|
Trml dstrj ios bvn ea addl
|
$1,750.00 |
$1,750.00 |
$1,750.00 |
$9,781.50
|
|
Trnscath plc stent crv crtd w/prtct
|
$2,500.00 |
$2,500.00 |
$2,500.00 |
$11,099.98
|
|
Trnscath plc vas stent w/s&i ea addl artery
|
$1,750.00 |
$1,750.00 |
$1,750.00 |
$8,244.55
|
|
Trnscath plc vas stent w/s&i ea addl vein
|
$1,750.00 |
$1,750.00 |
$1,750.00 |
$8,990.80
|
|
Trnscath plc vas stent w/s&i ini vein
|
$3,750.00 |
$3,750.00 |
$3,750.00 |
$15,408.00
|
|
Trnscath retrv pq vasc fb w/guide
|
$1,875.00 |
$1,875.00 |
$1,875.00 |
$4,969.90
|
|
Trnscath tx thromblytc artery non-intracrn ini day
|
$2,737.50 |
$2,737.50 |
$2,737.50 |
$6,156.00
|
|
Trnscath tx thromblytc cath rmv sbsq day
|
$1,875.00 |
$1,875.00 |
$1,875.00 |
$4,793.13
|
|
Trnscath tx thromblytc vein ini day
|
$1,875.00 |
$1,875.00 |
$1,875.00 |
$4,329.36
|
|
Troponin quantitative
|
$61.50 |
$61.50 |
$61.50 |
$123.75
|
|
Tx atrial fib pulm vein isol
|
$9,150.00 |
$9,150.00 |
$9,150.00 |
$32,426.20
|
|
Tx closed hip disl traumatic without anes
|
$131.25 |
$131.25 |
$131.25 |
$657.28
|
|
Tx l/r atrial fib addl
|
$2,300.00 |
$2,300.00 |
$2,300.00 |
$7,717.80
|
|
Tx open dstl phlngl fx f/t internal fixation ea
|
$1,875.00 |
$1,875.00 |
$1,875.00 |
$4,499.12
|
|
Ua w/micro/comp poc
|
$33.25 |
$33.25 |
$33.25 |
$24.45
|
|
Ublituximab-xiiy 25 mg/ml intravenous solution
|
$1,324.69 |
$1,324.69 |
$1,324.69 |
$17,191.88
|
|
Ugt1a1 gene analy common variants
|
$145.00 |
$145.00 |
$145.00 |
$438.75
|
|
Ultrasound abdomen aorta screening study aaa
|
$127.50 |
$127.50 |
$127.50 |
$403.26
|
|
Ultrasound breast complete
|
$175.00 |
$175.00 |
$175.00 |
$519.75
|
|
Ultrasound breast unilateral limited (both sides)
|
$150.00 |
$150.00 |
$150.00 |
$449.35
|
|
Ultrasound chest
|
$175.00 |
$175.00 |
$175.00 |
$459.55
|
|
Ultrasound doppler velocimetry fetal umbilical artery
|
$162.50 |
$162.50 |
$162.50 |
$340.14
|
|
Ultrasound elastography parenchyma
|
$150.00 |
$150.00 |
$150.00 |
$284.25
|
|
Ultrasound encephalogram
|
$175.00 |
$175.00 |
$175.00 |
$481.60
|
|
Ultrasound exam k transpl w/doppler
|
$275.00 |
$275.00 |
$275.00 |
$570.44
|
|
Ultrasound fetal biophysical profile without non-stress testing
|
$150.00 |
$150.00 |
$150.00 |
$477.88
|
|
Ultrasound guidance for vascular access
|
$125.00 |
$125.00 |
$125.00 |
$340.22
|
|
Ultrasound guided needle placement supervision & interpretation
|
$375.00 |
$375.00 |
$375.00 |
$701.35
|
|
Ultrasound guide intraoperative
|
$250.00 |
$250.00 |
$250.00 |
$632.90
|
|
Ultrasound hips infant dynamic
|
$187.50 |
$187.50 |
$187.50 |
$403.00
|
|
Ultrasound joint complete left
|
$250.00 |
$250.00 |
$250.00 |
$556.14
|
|
Ultrasound joint/nonvascular extremity limited left
|
$127.50 |
$127.50 |
$127.50 |
$448.50
|
|
Ultrasound ob >=14wks ea addl gest
|
$62.50 |
$62.50 |
$62.50 |
$454.11
|
|
Ultrasound pregnant uterus < 14 weeks each additional gestation
|
$62.50 |
$62.50 |
$62.50 |
$326.54
|
|
Ultrasound pregnant uterus detailed fetal exam single/1st gestation
|
$375.00 |
$375.00 |
$375.00 |
$690.48
|
|
Ultrasound pregnant uterus follow up per fetus
|
$212.50 |
$212.50 |
$212.50 |
$450.75
|
|
Ultrasound pregnant uterus limited >= 1 fetuses
|
$275.00 |
$275.00 |
$275.00 |
$459.00
|
|
Ultrasound pregnant uterus transvaginal
|
$250.00 |
$250.00 |
$250.00 |
$485.48
|
|
Ultrasound retroperitoneal limited
|
$243.75 |
$243.75 |
$243.75 |
$498.00
|
|
Ultrasound scrotum and contents
|
$337.50 |
$337.50 |
$337.50 |
$617.28
|
|
Ultrasound spinal canal and contents
|
$175.00 |
$175.00 |
$175.00 |
$450.60
|
|
Ultrasound transabd ea addl gest
|
$237.50 |
$237.50 |
$237.50 |
$425.10
|
|
Ultrasound transvaginal non obstetric
|
$250.00 |
$250.00 |
$250.00 |
$567.44
|
|
Unlisted transfusion med px
|
$25.00 |
$25.00 |
$25.00 |
$141.35
|
|
Unsched dialysis esrd pt hos
|
$500.00 |
$500.00 |
$500.00 |
$1,480.70
|
|
Upgrade pm system
|
$5,750.00 |
$5,750.00 |
$5,750.00 |
$12,324.60
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$1,350.00 |
$1,350.00 |
$1,350.00 |
$2,916.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$1,050.00 |
$1,050.00 |
$1,050.00 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$950.00 |
$950.00 |
$950.00 |
$2,013.08
|
|
Urea nitrogen
