|
Tte w or without fol w/cont, com
|
$904.80 |
$904.80 |
$904.80 |
$1,254.50
|
|
Tte w or without fol w/cont, f/u
|
$647.20 |
$647.20 |
$647.20 |
$1,178.00
|
|
Tube trach disp innr can 5 xlt
|
$266.40 |
$266.40 |
$266.40 |
$445.99
|
|
Tubular dressing
|
$5.80 |
$5.80 |
$5.80 |
$28.46
|
|
Tx closed distal humerus fx
|
$153.60 |
$153.60 |
$153.60 |
$594.88
|
|
Tx closed hip disl traumatic without anes
|
$998.40 |
$998.40 |
$998.40 |
$586.80
|
|
Tx closed tib fx proximal w/w/o manip w/skel trac
|
$4,518.40 |
$4,518.40 |
$4,518.40 |
$3,977.49
|
|
Tx closed tib shaft fx without manip
|
$718.20 |
$718.20 |
$718.20 |
$535.60
|
|
Tx open dstl phlngl fx f/t internal fixation ea
|
$7,873.60 |
$7,873.60 |
$7,873.60 |
$4,499.12
|
|
Tx open nsl fx uncomp
|
$6,492.00 |
$6,492.00 |
$6,492.00 |
$3,837.72
|
|
Tx phalangeal shaft fx open prox/middle ea
|
$6,348.00 |
$6,348.00 |
$6,348.00 |
$4,529.60
|
|
Tx tarsal bone fx without manip 28450
|
$825.60 |
$825.60 |
$825.60 |
$419.73
|
|
Ultrasound breast complete
|
$888.80 |
$888.80 |
$888.80 |
$532.00
|
|
Ultrasound breast unilateral limited (both sides)
|
$630.40 |
$630.40 |
$630.40 |
$452.40
|
|
Ultrasound encephalogram
|
$738.40 |
$738.40 |
$738.40 |
$494.92
|
|
Ultrasound exam k transpl w/doppler
|
$869.60 |
$869.60 |
$869.60 |
$575.40
|
|
Ultrasound fetal biophysical profile without non-stress testing
|
$652.80 |
$652.80 |
$652.80 |
$476.94
|
|
Ultrasound Guidance for a Needle Procedure
|
$1,221.60 |
$1,221.60 |
$1,221.60 |
$720.15
|
|
Ultrasound guidance for vascular access
|
$484.00 |
$484.00 |
$484.00 |
$388.08
|
|
Ultrasound guide intraoperative
|
$760.00 |
$760.00 |
$760.00 |
$632.85
|
|
Ultrasound hips infant dynamic
|
$1,209.60 |
$1,209.60 |
$1,209.60 |
$403.88
|
|
Ultrasound infant hips ltd without stress
|
$796.80 |
$796.80 |
$796.80 |
$311.25
|
|
Ultrasound joint complete left
|
$1,025.60 |
$1,025.60 |
$1,025.60 |
$557.99
|
|
Ultrasound ob >=14wks ea addl gest
|
$373.60 |
$373.60 |
$373.60 |
$409.20
|
|
Ultrasound pregnant uterus < 14 weeks each additional gestation
|
$373.60 |
$373.60 |
$373.60 |
$335.00
|
|
Ultrasound pregnant uterus follow up per fetus
|
$835.20 |
$835.20 |
$835.20 |
$425.60
|
|
Ultrasound prostate/transrectal
|
$840.80 |
$840.80 |
$840.80 |
$557.40
|
|
Ultrasound spinal canal and contents
|
$692.00 |
$692.00 |
$692.00 |
$463.00
|
|
Unlisted CT procedure
|
$917.60 |
$917.60 |
$917.60 |
$732.70
|
|
Unlisted cv px dx nuc med
|
$2,254.40 |
$2,254.40 |
$2,254.40 |
$1,747.20
|
|
Unlisted gi px dx nuc med
|
$944.00 |
$944.00 |
$944.00 |
$995.00
|
|
Unlisted misc path test
|
$112.80 |
$112.80 |
$112.80 |
$89.40
|
|
Unlisted muscskel px dx nuc
|
$660.00 |
$660.00 |
$660.00 |
$1,279.98
|
|
Unlisted procedure microbiology
|
$151.20 |
$151.20 |
$151.20 |
$530.00
|
|
Unlisted procedure rectum
|
$3,816.80 |
$3,816.80 |
$3,816.80 |
$1,223.20
|
|
Unlisted px casting/strpg
|
$152.00 |
$152.00 |
$152.00 |
$222.00
|
|
Unlisted px hands/fingers
|
$5,143.20 |
$5,143.20 |
$5,143.20 |
$354.20
|
|
Unlisted px mediastinum
|
$114.40 |
$114.40 |
$114.40 |
$397.60
|
|
Unlisted px small intestine
|
$4,264.00 |
$4,264.00 |
$4,264.00 |
$2,118.35
|
|
Unlisted ultrasound procedure
|
$146.40 |
$146.40 |
$146.40 |
$335.00
|
|
Unlstd hematop ret/endo lymp
|
$734.40 |
$734.40 |
$734.40 |
$473.22
|
|
Unsched dialysis esrd pt hos
|
$2,013.60 |
$2,013.60 |
$2,013.60 |
$1,296.00
|
|
Upper Arm (Humerus) X-ray (left side)
|
$685.60 |
$685.60 |
$685.60 |
$309.31
|
|
Upper Back (Thoracic Spine) CT Scan (with contrast)
|
$3,090.40 |
$3,090.40 |
$3,090.40 |
$1,669.00
|
|
Upper Back (Thoracic Spine) CT Scan (without contrast)
|
$2,508.00 |
$2,508.00 |
$2,508.00 |
$1,425.85
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$4,850.40 |
$4,850.40 |
$4,850.40 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$3,689.60 |
$3,689.60 |
$3,689.60 |
$2,392.00
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$3,040.00 |
$3,040.00 |
$3,040.00 |
$2,034.41
|
|
Upper Back (Thoracic Spine) X-ray (2 views)
|
$776.00 |
$776.00 |
$776.00 |
$321.95
|
|
