| Abdominal Ultrasound | imaging | $0 | $100 to $983 | High |
| Ankle X-Ray | imaging | $0 | $83 to $485 | High |
| Asthma Management | other | $0 | $116 to $581 | High |
| Basic Metabolic Panel (BMP) | lab | $0 | $8 to $110 | High |
| Blood Draw (Venipuncture) | lab | $0 | $5 to $25 | High |
| Carotid Ultrasound | imaging | $0 | $106 to $535 | High |
| Chest X-Ray | imaging | $0 | $76 to $382 | High |
| Circumcision | surgery | $0 | $572 to $2,875 | High |
| Complete Blood Count (CBC) | lab | $0 | $6 to $123 | High |
| Critical Care | emergency | $0 | $23 to $751 | High |
| CT Abdomen and Pelvis | imaging | $0 | $333 to $7,564 | High |
| CT Chest | imaging | $0 | $168 to $3,776 | High |
| CT Spine | imaging | $0 | $168 to $4,689 | High |
| Diabetes Management | other | $0 | $82 to $488 | High |
| Emergency Room Visit | emergency | $0 | $228 to $1,148 | High |
| Foot X-Ray | imaging | $0 | $83 to $485 | High |
| Hand/Wrist X-Ray | imaging | $0 | $83 to $491 | High |
| Hip/Pelvis X-Ray | imaging | $0 | $48 to $242 | High |
| Hospital Observation | other | $0 | $10 to $827 | High |
| Hypertension Management | cardiac | $0 | $56 to $422 | High |
| IV Drug Infusion | therapy | $0 | $27 to $137 | High |
| IV Hydration | therapy | $0 | $27 to $137 | High |
| Liver Function Panel | lab | $0 | $8 to $231 | High |
| Lumbar Puncture (Spinal Tap) | other | $0 | $178 to $894 | High |
| Lumbar Spine X-Ray | imaging | $0 | $100 to $772 | High |
| Moderate Sedation | other | $0 | $11 to $334 | High |
| MRI of the Abdomen | imaging | $0 | $333 to $4,490 | High |
| MRI of the Brain | imaging | $0 | $333 to $5,260 | High |
| MRI of the Knee | imaging | $0 | $333 to $4,326 | High |
| MRI of the Shoulder | imaging | $0 | $333 to $3,607 | High |
| MRI Spine | imaging | $0 | $333 to $3,607 | High |
| Albuterol, Inhalation Solution, Fda-approved Final Product, Non-compounded, A... | other | $1 | $1 to $2 | Low |
| Albuterol, Up to 2.5 Mg and Ipratropium Bromide, Up to 0.5 Mg, Fda-approved F... | other | $1 | $1 to $2 | Low |
| Azathioprine, Oral, 50 Mg | other | $1 | $1 to $2 | Low |
| Bacitracin Oint 0.9gm | other | $1 | $1 to $2 | Low |
| Hyoscyamine Sulfate 120 Ml Dos | other | $1 | $1 to $2 | Low |
| Injection, Fosphenytoin, 50 Mg Phenytoin Equivalent | other | $1 | $1 to $24 | Low |
| Injection, Heparin Sodium, (heparin Lock Flush), Per 10 Units | other | $1 | $1 to $2 | Low |
| Injection, Ondansetron Hydrochloride, Per 1 Mg | other | $1 | $1 to $2 | Low |
| Injection, Triamcinolone Acetonide, Not Otherwise Specified, 10 Mg | other | $1 | $1 to $2 | Low |
| Mycophenolate Mofetil, Oral, 250 Mg | other | $1 | $1 to $2 | Low |
| No Charge Item | other | $1 | $1 to $5 | Low |
| Noc Drugs, Inhalation Solution Administered Through DME | other | $1 | $1 to $7 | Low |
| Analysis of Urine, Except Immunoassays | other | $2 | $2 to $81,005 | Low |
| Blood Count, Hemoglobin | other | $2 | $2 to $85,018 | Low |
| Buprenorphine, Oral, 1 Mg | other | $2 | $2 to $10 | Low |
| Injection, Lorazepam, 2 Mg | other | $2 | $2 to $9 | Low |
| Injection, Meperidine Hydrochloride, Per 100 Mg | other | $2 | $2 to $12 | Low |
| Injection, Metronidazole, 10 Mg | other | $2 | $2 to $10 | Low |
| Injection, Morphine Sulfate (fresenius Kabi), Not Therapeutically Equivalent ... | other | $2 | $2 to $13 | Low |
| Injection, Phenytoin Sodium, Per 50 Mg | other | $2 | $2 to $10 | Low |
| Injection, Promethazine Hcl, Up to 50 Mg | other | $2 | $2 to $9 | Low |
| Injection, Prothrombin Complex Concentrate, Human-lans, Per I.u. of Factor Ix... | other | $2 | $2 to $12,768 | Low |
| Injection, Zidovudine, 10 Mg | other | $2 | $2 to $146 | Low |
| Loperamide Hcl 1mg/7.5 Ml Ud | other | $2 | $2 to $11 | Low |
| Methylprednisolone Oral, Per 4 Mg | other | $2 | $2 to $8 | Low |
| Automated White Blood Cell Count | other | $3 | $3 to $85,048 | Low |
| Blood Group Typing | other | $3 | $3 to $86,900 | Low |
| Blood Typing for Rh (d) Antigen | other | $3 | $3 to $86,901 | Low |
| Glutose 15 Gel | other | $3 | $3 to $5 | Low |
| Injection, Ciprofloxacin for Intravenous Infusion, 200 Mg | surgery | $3 | $3 to $17 | Low |
| Injection, Dexamethasone Sodium Phosphate, 1 Mg | imaging | $3 | $3 to $14 | Low |
| Injection, Diphenhydramine Hcl, Up to 50 Mg | other | $3 | $3 to $15 | Low |
| Injection, Hydromorphone, 0.1 Mg | other | $3 | $3 to $13 | Low |
| Injection, Metoclopramide Hcl, Up to 10 Mg | other | $3 | $3 to $13 | Low |
| Injection, Midazolam Hydrochloride, Per 1 Mg | other | $3 | $3 to $5 | Low |
| Injection, Midazolam in 0.9% Sodium Chloride, Intravenous, Not Therapeuticall... | other | $3 | $3 to $16 | Low |
| Injection, Morphine Sulfate, Up to 10 Mg | other | $3 | $3 to $15 | Low |
| Injection, Sterile Cefuroxime Sodium, Per 750 Mg | other | $3 | $3 to $15 | Low |
| Injection, Ziprasidone Mesylate, 10 Mg | other | $3 | $3 to $14 | Low |
| Methotrexate; Oral, 2.5 Mg | other | $3 | $3 to $14 | Low |
| 5% Dextrose and 0.45% Normal Saline, 1000 Ml | other | $4 | $4 to $20 | Low |
| Blood Glucose (sugar) Level | other | $4 | $4 to $82,947 | Low |
| Blood Glucose (sugar) Tolerance Test, Each Additional Beyond 3 Specimens | lab | $4 | $4 to $82,952 | Low |
| Blood Typing for Red Blood Cell Antigens | other | $4 | $4 to $86,905 | Low |
| Cholesterol Level | other | $4 | $4 to $82,465 | Low |
| Cryoglobulin (protein) Measurement | other | $4 | $4 to $82,595 | Low |
| Dexamethasone, Oral, 0.25 Mg | imaging | $4 | $4 to $20 | Low |
| Glucose (sugar) Level On Body Fluid | other | $4 | $4 to $82,945 | Low |
| Injection, Acetylcysteine, 100 Mg | other | $4 | $4 to $18 | Low |
| Injection, Amiodarone Hydrochloride, 30 Mg | other | $4 | $4 to $19 | Low |
| Injection, Labetalol Hydrochloride, 5 Mg | other | $4 | $4 to $21 | Low |
| Injection, Nalbuphine Hydrochloride, Per 10 Mg | other | $4 | $4 to $22 | Low |
| Injection, Terbutaline Sulfate, Up to 1 Mg | other | $4 | $4 to $20 | Low |
| Microscopic Examination for White Blood Cells with Manual Cell Count | other | $4 | $4 to $85,007 | Low |
| 5% Dextrose/normal Saline | other | $5 | $5 to $24 | Low |
| Albumin (protein) Level | other | $5 | $5 to $82,040 | Low |
| Bilirubin Level, Direct | other | $5 | $5 to $82,248 | Low |
| Bilirubin Level, Total | other | $5 | $5 to $82,247 | Low |
| Bleeding Time | other | $5 | $5 to $85,002 | Low |
| Blocking Needle | other | $5 | $5 to $27 | Low |
| Blood Chloride Level | other | $5 | $5 to $82,435 | Low |
| Blood Creatinine Level | other | $5 | $5 to $82,565 | Low |
| Blood Glucose (sugar) Level After Receiving Dose of Glucose | other | $5 | $5 to $82,950 | Low |
| Blood Potassium Level | other | $5 | $5 to $84,132 | Low |
| Blood Sodium Level | other | $5 | $5 to $84,295 | Low |
| Body Fluid Cell Count | other | $5 | $5 to $89,050 | Low |
| Calcium Level, Total | other | $5 | $5 to $82,310 | Low |
| Carbon Dioxide (bicarbonate) Level | other | $5 | $5 to $82,374 | Low |
| Cath Ua Collection | other | $5 | $5 to $26 | Low |
| Cerebrospinal Fluid, OR Amniotic Fluid Albumin (protein) Level | other | $5 | $5 to $82,042 | Low |
| Chlorhexidine Gluconate 4% Liq | other | $5 | $5 to $28 | Low |
| Chloride Level | other | $5 | $5 to $82,438 | Low |
| Creatinine Level to Test for Kidney Function OR Muscle Injury | other | $5 | $5 to $82,570 | Low |
| Detection of Antimicrobial Drug | other | $5 | $5 to $87,185 | Low |
| Fern Test | other | $5 | $5 to $23 | Low |
| G6pd (enzyme) Level | other | $5 | $5 to $82,955 | Low |
| Infusion, Normal Saline Solution, 250 Cc | surgery | $5 | $5 to $25 | Low |
| Injection, Digoxin, Up to 0.5 Mg | other | $5 | $5 to $28 | Low |
| Injection, Droperidol, Up to 5 Mg | other | $5 | $5 to $26 | Low |
| Injection, Furosemide, 1 Mg | other | $5 | $5 to $25 | Low |
| Injection, Lidocaine Hcl with Epinephrine, 1 Mg | other | $5 | $5 to $26 | Low |
| Injection, Meropenem, 100 Mg | other | $5 | $5 to $25 | Low |
| Insertion of Needle Into Vein for Collection of Blood Sample | other | $5 | $5 to $36,415 | Low |
| Ketone Bodies Analysis, Qualitative | other | $5 | $5 to $82,009 | Low |
| Liver Enzyme (sgot), Level | other | $5 | $5 to $84,450 | Low |
| Liver Enzyme (sgpt), Level | other | $5 | $5 to $84,460 | Low |
| Measurement C-reactive Protein for Detection of Infection OR Inflammation | other | $5 | $5 to $86,140 | Low |
| Measurement of Antibody (ige) to Allergic Substance, Crude Allergen Extract, ... | other | $5 | $5 to $86,003 | Low |
| 5% Dextrose in Lactated Ringers Infusion, Up to 1000 Cc | surgery | $6 | $6 to $30 | Low |
| 5% Dextrose/water | other | $6 | $6 to $29 | Low |
| Amylase (enzyme) Level | other | $6 | $6 to $82,150 | Low |
| Application of Hot Wax Bath | other | $6 | $6 to $97,018 | Low |
| Benzocaine 20 % Gel | other | $6 | $6 to $28 | Low |
| Body Fluid Cell Count with Cell Identification | other | $6 | $6 to $89,051 | Low |
| Chemotherapy Administration | other | $6 | $6 to $32 | High |
| Chlorpromazine Hydrochloride, 5 Mg, Oral, Fda Approved Prescription Anti-emet... | other | $6 | $6 to $32 | Low |
| Complete Blood Cell Count (red Cells, White Blood Cell, Platelets), Automated... | other | $6 | $6 to $85,027 | Low |
| Concentration of Specimen for Infectious Agents | lab | $6 | $6 to $87,015 | Low |
| Confirmation Test for Antibody to Borrelia Burgdorferi | other | $6 | $6 to $86,617 | Low |
| Dextrose 10%-water IV Solution | other | $6 | $6 to $32 | Low |
| G6pd (enzyme) Screening Test | preventive | $6 | $6 to $82,960 | Low |
| Hypertonic Saline Solution, 1 Ml | other | $6 | $6 to $32 | Low |
| Injection, Adenosine, 1 Mg | other | $6 | $6 to $30 | Low |
| Injection, Azithromycin, 500 Mg | other | $6 | $6 to $30 | Low |
| Injection, Gadolinium-based Magnetic Resonance Contrast Agent, Not Otherwise ... | other | $6 | $6 to $29 | Low |
| Injection, Haloperidol, Up to 5 Mg | other | $6 | $6 to $30 | Low |
| Injection, Levofloxacin, 250 Mg | other | $6 | $6 to $30 | Low |
| Injection, Octreotide, Non-depot Form for Subcutaneous OR Intravenous Injecti... | other | $6 | $6 to $33 | Low |
| Injection, Prochlorperazine, Up to 10 Mg | other | $6 | $6 to $30 | Low |
| Iron Level | other | $6 | $6 to $83,540 | Low |
| Lactate Dehydrogenase (enzyme) Level | other | $6 | $6 to $83,615 | Low |
| Lidocaine Jell Ur | other | $6 | $6 to $32 | Low |
| Measurement of Range of Motion in Arm, Leg OR Each Spine Section | other | $6 | $6 to $95,851 | Low |
| Nasal Smear for Eosinophils | other | $6 | $6 to $89,190 | Low |
