NPI: 1316945991 · BIG RAPIDS, MI 49307 · General Acute Care Hospital · NPI assigned 07/08/2005
Authorized official COX, MATTHEW controls 20+ related entities in our dataset. Read more
| Authorized Official | COX, MATTHEW (CFO) |
| NPI Enumeration Date | 07/08/2005 |
Other providers sharing the same authorized official: COX, MATTHEW
| Year | Claims | Total Paid |
|---|---|---|
| 2018 | 62,185 | $1.70M |
| 2019 | 53,408 | $1.48M |
| 2020 | 72,976 | $2.10M |
| 2021 | 126,497 | $3.68M |
| 2022 | 121,720 | $3.56M |
| 2023 | 125,734 | $3.57M |
| 2024 | 111,520 | $3.41M |
| Code | Description | Claims | Beneficiaries | Total Paid |
|---|---|---|---|---|
| 99284 | Emergency department visit for the evaluation and management, high severity | 19,043 | 17,988 | $3.75M |
| 99285 | Emergency department visit for the evaluation and management, high severity with immediate threat to life | 9,462 | 8,867 | $2.80M |
| 99283 | Emergency department visit for the evaluation and management, moderate severity | 20,972 | 20,022 | $2.66M |
| 96374 | Therapeutic, prophylactic, or diagnostic injection; intravenous push, single or initial substance | 12,888 | 11,837 | $1.30M |
| U0004 | 2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high throughput technologies as described by cms-2020-01-r | 11,267 | 10,829 | $674K |
| 74177 | Computed tomography, abdomen and pelvis; with contrast material | 4,271 | 4,150 | $646K |
| 97110 | Therapeutic procedure, each 15 minutes; therapeutic exercises to develop strength and endurance, flexibility and range of motion | 21,558 | 6,702 | $610K |
| 99282 | Emergency department visit for the evaluation and management, low to moderate severity | 8,132 | 7,890 | $586K |
| 87637 | Infectious agent detection by nucleic acid; SARS-CoV-2, influenza, and RSV | 4,652 | 4,575 | $458K |
| 87633 | Infectious agent detection by nucleic acid, respiratory virus, 12-25 targets | 1,799 | 1,766 | $291K |
| 71046 | Radiologic examination, chest; 2 views | 7,540 | 7,297 | $285K |
| 96361 | Intravenous infusion, hydration; each additional hour | 8,806 | 7,937 | $245K |
| 96375 | Therapeutic injection; each additional sequential IV push | 9,820 | 8,592 | $209K |
| 59025 | Fetal non-stress test | 2,026 | 976 | $197K |
| G0378 | Hospital observation service, per hour | 1,377 | 959 | $193K |
| 96360 | Intravenous infusion, hydration; initial, 31 minutes to 1 hour | 1,896 | 1,858 | $190K |
| 96365 | Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour | 1,834 | 1,708 | $172K |
| U0005 | Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2 | 8,169 | 7,888 | $142K |
| 36415 | Collection of venous blood by venipuncture | 44,290 | 38,330 | $133K |
| 99281 | Emergency department visit for the evaluation and management, self-limited or minor | 3,100 | 3,054 | $129K |
| 76705 | Ultrasound, abdominal, real time with image documentation; limited | 2,058 | 2,027 | $126K |
| G0463 | Hospital outpatient clinic visit for assessment and management of a patient | 1,756 | 1,396 | $115K |
| 87491 | Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe | 6,965 | 6,897 | $114K |
| 93975 | 913 | 898 | $111K | |
| 87591 | Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe | 6,652 | 6,591 | $108K |
| 70450 | Computed tomography, head or brain; without contrast material | 2,284 | 2,226 | $107K |
| 80061 | Lipid panel | 9,076 | 9,025 | $106K |
| 76830 | Ultrasound, transvaginal | 1,802 | 1,777 | $106K |
