|
Treat ulnar fracture
|
$902.34 |
$902.34 |
$902.34 |
$1,662.00
|
|
Treat ulnar fracture
|
$1,494.99 |
$1,494.99 |
$1,494.99 |
$5,926.25
|
|
Treat vaginal bleeding
|
$286.74 |
$286.74 |
$286.74 |
$392.00
|
|
Treat wrist bone fracture
|
$922.32 |
$922.32 |
$922.32 |
$1,588.95
|
|
Treat wrist dislocation
|
$898.56 |
$898.56 |
$898.56 |
$656.25
|
|
Triamcinolone acetonide 40 mg/ml suspension for injection
|
$28.08 |
$28.08 |
$28.08 |
$43.09
|
|
Triamcinolone a inj prs-free
|
$2.15 |
$2.15 |
$2.15 |
$239.62
|
|
Trim nail(s)
|
$30.78 |
$30.78 |
$30.78 |
$78.50
|
|
Trim nondyst nails
|
$33.21 |
$33.21 |
$33.21 |
$115.70
|
|
Trnsfr/rearrngmnt adjcnt tiss e/n/e/l dfct 10sqcm/<
|
$1,402.38 |
$1,402.38 |
$1,402.38 |
$2,986.34
|
|
Trnsfr/rearrngmnt adjcnt tiss eye/nose/ear/lip 10.1-30sqcm
|
$1,722.06 |
$1,722.06 |
$1,722.06 |
$3,078.00
|
|
Trnsfr/rearrngmnt adjcnt tiss trnk 10.1-30sqcm
|
$1,367.82 |
$1,367.82 |
$1,367.82 |
$2,371.50
|
|
Trnsfr/rearrngmnt adjcnt tiss trnk 10sqcm/<
|
$1,062.72 |
$1,062.72 |
$1,062.72 |
$2,406.77
|
|
Tubal Ligation (Laparoscopic)
|
$778.41 |
$778.41 |
$778.41 |
$4,323.20
|
|
Tvh >250 gms 58290
|
$2,479.14 |
$2,479.14 |
$2,479.14 |
$6,872.92
|
|
Tx closed hip disl traumatic without anes
|
$486.00 |
$486.00 |
$486.00 |
$581.07
|
|
Tx closed tib fx proximal w/w/o manip w/skel trac
|
$1,237.14 |
$1,237.14 |
$1,237.14 |
$3,986.00
|
|
Tx closed tib shaft fx without manip
|
$762.48 |
$762.48 |
$762.48 |
$535.60
|
|
Tx open art fx mcp/iphlngl jnt incl int fixtn ea
|
$1,576.80 |
$1,576.80 |
$1,576.80 |
$4,499.12
|
|
Tx open dstl phlngl fx f/t internal fixation ea
|
$1,081.62 |
$1,081.62 |
$1,081.62 |
$4,499.12
|
|
Tx open nsl sptl fx
|
$1,339.74 |
$1,339.74 |
$1,339.74 |
$4,308.40
|
|
Tx phalangeal shaft fx open prox/middle ea
|
$1,272.24 |
$1,272.24 |
$1,272.24 |
$4,499.12
|
|
Tx tarsal bone fx without manip 28450
|
$419.04 |
$419.04 |
$419.04 |
$419.04
|
|
Tympanic membrane repair
|
$1,018.98 |
$1,018.98 |
$1,018.98 |
$2,638.87
|
|
Tympanometry & reflex thresh
|
$41.58 |
$41.58 |
$41.58 |
$170.99
|
|
Tympanostomy/ven tube/loc/top anes 69433
|
$778.68 |
$778.68 |
$778.68 |
$911.43
|
|
Ultrasound abdomen aorta screening study aaa
|
$97.20 |
$97.20 |
$97.20 |
$394.20
|
|
Ultrasound breast complete
|
$209.52 |
$209.52 |
$209.52 |
$532.00
|
|
Ultrasound breast unilateral limited (both sides)
|
$194.67 |
$194.67 |
$194.67 |
$452.00
|
|
Ultrasound chest
|
$102.06 |
$102.06 |
$102.06 |
$460.85
|
|
Ultrasound encephalogram
|
$112.32 |
$112.32 |
$112.32 |
$494.92
|
|
Ultrasound fetal biophysical profile without non-stress testing
|
$136.08 |
$136.08 |
$136.08 |
$477.10
|
|
Ultrasound guidance for vascular access
|
$51.30 |
$51.30 |
$51.30 |
$388.08
|
|
Ultrasound guided needle placement supervision & interpretation
|
$112.32 |
$112.32 |
$112.32 |
$720.15
|
|
Ultrasound joint complete left
|
$160.38 |
$160.38 |
$160.38 |
$556.14
|
|
Ultrasound joint/nonvascular extremity limited left
|
$122.58 |
$122.58 |
$122.58 |
$424.00
|
|
Ultrasound ob >=14wks ea addl gest
|
$329.94 |
$329.94 |
$329.94 |
$393.86
|
|
Ultrasound pregnant uterus < 14 weeks each additional gestation
|
$227.88 |
$227.88 |
$227.88 |
$331.50
|
|
Ultrasound pregnant uterus detailed fetal exam single/1st gestation
|
$338.04 |
$338.04 |
$338.04 |
$707.20
|
|
Ultrasound pregnant uterus follow up per fetus
|
$409.32 |
$409.32 |
$409.32 |
$428.25
|
|
Ultrasound pregnant uterus limited >= 1 fetuses
|
$303.48 |
$303.48 |
$303.48 |
$452.10
|
|
Ultrasound pregnant uterus transvaginal
|
$346.14 |
$346.14 |
$346.14 |
$490.00
|
|
Ultrasound prostate/transrectal
|
$119.34 |
$119.34 |
$119.34 |
$549.95
|
|
Ultrasound retroperitoneal limited
|
$102.06 |
$102.06 |
$102.06 |
$479.60
|
|
Ultrasound scrotum and contents
|
$113.40 |
$113.40 |
$113.40 |
$612.55
|
|
Ultrasound spinal canal and contents
|
$219.24 |
$219.24 |
$219.24 |
$459.00
|
|
Ultrasound transabd ea addl gest
|
$316.44 |
$316.44 |
$316.44 |
$424.80
|
|
Ultrasound transvaginal non obstetric
|
$447.12 |
$447.12 |
$447.12 |
$558.35
|
|
Umbilical artery cath newborn 36660
|
$171.72 |
$171.72 |
$171.72 |
$205.80
|
|
Unlisted laparoscopic liver biopy 47379
