|
Ultrasound breast unilateral limited (both sides)
|
$376.80 |
$376.80 |
$376.80 |
$452.40
|
|
Ultrasound doppler velocimetry fetal umbilical artery
|
$512.00 |
$512.00 |
$512.00 |
$338.00
|
|
Ultrasound dx ophth b-scan
|
$390.40 |
$390.40 |
$390.40 |
$296.80
|
|
Ultrasound elastography parenchyma
|
$241.60 |
$241.60 |
$241.60 |
$313.95
|
|
Ultrasound encephalogram
|
$483.20 |
$483.20 |
$483.20 |
$494.92
|
|
Ultrasound exam k transpl w/doppler
|
$987.20 |
$987.20 |
$987.20 |
$575.40
|
|
Ultrasound fetal biophysical profile without non-stress testing
|
$627.20 |
$627.20 |
$627.20 |
$476.94
|
|
Ultrasound Guidance for a Needle Procedure
|
$954.40 |
$954.40 |
$954.40 |
$720.15
|
|
Ultrasound guidance for vascular access
|
$589.60 |
$589.60 |
$589.60 |
$388.08
|
|
Ultrasound guide intraoperative
|
$900.80 |
$900.80 |
$900.80 |
$632.85
|
|
Ultrasound guide tissue ablation
|
$480.80 |
$480.80 |
$480.80 |
$560.00
|
|
Ultrasound hips infant dynamic
|
$348.80 |
$348.80 |
$348.80 |
$403.88
|
|
Ultrasound infant hips ltd without stress
|
$391.20 |
$391.20 |
$391.20 |
$311.25
|
|
Ultrasound joint complete left
|
$549.60 |
$549.60 |
$549.60 |
$557.99
|
|
Ultrasound ob >=14wks ea addl gest
|
$618.40 |
$618.40 |
$618.40 |
$409.20
|
|
Ultrasound pregnant uterus < 14 weeks each additional gestation
|
$396.80 |
$396.80 |
$396.80 |
$335.00
|
|
Ultrasound pregnant uterus detailed fetal exam single/1st gestation
|
$565.60 |
$565.60 |
$565.60 |
$707.20
|
|
Ultrasound pregnant uterus follow up per fetus
|
$486.40 |
$486.40 |
$486.40 |
$425.60
|
|
Ultrasound prostate/transrectal
|
$638.40 |
$638.40 |
$638.40 |
$557.40
|
|
Ultrasound spinal canal and contents
|
$520.00 |
$520.00 |
$520.00 |
$463.00
|
|
Ultrasound transabd ea addl gest
|
$581.60 |
$581.60 |
$581.60 |
$421.00
|
|
Umbilical artery cath newborn 36660
|
$148.00 |
$148.00 |
$148.00 |
$223.80
|
|
Unlisted chemotherapy px
|
$188.80 |
$188.80 |
$188.80 |
$143.75
|
|
Unlisted cranfcl&maxlfcl px
|
$1,226.40 |
$1,226.40 |
$1,226.40 |
$571.20
|
|
Unlisted cv px dx nuc med
|
$812.00 |
$812.00 |
$812.00 |
$1,747.20
|
|
Unlisted dialysis procedure
|
$1,620.00 |
$1,620.00 |
$1,620.00 |
$1,144.00
|
|
Unlisted dx gi procedure
|
$1,761.60 |
$1,761.60 |
$1,761.60 |
$649.22
|
|
Unlisted mr procedure
|
$528.80 |
$528.80 |
$528.80 |
$1,163.00
|
|
Unlisted muscskel px head
|
$708.00 |
$708.00 |
$708.00 |
$1,224.08
|
|
Unlisted procedure colon
|
$2,791.20 |
$2,791.20 |
$2,791.20 |
$1,839.55
|
|
Unlisted procedure esophagus
|
$2,642.40 |
$2,642.40 |
$2,642.40 |
$1,998.88
|
|
Unlisted procedure larynx
|
$1,518.40 |
$1,518.40 |
$1,518.40 |
$924.00
|
|
Unlisted procedure liver
|
$4,038.40 |
$4,038.40 |
$4,038.40 |
$2,287.20
|
|
Unlisted procedure pancreas
|
$3,272.00 |
