|
Unlisted procedure esophagus
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$1,215.50
|
|
Unlisted procedure eyelids
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$479.62
|
|
Unlisted procedure larynx
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$4,350.00
|
|
Unlisted procedure liver
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$2,694.00
|
|
Unlisted procedure orbit
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$353.74
|
|
Unlisted procedure pancreas
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$2,967.75
|
|
Unlisted procedure rectum
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$1,278.72
|
|
Unlisted procedure spine
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$4,706.35
|
|
Unlisted px abdomen muscskel
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$2,633.80
|
|
Unlisted px accessory sinus
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$257.26
|
|
Unlisted px ant segment eye
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$2,698.92
|
|
Unlisted px arthroscopy
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$4,087.20
|
|
Unlisted px biliary tract
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$2,718.10
|
|
Unlisted px casting/strpg
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$224.93
|
|
Unlisted px conjunctiva
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$353.74
|
|
Unlisted px exc pressure ulc
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$832.60
|
|
Unlisted px external ear
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$354.00
|
|
Unlisted px extraocular musc
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$352.04
|
|
Unlisted px foot/toes
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$3,105.70
|
|
Unlisted px forearm/wrist
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$3,521.60
|
|
Unlisted px hands/fingers
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$379.44
|
|
Unlisted px inner ear
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$4,881.00
|
|
Unlisted px lacrimal system
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$359.15
|
|
Unlisted px leg/ankle
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$811.00
|
|
Unlisted px male genital sys
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$897.95
|
|
Unlisted px middle ear
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$1,975.05
|
|
Unlisted px neck/thorax
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$2,680.22
|
|
Unlisted px palate uvula
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$257.04
|
|
Unlisted px pelvis/hip joint
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$2,108.82
|
|
Unlisted px posterior segmnt
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$3,997.80
|
|
Unlisted px salivry glnd/dux
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$486.72
|
|
Unlisted px small intestine
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$2,118.35
|
|
Unlisted px temporal bone
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$274.80
|
|
Unlisted px tongue flr mouth
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$274.80
|
|
Unlisted px vestibule mouth
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$274.80
|
|
Unlisted vasc endoscopy px
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$862.57
|
|
Unlstd laps px mat care&dlvr
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$6,463.42
|
|
Unlstd laps px sprmatic cord
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$4,881.00
|
|
Unsched dialysis esrd pt hos
|
$363.19 |
$363.19 |
$363.19 |
$1,469.76
|
|
Upgrade pm system
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$12,324.60
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$938.68 |
$938.68 |
$938.68 |
$2,916.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$708.00 |
$708.00 |
$708.00 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$562.34 |
$562.34 |
$562.34 |
$2,013.08
|
|
Upper Endoscopy (EGD, diagnostic)
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$1,588.59
|
|
Upper Endoscopy (EGD, with biopsy)
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$1,656.60
|
|
Upper ext fx orthosis rad/ul
|
$65.69 |
$65.69 |
$65.69 |
$619.49
|
|
Uppr gi scope w/submuc inj
