to $19,411 | Low |
| Pleural Effusion with Cc | surgery | $5,182 | $5,182 to $28,761 | Low |
| Major Esophageal Disorders with Cc | other | $5,196 | $5,196 to $24,754 | Low |
| Other Ear, Nose, Mouth and Throat O.r. Procedures without Cc/mcc | other | $5,204 | $5,204 to $21,196 | Low |
| Hypertensive Encephalopathy with Cc | other | $5,205 | $5,205 to $19,566 | Low |
| C-Section (Cesarean Delivery) | obstetric | $5,232 | $5,232 to $23,853 | High |
| Inflammatory Bowel Disease with Cc | other | $5,256 | $5,256 to $27,284 | Low |
| Syncope and Collapse | other | $5,258 | $5,258 to $23,659 | Low |
| Headaches without Mcc | other | $5,314 | $5,314 to $21,089 | Low |
| Medical Back Problems without Mcc | other | $5,353 | $5,353 to $25,203 | Low |
| Signs and Symptoms of Musculoskeletal System and Connective Tissue without Mcc | other | $5,360 | $5,360 to $24,296 | Low |
| Generator, Neurostimulator (implantable), Non-rechargeable | surgery | $5,453 | $5,453 to $20,500 | Low |
| COPD Management | other | $5,466 | $5,466 to $20,550 | High |
| COPD without CC/MCC | other | $5,466 | $5,466 to $20,550 | Low |
| Neurological Eye Disorders | other | $5,470 | $5,470 to $21,082 | Low |
| Prostatectomy with Cc | other | $5,489 | $5,489 to $44,593 | Low |
| Simple Pneumonia without CC/MCC | other | $5,491 | $5,491 to $28,313 | Low |
| Concussion with Cc | other | $5,532 | $5,532 to $25,633 | Low |
| Major Chest Trauma with Cc | emergency | $5,592 | $5,592 to $27,469 | Low |
| Alcohol/Drug Abuse or Dependence without Rehabilitation without MCC | therapy | $5,597 | $5,597 to $21,040 | Low |
| Fractures of Hip and Pelvis with Mcc | other | $5,602 | $5,602 to $33,547 | Low |
| Prostatectomy without Cc/mcc | other | $5,630 | $5,630 to $44,593 | Low |
| Mastectomy for Malignancy without Cc/mcc | other | $5,644 | $5,644 to $72,447 | Low |
| Implantable Wireless Pulmonary Artery Pressure Sensor with Delivery Catheter,... | surgery | $5,692 | $5,692 to $21,400 | Low |
| Hernia Procedures Except Inguinal and Femoral without Cc/mcc | other | $5,706 | $5,706 to $31,848 | Low |
| Urethral Stricture | other | $5,709 | $5,709 to $29,550 | Low |
| Pulmonary Edema and Respiratory Failure | other | $5,732 | $5,732 to $30,302 | Low |
| Atherosclerosis without Mcc | other | $5,736 | $5,736 to $21,563 | Low |
| D&c, Conization, Laparoscopy and Tubal Interruption with Cc/mcc | surgery | $5,737 | $5,737 to $44,180 | Low |
| Angina Pectoris | other | $5,758 | $5,758 to $21,646 | Low |
| Hypertensive Encephalopathy without Cc/mcc | other | $5,780 | $5,780 to $44,113 | Low |
| Hand OR Wrist Procedures, Except Major Thumb OR Joint Procedures with Cc/mcc | other | $5,782 | $5,782 to $36,753 | Low |
| Extracranial Vascular Procedures with MCC | other | $5,795 | $5,795 to $33,547 | Low |
| Complications of Treatment with Cc | other | $5,800 | $5,800 to $29,448 | Low |
| Disorders of Pancreas Except Malignancy with Cc | other | $5,801 | $5,801 to $25,738 | Low |
| Other Endocrine, Nutritional and Metabolic O.r. Procedures without Cc/mcc | lab | $5,816 | $5,816 to $54,231 | Low |
| Removal of Plaque in Artery of Leg, Initial Vessel | surgery | $5,836 | $5,836 to $43,876 | Low |
| Signs and Symptoms with Mcc | other | $5,844 | $5,844 to $46,338 | Low |
| Multiple Sclerosis and Cerebellar Ataxia with Mcc | other | $5,849 | $5,849 to $52,695 | Low |
| Kidney and Urinary Tract Neoplasms with Cc | other | $5,865 | $5,865 to $30,404 | Low |
| Endocrine Disorders with Mcc | other | $5,865 | $5,865 to $47,935 | Low |
| Seizures without MCC | other | $5,896 | $5,896 to $22,166 | Low |
| Heart Failure and Shock with MCC | cardiac | $5,915 | $5,915 to $35,421 | Low |
| Heart Failure and Shock with CC | cardiac | $5,953 | $5,953 to $28,674 | Low |
| Nutritional and Metabolic Disorders without MCC | other | $5,968 | $5,968 to $41,325 | Low |
| Simple Pneumonia with MCC | other | $5,970 | $5,970 to $31,089 | Low |
| Intracranial Hemorrhage or Cerebral Infarction with CC | other | $5,979 | $5,979 to $25,754 | Low |
| Postoperative OR Post-traumatic Infections with O.r. Procedures with Cc | emergency | $5,990 | $5,990 to $54,012 | Low |
| Gastrointestinal Obstruction with Cc | other | $5,994 | $5,994 to $22,536 | Low |
| Fever and Inflammatory Conditions | other | $6,037 | $6,037 to $22,694 | Low |
| Other Kidney and Urinary Tract Diagnoses with Cc | other | $6,077 | $6,077 to $26,058 | Low |
| COPD with MCC | other | $6,085 | $6,085 to $29,217 | Low |
| Tracheostomy for Face, Mouth and Neck Diagnoses OR Laryngectomy without Cc/mcc | other | $6,094 | $6,094 to $94,374 | Low |
| Septicemia or Severe Sepsis without Ventilator 96+ Hours without MCC | other | $6,113 | $6,113 to $26,188 | Low |
| Minor Skin Disorders without Mcc | other | $6,126 | $6,126 to $24,439 | Low |
