|
Special teletx port plan
|
$5,364.57 |
$5,364.57 |
$5,364.57 |
$1,050.06
|
|
Spirometry bronchodilation responsiveness pre/post bronchodilator administration
|
$2,781.55 |
$2,781.55 |
$2,781.55 |
$536.34
|
|
St evaluate speech sound production comprehensive/expressive
|
$920.00 |
$920.00 |
$920.00 |
$376.84
|
|
St evaluation motion fluoroscopic swallow function cine/video
|
$1,419.84 |
$1,419.84 |
$1,419.84 |
$373.50
|
|
St evaluation swallow function
|
$1,419.84 |
$1,419.84 |
$1,419.84 |
$311.36
|
|
Strep b dna amp probe
|
$30.83 |
$30.83 |
$30.83 |
$122.43
|
|
St treatment speech individual
|
$484.24 |
$484.24 |
$484.24 |
$253.80
|
|
St treatment swallow dysfunction/oral
|
$544.61 |
$544.61 |
$544.61 |
$245.50
|
|
Succinylcholine chloride 20 mg/ml injection solution (wrapper)
|
$84.90 |
$84.90 |
$84.90 |
$50.22
|
|
Sumatriptan 6 mg/0.5 ml subcutaneous solution
|
$259.11 |
$259.11 |
$259.11 |
$123.58
|
|
Surgical pathology level 1 gross examination only
|
$172.00 |
$172.00 |
$172.00 |
$80.60
|
|
Surgical pathology level 2 gross & microscopic examination
|
$172.00 |
$172.00 |
$172.00 |
$146.30
|
|
Surgical pathology level 3 gross & microscopic examination
|
$225.00 |
$225.00 |
$225.00 |
$184.50
|
|
Surgical pathology level 4 gross & microscopic examination
|
$225.00 |
$225.00 |
$225.00 |
$250.20
|
|
Surgical pathology level 5 gross & microscopic examination
|
$390.00 |
$390.00 |
$390.00 |
$489.00
|
|
Surgical pathology level 6 gross & microscopic examination
|
$390.00 |
$390.00 |
$390.00 |
$730.20
|
|
Susceptibility enzyme detection per enzyme
|
$21.38 |
$21.38 |
$21.38 |
$35.10
|
|
Suscept studies macrobroth dilution ea
|
$29.88 |
$29.88 |
$29.88 |
$59.28
|
|
Svc venogram s&i
|
$4,613.99 |
$4,613.99 |
$4,613.99 |
$1,934.62
|
|
T3 (triiodothyronine) free
|
$1,164.60 |
$1,164.60 |
$1,164.60 |
$99.20
|
|
T3 (triiodothyronine) total
|
$882.27 |
$882.27 |
$882.27 |
$93.52
|
|
T4 (thyroxine) free
|
$460.64 |
$460.64 |
$460.64 |
$85.20
|
|
T4 (thyroxine) total
|
$269.29 |
$269.29 |
$269.29 |
$67.80
|
|
Tacrolimus 1 mg capsule, immediate-release
|
$20.40 |
$20.40 |
$20.40 |
$10.03
|
|
Tacrolimus therapeutic drug level
|
$1,374.53 |
$1,374.53 |
$1,374.53 |
$120.60
|
|
Tamoxifen 10 mg tabs 60 each bottle
|
$34.99 |
$34.99 |
$34.99 |
$14.62
|
|
Tb test cell mediated immunity antigen response gamma interferon
|
$607.36 |
$607.36 |
$607.36 |
$175.00
|
|
Tc-99m exametazime diag
|
$7,373.08 |
$7,373.08 |
$7,373.08 |
$2,033.20
|
|
Tc-99m maa
|
$318.15 |
$318.15 |
$318.15 |
$283.41
|
|
Tc-99m mebrofenin
|
$635.35 |
$635.35 |
$635.35 |
$160.58
|
|
Tc-99m medronate
|
$213.20 |
$213.20 |
$213.20 |
$109.50
|
|
Tc-99m mertiatide
|
$1,778.25 |
$1,778.25 |
$1,778.25 |
$756.00
|
|
Tc-99m pentetate dtpa
|
$417.36 |
$417.36 |
$417.36 |
$222.60
|
|
Tc-99m pentetate dtpa aerosol
|