| Blood Osmolality (concentration) Measurement | other | $7 | $7 to $83,930 | Low |
| Catheter, Ureteral | cardiac | $7 | $7 to $35 | Low |
| Creatine Kinase (cardiac Enzyme) Level, Total | cardiac | $7 | $7 to $82,550 | Low |
| Crystal Identification From Tissue OR Body Fluid | other | $7 | $7 to $89,060 | Low |
| Evaluation of Antimicrobial Drug | other | $7 | $7 to $87,184 | Low |
| Glutamyltransferase (liver Enzyme) Level | other | $7 | $7 to $82,977 | Low |
| Injection, Ampicillin Sodium, 500 Mg | other | $7 | $7 to $38 | Low |
| Injection, Bupivicaine, Not Otherwise Specified, 0.5 Mg | other | $7 | $7 to $34 | Low |
| Injection, Cefoxitin Sodium, 1 Gm | other | $7 | $7 to $35 | Low |
| Injection, Ceftriaxone Sodium, Per 250 Mg | other | $7 | $7 to $36 | Low |
| Injection, Heparin Sodium (pfizer), Not Therapeutically Equivalent to J1644, ... | other | $7 | $7 to $36 | Low |
| Injection, Lidocaine Hcl in 5% Dextrose, 1 Mg | other | $7 | $7 to $34 | Low |
| Injection, Lidocaine Hydrochloride, 1 Mg | other | $7 | $7 to $34 | Low |
| Injection, Remdesivir, 1 Mg | other | $7 | $7 to $2,451 | Low |
| Injection, Vitamin B-12 Cyanocobalamin, Up to 1000 Mcg | other | $7 | $7 to $35 | Low |
| Lipase (fat Enzyme) Level | other | $7 | $7 to $83,690 | Low |
| Lithium Level | other | $7 | $7 to $80,178 | Low |
| Magnesium Level | other | $7 | $7 to $83,735 | Low |
| Measurement for Strep Antibody | other | $7 | $7 to $86,060 | Low |
| Measurement of Antibody to Infectious Organism | other | $7 | $7 to $86,000 | Low |
| Analysis for Antibody to Brucella | other | $8 | $8 to $86,622 | Low |
| Analysis for Antibody to Coccidioides | other | $8 | $8 to $86,635 | Low |
| Bacterial Culture | lab | $8 | $8 to $87,077 | Low |
| Blood Test | lab | $8 | $8 to $85,730 | High |
| Chemical Analysis Using Spectrophotometry | other | $8 | $8 to $84,311 | Low |
| Cholinesterase (enzyme) Level, to Test for Exposure to Chemical OR Liver Disease | other | $8 | $8 to $82,480 | Low |
| Clotting Factor X Assessment Test, Diluted | other | $8 | $8 to $85,613 | Low |
| Detection Test By Immunoassay Technique for Histoplasma Capsulatum | other | $8 | $8 to $87,385 | Low |
| Fetal Hemoglobin Analysis | other | $8 | $8 to $83,033 | Low |
| Fungal Culture | lab | $8 | $8 to $87,102 | Low |
| Fungal Culture (mold OR Yeast) of Skin, Hair, OR Nail | lab | $8 | $8 to $87,101 | Low |
| Gonadotropin (reproductive Hormone) Analysis | other | $8 | $8 to $84,703 | Low |
| Guide Wire | other | $8 | $8 to $42 | Low |
| Hdl Cholesterol Level | other | $8 | $8 to $83,718 | Low |
| Injection, Ampicillin Sodium/sulbactam Sodium, Per 1.5 Gm | other | $8 | $8 to $38 | Low |
| Ketone Bodies Analysis, Quantitative | other | $8 | $8 to $82,010 | Low |
| Measurement of Cold Agglutinin (protein) to Screen for Infection OR Disease | other | $8 | $8 to $86,156 | Low |
| Measurement of Hepatitis a Antibody | other | $8 | $8 to $86,708 | Low |
| Methemoglobin (hemoglobin) Analysis, Quantitative | other | $8 | $8 to $83,050 | Low |
| Analysis for Antibody to HIV -1 Virus | other | $9 | $9 to $86,701 | Low |
| Benzocaine 20% 60 Ml Spray | other | $9 | $9 to $45 | Low |
| Carotene Level | other | $9 | $9 to $82,380 | Low |
| Creatinine Clearance Measurement to Test for Kidney Function | other | $9 | $9 to $82,575 | Low |
| Evaluation of Antimicrobial Drug (antibiotic, Antifungal, Antiviral), Microdi... | other | $9 | $9 to $87,186 | Low |
| Fetal Hemoglobin OR Red Blood Cells Measurement for Assessment of Fetal-mater... | other | $9 | $9 to $85,461 | Low |
| Gammaglobulin (immune System Protein) Measurement | other | $9 | $9 to $82,784 | Low |
| Injection, Butorphanol Tartrate, 1 Mg | other | $9 | $9 to $48 | Low |
| Injection, Epinephrine (international Medication Systems), Not Therapeuticall... | other | $9 | $9 to $44 | Low |
| Injection, Epoetin Alfa, (for Non-esrd Use), 1000 Units | other | $9 | $9 to $535 | Low |
| Injection, Non-radioactive, Non-contrast, Visualization Adjunct (e.g., Methyl... | other | $9 | $9 to $746 | Low |
| Injection, Phenylephrine Hydrochloride, 20 Micrograms | other | $9 | $9 to $44 | Low |
| Injection, Piperacillin Sodium/tazobactam Sodium, 1 Gram/0.125 Grams | other | $9 | $9 to $44 | Low |
| Iron Binding Capacity | other | $9 | $9 to $83,550 | Low |
| Non-covered Item OR Service | other | $9 | $9 to $44 | Low |
| Aldolase (enzyme) Level | other | $10 | $10 to $82,085 | Low |
| Analysis for Antibody to Aspergillus | other | $10 | $10 to $86,606 | Low |
| Analysis for Antibody to Bartonella | other | $10 | $10 to $86,611 | Low |
| Analysis for Antibody to Blastomyces | other | $10 | $10 to $86,612 | Low |
| Analysis for Antibody to Histoplasma | other | $10 | $10 to $86,698 | Low |
| Ascorbic Acid (vitamin C) Level, Blood | other | $10 | $10 to $82,180 | Low |
| Cholangiogram Catheter | cardiac | $10 | $10 to $48 | Low |
| Coagulation Function Measurement, D-dimer; Quantitative | other | $10 | $10 to $85,379 | Low |
| Detection Test By Immunoassay Technique for Hepatitis B Surface Antigen | other | $10 | $10 to $87,340 | Low |
| Detection Test By Immunoassay with Direct Visual Observation for Other Organism | other | $10 | $10 to $87,899 | Low |
| Detection Test By Immunoassay with Direct Visual Observation for Streptococcu... | other | $10 | $10 to $87,802 | Low |
| Dextrose 5%-0.45% Nacl IV Soln | other | $10 | $10 to $48 | Low |
| Fibrinogen (factor 1) Activity Measurement | other | $10 | $10 to $85,384 | Low |
| Hemoglobin A1C | lab | $10 | $10 to $83,036 | High |
| Injection, Acyclovir, 5 Mg | other | $10 | $10 to $53 | Low |
| Injection, Cefepime Hydrochloride, 500 Mg | other | $10 | $10 to $50 | Low |
| Injection, Ceftazidime, Per 500 Mg | other | $10 | $10 to $50 | Low |
| Injection, Pantoprazole Sodium, 40 Mg | other | $10 | $10 to $53 | Low |
| Injection, Potassium Chloride, Per 2 Meq | other | $10 | $10 to $49 | Low |
| Injection, Thiamine Hcl, 100 Mg | other | $10 | $10 to $49 | Low |
| Injection, Vancomycin Hcl (mylan), Not Therapeutically Equivalent to J3370, 5... | other | $10 | $10 to $49 | Low |
| Low Osmolar Contrast Material, 300-399 Mg/ml Iodine Concentration, Per Ml | other | $10 | $10 to $50 | Low |
| Analysis for Antibody to Hiv-1 and Hiv-2 Virus | other | $11 | $11 to $86,703 | Low |
| Analysis for Antibody to Virus | other | $11 | $11 to $86,790 | Low |
| Analysis for Antibody to Zika Virus | other | $11 | $11 to $86,794 | Low |
| Antithrombin Iii Antigen (clotting Inhibitor) Level | other | $11 | $11 to $85,301 | Low |
| Blood Ph Level | other | $11 | $11 to $82,800 | Low |
| Ceruloplasmin (protein) Level | other | $11 | $11 to $82,390 | Low |
| Culture for Acid-fast Bacilli | lab | $11 | $11 to $87,116 | Low |
| Detection Test By Immunoassay Technique for Helicobacter Pylori (gi Tract Bac... | other | $11 | $11 to $87,338 | Low |
| Diclofenac Sodium 1% Gel | other | $11 | $11 to $55 | Low |
| Flector Patch | other | $11 | $11 to $54 | Low |
| Hepatitis B Surface Antibody Measurement | other | $11 | $11 to $86,706 | Low |
| Infusion, Albumin (human), 5%, 50 Ml | surgery | $11 | $11 to $900 | Low |
| Injection, Betamethasone Acetate 3 Mg and Betamethasone Sodium Phosphate 3 Mg | other | $11 | $11 to $55 | Low |
| Injection, Methylprednisolone Acetate, 1 Mg | other | $11 | $11 to $57 | Low |
| Injection, Sumatriptan Succinate, 6 Mg | other | $11 | $11 to $55 | Low |
| Insulin Measurement, Total | other | $11 | $11 to $83,525 | Low |
| Ldl Cholesterol Level | other | $11 | $11 to $83,721 | Low |
| Analysis for Antibody to Chlamydia | other | $12 | $12 to $86,631 | Low |
| Analysis for Antibody to Cytomegalovirus | other | $12 | $12 to $86,644 | Low |
| Analysis for Antibody to Parvovirus | other | $12 | $12 to $86,747 | Low |
| Analysis of Substance Using Immunoassay Technique, Multiple Step Method | other | $12 | $12 to $83,516 | Low |
| Antibody Identification Test, Platelet Associated Immunoglobulin Assay | other | $12 | $12 to $86,023 | Low |
| Antithrombin Iii Antigen (clotting Inhibitor) Activity | other | $12 | $12 to $85,300 | Low |
| Application of Blood Vessel Compression Device | other | $12 | $12 to $97,016 | Low |
| Blood Viscosity Measurement | other | $12 | $12 to $85,810 | Low |
| Carboxyhemoglobin (protein) Level | other | $12 | $12 to $82,375 | Low |
| Copper Level | other | $12 | $12 to $82,525 | Low |
| Creatine Kinase (cardiac Enzyme) Level, Mb Fraction Only | cardiac | $12 | $12 to $82,553 | Low |
| Cryoprecipitate, Each Unit | other | $12 | $12 to $79 | Low |
| Detection Test By Immunoassay Technique for Giardia | other | $12 | $12 to $87,329 | Low |
| Detection Test By Immunoassay Technique for Hepatitis Be Surface Antigen | other | $12 | $12 to $87,350 | 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 |
| Detection Test By Immunoassay Technique for Shiga-like Toxin | other | $12 | $12 to $87,427 | Low |
| Electrical Stimulation (unattended), to One OR More Areas for Indication(s) O... | other | $12 | $12 to $195 | Low |
| Hepatitis B Core Antibody (igm) Measurement | other | $12 | $12 to $86,705 | Low |
| Hepatitis Be Antibody Measurement | other | $12 | $12 to $86,707 | Low |
| Injection, Amikacin Sulfate, 100 Mg | other | $12 | $12 to $61 | Low |
| Injection, Atropine Sulfate, 0.01 Mg | other | $12 | $12 to $63 | Low |
| Injection, Succinylcholine Chloride, Up to 20 Mg | other | $12 | $12 to $58 | Low |
| Islet Cell (pancreas) Antibody Measurement | other | $12 | $12 to $86,341 | Low |
| Lactic Acid Level | other | $12 | $12 to $83,605 | Low |
| Lead Level | other | $12 | $12 to $83,655 | Low |
| Measurement of Antibody to Noninfectious Agent | other | $12 | $12 to $86,256 | Low |
| Measurement of Complement (immune System Proteins), Antigen | other | $12 | $12 to $86,160 | Low |
| Measurement of Complement Function | other | $12 | $12 to $86,161 | Low |
| Nephelometry, Test Method Using Light | other | $12 | $12 to $83,883 | Low |
| Activated Charcoal 25gm Oral | other | $13 | $13 to $67 | Low |
| Activated Charcoal; 25gm Water | other | $13 | $13 to $67 | Low |
| Amino Acid Analysis, Quantitative, Each Specimen | lab | $13 | $13 to $82,131 | Low |
| Amino Acid Level, 6 OR More Amino Acids, Quantitative, Each Specimen | lab | $13 | $13 to $82,139 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Early Antigen | other | $13 | $13 to $86,663 | Low |
| Analysis for Antibody to Herpes Simplex Virus, Type 1 | other | $13 | $13 to $86,695 | Low |