| Other Disorders of Nervous System with Cc | other | $6,145 | $6,145 to $33,004 | Low |
| GI Hemorrhage with CC | other | $6,146 | $6,146 to $28,086 | Low |
| Connective Tissue Disorders with Mcc | other | $6,179 | $6,179 to $54,621 | Low |
| Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh ... | other | $6,195 | $6,195 to $27,021 | Low |
| Red Blood Cell Disorders with Mcc | other | $6,231 | $6,231 to $38,238 | Low |
| Disorders of Liver Except Malignancy, Cirrhosis OR Alcoholic Hepatitis with Cc | other | $6,234 | $6,234 to $27,434 | Low |
| Other Musculoskeletal System and Connective Tissue Diagnoses with Cc | other | $6,268 | $6,268 to $34,904 | Low |
| Skin Graft for Skin Ulcer OR Cellulitis with Cc | other | $6,274 | $6,274 to $89,252 | Low |
| Removal of Plaque in Arteries of Leg | surgery | $6,293 | $6,293 to $47,316 | 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 |
| Peripheral Vascular Disorders with Mcc | other | $6,329 | $6,329 to $32,563 | Low |
| Other Circulatory System Diagnoses with Cc | other | $6,333 | $6,333 to $35,118 | Low |
| Cellulitis with Mcc | other | $6,368 | $6,368 to $38,113 | Low |
| Inflammation of the Male Reproductive System without Mcc | other | $6,384 | $6,384 to $23,999 | Low |
| Epistaxis without Mcc | other | $6,412 | $6,412 to $27,144 | Low |
| Minor Skin Disorders with Mcc | other | $6,415 | $6,415 to $35,421 | Low |
| Other Injury, Poisoning and Toxic Effect Diagnoses without Mcc | other | $6,420 | $6,420 to $24,136 | Low |
| Major Head and Neck Procedures with Cc | other | $6,465 | $6,465 to $57,473 | Low |
| Malignant Breast Disorders with Cc | other | $6,535 | $6,535 to $33,903 | Low |
| Dysequilibrium | other | $6,566 | $6,566 to $27,603 | Low |
| Respiratory Infections and Inflammations without Cc/mcc | other | $6,596 | $6,596 to $37,330 | Low |
| Tendonitis, Myositis and Bursitis with Mcc | other | $6,626 | $6,626 to $39,728 | Low |
| Other Infectious and Parasitic Diseases Diagnoses with Mcc | other | $6,627 | $6,627 to $60,094 | Low |
| Impella Cp #4000021 | other | $6,650 | $6,650 to $25,000 | Low |
| Other Respiratory System O.r. Procedures without Cc/mcc | other | $6,664 | $6,664 to $38,264 | Low |
| Respiratory Neoplasms with Cc | other | $6,687 | $6,687 to $31,399 | Low |
| Cardiac Pacemaker Revision Except Device Replacement with Cc | surgery | $6,747 | $6,747 to $58,836 | Low |
| Kidney and Urinary Tract Infections with MCC | other | $6,748 | $6,748 to $32,245 | Low |
| Major Gastrointestinal Disorders and Peritoneal Infections with Cc | other | $6,762 | $6,762 to $25,855 | Low |
| Samarium Sm 153 Lexidronam 1850 Mbq/ml IV Soln | other | $6,767 | $6,767 to $25,442 | Low |
| Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with Mcc | other | $6,781 | $6,781 to $35,500 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue with Mcc | other | $6,839 | $6,839 to $51,562 | Low |
| Signs and Symptoms without Mcc | other | $6,867 | $6,867 to $25,815 | Low |
| Cardiac Arrhythmia and Conduction Disorders with Mcc | cardiac | $6,869 | $6,869 to $40,678 | Low |
| Craniotomy and Endovascular Intracranial Procedures without Cc/mcc | other | $6,891 | $6,891 to $62,127 | Low |
| Generator, Neurostimulator (implantable), High Frequency, with Rechargeable B... | surgery | $6,916 | $6,916 to $26,000 | Low |
| Transient Ischemia | other | $6,979 | $6,979 to $31,389 | Low |
| Malignancy, Female Reproductive System with Cc | other | $7,017 | $7,017 to $31,130 | Low |
| Other Disorders of Nervous System with Mcc | other | $7,028 | $7,028 to $57,758 | Low |
| Renal Failure with MCC | other | $7,055 | $7,055 to $41,995 | Low |
| Aftercare with Cc/mcc | other | $7,058 | $7,058 to $59,796 | Low |
| Intracranial Hemorrhage or Cerebral Infarction | other | $7,072 | $7,072 to $35,783 | Low |
| Minor Bladder Procedures with Mcc | other | $7,085 | $7,085 to $72,636 | Low |
| Removal of Plaque and Insertion of Stents in Arteries of Leg | surgery | $7,103 | $7,103 to $53,406 | Low |
| Medical Back Problems with Mcc | other | $7,107 | $7,107 to $46,108 | Low |
| Seizures with Mcc | other | $7,110 | $7,110 to $43,628 | Low |
| Urinary Stones with Mcc | other | $7,130 | $7,130 to $32,011 | Low |
| Organic Disturbances and Intellectual Disability | other | $7,167 | $7,167 to $26,943 | Low |
| Other Injury, Poisoning and Toxic Effect Diagnoses with Mcc | other | $7,180 | $7,180 to $59,088 | Low |
| Thyroid, Parathyroid and Thyroglossal Procedures without Cc/mcc | other | $7,180 | $7,180 to $30,286 | Low |
| Other Antepartum Diagnoses with O.r. Procedures without Cc/mcc | other | $7,207 | $7,207 to $27,093 | Low |
| Disorders of the Biliary Tract without Cc/mcc | other | $7,228 | $7,228 to $34,253 | Low |
| Bone Diseases and Arthropathies without Mcc | other | $7,252 | $7,252 to $33,381 | Low |