$635.35 |
$635.35 |
$635.35 |
$181.37
|
|
Tc-99m pertechnetate per mci
|
$213.20 |
$213.20 |
$213.20 |
$27.20
|
|
Tc-99m sestamibi p study dose
|
$5,127.83 |
$5,127.83 |
$5,127.83 |
$293.73
|
|
Tc-99m sulfur colloid
|
$182.19 |
$182.19 |
$182.19 |
$239.40
|
|
Tc-99m tetrofosmin p study dose
|
$527.08 |
$527.08 |
$527.08 |
$188.50
|
|
T cells absolute cd4/cd8 including ratio
|
$139.55 |
$139.55 |
$139.55 |
$175.00
|
|
T cells total count
|
$908.02 |
$908.02 |
$908.02 |
$123.00
|
|
Telethx isodose plan cplx
|
$12,183.11 |
$12,183.11 |
$12,183.11 |
$1,488.40
|
|
Terbutaline 1 mg/ml subcutaneous solution
|
$68.01 |
$68.01 |
$68.01 |
$39.18
|
|
Test pathogen(s) for platelets reference
|
$762.00 |
$762.00 |
$762.00 |
$66.00
|
|
Test stress cardiovascular tracing only
|
$4,542.94 |
$4,542.94 |
$4,542.94 |
$953.40
|
|
Tetanus immune globulin inj
|
$235.15 |
$235.15 |
$235.15 |
$1,228.80
|
|
Theophylline therapeutic drug level
|
$203.00 |
$203.00 |
$203.00 |
$108.00
|
|
Therapy nutrition individual initial f2f w/patient each 15 minutes
|
$198.87 |
$198.87 |
$198.87 |
$57.50
|
|
Thiamine hcl (vitamin b1) 100 mg/ml injection solution
|
$35.33 |
$35.33 |
$35.33 |
$25.54
|
|
Thrombin time
|
$216.02 |
$216.02 |
$216.02 |
$53.60
|
|
Thyroglobulin antibody
|
$504.00 |
$504.00 |
$504.00 |
$81.90
|
|
Thyroxine binding globulin (tbg)
|
$342.38 |
$342.38 |
$342.38 |
$64.92
|
|
Tilt table study
|
$1,323.22 |
$1,323.22 |
$1,323.22 |
$1,495.00
|
|
Tomosynthesis breast diagnostic left
|
$83.47 |
$83.47 |
$83.47 |
$74.10
|
|
Tomosynthesis breast screen bilateral
|
$83.47 |
$83.47 |
$83.47 |
$70.89
|
|
Toxoplasma antibody igg
|
$448.84 |
$448.84 |
$448.84 |
$89.57
|
|
Toxoplasma antibody igm
|
$549.78 |
$549.78 |
$549.78 |
$87.00
|
|
Training self management diabetes individual outpatient department per 30 minutes
|
$382.29 |
$382.29 |
$382.29 |
$101.58
|
|
Tranexamic acid 1,000 mg/10 ml (100 mg/ml) intravenous solution
|
$211.81 |
$211.81 |
$211.81 |
$55.69
|
|
Transferrin
|
$411.70 |
$411.70 |
$411.70 |
$81.60
|
|
Treatment inhalation continuous aerosol medication acute airway obstruction 1st hour
|
$826.98 |
$826.98 |
$826.98 |
$224.90
|
|
Treatment inhalation continuous aerosol medication acute airway obstruction each additional hour
|
$647.34 |
$647.34 |
$647.34 |
$141.00
|
|
Treatment radiation delivery level 2
|
$4,523.29 |
$4,523.29 |
$4,523.29 |
$737.25
|
|
Treponema pallidum antibody
|
$207.00 |
$207.00 |
$207.00 |
$70.85
|
|
Triamcinolone acetonide 40 mg/ml suspension for injection
|
$62.68 |
$62.68 |
$62.68 |
$43.80
|
|
Trichomonas assay w/optic
|
$68.80 |
$68.80 |
$68.80 |
$58.25
|
|
Ultrasound encephalogram
|
$2,278.63 |
$2,278.63 |
$2,278.63 |
$494.92
|
|
Ultrasound exam k transpl w/doppler
|
$788.49 |
$788.49 |
$788.49 |
$573.54
|
|
Ultrasound fetal biophysical profile without non-stress testing