| 86900 | 3,099 | 2,997 | $102K | |
| U0002 | 2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc | 3,298 | 3,181 | $100K |
| 71045 | Radiologic examination, chest; single view | 2,369 | 2,289 | $97K |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder | 2,340 | 960 | $94K |
| 71260 | Computed tomography, thorax, diagnostic; with contrast material | 591 | 588 | $93K |
| 77067 | Screening mammography, bilateral, including computer-aided detection | 1,948 | 1,946 | $89K |
| 76816 | Ultrasound, pregnant uterus, real time with image documentation, follow-up | 1,682 | 1,639 | $89K |
| C9803 | Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source | 9,979 | 9,511 | $85K |
| 74176 | Computed tomography, abdomen and pelvis; without contrast material | 786 | 763 | $84K |
| 97140 | Manual therapy techniques, each 15 minutes (e.g., mobilization/manipulation, manual lymphatic drainage) | 5,581 | 2,085 | $79K |
| 76856 | Ultrasound, pelvic (nonobstetric), real time with image documentation; complete | 1,453 | 1,438 | $76K |
| 80050 | General health panel | 2,704 | 2,669 | $75K |
| 82947 | 3,700 | 2,653 | $74K | |
| 78452 | Myocardial perfusion imaging, tomographic (SPECT); multiple studies at rest and/or stress | 127 | 124 | $69K |
| G0472 | Hepatitis c antibody screening, for individual at high risk and other covered indication(s) | 2,589 | 2,581 | $66K |
| 80307 | Drug test(s), presumptive, any number of drug classes; immunoassay | 4,228 | 4,028 | $66K |
| 97162 | 1,422 | 1,413 | $65K | |
| 80053 | Comprehensive metabolic panel | 32,404 | 29,389 | $64K |
| 72148 | Magnetic resonance imaging, lumbar spine; without contrast material | 569 | 568 | $59K |
| 71275 | Computed tomographic angiography, chest, with contrast material | 749 | 742 | $57K |
| 84443 | Thyroid stimulating hormone (TSH) | 8,353 | 8,189 | $53K |
| 76805 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation | 854 | 854 | $52K |
| 87661 | Infectious agent detection by nucleic acid; Trichomonas vaginalis, amplified probe | 2,791 | 2,781 | $49K |
| 96372 | Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular | 4,940 | 4,282 | $45K |
| 97530 | Therapeutic activities, direct patient contact, each 15 minutes | 1,351 | 654 | $43K |
| 85025 | Blood count; complete (CBC), automated, and automated differential WBC count | 31,450 | 28,275 | $40K |
| 82306 | Vitamin D; 25 hydroxy, includes fraction(s), if performed | 3,247 | 3,224 | $37K |
| G0482 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed | 600 | 576 | $37K |
| 97112 | Therapeutic procedure, each 15 minutes; neuromuscular reeducation of movement, balance, coordination | 1,814 | 728 | $34K |
| 72100 | 913 | 904 | $28K | |
| 76801 | 470 | 460 | $28K | |
| 83036 | Hemoglobin; glycosylated (A1C) | 6,630 | 6,598 | $27K |
| G0432 | Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv-1 and/or hiv-2, screening | 2,541 | 2,533 | $27K |
| 87502 | Infectious agent detection by nucleic acid, influenza virus, for multiple types or subtypes, includes all targets | 1,429 | 1,418 | $26K |
| 72141 | 193 | 193 | $26K | |
| 87624 | Infectious agent detection by nucleic acid; human papillomavirus (HPV), high-risk types | 1,350 | 1,350 | $24K |
| 76642 | 534 | 533 | $23K | |
| 86780 | 3,048 | 3,039 | $23K | |
| G0145 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision | 1,497 | 1,496 | $23K |