| Cirrhosis and Alcoholic Hepatitis with Cc | other | $7,265 | $7,265 to $30,432 | Low |
| Postoperative and Post-traumatic Infections with Mcc | emergency | $7,292 | $7,292 to $33,109 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue with Cc | other | $7,327 | $7,327 to $37,637 | Low |
| Other Cerebrovascular Disorders with Cc | other | $7,388 | $7,388 to $30,564 | Low |
| Digestive Malignancy with Mcc | other | $7,399 | $7,399 to $59,226 | Low |
| Transurethral Procedures with Cc | other | $7,490 | $7,490 to $48,225 | Low |
| Biliary Tract Procedures Except Only Cholecystectomy with OR without C.d.e. w... | other | $7,586 | $7,586 to $39,260 | Low |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis without Cc/mcc | other | $7,591 | $7,591 to $36,078 | Low |
| Spinal Disorders and Injuries with Cc/mcc | other | $7,601 | $7,601 to $61,299 | Low |
| Concussion with Mcc | other | $7,751 | $7,751 to $36,748 | Low |
| Kidney and Ureter Procedures for Non-neoplasm without Cc/mcc | other | $7,754 | $7,754 to $29,152 | Low |
| Coagulation Disorders | other | $7,755 | $7,755 to $44,494 | Low |
| Nervous System Neoplasms with Mcc | other | $7,768 | $7,768 to $44,713 | Low |
| Insertion of Defibrillator with Existing Single Lead | other | $7,792 | $7,792 to $33,240 | Low |
| Soft Tissue Procedures with Cc | other | $7,799 | $7,799 to $48,826 | Low |
| HIV with Major Related Condition without Cc/mcc | other | $7,815 | $7,815 to $29,818 | Low |
| Dental and Oral Diseases with Mcc | other | $7,853 | $7,853 to $56,651 | Low |
| Other Kidney and Urinary Tract Diagnoses with Mcc | other | $7,867 | $7,867 to $43,605 | Low |
| Peritoneal Adhesiolysis without Cc/mcc | other | $7,872 | $7,872 to $39,061 | Low |
| Postoperative OR Post-traumatic Infections with O.r. Procedures without Cc/mcc | emergency | $7,900 | $7,900 to $38,712 | Low |
| Degenerative Nervous System Disorders with Mcc | other | $8,000 | $8,000 to $100,337 | Low |
| Acute Myocardial Infarction Discharged Alive with CC | cardiac | $8,030 | $8,030 to $38,657 | Low |
| Inguinal and Femoral Hernia Procedures without Cc/mcc | other | $8,072 | $8,072 to $30,346 | Low |
| Malignancy, Female Reproductive System with Mcc | other | $8,103 | $8,103 to $49,651 | Low |
| Ungroupable | other | $8,110 | $8,110 to $30,489 | Low |
| Other Musculoskeletal System and Connective Tissue Diagnoses with Mcc | other | $8,121 | $8,121 to $43,256 | Low |
| Appendectomy (Laparoscopic) | surgery | $8,148 | $537 to $30,632 | High |
| Lymphoma and Non-acute Leukemia with Cc | other | $8,150 | $8,150 to $50,143 | Low |
| Major Head and Neck Procedures without Cc/mcc | other | $8,167 | $8,167 to $46,164 | Low |
| Other Digestive System Diagnoses with Cc | other | $8,175 | $8,175 to $30,974 | Low |
| Acute Adjustment Reaction and Psychosocial Dysfunction | other | $8,193 | $8,193 to $30,803 | Low |
| Lower Extremity and Humerus Procedures Except Hip, Foot and Femur without Cc/mcc | other | $8,384 | $8,384 to $40,571 | Low |
| Digestive Malignancy with Cc | other | $8,395 | $8,395 to $34,257 | Low |
| Biopsies of Musculoskeletal System and Connective Tissue without Cc/mcc | other | $8,406 | $8,406 to $44,901 | Low |
| Hip and Femur Procedures except Major Joint without CC/MCC | surgery | $8,448 | $8,448 to $38,554 | Low |
| Kidney and Urinary Tract Neoplasms with Mcc | other | $8,459 | $8,459 to $52,968 | Low |
| Alcohol, Drug Abuse OR Dependence without Rehabilitation Therapy with Mcc | therapy | $8,528 | $8,528 to $32,060 | Low |
| Infectious and Parasitic Diseases with O.r. Procedures with Cc | other | $8,532 | $8,532 to $53,367 | Low |
| Other Myeloproliferative Disorders OR Poorly Differentiated Neoplastic Diagno... | other | $8,549 | $8,549 to $55,441 | Low |
| Pulmonary Embolism with MCC | other | $8,553 | $8,553 to $42,489 | Low |
| Transcath Heart Valve 20mm Sapien 3 Ref# S3ucm220a | cardiac | $8,645 | $8,645 to $32,500 | Low |
| Transcath Heart Valve 23mm Sapien 3 S3ucm223a | cardiac | $8,645 | $8,645 to $32,500 | Low |
| Transcath Heart Valve 26mm Sapien 3 S3ucm226a | cardiac | $8,645 | $8,645 to $32,500 | Low |
| Transcath Heart Valve 29mm Sapien 3 9600cm29a | cardiac | $8,645 | $8,645 to $32,500 | Low |
| Hepatobiliary Diagnostic Procedures without Cc/mcc | other | $8,656 | $8,656 to $49,437 | Low |
| Other Skin, Subcutaneous Tissue and Breast Procedures with Cc | other | $8,668 | $8,668 to $40,166 | Low |
| Complicated Peptic Ulcer with Cc | other | $8,670 | $8,670 to $32,594 | Low |
| Soft Tissue Procedures with Mcc | other | $8,693 | $8,693 to $93,149 | Low |
| Postoperative and Post-traumatic Infections without Mcc | emergency | $8,718 | $8,718 to $33,524 | Low |
| Inborn and Other Disorders of Metabolism | other | $8,723 | $8,723 to $33,944 | Low |
