|
Unlisted laparoscopic procedure 49659
|
$6,838.32 |
$6,838.32 |
$6,838.32 |
$6,838.32
|
|
Unlisted laparoscopy procedure biliary tract 47579
|
$9,492.80 |
$9,492.80 |
$9,492.80 |
$6,463.42
|
|
Unlisted laps px appendix
|
$2,890.09 |
$2,890.09 |
$2,890.09 |
$3,617.40
|
|
Unlisted laps px endoc sys
|
$6,548.98 |
$6,548.98 |
$6,548.98 |
$5,855.00
|
|
Unlisted laps px lymphtc sys
|
$10,488.59 |
$10,488.59 |
$10,488.59 |
$6,870.89
|
|
Unlisted laps px renal
|
$3,891.34 |
$3,891.34 |
$3,891.34 |
$5,110.00
|
|
Unlisted maxlfcl prosth px
|
$1,607.44 |
$1,607.44 |
$1,607.44 |
$571.20
|
|
Unlisted misc path test
|
$89.40 |
$89.40 |
$89.40 |
$89.40
|
|
Unlisted mr procedure
|
$1,728.00 |
$1,728.00 |
$1,789.43 |
$1,163.00
|
|
Unlisted neurological dx px
|
$5,418.65 |
$5,418.65 |
$5,418.65 |
$242.50
|
|
Unlisted orl service/px
|
$343.84 |
$343.84 |
$343.84 |
$132.60
|
|
Unlisted procedure colon
|
$1,569.10 |
$1,569.10 |
$1,569.10 |
$1,839.55
|
|
Unlisted procedure esophagus
|
$442.53 |
$442.53 |
$442.53 |
$1,998.88
|
|
Unlisted procedure larynx
|
$5,107.38 |
$5,107.38 |
$5,107.38 |
$924.00
|
|
Unlisted procedure liver
|
$3,003.11 |
$3,003.11 |
$3,003.11 |
$2,287.20
|
|
Unlisted procedure microbiology
|
$1,069.61 |
$1,069.61 |
$1,069.61 |
$530.00
|
|
Unlisted procedure orbit
|
$334.84 |
$334.84 |
$334.84 |
$437.00
|
|
Unlisted procedure pancreas
|
$6,597.79 |
$6,597.79 |
$6,597.79 |
$4,810.00
|
|
Unlisted procedure rectum
|
$543.60 |
$1,603.06 |
$1,603.06 |
$1,223.20
|
|
Unlisted procedure spine
|
$4,478.85 |
$8,245.45 |
$8,245.45 |
$4,659.85
|
|
Unlisted px abdomen muscskel
|
$11,582.59 |
$11,582.59 |
$11,582.59 |
$1,956.50
|
|
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
|
$2,688.75 |
$15,692.77 |
$15,692.77 |
$3,055.00
|
|
Unlisted px casting/strpg
|
$136.50 |
$442.48 |
$686.14 |
$222.00
|
|
Unlisted px diaphragm
|
$6,547.57 |
$6,547.57 |
$6,547.57 |
$6,325.20
|
|
Unlisted px external ear
|
$329.70 |
$433.65 |
$433.65 |
$325.68
|
|
Unlisted px foot/toes
|
$7,763.00 |
$7,763.00 |
$7,763.00 |
$1,239.20
|
|
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 |
$354.20
|
|
Unlisted px inner ear
|
$17,114.99 |
$17,114.99 |
$17,114.99 |
$571.20
|
|
Unlisted px leg/ankle
|
$6,818.24 |
$6,818.24 |
$6,818.24 |
$882.30
|
|
Unlisted px male genital sys
|
$6,664.68 |
$6,664.68 |
$6,664.68 |
$387.84
|
|
Unlisted px med radj physics
|
$376.03 |
$376.03 |
$641.68 |
$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 |
$448.95 |
$274.80
|
|
Unlisted px pelvis/hip joint
|
$458.25 |
$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
|
$2,671.50 |
$3,029.95 |
$3,029.95 |
$2,118.35
|
|
Unlisted px tongue flr mouth
|
$211.95 |
$243.44 |
$243.44 |
$282.50
|
|
Unlisted special svc px/rprt
|
$90.00 |
$210.00 |
$210.00 |
$90.00
|
|
Unlisted transfusion med px
|
$469.05 |
$469.05 |
$469.05 |
$147.50
|
|
Unlisted ultrasound procedure
|
$483.30 |
$1,867.10 |
$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 |
$1,951.63 |
$7,708.19 |
$1,296.00
|
|
Upgrade pm system
|
$13,940.67 |
$13,940.67 |
$35,075.03 |
$12,077.00
|
|
Upper Arm (Humerus) X-ray (left side)
|
$309.31 |
$309.31 |
$351.00 |
$309.31
|
|
Upper Back (Thoracic Spine) CT Scan (with contrast)
|
$2,274.17 |
$2,274.17 |
$7,053.27 |
$1,669.00
|
|
Upper Back (Thoracic Spine) CT Scan (without contrast)
|
$1,890.44 |
$1,890.44 |
$6,608.08 |
$1,425.85
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$3,264.90 |
