|
Unlisted procedure spine
|
$8,245.45 |
$8,245.45 |
$8,245.45 |
$4,706.35
|
|
Unlisted px abdomen muscskel
|
$11,582.59 |
$11,582.59 |
$11,582.59 |
$2,053.50
|
|
Unlisted px ant segment eye
|
$2,264.15 |
$2,264.15 |
$2,264.15 |
$2,698.92
|
|
Unlisted px arthroscopy
|
$13,708.47 |
$13,708.47 |
$13,708.47 |
$2,765.60
|
|
Unlisted px biliary tract
|
$539.10 |
$539.10 |
$15,692.77 |
$3,055.00
|
|
Unlisted px casting/strpg
|
$136.50 |
$442.48 |
$540.34 |
$222.00
|
|
Unlisted px diaphragm
|
$6,547.57 |
$6,547.57 |
$6,547.57 |
$6,325.20
|
|
Unlisted px external ear
|
$329.70 |
$329.70 |
$433.65 |
$325.68
|
|
Unlisted px foot/toes
|
$7,763.00 |
$7,763.00 |
$7,763.00 |
$1,225.50
|
|
Unlisted px forearm/wrist
|
$6,515.57 |
$6,515.57 |
$6,515.57 |
$859.50
|
|
Unlisted px hands/fingers
|
$7,183.52 |
$7,183.52 |
$7,183.52 |
$349.70
|
|
Unlisted px inner ear
|
$17,114.99 |
$17,114.99 |
$17,114.99 |
$571.20
|
|
Unlisted px lacrimal system
|
$603.30 |
$603.30 |
$603.30 |
$416.50
|
|
Unlisted px leg/ankle
|
$6,818.24 |
$6,818.24 |
$6,818.24 |
$813.24
|
|
Unlisted px male genital sys
|
$6,664.68 |
$6,664.68 |
$6,664.68 |
$362.00
|
|
Unlisted px med radj physics
|
$376.03 |
$376.03 |
$376.03 |
$462.35
|
|
Unlisted px neck/thorax
|
$3,385.58 |
$3,385.58 |
$3,385.58 |
$571.20
|
|
Unlisted px palate uvula
|
$243.44 |
$243.44 |
$243.44 |
$274.80
|
|
Unlisted px pelvis/hip joint
|
$10,031.98 |
$10,031.98 |
$10,031.98 |
$3,251.90
|
|
Unlisted px salivry glnd/dux
|
$2,838.66 |
$2,838.66 |
$2,838.66 |
$1,265.16
|
|
Unlisted px small intestine
|
$2,754.15 |
$2,754.15 |
$3,029.95 |
$2,118.35
|
|
Unlisted px tongue flr mouth
|
$211.95 |
$211.95 |
$243.44 |
$282.50
|
|
Unlisted special svc px/rprt
|
$90.00 |
$90.00 |
$210.00 |
$90.00
|
|
Unlisted surgical path px
|
$360.00 |
$360.00 |
$558.28 |
$217.75
|
|
Unlisted transfusion med px
|
$469.05 |
$469.05 |
$469.05 |
$147.50
|
|
Unlisted ultrasound procedure
|
$483.30 |
$527.60 |
$2,231.09 |
$335.00
|
|
Unlstd laps px sprmatic cord
|
$3,961.44 |
$3,961.44 |
$3,961.44 |
$4,713.11
|
|
Unsched dialysis esrd pt hos
|
$1,951.63 |
$3,505.97 |
$3,632.50 |
$1,316.90
|
|
Upgrade pm system
|
$13,940.67 |
$18,019.35 |
$37,952.90 |
$12,087.24
|
|
Upper Arm (Humerus) X-ray (left side)
|
$283.50 |
$283.50 |
$351.00 |
$309.31
|
|
Upper Back (Thoracic Spine) CT Scan (with contrast)
|
$2,274.17 |
$2,577.00 |
$4,883.82 |
$1,680.60
|
|
Upper Back (Thoracic Spine) CT Scan (without contrast)
|
$1,890.44 |
$2,240.50 |
$5,888.27 |
$1,425.85
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$2,998.00 |
$3,264.90 |
$8,652.42 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$1,853.47 |
$2,652.50 |
$7,146.26 |
$2,410.98
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$2,034.41 |
$2,307.00 |
$7,070.90 |
$2,034.41
|
|
Upper Back (Thoracic Spine) X-ray (2 views)
|
$312.80 |
$373.00 |
$1,248.25 |
$322.50
|
|
Upper Back (Thoracic Spine) X-ray (3 views)
|
$371.85 |
$467.00 |
$1,422.26 |
$381.75
|
|
Upper Endoscopy (EGD, diagnostic)
|
$1,824.75 |
$1,824.75 |
$1,824.75 |
$1,824.75
|
|
Upper Endoscopy (EGD, with biopsy)
|
$1,707.60 |
$1,707.60 |
$1,707.60 |
$1,768.00
|
|
Upper ext fx orthosis rad/ul
|
$619.49 |
$619.49 |
$760.76 |
$619.49
|
|
Upper GI Barium X-ray (barium and gas)
|
$643.95 |
$707.50 |
$2,304.97 |
$660.40
|
|
Upper GI Barium X-ray (barium only)
|
$555.04 |
$707.50 |
$2,121.39 |
$612.00
|
|
Uppr gi scope w/submuc inj
|
$731.70 |
$731.70 |
$731.70 |
$1,872.00
|
|
Urea nitrogen
|
$63.28 |
$117.00 |
$133.20 |
$42.00
|
|
Urea nitrogen 24 hour urine
|
$71.51 |
$101.00 |
$643.78 |
$51.77
|
|
Urea nitrogen clearance
|
$20.07 |
$20.07 |
$20.07 |
$34.02
|
|
Ureteral embolization/occl
|
$3,689.40 |
$3,689.40 |
$3,689.40 |
$2,079.31
|
|
Ureteral reflux study
|
$432.89 |
$475.50 |
$2,930.56 |
$952.50
|
|
Ureter endoscopy & biopsy
|
$5,696.72 |
$5,696.72 |
$5,696.72 |
$5,696.72
|
|
Ureteroureterostomy 50760
|
$2,999.40 |
$2,999.40 |
$2,999.40 |
$2,773.01
|
|
Urethrcystgrphy rtrgrde s&i
|
$442.50 |
$615.08 |
$1,893.12 |
$584.23