Upper Back (Thoracic Spine) X-ray (3 views)
|
$666.40 |
$666.40 |
$666.40 |
$381.60
|
|
Upper Endoscopy (EGD, diagnostic)
|
$4,264.00 |
$4,264.00 |
$4,264.00 |
$1,824.75
|
|
Upper Endoscopy (EGD, with biopsy)
|
$4,264.00 |
$4,264.00 |
$4,264.00 |
$1,768.00
|
|
Upper GI Barium X-ray (barium and gas)
|
$701.60 |
$701.60 |
$701.60 |
$660.40
|
|
Upper GI Barium X-ray (barium only)
|
$701.60 |
$701.60 |
$701.60 |
$607.20
|
|
Uppr gi scope w/submuc inj
|
$4,264.00 |
$4,264.00 |
$4,264.00 |
$1,872.00
|
|
Urea nitrogen
|
$47.80 |
$47.80 |
$47.80 |
$42.01
|
|
Urea nitrogen 24 hour urine
|
$76.60 |
$76.60 |
$76.60 |
$51.84
|
|
Ureteral reflux study
|
$2,251.20 |
$2,251.20 |
$2,251.20 |
$952.50
|
|
Urethrcystgrphy rtrgrde s&i
|
$776.80 |
$776.80 |
$776.80 |
$584.00
|
|
Urethrocystography void s&i
|
$1,539.20 |
$1,539.20 |
$1,539.20 |
$634.50
|
|
Uric acid blood
|
$59.20 |
$59.20 |
$59.20 |
$49.32
|
|
Uric acid urine
|
$99.20 |
$99.20 |
$99.20 |
$44.52
|
|
Urinalysis qual/semiquant excpt ia
|
$62.20 |
$62.20 |
$62.20 |
$25.72
|
|
Urinalysis (with microscopy)
|
$84.80 |
$84.80 |
$84.80 |
$55.20
|
|
Urinalysis (without microscopy)
|
$45.80 |
$45.80 |
$45.80 |
$35.91
|
|
Urinary bldr retent nuc study
|
$1,801.60 |
$1,801.60 |
$1,801.60 |
$350.66
|
|
Urinary pouch on barr w/flng
|
$244.00 |
$244.00 |
$244.00 |
$9.89
|
|
Urinary suspensory
|
$23.40 |
$23.40 |
$23.40 |
$52.20
|
|
Urine Culture Test
|
$264.00 |
$264.00 |
$264.00 |
$82.32
|
|
Urine pregnancy test
|
$137.40 |
$137.40 |
$137.40 |
$68.21
|
|
Urography, antegrade
|
$1,369.60 |
$1,369.60 |
$1,369.60 |
$622.35
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$76.00 |
$76.00 |
$76.00 |
$5,205.00
|
|
Ustekinumab 45 mg/0.5 ml subcutaneous solution
|
$57.00 |
$57.00 |
$57.00 |
$51,633.07
|
|
Vaccine Administration (one shot)
|
$16.00 |
$16.00 |
$16.00 |
$67.74
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$340.00 |
$340.00 |
$340.00 |
$224.25
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$209.40 |
$209.40 |
$209.40 |
$209.40
|
|
Vaccine dtap < 7 years im
|
$33.60 |
$33.60 |
$33.60 |
$71.17
|
|
Vaccine dtap-hep b-ipv im
|
$39.60 |
$39.60 |
$39.60 |
$164.63
|
|
Vaccine dtap-ipv 4-6 years im
|
$31.20 |
$31.20 |
$31.20 |
$105.95
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$31.20 |
$31.20 |
$31.20 |
$70.53
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$32.40 |
$32.40 |
$32.40 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$108.00 |
$108.00 |
$108.00 |
$166.62
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$67.80 |
$67.80 |
$67.80 |
$78.25
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$86.40 |
$86.40 |
$86.40 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$168.80 |
$168.80 |
$168.80 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$63.20 |
$63.20 |
$63.20 |
$75.39
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$157.80 |
$157.80 |
$157.80 |
$576.48
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$195.60 |
$195.60 |
$195.60 |
$282.50
|
|
Vaccine influenza quadrivalent (iiv4) 0.5ml dose im
|
$12.60 |
$12.60 |
$12.60 |
$35.88
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.25ml dose im
|
$12.00 |
$12.00 |
$12.00 |
$28.77
|
|
Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im
|
$14.40 |
$14.40 |
$14.40 |
$33.60
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$54.00 |
$54.00 |
$54.00 |
$72.00
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$24.00 |
$24.00 |
$24.00 |
$82.71
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$111.60 |
$111.60 |
$111.60 |
$394.26
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$86.40 |
$86.40 |
$86.40 |
$310.93
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$108.80 |
$108.80 |
$108.80 |
$327.37
|
|
Vaccine mmr live subcutaneous
|
$64.80 |
$64.80 |
$64.80 |
$213.00
|
|
Vaccine mmrv live subcutaneous
|
$112.20 |
$112.20 |
$112.20 |
$424.32
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$75.00 |
$75.00 |
$75.00 |
$252.87
|
|
Vaccine pneumococcal conjugate 13 valent (pcv13) im
|
$144.00 |
$144.00 |
$144.00 |
$393.25
|