| Other Infectious and Parasitic Diseases Diagnoses with Cc | other | $8,727 | $8,727 to $32,807 | Low |
| Skin Ulcers with Mcc | other | $8,735 | $8,735 to $53,793 | Low |
| Major Gastrointestinal Disorders and Peritoneal Infections with Mcc | other | $8,737 | $8,737 to $46,007 | Low |
| Connective Tissue Disorders with Cc | other | $8,754 | $8,754 to $32,908 | Low |
| Respiratory Infections with MCC | other | $8,765 | $8,765 to $43,139 | Low |
| Cranial and Peripheral Nerve Disorders with Mcc | other | $8,779 | $8,779 to $41,086 | Low |
| Other Antepartum Diagnoses with O.r. Procedures with Mcc | other | $8,916 | $8,916 to $40,457 | Low |
| Inguinal and Femoral Hernia Procedures with Cc | other | $8,958 | $8,958 to $50,968 | Low |
| Trauma to the Skin, Subcutaneous Tissue and Breast with Mcc | emergency | $8,996 | $8,996 to $44,099 | Low |
| Penis Procedures with Cc/mcc | other | $9,005 | $9,005 to $63,308 | Low |
| Transcath Heart Valve 20mm Sapien 3 Resilia S3urcm20a | cardiac | $9,044 | $9,044 to $34,000 | Low |
| Transcath Heart Valve 23mm Sapien 3 Resilia S3urcm23a | cardiac | $9,044 | $9,044 to $34,000 | Low |
| Transcath Heart Valve 26mm Sapien 3 Resilia S3urcm26a | cardiac | $9,044 | $9,044 to $34,000 | Low |
| Transcath Heart Valve 29mm Sapien 3 Resilia S3urcm29a | cardiac | $9,044 | $9,044 to $34,000 | Low |
| Viral Illness with Mcc | other | $9,059 | $9,059 to $34,057 | Low |
| Repair of Congenital Abnormality in Wall Between Upper Heart Chambers with Im... | surgery | $9,064 | $9,064 to $93,580 | Low |
| Uterine and Adnexa Procedures for Non-malignancy with Cc/mcc | other | $9,071 | $9,071 to $34,101 | Low |
| Upper Limb and Toe Amputation for Circulatory System Disorders with Cc | other | $9,106 | $9,106 to $39,535 | Low |
| Complicated Peptic Ulcer with Mcc | other | $9,173 | $9,173 to $62,002 | Low |
| Other Digestive System Diagnoses with Mcc | other | $9,182 | $9,182 to $43,523 | Low |
| Prostatectomy | other | $9,238 | $9,238 to $58,395 | High |
| Transurethral Prostatectomy without Cc/mcc | other | $9,238 | $9,238 to $58,395 | Low |
| Spinal Procedures without Cc/mcc | other | $9,256 | $9,256 to $43,462 | Low |
| Skin Debridement with Cc | other | $9,260 | $9,260 to $43,865 | Low |
| Other Respiratory System O.r. Procedures with Cc | other | $9,275 | $9,275 to $69,108 | Low |
| Knee Procedures without Principal Diagnosis of Infection without Cc/mcc | other | $9,304 | $9,304 to $46,895 | Low |
| Intracranial Hemorrhage OR Cerebral Infarction with Mcc | other | $9,313 | $9,313 to $66,406 | Low |
| Cirrhosis and Alcoholic Hepatitis with Mcc | other | $9,313 | $9,313 to $52,629 | Low |
| Cardiac Catheterization | cardiac | $9,349 | $9,349 to $40,525 | High |
| Other Male Reproductive System O.r. Procedures Except Malignancy without Cc/mcc | other | $9,398 | $9,398 to $35,332 | Low |
| Degenerative Nervous System Disorders without Mcc | other | $9,421 | $9,421 to $44,606 | Low |
| Diabetes with Mcc | other | $9,448 | $9,448 to $36,519 | 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 |
| Disorders of the Biliary Tract with Cc | other | $9,561 | $9,561 to $42,532 | Low |
| Other Hepatobiliary OR Pancreas O.r. Procedures with Cc | other | $9,565 | $9,565 to $63,112 | Low |
| Cardiac Pacemaker Revision Except Device Replacement without Cc/mcc | surgery | $9,619 | $9,619 to $57,262 | Low |
| Inflammation of the Male Reproductive System with Mcc | other | $9,623 | $9,623 to $36,178 | Low |
| Lymphoma and Non-acute Leukemia with Mcc | other | $9,639 | $9,639 to $93,809 | Low |
| Other Respiratory System Diagnoses with Mcc | other | $9,639 | $9,639 to $37,441 | Low |
| Disorders of Liver Except Malignancy, Cirrhosis OR Alcoholic Hepatitis with Mcc | other | $9,668 | $9,668 to $50,459 | Low |
| Kidney and Ureter Procedures for Neoplasm without Cc/mcc | other | $9,696 | $9,696 to $38,692 | Low |
| Reticuloendothelial and Immunity Disorders with Mcc | other | $9,708 | $9,708 to $58,306 | Low |
| Minor Small and Large Bowel Procedures with Mcc | other | $9,808 | $9,808 to $44,894 | Low |
| Myeloproliferative Disorders OR Poorly Differentiated Neoplasms with Major O.... | other | $9,821 | $9,821 to $59,055 | Low |
| Minor Bladder Procedures with Cc | other | $9,837 | $9,837 to $45,044 | Low |
| Malignancy of Hepatobiliary System OR Pancreas with Cc | other | $9,882 | $9,882 to $51,475 | Low |
| Cervical Spinal Fusion with CC | surgery | $9,977 | $9,977 to $53,956 | Low |
| Appendix Procedures without Cc/mcc | other | $10,001 | $10,001 to $44,389 | Low |
| Gastrointestinal Obstruction with Mcc | other | $10,001 | $10,001 to $37,596 | Low |
| Traumatic Stupor and Coma <1 Hour with Mcc | emergency | $10,066 | $10,066 to $46,080 | Low |