|
$768.42 |
$768.42 |
$768.42 |
$5,323.76
|
|
Unlisted px foot/toes
|
$466.56 |
$466.56 |
$466.56 |
$1,225.50
|
|
Unlisted px leg/ankle
|
$813.24 |
$813.24 |
$813.24 |
$811.00
|
|
Unlisted ultrasound procedure
|
$75.06 |
$75.06 |
$75.06 |
$326.40
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$405.00 |
$405.00 |
$405.00 |
$2,984.45
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$315.90 |
$315.90 |
$315.90 |
$2,369.00
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$262.44 |
$262.44 |
$262.44 |
$2,034.41
|
|
Upper Endoscopy (EGD, diagnostic)
|
$301.32 |
$301.32 |
$301.32 |
$1,794.22
|
|
Upper Endoscopy (EGD, with biopsy)
|
$355.05 |
$355.05 |
$355.05 |
$1,768.00
|
|
Uppr gi scope w/submuc inj
|
$357.48 |
$357.48 |
$357.48 |
$1,774.00
|
|
Urethrcystgrphy rtrgrde s&i
|
$58.86 |
$58.86 |
$58.86 |
$584.00
|
|
Urethrocystography void s&i
|
$57.78 |
$57.78 |
$57.78 |
$648.05
|
|
Urography, antegrade
|
$89.10 |
$89.10 |
$89.10 |
$622.35
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$14.58 |
$14.58 |
$14.58 |
$5,084.76
|
|
Vaccine dtap < 7 years im
|
$12.96 |
$12.96 |
$12.96 |
$71.17
|
|
Vaccine dtap-hep b-ipv im
|
$49.68 |
$49.68 |
$49.68 |
$164.63
|
|
Vaccine dtap-ipv 4-6 years im
|
$75.60 |
$75.60 |
$75.60 |
$105.95
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$15.66 |
$15.66 |
$15.66 |
$71.62
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$26.46 |
$26.46 |
$26.46 |
$42.90
|
|
Vaccine hepatitis a (hepa) adult im
|
$58.86 |
$58.86 |
$58.86 |
$168.95
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$59.94 |
$59.94 |
$59.94 |
$218.40
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$26.46 |
$26.46 |
$26.46 |
$80.75
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$57.24 |
$57.24 |
$57.24 |
$154.78
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$143.64 |
$143.64 |
$143.64 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$25.92 |
$25.92 |
$25.92 |
$74.42
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$99.90 |
$99.90 |
$99.90 |
$576.48
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$67.50 |
$67.50 |
$67.50 |
$143.20
|
|
Vaccine influenza inactivated adjuvant im
|
$67.50 |
$67.50 |
$67.50 |
$106.41
|
|
Vaccine influenza nos 0.5ml dose im
|
$17.82 |
$17.82 |
$17.82 |
$24.20
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$18.36 |
$18.36 |
$18.36 |
$47.88
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$18.36 |
$18.36 |
$18.36 |
$33.60
|
|
Vaccine influenza quadrivalent live (laiv4) intranasal
|
$22.68 |
$22.68 |
$22.68 |
$37.05
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$59.40 |
$59.40 |
$59.40 |
$72.00
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$29.70 |
$29.70 |
$29.70 |
$76.50
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$102.87 |
$102.87 |
$102.87 |
$395.24
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$70.20 |
$70.20 |
$70.20 |
$337.91
|
|
Vaccine mmr live subcutaneous
|
$50.76 |
$50.76 |
$50.76 |
$213.00
|
|
Vaccine mmrv live subcutaneous
|
$93.96 |
$93.96 |
$93.96 |
$424.32
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$108.00 |
$108.00 |
$108.00 |
$252.87
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$208.98 |
$208.98 |
$208.98 |
$397.11
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$253.26 |
$253.26 |
$253.26 |
$563.36
|
|
Vaccine polio (ipv) subcutaneous/im
|
$29.16 |
$29.16 |
$29.16 |
$90.70
|
|
Vaccine rabies im
|
$274.32 |
$274.32 |
$274.32 |
$858.95
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$329.94 |
$329.94 |
$329.94 |
$1,104.47
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$329.94 |
$329.94 |
$329.94 |
$997.44
|
|
Vaccine rotavirus attenuated (rv1) live 2 dose oral
|
$74.52 |
$74.52 |
$74.52 |
$200.70
|
|
Vaccine rotavirus pentavalent (rv5) live 3 dose oral
|
$50.22 |
$50.22 |
$50.22 |
$125.58
|
|
Vaccine tdap >=7 years im
|
$32.40 |
$32.40 |
$32.40 |
$132.88
|
|
Vaccine td preservative free >= 7 years im
|
$29.70 |
$29.70 |
$29.70 |
$112.10
|
|
Vaccine typhoid vicps im
|
$73.44 |
$73.44 |
$73.44 |
$264.78
|
|
Vaccine varicella live subcutaneous
|
$98.28 |
$98.28 |
$98.28 |
$386.44
|
