|
Unlisted laparoscopic reduction intestine 44238
|
$2,545.20 |
$2,545.20 |
$2,545.20 |
$5,419.00
|
|
Unlisted laparoscopy procedure biliary tract 47579
|
$1,219.20 |
$1,219.20 |
$1,219.20 |
$6,463.42
|
|
Unlisted procedure urinary 58750
|
$1,758.60 |
$1,758.60 |
$1,758.60 |
$926.40
|
|
Unlisted psychiatric service/proc 90899
|
$121.20 |
$121.20 |
$121.20 |
$277.76
|
|
Unlisted special svc px/rprt
|
$9.00 |
$9.00 |
$9.00 |
$90.00
|
|
Unlisted ultrasound procedure
|
$157.80 |
$157.80 |
$157.80 |
$335.00
|
|
Upgrade pm system
|
$932.40 |
$932.40 |
$932.40 |
$12,077.00
|
|
Upper Arm (Humerus) X-ray (left side)
|
$281.40 |
$281.40 |
$281.40 |
$309.31
|
|
Upper Back (Thoracic Spine) CT Scan (with contrast)
|
$1,443.00 |
$1,443.00 |
$1,443.00 |
$1,669.00
|
|
Upper Back (Thoracic Spine) CT Scan (without contrast)
|
$1,381.20 |
$1,381.20 |
$1,381.20 |
$1,425.85
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$2,361.60 |
$2,361.60 |
$2,361.60 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$1,275.60 |
$1,275.60 |
$1,275.60 |
$2,392.00
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$1,741.80 |
$1,741.80 |
$1,741.80 |
$2,034.41
|
|
Upper Back (Thoracic Spine) X-ray (2 views)
|
$223.20 |
$223.20 |
$223.20 |
$321.95
|
|
Upper Back (Thoracic Spine) X-ray (3 views)
|
$246.00 |
$246.00 |
$246.00 |
$381.60
|
|
Upper Endoscopy (EGD, diagnostic)
|
$181.20 |
$181.20 |
$181.20 |
$1,824.75
|
|
Upper Endoscopy (EGD, with biopsy)
|
$204.60 |
$204.60 |
$204.60 |
$1,768.00
|
|
Upper ext harvest for cabg1 seg 35600
|
$504.00 |
$504.00 |
$504.00 |
$627.20
|
|
Upper GI Barium X-ray (barium and gas)
|
$363.60 |
$363.60 |
$363.60 |
$660.40
|
|
Upper GI Barium X-ray (barium only)
|
$346.80 |
$346.80 |
$346.80 |
$607.20
|
|
Uppr gi scope w/submuc inj
|
$661.80 |
$661.80 |
$661.80 |
$1,872.00
|
|
Urachal cyst/sinus excision 51500
|
$1,317.60 |
$1,317.60 |
$1,317.60 |
$6,082.67
|
|
Urea nitrogen
|
$34.80 |
$34.80 |
$34.80 |
$42.01
|
|
Urea nitrogen 24 hour urine
|
$56.40 |
$56.40 |
$56.40 |
$51.84
|
|
Ureteroneocystostomy 50780
|
$2,313.60 |
$2,313.60 |
$2,313.60 |
$4,457.05
|
|
Ureteroureterostomy 50760
|
$2,200.20 |
$2,200.20 |
$2,200.20 |
$2,773.01
|
|
Urethrocystography void s&i
|
$480.60 |
$480.60 |
$480.60 |
$634.50
|
|
Uric acid blood
|
$31.20 |
$31.20 |
$31.20 |
$49.32
|
|
Uric acid urine
|
$32.40 |
$32.40 |
$32.40 |
$44.52
|
|
Urinalysis microscopic only
|
$17.40 |
$17.40 |
$17.40 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$113.40 |
$113.40 |
$113.40 |
$25.72
|
|
Urinalysis (with microscopy)
|
$27.60 |
$27.60 |
$27.60 |
$55.20
|
|
Urinalysis (without microscopy)
|
$21.00 |
$21.00 |
$21.00 |
$35.91
|
|
Urine Culture Test
|
$47.40 |
$47.40 |
$47.40 |
$82.32
|
|
Urine flow measurement 51736
|
$90.00 |
$90.00 |
$90.00 |
$210.00
|
|
Urine pregnancy test
|
$52.20 |
$52.20 |
$52.20 |
$68.21
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$25,816.55 |
$25,816.55 |
$25,816.55 |
$5,205.00
|
|
Ustekinumab 45 mg/0.5 ml subcutaneous solution
|
$51,633.07 |
$51,633.07 |
$51,633.07 |
$51,633.07
|
|
Vaccine Administration (one shot)
|
$52.80 |
$52.80 |
$52.80 |
$67.74
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$263.57 |
$263.57 |
$263.57 |
$224.25
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$240.91 |
$240.91 |
$240.91 |
$209.40
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$274.01 |
$274.01 |
$274.01 |
$236.50
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$159.71 |
$159.71 |
$159.71 |
$123.20
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$114.26 |
$114.26 |
$114.26 |
$80.15
|
|
Vaccine dtap < 7 years im
|
$66.25 |
$66.25 |
$66.25 |
$71.17
|
|
Vaccine dtap-hep b-ipv im
|
$195.95 |
$195.95 |
$195.95 |
$164.63
|
|
Vaccine dtap-ipv 4-6 years im
|
$126.79 |
$126.79 |
$126.79 |
$105.95
|
|
Vaccine dtap-ipv-hib-hepb im
|
$288.65 |
$288.65 |
$288.65 |
$174.72
|
|
Vaccine dtap-ipv/hib im
|
$199.37 |
$199.37 |
$199.37 |
$221.24
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$65.04 |
$65.04 |
$65.04 |
$70.53
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$63.25 |
$63.25 |
$63.25 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$165.01 |