|
$20.00 |
$20.00 |
$20.00 |
$45.10
|
|
Urea nitrogen 24 hour urine
|
$22.50 |
$22.50 |
$22.50 |
$50.00
|
|
Urethrcystgrphy rtrgrde s&i
|
$300.00 |
$300.00 |
$300.00 |
$574.40
|
|
Urethrocystography void s&i
|
$300.00 |
$300.00 |
$300.00 |
$634.50
|
|
Uric acid blood
|
$20.00 |
$20.00 |
$20.00 |
$46.64
|
|
Uric acid urine
|
$22.50 |
$22.50 |
$22.50 |
$46.75
|
|
Urinalysis microscopic only
|
$2.75 |
$2.75 |
$2.75 |
$26.35
|
|
Urinalysis (with microscopy)
|
$30.00 |
$30.00 |
$30.00 |
$48.14
|
|
Urinalysis (without microscopy)
|
$27.75 |
$27.75 |
$27.75 |
$38.99
|
|
Urine Culture Test
|
$57.50 |
$57.50 |
$57.50 |
$84.81
|
|
Urine pregnancy test
|
$17.50 |
$17.50 |
$17.50 |
$66.40
|
|
Urography, antegrade
|
$231.25 |
$231.25 |
$231.25 |
$593.37
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$183.58 |
$183.58 |
$183.58 |
$5,521.54
|
|
Ustekinumab 45 mg/0.5 ml subcutaneous solution
|
$17,929.16 |
$17,929.16 |
$17,929.16 |
$56,553.85
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$305.74 |
$305.74 |
$305.74 |
$239.85
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$168.95 |
$168.95 |
$168.95 |
$131.67
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$126.88 |
$126.88 |
$126.88 |
$91.00
|
|
Vaccine dtap < 7 years im
|
$125.11 |
$125.11 |
$125.11 |
$87.80
|
|
Vaccine dtap-hep b-ipv im
|
$95.52 |
$95.52 |
$95.52 |
$193.83
|
|
Vaccine dtap-ipv/hib im
|
$176.39 |
$176.39 |
$176.39 |
$248.80
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$123.84 |
$123.84 |
$123.84 |
$85.00
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$49.68 |
$49.68 |
$49.68 |
$45.33
|
|
Vaccine hepatitis a (hepa) adult im
|
$143.75 |
$143.75 |
$143.75 |
$178.07
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$211.64 |
$211.64 |
$211.64 |
$218.40
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$121.44 |
$121.44 |
$121.44 |
$84.38
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$103.81 |
$103.81 |
$103.81 |
$173.98
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$185.29 |
$185.29 |
$185.29 |
$306.24
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$91.61 |
$91.61 |
$91.61 |
$79.04
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$212.47 |
$212.47 |
$212.47 |
$157.41
|
|
Vaccine influenza inactivated adjuvant im
|
$89.97 |
$89.97 |
$89.97 |
$110.25
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$86.69 |
$86.69 |
$86.69 |
$48.29
|
|
Vaccine influenza quadrivalent (iiv4) 0.5ml dose im
|
$75.89 |
$75.89 |
$75.89 |
$42.90
|
|
Vaccine influenza quadrivalent (iiv4) inactivated adjuvanted preservative free 0.5ml dose im
|
$94.63 |
$94.63 |
$94.63 |
$104.63
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.25ml dose im
|
$154.41 |
$154.41 |
$154.41 |
$26.40
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$102.98 |
$102.98 |
$102.98 |
$40.01
|
|
Vaccine influenza quadrivalent live (laiv4) intranasal
|
$174.72 |
$174.72 |
$174.72 |
$37.05
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$90.55 |
$90.55 |
$90.55 |
$72.00
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$105.98 |
$105.98 |
$105.98 |
$103.88
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$237.39 |
$237.39 |
$237.39 |
$499.00
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$226.48 |
$226.48 |
$226.48 |
$426.80
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$236.36 |
$236.36 |
$236.36 |
$349.15
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$200.72 |
$200.72 |
$200.72 |
$408.70
|
|
Vaccine mmr live subcutaneous
|
$191.25 |
$191.25 |
$191.25 |
$224.04
|
|
Vaccine mmrv live subcutaneous
|
$194.78 |
$194.78 |
$194.78 |
$474.24
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$181.93 |
$181.93 |
$181.93 |
$274.95
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$296.35 |
$296.35 |
$296.35 |
$397.18
|
|
Vaccine pneumonococcal conjugate 15 valent (pcv15) im
|
$291.48 |
$291.48 |
$291.48 |
$385.45
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$334.38 |
$334.38 |
$334.38 |
$715.41
|
|
Vaccine polio (ipv) subcutaneous/im
|
$171.17 |
$171.17 |
$171.17 |
$119.17
|
|
Vaccine rabies im
|
$306.56 |
$306.56 |
$306.56 |
$945.46
|
|
Vaccine tdap >=7 years im
|
$203.64 |
$203.64 |
$203.64 |
$150.76
|
