|
Ultrasound encephalogram
|
$1,406.30 |
$1,406.30 |
$1,406.30 |
$488.80
|
|
Ultrasound exam k transpl w/doppler
|
$1,237.60 |
$1,237.60 |
$1,237.60 |
$573.54
|
|
Ultrasound fetal biophysical profile without non-stress testing
|
$1,120.70 |
$1,120.70 |
$1,120.70 |
$469.50
|
|
Ultrasound guidance for vascular access
|
$1,292.20 |
$1,292.20 |
$1,292.20 |
$400.20
|
|
Ultrasound guided needle placement supervision & interpretation
|
$1,705.20 |
$1,705.20 |
$1,705.20 |
$720.15
|
|
Ultrasound guide intraoperative
|
$2,104.20 |
$2,104.20 |
$2,104.20 |
$632.85
|
|
Ultrasound guide tissue ablation
|
$2,603.30 |
$2,603.30 |
$2,603.30 |
$560.00
|
|
Ultrasound hips infant dynamic
|
$1,275.40 |
$1,275.40 |
$1,275.40 |
$403.88
|
|
Ultrasound infant hips ltd without stress
|
$1,087.80 |
$1,087.80 |
$1,087.80 |
$311.25
|
|
Ultrasound joint complete left
|
$1,269.80 |
$1,269.80 |
$1,269.80 |
$556.14
|
|
Ultrasound joint/nonvascular extremity limited left
|
$774.90 |
$774.90 |
$774.90 |
$425.45
|
|
Ultrasound nrv&acc strux 1xtr compre
|
$245.70 |
$245.70 |
$245.70 |
$277.80
|
|
Ultrasound ob >=14wks ea addl gest
|
$1,598.10 |
$1,598.10 |
$1,598.10 |
$407.20
|
|
Ultrasound pregnant uterus < 14 weeks each additional gestation
|
$819.70 |
$819.70 |
$819.70 |
$331.50
|
|
Ultrasound pregnant uterus detailed fetal exam single/1st gestation
|
$1,360.80 |
$1,360.80 |
$1,360.80 |
$707.20
|
|
Ultrasound pregnant uterus follow up per fetus
|
$830.90 |
$830.90 |
$830.90 |
$425.60
|
|
Ultrasound pregnant uterus limited >= 1 fetuses
|
$718.90 |
$718.90 |
$718.90 |
$459.00
|
|
Ultrasound pregnant uterus transvaginal
|
$749.00 |
$749.00 |
$749.00 |
$497.12
|
|
Ultrasound prostate/transrectal
|
$1,085.00 |
$1,085.00 |
$1,085.00 |
$557.40
|
|
Ultrasound retroperitoneal limited
|
$1,313.20 |
$1,313.20 |
$1,313.20 |
$486.50
|
|
Ultrasound scrotum and contents
|
$1,376.90 |
$1,376.90 |
$1,376.90 |
$608.90
|
|
Ultrasound spinal canal and contents
|
$1,559.60 |
$1,559.60 |
$1,559.60 |
$463.00
|
|
Ultrasound transabd ea addl gest
|
$1,157.10 |
$1,157.10 |
$1,157.10 |
$421.00
|
|
Ultrasound transvaginal non obstetric
|
$1,079.40 |
$1,079.40 |
$1,079.40 |
$558.35
|
|
Ultrasound trgt dyn mbubb 1st les
|
$3,213.00 |
$3,213.00 |
$3,213.00 |
$568.32
|
|
Ultrasound trgt dyn mbubb ea addl
|
$4,034.80 |
$4,034.80 |
$4,034.80 |
$348.00
|
|
Umbilical artery cath newborn 36660
|
$851.20 |
$851.20 |
$851.20 |
$206.64
|
|
Unlisted chemotherapy px
|
$540.40 |
$540.40 |
$540.40 |
$150.00
|
|
Unlisted CT procedure
|
$1,941.10 |
$1,941.10 |
$1,941.10 |
$732.70
|
|
Unlisted dx gi procedure
|
$1,908.20 |
$1,908.20 |
$1,908.20 |
$649.22
|
|
Unlisted fetal invas px w/us
|
$606.90 |
$606.90 |
$606.90 |
$498.40
|
|
Unlisted fluoroscopic px
|
$26,511.80 |
$26,511.80 |
$26,511.80 |
$305.76
|
|
Unlisted hematology&coagj px
|
$114.80 |
$114.80 |
$114.80 |
$39.52
|
|
Unlisted laparoscopic procedure 49659
|
$41,005.55 |
$41,005.55 |
$41,005.55 |
$6,838.32
|
|
Unlisted laparoscopic reduction intestine 44238
|
$43,924.96 |
$43,924.96 |
$43,924.96 |
$5,419.00
|
|
Unlisted laps px bladder
|
$66,066.48 |
$66,066.48 |
$66,066.48 |
$5,082.74
|
|
Unlisted laps px spleen
|
$46,693.39 |
$46,693.39 |
$46,693.39 |
$4,627.00
|
|
Unlisted maaa
|
$284.90 |
$284.90 |
$284.90 |
$235.20
|
|
Unlisted mr procedure
|
$2,110.50 |
$2,110.50 |
$2,110.50 |
$1,163.00
|
|
Unlisted procedure colon
|
$10,896.20 |
$10,896.20 |
$10,896.20 |
$1,702.50
|
|
Unlisted procedure esophagus
|
$15,993.60 |
$15,993.60 |
$15,993.60 |
$1,998.88
|
|
Unlisted procedure eyelids
|
$20,330.52 |
$20,330.52 |
$20,330.52 |
$833.00
|
|
Unlisted procedure liver
|
$26,043.50 |
$26,043.50 |
$26,043.50 |
$2,287.20
|
|
Unlisted procedure microbiology
|
$490.70 |
$490.70 |
$490.70 |
$523.50
|
|
Unlisted procedure pancreas
|
$8,447.60 |
$8,447.60 |
$8,447.60 |
$3,986.00
|
|
Unlisted procedure rectum
|
$12,129.60 |
$12,129.60 |
$12,129.60 |
$1,220.35
|
|
Unlisted px abdomen muscskel
|
$3,161.20 |
$3,161.20 |
$3,161.20 |
$1,848.60
|
|
Unlisted px accessory sinus
|
$50,684.85 |
$50,684.85 |
$50,684.85 |
$3,335.28
|
|
Unlisted px arthroscopy
|
$59,072.77 |
$59,072.77 |
