|
Ultrasound hips infant dynamic
|
$368.50 |
$368.50 |
$368.50 |
$403.88
|
|
Ultrasound joint/nonvascular extremity limited left
|
$670.00 |
$670.00 |
$670.00 |
$425.45
|
|
Ultrasound ob >=14wks ea addl gest
|
$194.50 |
$194.50 |
$194.50 |
$407.20
|
|
Ultrasound pregnant uterus < 14 weeks each additional gestation
|
$92.50 |
$92.50 |
$92.50 |
$331.50
|
|
Ultrasound pregnant uterus follow up per fetus
|
$360.50 |
$360.50 |
$360.50 |
$425.60
|
|
Ultrasound pregnant uterus limited >= 1 fetuses
|
$558.00 |
$558.00 |
$558.00 |
$459.00
|
|
Ultrasound pregnant uterus transvaginal
|
$600.00 |
$600.00 |
$600.00 |
$497.12
|
|
Ultrasound retroperitoneal limited
|
$600.00 |
$600.00 |
$600.00 |
$486.50
|
|
Ultrasound scrotum and contents
|
$600.00 |
$600.00 |
$600.00 |
$608.90
|
|
Ultrasound spinal canal and contents
|
$368.50 |
$368.50 |
$368.50 |
$463.00
|
|
Ultrasound transvaginal non obstetric
|
$569.50 |
$569.50 |
$569.50 |
$558.35
|
|
Unlisted chemotherapy px
|
$62.50 |
$62.50 |
$62.50 |
$150.00
|
|
Unlisted dialysis procedure
|
$752.00 |
$752.00 |
$752.00 |
$1,144.00
|
|
Unlisted hematology&coagj px
|
$48.50 |
$48.50 |
$48.50 |
$39.52
|
|
Unlisted laparoscopic procedure 49659
|
$7,925.50 |
$7,925.50 |
$7,925.50 |
$6,838.32
|
|
Unlisted laparoscopic reduction intestine 44238
|
$8,679.50 |
$8,679.50 |
$8,679.50 |
$5,419.00
|
|
Unlisted maaa
|
$587.00 |
$587.00 |
$587.00 |
$235.20
|
|
Unlisted procedure colon
|
$1,553.50 |
$1,553.50 |
$1,553.50 |
$1,702.50
|
|
Unlisted procedure esophagus
|
$2,933.00 |
$2,933.00 |
$2,933.00 |
$1,998.88
|
|
Unlisted procedure microbiology
|
$6.00 |
$6.00 |
$6.00 |
$523.50
|
|
Unlisted px abdomen muscskel
|
$1,550.33 |
$1,550.33 |
$1,550.33 |
$1,848.60
|
|
Unlisted px arthroscopy
|
$2,249.17 |
$2,249.17 |
$2,249.17 |
$2,765.60
|
|
Unlisted px forearm/wrist
|
$3,322.50 |
$3,322.50 |
$3,322.50 |
$593.60
|
|
Unlisted px hands/fingers
|
$308.50 |
$308.50 |
$308.50 |
$354.20
|
|
Unlisted px leg/ankle
|
$369.00 |
$369.00 |
$369.00 |
$811.00
|
|
Unlisted px pelvis/hip joint
|
$5,862.00 |
$5,862.00 |
$5,862.00 |
$3,118.44
|
|
Unlisted urinalysis px
|
$77.50 |
$77.50 |
$77.50 |
$25.72
|
|
Unlstd laps px sprmatic cord
|
$3,954.33 |
$3,954.33 |
$3,954.33 |
$4,713.11
|
|
Unsched dialysis esrd pt hos
|
$683.50 |
$683.50 |
$683.50 |
$1,268.17
|
|
Upgrade pm system
|
$5,363.00 |
$5,363.00 |
$5,363.00 |
$12,077.00
|
|
Upper Back (Thoracic Spine) MRI (with and without contrast)
|
$2,992.50 |
$2,992.50 |
$2,992.50 |
$2,998.00
|
|
Upper Back (Thoracic Spine) MRI (with contrast)
|
$2,783.50 |
$2,783.50 |
$2,783.50 |
$2,364.35
|
|
Upper Back (Thoracic Spine) MRI (without contrast)
|
$1,817.50 |
$1,817.50 |
$1,817.50 |
$2,034.41
|
|
Upper Endoscopy (EGD, diagnostic)
|
$3,726.00 |
$3,726.00 |
$3,726.00 |
$1,751.66
|
|
Upper Endoscopy (EGD, with biopsy)
|
$2,140.00 |
$2,140.00 |