| Other Kidney and Urinary Tract Procedures with Cc | other | $10,168 | $10,168 to $62,139 | Low |
| Thyroid, Parathyroid and Thyroglossal Procedures with Cc | other | $10,198 | $10,198 to $38,875 | Low |
| Benign Prostatic Hypertrophy with Mcc | other | $10,223 | $10,223 to $60,175 | Low |
| Inflammatory Bowel Disease with Mcc | other | $10,270 | $10,270 to $40,151 | Low |
| Major Shoulder OR Elbow Joint Procedures with Cc/mcc | other | $10,321 | $10,321 to $47,270 | Low |
| Other Female Reproductive System O.r. Procedures without Cc/mcc | other | $10,337 | $10,337 to $46,559 | Low |
| Minor Small and Large Bowel Procedures without Cc/mcc | other | $10,363 | $10,363 to $63,982 | Low |
| Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders w... | lab | $10,462 | $10,462 to $50,494 | Low |
| Tracheostomy for Face, Mouth and Neck Diagnoses OR Laryngectomy with Cc | other | $10,465 | $10,465 to $106,816 | Low |
| Minor Small and Large Bowel Procedures with Cc | other | $10,492 | $10,492 to $39,442 | Low |
| Lymphoma and Leukemia with Major O.r. Procedures without Cc/mcc | other | $10,519 | $10,519 to $57,398 | Low |
| Major Esophageal Disorders with Mcc | other | $10,560 | $10,560 to $41,692 | Low |
| Transurethral Procedures with Mcc | other | $10,574 | $10,574 to $77,197 | Low |
| Complications of Treatment with Mcc | other | $10,587 | $10,587 to $41,745 | Low |
| Septicemia or Severe Sepsis without Ventilator 96+ Hours with MCC | other | $10,646 | $10,646 to $52,015 | Low |
| Kidney and Ureter Procedures for Neoplasm with Cc | other | $10,702 | $10,702 to $55,805 | Low |
| Non-bacterial Infection of Nervous System Except Viral Meningitis without Cc/mcc | other | $10,717 | $10,717 to $43,414 | Low |
| Disorders of Pancreas Except Malignancy with Mcc | other | $10,726 | $10,726 to $49,809 | Low |
| Major Male Pelvic Procedures without Cc/mcc | other | $10,830 | $10,830 to $57,178 | Low |
| Respiratory Neoplasms with Mcc | other | $10,832 | $10,832 to $54,863 | Low |
| Insertion of Implantable Defibrillator System | surgery | $10,859 | $10,859 to $40,824 | Low |
| Hernia Procedures Except Inguinal and Femoral with Cc | other | $10,868 | $10,868 to $49,743 | Low |
| Appendix Procedures with Cc | other | $10,958 | $10,958 to $41,196 | Low |
| Other Cerebrovascular Disorders with Mcc | other | $10,964 | $10,964 to $58,989 | Low |
| Poisoning and Toxic Effects of Drugs with MCC | emergency | $11,044 | $11,044 to $41,518 | Low |
| Lower Extremity and Humerus Procedures Except Hip, Foot and Femur with Cc | other | $11,048 | $11,048 to $57,914 | Low |
| Lymphoma and Non-acute Leukemia with Other Procedures with Cc | other | $11,079 | $11,079 to $70,127 | Low |
| Hip and Femur Procedures except Major Joint with CC | surgery | $11,094 | $11,094 to $54,269 | Low |
| Traumatic Injury with Mcc | emergency | $11,101 | $11,101 to $45,716 | Low |
| Shoulder, Elbow OR Forearm Procedures, Except Major Joint Procedures without ... | other | $11,234 | $11,234 to $42,234 | Low |
| Splenic Procedures without Cc/mcc | other | $11,279 | $11,279 to $50,235 | Low |
| Bone Diseases and Arthropathies with Mcc | other | $11,325 | $11,325 to $43,779 | Low |
| Stomach, Esophageal and Duodenal Procedures without Cc/mcc | other | $11,351 | $11,351 to $42,675 | Low |
| Non-extensive O.r. Procedures Unrelated to Principal Diagnosis with Mcc | other | $11,384 | $11,384 to $122,908 | Low |
| Chemotherapy without Acute Leukemia As Secondary Diagnosis with Cc | other | $11,422 | $11,422 to $42,940 | Low |
| Major Small and Large Bowel Procedures without CC/MCC | surgery | $11,482 | $11,482 to $43,166 | Low |
| Kidney and Ureter Procedures for Non-neoplasm with Cc | other | $11,547 | $11,547 to $44,815 | Low |
| Osteomyelitis with Mcc | other | $11,573 | $11,573 to $60,583 | Low |
| Extracranial Procedures with Mcc | other | $11,661 | $11,661 to $112,802 | Low |
| Cholecystectomy with C.d.e. with Mcc | other | $11,674 | $11,674 to $73,430 | Low |
| Rectal Resection without Cc/mcc | other | $11,762 | $11,762 to $57,241 | Low |
| Lymphoma and Non-acute Leukemia with Other Procedures without Cc/mcc | other | $11,789 | $11,789 to $86,140 | Low |
| Wound Debridement and Skin Graft Except Hand for Musculoskeletal and Connecti... | other | $11,830 | $11,830 to $54,096 | Low |
| Cholecystectomy Except By Laparoscope without C.d.e. without Cc/mcc | surgery | $11,910 | $11,910 to $57,417 | Low |
| Gallbladder Removal (Laparoscopic) | surgery | $11,932 | $11,932 to $49,139 | High |
| Laparoscopic Cholecystectomy without CC/MCC | surgery | $11,932 | $11,932 to $49,139 | Low |
| Total Hip Replacement | surgery | $11,950 | $11,950 to $62,822 | High |
| Cardiac Congenital and Valvular Disorders with Mcc | cardiac | $11,972 | $11,972 to $45,006 | Low |
