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Unit Price Base Price Service Type Procedure University Physicians Group: Prices of Provider Services CPT Unit Base Service Procedure Modifier Code ype Current Procedural Terminology (CPT) Price Price T 00100 PR ANESTH,SALIVARY GLAND W/BX 1.00 5.00 Anesthesia 00102 PR ANESTH,CLEFT LIP REPAIR 1.00 6.00 Anesthesia 00103 PR ANESTH,BLEPHAROPLASTY 1.00 5.00 Anesthesia 00104 ANESTH,ELECTROSHOCK/ ECT 1.00 4.00 Anesthesia 00120 ANESTH,EAR SURGERY 1.00 5.00 Anesthesia 00124 ANESTH,EAR EXAM 1.00 4.00 Anesthesia 00126 PR ANESTH,TYMPANOTOMY 1.00 4.00 Anesthesia 00140 PR ANESTH,PROCEDURES ON EYE 1.00 5.00 Anesthesia 00142 ANESTH, LENS SURGERY 1.00 4.00 Anesthesia 00144 PR ANESTH,CORNEAL TRANSPLANT 1.00 6.00 Anesthesia 00145 ANESTH, VITREORETINAL SURG 1.00 6.00 Anesthesia 00147 PR ANESTH,IRIDECTOMY 1.00 4.00 Anesthesia 00148 ANESTH,EYE EXAM 1.00 4.00 Anesthesia 00160 PR ANESTH,NOSE,SINUS SURGERY 1.00 5.00 Anesthesia 00162 PR ANESTH,NOSE,RADICAL SINUS 1.00 7.00 Anesthesia SURGERY 00164 PR ANESTH,BIOPSY OF NOSE 1.00 4.00 Anesthesia 00170 PR ANESTH,PROCEDURE ON MOUTH 1.00 5.00 Anesthesia 00172 PR ANESTH,CLEFT PALATE REPAIR 1.00 6.00 Anesthesia 00174 PR ANESTH,EXCIS RETROPHARYNG 1.00 6.00 Anesthesia 00176 PR ANESTH,PHARYNX SURG 1.00 7.00 Anesthesia 00190 PR ANESTH,FACIAL BONE SURGERY 1.00 5.00 Anesthesia 00192 PR ANESTH,RADICAL FACIAL BONE 1.00 7.00 Anesthesia SURGERY 00210 PR ANESTH,OPEN HEAD SURGERY 1.00 11.00 Anesthesia 00211 PR ANESTH, INTRACRANIAL 1.00 10.00 Anesthesia HEMATOMA EVACUATION 00212 PR ANESTH,SKULL SURG SUBDUR 1.00 5.00 Anesthesia 00214 PR ANESTH,SKULL SURG BURR 1.00 9.00 Anesthesia 00215 PR ANESTH, CRANIOPLASTY 1.00 9.00 Anesthesia 00216 PR ANESTH,HEAD VESSEL 1.00 15.00 Anesthesia 00218 PR ANESTH,SPECIAL HEAD 1.00 13.00 Anesthesia 00220 PR ANESTH,INTRACRAN PROC; CSF 1.00 10.00 Anesthesia SHUNT PROC 00222 PR ANESTH,INTRACRAN NERVE 1.00 6.00 Anesthesia COAGULATN 00300 PR ANESTH,SKIN SURG HEAD/NECK 1.00 5.00 Anesthesia 00320 PR ANESTH,NECK ORG PROC; NOS, 1.00 6.00 Anesthesia AGE 1 YR/OLD 00322 PR ANESTH,NEEDLE BX THYROID 1.00 3.00 Anesthesia 00326 PR ANESTH,LARYNX/TRACH PROC; 1.00 7.00 Anesthesia CHILDREN <1 YR 00350 PR ANESTH,NECK VESSEL 1.00 10.00 Anesthesia 00352 PR ANESTH,NECK VESSEL SURG 1.00 5.00 Anesthesia SIMPL LIGAT 00400 PR ANESTH,SKIN SURG 1.00 3.00 Anesthesia 00402 PR ANESTH,SURG BREAST 1.00 5.00 Anesthesia RECONSTRUCTIVE 00404 PR