| 93306 | Echocardiography, transthoracic, real-time with image documentation, with and without Doppler, complete | 97 | 97 | $21K |
| 87086 | Culture, bacterial; quantitative colony count, urine | 9,696 | 9,225 | $21K |
| 94060 | 142 | 142 | $19K | |
| 97161 | 401 | 395 | $19K | |
| 87653 | 1,291 | 1,286 | $17K | |
| 70553 | Magnetic resonance imaging, brain; without contrast material, followed by contrast material and further sequences | 84 | 84 | $16K |
| 82728 | 2,366 | 2,328 | $15K | |
| 73721 | Magnetic resonance imaging, any joint of lower extremity; without contrast material | 115 | 111 | $15K |
| 93005 | Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report | 9,138 | 8,316 | $15K |
| 76817 | Ultrasound, pregnant uterus, real time with image documentation, transvaginal | 701 | 623 | $15K |
| 77063 | Screening digital breast tomosynthesis, bilateral | 1,260 | 1,259 | $15K |
| 84702 | 2,971 | 2,150 | $14K | |
| G0480 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed | 1,145 | 1,023 | $14K |
| 73562 | 1,182 | 1,126 | $14K | |
| 73630 | 1,758 | 1,701 | $14K | |
| 88305 | Level IV - Surgical pathology, gross and microscopic examination | 1,399 | 1,351 | $14K |
| 93971 | 247 | 245 | $13K | |
| 87808 | 2,678 | 2,653 | $13K | |
| 74018 | 502 | 494 | $13K | |
| 85027 | 7,460 | 6,955 | $13K | |
| 84439 | 2,983 | 2,931 | $12K | |
| 71250 | 205 | 205 | $12K | |
| 82607 | 1,857 | 1,851 | $11K | |
| 73030 | 963 | 922 | $11K | |
| 73610 | 1,270 | 1,238 | $11K | |
| 80048 | Basic metabolic panel (calcium, ionized) | 5,163 | 4,534 | $11K |
| 87205 | 6,586 | 6,388 | $10K | |
| 99291 | Critical care, evaluation and management of the critically ill patient, first 30-74 minutes | 25 | 24 | $10K |
| 87077 | 3,528 | 3,413 | $10K | |
| G0475 | Hiv antigen/antibody, combination assay, screening | 745 | 744 | $10K |
| 73130 | 1,128 | 1,099 | $9K | |
| 0002A | 287 | 287 | $9K | |
| 97014 | 1,357 | 503 | $9K | |
| 87506 | 76 | 76 | $8K | |
| 76536 | 164 | 163 | $8K | |
| 87081 | 4,491 | 4,443 | $8K | |
| 83550 | 1,946 | 1,922 | $8K | |
| 97535 | Self-care/home management training, each 15 minutes | 551 | 470 | $8K |
| 87070 | 2,329 | 2,251 | $8K | |
| 82746 | 1,026 | 1,025 | $7K | |
| 81001 | 21,910 | 19,817 | $7K | |
| 0001A | 306 | 306 | $7K | |
| 83655 | 986 | 965 | $7K | |
| 87186 | 2,354 | 2,286 | $7K | |
| C9399 | Unclassified drugs or biologicals | 137 | 137 | $6K |
| 83735 | 6,775 | 6,073 | $6K | |
| 93017 | 291 | 288 | $6K | |
| 83540 | 2,043 | 2,018 | $6K | |
| 73110 | 733 | 708 | $6K | |
| 76770 | 102 | 102 | $6K | |
| 87563 | 318 | 316 | $6K | |
| 87340 | 2,582 | 2,575 | $5K | |
| 70551 | Magnetic resonance imaging, brain; without contrast material | 45 | 45 | $5K |
| 72125 | Computed tomography, cervical spine; without contrast material | 115 | 113 | $5K |
| 96376 | 2,638 | 1,989 | $5K | |
| G0279 | Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) | 466 | 457 | $5K |
| G0103 | Prostate cancer screening; prostate specific antigen test (psa) | 534 | 530 | $5K |
| 83880 | 1,940 | 1,864 | $5K | |
| 97116 | 347 | 169 | $5K | |
| 82570 | 2,694 | 2,535 | $5K | |
| 85610 | 4,178 | 3,177 | $5K | |
| 90471 | Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine | 432 | 424 | $4K |
| 84403 | 293 | 291 | $4K | |
| 80074 | 190 | 190 | $4K | |
| 82950 | 1,396 | 1,391 | $4K | |
| 83970 | 202 | 201 | $4K | |
| 82043 | 1,234 | 1,230 | $3K | |
