|
Trnsfr/rearrngmnt adjcnt tiss defec ea addl 30sqcm/<
|
$2,364.18 |
$2,364.18 |
$2,364.18 |
$2,343.60
|
|
Trnsfr/rearrngmnt adjcnt tiss e/n/e/l dfct 10sqcm/<
|
$2,508.24 |
$2,508.24 |
$2,508.24 |
$2,986.34
|
|
Trnsfr/rearrngmnt adjcnt tiss eye/nose/ear/lip 10.1-30sqcm
|
$2,508.24 |
$2,508.24 |
$2,508.24 |
$3,322.20
|
|
Trnsfr/rearrngmnt adjcnt tiss sclp/arm/lg 10.1-30sqcm
|
$517.44 |
$517.44 |
$517.44 |
$2,355.65
|
|
Troponin quantitative
|
$73.50 |
$73.50 |
$73.50 |
$123.75
|
|
Tte w or without fol w/con,stres
|
$1,123.08 |
$1,123.08 |
$1,123.08 |
$1,446.48
|
|
Tube trach disp innr can 5 xlt
|
$872.21 |
$872.21 |
$872.21 |
$460.58
|
|
Tx closed hip disl traumatic without anes
|
$449.40 |
$449.40 |
$449.40 |
$657.28
|
|
Tx closed tib fx proximal w/w/o manip w/skel trac
|
$5,834.22 |
$5,834.22 |
$5,834.22 |
$3,874.79
|
|
Tx closed tib shaft fx without manip
|
$275.94 |
$275.94 |
$275.94 |
$635.46
|
|
Tx open art fx mcp/iphlngl jnt incl int fixtn ea
|
$3,969.00 |
$3,969.00 |
$3,969.00 |
$4,449.44
|
|
Tx open dstl phlngl fx f/t internal fixation ea
|
$1,448.16 |
$1,448.16 |
$1,448.16 |
$4,499.12
|
|
Tx open iphlngl jt disl internal fixation sngl
|
$3,969.00 |
$3,969.00 |
$3,969.00 |
$4,281.00
|
|
Tx open nsl fx uncomp
|
$3,793.02 |
$3,793.02 |
$3,793.02 |
$4,007.22
|
|
Tx open nsl sptl fx
|
$4,326.00 |
$4,326.00 |
$4,326.00 |
$4,289.04
|
|
Tx phalangeal shaft fx open prox/middle ea
|
$5,834.22 |
$5,834.22 |
$5,834.22 |
$4,499.12
|
|
Tx tarsal bone fx without manip 28450
|
$275.94 |
$275.94 |
$275.94 |
$469.20
|
|
Ultrasound abdomen aorta screening study aaa
|
$375.06 |
$375.06 |
$375.06 |
$403.26
|
|
Ultrasound breast complete
|
$375.06 |
$375.06 |
$375.06 |
$519.75
|
|
Ultrasound breast unilateral limited (both sides)
|
$328.02 |
$328.02 |
$328.02 |
$449.35
|
|
Ultrasound chest
|
$375.06 |
$375.06 |
$375.06 |
$459.55
|
|
Ultrasound doppler velocimetry fetal umbilical artery
|
$152.88 |
$152.88 |
$152.88 |
$340.14
|
|
Ultrasound encephalogram
|
$375.06 |
$375.06 |
$375.06 |
$481.60
|
|
Ultrasound exam k transpl w/doppler
|
$375.06 |
$375.06 |
$375.06 |
$570.44
|
|
Ultrasound fetal biophysical profile without non-stress testing
|
$375.06 |
$375.06 |
$375.06 |
$477.88
|
|
Ultrasound guidance for vascular access
|
$162.54 |
$162.54 |
$162.54 |
$340.22
|
|
Ultrasound guided needle placement supervision & interpretation
|
$531.72 |
$531.72 |
$531.72 |
$701.35
|
|
Ultrasound guide intraoperative
|
$346.08 |
$346.08 |
$346.08 |
$632.90
|
|
Ultrasound hips infant dynamic
|
$278.46 |
$278.46 |
$278.46 |
$403.00
|
|
Ultrasound infant hips ltd without stress
|
$278.46 |
$278.46 |
$278.46 |
$321.35
|
|
Ultrasound joint complete left
|
$375.06 |
$375.06 |
$375.06 |
$556.14
|
|
Ultrasound joint/nonvascular extremity limited left
|
$375.06 |
$375.06 |
$375.06 |
$448.50
|
|
Ultrasound ob >=14wks ea addl gest
|
$698.46 |
$698.46 |
$698.46 |
$454.11
|
|
Ultrasound pregnant uterus < 14 weeks each additional gestation
|
$181.02 |
$181.02 |
$181.02 |
$326.54
|
|
Ultrasound pregnant uterus detailed fetal exam single/1st gestation
|
$901.32 |
$901.32 |
$901.32 |
$690.48
|
|
Ultrasound pregnant uterus follow up per fetus
|
$375.06 |
$375.06 |
$375.06 |
$450.75
|
|
Ultrasound pregnant uterus limited >= 1 fetuses
|
$375.06 |
$375.06 |
$375.06 |
$459.00
|
|
Ultrasound pregnant uterus transvaginal
|
$375.06 |
$375.06 |
$375.06 |
$485.48
|
|
Ultrasound retroperitoneal limited
|
$375.06 |
$375.06 |
$375.06 |
$498.00
|
|
Ultrasound scrotum and contents
|
$375.06 |
$375.06 |
$375.06 |
$617.28
|
|
Ultrasound spinal canal and contents
|
$375.06 |
$375.06 |
$375.06 |
$450.60
|
|
Ultrasound transvaginal non obstetric
|
$375.06 |
$375.06 |
$375.06 |
$567.44
|
|
Umbilical artery cath newborn 36660
|
$384.72 |
$384.72 |
$384.72 |
$265.85
|
|
Unlisted chemotherapy px
|
$299.88 |
$299.88 |
$299.88 |
$153.85
|
|
Unlisted procedure rectum
|
$1,208.34 |
$1,208.34 |
$1,208.34 |
$1,278.72
|
|
Unlisted px foot/toes
|
$63.00 |
$63.00 |
$63.00 |
$3,105.70
|
|
Unlisted px hands/fingers
|
$300.72 |
$300.72 |
$300.72 |
$379.44
|
|
Unlisted px salivry glnd/dux
|
$277.62 |
$277.62 |
$277.62 |
$486.72
|
|
Unlisted px small intestine
|
$1,199.94 |
$1,199.94 |