ANESTH,SURG BREAST RAD 1.00 5.00 Anesthesia 00406 PR ANESTH,SURG BREAST RAD 1.00 13.00 Anesthesia MAST W NODE 00410 PR ANESTH,CORRECT HEART 1.00 4.00 Anesthesia 0042T CEREBRAL PERFUS ANALYSIS, CT 200.00 W/CONTRAST 00450 PR ANESTH,SURG 1.00 5.00 Anesthesia 00454 PR ANESTH,CLAVICLE BIOPSY 1.00 3.00 Anesthesia 00470 PR ANESTH,PARTIAL RIB RESECTN 1.00 6.00 Anesthesia 00472 PR ANESTH,CHEST WALL REPAIR 1.00 10.00 Anesthesia 00474 PR ANESTH,CHEST WALL REPAIR 1.00 13.00 Anesthesia EXTENSIVE 00500 PR ANESTH,ESOPHAGEAL SURGERY 1.00 15.00 Anesthesia 00520 PR ANESTH,CHEST PROC 1.00 6.00 Anesthesia 00522 PR ANESTH,CHEST PLEURAL 1.00 4.00 Anesthesia 00524 PR ANESTH,CHEST DRAINAGE 1.00 4.00 Anesthesia 00528 PR ANESTH,MEDIASTINOSCOPY 1.00 8.00 Anesthesia 00529 PR ANESTH, CHEST PARTITION VIEW 1.00 11.00 Anesthesia 00530 PR ANESTH,PACEMAKER INSERTION 1.00 4.00 Anesthesia 00532 PR ANESTH,CENTRL VASCULAR 1.00 4.00 Anesthesia 00534 PR ANESTH,CARDIOVERTER/DEFIB 1.00 7.00 Anesthesia 00537 PR ANESTH,CARD ELECTROPHYS 1.00 7.00 Anesthesia 00539 PR ANESTH,TRACHEOBRONCHIAL 1.00 18.00 Anesthesia RECONSTRUCT 00540 PR ANESTH,CHEST 1.00 12.00 Anesthesia SURGERY,THORACOTOMY 00541 PR ANESTH,THORACOTOMY PROC, 1.00 15.00 Anesthesia W/1 LUNG VENT 00542 PR ANESTH,CHEST DECORTICATION 1.00 15.00 Anesthesia 00546 PR ANESTH,LUNG 1.00 15.00 Anesthesia 00548 PR ANESTH,TRACH,BRONCHI 1.00 17.00 Anesthesia INTRATHOR SURG 0054T BONE SURGERY USING COMPUTER 640.00 ASSIST, FLURO GUIDED 00550 PR ANESTH,STERNAL 1.00 10.00 Anesthesia 00560 PR ANESTH,OPEN HEART; W/O 1.00 15.00 Anesthesia PUMP OXYEGENATOR 00561 PR ANESTH, HEART SURG < AGE 1 1.00 25.00 Anesthesia 00562 PR ANESTH,OPEN HEART 1.00 20.00 Anesthesia 00563 PR ANESTH,OPEN 1.00 25.00 Anesthesia HEART,PUMP+HYPOTHERM 00566 PR ANESTH,DIRECT CABG W/O 1.00 25.00 Anesthesia PUMP OXYGENATOR 00567 PR ANESTH, DIRECT CABG W PUMP 1.00 18.00 Anesthesia OXYGENATOR 00580 PR ANESTH,HEART/LUNG 1.00 20.00 Anesthesia 00600 PR ANESTH,CERV SPINE,CORD 1.00 10.00 Anesthesia 00604 PR ANESTH,CERV SPINE, SITTING 1.00 13.00 Anesthesia 00620 PR ANESTH,THOR SPINE,CORD 1.00 10.00 Anesthesia 00630 PR ANESTH,LUMBAR SPINE,CORD 1.00 8.00 Anesthesia SURGERY 00632 PR ANESTH,LUMBAR 1.00 7.00 Anesthesia 00635 PR ANESTH,LUMBAR PUNCTURE 1.00 4.00 Anesthesia 00640 PR ANESTH,CLOSED 1.00 3.00 Anesthesia MANIPULATION, SPINE C/T/L 00670 PR ANESTH,EXTENSIVE SPINE,CORD 1.00 13.00 Anesthesia PROCED 00700 PR ANESTH,ABD WALL,UPER 1.00 4.00 