$2,140.00 |
$1,768.00
|
|
Uppr gi scope w/submuc inj
|
$1,774.00 |
$1,774.00 |
$1,774.00 |
$1,872.00
|
|
Urea nitrogen
|
$20.50 |
$20.50 |
$20.50 |
$41.46
|
|
Urea nitrogen 24 hour urine
|
$23.50 |
$23.50 |
$23.50 |
$51.75
|
|
Ureter endoscopy & treatment
|
$5,400.50 |
$5,400.50 |
$5,400.50 |
$5,631.74
|
|
Urethrocystography void s&i
|
$1,224.50 |
$1,224.50 |
$1,224.50 |
$622.35
|
|
Uric acid blood
|
$23.50 |
$23.50 |
$23.50 |
$48.75
|
|
Uric acid urine
|
$23.00 |
$23.00 |
$23.00 |
$44.33
|
|
Urinalysis microscopic only
|
$28.50 |
$28.50 |
$28.50 |
$26.35
|
|
Urinalysis (with microscopy)
|
$27.00 |
$27.00 |
$27.00 |
$55.00
|
|
Urinalysis (without microscopy)
|
$12.50 |
$12.50 |
$12.50 |
$35.75
|
|
Urine Culture Test
|
$44.00 |
$44.00 |
$44.00 |
$81.50
|
|
Urine pregnancy test
|
$33.50 |
$33.50 |
$33.50 |
$67.20
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$16,188.02 |
$16,188.02 |
$16,188.02 |
$5,184.34
|
|
Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml
|
$124.00 |
$124.00 |
$124.00 |
$224.25
|
|
Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml
|
$113.00 |
$113.00 |
$113.00 |
$209.40
|
|
Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im
|
$100.50 |
$100.50 |
$100.50 |
$236.50
|
|
Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im
|
$45.00 |
$45.00 |
$45.00 |
$123.20
|
|
Vaccine dtap < 7 years im
|
$27.50 |
$27.50 |
$27.50 |
$68.19
|
|
Vaccine dtap-hep b-ipv im
|
$63.00 |
$63.00 |
$63.00 |
$164.63
|
|
Vaccine dtap-ipv 4-6 years im
|
$57.50 |
$57.50 |
$57.50 |
$105.95
|
|
Vaccine dtap-ipv/hib im
|
$106.00 |
$106.00 |
$106.00 |
$221.24
|
|
Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im
|
$28.00 |
$28.00 |
$28.00 |
$70.26
|
|
Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im
|
$12.50 |
$12.50 |
$12.50 |
$43.12
|
|
Vaccine hepatitis a (hepa) adult im
|
$68.00 |
$68.00 |
$68.00 |
$166.62
|
|
Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im
|
$95.50 |
$95.50 |
$95.50 |
$218.40
|
|
Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im
|
$32.50 |
$32.50 |
$32.50 |
$79.15
|
|
Vaccine hepatitis b (hepb) adolescent 2 dose im
|
$46.50 |
$46.50 |
$46.50 |
$84.75
|
|
Vaccine hepatitis b (hepb) adult 3 dose im
|
$46.50 |
$46.50 |
$46.50 |
$155.16
|
|
Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im
|
$127.00 |
$127.00 |
$127.00 |
$274.93
|
|
Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im
|
$22.00 |
$22.00 |
$22.00 |
$75.39
|
|
Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im
|
$290.50 |
$290.50 |
$290.50 |
$576.48
|
|
Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im
|
$282.50 |
$282.50 |
$282.50 |
$282.50
|
|
Vaccine influenza (iiv) preservative free antigen content im
|
$79.50 |
$79.50 |
$79.50 |
$143.20
|
|
Vaccine influenza inactivated adjuvant im
|
$73.00 |
$73.00 |
$73.00 |
$109.50
|
|
Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im
|
$19.50 |
$19.50 |
$19.50 |
$47.88
|
|
Vaccine influenza quadrivalent (iiv4) inactivated adjuvanted preservative free 0.5ml dose im
|
$69.00 |
$69.00 |
$69.00 |
$72.80
|
|
Vaccine influenza quadrivalent (iiv4) split virus 0.25 ml im
|
$10.00 |
$10.00 |
$10.00 |
$20.80
|
|
Vaccine influenza quadrivalent live (laiv4) intranasal
|
$59.00 |
$59.00 |
$59.00 |
$37.05
|
|
Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im
|
$66.00 |
$66.00 |
$66.00 |
$72.00
|
|
Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im
|
$32.50 |
$32.50 |
$32.50 |
$76.50
|
|
Vaccine influenza trivalent (iiv3) 0.25ml dose im
|
$10.00 |
$10.00 |
$10.00 |
$31.20
|
|
Vaccine mengingoccocal serogroup b 2 dose im
|
$154.50 |
$154.50 |
$154.50 |
$400.03
|
|
Vaccine mengingoccocal serogroup b 2 or 3 dose im
|
$170.00 |
$170.00 |
$170.00 |
$409.35
|
|
Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im
|
$147.00 |
$147.00 |
$147.00 |
$310.93
|
|
Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im
|
$104.50 |
$104.50 |
$104.50 |
$329.24
|
|
Vaccine mmr live subcutaneous
|
$86.00 |
$86.00 |
$86.00 |
$211.68
|
|
Vaccine mmrv live subcutaneous
|
$269.50 |
$269.50 |
$269.50 |
$424.32
|
|
Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im
|
$105.50 |
$105.50 |
$105.50 |
$251.64
|
|
Vaccine pneumonococcal conjugate 15 valent (pcv15) im
|
$196.00 |
$196.00 |
$196.00 |
$414.46
|
|
Vaccine pneumonococcal conjugate 20 valent (pcv20) im
|
$242.50 |
$242.50 |
$242.50 |
$563.36
|
|
Vaccine polio (ipv) subcutaneous/im
|
$41.00 |
$41.00 |
$41.00 |
$90.70
|
|
Vaccine rabies im
|
$406.00 |
$406.00 |
$406.00 |
$858.95
|
|
Vaccine respiratory syncytial virus bivalent subunit/preservative free im
|
$271.00 |
$271.00 |
$271.00 |
$538.84
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im
|
$1,183.50 |
$1,183.50 |
$1,183.50 |
$1,104.47
|
|
Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im
|
$1,183.50 |
$1,183.50 |
$1,183.50 |
$997.44
|
|
Vaccine respiratory syncytial virus recombinant subunit adjuvanted/preservative free im
|
$228.00 |
$228.00 |
$228.00 |
$499.62
|
|
Vaccine rotavirus attenuated (rv1) live 2 dose oral
|
$103.00 |
$103.00 |
$103.00 |
$200.70
|
|
Vaccine rotavirus pentavalent (rv5) live 3 dose oral
|
$84.50 |
$84.50 |
$84.50 |
$126.14
|
|
Vaccine tdap >=7 years im
|
$45.50 |
$45.50 |
$45.50 |
$131.34
|
|
Vaccine td preservative free >= 7 years im
|
$46.50 |
$46.50 |
$46.50 |
$112.10
|
|
Vaccine typhoid vicps im
|
$141.50 |
$141.50 |
$141.50 |
$264.78
|
|
Vaccine varicella live subcutaneous
|
$183.00 |
$183.00 |
$183.00 |
$365.17
|
|
Vaccine yellow fever live subcutaneous
|
$205.50 |
$205.50 |
$205.50 |
$418.46
|
|
Vag hyst including t/o
|
$9,645.50 |
$9,645.50 |
$9,645.50 |
$4,827.18
|
|
Vaginal bx
|
$4,195.00 |
$4,195.00 |
$4,195.00 |
$455.94
|