| Analysis for Antibody to Mumps Virus | other | $13 | $13 to $86,735 | Low |
| Analysis for Antibody to Mycoplasma | other | $13 | $13 to $86,738 | Low |
| Analysis for Antibody to Rubeola | other | $13 | $13 to $86,765 | Low |
| Analysis for Antibody to Salmonella | other | $13 | $13 to $86,768 | Low |
| Analysis for Antibody to Varicella-zoster Virus | other | $13 | $13 to $86,787 | Low |
| Analysis for Antibody, Treponema Pallidum | other | $13 | $13 to $86,780 | Low |
| Bile Acids Level, Total | other | $13 | $13 to $82,239 | Low |
| Blood Glucose (sugar) Tolerance Test, 3 Specimens | lab | $13 | $13 to $82,951 | Low |
| Breathing Bag OR Tube | other | $13 | $13 to $64 | Low |
| Chemical Analysis of Stone | other | $13 | $13 to $82,360 | Low |
| Creatine Kinase (cardiac Enzyme) Level, Isoenzymes | cardiac | $13 | $13 to $82,552 | Low |
| Cyanocobalamin (vitamin B-12) Level | other | $13 | $13 to $82,607 | Low |
| Detection Test By Immunoassay Technique for Escherichia Coli 0157 | other | $13 | $13 to $87,335 | Low |
| Digoxin Level, Total | other | $13 | $13 to $80,162 | Low |
| Haptoglobin (serum Protein) Level | other | $13 | $13 to $83,010 | Low |
| Hemoglobin Analysis and Measurement, Electrophoresis | other | $13 | $13 to $83,020 | Low |
| Hydroxyindolacetic Acid (product of Metabolism) Level | other | $13 | $13 to $83,497 | Low |
| Ige (immune System Protein) Level | other | $13 | $13 to $82,785 | Low |
| Inhibin a (reproductive Organ Hormone) Measurement | other | $13 | $13 to $86,336 | Low |
| Injection, Cefazolin Sodium, 500 Mg | other | $13 | $13 to $66 | Low |
| Injection, Magnesium Sulfate, Per 500 Mg | other | $13 | $13 to $63 | Low |
| Ketosteroids, 17 (hormone) Measurement, Total | other | $13 | $13 to $83,586 | Low |
| Lactate Dehydrogenase (enzyme) Measurement | other | $13 | $13 to $83,625 | Low |
| Lamotrigine Level | other | $13 | $13 to $80,175 | Low |
| Levetiracetam Level | other | $13 | $13 to $80,177 | 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 |
| Measurement of Dna Antibody, Native OR Double Stranded | other | $13 | $13 to $86,225 | Low |
| Measurement of Substance Using Immunoassay Technique | other | $13 | $13 to $83,520 | Low |
| Myoglobin (muscle Protein) Level | other | $13 | $13 to $83,874 | Low |
| Amino Acid Analysis, Multiple Amino Acids, Qualitative, Each Specimen | lab | $14 | $14 to $82,128 | Low |
| Analysis for Antibody to Cryptococcus | other | $14 | $14 to $86,641 | 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 West Nile Virus | other | $14 | $14 to $86,789 | Low |
| Analysis Using Chemiluminescent Technique (light and Chemical )reaction | other | $14 | $14 to $82,397 | Low |
| Application of Electrical Stimulation with Therapist Present, Each 15 Minutes | other | $14 | $14 to $97,032 | Low |
| Application of Mechanical Traction | other | $14 | $14 to $97,012 | Low |
| Application of Ultrasound, Each 15 Minutes | imaging | $14 | $14 to $97,035 | Low |
| Calcium Level, Ionized | other | $14 | $14 to $82,330 | Low |
| Detection Test By Immunoassay Technique for Influenza Virus | other | $14 | $14 to $87,400 | Low |
| Detection Test By Immunoassay Technique for Respiratory Syncytial Virus | other | $14 | $14 to $87,420 | Low |
| Detection Test By Immunoassay with Direct Visual Observation for Influenza Virus | other | $14 | $14 to $87,804 | Low |
| Ferritin (blood Protein) Level | other | $14 | $14 to $82,728 | Low |
| Hepatitis C Antibody Measurement | other | $14 | $14 to $86,803 | Low |
| Injection, Clindamycin Phosphate, 300 Mg | other | $14 | $14 to $73 | Low |
| Injection, Heparin Sodium, Per 1000 Units | other | $14 | $14 to $70 | Low |
| Injection, Hydralazine Hcl, Up to 20 Mg | other | $14 | $14 to $72 | Low |
| Nacl 0.45 500 | other | $14 | $14 to $70 | Low |
| Amikacin (antibiotic) Level | other | $15 | $15 to $80,150 | Low |
| Ammonia Level | other | $15 | $15 to $82,140 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Nuclear An... | imaging | $15 | $15 to $86,664 | Low |
| Analysis for Antibody to Legionella | other | $15 | $15 to $86,713 | Low |
| Angiotensin L - Converting Enzyme (ace) Level | other | $15 | $15 to $82,164 | Low |
| Application of Whirlpool Therapy | other | $15 | $15 to $97,022 | Low |
| Carbamazepine Level, Total | other | $15 | $15 to $80,156 | Low |
| Folic Acid Level, Serum | other | $15 | $15 to $82,746 | Low |
| Gonadotropin, Chorionic (reproductive Hormone) Level | other | $15 | $15 to $84,702 | Low |
| Hemoglobin Analysis and Measurement, Chromatography | other | $15 | $15 to $83,021 | Low |
| Inhalation Treatment for Acute Airway Obstruction, Each Additional Hour | other | $15 | $15 to $94,645 | Low |
| Injection, Neostigmine Methylsulfate, Up to 0.5 Mg | other | $15 | $15 to $75 | Low |
| Lidocaine Level | other | $15 | $15 to $80,176 | Low |
| Microsomal Antibodies (autoantibody) Measurement | other | $15 | $15 to $86,376 | Low |
| Beta-2 Microglobulin (protein) Level | other | $16 | $16 to $82,232 | Low |
| Cell Examination of Specimen, Concentration Technique | lab | $16 | $16 to $88,108 | Low |
| Cement Mixer Optivac Triple Mi | other | $16 | $16 to $82 | Low |
| Cortisol (hormone) Measurement, Total | other | $16 | $16 to $82,533 | Low |
| Gentamicin (antibiotic) Level | other | $16 | $16 to $80,170 | Low |
| Haloperidol Level | other | $16 | $16 to $80,173 | Low |
| Immunologic Analysis for Detection of Tumor Antigen, Quantitative; Ca 15 | other | $16 | $16 to $86,300 | Low |
| Injection, Aminophyllin, Up to 250 Mg | other | $16 | $16 to $82 | Low |
| L.e.t. (lido-epineph-tetra) Ge | other | $16 | $16 to $79 | Low |
| Mercury Level | other | $16 | $16 to $83,825 | Low |
| Alpha-fetoprotein (afp) Level, Serum | other | $17 | $17 to $82,105 | Low |
| Analysis for Antibody | other | $17 | $17 to $86,645 | Low |
| Analysis for Antibody (igm) to West Nile Virus | other | $17 | $17 to $86,788 | Low |
| Analysis for Antibody Borrelia Burgdorferi | other | $17 | $17 to $86,618 | Low |
| Analysis for Antibody to Helicobacter Pylori | other | $17 | $17 to $86,677 | Low |
| Aspiration of Cyst of Breast, Each Additional Cyst | other | $17 | $17 to $19,001 | Low |
| Carnitine Level | other | $17 | $17 to $82,379 | Low |
| Catheter, Intradiscal | cardiac | $17 | $17 to $86 | Low |
| Cholesterol Management | cardiac | $17 | $8 to $123 | High |
| Cortisol (hormone) Measurement, Free | other | $17 | $17 to $82,530 | Low |
| D-5 Lr 500 Cc | other | $17 | $17 to $86 | Low |
| D-5- 1/2 500cc | other | $17 | $17 to $86 | Low |
| D-5- 1/4 500 Cc | other | $17 | $17 to $86 | Low |
| D-5- Lr 1000 Cc | other | $17 | $17 to $86 | Low |
| D-5-1/2 Ns 1000 Cc | other | $17 | $17 to $86 | Low |
| D-5-1/4 1000 Cc | other | $17 | $17 to $86 | Low |
| D-5-s 100o Cc | other | $17 | $17 to $86 | Low |
| D-5-s 500 Cc | other | $17 | $17 to $86 | Low |
| D-5-w 1000 Cc | other | $17 | $17 to $86 | Low |
| D-5-w 500 Cc | other | $17 | $17 to $86 | Low |
| Detection Test By Immunoassay Technique for Streptococcus, Group a | other | $17 | $17 to $87,430 | Low |
| Estrogen Analysis, Total | other | $17 | $17 to $82,672 | Low |
| Glycated Protein Level | other | $17 | $17 to $82,985 | Low |
| Injection, Glycopyrrolate, 0.1 Mg | other | $17 | $17 to $88 | Low |
| Lactated Ringers 500 Cc | other | $17 | $17 to $86 | Low |
| Lactated Ringers-1000cc | other | $17 | $17 to $86 | Low |
| Measurement of Antibody for Assessment of Autoimmune Disorder, Any Method | other | $17 | $17 to $86,235 | Low |
| Metanephrines Level | other | $17 | $17 to $83,835 | Low |
| Nacl 0.45 1000 Cc | other | $17 | $17 to $86 | Low |
| Abreva 2 Gm Tube | other | $18 | $18 to $89 | Low |
| Analysis for Antibody to Epstein-barr Virus (mononucleosis Virus), Viral Capsid | other | $18 | $18 to $86,665 | Low |
| Antibody Identification Test, Platelet Antibodies | other | $18 | $18 to $86,022 | Low |
| Application of Medication Using Electrical Current, Each 15 Minutes | other | $18 | $18 to $97,033 | Low |
| C-peptide (protein) Level | other | $18 | $18 to $84,681 | Low |
| Cyclosporine Level | other | $18 | $18 to $80,158 | Low |
| Folic Acid Level, Rbc | other | $18 | $18 to $82,747 | Low |
| Gastrin (gi Tract Hormone) Level | other | $18 | $18 to $82,941 | Low |
| Glycine Sol.1.5%-3000cc | other | $18 | $18 to $89 | Low |
| Homocysteine (amino Acid) Level | other | $18 | $18 to $83,090 | Low |
| Hydroxycorticosteroids, 17 (adrenal Gland Hormone) Level | other | $18 | $18 to $83,491 | Low |
| Injection, Dopamine Hcl, 40 Mg | other | $18 | $18 to $91 | Low |
| Injection, Iron Dextran, 50 Mg | other | $18 | $18 to $182 | Low |
| Injection, Levetiracetam, 10 Mg | other | $18 | $18 to $91 | Low |
| Alcohol 5%&dextr.5%in Water 10 | other | $19 | $19 to $97 | Low |
| Analysis for Antibody to Herpes Simplex Virus, Type 2 | other | $19 | $19 to $86,696 | Low |
| Analysis for Antibody to Rickettsia | other | $19 | $19 to $86,757 | Low |
| Arsenic Level | other | $19 | $19 to $82,175 | Low |
| Beta 2 Glycoprotein 1 Antibody (autoantibody) Measurement | other | $19 | $19 to $86,146 | Low |
| Carcinoembryonic Antigen (cea) Protein Level | other | $19 | $19 to $82,378 | Low |
| Collagen Cross Links Test | other | $19 | $19 to $82,523 | Low |
| D-10-w 500ml | other | $19 | $19 to $97 | Low |
| D-5-0.2% Sodium Chloride(250cc | other | $19 | $19 to $97 | Low |
| D-5-r 1000 Cc | other | $19 | $19 to $97 | Low |
| Detection Test By Immunoassay Technique for Hiv-1 Antigen and Hiv-1 and Hiv-2... | other | $19 | $19 to $87,389 | Low |
| Detection Test By Nucleic Acid for Chlamydia Trachomatis, Amplified Probe Tec... | other | $19 | $19 to $87,491 | Low |
| Detection Test By Nucleic Acid for Clostridium Difficile, Amplified Probe Tec... | other | $19 | $19 to $87,493 | Low |
| Detection Test By Nucleic Acid for Cytomegalovirus (cmv), Amplified Probe Tec... | other | $19 | $19 to $87,496 | Low |
| Detection Test By Nucleic Acid for Neisseria Gonorrhoeae (gonorrhoeae Bacteri... | other | $19 | $19 to $87,591 | Low |
| Detection Test By Nucleic Acid for Trichomonas Vaginalis (genital Parasite), ... | other | $19 | $19 to $87,661 | Low |
| Dextrose 10%in Saline(d-10-s)1 | other | $19 | $19 to $97 | Low |
| Dextrose 2.5% Strength Saline | other | $19 | $19 to $97 | Low |
| Dextrose 5.5%in Salinec\20meq5 | other | $19 | $19 to $97 | Low |
| Dextrose 5.5%in Salinec\meq 10 | other | $19 | $19 to $97 | Low |