Anesthesia 00702 PR ANESTH,FOR LIVER BIOPSY 1.00 4.00 Anesthesia 0071T U/S LEIOMYOMATA ABLATE <200 CC 2500.00 00730 PR ANESTH,ABD WALL,UPPER 1.00 5.00 Anesthesia 00731 PR ANESTHESIA UPPER GI 1.00 5.00 Anesthesia ENDOSCOPIC PX NOS 00732 PR ANESTHESIA UPPER GI 1.00 6.00 Anesthesia ENDOSCOPIC PX ERCP 00740 PR ANESTH,UGI ENDOSCOPY 1.00 5.00 Anesthesia 00750 PR ANESTH,REPAIR UPPER ABD 1.00 4.00 Anesthesia HERNIA NOS 00752 PR ANESTH,REPAIR UP HERNIA 1.00 6.00 Anesthesia LUMBAR/VENTR 00754 PR ANESTH,REPAIR UP HERNIA 1.00 7.00 Anesthesia OMPHALOCELE 00756 PR ANESTH,REPAIR UP HERNIA 1.00 7.00 Anesthesia 0075T PR TCAT PLMT XTRC VRT CRTD 26 2136.00 STENT RS&I PRQ 1ST VSL 00770 PR ANESTH,MAJOR ABD BLOOD 1.00 15.00 Anesthesia VESSEL REPAIR 00790 PR ANESTH,SURG UPPER ABDOMEN 1.00 7.00 Anesthesia 00792 PR ANESTH,PARTIAL LIVER 1.00 13.00 Anesthesia 00794 PR ANESTH,PANCREAS REMOVAL 1.00 8.00 Anesthesia 00796 PR ANESTH,FOR LIVER 1.00 30.00 Anesthesia 00797 PR ANESTH,GASTRIC RESTRICT, 1.00 11.00 Anesthesia MORBID OBESITY 00800 PR ANESTH,ABD WALL,LOWER 1.00 4.00 Anesthesia 00802 PR ANESTH,FAT LAYER REMOVAL 1.00 5.00 Anesthesia 00810 PR ANESTH,INTESTINE,SCOPE,LOW 1.00 5.00 Anesthesia 00811 PR ANESTHESIA LOWER INTST 1.00 4.00 Anesthesia ENDOSCOPIC PX NOS 00812 PR ANESTHESIA LOWER INTST 1.00 3.00 Anesthesia ENDOSCOPIC PX SCR COLSC 00813 PR ANESTHESIA COMBINED 1.00 5.00 Anesthesia UPPER&LOWER GI ENDOSCOPIC PX 00820 PR ANESTH,ABD WALL,LOWER 1.00 5.00 Anesthesia 00830 PR ANESTH,REPAIR LO ABD HERNIA 1.00 4.00 Anesthesia 00832 PR ANESTH,REPAIR LO HERNIA 1.00 6.00 Anesthesia VENTR/INCIS 00834 PR ANESTH,REPAIR LO ABD HERNIA 1.00 5.00 Anesthesia NOS, < 1 YR 00836 PR ANESTH,REP LO ABD HERN NOS, 1.00 6.00 Anesthesia PREM <50 WKS 00840 PR ANESTH,SURG LOWER 1.00 6.00 Anesthesia 00842 PR ANESTH,AMNIOCENTESIS 1.00 4.00 Anesthesia 00844 PR ANESTH,ABD-PERINEAL 1.00 7.00 Anesthesia 00846 PR ANESTH,RADICAL 1.00 8.00 Anesthesia 00848 PR ANESTH,PELVIC EXENTERATION 1.00 8.00 Anesthesia 00851 PR ANESTH,TUBAL 1.00 6.00 Anesthesia 00860 PR ANESTH,SURG LOW 1.00 6.00 Anesthesia ABD,EXTRAPERINTONEAL 00862 PR ANESTH,KIDNEY,PROX URETER 1.00 7.00 Anesthesia 00864 PR ANESTH,REMOVAL OF BLADDER 1.00 8.00 Anesthesia 00865 PR ANESTH,REMOVAL OF 1.00 7.00 Anesthesia 00866 PR ANESTH,REMOVAL OF ADRENAL 1.00 10.00 Anesthesia 00868 PR ANESTH,KIDNEY TRANSPLANT 1.00 10.00 Anesthesia 00870 PR ANESTH,BLADDER STONE SURG 1.00 5.00 Anesthesia 00872 PR ANESTH,KID STONE 