|
Unlisted CT procedure
|
$1,941.10 |
$1,941.10 |
$1,941.10 |
$732.70
|
|
Unlisted dx gi procedure
|
$1,908.20 |
$1,908.20 |
$1,908.20 |
$649.22
|
|
Unlisted fetal invas px w/us
|
$606.90 |
$606.90 |
$606.90 |
$498.40
|
|
Unlisted fluoroscopic px
|
$26,511.80 |
$26,511.80 |
$26,511.80 |
$305.76
|
|
Unlisted hematology&coagj px
|
$65.10 |
$65.10 |
$65.10 |
$39.52
|
|
Unlisted hystsc px uterus
|
$25,169.37 |
$25,169.37 |
$25,169.37 |
$2,803.60
|
|
Unlisted laparoscopic liver biopy 47379
|
$62,083.55 |
$62,083.55 |
$62,083.55 |
$5,419.00
|
|
Unlisted laparoscopic procedure 49659
|
$56,010.92 |
$56,010.92 |
$56,010.92 |
$6,838.32
|
|
Unlisted laparoscopic reduction intestine 44238
|
$36,574.83 |
$36,574.83 |
$36,574.83 |
$5,419.00
|
|
Unlisted laps px appendix
|
$33,884.13 |
$33,884.13 |
$33,884.13 |
$3,617.40
|
|
Unlisted laps px esoph
|
$41,301.50 |
$41,301.50 |
$41,301.50 |
$5,741.00
|
|
Unlisted laps px lymphtc sys
|
$85,922.33 |
$85,922.33 |
$85,922.33 |
$6,870.89
|
|
Unlisted laps px spleen
|
$54,166.60 |
$54,166.60 |
$54,166.60 |
$4,627.00
|
|
Unlisted laps px ureter
|
$68,499.22 |
$68,499.22 |
$68,499.22 |
$6,212.70
|
|
Unlisted laps px uterus
|
$39,720.06 |
$39,720.06 |
$39,720.06 |
$4,627.00
|
|
Unlisted maaa
|
$284.90 |
$284.90 |
$284.90 |
$235.20
|
|
Unlisted mr procedure
|
$2,110.50 |
$2,110.50 |
$2,110.50 |
$1,163.00
|
|
Unlisted procedure colon
|
$10,896.20 |
$10,896.20 |
$10,896.20 |
$1,702.50
|
|
Unlisted procedure esophagus
|
$18,933.31 |
$18,933.31 |
$18,933.31 |
$1,998.88
|
|
Unlisted procedure larynx
|
$25,931.07 |
$25,931.07 |
$25,931.07 |
$924.00
|
|
Unlisted procedure liver
|
$72,677.02 |
$72,677.02 |
$72,677.02 |
$2,287.20
|
|
Unlisted procedure microbiology
|
$2,748.20 |
$2,748.20 |
$2,748.20 |
$523.50
|
|
Unlisted procedure pancreas
|
$23,156.57 |
$23,156.57 |
$23,156.57 |
$3,986.00
|
|
Unlisted procedure rectum
|
$14,082.42 |
$14,082.42 |
$14,082.42 |
$1,220.35
|
|
Unlisted px abdomen muscskel
|
$3,161.20 |
$3,161.20 |
$3,161.20 |
$1,848.60
|
|
Unlisted px accessory sinus
|
$73,519.42 |
$73,519.42 |
$73,519.42 |
$3,335.28
|
|
Unlisted px ant segment eye
|
$16,538.42 |
$16,538.42 |
$16,538.42 |
$2,698.92
|
|
Unlisted px arthroscopy
|
$92,664.84 |
$92,664.84 |
$92,664.84 |
$2,765.60
|
|
Unlisted px biliary tract
|
$23,227.40 |
$23,227.40 |
$23,227.40 |
$2,718.10
|
|
Unlisted px lacrimal system
|
$20,229.44 |
$20,229.44 |
$20,229.44 |
$416.50
|
|
Unlisted px leg/ankle
|
$13,652.80 |
$13,652.80 |
$13,652.80 |
$811.00
|
|
Unlisted px med radj physics
|
$1,124.20 |
$1,124.20 |
$1,124.20 |
$462.35
|
|
Unlisted px posterior segmnt
|
$15,743.22 |
$15,743.22 |
$15,743.22 |
$3,173.34
|
|
Unlisted px salivry glnd/dux
|
$19,045.94 |
$19,045.94 |
$19,045.94 |
$1,265.16
|
|
Unlisted px small intestine
|
$12,495.70 |
$12,495.70 |
$12,495.70 |
$2,102.10
|
|
Unlisted surgical path px
|
$249.20 |
$249.20 |
$249.20 |
$217.75
|
|
Unlisted ultrasound procedure
|
$105.00 |
$105.00 |
$105.00 |
$321.20
|
|
Unlisted urinalysis px
|
$114.10 |
$114.10 |
$114.10 |
$25.72
|
|
Unlisted vasc endoscopy px
|
$62,361.53 |
$62,361.53 |
$62,361.53 |
$1,523.20
|
|
Unlstd laps px sprmatic cord
|
$44,377.53 |
$44,377.53 |
$44,377.53 |
$4,713.11
|
|
Unsched dialysis esrd pt hos
|
$5,777.80 |
$5,777.80 |
$5,777.80 |
$1,268.17
|
|
Upgrade pm system
|
$60,848.77 |
$60,848.77 |
$60,848.77 |
$12,077.00
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$4,696.30 |
$4,696.30 |
$4,696.30 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$4,101.30 |
$4,101.30 |
$4,101.30 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$3,809.40 |
$3,809.40 |
$3,809.40 |
$2,034.41
|
|
Upper Endoscopy (EGD, diagnostic)
|
$8,412.00 |
$8,412.00 |
$8,412.00 |
$1,751.66
|
|
Upper Endoscopy (EGD, with biopsy)
|
$11,894.69 |
$11,894.69 |
$11,894.69 |
$1,768.00
|
|
Uppr gi scope w/submuc inj
|
$16,539.54 |
$16,539.54 |
$16,539.54 |
$1,872.00
|
|
Urea nitrogen
|
$109.20 |
$109.20 |
$109.20 |
$41.46
|
|
Urea nitrogen 24 hour urine
|
$205.10 |
$205.10 |
$205.10 |
$51.75
|
|
Ureteral embolization/occl
|
$2,184.00 |
