|
Unlisted px middle ear
|
$196.30 |
$196.30 |
$196.30 |
$343.50
|
|
Unlisted px neck/thorax
|
$4,011.15 |
$4,011.15 |
$4,011.15 |
$571.20
|
|
Unlisted px pelvis/hip joint
|
$8,660.60 |
$8,660.60 |
$8,660.60 |
$3,251.90
|
|
Unlisted px posterior segmnt
|
$4,245.80 |
$4,245.80 |
$4,245.80 |
$3,173.34
|
|
Unlisted px salivry glnd/dux
|
$1,607.45 |
$1,607.45 |
$1,607.45 |
$1,173.42
|
|
Unlisted px small intestine
|
$7,163.00 |
$7,163.00 |
$7,163.00 |
$2,118.35
|
|
Unlisted px tongue flr mouth
|
$897.00 |
$897.00 |
$897.00 |
$282.50
|
|
Unlisted px vestibule mouth
|
$1,409.20 |
$1,409.20 |
$1,409.20 |
$456.96
|
|
Unlisted special svc px/rprt
|
$455.00 |
$455.00 |
$455.00 |
$90.00
|
|
Unlisted surgical path px
|
$217.75 |
$217.75 |
$217.75 |
$216.00
|
|
Unlisted ultrasound procedure
|
$216.45 |
$216.45 |
$216.45 |
$335.00
|
|
Unlisted urinalysis px
|
$7.15 |
$7.15 |
$7.15 |
$25.72
|
|
Unlstd laps px sprmatic cord
|
$1,731.60 |
$1,731.60 |
$1,731.60 |
$4,713.11
|
|
Upgrade pm system
|
$16,760.25 |
$16,760.25 |
$16,760.25 |
$12,087.24
|
|
Upper Arm (Humerus) X-ray (left side)
|
$436.80 |
$436.80 |
$436.80 |
$309.31
|
|
Upper Back (Thoracic Spine) CT Scan (with contrast)
|
$1,115.40 |
$1,115.40 |
$1,115.40 |
$1,652.95
|
|
Upper Back (Thoracic Spine) CT Scan (without contrast)
|
$737.10 |
$737.10 |
$737.10 |
$1,422.05
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$2,197.00 |
$2,197.00 |
$2,197.00 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$2,110.55 |
$2,110.55 |
$2,110.55 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$1,507.35 |
$1,507.35 |
$1,507.35 |
$2,034.41
|
|
Upper Back (Thoracic Spine) X-ray (2 views)
|
$534.30 |
$534.30 |
$534.30 |
$320.45
|
|
Upper Back (Thoracic Spine) X-ray (3 views)
|
$542.75 |
$542.75 |
$542.75 |
$380.82
|
|
Upper Endoscopy (EGD, diagnostic)
|
$2,803.45 |
$2,803.45 |
$2,803.45 |
$1,824.75
|
|
Upper Endoscopy (EGD, with biopsy)
|
$683.80 |
$683.80 |
$683.80 |
$1,768.00
|
|
Upper ext fx orthosis rad/ul
|
$427.05 |
$427.05 |
$427.05 |
$619.49
|
|
Upper ext harvest for cabg1 seg 35600
|
$1,027.00 |
$1,027.00 |
$1,027.00 |
$627.20
|
|
Upper GI Barium X-ray (barium and gas)
|
$798.20 |
$798.20 |
$798.20 |
$657.77
|
|
Upper GI Barium X-ray (barium only)
|
$798.20 |
$798.20 |
$798.20 |
$603.20
|
|
Uppr gi scope w/submuc inj
|
$683.80 |
$683.80 |
$683.80 |
$1,872.00
|
|
Urachal cyst/sinus excision 51500
|
$2,873.00 |
$2,873.00 |
$2,873.00 |
$6,082.67
|
|
Urea nitrogen
|
$17.55 |
$17.55 |
$17.55 |
$42.00
|
|
Urea nitrogen 24 hour urine
|
$24.70 |
$24.70 |
$24.70 |
$51.77
|
|
Urea nitrogen semi-quant
|
$22.75 |
$22.75 |
$22.75 |
$10.40
|
|
Ureteral embolization/occl
|
$392.60 |
$392.60 |
$392.60 |
$2,079.31
|
|
Ureteral reflux study
|
$1,950.65 |
$1,950.65 |
$1,950.65 |
$952.50
|
|
Ureteroneocystostomy 50780
|
$5,705.70 |
$5,705.70 |
$5,705.70 |
$4,457.05
|
|
Ureteroureterostomy 50760
|
$5,218.20 |
$5,218.20 |
$5,218.20 |
$2,773.01
|
|
Urethrcystgrphy rtrgrde s&i
|
$1,170.00 |
$1,170.00 |
$1,170.00 |
$592.80
|
|
Urethrlys transvag with scope
|
$3,380.00 |
$3,380.00 |
$3,380.00 |
$4,081.37
|
|
Urethrocystography void s&i
|
$1,170.00 |
$1,170.00 |
$1,170.00 |
$631.75
|
|
Uric acid blood
|
$20.15 |
$20.15 |
$20.15 |
$48.96
|
|
Uric acid urine
|
$22.75 |
$22.75 |
$22.75 |
$44.14
|
|
Urinalysis microscopic only
|
$13.65 |
$13.65 |
$13.65 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$9.75 |
$9.75 |
$9.75 |
$25.72
|
|
Urinalysis (with microscopy)
|
$14.30 |
$14.30 |
$14.30 |
$54.60
|
|
Urinalysis (without microscopy)
|
$10.40 |
$10.40 |
$10.40 |
$35.15
|
|
Urine Culture Test
|
$36.40 |
$36.40 |
$36.40 |
$81.00
|
|
Urine flow measurement 51736
|
$44.20 |
$44.20 |
$44.20 |
$210.00
|
|
Urine pregnancy test
|
$38.35 |
$38.35 |
$38.35 |
$66.87
|
|
Urography, antegrade
|
$1,734.20 |
$1,734.20 |
$1,734.20 |
$622.35
|
|
Urography inf drip &/or bolus
|
$798.20 |
$798.20 |
$798.20 |
$642.50
|
|
Use 1st target lesion
|
$630.50 |
$630.50 |
$630.50 |
$332.00
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$190.77 |
$190.77 |
$190.77 |
$5,205.00
|
|
Ustekinumab 45 mg/0.5 ml subcutaneous solution
|
$68,214.47 |
$68,214.47 |
$68,214.47 |
