|
Tx contour defects 1.1-5.0cc 11951
|
$164.00 |
$164.00 |
$164.00 |
$724.37
|
|
Tx ectopic pregnancy abdl pregnancy 59130
|
$1,400.80 |
$1,400.80 |
$1,400.80 |
$2,277.60
|
|
Tx open art fx mcp/iphlngl jnt incl int fixtn ea
|
$1,096.00 |
$1,096.00 |
$1,096.00 |
$4,449.44
|
|
Tx open dstl phlngl fx f/t internal fixation ea
|
$743.20 |
$743.20 |
$743.20 |
$4,499.12
|
|
Tx phalangeal shaft fx open prox/middle ea
|
$879.20 |
$879.20 |
$879.20 |
$4,499.12
|
|
Tx septic abortion surgical 59830
|
$696.00 |
$696.00 |
$696.00 |
$1,094.40
|
|
Tympanic membrane repair
|
$567.20 |
$567.20 |
$567.20 |
$1,856.00
|
|
Tympanometry & reflex thresh
|
$32.80 |
$32.80 |
$32.80 |
$173.18
|
|
Tympanostomy/ven tube/loc/top anes 69433
|
$300.00 |
$300.00 |
$300.00 |
$911.43
|
|
Ua w/micro/comp poc
|
$19.20 |
$19.20 |
$19.20 |
$24.45
|
|
Ultrasound abdomen aorta screening study aaa
|
$287.20 |
$287.20 |
$287.20 |
$403.26
|
|
Ultrasound breast complete
|
$187.20 |
$187.20 |
$187.20 |
$519.75
|
|
Ultrasound breast unilateral limited (both sides)
|
$187.20 |
$187.20 |
$187.20 |
$449.35
|
|
Ultrasound chest
|
$477.60 |
$477.60 |
$477.60 |
$459.55
|
|
Ultrasound doppler velocimetry fetal umbilical artery
|
$104.80 |
$104.80 |
$104.80 |
$340.14
|
|
Ultrasound elastography parenchyma
|
$396.00 |
$396.00 |
$396.00 |
$284.25
|
|
Ultrasound encephalogram
|
$187.20 |
$187.20 |
$187.20 |
$481.60
|
|
Ultrasound exam k transpl w/doppler
|
$508.00 |
$508.00 |
$508.00 |
$570.44
|
|
Ultrasound fetal biophysical profile without non-stress testing
|
$466.40 |
$466.40 |
$466.40 |
$477.88
|
|
Ultrasound guidance for vascular access
|
$497.60 |
$497.60 |
$497.60 |
$340.22
|
|
Ultrasound guided needle placement supervision & interpretation
|
$455.20 |
$455.20 |
$455.20 |
$701.35
|
|
Ultrasound guide intraoperative
|
$657.60 |
$657.60 |
$657.60 |
$632.90
|
|
Ultrasound hips infant dynamic
|
$414.40 |
$414.40 |
$414.40 |
$403.00
|
|
Ultrasound infant hips ltd without stress
|
$178.40 |
$178.40 |
$178.40 |
$321.35
|
|
Ultrasound joint complete left
|
$292.80 |
$292.80 |
$292.80 |
$556.14
|
|
Ultrasound joint/nonvascular extremity limited left
|
$191.20 |
$191.20 |
$191.20 |
$448.50
|
|
Ultrasound ob >=14wks ea addl gest
|
$284.80 |
$284.80 |
$284.80 |
$454.11
|
|
Ultrasound pregnant uterus < 14 weeks each additional gestation
|
$208.80 |
$208.80 |
$208.80 |
$326.54
|
|
Ultrasound pregnant uterus detailed fetal exam single/1st gestation
|
$853.60 |
$853.60 |
$853.60 |
$690.48
|
|
Ultrasound pregnant uterus follow up per fetus
|
$340.80 |
$340.80 |
$340.80 |
$450.75
|
|
Ultrasound pregnant uterus limited >= 1 fetuses
|
$280.80 |
$280.80 |
$280.80 |
$459.00
|
|
Ultrasound pregnant uterus transvaginal
|
$544.00 |
$544.00 |
$544.00 |
$485.48
|
|
Ultrasound prostate/transrectal
|
$645.60 |
$645.60 |
$645.60 |
$545.16
|
|
Ultrasound retroperitoneal limited
|
$434.40 |
$434.40 |
$434.40 |
$498.00
|
|
Ultrasound scrotum and contents
|
$477.60 |
$477.60 |
$477.60 |
$617.28
|
|
Ultrasound spinal canal and contents
|
$776.00 |
$776.00 |
$776.00 |
$450.60
|
|
Ultrasound transabd ea addl gest
|
$512.80 |
$512.80 |
$512.80 |
$425.10
|
|
Ultrasound transvaginal non obstetric
|
$457.60 |
$457.60 |
$457.60 |
$567.44
|
|
Umbilical artery cath newborn 36660
|
$100.00 |
$100.00 |
$100.00 |
$265.85
|
|
Unlisted chemotherapy px
|
$86.40 |
$86.40 |
$86.40 |
$153.85
|
|
Unlisted laparoscopic procedure 49659
|
$651.20 |
$651.20 |
$651.20 |
$6,838.32
|
|
Unlisted procedure microbiology
|
$2,585.60 |
$2,585.60 |
$2,585.60 |
$487.50
|
|
Unlisted transfusion med px
|
$200.80 |
$200.80 |
$200.80 |
$141.35
|
|
Unlisted ultrasound procedure
|
$136.00 |
$136.00 |
$136.00 |
$321.20
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$2,889.60 |
$2,889.60 |
$2,889.60 |
$2,916.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$1,895.20 |
$1,895.20 |
$1,895.20 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$1,821.60 |
$1,821.60 |
$1,821.60 |
$2,013.08
|
|
Upper Endoscopy (EGD, diagnostic)
|
$451.20 |
$451.20 |
$451.20 |
$1,588.59
|
|
Upper Endoscopy (EGD, with biopsy)
|
$577.60 |
$577.60 |