$3,957.73 |
$10,262.84 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$1,853.47 |
$1,853.47 |
$11,155.26 |
$2,392.00
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$2,034.41 |
$2,034.41 |
$9,320.00 |
$2,034.41
|
|
Upper Back (Thoracic Spine) X-ray (2 views)
|
$312.80 |
$312.80 |
$1,059.84 |
$321.95
|
|
Upper Back (Thoracic Spine) X-ray (3 views)
|
$371.85 |
$395.95 |
$2,335.21 |
$381.60
|
|
Upper Endoscopy (EGD, diagnostic)
|
$1,824.75 |
$1,824.75 |
$1,824.75 |
$1,824.75
|
|
Upper Endoscopy (EGD, with biopsy)
|
$731.70 |
$731.70 |
$731.70 |
$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 |
$657.77 |
$2,232.65 |
$660.40
|
|
Upper GI Barium X-ray (barium only)
|
$555.04 |
$555.04 |
$1,811.98 |
$607.20
|
|
Uppr gi scope w/submuc inj
|
$731.70 |
$731.70 |
$731.70 |
$1,872.00
|
|
Urea nitrogen
|
$63.28 |
$63.28 |
$133.20 |
$42.01
|
|
Urea nitrogen 24 hour urine
|
$71.51 |
$71.51 |
$861.66 |
$51.84
|
|
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 |
$432.89 |
$4,198.54 |
$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
|
$615.08 |
$615.08 |
$2,347.08 |
$584.00
|
|
Urethrocystography void s&i
|
$622.35 |
$702.97 |
$702.97 |
$634.50
|
|
Uric acid blood
|
$70.34 |
$70.34 |
$568.63 |
$49.32
|
|
Uric acid urine
|
$69.30 |
$69.30 |
$568.63 |
$44.52
|
|
Urinalysis microscopic only
|
$31.75 |
$31.75 |
$475.18 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$46.86 |
$46.86 |
$194.82 |
$25.72
|
|
Urinalysis (with microscopy)
|
$77.87 |
$77.87 |
$612.98 |
$55.20
|
|
Urinalysis (without microscopy)
|
$96.30 |
$96.30 |
$555.96 |
$35.91
|
|
Urinary bldr retent nuc study
|
$309.22 |
$309.22 |
$2,948.61 |
$350.66
|
|
Urine Culture Test
|
$129.30 |
$129.30 |
$799.88 |
$82.32
|
|
Urine ost pouch w faucet/tap
|
$2.00 |
$2.00 |
$2.00 |
$2.00
|
|
Urine pregnancy test
|
$97.30 |
$97.30 |
$793.55 |
$68.21
|
|
Urography, antegrade
|
$593.37 |
$593.37 |
$2,436.28 |
$622.35
|
|
Urography inf drip &/or bolus
|
$591.75 |
$690.85 |
$2,069.13 |
$642.50
|
|
Use 1st target lesion
|
$355.91 |
$355.91 |
$1,607.44 |
$332.00
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$3,644.13 |
$3,644.13 |
$4,008.54 |
$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)
|
$77.72 |
$77.72 |
$113.70 |
$67.74
|
|
Vaccine dtap < 7 years im
|
$68.19 |
$101.02 |
$197.15 |
$71.17
|
|
Vaccine dtap-ipv/hib im
|
$221.24 |
$280.15 |
$352.98 |
$221.24
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$66.24 |
$66.24 |
$72.98 |
$70.53
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$33.30 |
$46.99 |
$66.25 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$192.15 |
$225.31 |
$385.16 |
$166.62
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$93.90 |
$93.90 |
$98.80 |
$78.25
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$160.86 |
$179.89 |
$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
|
$69.74 |
$103.22 |
$111.99 |
$75.39
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$81.00 |
$81.00 |
$149.21 |
$149.21
|
|
Vaccine influenza inactivated adjuvant im
|
$81.00 |
$81.00 |
$81.00 |
$110.25
|
|
Vaccine influenza nos 0.5ml dose im
|
$61.53 |
$61.53 |
$61.53 |
$24.20
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$27.00 |
$27.00 |
$61.00 |
$48.59
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$54.84 |
$54.84 |
$280.06 |
$33.60
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$149.21 |
$149.21 |
$279.78 |
$72.00
|