| Dextrose 5%inh2o(d5w)1000cc | other | $19 | $19 to $97 | Low |
| Dextrose 5%inwatr(d5w)500cc | other | $19 | $19 to $97 | Low |
| Dextrose 5%ring.inj.500cc | other | $19 | $19 to $97 | Low |
| Diagnostic Digital Breast Tomosynthesis, Unilateral OR Bilateral | other | $19 | $19 to $96 | Low |
| Erythropoietin (protein) Level | other | $19 | $19 to $82,668 | Low |
| Evaluation for Wheelchair, Each 15 Minutes | other | $19 | $19 to $97,542 | Low |
| Gonadotropin, Follicle Stimulating (reproductive Hormone) Level | other | $19 | $19 to $83,001 | Low |
| Gonadotropin, Luteinizing (reproductive Hormone) Level | other | $19 | $19 to $83,002 | Low |
| Injection Fluconazole, 200 Mg | other | $19 | $19 to $93 | Low |
| Mammogram | preventive | $19 | $19 to $77,065 | High |
| Microbial Toxin OR Antitoxin Assay | other | $19 | $19 to $87,230 | Low |
| Astelin | other | $20 | $20 to $100 | Low |
| Blood Culture | lab | $20 | $20 to $87,103 | Low |
| Culture for Chlamydia | lab | $20 | $20 to $87,110 | Low |
| Detection Test By Nucleic Acid for Chlamydia, Direct Probe Technique | other | $20 | $20 to $87,490 | Low |
| Detection Test By Nucleic Acid for Enterovirus (intestinal Virus), Amplified ... | other | $20 | $20 to $87,498 | Low |
| Estriol (hormone) Level | other | $20 | $20 to $82,677 | Low |
| Hydroxyprogesterone, 17-d (synthetic Hormone) Level | other | $20 | $20 to $83,498 | Low |
| Infectious Agent Detection By Nucleic Acid (dna OR Rna); Human Papillomavirus... | other | $20 | $20 to $100 | Low |
| Injection, Fentanyl Citrate, 0.1 Mg | other | $20 | $20 to $100 | Low |
| Injection, Methocarbamol, Up to 10 Ml | other | $20 | $20 to $99 | Low |
| Injection, Nitroglycerin, 5 Mg | other | $20 | $20 to $102 | Low |
| Injection, Regadenoson, 0.1 Mg | other | $20 | $20 to $100 | Low |
| Measurement of Complement (immune System Proteins), Total Hemolytic | other | $20 | $20 to $86,162 | Low |
| Abo & Rh Blood Type | other | $21 | $21 to $106 | Low |
| Analysis of Female Reproductive Genetic Marker | other | $21 | $21 to $86,305 | Low |
| Cell Examination of Body Fluid, Smears | other | $21 | $21 to $88,104 | Low |
| Flu Vaccination | preventive | $21 | $21 to $104 | High |
| 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 19 | other | $21 | $21 to $86,301 | Low |
| Influenza Vaccine, Quadrivalent, Preservative Free, 0.5 Ml Dosage | preventive | $21 | $21 to $90,686 | Low |
| Injection, Esmolol Hydrochloride, 10 Mg | other | $21 | $21 to $107 | Low |
| Insulin Antibody Measurement | other | $21 | $21 to $86,337 | Low |
| Muri-lube Mineral Oil Vial | other | $21 | $21 to $104 | Low |
| Dehydroepiandrosterone (dhea-s) Hormone Level | other | $22 | $22 to $82,627 | Low |
| EKG (Electrocardiogram) | cardiac | $22 | $17 to $93,244 | High |
| Fetal Lung Maturity Assessment, Lecithin Sphingomyelin (l/s) Ratio | other | $22 | $22 to $83,661 | Low |
| Gabapentin Level | other | $22 | $22 to $80,171 | Low |
| Hemoglobin & Hematocrit | other | $22 | $22 to $110 | Low |
| Immunologic Analysis Technique On Serum | other | $22 | $22 to $86,334 | Low |
| Injection, Hydrocortisone Sodium Succinate, Up to 100 Mg | other | $22 | $22 to $111 | Low |
| Injection, Ropivacaine Hydrochloride, 1 Mg | other | $22 | $22 to $109 | Low |
| Immunologic Analysis Technique On Body Fluid | other | $23 | $23 to $86,325 | Low |
| Injection, Calcium Gluconate (wg Critical Care), Not Therapeutically Equivale... | other | $23 | $23 to $118 | Low |
| Injection, Ketorolac Tromethamine, Per 15 Mg | other | $23 | $23 to $33 | Low |
| Lipoprotein Level, Quantitation of Lipoprotein Particle Number | other | $23 | $23 to $83,704 | Low |
| 3d Radiographic Procedure | imaging | $24 | $24 to $76,376 | Low |
| Chemical Analysis Using Chromatography Technique | other | $24 | $24 to $82,542 | Low |
| Icd-s/d/m In/cl-chec | other | $24 | $24 to $119 | Low |
| Injection, Vancomycin Hydrochloride, 10 Mg | other | $24 | $24 to $119 | Low |
| Iodine I-131 Sodium Iodide Capsule(s), Therapeutic, Per Millicurie | other | $24 | $24 to $279 | Low |
| Aluminum Level | other | $25 | $25 to $82,108 | Low |
| Amplifed Dna OR Rna Probe Detection of Severe Acute Respiratory Syndrome Coro... | other | $25 | $25 to $87,635 | Low |
| Cardiolipin Antibody (tissue Antibody) Measurement | other | $25 | $25 to $86,147 | Low |
| Catecholamines (organic Nitrogen) Level | imaging | $25 | $25 to $82,384 | Low |
| Detection Test By Immunoassay Technique for Severe Acute Respiratory Syndrome... | other | $25 | $25 to $87,426 | Low |
| Detection Test By Nucleic Acid for Organism, Quantification | other | $25 | $25 to $87,799 | Low |
| Fine Needle Aspiration Biopsy Using Ultrasound Guidance, Each Additional Growth | imaging | $25 | $25 to $10,006 | Low |
| Injection, Enoxaparin Sodium, 10 Mg | other | $25 | $25 to $124 | Low |
| Measure of Severe Acute Respiratory Syndrome Coronavirus 2 (covid-19) Antibody | other | $25 | $25 to $86,769 | Low |
| Blood Gases Measurement | other | $26 | $26 to $82,803 | Low |
| Catheter, Suprapubic/cystoscopic | cardiac | $26 | $26 to $130 | Low |
| Detection Test By Nucleic Acid for Hepatitis C Virus, Quantification | other | $26 | $26 to $87,522 | Low |
| Follow-up Therapy Service to Facilitate Lung Function | other | $26 | $26 to $94,668 | Low |
| Immunologic Analysis for Autoimmune Disease, A, B, OR C, Single Antigen | other | $26 | $26 to $86,812 | Low |
| Injection, Haloperidol Decanoate, Per 50 Mg | other | $26 | $26 to $129 | Low |
| Injection, Phenobarbital Sodium, Up to 120 Mg | other | $26 | $26 to $132 | Low |
| Iodine I-123 Sodium Iodide, Diagnostic, Per Millicurie | other | $26 | $26 to $130 | Low |
| Hepatitis B Vaccine, Pediatric OR Adolescent Dosage | preventive | $27 | $27 to $90,744 | Low |
| Initial Oxygen 30 Min | other | $27 | $27 to $135 | Low |
| Injection, Infliximab-abda, Biosimilar, (renflexis), 10 Mg | other | $27 | $27 to $3,014 | Low |
| Injection, Medroxyprogesterone Acetate, 1 Mg | other | $27 | $27 to $136 | Low |
| Citrate Level | other | $28 | $28 to $82,507 | Low |
| Evaluation of Fine Needle Aspirate with Interpretation and Report | other | $28 | $28 to $88,173 | Low |
| Impersol 1.5% 2000cc | other | $28 | $28 to $142 | Low |
| Impersol 4.25% 2000 Cc | other | $28 | $28 to $142 | Low |
| Injection, Hydroxyzine Hcl, Up to 25 Mg | other | $28 | $28 to $140 | Low |
| Injection, Propofol, 10 Mg | other | $28 | $28 to $140 | Low |
| Lokelma 10 Gm Powder Packet | other | $28 | $28 to $141 | Low |
| Measurement of Total Estradiol | other | $28 | $28 to $82,670 | Low |
| Cardiac Catheterization | cardiac | $29 | $29 to $144 | High |
| Detection Test By Nucleic Acid for Cytomegalovirus, Quantification | other | $29 | $29 to $87,497 | Low |
| Immunologic Analysis Technique On Body Fluid, Other Fluids with Concentration | other | $29 | $29 to $86,335 | Low |
| Injection, Meropenem (b. Braun), Not Therapeutically Equivalent to J2185, 100 Mg | other | $29 | $29 to $146 | Low |
| Injection, Oxytocin, Up to 10 Units | other | $29 | $29 to $148 | Low |
| Detection Test By Nucleic Acid for Organism, Amplified Probe Technique | other | $30 | $30 to $87,798 | Low |
| Detection Test By Nucleic Acid for Zika Virus, Amplified Probe Technique | other | $30 | $30 to $87,662 | Low |
| Dxa Bone Density Measurement of Forearm, Finger, Hand, OR Foot | other | $30 | $30 to $77,081 | Low |
| Injection, Cefepime Hydrochloride (b Braun), Not Therapeutically Equivalent t... | other | $30 | $30 to $149 | Low |
| Injection, Daptomycin, 1 Mg | other | $30 | $30 to $150 | Low |
| Injection, Methylergonovine Maleate, Up to 0.2 Mg | other | $30 | $30 to $153 | Low |
| Injection, Penicillin G Benzathine, 100,000 Units | other | $30 | $30 to $2,632 | Low |
| Follow-up Training in the Use of Orthopedic Device OR Artificial Arm, Leg And... | other | $31 | $31 to $97,763 | Low |
| Fracture Assessment of Spine Bones Using Dxa | other | $31 | $31 to $77,086 | Low |
| Injection, Infliximab, Excludes Biosimilar, 10 Mg | other | $31 | $31 to $4,087 | Low |
| Injection, Sodium Ferric Gluconate Complex in Sucrose Injection, 12.5 Mg | other | $32 | $32 to $159 | Low |
| Injection, Chlorpromazine Hcl, Up to 50 Mg | other | $33 | $33 to $166 | Low |
| Injection, Diazepam, Up to 5 Mg | other | $33 | $33 to $168 | Low |
| Injection, Garamycin, Gentamicin, Up to 80 Mg | other | $33 | $33 to $167 | Low |
| Lipoprotein-associated Phospholipase A2 (enzyme) Level | other | $33 | $33 to $83,698 | Low |
| Newborn Metabolic Screening Panel, Includes Test Kit, Postage and the Laborat... | lab | $33 | $33 to $166 | Low |
| 3d/4d Prenatal Ultrasound | imaging | $34 | $34 to $170 | Low |
| Injection, Amiodarone Hydrochloride (nexterone), 30 Mg | other | $34 | $34 to $173 | Low |
| Injection, Caffeine Citrate, 5 Mg | other | $34 | $34 to $170 | 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 Hiv-1 Virus, Amplified Probe Technique | other | $35 | $35 to $87,535 | Low |
| Detection Test By Nucleic Acid for Multiple Organisms, Direct Probe(s) Technique | other | $35 | $35 to $87,800 | Low |
| Initial Aerosol O2 - 30 Min | other | $35 | $35 to $177 | Low |
| Injection, Acetaminophen, Not Otherwise Specified,10 Mg | other | $35 | $35 to $178 | Low |
| Injection, Insulin, Per 5 Units | other | $35 | $35 to $175 | Low |
| Introducer/sheath, Other Than Guiding, Other Than Intracardiac Electrophysiol... | cardiac | $35 | $35 to $176 | Low |
| Atropine Sulf Opth Sol | other | $36 | $36 to $183 | Low |
| Inhalational Anesth Ea 30min | other | $36 | $36 to $182 | Low |
| Injection, Aztreonam, 100 Mg | other | $36 | $36 to $180 | Low |
| Irradiation of Blood Product, Each Unit | other | $36 | $36 to $86,945 | Low |
| 17 Ketogenicsteroids | other | $37 | $37 to $187 | Low |
| Initial Oxy Hood 30 Min | other | $37 | $37 to $187 | Low |
| Injection for X-ray of Hinged Joint of Upper and Lower Jaw Bones | imaging | $37 | $37 to $21,116 | Low |
| Blood Unit Compatibility Test, Incubation Technique | other | $38 | $38 to $86,921 | Low |
| Adrenocorticotropic Hormone (acth) Level | other | $39 | $39 to $82,024 | Low |
| Dihydroxyvitamin D, 1, 25 Level | other | $39 | $39 to $82,652 | Low |
| Fresh Frozen Plasma (single Donor), Frozen Within 8 Hours of Collection, Each... | other | $39 | $39 to $197 | Low |
| Fresh Frozen Plasma Between 8-24 Hours of Collection, Each Unit | other | $39 | $39 to $197 | Low |
| Natriuretic Peptide (heart and Blood Vessel Protein) Level | cardiac | $39 | $39 to $83,880 | Low |