$577.60 |
$1,656.60
|
|
Urea nitrogen
|
$52.80 |
$52.80 |
$52.80 |
$45.10
|
|
Urea nitrogen 24 hour urine
|
$73.60 |
$73.60 |
$73.60 |
$50.00
|
|
Ureter endoscopy & treatment
|
$579.20 |
$579.20 |
$579.20 |
$5,339.00
|
|
Urethrocystography void s&i
|
$957.60 |
$957.60 |
$957.60 |
$634.50
|
|
Uric acid blood
|
$55.20 |
$55.20 |
$55.20 |
$46.64
|
|
Uric acid urine
|
$42.40 |
$42.40 |
$42.40 |
$46.75
|
|
Urinalysis microscopic only
|
$47.20 |
$47.20 |
$47.20 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$84.00 |
$84.00 |
$84.00 |
$25.72
|
|
Urinalysis (with microscopy)
|
$57.60 |
$57.60 |
$57.60 |
$48.14
|
|
Urinalysis (without microscopy)
|
$44.00 |
$44.00 |
$44.00 |
$38.99
|
|
Urine Culture Test
|
$88.00 |
$88.00 |
$88.00 |
$84.81
|
|
Urine flow measurement 51736
|
$20.80 |
$20.80 |
$20.80 |
$152.54
|
|
Urine pregnancy test
|
$61.60 |
$61.60 |
$61.60 |
$66.40
|
|
Urography, antegrade
|
$371.20 |
$371.20 |
$371.20 |
$593.37
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$5,701.18 |
$5,701.18 |
$5,701.18 |
$5,521.54
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$233.47 |
$233.47 |
$233.47 |
$223.08
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$233.47 |
$233.47 |
$233.47 |
$218.88
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$209.76 |
$209.76 |
$209.76 |
$239.85
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$140.45 |
$140.45 |
$140.45 |
$131.67
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$104.58 |
$104.58 |
$104.58 |
$91.00
|
|
Vaccine dtap < 7 years im
|
$157.21 |
$157.21 |
$157.21 |
$87.80
|
|
Vaccine dtap-hep b-ipv im
|
$88.00 |
$88.00 |
$88.00 |
$193.83
|
|
Vaccine dtap-ipv 4-6 years im
|
$235.06 |
$235.06 |
$235.06 |
$126.84
|
|
Vaccine dtap-ipv-hib-hepb im
|
$88.00 |
$88.00 |
$88.00 |
$158.30
|
|
Vaccine dtap-ipv/hib im
|
$61.60 |
$61.60 |
$61.60 |
$248.80
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$10.40 |
$10.40 |
$10.40 |
$45.33
|
|
Vaccine hepatitis a (hepa) adult im
|
$391.94 |
$391.94 |
$391.94 |
$178.07
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$24.80 |
$24.80 |
$24.80 |
$84.38
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$40.00 |
$40.00 |
$40.00 |
$173.98
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$16.00 |
$16.00 |
$16.00 |
$79.04
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$218.40 |
$218.40 |
$218.40 |
$686.67
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$218.40 |
$218.40 |
$218.40 |
$226.20
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$55.20 |
$55.20 |
$55.20 |
$157.41
|
|
Vaccine influenza inactivated adjuvant im
|
$339.74 |
$339.74 |
$339.74 |
$110.25
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$13.60 |
$13.60 |
$13.60 |
$48.29
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$18.40 |
$18.40 |
$18.40 |
$40.01
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$59.20 |
$59.20 |
$59.20 |
$72.00
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$163.34 |
$163.34 |
$163.34 |
$103.88
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$147.20 |
$147.20 |
$147.20 |
$499.00
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$96.00 |
$96.00 |
$96.00 |
$349.15
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$96.00 |
$96.00 |
$96.00 |
$408.70
|
|
Vaccine mmr live subcutaneous
|
$74.40 |
$74.40 |
$74.40 |
$224.04
|
|
Vaccine mmrv live subcutaneous
|
$228.80 |
$228.80 |
$228.80 |
$474.24
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$100.80 |
$100.80 |
$100.80 |
$274.95
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$192.80 |
$192.80 |
$192.80 |
$397.18
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$634.68 |
$634.68 |
$634.68 |
$715.41
|
|
Vaccine polio (ipv) subcutaneous/im
|
$212.80 |
$212.80 |
$212.80 |
$119.17
|
|
Vaccine rabies im
|
$1,683.17 |
$1,683.17 |
$1,683.17 |
$945.46
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$376.00 |
$376.00 |
$376.00 |
$1,196.00
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$376.00 |
$376.00 |
$376.00 |
$1,159.00
|
|
Vaccine rotavirus pentavalent (rv5) live 3 dose oral
|
$72.00 |
$72.00 |
$72.00 |
$108.00
|