|
$2,505.33 |
$2,505.33 |
$2,505.33 |
$469.50
|
|
Ultrasound guided needle placement supervision & interpretation
|
$2,340.07 |
$2,340.07 |
$2,340.07 |
$720.00
|
|
Ultrasound guide intraoperative
|
$880.87 |
$880.87 |
$880.87 |
$625.15
|
|
Ultrasound ob >=14wks ea addl gest
|
$1,239.93 |
$1,239.93 |
$1,239.93 |
$397.15
|
|
Ultrasound spinal canal and contents
|
$788.49 |
$788.49 |
$788.49 |
$459.00
|
|
Urea nitrogen
|
$489.69 |
$489.69 |
$489.69 |
$39.90
|
|
Urea nitrogen 24 hour urine
|
$313.28 |
$313.28 |
$313.28 |
$52.00
|
|
Urinalysis (with microscopy)
|
$337.41 |
$337.41 |
$337.41 |
$55.00
|
|
Urine Culture Test
|
$756.58 |
$756.58 |
$756.58 |
$84.00
|
|
Vaccine dtap < 7 years im
|
$182.36 |
$182.36 |
$182.36 |
$73.01
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$61.62 |
$61.62 |
$61.62 |
$42.90
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$175.22 |
$175.22 |
$175.22 |
$74.42
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$82.29 |
$82.29 |
$82.29 |
$143.20
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$33.39 |
$33.39 |
$33.39 |
$47.88
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$110.86 |
$110.86 |
$110.86 |
$31.91
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$407.20 |
$407.20 |
$407.20 |
$409.35
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$353.69 |
$353.69 |
$353.69 |
$310.93
|
|
Vaccine mmr live subcutaneous
|
$384.64 |
$384.64 |
$384.64 |
$213.00
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$310.71 |
$310.71 |
$310.71 |
$252.90
|
|
Vaccine pneumonococcal conjugate 15 valent (pcv15) im
|
$466.99 |
$466.99 |
$466.99 |
$385.45
|
|
Vaccine rabies im
|
$1,056.52 |
$1,056.52 |
$1,056.52 |
$858.95
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$1,010.39 |
$1,010.39 |
$1,010.39 |
$1,105.21
|
|
Vaccine tdap >=7 years im
|
$298.93 |
$298.93 |
$298.93 |
$136.80
|
|
Vaccine td preservative free >= 7 years im
|
$175.51 |
$175.51 |
$175.51 |
$112.10
|
|
Vaccine varicella live subcutaneous
|
$489.62 |
$489.62 |
$489.62 |
$396.97
|
|
Valproate in ns IV syringe 10 mg/ml (pediatric) - cnr
|
$171.12 |
$171.12 |
$171.12 |
$24.12
|
|
Valproic acid total therapeutic drug level
|
$1,138.61 |
$1,138.61 |
$1,138.61 |
$115.00
|
|
Vasopressin 20 unit/ml intravenous solution
|
$593.92 |
$593.92 |
$593.92 |
$342.98
|
|
Venipuncture >= 3 years diagnostic/therapeutic (not to be used for routine venipuncture)
|
$1,041.24 |
$1,041.24 |
$1,041.24 |
$188.83
|
|
Venogram extremity supervision & interpretation unilateral
|
$4,149.16 |
$4,149.16 |
$4,149.16 |
$1,344.60
|
|
Ventilator each subsequent day
|
$6,019.51 |
$6,019.51 |
$6,019.51 |
$1,148.00
|
|
Ventilator initial day
|
$7,036.17 |
$7,036.17 |
$7,036.17 |
$1,433.60
|
|
Very long chain fatty acids
|
$204.25 |
$204.25 |
$204.25 |
$139.88
|