| Knee Procedures with Principal Diagnosis of Infection without Cc/mcc | other | $12,036 | $12,036 to $45,248 | 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 |
| Ischemic Stroke, Precerebral Occlusion OR Transient Ischemia with Thrombolyti... | other | $12,264 | $12,264 to $52,233 | Low |
| Skin Graft Except for Skin Ulcer OR Cellulitis with Mcc | other | $12,286 | $12,286 to $218,745 | Low |
| Other Vascular Procedures without Cc/mcc | other | $12,341 | $12,341 to $48,877 | Low |
| Major Hip and Knee Joint Replacement without MCC | surgery | $12,360 | $12,360 to $53,890 | Low |
| Total Knee Replacement | surgery | $12,360 | $12,360 to $53,890 | High |
| Peritoneal Adhesiolysis with Mcc | other | $12,477 | $12,477 to $103,521 | Low |
| Non-extensive O.r. Procedures Unrelated to Principal Diagnosis with Cc | other | $12,497 | $12,497 to $46,979 | Low |
| Other Hepatobiliary OR Pancreas O.r. Procedures with Mcc | other | $12,501 | $12,501 to $111,903 | Low |
| Insertion OR Replacement of Defibrillator with Electrode | surgery | $12,587 | $12,587 to $47,318 | Low |
| Major Bladder Procedures without Cc/mcc | other | $12,635 | $12,635 to $79,171 | Low |
| GI Hemorrhage with MCC | other | $12,788 | $12,788 to $49,246 | Low |
| Pneumothorax with Mcc | other | $12,838 | $12,838 to $48,264 | Low |
| Other Vascular Procedures with Cc | other | $12,888 | $12,888 to $70,504 | Low |
| Percutaneous Cardiovascular Procedures without Intraluminal Device without Mcc | cardiac | $13,056 | $13,056 to $54,396 | Low |
| Zevalin Y-90 Vial | other | $13,113 | $13,113 to $49,298 | Low |
| Uterine and Adnexa Procedures for Non-ovarian and Non-adnexal Malignancy with Cc | other | $13,117 | $13,117 to $49,312 | Low |
| Transurethral Prostatectomy with Cc/mcc | other | $13,134 | $13,134 to $55,113 | Low |
| Cardiac Pacemaker Revision Except Device Replacement with Mcc | surgery | $13,161 | $13,161 to $110,066 | Low |
| Other Endocrine, Nutritional and Metabolic O.r. Procedures with Cc | lab | $13,189 | $13,189 to $54,231 | Low |
| Major Joint OR Limb Reattachment Procedures of Upper Extremities | other | $13,298 | $13,298 to $73,769 | Low |
| Disorders of the Biliary Tract with Mcc | other | $13,345 | $13,345 to $50,170 | Low |
| Other Musculoskeletal System and Connective Tissue O.r. Procedures without Cc... | other | $13,425 | $13,425 to $75,908 | Low |
| Other Digestive System O.r. Procedures with Cc | other | $13,465 | $13,465 to $55,043 | Low |
| Pleural Effusion with Mcc | surgery | $13,616 | $13,616 to $61,318 | Low |
| Cardiac Arrest, Unexplained with Mcc | cardiac | $13,645 | $13,645 to $74,434 | Low |
| Other Circulatory System O.r. Procedures | other | $13,664 | $13,664 to $90,984 | Low |
| Malignancy of Hepatobiliary System OR Pancreas with Mcc | other | $13,694 | $13,694 to $51,481 | Low |
| Other O.r. Procedures for Injuries with Mcc | other | $13,695 | $13,695 to $124,161 | Low |
| Fractures of Femur with Mcc | other | $13,696 | $13,696 to $58,222 | Low |
| Major Chest Procedures without Cc/mcc | other | $13,733 | $13,733 to $51,893 | Low |
| Pacemaker Insertion | cardiac | $13,758 | $13,758 to $60,754 | High |
| Permanent Cardiac Pacemaker Implant without Cc/mcc | surgery | $13,758 | $13,758 to $60,754 | Low |
| Bilateral or Multiple Major Joint Procedures of Lower Extremity | surgery | $13,799 | $13,799 to $110,757 | Low |
| Laparoscopic Cholecystectomy without Common Duct with CC | surgery | $13,868 | $13,868 to $52,136 | Low |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Cc | other | $13,944 | $13,944 to $77,299 | Low |
| Local Excision and Removal of Internal Fixation Devices of Hip and Femur with... | surgery | $14,124 | $14,124 to $72,467 | Low |
| Kidney and Ureter Procedures for Neoplasm with Mcc | other | $14,207 | $14,207 to $62,730 | Low |
| Peritoneal Adhesiolysis with Cc | other | $14,500 | $14,500 to $54,513 | Low |
| Hip and Femur Procedures except Major Joint with MCC | surgery | $14,531 | $14,531 to $97,364 | Low |
| Anal and Stomal Procedures with Mcc | other | $14,725 | $14,725 to $67,343 | Low |
| Testes Procedures with Cc/mcc | other | $14,839 | $14,839 to $58,688 | Low |
| Knee Procedures with Principal Diagnosis of Infection with Mcc | other | $15,040 | $15,040 to $105,056 | Low |
| Cardiac Pacemaker Device Replacement with Mcc | surgery | $15,157 | $15,157 to $97,634 | Low |
| Shoulder, Elbow OR Forearm Procedures, Except Major Joint Procedures with Cc | other | $15,319 | $15,319 to $57,591 | Low |
| Upper Limb and Toe Amputation for Circulatory System Disorders with Mcc | other | $15,363 | $15,363 to $82,419 | Low |
| Kidney and Ureter Procedures for Non-neoplasm with Mcc | other | $15,365 | $15,365 to $65,524 | Low |
| Percutaneous Cardiovascular Procedures with Intraluminal Device without Mcc | cardiac | $15,402 | $15,402 to $66,334 | Low |