| Limited OR Follow-up CT Scan | imaging | $40 | $40 to $76,380 | Low |
| New Patient Office OR Other Outpatient Visit with Straightforward Medical Dec... | other | $40 | $40 to $99,202 | Low |
| Aldosterone Hormone Level | other | $41 | $41 to $82,088 | Low |
| Absorb.gelantin Sponge | other | $44 | $44 to $220 | Low |
| Injection, Acetazolamide Sodium, Up to 500 Mg | other | $44 | $44 to $220 | Low |
| Application of Vein Wound Compression Bandages On Upper Arm, Forearm, Hand, a... | other | $45 | $45 to $29,584 | Low |
| Diphtheria, Tetanus, and Acellular Pertussis Vaccine | preventive | $45 | $45 to $90,715 | Low |
| Injection of Ureter for Imaging | other | $45 | $45 to $50,684 | Low |
| 3 Hour Gtt | other | $46 | $46 to $231 | Low |
| Evaluation for Work Hardening OR Conditioning, Each Additional Hour | other | $46 | $46 to $97,546 | Low |
| Gene Analysis (coagulation Factor V) Leiden Variant | other | $46 | $46 to $81,241 | Low |
| Injection, Penicillin G Potassium, Up to 600,000 Units | other | $46 | $46 to $230 | Low |
| Bone Density Scan | imaging | $47 | $47 to $234 | High |
| Dxa Bone Density Measurement of Hip, Pelvis, Spine Including Spine Fracture A... | other | $47 | $47 to $77,085 | Low |
| Injection, Vancomycin Hydrochloride (mylan) Not Therapeutically Equivalent to... | other | $47 | $47 to $234 | Low |
| Limited Ultrasound Scan of Pelvis | imaging | $47 | $47 to $76,857 | Low |
| Acute Hepatitis Panel | lab | $48 | $48 to $80,074 | Low |
| Cervicovaginal Secretion of Placenta Protein | other | $48 | $48 to $84,112 | Low |
| Gentran 10%-5% Dextrose | other | $48 | $48 to $240 | Low |
| Gentran 10%-saline 0.9% | other | $48 | $48 to $240 | Low |
| Collection of Blood Sample From Implanted Device | surgery | $49 | $49 to $36,591 | Low |
| Injection, Phytonadione (vitamin K), Per 1 Mg | other | $49 | $49 to $245 | Low |
| Insertion of Tube and Introduction of Contrast for X-ray of Uterus and Fallop... | imaging | $49 | $49 to $58,340 | Low |
| Flow Cytometry Technique for Dna OR Cell Analysis | other | $50 | $50 to $88,182 | Low |
| Injection, Mannitol, 25% in 50 Ml | other | $50 | $50 to $251 | Low |
| Anterior Chamber Intraocular Lens | other | $51 | $51 to $255 | Low |
| Insertion of Temporary Bladder Tube | other | $51 | $51 to $51,701 | Low |
| Low Dose CT Scan of Chest for Lung Cancer Screening | imaging | $51 | $51 to $71,271 | Low |
| Application of Vein Wound Compression Bandages On Lower Leg, Ankle, and Foot | other | $52 | $52 to $29,581 | Low |
| Diffcult Airway-video-larygeo | other | $53 | $53 to $268 | Low |
| Drug Test(s), Definitive, Utilizing (1) Drug Identification Methods Able to I... | other | $53 | $53 to $269 | Low |
| Evaluation and Recording of Swallowing Using an Endoscope | other | $53 | $53 to $92,612 | Low |
| Gene Analysis (prothrombin, Coagulation Factor Ii) a Variant | other | $53 | $53 to $81,240 | Low |
| Infusion, Albumin (human), 25%, 50 Ml | surgery | $53 | $53 to $575 | Low |
| Injection Procedure Through Bladder and Urethra for X-ray Imaging | imaging | $53 | $53 to $51,610 | Low |
| Biopsy of Breast and Placement of Locating Device Using X-ray with Needle, Ea... | imaging | $54 | $54 to $19,082 | Low |
| Drawing of Blood for a Medical Problem | other | $56 | $56 to $99,195 | Low |
| Established Patient Office OR Other Outpatient Visit with Low Level of Decisi... | other | $56 | $56 to $99,213 | Low |
| Evaluation of Swallowing Function | other | $57 | $57 to $92,610 | Low |
| 4 Hour Gtt | other | $59 | $59 to $299 | Low |
| Atb45mm Standard Artic Cutter | other | $59 | $59 to $299 | Low |
| Injection of Bladder and Ureter for Imaging | other | $59 | $59 to $50,690 | Low |
| Gene Analysis (survival of Motor Neuron 1, Telomeric) for Dosage/deletion | other | $60 | $60 to $81,329 | Low |
| Injection, Benztropine Mesylate, Per 1 Mg | other | $60 | $60 to $300 | Low |
| Anesthesia Facility Charge | other | $61 | $61 to $309 | Low |
| Dxa Bone Density Measurement of Hip, Pelvis, Spine | other | $61 | $61 to $77,080 | Low |
| Evaluation for Use of Voice Artificial Device to Supplement Oral Speech | other | $61 | $61 to $92,597 | Low |
| Blood Unit Compatibility Test, Antiglobulin Technique | other | $62 | $62 to $86,922 | Low |
| Blood Unit Compatibility Test, Immediate Spin Technique | other | $62 | $62 to $86,920 | Low |
| Insertion of Tube Into Vena Cava | other | $62 | $62 to $36,010 | Low |
| Evaluation of Speech Sound Production | other | $63 | $63 to $92,522 | Low |
| Analysis of Voice and Resonance Production | other | $65 | $65 to $92,524 | Low |
| Artery Puncture Collection of Blood Sample | other | $65 | $65 to $36,600 | Low |
| Blood Bank Physician Services for Investigation of Transfusion Reaction with ... | surgery | $65 | $65 to $86,078 | Low |
| Catheter, Balloon Dilatation, Non-vascular | cardiac | $65 | $65 to $327 | Low |
| Imaging for Evaluation of Swallowing Function | other | $65 | $65 to $74,230 | Low |
| Inhalation Treatment for Acute Airway Obstruction, First Hour | other | $65 | $65 to $94,644 | Low |
| Injection, Lacosamide, 1 Mg | other | $65 | $65 to $328 | Low |
| Low Osmolar Contrast Material, 200-299 Mg/ml Iodine Concentration, Per Ml | other | $66 | $66 to $330 | Low |
| High Osmolar Contrast Material, 350-399 Mg/ml Iodine Concentration, Per Ml | other | $67 | $67 to $340 | Low |
| Complete Ultrasound Scan of 1 Breast | imaging | $69 | $69 to $76,641 | Low |
| Hormone Receptor Analysis | other | $69 | $69 to $84,235 | Low |
| Injection of Contrast for Imaging of Lower Spinal Canal | other | $69 | $69 to $62,284 | Low |
| Monurol 3 Gm Sacet | other | $69 | $69 to $349 | Low |
| New Patient Office OR Other Outpatient Visit with Low Level of Medical Decisi... | other | $69 | $69 to $99,203 | Low |
| Albuterol Inhaler | other | $70 | $70 to $352 | Low |
| Detection Test By Nucleic Acid for Hiv-1 Virus, Quantification | other | $72 | $72 to $87,536 | Low |
| Limited Ultrasound Scan of 1 Breast | imaging | $72 | $72 to $76,642 | Low |
| Levalbuterol, Inhalation Solution, Compounded Product, Administered Through D... | other | $73 | $73 to $369 | Low |
| 5 Hour Gtt | other | $74 | $74 to $370 | Low |
| Blood (whole), for Transfusion, Per Unit | surgery | $75 | $75 to $376 | Low |
| Contrast Injection for X-ray Imaging Through Existing Tube in Stomach, Small ... | imaging | $77 | $77 to $49,465 | Low |
| Evaluation of Speech Continuity, Smoothness, Rate, and Effort | other | $77 | $77 to $92,521 | Low |
| Molecular Pathology Procedure | lab | $77 | $77 to $81,479 | Low |
| Complete X-ray of Body Bones | imaging | $78 | $78 to $77,075 | Low |
| Limited X-ray of Body Bones | imaging | $78 | $78 to $77,074 | Low |
| Fluoroscopic Guidance for Insertion OR Removal of Central Vein Access Device | surgery | $80 | $80 to $77,001 | Low |
| Injection, Linezolid, 200 Mg | other | $80 | $80 to $400 | Low |
| Initial Therapy Service to Facilitate Lung Function | other | $81 | $81 to $94,667 | Low |
| Injection, Desmopressin Acetate, Per 1 Mcg | other | $81 | $81 to $406 | Low |
| Imaging of Gallbladder with Contrast | other | $82 | $82 to $74,290 | Low |
| Injection, Vasopressin, 1 Unit | other | $82 | $82 to $413 | Low |
| CT Scan for Measuring Calcium and Other Minerals in Bone | imaging | $83 | $83 to $77,078 | Low |
| 6 Hour Gtt | other | $86 | $86 to $434 | Low |
| Inhalation Treatment for Airway Obstruction OR Sputum Production | other | $89 | $89 to $94,640 | Low |
| Insertion of Tube Into Airway for Aspiration of Secretions | other | $89 | $89 to $31,720 | Low |
| Anchor/screw for Opposing Bone-to-bone OR Soft Tissue-to-bone | other | $90 | $90 to $455 | Low |
| Identification of Red Blood Cell Antibodies | other | $90 | $90 to $86,870 | Low |
| Catheter, Intraspinal | cardiac | $91 | $91 to $457 | Low |
| Injection, Dobutamine Hydrochloride, Per 250 Mg | other | $92 | $92 to $462 | Low |
| Injection, Naloxone Hydrochloride, Not Otherwise Specified, 0.01 Mg | other | $92 | $92 to $465 | Low |
| Injection, Alteplase Recombinant, 1 Mg | other | $94 | $94 to $26,401 | Low |
| Double Contrast X-ray of Small Intestine | imaging | $95 | $95 to $74,251 | Low |
| Fluoroscopic Guidance for Needle Placement | other | $95 | $95 to $77,002 | Low |
| Complete Ultrasound of Abdomen and Pelvis Artery and Vein Blood Flow | imaging | $97 | $97 to $93,975 | Low |
| Evaluation of Fine Needle Aspirate | other | $97 | $97 to $88,172 | Low |
| Incision of Sperm Duct for X-ray Procedure | imaging | $97 | $97 to $55,300 | Low |
| Microscopic Genetic Analysis of Tissue, Computer-assisted Technology, Initial... | other | $97 | $97 to $88,367 | Low |
| Fluoroscopic Guidance for Spine OR Back Muscle Injection | other | $98 | $98 to $77,003 | Low |
| Imaging Guidance for Procedure, 60 Minutes OR Less | other | $98 | $98 to $76,000 | Low |
| 2d Ultrasound Scan of Eye Tissue and Structures | imaging | $100 | $100 to $76,512 | Low |
| Complete Ultrasound Scan Behind Abdominal Cavity | imaging | $100 | $100 to $76,770 | Low |
| Complete Ultrasound Scan of Abdomen | imaging | $100 | $100 to $76,700 | Low |
| Complete Ultrasound Scan of Pelvis | imaging | $100 | $100 to $76,856 | Low |
| Contrast Injection for Imaging to Evaluate Central Venous Access Device | other | $100 | $100 to $36,598 | Low |
| CT Scan Head OR Brain without Contrast | imaging | $100 | $100 to $70,450 | Low |
| CT Scan of Abdomen without Contrast | imaging | $100 | $100 to $74,150 | Low |
| CT Scan of Arm without Contrast | imaging | $100 | $100 to $73,200 | Low |
| CT Scan of Chest without Contrast | imaging | $100 | $100 to $71,250 | Low |
| CT Scan of Cranial Cavity without Contrast | imaging | $100 | $100 to $70,480 | Low |
| CT Scan of Face without Contrast | imaging | $100 | $100 to $70,486 | Low |
| CT Scan of Leg without Contrast | imaging | $100 | $100 to $73,700 | Low |
| CT Scan of Lower Spine without Contrast | imaging | $100 | $100 to $72,131 | Low |
| CT Scan of Middle Spine without Contrast | imaging | $100 | $100 to $72,128 | Low |
| CT Scan of Pelvis without Contrast | imaging | $100 | $100 to $72,192 | Low |
| CT Scan of Soft Tissue of Neck without Contrast | imaging | $100 | $100 to $70,490 | Low |
| CT Scan of Upper Spine without Contrast | imaging | $100 | $100 to $72,125 | Low |
| Follow-up Ultrasound Scan of Pregnant Uterus | imaging | $100 | $100 to $76,816 | Low |