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$1,773.85
|
|
Urachal cyst/sinus excision 51500
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$6,082.67
|
|
Urea nitrogen
|
$4.35 |
$4.35 |
$4.35 |
$45.10
|
|
Urea nitrogen 24 hour urine
|
$6.12 |
$6.12 |
$6.12 |
$50.00
|
|
Urea nitrogen clearance
|
$7.92 |
$7.92 |
$7.92 |
$33.57
|
|
Urea nitrogen semi-quant
|
$5.64 |
$5.64 |
$5.64 |
$5.64
|
|
Ureter endoscopy
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$3,820.84
|
|
Ureter endoscopy & biopsy
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$5,626.86
|
|
Ureter endoscopy & biopsy
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$5,626.86
|
|
Ureter endoscopy & catheter
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$3,820.84
|
|
Ureter endoscopy & treatment
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$5,626.86
|
|
Ureter endoscopy & treatment
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$5,339.00
|
|
Ureter endoscopy & treatment
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$5,626.86
|
|
Ureter endoscopy & treatment
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$5,339.00
|
|
Urethrcystgrphy rtrgrde s&i
|
$294.31 |
$294.31 |
$294.31 |
$574.40
|
|
Urethrlys transvag with scope
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$4,081.37
|
|
Urethrocystography void s&i
|
$193.89 |
$193.89 |
$193.89 |
$634.50
|
|
Uric acid blood
|
$4.97 |
$4.97 |
$4.97 |
$46.64
|
|
Uric acid urine
|
$5.59 |
$5.59 |
$5.59 |
$46.75
|
|
Urinalysis glass test
|
$5.17 |
$5.17 |
$5.17 |
$5.17
|
|
Urinalysis microscopic only
|
$3.36 |
$3.36 |
$3.36 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$2.39 |
$2.39 |
$2.39 |
$25.72
|
|
Urinalysis (with microscopy)
|
$3.49 |
$3.49 |
$3.49 |
$48.14
|
|
Urinalysis (without microscopy)
|
$2.48 |
$2.48 |
$2.48 |
$38.99
|
|
Urinary reflex study
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$152.00
|
|
Urine Culture Test
|
$8.88 |
$8.88 |
$8.88 |
$84.81
|
|
Urine flow measurement 51736
|
$5,855.00 |
$5,855.00 |
$5,855.00 |
$152.54
|
|
Urine pregnancy test
|
$9.47 |
$9.47 |
$9.47 |
$66.40
|
|
Urine screen for bacteria
|
$32.98 |
$32.98 |
$32.98 |
$32.98
|
|
Urine specimen collect mult
|
$9.71 |
$9.71 |
$9.71 |
$12.89
|
|
Urography, antegrade
|
$251.70 |
$251.70 |
$251.70 |
$593.37
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$140.67 |
$140.67 |
$140.67 |
$223.08
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$139.06 |
$139.06 |
$139.06 |
$218.88
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$157.38 |
$157.38 |
$157.38 |
$239.85
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$93.94 |
$93.94 |
$93.94 |
$131.67
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$70.15 |
$70.15 |
$70.15 |
$91.00
|
|
Vaccine dtap < 7 years im
|
$46.83 |
$46.83 |
$46.83 |
$87.80
|
|
Vaccine dtap-hep b-ipv im
|
$71.55 |
$71.55 |
$71.55 |
$193.83
|
|
Vaccine dtap-ipv 4-6 years im
|
$50.61 |
$50.61 |
$50.61 |
$126.84
|
|
Vaccine dtap-ipv-hib-hepb im
|
$153.97 |
$153.97 |
$153.97 |
$158.30
|
|
Vaccine dtap-ipv/hib im
|
$78.13 |
$78.13 |
$78.13 |
$248.80
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$29.62 |
$29.62 |
$29.62 |
$85.00
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$12.36 |
$12.36 |
$12.36 |
$45.33
|
|
Vaccine hepatitis a (hepa) adult im
|
$73.07 |
$73.07 |
$73.07 |
$178.07
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$111.00 |
$111.00 |
$111.00 |
$218.40
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$30.64 |
$30.64 |
$30.64 |
$84.38
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$48.70 |
$48.70 |
$48.70 |
$173.98
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$135.21 |
$135.21 |
$135.21 |
$306.24
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$17.93 |
$17.93 |
$17.93 |
$79.04
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$264.75 |
$264.75 |
$264.75 |
$686.67
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$281.66 |
$281.66 |
$281.66 |
$226.20
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$80.68 |
$80.68 |
$80.68 |
$157.41
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$17.44 |
$17.44 |
$17.44 |
$48.29
|
|
Vaccine influenza quadrivalent (iiv4) 0.5ml dose im
|
$20.48 |
$20.48 |
$20.48 |
$42.90
|