$3,272.00 |
$3,272.00 |
$4,810.00
|
|
Unlisted procedure rectum
|
$1,276.80 |
$1,276.80 |
$1,276.80 |
$1,223.20
|
|
Unlisted procedure spine
|
$1,569.60 |
$1,569.60 |
$1,569.60 |
$4,659.85
|
|
Unlisted px abdomen muscskel
|
$2,956.80 |
$2,956.80 |
$2,956.80 |
$1,956.50
|
|
Unlisted px ant segment eye
|
$3,416.80 |
$3,416.80 |
$3,416.80 |
$2,698.92
|
|
Unlisted px biliary tract
|
$4,723.20 |
$4,723.20 |
$4,723.20 |
$3,055.00
|
|
Unlisted px casting/strpg
|
$224.80 |
$224.80 |
$224.80 |
$222.00
|
|
Unlisted px hands/fingers
|
$932.00 |
$932.00 |
$932.00 |
$354.20
|
|
Unlisted px leg/ankle
|
$4,000.00 |
$4,000.00 |
$4,000.00 |
$882.30
|
|
Unlisted px mediastinum
|
$2,838.40 |
$2,838.40 |
$2,838.40 |
$397.60
|
|
Unlisted px neck/thorax
|
$280.80 |
$280.80 |
$280.80 |
$571.20
|
|
Unlisted px palate uvula
|
$2,411.20 |
$2,411.20 |
$2,411.20 |
$274.80
|
|
Unlisted px pelvis/hip joint
|
$783.20 |
$783.20 |
$783.20 |
$3,251.90
|
|
Unlisted px small intestine
|
$3,737.60 |
$3,737.60 |
$3,737.60 |
$2,118.35
|
|
Unlisted reprod med lab proc
|
$60.00 |
$60.00 |
$60.00 |
$70.00
|
|
Unlisted ultrasound procedure
|
$415.20 |
$415.20 |
$415.20 |
$335.00
|
|
Unsched dialysis esrd pt hos
|
$1,620.00 |
$1,620.00 |
$1,620.00 |
$1,296.00
|
|
Upgrade pm system
|
$16,259.20 |
$16,259.20 |
$16,259.20 |
$12,077.00
|
|
Upper Arm (Humerus) X-ray (left side)
|
$393.60 |
$393.60 |
$393.60 |
$309.31
|
|
Upper Back (Thoracic Spine) CT Scan (with contrast)
|
$2,820.80 |
$2,820.80 |
$2,820.80 |
$1,669.00
|
|
Upper Back (Thoracic Spine) CT Scan (without contrast)
|
$2,528.80 |
$2,528.80 |
$2,528.80 |
$1,425.85
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$4,052.80 |
$4,052.80 |
$4,052.80 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$3,355.20 |
$3,355.20 |
$3,355.20 |
$2,392.00
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$3,093.60 |
$3,093.60 |
$3,093.60 |
$2,034.41
|
|
Upper Back (Thoracic Spine) X-ray (2 views)
|
$388.00 |
$388.00 |
$388.00 |
$321.95
|
|
Upper Back (Thoracic Spine) X-ray (3 views)
|
$443.20 |
$443.20 |
$443.20 |
$381.60
|
|
Upper Endoscopy (EGD, diagnostic)
|
$2,561.60 |
$2,561.60 |
$2,561.60 |
$1,824.75
|
|
Upper Endoscopy (EGD, with biopsy)
|
$2,573.60 |
$2,573.60 |
$2,573.60 |
$1,768.00
|
|
Upper ext fx orthosis rad/ul
|
$227.00 |
$227.00 |
$227.00 |
$619.49
|
|
Upper GI Barium X-ray (barium and gas)
|
$984.00 |
$984.00 |
$984.00 |
$660.40
|
|
Upper GI Barium X-ray (barium only)
|
$893.60 |
$893.60 |
$893.60 |
$607.20
|
|
Uppr gi scope w/submuc inj
|
$2,408.00 |
$2,408.00 |
$2,408.00 |
$1,872.00
|
|
Ureteral embolization/occl
|
$4,580.80 |
$4,580.80 |
$4,580.80 |
$2,079.31
|
|
Ureteral reflux study
|
$692.00 |
$692.00 |
$692.00 |
$952.50
|
|
Urethrcystgrphy rtrgrde s&i
|
$679.20 |