| 88175 | Cytopathology, cervical or vaginal, any reporting system; collected in preservative fluid, automated thin layer | 223 | 221 | $3K |
| 94640 | Pressurized or nonpressurized inhalation treatment for acute airway obstruction | 2,275 | 2,006 | $3K |
| 96366 | Intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour | 198 | 166 | $3K |
| 86038 | 544 | 540 | $3K | |
| 86140 | 2,036 | 1,939 | $3K | |
| 76819 | Fetal biophysical profile; without non-stress testing | 42 | 26 | $3K |
| 87147 | 1,241 | 1,226 | $3K | |
| 97163 | 53 | 53 | $3K | |
| 81025 | 8,852 | 8,434 | $2K | |
| 77066 | Tomosynthesis, mammo | 36 | 36 | $2K |
| 77065 | Tomosynthesis, mammo | 55 | 49 | $2K |
| J7050 | Infusion, normal saline solution, 250 cc | 8,502 | 7,436 | $2K |
| 85652 | 2,219 | 2,157 | $2K | |
| 87635 | Infectious agent detection by nucleic acid; SARS-CoV-2 (COVID-19), amplified probe | 65 | 65 | $2K |
| 80076 | 468 | 444 | $2K | |
| 73502 | 142 | 139 | $2K | |
| 85007 | 1,725 | 1,589 | $2K | |
| 73140 | 162 | 159 | $1K | |
| 84100 | 1,260 | 1,088 | $1K | |
| 84156 | 1,426 | 1,274 | $1K | |
| 83690 | 7,401 | 6,934 | $1K | |
| 82565 | 1,792 | 1,734 | $932.71 | |
| 71271 | 24 | 24 | $859.50 | |
| 85730 | 1,661 | 1,561 | $768.30 | |
| 84146 | 80 | 78 | $767.69 | |
| 86376 | 109 | 108 | $758.96 | |
| 87184 | 187 | 187 | $733.33 | |
| 84550 | 820 | 797 | $667.92 | |
| 97166 | 13 | 13 | $584.21 | |
| 87807 | 255 | 253 | $564.86 | |
| 86431 | 213 | 213 | $549.95 | |
| 82248 | 233 | 198 | $544.19 | |
| 84145 | 361 | 350 | $540.89 | |
| 73080 | 84 | 84 | $497.64 | |
| 86480 | 15 | 15 | $440.70 | |
| 87328 | 66 | 66 | $410.91 | |
| 86762 | 1,288 | 1,285 | $382.68 | |
| 82670 | 26 | 26 | $382.00 | |
| 87804 | Infectious agent antigen detection by immunoassay; Influenza, each type | 60 | 60 | $371.15 |
| 86308 | 229 | 227 | $348.47 | |
| 80069 | 87 | 81 | $332.64 | |
| 87329 | 66 | 66 | $323.01 | |
| 83605 | 4,384 | 3,677 | $303.81 | |
| 84425 | 36 | 36 | $299.76 | |
| 85379 | 1,208 | 1,185 | $299.27 | |
| 74019 | 38 | 37 | $267.62 | |
| 76815 | Ultrasound, pregnant uterus, real time with image documentation, limited | 13 | 13 | $260.20 |
| 87420 | 81 | 79 | $248.51 | |
| 84112 | 27 | 25 | $230.55 | |
| 83001 | 26 | 26 | $223.26 | |
| 88304 | 90 | 90 | $192.92 | |
| 83516 | 27 | 24 | $185.25 | |
| 86850 | 2,875 | 2,792 | $176.37 | |
| 86665 | 26 | 25 | $175.47 | |
| 97022 | 34 | 14 | $171.27 | |
| 86738 | 59 | 59 | $170.39 | |
| 84402 | 12 | 12 | $163.90 | |
| 86200 | 25 | 25 | $159.18 | |
| 87880 | Infectious agent antigen detection by immunoassay; Streptococcus, group A | 2,486 | 2,464 | $153.38 |
| 82784 | 24 | 24 | $149.57 | |
| 93246 | 12 | 12 | $146.30 | |
| 82550 | 92 | 87 | $141.58 | |
| G0328 | Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous | 13 | 13 | $137.28 |
| 83993 | 12 | 12 | $128.88 | |
| 84484 | 6,187 | 4,086 | $125.19 | |
| 82247 | 48 | 37 | $119.82 | |
| 87040 | 444 | 300 | $110.20 | |
| 73090 | 12 | 12 | $104.18 | |
| 87338 | 14 | 14 | $100.92 | |
| 84481 | 12 | 12 | $94.50 | |
| 82077 | 934 | 871 | $89.96 | |
| 83615 | 30 | 26 | $74.13 | |
| 73590 | 14 | 13 | $48.33 | |
| 87503 | 54 | 53 | $44.61 | |
| 82805 | 81 | 69 | $43.95 | |
| 87088 | 28 | 28 | $41.30 | |
| 80143 | 209 | 201 | $11.09 | |
| 80179 | 166 | 161 | $11.09 | |
| J2250 | Injection, midazolam hydrochloride, per 1 mg | 2,739 | 2,585 | $0.08 |
| G1004 | Clinical decision support mechanism national decision support company, as defined by the medicare appropriate use criteria program | 9,576 | 8,897 | $0.02 |