| Limited Ultrasound of Pregnant Uterus | imaging | $100 | $100 to $76,815 | Low |
| Limited Ultrasound Scan Behind Abdominal Cavity | imaging | $100 | $100 to $76,775 | Low |
| Limited Ultrasound Scan of Abdomen | imaging | $100 | $100 to $76,705 | Low |
| Limited Ultrasound Scan of Joint OR Other Extremity Structure Except Blood Ve... | imaging | $100 | $100 to $76,882 | Low |
| Injection, Nicardipine, 0.1 Mg | other | $101 | $101 to $508 | Low |
| Microscopic Genetic Analysis of Tumor, Using Computer-assisted Technology | other | $101 | $101 to $88,361 | Low |
| Emergency Surgery Fee | surgery | $104 | $104 to $524 | Low |
| Injection, Cosyntropin, 0.25 Mg | other | $106 | $106 to $533 | Low |
| Injection, Epinephrine (adrenalin), Not Therapeutically Equivalent to J0165, ... | other | $107 | $107 to $540 | Low |
| Mesh | other | $107 | $107 to $538 | Low |
| Injection, Methylprednisolone Sodium Succinate, 5 Mg | other | $108 | $108 to $544 | Low |
| New Patient Office OR Other Outpatient Visit with Moderate Level of Medical D... | other | $111 | $111 to $99,204 | Low |
| Catheter, Drainage | cardiac | $118 | $118 to $595 | Low |
| Fetal Test | other | $119 | $119 to $59,025 | Low |
| Injection, Esmolol Hydrochloride (wg Critical Care), Not Therapeutically Equi... | other | $119 | $119 to $598 | Low |
| Chromosome Analysis for Genetic Defects, Count 15-20 Cells | other | $125 | $125 to $88,262 | Low |
| Injection, Ertapenem Sodium, 500 Mg | other | $128 | $128 to $643 | Low |
| Evaluation of Speech Sound Production with Evaluation of Language Comprehensi... | other | $129 | $129 to $92,523 | Low |
| Injection of Radioactive Material for X-ray Identification of Lymph Node | imaging | $130 | $130 to $38,792 | Low |
| Emergent Insertion of Breathing Tube Into Windpipe Using an Endoscope | other | $132 | $132 to $31,500 | Low |
| New Patient Office OR Other Outpatient Visit with a High Level of Medical Dec... | other | $135 | $135 to $99,205 | Low |
| Evaluation for Work Hardening OR Conditioning, Initial 2 Hours | other | $144 | $144 to $97,545 | Low |
| Fetal Congenital Abnormalities, Biochemical Assays of Four Analytes (afp, Ue3... | other | $145 | $145 to $81,511 | Low |
| Imaging of Urinary Tract Following Injection of a Contrast Agent | other | $146 | $146 to $74,420 | Low |
| Magnetic Resonance Angiography without Contrast, Chest | imaging | $154 | $154 to $1,841 | Low |
| Complete Ultrasound of Aorta, Vena Cava, Groin Vessels OR Bypass Grafts | imaging | $157 | $157 to $93,978 | Low |
| Injection, Methylnaltrexone, 0.1 Mg | other | $162 | $162 to $815 | Low |
| Double Contrast X-ray of Upper Digestive Tract | imaging | $164 | $164 to $74,246 | Low |
| Injection, Rho(d) Immune Globulin (human), (rhophylac), Intramuscular OR Intr... | other | $166 | $166 to $833 | Low |
| CT Head | imaging | $168 | $168 to $2,222 | High |
| CT Scan Head OR Brain with Contrast | imaging | $168 | $168 to $70,460 | Low |
| CT Scan of Abdomen Before and After Contrast | imaging | $168 | $168 to $74,170 | Low |
| CT Scan of Abdomen with Contrast | imaging | $168 | $168 to $74,160 | Low |
| CT Scan of Abdominal Aorta and Both Leg Arteries with Contrast | imaging | $168 | $168 to $75,635 | Low |
| CT Scan of Arm Before and After Contrast | imaging | $168 | $168 to $73,202 | Low |
| CT Scan of Blood Vessels of Abdomen with Contrast | imaging | $168 | $168 to $74,175 | Low |
| CT Scan of Blood Vessels of Arm with Contrast | imaging | $168 | $168 to $73,206 | Low |
| CT Scan of Blood Vessels of Chest with Contrast | imaging | $168 | $168 to $71,275 | Low |
| CT Scan of Blood Vessels of Head with Contrast | imaging | $168 | $168 to $70,496 | Low |
| CT Scan of Blood Vessels of Lower Leg with Contrast | imaging | $168 | $168 to $73,706 | Low |
| CT Scan of Blood Vessels of Neck with Contrast | imaging | $168 | $168 to $70,498 | Low |
| CT Scan of Blood Vessels of Pelvis with Contrast | imaging | $168 | $168 to $72,191 | Low |
| CT Scan of Chest Before and After Contrast | imaging | $168 | $168 to $71,270 | Low |
| CT Scan of Chest with Contrast | imaging | $168 | $168 to $71,260 | Low |
| CT Scan of Cranial Cavity Before and After Contrast | imaging | $168 | $168 to $70,482 | Low |
| CT Scan of Cranial Cavity with Contrast | imaging | $168 | $168 to $70,481 | Low |
| CT Scan of Face Before and After Contrast | imaging | $168 | $168 to $70,488 | Low |
| CT Scan of Face with Contrast | imaging | $168 | $168 to $70,487 | Low |
| CT Scan of Head OR Brain Before and After Contrast | imaging | $168 | $168 to $70,470 | 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 Middle Spine with Contrast | imaging | $168 | $168 to $72,129 | Low |
| CT Scan of Pelvis Before and After Contrast | imaging | $168 | $168 to $72,194 | Low |
| CT Scan of Pelvis with Contrast | imaging | $168 | $168 to $72,193 | Low |
| CT Scan of Soft Tissue of Neck Before and After Contrast | imaging | $168 | $168 to $70,492 | Low |
| CT Scan of Soft Tissue of Neck with Contrast | imaging | $168 | $168 to $70,491 | 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 |
| Imaging of Urinary Tract Using Infusion Technique | surgery | $168 | $168 to $74,410 | Low |
| Imaging of Urinary Tract Using Infusion Technique with Kidney Section Filming | surgery | $168 | $168 to $74,415 | Low |
| Imaging of Urinary Tract with Injection of Contrast Into a Vein | other | $168 | $168 to $74,400 | Low |
| Injection, Tenecteplase, 1 Mg | other | $172 | $172 to $24,314 | Low |
| 000-030 Min - Anesthesia | other | $179 | $179 to $900 | Low |
| Add'l 30 Min Anesthesia | other | $179 | $179 to $900 | Low |
| Convalescent Plasma | other | $179 | $179 to $902 | Low |
| Injection, Zoledronic Acid, 1 Mg | other | $179 | $179 to $900 | Low |
| Nuclear Medicine Study of Bone And/or Joint Limited Area | imaging | $179 | $179 to $78,300 | Low |
| Injection, Glucagon Hydrochloride, Per 1 Mg | other | $182 | $182 to $1,411 | Low |
| Injection, Micafungin Sodium, 1 Mg | other | $186 | $186 to $935 | Low |
| Fine Needle Aspiration Biopsy Using Fluoroscopic Guidance, First Growth | lab | $208 | $208 to $10,007 | Low |
| Intravenous Infusion OR Subcutaneous Injection, Casirivimab and Imdevimab Inc... | surgery | $208 | $208 to $1,045 | Low |
| Intravenous Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post... | surgery | $208 | $208 to $1,045 | Low |
| Echo Limit | imaging | $213 | $213 to $1,072 | Low |
| Echocardiogram | imaging | $213 | $91 to $1,072 | High |
| Nuclear Medicine Studies of Kidney, Blood Flow, and Function | imaging | $226 | $226 to $78,709 | Low |
| CT Scan of Abdomen and Pelvis without Contrast | imaging | $228 | $228 to $74,176 | Low |
| MRI Scan of Abdomen without Contrast | imaging | $228 | $228 to $74,181 | Low |
| MRI Scan of Arm Joint without Contrast | imaging | $228 | $228 to $73,221 | Low |
| MRI Scan of Arm without Contrast | imaging | $228 | $228 to $73,218 | Low |
| MRI Scan of Blood Vessels of Head without Contrast | imaging | $228 | $228 to $70,544 | Low |
| MRI Scan of Blood Vessels of Neck without Contrast | imaging | $228 | $228 to $70,547 | Low |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck without Contrast | imaging | $228 | $228 to $70,540 | Low |
| MRI Scan of Brain without Contrast | imaging | $228 | $228 to $70,551 | Low |
| MRI Scan of Chest without Contrast | imaging | $228 | $228 to $71,550 | Low |
| MRI Scan of Jaw Joint | imaging | $228 | $228 to $70,336 | Low |
| MRI Scan of Leg Joint without Contrast | imaging | $228 | $228 to $73,721 | Low |
| MRI Scan of Leg without Contrast | imaging | $228 | $228 to $73,718 | Low |
| MRI Scan of Lower Spinal Canal without Contrast | imaging | $228 | $228 to $72,148 | Low |
| MRI Scan of Middle Spinal Canal without Contrast | imaging | $228 | $228 to $72,146 | Low |
| MRI Scan of Pelvis without Contrast | imaging | $228 | $228 to $72,195 | Low |
| MRI Scan of Upper Spinal Canal without Contrast | imaging | $228 | $228 to $72,141 | Low |
| Magnetic Resonance Angiography with Contrast, Chest | imaging | $229 | $229 to $1,841 | Low |
| Bone Marrow, Smear Interpretation | other | $236 | $236 to $85,097 | Low |
| Dilation of Stomach And/or Small Bowel Using Long Gastrointestinal Tube | other | $236 | $236 to $44,500 | Low |
| Joint Device | other | $244 | $244 to $1,226 | Low |
| ICU Nursing Increment | other | $249 | $249 to $1,254 | Low |
| Fine Needle Aspiration Biopsy Using Ultrasound Guidance, First Growth | imaging | $251 | $251 to $10,005 | Low |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Chest | imaging | $259 | $259 to $1,841 | Low |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Sp... | imaging | $259 | $259 to $1,841 | Low |
| Drainage of Fluid From Abdominal Cavity Using Imaging Guidance | other | $264 | $264 to $49,083 | Low |
| Injection, Epinephrine, Not Otherwise Specified, 0.1 Mg | other | $268 | $268 to $1,350 | Low |
| Bronchospam Complete | other | $273 | $273 to $1,371 | Low |
| Follow-up Inpatient OR Observation Ventilation Assistance and Management | other | $277 | $277 to $94,003 | Low |
| Initial Hospital Inpatient OR Observation Ventilation Assistance and Management | other | $277 | $277 to $94,002 | Low |
| Dialysis | other | $316 | $316 to $90,935 | High |
| Injection, Amphotericin B, 50 Mg | other | $316 | $316 to $1,592 | Low |
| Hemabate 250 Mcg IM | other | $317 | $317 to $1,595 | Low |
| Mitomycin Pyelocalyceal Instillation, 1 Mg | other | $319 | $319 to $4,424 | Low |
| CT Scan of Arm with Contrast | imaging | $332 | $332 to $73,201 | Low |
| CT Scan of Abdomen and Pelvis Before and After Contrast | imaging | $333 | $333 to $74,178 | Low |
| CT Scan of Abdomen and Pelvis with Contrast | imaging | $333 | $333 to $74,177 | Low |
| CT Scan of Blood Vessels of Abdomen and Pelvis with Contrast | imaging | $333 | $333 to $74,174 | Low |
| CT Scan of Lower Spine with Contrast | imaging | $333 | $333 to $72,132 | Low |
| CT Scan of Upper Spine with Contrast | imaging | $333 | $333 to $72,126 | Low |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Ab... | imaging | $333 | $333 to $2,935 | Low |
| Magnetic Resonance Angiography without Contrast Followed By with Contrast, Pe... | imaging | $333 | $333 to $2,935 | Low |
| MRI Scan of Abdomen Before and After Contrast | imaging | $333 | $333 to $74,183 | Low |
| MRI Scan of Abdomen with Contrast | imaging | $333 | $333 to $74,182 | Low |
| MRI Scan of Arm Before and After Contrast | imaging | $333 | $333 to $73,220 | Low |