$59,072.77 |
$2,765.60
|
|
Unlisted px biliary tract
|
$23,227.40 |
$23,227.40 |
$23,227.40 |
$2,718.10
|
|
Unlisted px leg/ankle
|
$13,652.80 |
$13,652.80 |
$13,652.80 |
$811.00
|
|
Unlisted px med radj physics
|
$1,124.20 |
$1,124.20 |
$1,124.20 |
$462.35
|
|
Unlisted px posterior segmnt
|
$8,799.70 |
$8,799.70 |
$8,799.70 |
$3,173.34
|
|
Unlisted px small intestine
|
$12,495.70 |
$12,495.70 |
$12,495.70 |
$2,102.10
|
|
Unlisted surgical path px
|
$81.20 |
$81.20 |
$81.20 |
$217.75
|
|
Unlisted ultrasound procedure
|
$105.00 |
$105.00 |
$105.00 |
$321.20
|
|
Unlisted urinalysis px
|
$114.10 |
$114.10 |
$114.10 |
$25.72
|
|
Unlstd laps px sprmatic cord
|
$56,541.03 |
$56,541.03 |
$56,541.03 |
$4,713.11
|
|
Unsched dialysis esrd pt hos
|
$1,050.00 |
$1,050.00 |
$1,050.00 |
$1,268.17
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$4,696.30 |
$4,696.30 |
$4,696.30 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$4,101.30 |
$4,101.30 |
$4,101.30 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$3,809.40 |
$3,809.40 |
$3,809.40 |
$2,034.41
|
|
Upper Endoscopy (EGD, diagnostic)
|
$4,437.85 |
$4,437.85 |
$4,437.85 |
$1,751.66
|
|
Upper Endoscopy (EGD, with biopsy)
|
$11,181.04 |
$11,181.04 |
$11,181.04 |
$1,768.00
|
|
Uppr gi scope w/submuc inj
|
$12,270.40 |
$12,270.40 |
$12,270.40 |
$1,872.00
|
|
Urea nitrogen
|
$74.90 |
$74.90 |
$74.90 |
$41.46
|
|
Urea nitrogen 24 hour urine
|
$52.50 |
$52.50 |
$52.50 |
$51.75
|
|
Urethrcystgrphy rtrgrde s&i
|
$839.30 |
$839.30 |
$839.30 |
$579.73
|
|
Urethrocystography void s&i
|
$897.40 |
$897.40 |
$897.40 |
$622.35
|
|
Uric acid blood
|
$79.10 |
$79.10 |
$79.10 |
$48.75
|
|
Uric acid urine
|
$55.30 |
$55.30 |
$55.30 |
$44.33
|
|
Urinalysis microscopic only
|
$32.90 |
$32.90 |
$32.90 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$30.10 |
$30.10 |
$30.10 |
$25.72
|
|
Urinalysis (with microscopy)
|
$60.20 |
$60.20 |
$60.20 |
$55.00
|
|
Urinalysis (without microscopy)
|
$56.00 |
$56.00 |
$56.00 |
$35.75
|
|
Urine Culture Test
|
$128.80 |
$128.80 |
$128.80 |
$81.50
|
|
Urine pregnancy test
|
$103.60 |
$103.60 |
$103.60 |
$67.20
|
|
Urography, antegrade
|
$1,262.80 |
$1,262.80 |
$1,262.80 |
$622.35
|
|
Use 1st target lesion
|
$482.30 |
$482.30 |
$482.30 |
$332.00
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$69.30 |
$69.30 |
$69.30 |
$209.40
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$137.90 |
$137.90 |
$137.90 |
$236.50
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$92.40 |
$92.40 |
$92.40 |
$123.20
|
|
Vaccine dtap < 7 years im
|
$311.85 |
$311.85 |
$311.85 |
$68.19
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$97.12 |
$97.12 |
$97.12 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$901.77 |
$901.77 |
$901.77 |
$166.62
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$326.90 |
$326.90 |
$326.90 |
$218.40
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$756.35 |
$756.35 |
$756.35 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$893.20 |
$893.20 |
$893.20 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$309.40 |
$309.40 |
$309.40 |
$75.39
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$2,111.02 |
$2,111.02 |
$2,111.02 |
$576.48
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$347.20 |
$347.20 |
$347.20 |
$282.50
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$81.20 |
$81.20 |
$81.20 |
$143.20
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$33.60 |
$33.60 |
$33.60 |
$47.88
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$33.60 |
$33.60 |
$33.60 |
$33.60
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$1,460.02 |
$1,460.02 |
$1,460.02 |
$400.03
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$1,053.67 |
$1,053.67 |
$1,053.67 |
$310.93
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$1,069.95 |
$1,069.95 |
$1,069.95 |
$329.24
|
|
Vaccine mmr live subcutaneous
|
$673.05 |
$673.05 |
$673.05 |
$211.68
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$1,113.00 |
$1,113.00 |
$1,113.00 |
$251.64
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$275.80 |
$275.80 |
$275.80 |
$397.11
|