| J2765 | Injection, metoclopramide hcl, up to 10 mg | 1,296 | 1,218 | $0.00 |
| J1885 | Injection, ketorolac tromethamine, per 15 mg | 9,191 | 8,520 | $0.00 |
| J0690 | Injection, cefazolin sodium, 500 mg | 1,122 | 1,071 | $0.00 |
| J1100 | Injection, dexamethasone sodium phosphate, 1 mg | 2,866 | 2,680 | $0.00 |
| J2360 | Injection, orphenadrine citrate, up to 60 mg | 1,062 | 1,031 | $0.00 |
| A9270 | Non-covered item or service | 841 | 569 | $0.00 |
| J0696 | Injection, ceftriaxone sodium, per 250 mg | 1,391 | 1,274 | $0.00 |
| J2704 | Injection, propofol, 10 mg | 2,386 | 2,263 | $0.00 |
| J1170 | Injection, hydromorphone, up to 4 mg | 2,448 | 1,971 | $0.00 |
| A9579 | Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml | 282 | 275 | $0.00 |
| A9573 | Injection, gadopiclenol, 1 ml | 235 | 232 | $0.00 |
| J3010 | Injection, fentanyl citrate, 0.1 mg | 3,279 | 2,771 | $0.00 |
| 12001 | 126 | 125 | $0.00 | |
| 71101 | 13 | 12 | $0.00 | |
| 86901 | 202 | 194 | $0.00 | |
| J2060 | Injection, lorazepam, 2 mg | 352 | 297 | $0.00 |
| J2470 | Injection, pantoprazole sodium, 40 mg | 31 | 26 | $0.00 |
| J8540 | Dexamethasone, oral, 0.25 mg | 148 | 143 | $0.00 |
| J2785 | Injection, regadenoson, 0.1 mg | 54 | 53 | $0.00 |
| J2003 | Injection, lidocaine hydrochloride, 1 mg | 103 | 90 | $0.00 |
| J1630 | Injection, haloperidol, up to 5 mg | 267 | 237 | $0.00 |
| J1790 | Injection, droperidol, up to 5 mg | 88 | 82 | $0.00 |
| G0283 | Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care | 274 | 101 | $0.00 |
| J2543 | Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) | 17 | 12 | $0.00 |
| J0131 | Injection, acetaminophen, not otherwise specified,10 mg | 122 | 119 | $0.00 |
| J1200 | Injection, diphenhydramine hcl, up to 50 mg | 3,268 | 2,977 | $0.00 |
| J2405 | Injection, ondansetron hydrochloride, per 1 mg | 7,626 | 6,909 | $0.00 |
| J7030 | Infusion, normal saline solution , 1000 cc | 12,517 | 11,164 | $0.00 |
| Q9967 | Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml | 7,089 | 6,790 | $0.00 |
| J0780 | Injection, prochlorperazine, up to 10 mg | 1,610 | 1,472 | $0.00 |
| J2270 | Injection, morphine sulfate, up to 10 mg | 1,758 | 1,546 | $0.00 |
| J7120 | Ringers lactate infusion, up to 1000 cc | 3,254 | 2,909 | $0.00 |
| J2930 | Injection, methylprednisolone sodium succinate, up to 125 mg | 582 | 544 | $0.00 |
| 91300 | 585 | 561 | $0.00 | |
| 94729 | 100 | 100 | $0.00 | |
| C9113 | Injection, pantoprazole sodium, per vial | 630 | 564 | $0.00 |
| 90715 | 252 | 252 | $0.00 | |
| A9577 | Injection, gadobenate dimeglumine (multihance), per ml | 777 | 767 | $0.00 |
| A9576 | Injection, gadoteridol, (prohance multipack), per ml | 60 | 60 | $0.00 |
| A9502 | Technetium tc-99m tetrofosmin, diagnostic, per study dose | 127 | 123 | $0.00 |
| J1171 | Injection, hydromorphone, 0.1 mg | 44 | 33 | $0.00 |
| J7040 | Infusion, normal saline solution, sterile (500 ml = 1 unit) | 99 | 97 | $0.00 |
| J0171 | Injection, adrenalin, epinephrine, 0.1 mg | 47 | 43 | $0.00 |
| J2919 | Injection, methylprednisolone sodium succinate, 5 mg | 19 | 16 | $0.00 |
| J2550 | Injection, promethazine hcl, up to 50 mg | 31 | 27 | $0.00 |
| J2710 | Injection, neostigmine methylsulfate, up to 0.5 mg | 14 | 14 | $0.00 |
| 29125 | 13 | 13 | $0.00 | |
| J3475 | Injection, magnesium sulfate, per 500 mg | 15 | 13 | $0.00 |