$679.20 |
$679.20 |
$584.00
|
|
Urethrocystography void s&i
|
$915.20 |
$915.20 |
$915.20 |
$634.50
|
|
Urinalysis (without microscopy)
|
$9.60 |
$9.60 |
$9.60 |
$35.91
|
|
Urography, antegrade
|
$830.40 |
$830.40 |
$830.40 |
$622.35
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$2,698.88 |
$2,698.88 |
$2,698.88 |
$5,205.00
|
|
Vaccine Administration (one shot)
|
$95.20 |
$95.20 |
$95.20 |
$67.74
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$369.31 |
$369.31 |
$369.31 |
$236.50
|
|
Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im
|
$537.52 |
$537.52 |
$537.52 |
$80.15
|
|
Vaccine dtap < 7 years im
|
$86.28 |
$86.28 |
$86.28 |
$71.17
|
|
Vaccine dtap-ipv 4-6 years im
|
$143.68 |
$143.68 |
$143.68 |
$105.95
|
|
Vaccine dtap-ipv-hib-hepb im
|
$480.00 |
$480.00 |
$480.00 |
$174.72
|
|
Vaccine dtap-ipv/hib im
|
$248.80 |
$248.80 |
$248.80 |
$221.24
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$44.00 |
$44.00 |
$44.00 |
$43.12
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$88.80 |
$88.80 |
$88.80 |
$78.25
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$186.40 |
$186.40 |
$186.40 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$321.04 |
$321.04 |
$321.04 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$43.44 |
$43.44 |
$43.44 |
$75.39
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$98.40 |
$98.40 |
$98.40 |
$149.21
|
|
Vaccine influenza inactivated adjuvant im
|
$221.20 |
$221.20 |
$221.20 |
$110.25
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.25ml dose im
|
$25.60 |
$25.60 |
$25.60 |
$28.77
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$26.40 |
$26.40 |
$26.40 |
$33.60
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$66.56 |
$66.56 |
$66.56 |
$82.71
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$442.48 |
$442.48 |
$442.48 |
$394.26
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$315.07 |
$315.07 |
$315.07 |
$409.35
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$349.15 |
$349.15 |
$349.15 |
$310.93
|
|
Vaccine mmr live subcutaneous
|
$220.29 |
$220.29 |
$220.29 |
$213.00
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$292.43 |
$292.43 |
$292.43 |
$252.87
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$620.80 |
$620.80 |
$620.80 |
$393.25
|
|
Vaccine pneumonococcal conjugate 15 valent (pcv15) im
|
$704.80 |
$704.80 |
$704.80 |
$414.46
|
|
Vaccine polio (ipv) subcutaneous/im
|
$734.64 |
$734.64 |
$734.64 |
$90.70
|
|
Vaccine rabies im
|
$890.76 |
$890.76 |
$890.76 |
$858.95
|
|
Vaccine respiratory syncytial virus bivalent subunit/preservative free im
|
$847.53 |
$847.53 |
$847.53 |
$538.84
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$1,226.48 |
$1,226.48 |
$1,226.48 |
$1,105.21
|