$1,199.94 |
$2,118.35
|
|
Unlisted ultrasound procedure
|
$278.46 |
$278.46 |
$278.46 |
$321.20
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$2,559.48 |
$2,559.48 |
$2,559.48 |
$2,916.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$2,512.86 |
$2,512.86 |
$2,512.86 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$1,570.80 |
$1,570.80 |
$1,570.80 |
$2,013.08
|
|
Upper Endoscopy (EGD, diagnostic)
|
$957.18 |
$957.18 |
$957.18 |
$1,588.59
|
|
Upper Endoscopy (EGD, with biopsy)
|
$957.18 |
$957.18 |
$957.18 |
$1,656.60
|
|
Urea nitrogen
|
$23.52 |
$23.52 |
$23.52 |
$45.10
|
|
Urea nitrogen 24 hour urine
|
$33.18 |
$33.18 |
$33.18 |
$50.00
|
|
Urethrcystgrphy rtrgrde s&i
|
$490.98 |
$490.98 |
$490.98 |
$574.40
|
|
Urethrocystography void s&i
|
$490.98 |
$490.98 |
$490.98 |
$634.50
|
|
Uric acid blood
|
$26.88 |
$26.88 |
$26.88 |
$46.64
|
|
Uric acid urine
|
$30.24 |
$30.24 |
$30.24 |
$46.75
|
|
Urinalysis microscopic only
|
$44.52 |
$44.52 |
$44.52 |
$26.35
|
|
Urinalysis (with microscopy)
|
$46.62 |
$46.62 |
$46.62 |
$48.14
|
|
Urinalysis (without microscopy)
|
$33.18 |
$33.18 |
$33.18 |
$38.99
|
|
Urine Culture Test
|
$56.28 |
$56.28 |
$56.28 |
$84.81
|
|
Urine pregnancy test
|
$126.42 |
$126.42 |
$126.42 |
$66.40
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$122.57 |
$122.57 |
$122.57 |
$223.08
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$122.57 |
$122.57 |
$122.57 |
$218.88
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$110.12 |
$110.12 |
$110.12 |
$239.85
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$73.74 |
$73.74 |
$73.74 |
$131.67
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$54.90 |
$54.90 |
$54.90 |
$91.00
|
|
Vaccine dtap < 7 years im
|
$10.50 |
$10.50 |
$10.50 |
$87.80
|
|
Vaccine dtap-hep b-ipv im
|
$29.40 |
$29.40 |
$29.40 |
$193.83
|
|
Vaccine dtap-ipv 4-6 years im
|
$14.70 |
$14.70 |
$14.70 |
$126.84
|
|
Vaccine dtap-ipv-hib-hepb im
|
$155.99 |
$155.99 |
$155.99 |
$158.30
|
|
Vaccine dtap-ipv/hib im
|
$29.40 |
$29.40 |
$29.40 |
$248.80
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$12.60 |
$12.60 |
$12.60 |
$85.00
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$12.60 |
$12.60 |
$12.60 |
$45.33
|
|
Vaccine hepatitis a (hepa) adult im
|
$21.00 |
$21.00 |
$21.00 |
$178.07
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$21.00 |
$21.00 |
$21.00 |
$84.38
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$445.58 |
$445.58 |
$445.58 |
$173.98
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$106.26 |
$106.26 |
$106.26 |
$306.24
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$151.91 |
$151.91 |
$151.91 |
$79.04
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$66.36 |
$66.36 |
$66.36 |
$686.67
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$66.36 |
$66.36 |
$66.36 |
$226.20
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$25.20 |
$25.20 |
$25.20 |
$157.41
|
|
Vaccine influenza inactivated adjuvant im
|
$508.57 |
$508.57 |
$508.57 |
$110.25
|
|
Vaccine influenza nos 0.5ml dose im
|
$8.40 |
$8.40 |
$8.40 |
$36.80
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$128.02 |
$128.02 |
$128.02 |
$48.29
|
|
Vaccine influenza quadrivalent (iiv4) inactivated adjuvanted preservative free 0.5ml dose im
|
$525.18 |
$525.18 |
$525.18 |
$104.63
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.25ml dose im
|
$10.50 |
$10.50 |
$10.50 |
$26.40
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$28.35 |
$28.35 |
$28.35 |
$40.01
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$23.10 |
$23.10 |
$23.10 |
$72.00
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$203.70 |
$203.70 |
$203.70 |
$103.88
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$232.26 |
$232.26 |
$232.26 |
$499.00
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$163.80 |
$163.80 |
$163.80 |
$426.80
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$126.00 |
$126.00 |
$126.00 |
$349.15
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$46.20 |
$46.20 |
$46.20 |
$408.70
|
|
Vaccine mmr live subcutaneous
|
$685.24 |
$685.24 |
$685.24 |
$224.04
|
|
Vaccine mmrv live subcutaneous
|
$86.10 |
$86.10 |
$86.10 |
$474.24
|
