|
Unlisted px pelvis/hip joint
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$2,108.82
|
|
Unlisted px posterior segmnt
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$3,997.80
|
|
Unlisted px salivry glnd/dux
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$486.72
|
|
Unlisted px small intestine
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$2,118.35
|
|
Unlisted px temporal bone
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$274.80
|
|
Unlisted px tongue flr mouth
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$274.80
|
|
Unlisted px vestibule mouth
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$274.80
|
|
Unlisted transfusion med px
|
$159.13 |
$159.13 |
$159.13 |
$141.35
|
|
Unlisted vasc endoscopy px
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$862.57
|
|
Unlstd laps px mat care&dlvr
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$6,463.42
|
|
Unlstd laps px sprmatic cord
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$4,881.00
|
|
Unsched dialysis esrd pt hos
|
$735.92 |
$735.92 |
$735.92 |
$1,469.76
|
|
Upgrade pm system
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$12,324.60
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$1,059.71 |
$1,059.71 |
$1,059.71 |
$2,916.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$799.28 |
$799.28 |
$799.28 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$634.85 |
$634.85 |
$634.85 |
$2,013.08
|
|
Upper Endoscopy (EGD, diagnostic)
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$1,588.59
|
|
Upper Endoscopy (EGD, with biopsy)
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$1,656.60
|
|
Upper ext fx orthosis rad/ul
|
$52.97 |
$52.97 |
$52.97 |
$619.49
|
|
Uppr gi scope w/submuc inj
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$1,773.85
|
|
Urachal cyst/sinus excision 51500
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$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
|
|
Ureteral reflux study
|
$425.07 |
$425.07 |
$425.07 |
$961.20
|
|
Ureter endoscopy
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$3,820.84
|
|
Ureter endoscopy & biopsy
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,626.86
|
|
Ureter endoscopy & biopsy
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,626.86
|
|
Ureter endoscopy & catheter
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$3,820.84
|
|
Ureter endoscopy & treatment
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,626.86
|
|
Ureter endoscopy & treatment
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,339.00
|
|
Ureter endoscopy & treatment
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,626.86
|
|
Ureter endoscopy & treatment
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,339.00
|
|
Urethrcystgrphy rtrgrde s&i
|
$269.96 |
$269.96 |
$269.96 |
$574.40
|
|
Urethrlys transvag with scope
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$4,081.37
|
|
Urethrocystography void s&i
|
$221.85 |
$221.85 |
$221.85 |
$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
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$152.00
|
|
Urine Culture Test
|
$8.88 |
$8.88 |
$8.88 |
$84.81
|
|
Urine flow measurement 51736
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$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
|
$272.29 |
$272.29 |
$272.29 |
$593.37
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$61.08 |
$61.08 |
$61.08 |
$223.08
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$60.38 |
$60.38 |
$60.38 |
$218.88
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$68.33 |
$68.33 |
$68.33 |
$239.85
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$40.79 |
$40.79 |
$40.79 |
$131.67
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$30.46 |
$30.46 |
$30.46 |
$91.00
|
|
Vaccine dtap < 7 years im
|
$20.33 |
$20.33 |
$20.33 |
$87.80
|
|
Vaccine dtap-hep b-ipv im
|
$31.07 |
$31.07 |
$31.07 |
$193.83
|
|
Vaccine dtap-ipv 4-6 years im
|
$21.97 |
$21.97 |
$21.97 |
$126.84
|
|
Vaccine dtap-ipv-hib-hepb im
|
$66.85 |
$66.85 |
$66.85 |
$158.30
|
|
Vaccine dtap-ipv/hib im
|
$33.92 |
$33.92 |
$33.92 |
$248.80
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$12.86 |
$12.86 |
$12.86 |
$85.00
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$5.37 |
$5.37 |
$5.37 |
$45.33
|
|
Vaccine hepatitis a (hepa) adult im
|
$31.72 |
$31.72 |
$31.72 |
$178.07
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$48.19 |
$48.19 |
$48.19 |
$218.40
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$13.30 |
$13.30 |
$13.30 |
$84.38
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$21.14 |
$21.14 |
$21.14 |
$173.98
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$58.71 |
$58.71 |
$58.71 |
$306.24
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$7.78 |
$7.78 |
$7.78 |
$79.04
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$114.95 |
$114.95 |
$114.95 |
$686.67
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$122.29 |
$122.29 |
$122.29 |
$226.20
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$35.03 |
$35.03 |
$35.03 |
$157.41
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$7.57 |
$7.57 |
$7.57 |
$48.29
|
|
Vaccine influenza quadrivalent (iiv4) 0.5ml dose im
|
$8.89 |
$8.89 |
$8.89 |
$42.90
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$9.11 |
$9.11 |
$9.11 |
$40.01
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$28.94 |
$28.94 |
$28.94 |
$72.00
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$77.94 |
$77.94 |
$77.94 |
$499.00
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$57.08 |
$57.08 |
$57.08 |
$349.15
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$25.45 |
$25.45 |
$25.45 |
$408.70
|
|
Vaccine mmr live subcutaneous
|
$19.42 |
$19.42 |
$19.42 |
$224.04
|
|
Vaccine mmrv live subcutaneous
|
$132.44 |
$132.44 |
$132.44 |
$474.24
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$53.04 |
$53.04 |
$53.04 |
$274.95
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$100.73 |
$100.73 |
$100.73 |
$397.18
|
|
Vaccine pneumonococcal conjugate 15 valent (pcv15) im
|
$107.16 |
$107.16 |
$107.16 |
$385.45
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$114.60 |
$114.60 |
$114.60 |
$715.41
|
|
Vaccine polio (ipv) subcutaneous/im
|
$12.05 |
$12.05 |
$12.05 |
$119.17
|
|
Vaccine rabies im
|
$168.43 |
$168.43 |
$168.43 |
$945.46
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$251.75 |
$251.75 |
$251.75 |
$1,196.00
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$251.75 |
$251.75 |
$251.75 |
$1,159.00
|
|
Vaccine rotavirus attenuated (rv1) live 2 dose oral
|
$49.72 |
$49.72 |
$49.72 |
$200.70
|
|
Vaccine rotavirus pentavalent (rv5) live 3 dose oral
|
$44.97 |
$44.97 |
$44.97 |
$108.00
|
|
Vaccine tdap >=7 years im
|
$17.96 |
$17.96 |
$17.96 |
$150.76
|
|
Vaccine td preservative free >= 7 years im
|
$16.01 |
$16.01 |
$16.01 |
$131.77
|
|
Vaccine typhoid vicps im
|
$47.82 |
$47.82 |
$47.82 |
$205.22
|
|
Vaccine varicella live subcutaneous
|
$71.72 |
$71.72 |
$71.72 |
$447.80
|
|
Vag hys/<250g/rmv tube/rpr entero 58263
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,345.59
|
|
Vag hyst incl t/o complex
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,735.60
|
|
Vag hyst including t/o
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,110.00
|
|
Vag hyst t/o & repair compl
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$6,037.58
|
|
Vag hyst w/enterocele compl 58294
|
$6,839.00 |
$6,839.00 |
$6,839.00 |
$5,232.57
|
