|
Unlisted procedure pancreas
|
$801.47 |
$1,416.91 |
$1,416.91 |
|
|
Unlisted procedure rectum
|
$1,149.23 |
$1,292.80 |
$1,845.70 |
|
|
Unlisted procedure spine
|
$1,889.14 |
$1,889.14 |
$1,889.14 |
|
|
Unlisted px abdomen muscskel
|
$564.09 |
$564.09 |
$671.33 |
|
|
Unlisted px ant segment eye
|
$2,442.40 |
$2,442.40 |
$2,442.40 |
|
|
Unlisted px biliary tract
|
$1,504.99 |
$1,504.99 |
$1,504.99 |
|
|
Unlisted px casting/strpg
|
$81.48 |
$81.48 |
$352.00 |
|
|
Unlisted px foot/toes
|
$206.40 |
$751.46 |
$788.45 |
|
|
Unlisted px forearm/wrist
|
$206.40 |
$3,908.80 |
$3,908.80 |
|
|
Unlisted px hands/fingers
|
$206.40 |
$2,334.40 |
$2,334.40 |
|
|
Unlisted px leg/ankle
|
$1,323.20 |
$1,323.20 |
$1,323.20 |
|
|
Unlisted px med radj physics
|
$640.80 |
$5,039.52 |
$5,039.52 |
|
|
Unlisted px neck/thorax
|
$380.69 |
$380.69 |
$380.69 |
|
|
Unlisted px palate uvula
|
$452.80 |
$452.80 |
$452.80 |
|
|
Unlisted px pelvis/hip joint
|
$206.40 |
$206.40 |
$637.60 |
|
|
Unlisted px salivry glnd/dux
|
$535.82 |
$545.72 |
$545.72 |
|
|
Unlisted px small intestine
|
$700.17 |
$775.77 |
$3,644.80 |
|
|
Unlisted px tongue flr mouth
|
$525.00 |
$525.00 |
$3,837.60 |
|
|
Unlisted px vestibule mouth
|
$2,883.20 |
$2,883.20 |
$2,883.20 |
|
|
Unlisted reprod med lab proc
|
$60.00 |
$66.40 |
$92.68 |
|
|
Unlisted resp px dx nuc med
|
$665.62 |
$665.62 |
$665.62 |
|
|
Unlisted transfusion med px
|
$338.69 |
$414.90 |
$484.80 |
|
|
Unlisted ultrasound procedure
|
$326.40 |
$544.71 |
$730.51 |
|
|
Unlisted urinalysis px
|
$46.48 |
$46.48 |
$57.62 |
|
|
Unsched dialysis esrd pt hos
|
$778.27 |
$1,854.89 |
$1,854.89 |
|
|
Upgrade pm system
|
$6,808.80 |
$9,864.72 |
$9,864.72 |
|
|
Upper Arm (Humerus) X-ray (left side)
|
$198.40 |
$257.66 |
$532.80 |
|
|
Upper Back (Thoracic Spine) CT Scan (with contrast)
|
$647.76 |
$1,368.81 |
$2,464.80 |
|
|
Upper Back (Thoracic Spine) CT Scan (without contrast)
|
$431.81 |
$1,844.00 |
$2,564.00 |
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$912.00 |
$3,820.00 |
$4,724.80 |
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$729.74 |
$3,209.60 |
$3,636.80 |
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$547.30 |
$2,707.20 |
$3,441.60 |
|
|
Upper Back (Thoracic Spine) X-ray (2 views)
|
$207.79 |
$257.66 |
$463.20 |
|
|
Upper Back (Thoracic Spine) X-ray (3 views)
|
$138.43 |
$230.40 |
$580.80 |
|
|
Upper Endoscopy (EGD, diagnostic)
|
$2,584.80 |
$2,584.80 |
$2,694.40 |
|
|
Upper Endoscopy (EGD, with biopsy)
|
$2,576.80 |
$2,576.80 |
$2,652.00 |
|
|
Upper ext fx orthosis rad/ul
|
$565.66 |
$644.11 |
$751.46 |
|
|
Upper GI Barium X-ray (barium and gas)
|
$207.79 |
$208.99 |
$1,020.00 |
|
|
Upper GI Barium X-ray (barium only)
|
$207.98 |
$208.99 |
$924.00 |
|
|
Urea nitrogen
|
$25.60 |
$80.86 |
$88.51 |
|
|
Urea nitrogen 24 hour urine
|
$16.00 |
$33.04 |
$69.60 |
|
|
Ureteral embolization/occl
|
$1,520.90 |
$1,520.90 |
$2,079.31 |
|
|
Ureteral reflux study
|
$597.46 |
$1,073.58 |
$1,508.00 |
|
|
Urethrcystgrphy rtrgrde s&i
|
$343.56 |
$358.06 |
$884.80 |
|
|
Urethrocystography void s&i
|
$416.02 |
$417.98 |
$1,009.60 |
|
|
Uric acid blood
|
$23.52 |
$25.73 |
$74.40 |
|
|
Uric acid urine
|
$13.60 |
$36.19 |
$72.00 |
|
|
Urinalysis microscopic only
|
$16.80 |
$34.61 |
$76.00 |
|
|
Urinalysis qual/semiquant excpt ia
|
$9.60 |
$17.98 |
$68.00 |
|
|
Urinalysis (with microscopy)
|
$32.00 |
$72.91 |
$83.10 |
|
|
Urinalysis (without microscopy)
|
$9.60 |
$38.81 |
$47.66 |
|
|
Urinary bldr retent nuc study
|
$455.20 |
$455.20 |
$455.20 |
|
|
Urinary reflex study
|
$216.05 |
$216.05 |
