|
Unlisted laparoscopy procedure biliary tract 47579
|
$229.68 |
$229.68 |
$229.68 |
$6,463.42
|
|
Unlisted laps px bladder
|
$3,717.78 |
$3,717.78 |
$3,717.78 |
$5,082.74
|
|
Unlisted laps px ovidct ovry
|
$601.92 |
$601.92 |
$601.92 |
$6,904.15
|
|
Unlisted laps px renal
|
$1,709.40 |
$1,709.40 |
$1,709.40 |
$5,110.00
|
|
Unlisted laps px spleen
|
$2,983.86 |
$2,983.86 |
$2,983.86 |
$4,627.00
|
|
Unlisted laps px uterus
|
$1,321.32 |
$1,321.32 |
$1,321.32 |
$4,627.00
|
|
Unlisted oph svc/procedure
|
$40.26 |
$40.26 |
$40.26 |
$40.26
|
|
Unlisted procedure rectum
|
$793.32 |
$793.32 |
$793.32 |
$1,220.35
|
|
Unlisted procedure urinary 58750
|
$2,038.08 |
$2,038.08 |
$2,038.08 |
$1,181.29
|
|
Unlisted px abdomen muscskel
|
$1,399.86 |
$1,399.86 |
$1,399.86 |
$1,848.60
|
|
Unlisted px accessory sinus
|
$289.74 |
$289.74 |
$289.74 |
$3,335.28
|
|
Unlisted px ant segment eye
|
$415.80 |
$415.80 |
$415.80 |
$2,698.92
|
|
Unlisted px arthroscopy
|
$1,622.28 |
$1,622.28 |
$1,622.28 |
$2,765.60
|
|
Unlisted px conjunctiva
|
$170.94 |
$170.94 |
$170.94 |
$479.62
|
|
Unlisted px external ear
|
$170.94 |
$170.94 |
$170.94 |
$325.68
|
|
Unlisted px foot/toes
|
$3,607.56 |
$3,607.56 |
$3,607.56 |
$1,225.50
|
|
Unlisted px leg/ankle
|
$1,941.06 |
$1,941.06 |
$1,941.06 |
$811.00
|
|
Unlisted px male genital sys
|
$636.90 |
$636.90 |
$636.90 |
$343.55
|
|
Unlisted px middle ear
|
$208.56 |
$208.56 |
$208.56 |
$343.50
|
|
Unlisted px neck/thorax
|
$291.06 |
$291.06 |
$291.06 |
$571.20
|
|
Unlisted px pelvis/hip joint
|
$170.94 |
$170.94 |
$170.94 |
$3,118.44
|
|
Unlisted px small intestine
|
$3,622.08 |
$3,622.08 |
$3,622.08 |
$2,102.10
|
|
Unlisted px tongue flr mouth
|
$180.84 |
$180.84 |
$180.84 |
$282.50
|
|
Unlisted special svc px/rprt
|
$147.18 |
$147.18 |
$147.18 |
$90.00
|
|
Unlisted ultrasound procedure
|
$642.18 |
$642.18 |
$642.18 |
$321.20
|
|
Upgrade pm system
|
$1,045.44 |
$1,045.44 |
$1,045.44 |
$12,077.00
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$4,090.68 |
$4,090.68 |
$4,090.68 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$218.46 |
$218.46 |
$218.46 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$3,119.16 |
$3,119.16 |
$3,119.16 |
$2,034.41
|
|
Upper Endoscopy (EGD, diagnostic)
|
$275.22 |
$275.22 |
$275.22 |
$1,751.66
|
|
Upper Endoscopy (EGD, with biopsy)
|
$308.88 |
$308.88 |
$308.88 |
$1,768.00
|
|
Uppr gi scope w/submuc inj
|
$308.88 |
$308.88 |
$308.88 |
$1,872.00
|
|
Urachal cyst/sinus excision 51500
|
$1,452.00 |
$1,452.00 |
$1,452.00 |
$6,082.67
|
|
Urea nitrogen
|
$69.96 |
$69.96 |
$69.96 |
$41.46
|
|
Urea nitrogen 24 hour urine
|
$94.38 |
$94.38 |
$94.38 |
$51.75
|
|
Ureteral reflux study
|
$498.96 |
$498.96 |
$498.96 |
$952.50
|
|
Ureter endoscopy & treatment
|
$699.60 |
$699.60 |
$699.60 |
$5,631.74
|
|
Ureteroneocystostomy 50780
|
$2,492.82 |
$2,492.82 |
$2,492.82 |
$4,457.05
|
|
Ureteroureterostomy 50760
|
$2,521.86 |
$2,521.86 |
$2,521.86 |
$2,999.40
|
|
Urethrcystgrphy rtrgrde s&i
|
$345.84 |
$345.84 |
$345.84 |
$579.73
|
|
Urethrlys transvag with scope
|
$1,685.64 |
$1,685.64 |
$1,685.64 |
$4,081.37
|
|
Urethrocystography void s&i
|
$382.80 |
$382.80 |
$382.80 |
$622.35
|
|
Uric acid blood
|
$33.00 |
$33.00 |
$33.00 |
$48.75
|
|
Uric acid urine
|
$23.76 |
$23.76 |
$23.76 |
$44.33
|
|
Urinalysis qual/semiquant excpt ia
|
$5.94 |
$5.94 |
$5.94 |
$25.72
|
|
Urinalysis (with microscopy)
|
$93.72 |
$93.72 |
$93.72 |
$55.00
|
|
Urinalysis (without microscopy)
|
$54.12 |
$54.12 |
$54.12 |
$35.75
|
|
Urine Culture Test
|
$73.92 |
$73.92 |
$73.92 |
$81.50
|
|
Urine flow measurement 51736
|
$31.68 |
$31.68 |
$31.68 |
$210.00
|
|
Urine pregnancy test
|
$76.56 |
$76.56 |
$76.56 |
$67.20
|
|
Urography, antegrade
|
$299.64 |
$299.64 |
$299.64 |
$622.35
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$266.64 |
$266.64 |
$266.64 |
$224.25
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$242.88 |
$242.88 |
$242.88 |
$209.40
|
|
Vaccine dtap < 7 years im
|
$99.00 |
$99.00 |
$99.00 |
$68.19
|
|
Vaccine dtap-hep b-ipv im
|
$183.48 |
$183.48 |
$183.48 |