$2,184.00 |
$2,184.00 |
$2,181.40
|
|
Urethrcystgrphy rtrgrde s&i
|
$839.30 |
$839.30 |
$839.30 |
$579.73
|
|
Urethrlys transvag with scope
|
$14,962.42 |
$14,962.42 |
$14,962.42 |
$4,081.37
|
|
Urethrocystography void s&i
|
$897.40 |
$897.40 |
$897.40 |
$622.35
|
|
Uric acid blood
|
$79.10 |
$79.10 |
$79.10 |
$48.75
|
|
Uric acid urine
|
$128.80 |
$128.80 |
$128.80 |
$44.33
|
|
Urinalysis microscopic only
|
$67.20 |
$67.20 |
$67.20 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$30.10 |
$30.10 |
$30.10 |
$25.72
|
|
Urinalysis (with microscopy)
|
$140.00 |
$140.00 |
$140.00 |
$55.00
|
|
Urinalysis (without microscopy)
|
$85.40 |
$85.40 |
$85.40 |
$35.75
|
|
Urine Culture Test
|
$192.50 |
$192.50 |
$192.50 |
$81.50
|
|
Urine pregnancy test
|
$142.10 |
$142.10 |
$142.10 |
$67.20
|
|
Urography, antegrade
|
$1,262.80 |
$1,262.80 |
$1,262.80 |
$622.35
|
|
Use 1st target lesion
|
$482.30 |
$482.30 |
$482.30 |
$332.00
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$37,584.40 |
$37,584.40 |
$37,584.40 |
$5,184.34
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$69.30 |
$69.30 |
$69.30 |
$209.40
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$137.90 |
$137.90 |
$137.90 |
$236.50
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$92.40 |
$92.40 |
$92.40 |
$123.20
|
|
Vaccine dtap < 7 years im
|
$463.40 |
$463.40 |
$463.40 |
$68.19
|
|
Vaccine dtap-ipv/hib im
|
$1,039.32 |
$1,039.32 |
$1,039.32 |
$221.24
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$221.55 |
$221.55 |
$221.55 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$1,339.62 |
$1,339.62 |
$1,339.62 |
$166.62
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$326.90 |
$326.90 |
$326.90 |
$218.40
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$1,123.50 |
$1,123.50 |
$1,123.50 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$1,093.92 |
$1,093.92 |
$1,093.92 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$459.72 |
$459.72 |
$459.72 |
$75.39
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$2,585.45 |
$2,585.45 |
$2,585.45 |
$576.48
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$347.20 |
$347.20 |
$347.20 |
$282.50
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$81.20 |
$81.20 |
$81.20 |
$143.20
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$33.60 |
$33.60 |
$33.60 |
$47.88
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$33.60 |
$33.60 |
$33.60 |
$33.60
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$1,788.15 |
$1,788.15 |
$1,788.15 |
$400.03
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$1,484.87 |
$1,484.87 |
$1,484.87 |
$310.93
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$1,310.40 |
$1,310.40 |
$1,310.40 |
$329.24
|
|
Vaccine mmr live subcutaneous
|
$1,535.45 |
$1,535.45 |
$1,535.45 |
$211.68
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$607.60 |
$607.60 |
$607.60 |
$251.64
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$275.80 |
$275.80 |
$275.80 |
$397.11
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$1,842.40 |
$1,842.40 |
$1,842.40 |
$563.36
|
|
Vaccine polio (ipv) subcutaneous/im
|
$355.60 |
$355.60 |
$355.60 |
$90.70
|
|
Vaccine rabies im
|
$3,563.70 |
$3,563.70 |
$3,563.70 |
$858.95
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$3,794.35 |
$3,794.35 |
$3,794.35 |
$1,104.47
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$3,794.35 |
$3,794.35 |
$3,794.35 |
$997.44
|
|
Vaccine tdap >=7 years im
|
$775.42 |
$775.42 |
$775.42 |
$131.34
|
|
Vaccine td preservative free >= 7 years im
|
$665.17 |
$665.17 |
$665.17 |
$112.10
|
|
Vag hyst incl t/o complex
|
$48,803.60 |
$48,803.60 |
$48,803.60 |
$5,735.60
|
|
Vag hyst including t/o
|
$44,992.84 |
$44,992.84 |
$44,992.84 |
$4,827.18
|
|
Vag hyst t/o & repair compl
|
$66,211.27 |
$66,211.27 |
$66,211.27 |
$8,185.02
|
|
Vaginal bx
|
$31,864.34 |
$31,864.34 |
$31,864.34 |
$455.94
|
|
Vaginal hysterectomy
|
$43,877.75 |
$43,877.75 |
$43,877.75 |
$5,766.00
|
|
Valproate in ns IV syringe 10 mg/ml (pediatric) - cnr
|
$59.50 |
$59.50 |
$59.50 |
$24.12
|