| MRI Scan of Arm Joint Before and After Contrast | imaging | $333 | $333 to $73,223 | Low |
| MRI Scan of Arm with Contrast | imaging | $333 | $333 to $73,219 | Low |
| MRI Scan of Blood Vessels of Head Before and After Contrast | imaging | $333 | $333 to $70,546 | Low |
| MRI Scan of Blood Vessels of Head with Contrast | imaging | $333 | $333 to $70,545 | Low |
| MRI Scan of Blood Vessels of Neck Before and After Contrast | imaging | $333 | $333 to $70,549 | Low |
| MRI Scan of Blood Vessels of Neck with Contrast | imaging | $333 | $333 to $70,548 | Low |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck Before and After Contrast | imaging | $333 | $333 to $70,543 | Low |
| MRI Scan of Bone of Eye Socket, Face, And/or Neck with Contrast | imaging | $333 | $333 to $70,542 | Low |
| MRI Scan of Brain Before and After Contrast | imaging | $333 | $333 to $70,553 | Low |
| MRI Scan of Brain with Contrast | imaging | $333 | $333 to $70,552 | Low |
| MRI Scan of Chest Before and After Contrast | imaging | $333 | $333 to $71,552 | Low |
| MRI Scan of Leg Before and After Contrast | imaging | $333 | $333 to $73,720 | Low |
| MRI Scan of Leg Joint Before and After Contrast | imaging | $333 | $333 to $73,723 | Low |
| MRI Scan of Leg with Contrast | imaging | $333 | $333 to $73,719 | Low |
| MRI Scan of Lower Spinal Canal Before and After Contrast | imaging | $333 | $333 to $72,158 | Low |
| MRI Scan of Lower Spinal Canal with Contrast | imaging | $333 | $333 to $72,149 | Low |
| MRI Scan of Middle Spinal Canal Before and After Contrast | imaging | $333 | $333 to $72,157 | Low |
| MRI Scan of Middle Spinal Canal with Contrast | imaging | $333 | $333 to $72,147 | Low |
| MRI Scan of Pelvis Before and After Contrast | imaging | $333 | $333 to $72,197 | Low |
| MRI Scan of Pelvis with Contrast | imaging | $333 | $333 to $72,196 | Low |
| MRI Scan of Upper Spinal Canal Before and After Contrast | imaging | $333 | $333 to $72,156 | Low |
| MRI Scan of Upper Spinal Canal with Contrast | imaging | $333 | $333 to $72,142 | Low |
| Implantable Surgical Supplies | surgery | $339 | $339 to $1,703 | Low |
| Nuclear Medicine Study of Bone And/or Joint Multiple Areas | imaging | $379 | $379 to $78,305 | Low |
| Aspiration And/or Injection of Cyst of Kidney | other | $382 | $382 to $50,390 | Low |
| Needle Biopsy of Lining of Lung | lab | $382 | $382 to $32,400 | Low |
| Intensive Care Unit - General Classification | other | $388 | $388 to $4,424 | Low |
| Aspiration of Fluid From Cyst of Spinal Cord OR Fluid-filled Cavity | other | $406 | $406 to $62,268 | Low |
| Aspiration of Fluid From Chest Cavity Using Imaging Guidance | other | $424 | $424 to $32,555 | Low |
| Gene Analysis (cystic Fibrosis Transmembrane Conductance Regular) Common Vari... | other | $446 | $446 to $81,220 | Low |
| Aspiration of Initial Secretion of Lung Airway Using an Endoscope | other | $472 | $472 to $31,645 | Low |
| Labor Room/delivery - General Classification | obstetric | $519 | $519 to $2,613 | Low |
| Injection, Tetanus Immune Globulin, Human, Up to 250 Units | other | $557 | $557 to $2,804 | Low |
| Lymph OR Ln Nm Scan | other | $558 | $558 to $2,809 | Low |
| Biopsy of Breast and Placement of Locating Device Using X-ray with Needle, Fi... | imaging | $564 | $564 to $19,081 | Low |
| Insertion of Stomach Tube Using Fluoroscopic Guidance with Contrast | other | $570 | $570 to $49,440 | Low |
| MRI Scan of Chest with Contrast | imaging | $588 | $588 to $71,551 | Low |
| MRI Scan of Arm Joint with Contrast | imaging | $613 | $613 to $73,222 | Low |
| Misc Implant | surgery | $637 | $637 to $3,205 | Low |
| MRI Scan of Leg Joint with Contrast | imaging | $661 | $661 to $73,722 | Low |
| Deep Biopsy of Bone Using Needle OR Trocar | lab | $718 | $718 to $20,225 | Low |
| Insertion of Indwelling Tube for Drainage of Lung Fluid | other | $831 | $831 to $32,550 | Low |
| Injection, Tbo-filgrastim, 1 Microgram | other | $875 | $875 to $1,249 | Low |
| Injection, Crotalidae Immune F(ab')2 (equine), 120 Mg | other | $918 | $918 to $4,620 | Low |
| Nuclear Medicine Studies of Heart Muscle At Rest and with Stress and SPECT | imaging | $1,237 | $1,237 to $78,452 | Low |
| Normal Newborn | other | $1,469 | $1,469 to $7,139 | Low |
| Abortion without D&c | other | $1,598 | $1,598 to $7,023 | Low |
| Acute Leukemia with Cc | other | $1,598 | $1,598 to $25,490 | Low |
| Acute Myocardial Infarction, Expired with Mcc | other | $1,598 | $1,598 to $17,777 | Low |
| Allergic Reactions with Mcc | other | $1,598 | $1,598 to $15,092 | Low |
| Bone Diseases and Arthropathies with Mcc | other | $1,598 | $1,598 to $11,634 | Low |
| Cardiac Congenital and Valvular Disorders without Mcc | cardiac | $1,598 | $1,598 to $11,355 | Low |
| Complications of Treatment with Mcc | other | $1,598 | $1,598 to $16,431 | Low |
| Connective Tissue Disorders with Cc | other | $1,598 | $1,598 to $10,351 | Low |
| Endocrine Disorders without Cc/mcc | other | $1,598 | $1,598 to $7,023 | Low |
| Fever and Inflammatory Conditions | other | $1,598 | $1,598 to $9,921 | Low |
| Headaches without Mcc | other | $1,598 | $1,598 to $24,297 | Low |
| Heart Failure and Shock without CC/MCC | cardiac | $1,598 | $1,598 to $8,571 | Low |
| Inborn and Other Disorders of Metabolism | other | $1,598 | $1,598 to $19,400 | Low |
| Inflammation of the Male Reproductive System with Mcc | other | $1,598 | $1,598 to $13,309 | Low |
| Major Chest Trauma without Cc/mcc | emergency | $1,598 | $1,598 to $7,059 | Low |
| Major Hematological and Immunological Diagnoses Except Sickle Cell Crisis and... | other | $1,598 | $1,598 to $16,902 | Low |
| Malignancy, Male Reproductive System with Cc | other | $1,598 | $1,598 to $35,812 | Low |
| Neonates, Died OR Transferred to Another Acute Care Facility | other | $1,598 | $1,598 to $16,174 | Low |
| Nervous System Neoplasms with Mcc | other | $1,598 | $1,598 to $13,704 | Low |
| Alcohol, Drug Abuse OR Dependence, Left Ama | other | $1,681 | $1,681 to $7,023 | Low |
| Kidney Stone Removal | other | $1,704 | $1,704 to $8,570 | High |
| Lithotripsy-s/w | other | $1,704 | $1,704 to $8,570 | Low |
| Appendectomy (Laparoscopic) | surgery | $1,800 | $1,800 to $21,231 | High |
| Appendix Procedures without Cc/mcc | other | $1,800 | $1,800 to $21,272 | Low |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis without Cc/mcc | other | $1,800 | $1,800 to $33,767 | Low |
| Hernia Procedures Except Inguinal and Femoral without Cc/mcc | other | $1,800 | $1,800 to $21,650 | Low |
| Minor Bladder Procedures with Mcc | other | $1,800 | $1,800 to $55,552 | Low |
| Minor Small and Large Bowel Procedures without Cc/mcc | other | $1,800 | $1,800 to $24,373 | Low |
| Injection, Calcitonin Salmon, Up to 400 Units | other | $1,917 | $1,917 to $9,641 | Low |
| Neonate with Other Significant Problems | other | $1,990 | $1,990 to $13,246 | Low |
| Injection, Ferumoxytol, for Treatment of Iron Deficiency Anemia, 1 Mg | other | $2,208 | $2,208 to $3,154 | Low |
| Alcohol/Drug Abuse or Dependence without Rehabilitation without MCC | therapy | $2,521 | $2,521 to $12,799 | Low |
| Bronchitis and Asthma without Cc/mcc | other | $3,160 | $3,160 to $8,042 | Low |
| Atherosclerosis without Mcc | other | $3,196 | $3,196 to $13,606 | Low |
| Benign Prostatic Hypertrophy without Mcc | other | $3,196 | $3,196 to $21,655 | Low |
| Bronchitis and Asthma with Cc/mcc | other | $3,196 | $3,196 to $17,501 | Low |
| Cardiac Arrhythmia and Conduction Disorders without Cc/mcc | cardiac | $3,196 | $3,196 to $9,145 | Low |
| Complicated Peptic Ulcer with Cc | other | $3,196 | $3,196 to $26,490 | Low |
| Diabetes without Cc/mcc | other | $3,196 | $3,196 to $9,754 | Low |
| Digestive Malignancy with Cc | other | $3,196 | $3,196 to $25,086 | Low |
| Disorders of Liver Except Malignancy, Cirrhosis OR Alcoholic Hepatitis with Cc | other | $3,196 | $3,196 to $11,929 | Low |
| Disorders of Pancreas Except Malignancy without Cc/mcc | other | $3,196 | $3,196 to $18,258 | Low |
| Disorders of the Biliary Tract with Cc | other | $3,196 | $3,196 to $18,177 | Low |
| Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders with Mcc | other | $3,196 | $3,196 to $15,297 | Low |
| Fractures of Hip and Pelvis with Mcc | other | $3,196 | $3,196 to $16,790 | Low |
| Gastrointestinal Hemorrhage without Cc/mcc | other | $3,196 | $3,196 to $16,300 | Low |
| Inflammatory Bowel Disease without Cc/mcc | other | $3,196 | $3,196 to $13,182 | Low |
| Lymphoma and Non-acute Leukemia with Cc | other | $3,196 | $3,196 to $18,528 | Low |
| Malignancy, Female Reproductive System with Cc | other | $3,196 | $3,196 to $11,813 | Low |
| C-Section (Cesarean Delivery) | obstetric | $3,273 | $3,273 to $22,034 | High |
| Gastrointestinal Obstruction without Cc/mcc | other | $3,538 | $3,538 to $13,382 | Low |
| Abortion with D&c, Aspiration Curettage OR Hysterotomy | other | $3,600 | $3,600 to $30,050 | Low |
| Anal and Stomal Procedures with Cc | other | $3,600 | $3,600 to $25,561 | Low |
| Appendix Procedures with Cc | other | $3,600 | $3,600 to $23,193 | Low |
| Gallbladder Removal (Laparoscopic) | surgery | $3,600 | $3,600 to $24,903 | High |
| Hip and Femur Procedures except Major Joint without CC/MCC | surgery | $3,600 | $3,600 to $22,921 | Low |
| Inguinal and Femoral Hernia Procedures with Cc | other | $3,600 | $3,600 to $25,185 | Low |
| Knee Procedures without Principal Diagnosis of Infection with Cc/mcc | other | $3,600 | $3,600 to $18,222 | Low |
| Laparoscopic Cholecystectomy without CC/MCC | surgery | $3,600 | $3,600 to $24,903 | Low |
| Dental and Oral Diseases without Cc/mcc | other | $3,665 | $3,665 to $12,043 | Low |
| Full Term Neonate with Major Problems | other | $4,467 | $4,467 to $37,421 | Low |
| Kidney and Urinary Tract Signs and Symptoms without Mcc | other | $4,496 | $4,496 to $33,046 | Low |
| Major Skin Disorders without Mcc | other | $4,522 | $4,522 to $9,715 | Low |
| Cellulitis without Mcc | other | $4,556 | $4,556 to $14,614 | Low |
| COPD Management | other | $4,627 | $121 to $9,081 | High |
| COPD without CC/MCC | other | $4,627 | $4,627 to $9,081 | Low |
| Esophagitis and GI Disorders with MCC | other | $4,632 | $4,632 to $17,717 | Low |
| Inflammation of the Male Reproductive System without Mcc | other | $4,647 | $4,647 to $12,085 | Low |
| Kidney and Urinary Tract Infections without MCC | other | $4,748 | $4,748 to $16,437 | Low |