| Other Musculoskeletal System and Connective Tissue O.r. Procedures with Mcc | other | $15,420 | $15,420 to $97,403 | Low |
| Respiratory System Diagnosis with Ventilator Support <=96 Hours | other | $15,568 | $15,568 to $61,913 | Low |
| Wound Debridements for Injuries with Mcc | other | $15,588 | $15,588 to $136,606 | Low |
| Other Circulatory System Diagnoses with Mcc | other | $15,658 | $15,658 to $66,938 | Low |
| Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Di... | lab | $15,672 | $15,672 to $68,034 | Low |
| Biopsies of Musculoskeletal System and Connective Tissue with Cc | other | $15,744 | $15,744 to $61,620 | Low |
| Sipuleucel-t, Minimum of 50 Million Autologous Cd54+ Cells Activated with Pap... | other | $15,783 | $15,783 to $118,672 | Low |
| Malignancy, Male Reproductive System with Mcc | other | $15,810 | $15,810 to $105,064 | Low |
| Stomach, Esophageal and Duodenal Procedures with Cc | other | $15,836 | $15,836 to $59,533 | Low |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis with Cc | other | $16,042 | $16,042 to $66,209 | Low |
| Permanent Cardiac Pacemaker Implant with Mcc | surgery | $16,245 | $16,245 to $98,495 | Low |
| Other Skin, Subcutaneous Tissue and Breast Procedures with Mcc | other | $16,331 | $16,331 to $101,908 | Low |
| Peripheral, Cranial Nerve and Other Nervous System Procedures with Mcc | other | $16,409 | $16,409 to $96,346 | Low |
| Major Chest Procedures with Cc | other | $16,501 | $16,501 to $73,012 | Low |
| Acute Myocardial Infarction, Expired with Mcc | other | $16,614 | $16,614 to $62,459 | Low |
| Cervical Spinal Fusion without CC/MCC | surgery | $16,632 | $16,632 to $110,448 | Low |
| Spinal Fusion except Cervical without MCC | surgery | $16,653 | $16,653 to $62,604 | Low |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Mcc | other | $16,792 | $16,792 to $122,712 | Low |
| Ear, Nose, Mouth and Throat Malignancy with Mcc | other | $16,889 | $16,889 to $63,492 | Low |
| Carotid Artery Stent Procedures without Cc/mcc | cardiac | $16,973 | $16,973 to $72,938 | Low |
| Amputation for Musculoskeletal System and Connective Tissue Disorders with Cc | other | $17,022 | $17,022 to $68,425 | Low |
| Other O.r. Procedures for Injuries with Cc | other | $17,431 | $17,431 to $81,709 | Low |
| Other Respiratory System O.r. Procedures with Mcc | other | $17,474 | $17,474 to $139,831 | Low |
| Cardiac Pacemaker Device Replacement without Mcc | surgery | $17,571 | $17,571 to $66,055 | Low |
| Cholecystectomy with C.d.e. with Cc | other | $17,667 | $17,667 to $73,430 | Low |
| O.r. Procedures with Diagnoses of Other Contact with Health Services without ... | other | $17,715 | $17,715 to $123,242 | Low |
| Major Hip and Knee Joint Replacement with MCC | surgery | $17,803 | $17,803 to $95,864 | Low |
| Major Small and Large Bowel Procedures with CC | surgery | $17,979 | $17,979 to $67,589 | Low |
| Other Musculoskeletal System and Connective Tissue O.r. Procedures with Cc | other | $18,155 | $18,155 to $74,186 | Low |
| Knee Procedures with Principal Diagnosis of Infection with Cc | other | $18,269 | $18,269 to $79,088 | Low |
| O.r. Procedures with Principal Diagnosis of Mental Illness | other | $18,475 | $18,475 to $69,457 | Low |
| Hepatobiliary Diagnostic Procedures with Mcc | other | $18,524 | $18,524 to $114,121 | Low |
| Permanent Cardiac Pacemaker Implant with Cc | surgery | $18,616 | $18,616 to $75,471 | Low |
| Stomach, Esophageal and Duodenal Procedures with Mcc | other | $19,025 | $19,025 to $109,419 | Low |
| Percutaneous Cardiovascular Procedures without Intraluminal Device with Mcc | cardiac | $19,067 | $19,067 to $87,052 | Low |
| Major Bladder Procedures with Cc | other | $19,092 | $19,092 to $104,297 | Low |
| Bacterial and Tuberculous Infections of Nervous System with Cc | other | $20,182 | $20,182 to $75,871 | Low |
| O.r. Procedures with Diagnoses of Other Contact with Health Services with Cc | other | $20,416 | $20,416 to $87,389 | Low |
| Hernia Procedures Except Inguinal and Femoral with Mcc | other | $20,526 | $20,526 to $84,683 | 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 |
| Carotid Artery Stent Procedures with Cc | cardiac | $20,884 | $20,884 to $81,568 | Low |
| Appendix Procedures with Mcc | other | $20,923 | $20,923 to $81,065 | Low |
| Lymphoma and Non-acute Leukemia with Other Procedures with Mcc | other | $21,092 | $21,092 to $139,280 | Low |
| Postoperative OR Post-traumatic Infections with O.r. Procedures with Mcc | emergency | $21,117 | $21,117 to $96,975 | Low |
| Coronary Bypass without Cardiac Catheter without MCC | cardiac | $22,290 | $22,290 to $111,047 | Low |
| Other Major Cardiovascular Procedures without Cc/mcc | cardiac | $22,304 | $22,304 to $179,057 | Low |