$165.01 |
$165.01 |
$166.62
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$116.72 |
$116.72 |
$116.72 |
$231.56
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$144.41 |
$144.41 |
$144.41 |
$78.25
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$140.37 |
$140.37 |
$140.37 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$273.90 |
$273.90 |
$273.90 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$64.23 |
$64.23 |
$64.23 |
$75.39
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$557.26 |
$557.26 |
$557.26 |
$576.48
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$152.43 |
$152.43 |
$152.43 |
$149.21
|
|
Vaccine influenza inactivated adjuvant im
|
$142.36 |
$142.36 |
$142.36 |
$110.25
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$47.38 |
$47.38 |
$47.38 |
$48.59
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$432.42 |
$432.42 |
$432.42 |
$394.26
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$354.77 |
$354.77 |
$354.77 |
$409.35
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$317.02 |
$317.02 |
$317.02 |
$310.93
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$513.94 |
$513.94 |
$513.94 |
$327.37
|
|
Vaccine mmr live subcutaneous
|
$181.04 |
$181.04 |
$181.04 |
$213.00
|
|
Vaccine mmrv live subcutaneous
|
$505.10 |
$505.10 |
$505.10 |
$424.32
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$219.79 |
$219.79 |
$219.79 |
$252.87
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$424.69 |
$424.69 |
$424.69 |
$393.25
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$512.71 |
$512.71 |
$512.71 |
$563.36
|
|
Vaccine polio (ipv) subcutaneous/im
|
$91.64 |
$91.64 |
$91.64 |
$90.70
|
|
Vaccine rabies im
|
$782.20 |
$782.20 |
$782.20 |
$858.95
|
|
Vaccine respiratory syncytial virus bivalent subunit/preservative free im
|
$555.82 |
$555.82 |
$555.82 |
$538.84
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$997.44 |
$997.44 |
$997.44 |
$1,105.21
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$997.44 |
$997.44 |
$997.44 |
$997.44
|
|
Vaccine respiratory syncytial virus recombinant subunit adjuvanted/preservative free im
|
$555.02 |
$555.02 |
$555.02 |
$499.62
|
|
Vaccine rotavirus attenuated (rv1) live 2 dose oral
|
$263.04 |
$263.04 |
$263.04 |
$200.70
|
|
Vaccine rotavirus pentavalent (rv5) live 3 dose oral
|
$90.16 |
$90.16 |
$90.16 |
$126.14
|
|
Vaccine tdap >=7 years im
|
$99.56 |
$99.56 |
$99.56 |
$131.34
|
|
Vaccine td preservative free >= 7 years im
|
$83.36 |
$83.36 |
$83.36 |
$112.10
|
|
Vaccine varicella live subcutaneous
|
$336.55 |
$336.55 |
$336.55 |
$365.17
|
|
Vag hys/<250g/rmv tube/rpr entero 58263
|
$1,993.20 |
$1,993.20 |
$1,993.20 |
$5,345.59
|
|
Vag hyst incl t/o complex
|
$2,430.60 |
$2,430.60 |
$2,430.60 |
$5,813.46
|
|
Vag hyst including t/o
|
$1,797.60 |
$1,797.60 |
$1,797.60 |
$5,110.00
|
|
Vag hyst t/o & repair compl
|
$2,566.80 |
$2,566.80 |
$2,566.80 |
$8,081.64
|
|
Vag hyst w/enterocele compl 58294
|
$2,378.40 |
$2,378.40 |
$2,378.40 |
$5,468.70
|
|
Vag hyst w/enterocele repair
|
$1,717.80 |
$1,717.80 |
$1,717.80 |
$5,463.96
|
|
Vag hyst w/uro repair compl 58293
|
$2,667.60 |
$2,667.60 |
$2,667.60 |
$2,667.60
|
|
Vaginal bx
|
$504.00 |
$504.00 |
$504.00 |
$459.42
|
|
Vaginal delivery after cesarean delivery 59612
|
$1,881.00 |
$1,881.00 |
$1,881.00 |
$3,866.47
|
|
Vaginal Delivery (full care)
|
$4,263.60 |
$4,263.60 |
$4,263.60 |
$4,184.00
|
|
Vaginal hysterectomy
|
$1,610.40 |
$1,610.40 |
$1,610.40 |
$5,766.00
|
|
Vagotomy pfrmd w/prtl dstl gstrct 43635
|
$212.40 |
$212.40 |
$212.40 |
$535.60
|
|
Vagotomy & pylorus repair 43640
|
$2,215.20 |
$2,215.20 |
$2,215.20 |
$2,215.20
|
|
Valproic acid total therapeutic drug level
|
$86.40 |
$86.40 |
$86.40 |
$115.00
|
|
Valvuloplasty aortic
|
$2,791.20 |
$2,791.20 |
$2,791.20 |
$7,944.16
|
|
Valvuloplasty mitral
|
$2,892.00 |
$2,892.00 |
$2,892.00 |
$10,845.00
|
|
Valvuloplasty/tv without ring insert 33463
|
$6,010.20 |
$6,010.20 |
$6,010.20 |
$7,556.80
|
|
Valvuloplasty/tv w/ring insertion 33464
|
$4,753.20 |
$4,753.20 |
$4,753.20 |
$5,965.60
|
|
Vancomycin 1,000 mg intravenous injection
|
$70.52 |
$70.52 |
$70.52 |
$251.86
|