| Fractures of Femur without Mcc | other | $4,765 | $4,765 to $38,569 | Low |
| Acute Myocardial Infarction Discharged Alive with CC | cardiac | $4,794 | $4,794 to $10,047 | Low |
| Acute Myocardial Infarction Discharged Alive with MCC | cardiac | $4,794 | $4,794 to $20,765 | Low |
| Benign Prostatic Hypertrophy with Mcc | other | $4,794 | $4,794 to $19,344 | Low |
| Cardiac Arrhythmia and Conduction Disorders with Cc | cardiac | $4,794 | $4,794 to $15,462 | Low |
| Cardiac Congenital and Valvular Disorders with Mcc | cardiac | $4,794 | $4,794 to $16,378 | Low |
| Cranial and Peripheral Nerve Disorders without Mcc | other | $4,794 | $4,794 to $17,503 | Low |
| Degenerative Nervous System Disorders without Mcc | other | $4,794 | $4,794 to $14,376 | Low |
| Dental and Oral Diseases with Cc | other | $4,794 | $4,794 to $12,441 | Low |
| Digestive Malignancy with Mcc | other | $4,794 | $4,794 to $39,586 | Low |
| Disorders of the Biliary Tract without Cc/mcc | other | $4,794 | $4,794 to $15,128 | Low |
| Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh ... | other | $4,794 | $4,794 to $16,427 | Low |
| Gastrointestinal Obstruction with Cc | other | $4,794 | $4,794 to $18,903 | Low |
| Gastrointestinal Obstruction with Mcc | other | $4,794 | $4,794 to $19,906 | Low |
| Heart Failure and Shock with CC | cardiac | $4,794 | $4,794 to $16,433 | Low |
| HIV with Major Related Condition with Cc | other | $4,794 | $4,794 to $12,522 | Low |
| Hypertensive Encephalopathy with Cc | other | $4,794 | $4,794 to $14,425 | Low |
| Inflammatory Bowel Disease with Cc | other | $4,794 | $4,794 to $16,446 | Low |
| Intracranial Hemorrhage or Cerebral Infarction with CC | other | $4,794 | $4,794 to $17,370 | Low |
| Lymphoma and Non-acute Leukemia with Mcc | other | $4,794 | $4,794 to $29,032 | Low |
| Major Esophageal Disorders with Cc | other | $4,794 | $4,794 to $30,266 | Low |
| Minor Skin Disorders without Mcc | other | $4,794 | $4,794 to $11,167 | Low |
| Complicated Peptic Ulcer without Cc/mcc | other | $4,967 | $4,967 to $23,674 | Low |
| Acute Adjustment Reaction and Psychosocial Dysfunction | other | $5,043 | $5,043 to $17,658 | Low |
| Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes wit... | other | $5,326 | $5,326 to $16,086 | Low |
| Diabetes with Cc | other | $5,397 | $5,397 to $14,214 | Low |
| Breast Biopsy | other | $5,400 | $54 to $21,103 | High |
| Breast Biopsy, Local Excision and Other Breast Procedures with Cc/mcc | surgery | $5,400 | $5,400 to $21,103 | Low |
| D&c, Conization, Laparoscopy and Tubal Interruption with Cc/mcc | surgery | $5,400 | $5,400 to $41,129 | Low |
| Kidney and Ureter Procedures for Non-neoplasm without Cc/mcc | other | $5,400 | $5,400 to $16,869 | Low |
| Nervous System Neoplasms without Mcc | other | $5,452 | $5,452 to $19,466 | Low |
| Hypertension without Mcc | other | $5,463 | $5,463 to $14,982 | Low |
| Infectious and Parasitic Diseases with O.r. Procedures with Cc | other | $5,629 | $5,629 to $33,146 | Low |
| Infectious and Parasitic Diseases with O.r. Procedures with Mcc | other | $5,629 | $5,629 to $53,214 | Low |
| Acute Myocardial Infarction Discharged Alive without CC/MCC | cardiac | $5,762 | $5,762 to $21,091 | Low |
| COPD with CC | other | $5,789 | $5,789 to $16,862 | Low |
| Endocrine Disorders with Cc | other | $6,164 | $6,164 to $16,003 | Low |
| Medical Back Problems without Mcc | other | $6,197 | $6,197 to $22,888 | Low |
| Disorders of Pancreas Except Malignancy with Cc | other | $6,329 | $6,329 to $16,505 | Low |
| Bone Diseases and Arthropathies without Mcc | other | $6,331 | $6,331 to $13,881 | Low |
| Major Gastrointestinal Disorders and Peritoneal Infections with Cc | other | $6,358 | $6,358 to $29,977 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue with Cc | other | $6,392 | $6,392 to $14,482 | Low |
| Cardiac Arrhythmia and Conduction Disorders with Mcc | cardiac | $6,392 | $6,392 to $16,593 | Low |
| COPD with MCC | other | $6,392 | $6,392 to $14,240 | Low |
| Cranial and Peripheral Nerve Disorders with Mcc | other | $6,392 | $6,392 to $20,201 | Low |
| Degenerative Nervous System Disorders with Mcc | other | $6,392 | $6,392 to $24,915 | Low |
| Diabetes with Mcc | other | $6,392 | $6,392 to $21,735 | Low |
| Disorders of Liver Except Malignancy, Cirrhosis OR Alcoholic Hepatitis with Mcc | other | $6,392 | $6,392 to $26,265 | Low |
| Endocrine Disorders with Mcc | other | $6,392 | $6,392 to $26,154 | Low |
| Fractures of Hip and Pelvis without Mcc | other | $6,392 | $6,392 to $14,620 | Low |
| GI Hemorrhage with CC | other | $6,392 | $6,392 to $27,308 | Low |
| Hypertension with Mcc | other | $6,392 | $6,392 to $17,794 | Low |
| Interstitial Lung Disease with Mcc | other | $6,392 | $6,392 to $18,018 | Low |
| Intracranial Hemorrhage or Cerebral Infarction | other | $6,392 | $6,392 to $20,369 | Low |
| Intracranial Hemorrhage OR Cerebral Infarction with Mcc | other | $6,392 | $6,392 to $29,917 | Low |
| Kidney and Urinary Tract Neoplasms with Cc | other | $6,392 | $6,392 to $29,052 | Low |
| Major Chest Trauma with Mcc | emergency | $6,392 | $6,392 to $20,793 | Low |
| Major Gastrointestinal Disorders and Peritoneal Infections with Mcc | other | $6,392 | $6,392 to $36,027 | Low |
| Multiple Sclerosis and Cerebellar Ataxia with Cc | other | $6,392 | $6,392 to $11,411 | Low |
| Non-extensive Burns | other | $6,392 | $6,392 to $18,488 | Low |
| Nontraumatic Stupor and Coma with Mcc | emergency | $6,392 | $6,392 to $25,684 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue without Cc/mcc | other | $6,559 | $6,559 to $30,893 | Low |
| Multiple Sclerosis and Cerebellar Ataxia without Cc/mcc | other | $6,618 | $6,618 to $16,911 | Low |
| Alcohol, Drug Abuse OR Dependence without Rehabilitation Therapy with Mcc | therapy | $6,724 | $6,724 to $24,641 | Low |
| Malignancy of Hepatobiliary System OR Pancreas with Cc | other | $6,808 | $6,808 to $16,387 | Low |
| Aftercare, Musculoskeletal System and Connective Tissue with Mcc | other | $7,023 | $7,023 to $28,590 | Low |
| Bacterial and Tuberculous Infections of Nervous System without Cc/mcc | other | $7,023 | $7,023 to $23,148 | Low |
| Cellulitis with Mcc | other | $7,023 | $7,023 to $36,076 | Low |
| Cirrhosis and Alcoholic Hepatitis with Cc | other | $7,023 | $7,023 to $32,275 | Low |
| Cirrhosis and Alcoholic Hepatitis with Mcc | other | $7,023 | $7,023 to $27,670 | Low |
| Coagulation Disorders | other | $7,023 | $7,023 to $37,983 | Low |
| Complications of Treatment with Cc | other | $7,023 | $7,023 to $25,376 | Low |
| Connective Tissue Disorders with Mcc | other | $7,023 | $7,023 to $27,722 | Low |
| Disorders of Pancreas Except Malignancy with Mcc | other | $7,023 | $7,023 to $40,403 | Low |
| GI Hemorrhage with MCC | other | $7,023 | $7,023 to $36,901 | Low |
| Heart Failure and Shock with MCC | cardiac | $7,023 | $7,023 to $20,328 | Low |
| HIV with Major Related Condition with Mcc | other | $7,023 | $7,023 to $91,367 | Low |
| Hypertensive Encephalopathy with Mcc | other | $7,023 | $7,023 to $37,522 | Low |
| Inflammatory Bowel Disease with Mcc | other | $7,023 | $7,023 to $21,410 | Low |
| Kidney and Urinary Tract Infections with MCC | other | $7,023 | $7,023 to $20,200 | Low |
| Malignancy of Hepatobiliary System OR Pancreas with Mcc | other | $7,023 | $7,023 to $57,456 | Low |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Cc | other | $7,200 | $7,200 to $25,582 | Low |
| Appendix Procedures with Mcc | other | $7,200 | $7,200 to $44,393 | Low |
| Biliary Tract Procedures Except Only Cholecystectomy with OR without C.d.e. w... | other | $7,200 | $7,200 to $34,119 | Low |
| Foot Procedures with Cc | other | $7,200 | $7,200 to $19,146 | Low |
| Hand Procedures for Injuries | other | $7,200 | $7,200 to $26,834 | Low |
| Laparoscopic Cholecystectomy without Common Duct with CC | surgery | $7,200 | $7,200 to $30,072 | Low |
| Local Excision and Removal of Internal Fixation Devices of Hip and Femur with... | surgery | $7,200 | $7,200 to $32,883 | Low |
| Lower Extremity and Humerus Procedures Except Hip, Foot and Femur without Cc/mcc | other | $7,200 | $7,200 to $35,880 | Low |
| Major Hip and Knee Joint Replacement without MCC | surgery | $7,200 | $7,200 to $48,956 | Low |
| Major Small and Large Bowel Procedures with MCC | surgery | $7,200 | $7,200 to $41,252 | Low |
| Major Small and Large Bowel Procedures without CC/MCC | surgery | $7,200 | $7,200 to $24,836 | Low |
| Non-extensive O.r. Procedures Unrelated to Principal Diagnosis with Cc | other | $7,200 | $7,200 to $25,551 | Low |
| Kidney and Ureter Procedures for Non-neoplasm with Cc | other | $7,722 | $7,722 to $30,572 | Low |
| Minor Small and Large Bowel Procedures with Cc | other | $8,031 | $8,031 to $41,241 | Low |
| Major Thumb OR Joint Procedures | other | $8,590 | $8,590 to $34,520 | Low |
| Hand OR Wrist Procedures, Except Major Thumb OR Joint Procedures with Cc/mcc | other | $9,000 | $9,000 to $21,477 | Low |
| Major Small and Large Bowel Procedures with CC | surgery | $9,000 | $9,000 to $38,916 | Low |
| Amputation for Circulatory System Disorders Except Upper Limb and Toe with Mcc | other | $9,736 | $9,736 to $44,171 | Low |
| Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders w... | lab | $9,736 | $9,736 to $32,485 | Low |
| Biopsies of Musculoskeletal System and Connective Tissue with Cc | other | $9,736 | $9,736 to $69,519 | Low |
| Cervical Spinal Fusion without CC/MCC | surgery | $9,736 | $9,736 to $77,125 | Low |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis with Cc | other | $9,736 | $9,736 to $45,744 | Low |
| Extensive O.r. Procedures Unrelated to Principal Diagnosis with Mcc | other | $9,736 | $9,736 to $42,884 | Low |
| Hernia Procedures Except Inguinal and Femoral with Cc | other | $9,736 | $9,736 to $59,138 | Low |
| Hip and Femur Procedures except Major Joint with CC | surgery | $9,736 | $9,736 to $35,142 | Low |
| Hip and Femur Procedures except Major Joint with MCC | surgery | $9,736 | $9,736 to $48,017 | Low |
| Kidney and Ureter Procedures for Non-neoplasm with Mcc | other | $9,736 | $9,736 to $46,272 | Low |
| Knee Procedures with Principal Diagnosis of Infection with Mcc | other | $9,736 | $9,736 to $60,757 | Low |
| Limb Reattachment, Hip and Femur Procedures for Multiple Significant Trauma | emergency | $9,736 | $9,736 to $61,779 | Low |
| Non-extensive O.r. Procedures Unrelated to Principal Diagnosis with Mcc | other | $9,736 | $9,736 to $74,772 | Low |