|
Tympanic membrane repair
|
$8,405.50 |
$8,405.50 |
$8,405.50 |
$2,638.87
|
|
Tympanometry & reflex thresh
|
$116.90 |
$116.90 |
$116.90 |
$170.00
|
|
Ugt1a1 gene analy common variants
|
$718.90 |
$718.90 |
$718.90 |
$438.75
|
|
Ultrasound abdomen aorta screening study aaa
|
$852.60 |
$852.60 |
$852.60 |
$394.20
|
|
Ultrasound breast complete
|
$532.00 |
$532.00 |
$532.00 |
$528.41
|
|
Ultrasound breast unilateral limited (both sides)
|
$438.90 |
$438.90 |
$438.90 |
$449.35
|
|
Ultrasound chest
|
$1,039.50 |
$1,039.50 |
$1,039.50 |
$460.85
|
|
Ultrasound doppler velocimetry fetal umbilical artery
|
$969.50 |
$969.50 |
$969.50 |
$338.00
|
|
Ultrasound elastography ea l target les
|
$434.00 |
$434.00 |
$434.00 |
$180.00
|
|
Ultrasound elastography parenchyma
|
$482.30 |
$482.30 |
$482.30 |
$307.00
|
|
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
|
$65.10 |
$65.10 |
$65.10 |
$39.52
|
|
Unlisted hystsc px uterus
|
$14,815.88 |
$14,815.88 |
$14,815.88 |
$2,803.60
|
|
Unlisted laparoscopic liver biopy 47379
|
$37,876.07 |
$37,876.07 |
$37,876.07 |
$5,419.00
|
|
Unlisted laparoscopic procedure 49659
|
$38,639.68 |
$38,639.68 |
$38,639.68 |
$6,838.32
|
|
Unlisted laparoscopic reduction intestine 44238
|
$56,516.07 |
$56,516.07 |
$56,516.07 |
$5,419.00
|
|
Unlisted laps px esoph
|
$136,052.30 |
$136,052.30 |
$136,052.30 |
$5,741.00
|
|
Unlisted laps px lymphtc sys
|
$58,200.55 |
$58,200.55 |
$58,200.55 |
$6,870.89
|
|
Unlisted laps px ureter
|
$41,228.08 |
$41,228.08 |
$41,228.08 |
$6,212.70
|
|
Unlisted laps px uterus
|
$16,931.84 |
$16,931.84 |
$16,931.84 |
$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
|
$33,050.76 |
$33,050.76 |
$33,050.76 |
$1,998.88
|
|
Unlisted procedure larynx
|
$25,928.71 |
$25,928.71 |
$25,928.71 |
$924.00
|
|
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
|
$18,955.01 |
$18,955.01 |
$18,955.01 |
$1,220.35
|
|
Unlisted px abdomen muscskel
|
$3,161.20 |
$3,161.20 |
$3,161.20 |
$1,848.60
|
|
Unlisted px accessory sinus
|
$56,041.45 |
$56,041.45 |
$56,041.45 |
$3,335.28
|
|
Unlisted px arthroscopy
|
$76,806.14 |
$76,806.14 |
$76,806.14 |
$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 salivry glnd/dux
|
$20,869.91 |
$20,869.91 |
$20,869.91 |
$1,265.16
|
|
Unlisted px small intestine
|
$13,778.91 |
$13,778.91 |
$13,778.91 |
$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
|
|
Unsched dialysis esrd pt hos
|
$5,777.80 |
$5,777.80 |
$5,777.80 |
$1,268.17
|
|
Upgrade pm system
|
$11,967.20 |
$11,967.20 |
$11,967.20 |
$12,077.00
|
|
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)
|
$8,083.00 |
$8,083.00 |
$8,083.00 |
$1,751.66
|
|
Upper Endoscopy (EGD, with biopsy)
|
$11,416.60 |
$11,416.60 |
$11,416.60 |
$1,768.00
|
|
Uppr gi scope w/submuc inj
|
$14,028.45 |
$14,028.45 |
$14,028.45 |
$1,872.00
|
|
Urea nitrogen
|
$66.50 |
$66.50 |
$66.50 |
$41.46
|
|
Urea nitrogen 24 hour urine
|
$60.90 |
$60.90 |
$60.90 |
$51.75
|
|
Ureteral embolization/occl
|
$2,184.00 |
$2,184.00 |
$2,184.00 |
$2,181.40
|
|
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
|
$128.80 |
$128.80 |
$128.80 |
$44.33
|
|
Urinalysis microscopic only
|
$39.90 |
$39.90 |
$39.90 |
$26.35
|
|
Urinalysis qual/semiquant excpt ia
|
$30.10 |
$30.10 |
$30.10 |
$25.72
|
|
Urinalysis (with microscopy)
|
$83.30 |
$83.30 |
$83.30 |
$55.00
|
|
Urinalysis (without microscopy)
|
$85.40 |
$85.40 |
$85.40 |
$35.75
|
|
Urine Culture Test
|
$115.50 |
$115.50 |
$115.50 |
$81.50
|
|
Urine pregnancy test
|
$142.10 |
$142.10 |
$142.10 |
$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
|
|
Ustekinumab 130 mg/26 ml intravenous solution
|
$35,246.22 |
$35,246.22 |
$35,246.22 |
$5,184.34
|
|
Ustekinumab 45 mg/0.5 ml subcutaneous solution
|
$49,433.12 |
$49,433.12 |
$49,433.12 |
$51,633.07
|
|
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
|