|
|
Urethrocystography void s&i
|
$547.50 |
$622.35 |
$2,071.91 |
$637.80
|
|
Uric acid blood
|
$70.34 |
$108.00 |
$811.61 |
$48.96
|
|
Uric acid urine
|
$61.00 |
$69.30 |
$266.10 |
$44.35
|
|
Urinalysis microscopic only
|
$31.75 |
$43.50 |
$70.00 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$46.86 |
$46.86 |
$46.86 |
$25.72
|
|
Urinalysis (with microscopy)
|
$77.87 |
$117.00 |
$701.88 |
$54.60
|
|
Urinalysis (without microscopy)
|
$47.00 |
$47.00 |
$107.85 |
$35.75
|
|
Urinary bldr retent nuc study
|
$309.22 |
$309.22 |
$309.22 |
$350.66
|
|
Urine Culture Test
|
$129.30 |
$201.00 |
$1,195.60 |
$81.27
|
|
Urine ost pouch w faucet/tap
|
$2.00 |
$2.00 |
$2.00 |
$2.00
|
|
Urine pregnancy test
|
$55.50 |
$97.30 |
$503.41 |
$67.80
|
|
Urography, antegrade
|
$505.00 |
$593.37 |
$842.82 |
$622.35
|
|
Urography inf drip &/or bolus
|
$591.75 |
$690.85 |
$4,284.29 |
$642.50
|
|
Use 1st target lesion
|
$355.91 |
$545.55 |
$673.23 |
$336.50
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$2,804.37 |
$3,644.13 |
$15,119.95 |
$5,205.00
|
|
Ustekinumab 45 mg/0.5 ml subcutaneous solution
|
$55,128.85 |
$55,128.85 |
$55,128.85 |
$51,633.07
|
|
Vaccine Administration (one shot)
|
$55.00 |
$55.00 |
$113.70 |
$67.74
|
|
Vaccine dtap < 7 years im
|
$55.75 |
$68.19 |
$177.78 |
$68.19
|
|
Vaccine dtap-hep b-ipv im
|
$200.00 |
$200.00 |
$200.00 |
$165.26
|
|
Vaccine dtap-ipv/hib im
|
$206.12 |
$221.24 |
$671.47 |
$221.24
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$64.62 |
$64.62 |
$72.98 |
$72.00
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$27.75 |
$33.30 |
$120.97 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$148.12 |
$192.15 |
$511.84 |
$168.95
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$78.25 |
$78.25 |
$93.90 |
$80.28
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$138.37 |
$138.37 |
$179.89 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$402.20 |
$402.20 |
$402.20 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$61.75 |
$69.74 |
$168.53 |
$75.39
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$570.87 |
$570.87 |
$610.75 |
$570.87
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$81.00 |
$81.00 |
$149.21 |
$143.20
|
|
Vaccine influenza inactivated adjuvant im
|
$81.00 |
$159.00 |
$159.00 |
$106.60
|
|
Vaccine influenza nos 0.5ml dose im
|
$113.17 |
$113.17 |
$113.17 |
$24.20
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$27.00 |
$45.62 |
$93.96 |
$48.59
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$54.84 |
$54.84 |
$81.77 |
$33.21
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$149.21 |
$149.21 |
$273.49 |
$72.00
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$66.62 |
$66.62 |
$87.50 |
$82.71
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$466.12 |
$466.12 |
$605.69 |
$400.03
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$409.35 |
$409.35 |
$1,154.93 |
$406.05
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$1,012.41 |
$1,012.41 |
$1,012.41 |
$310.93
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$327.37 |
$327.37 |
$953.96 |
$323.39
|
|
Vaccine mmr live subcutaneous
|
$178.12 |
$194.93 |
$575.51 |
$211.68
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$217.87 |
$252.90 |
$710.35 |
$251.64
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$487.47 |
$487.47 |
$487.47 |
$393.25
|
|
Vaccine pneumonococcal conjugate 15 valent (pcv15) im
|
$1,220.45 |
$1,220.45 |
$1,347.98 |
$414.46
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$555.25 |
$572.75 |
$1,571.10 |
$563.36
|
|
Vaccine polio (ipv) subcutaneous/im
|
$87.50 |
$260.59 |
$1,134.58 |
$90.70
|
|
Vaccine rabies im
|
$775.00 |
$858.95 |
$2,507.45 |
$858.95
|
|
Vaccine respiratory syncytial virus bivalent subunit/preservative free im
|
$184.08 |
$184.08 |
$637.20 |
$521.74
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$980.10 |
$980.10 |
$2,975.05 |
$1,104.47
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$980.10 |
$980.10 |
$2,975.05 |
$980.10
|