$51,633.07
|
|
Vaccine Administration (one shot)
|
$139.10 |
$139.10 |
$139.10 |
$67.74
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$1,207.44 |
$1,207.44 |
$1,207.44 |
$211.89
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$1,324.79 |
$1,324.79 |
$1,324.79 |
$234.36
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$180.70 |
$180.70 |
$180.70 |
$123.20
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$91.00 |
$91.00 |
$91.00 |
$80.15
|
|
Vaccine dtap < 7 years im
|
$136.99 |
$136.99 |
$136.99 |
$68.19
|
|
Vaccine dtap-hep b-ipv im
|
$502.91 |
$502.91 |
$502.91 |
$164.63
|
|
Vaccine dtap-ipv 4-6 years im
|
$291.15 |
$291.15 |
$291.15 |
$105.95
|
|
Vaccine dtap-ipv-hib-hepb im
|
$762.18 |
$762.18 |
$762.18 |
$174.72
|
|
Vaccine dtap-ipv/hib im
|
$303.99 |
$303.99 |
$303.99 |
$221.24
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$143.79 |
$143.79 |
$143.79 |
$72.00
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$30.79 |
$30.79 |
$30.79 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$207.83 |
$207.83 |
$207.83 |
$169.35
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$327.83 |
$327.83 |
$327.83 |
$231.56
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$185.00 |
$185.00 |
$185.00 |
$80.28
|
|
Vaccine hepatitis b (hepb) adolescent 2 dose im
|
$90.35 |
$90.35 |
$90.35 |
$90.35
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$173.98 |
$173.98 |
$173.98 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$728.91 |
$728.91 |
$728.91 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$137.40 |
$137.40 |
$137.40 |
$75.39
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$1,536.64 |
$1,536.64 |
$1,536.64 |
$562.20
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$287.30 |
$287.30 |
$287.30 |
$282.50
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$264.24 |
$264.24 |
$264.24 |
$143.20
|
|
Vaccine influenza nos 0.5ml dose im
|
$45.31 |
$45.31 |
$45.31 |
$24.20
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$97.11 |
$97.11 |
$97.11 |
$48.59
|
|
Vaccine influenza quadrivalent (iiv4) 0.5ml dose im
|
$43.55 |
$43.55 |
$43.55 |
$35.88
|
|
Vaccine influenza quadrivalent (iiv4) inactivated adjuvanted preservative free 0.5ml dose im
|
$157.95 |
$157.95 |
$157.95 |
$72.80
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.25ml dose im
|
$22.10 |
$22.10 |
$22.10 |
$28.77
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$45.50 |
$45.50 |
$45.50 |
$33.21
|
|
Vaccine influenza quadrivalent (iiv4) split virus 0.25 ml im
|
$21.45 |
$21.45 |
$21.45 |
$20.80
|
|
Vaccine influenza quadrivalent live (laiv4) intranasal
|
$37.05 |
$37.05 |
$37.05 |
$37.05
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$151.45 |
$151.45 |
$151.45 |
$72.00
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$1,172.61 |
$1,172.61 |
$1,172.61 |
$387.95
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$1,053.74 |
$1,053.74 |
$1,053.74 |
$406.05
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$825.36 |
$825.36 |
$825.36 |
$310.93
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$411.74 |
$411.74 |
$411.74 |
$323.39
|
|
Vaccine mmr live subcutaneous
|
$224.04 |
$224.04 |
$224.04 |
$211.68
|
|
Vaccine mmrv live subcutaneous
|
$669.63 |
$669.63 |
$669.63 |
$466.88
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$547.93 |
$547.93 |
$547.93 |
$251.64
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$1,089.31 |
$1,089.31 |
$1,089.31 |
$393.25
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$1,440.87 |
$1,440.87 |
$1,440.87 |
$563.36
|
|
Vaccine polio (ipv) subcutaneous/im
|
$220.25 |
$220.25 |
$220.25 |
$90.70
|
|
Vaccine rabies im
|
$1,016.98 |
$1,016.98 |
$1,016.98 |
$858.95
|
|
Vaccine respiratory syncytial virus bivalent subunit/preservative free im
|
$746.62 |
$746.62 |
$746.62 |
$521.74
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$2,784.89 |
$2,784.89 |
$2,784.89 |
$1,104.47
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$1,392.44 |
$1,392.44 |
$1,392.44 |
$980.10
|
|
Vaccine respiratory syncytial virus recombinant subunit adjuvanted/preservative free im
|
$235.95 |
$235.95 |
$235.95 |
$407.74
|