$164.63
|
|
Vaccine dtap-ipv 4-6 years im
|
$141.24 |
$141.24 |
$141.24 |
$105.95
|
|
Vaccine dtap-ipv/hib im
|
$186.12 |
$186.12 |
$186.12 |
$221.24
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$44.88 |
$44.88 |
$44.88 |
$70.26
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$66.66 |
$66.66 |
$66.66 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$118.14 |
$118.14 |
$118.14 |
$166.62
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$494.34 |
$494.34 |
$494.34 |
$218.40
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$64.68 |
$64.68 |
$64.68 |
$79.15
|
|
Vaccine hepatitis b (hepb) adolescent 2 dose im
|
$124.08 |
$124.08 |
$124.08 |
$84.75
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$116.16 |
$116.16 |
$116.16 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$277.86 |
$277.86 |
$277.86 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$50.82 |
$50.82 |
$50.82 |
$75.39
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$336.60 |
$336.60 |
$336.60 |
$576.48
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$268.62 |
$268.62 |
$268.62 |
$282.50
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$137.94 |
$137.94 |
$137.94 |
$143.20
|
|
Vaccine influenza inactivated adjuvant im
|
$137.94 |
$137.94 |
$137.94 |
$109.50
|
|
Vaccine influenza nos 0.5ml dose im
|
$36.30 |
$36.30 |
$36.30 |
$24.20
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$50.81 |
$50.81 |
$50.81 |
$47.88
|
|
Vaccine influenza quadrivalent (iiv4) 0.5ml dose im
|
$38.28 |
$38.28 |
$38.28 |
$35.88
|
|
Vaccine influenza quadrivalent (iiv4) inactivated adjuvanted preservative free 0.5ml dose im
|
$127.38 |
$127.38 |
$127.38 |
$72.80
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.25ml dose im
|
$38.28 |
$38.28 |
$38.28 |
$31.03
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$55.44 |
$55.44 |
$55.44 |
$33.60
|
|
Vaccine influenza quadrivalent (iiv4) split virus 0.25 ml im
|
$34.32 |
$34.32 |
$34.32 |
$20.80
|
|
Vaccine influenza quadrivalent live (laiv4) intranasal
|
$38.94 |
$38.94 |
$38.94 |
$37.05
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$121.44 |
$121.44 |
$121.44 |
$72.00
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$60.72 |
$60.72 |
$60.72 |
$76.50
|
|
Vaccine influenza trivalent (iiv3) 0.25ml dose im
|
$17.82 |
$17.82 |
$17.82 |
$31.20
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$261.36 |
$261.36 |
$261.36 |
$400.03
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$202.62 |
$202.62 |
$202.62 |
$409.35
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$689.70 |
$689.70 |
$689.70 |
$310.93
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$237.60 |
$237.60 |
$237.60 |
$329.24
|
|
Vaccine mmr live subcutaneous
|
$221.76 |
$221.76 |
$221.76 |
$211.68
|
|
Vaccine mmrv live subcutaneous
|
$533.28 |
$533.28 |
$533.28 |
$424.32
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$220.44 |
$220.44 |
$220.44 |
$251.64
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$425.70 |
$425.70 |
$425.70 |
$397.11
|
|
Vaccine pneumonococcal conjugate 15 valent (pcv15) im
|
$418.44 |
$418.44 |
$418.44 |
$414.46
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$491.70 |
$491.70 |
$491.70 |
$563.36
|
|
Vaccine polio (ipv) subcutaneous/im
|
$71.28 |
$71.28 |
$71.28 |
$90.70
|
|
Vaccine rabies im
|
$808.90 |
$808.90 |
$808.90 |
$858.95
|
|
Vaccine respiratory syncytial virus bivalent subunit/preservative free im
|
$958.98 |
$958.98 |
$958.98 |
$538.84
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$1,509.42 |
$1,509.42 |
$1,509.42 |
$1,104.47
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$1,509.42 |
$1,509.42 |
$1,509.42 |
$997.44
|
|
Vaccine respiratory syncytial virus recombinant subunit adjuvanted/preservative free im
|
$412.50 |
$412.50 |
$412.50 |
$499.62
|
|
Vaccine rotavirus attenuated (rv1) live 2 dose oral
|
$192.06 |
$192.06 |
$192.06 |
$200.70
|
|
Vaccine rotavirus pentavalent (rv5) live 3 dose oral
|
$186.12 |
$186.12 |
$186.12 |
$126.14
|
|
Vaccine tdap >=7 years im
|
$125.47 |
$125.47 |
$125.47 |
$131.34
|