1.00 7.00 Anesthesia DESTRUCT+WATER BATH 00873 PR ANESTH,KID STONE DESTRUCT 1.00 5.00 Anesthesia 00880 PR ANESTH,MAJOR LOW ABD 1.00 15.00 Anesthesia 00882 PR ANESTH,INFER VENA CAVAL 1.00 10.00 Anesthesia 00902 PR ANESTH,ANORECTAL SURGERY 1.00 5.00 Anesthesia 00904 PR ANESTH,RADICAL PERINEAL 1.00 7.00 Anesthesia 00906 PR ANESTH,REMOVAL OF VULVA 1.00 4.00 Anesthesia 00908 PR ANESTH,PERINEAL REMV OF 1.00 6.00 Anesthesia 00910 PR ANESTH,TRANSURETHRAL 1.00 3.00 Anesthesia 00912 PR ANESTH,XURETHRAL BLADDER 1.00 5.00 Anesthesia TUMOR SURG 00914 PR ANESTH,XURETHRAL REMOVAL 1.00 5.00 Anesthesia OF PROSTATE 00916 PR ANESTH,POST XURETHRAL 1.00 5.00 Anesthesia BLEEDING CONTR 00918 PR ANESTH,STONE RMVOVAL 1.00 5.00 Anesthesia 00920 PR ANESTH,MALE GENITALIA 1.00 3.00 Anesthesia 00921 PR ANESTH,VASECTOMY, 1.00 3.00 Anesthesia 00922 PR ANESTH,SPERM DUCT SURGERY 1.00 6.00 Anesthesia 00924 PR ANESTH,TESTIS EXPLORATION 1.00 4.00 Anesthesia 00926 PR ANESTH,RADICAL REMV 1.00 4.00 Anesthesia TESTIS,INGUINAL 00928 PR ANESTH,RADICAL REMV 1.00 6.00 Anesthesia TESTIS,ABDOMINAL 00930 PR ANESTH,TESTIS SUSPENSION 1.00 4.00 Anesthesia 00932 PR ANESTH,AMPUTATION OF PENIS 1.00 4.00 Anesthesia 00934 PR ANESTH,PENIS,NODES REMOVAL 1.00 6.00 Anesthesia 00936 PR ANESTH,PENIS,COMBO NODES 1.00 8.00 Anesthesia REMOVAL 00938 PR ANESTH,INSERT PENIS 1.00 4.00 Anesthesia 00940 PR ANESTH,VAGINAL PROCEDURES 1.00 3.00 Anesthesia 00942 PR 1.00 4.00 Anesthesia ANESTH,COLPOT,VAGINECT,COLPO RR,URETH PRO 00944 PR ANESTH,VAGINAL 1.00 6.00 Anesthesia 00948 PR ANESTH,REPAIR OF CERVIX 1.00 4.00 Anesthesia 00950 PR ANESTH,VAGINAL ENDOSCOPY 1.00 5.00 Anesthesia 00952 PR ANESTH,HYSTEROSCOPY/VAG 1.00 4.00 Anesthesia 01112 PR ANESTH,BONE MARROW ASP/BX 1.00 5.00 Anesthesia ILIAC CRST 01120 PR ANESTH,BONY PELVIS SURGERY 1.00 6.00 Anesthesia 01130 PR ANESTH,BODY CAST 1.00 3.00 Anesthesia 01140 PR ANESTH,AMPUTATION AT PELVIS 1.00 15.00 Anesthesia 01150 PR ANESTH,RADICAL PELVIC TUMOR 1.00 10.00 Anesthesia SURGERY 01160 PR ANESTH,PUBIS,SACROILIAC 1.00 4.00 Anesthesia CLOSED PROC 01170 PR ANESTH,PUBIS,SACROILIAC 1.00 8.00 Anesthesia 01173 PR ANESTH, FX REPAIR, PELVIS 1.00 12.00 Anesthesia 01180 PR ANESTH,PELV NERV REMOVAL 1.00 3.00 Anesthesia EXTRAPELV 01190 PR ANESTH,PELV NERV REMOVAL 1.00 4.00 Anesthesia INTRAPELV 01200 PR ANESTH,HIP JOINT PROCEDURE 1.00 4.00 Anesthesia 01202 PR ANESTH,ARTHROSCOPY OF HIP 1.00
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