$354.14 |
|
|
Urine Culture Test
|
$32.42 |
$35.42 |
$114.40 |
|
|
Urine flow measurement 51736
|
$68.83 |
$68.83 |
$68.83 |
|
|
Urine pregnancy test
|
$30.40 |
$51.41 |
$88.80 |
|
|
Urography, antegrade
|
$684.80 |
$794.08 |
$940.00 |
|
|
Urography inf drip &/or bolus
|
$277.34 |
$278.77 |
$1,040.00 |
|
|
Use 1st target lesion
|
$238.70 |
$405.94 |
$405.94 |
|
|
User adjustable heel height
|
$2,876.33 |
$3,820.71 |
$3,820.71 |
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$2,558.91 |
$5,717.43 |
$6,670.33 |
|
|
Ustekinumab 45 mg/0.5 ml subcutaneous solution
|
$31,052.44 |
$45,901.36 |
$45,901.36 |
|
|
Vaccine Administration (one shot)
|
$19.21 |
$64.00 |
$96.80 |
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$205.54 |
$214.00 |
$290.49 |
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$196.97 |
$196.97 |
$238.92 |
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$150.12 |
$229.80 |
$232.02 |
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$113.31 |
$113.31 |
$113.31 |
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$198.46 |
$198.46 |
$198.46 |
|
|
Vaccine dtap < 7 years im
|
$56.44 |
$71.17 |
$78.13 |
|
|
Vaccine dtap-hep b-ipv im
|
$138.56 |
$161.65 |
$161.65 |
|
|
Vaccine dtap-ipv 4-6 years im
|
$89.09 |
$98.16 |
$125.23 |
|
|
Vaccine dtap-ipv-hib-hepb im
|
$175.00 |
$214.68 |
$273.79 |
|
|
Vaccine dtap-ipv/hib im
|
$108.20 |
$108.26 |
$116.92 |
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$70.53 |
$77.13 |
$83.56 |
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$44.26 |
$73.56 |
$493.68 |
|
|
Vaccine hepatitis a (hepa) adult im
|
$93.75 |
$142.82 |
$166.62 |
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$135.40 |
$199.30 |
$245.62 |
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$79.15 |
$84.07 |
$84.07 |
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$78.76 |
$125.21 |
$216.32 |
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$143.15 |
$258.44 |
$367.17 |
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$56.32 |
$72.11 |
$125.21 |
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$242.92 |
$442.57 |
$469.81 |
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$544.93 |
$544.93 |
$544.93 |
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$45.20 |
$45.20 |
$61.20 |
|
|
Vaccine influenza inactivated adjuvant im
|
$38.00 |
$58.24 |
$122.85 |
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$12.64 |
$89.98 |
$95.23 |
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$15.00 |
$29.01 |
$60.37 |
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$170.28 |
$301.09 |
$394.26 |
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$186.47 |
$238.10 |
$294.05 |
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$220.52 |
$220.52 |
$234.96 |
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$277.19 |
$323.39 |
$323.39 |
|
|
Vaccine mmr live subcutaneous
|
$104.84 |
$190.84 |
$216.19 |
|
|
Vaccine mmrv live subcutaneous
|
$474.24 |
$474.24 |
$474.24 |
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$132.04 |
$216.74 |
$271.97 |
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$235.60 |
$382.87 |
$479.17 |
|
|
Vaccine pneumonococcal conjugate 15 valent (pcv15) im
|
$234.07 |
$365.22 |
$370.80 |
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$434.66 |
$507.11 |
$507.11 |
|
|
Vaccine polio (ipv) subcutaneous/im
|
$75.02 |
$108.81 |
$271.12 |
|
|
Vaccine rabies im
|
$344.93 |
$573.83 |
$963.04 |
|
|
Vaccine respiratory syncytial virus bivalent subunit/preservative free im
|
$300.00 |
$517.14 |
$517.14 |
|