| Other Kidney and Urinary Tract Procedures with Mcc | other | $22,694 | $22,694 to $124,248 | Low |
| Non-bacterial Infection of Nervous System Except Viral Meningitis with Mcc | other | $22,716 | $22,716 to $137,905 | Low |
| Other Digestive System O.r. Procedures with Mcc | other | $23,538 | $23,538 to $116,650 | Low |
| Acute and Subacute Endocarditis with Mcc | other | $23,642 | $23,642 to $133,961 | Low |
| Percutaneous Cardiovascular Procedures with Intraluminal Device with Mcc OR 4... | cardiac | $23,728 | $23,728 to $89,202 | Low |
| Other Vascular Procedures with Mcc | other | $23,909 | $23,909 to $99,371 | Low |
| Infectious and Parasitic Diseases with O.r. Procedures with Mcc | other | $23,978 | $23,978 to $149,425 | Low |
| Foot Procedures with Mcc | other | $24,384 | $24,384 to $147,189 | Low |
| Splenic Procedures with Mcc | other | $25,744 | $25,744 to $118,186 | Low |
| Thyroid, Parathyroid and Thyroglossal Procedures with Mcc | other | $25,835 | $25,835 to $97,123 | Low |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis with Mcc | other | $26,937 | $26,937 to $139,548 | Low |
| Other Cardiothoracic Procedures without Mcc | other | $27,097 | $27,097 to $101,870 | Low |
| Coronary Intravascular Lithotripsy with Intraluminal Device without Mcc | cardiac | $27,528 | $27,528 to $111,665 | Low |
| Kidney Stone Removal | other | $27,528 | $27,528 to $111,665 | High |
| Percutaneous and Other Intracardiac Procedures without Mcc | cardiac | $28,757 | $28,757 to $149,594 | Low |
| Respiratory System Diagnosis with Ventilator 96+ Hours | other | $28,878 | $28,878 to $172,058 | Low |
| Aortic and Heart Assist Procedures Except Pulsation Balloon without Mcc | cardiac | $29,028 | $29,028 to $109,128 | Low |
| Other Major Cardiovascular Procedures with Cc | cardiac | $31,069 | $31,069 to $117,378 | Low |
| Cholecystectomy Except By Laparoscope without C.d.e. with Mcc | surgery | $31,124 | $31,124 to $238,709 | Low |
| Tracheostomy for Face, Mouth and Neck Diagnoses OR Laryngectomy with Mcc | other | $31,190 | $31,190 to $127,814 | Low |
| Ultrasound Accelerated and Other Thrombolysis of Peripheral Vascular Structur... | imaging | $31,507 | $31,507 to $134,689 | Low |
| Septicemia OR Severe Sepsis with Mv >96 Hours | other | $32,199 | $32,199 to $188,578 | Low |
| Other Endovascular Cardiac Valve Procedures with Mcc | cardiac | $32,419 | $32,419 to $128,425 | Low |
| Cardiac Valve and Other Major Cardiothoracic without Cardiac Catheter | cardiac | $32,509 | $32,509 to $212,499 | Low |
| Major Small and Large Bowel Procedures with MCC | surgery | $32,552 | $32,552 to $122,375 | Low |
| Aortic and Heart Assist Procedures Except Pulsation Balloon with Mcc | cardiac | $33,878 | $33,878 to $218,222 | Low |
| Percutaneous and Other Intracardiac Procedures with Mcc | cardiac | $36,042 | $36,042 to $166,395 | Low |
| Spinal Procedures with Mcc | other | $36,510 | $36,510 to $186,438 | Low |
| Major Chest Procedures with Mcc | other | $36,629 | $36,629 to $137,702 | Low |
| Other Major Cardiovascular Procedures with Mcc | cardiac | $36,680 | $36,680 to $151,297 | Low |
| Coronary Intravascular Lithotripsy with Intraluminal Device with Mcc | cardiac | $37,806 | $37,806 to $144,572 | Low |
| Aicd Generator Procedures | other | $39,859 | $39,859 to $286,323 | Low |
| Cardiac Defibrillator Implant without Mcc | surgery | $40,349 | $40,349 to $160,158 | Low |
| Endovascular Cardiac Valve Replacement and Supplement Procedures without Mcc | surgery | $41,592 | $41,592 to $190,656 | Low |
| Heart Valve Replacement | other | $41,592 | $41,592 to $190,656 | High |
| Major Bladder Procedures with Mcc | other | $43,656 | $43,656 to $164,119 | Low |
| Angioplasty with Stent (PCI) | other | $44,214 | $44,214 to $190,761 | High |
| Coronary Bypass with PTCA without Mcc | cardiac | $44,214 | $44,214 to $190,761 | Low |
| Coronary Bypass with PTCA with MCC | cardiac | $44,413 | $44,413 to $231,406 | Low |
| Cardiac Defibrillator Implant with Mcc OR Carotid Sinus Neurostimulator | surgery | $45,752 | $45,752 to $171,999 | Low |
| Coronary Bypass with Cardiac Catheter with MCC | cardiac | $49,716 | $49,716 to $186,904 | Low |
| Cardiac Valve and Other Major Cardiothoracic with Cardiac Catheter | cardiac | $50,721 | $50,721 to $317,734 | Low |
| Endovascular Cardiac Valve Replacement and Supplement Procedures with Mcc | surgery | $53,540 | $53,540 to $224,119 | Low |
| Other Heart Assist System Implant | surgery | $64,199 | $64,199 to $241,350 | Low |
| Tracheostomy with Mv >96 Hours OR Principal Diagnosis Except Face, Mouth and ... | other | $91,022 | $91,022 to $528,873 | Low |
| Ecmo OR Tracheostomy with Mv >96 Hours OR Principal Diagnosis Except Face, Mo... | other | $122,514 | $122,514 to $572,885 | Low |