UNIVERSITY PHYSICIANS GROUP (UPG) PRICES OF PROVIDER SERVICES CODE PROCEDURE MOD CPT PRICE 0001A IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 1ST DOSE 0001A $40.00 0002A IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 2ND DOSE 0002A $40.00 0011A IMM ADMN SARSCOV2 100 MCG/0.5 ML 1ST DOSE 0011A $40.00 0012A IMM ADMN SARSCOV2 100 MCG/0.5 ML 2ND DOSE 0012A $40.00 0021A IMM ADMN SARSCOV2 5X1010 VP/0.5 ML 1ST DOSE 0021A $40.00 0022A IMM ADMN SARSCOV2 5X1010 VP/0.5 ML 2ND DOSE 0022A $40.00 0031A IMM ADMN SARSCOV2 AD26 5X10^10 VP/0.5 ML 1 DOSE 0031A $40.00 0042T CEREBRAL PERFUS ANALYSIS, CT W/CONTRAST 0042T $954.00 0054T BONE SURGERY USING COMPUTER ASSIST, FLURO GUIDED 0054T $640.00 0055T BONE SURGERY USING COMPUTER ASSIST, CT/ MRI GUIDED 0055T $1,188.00 0071T U/S LEIOMYOMATA ABLATE <200 CC 0071T $2,500.00 0075T 0075T PR TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL 26 26 $2,208.00 0126T CAROTID INT-MEDIA THICKNESS EVAL FOR ATHERSCLER 0126T $55.00 0159T 0159T COMPUTER AIDED BREAST MRI 26 26 $314.00 PR RECTAL TUMOR EXCISION, TRANSANAL ENDOSCOPIC 0184T MICROSURGICAL, FULL THICK 0184T $2,315.00 0191T PR ANT SEGMENT INSERTION DRAINAGE W/O RESERVOIR INT 0191T $2,396.00 01967 ANESTH, NEURAXIAL LABOR, PLAN VAG DEL 01967 $2,500.00 01996 PR DAILY MGMT,EPIDUR/SUBARACH CONT DRUG ADM 01996 $285.00 PR PERQ SAC AGMNTJ UNI W/WO BALO/MCHNL DEV 1/> 0200T NDL 0200T $5,106.00 PR PERQ SAC AGMNTJ BI W/WO BALO/MCHNL DEV 2/> 0201T NDLS 0201T $9,446.00 PR INJECT PLATELET RICH PLASMA W/IMG 0232T HARVEST/PREPARATOIN 0232T $1,509.00 0234T PR TRANSLUMINAL PERIPHERAL ATHERECTOMY, RENAL ARTERY 0234T $2,012.00 PR TRANSLUMINAL PERIPHERAL ATHERECTOMY, 0237T BRACHIOCEPHAL AND BRANCHES, EACH 0237T $1,868.00 PR TRANSLUMINAL PERIPHERAL ATHERECTOMY, ILIAC ARTERY, 0238T EACH 0238T $1,877.00 0253T PR INSERT ANT SGM DRAINAGE DEV W/O RESERVR INT APPR 0253T $2,584.00 0254T PR EVASC RPR ILAC ART BIFUR ENDGRFT CATHJ RS&I UNI 0254T $3,412.00 0275T PR PERC LAMINO-/LAMINECTOMY INDIR IMAG GUIDE LUMBAR 0275T $1,459.00 0281T PR PERC TRANSCTH CLOSR LT ATRIAL APPNDGE IMPLNT S&I 0281T $3,574.00 0296T PR EXT ECG > 48HR TO 21 DAY RCRD W/CONECT INTL RCRD 0296T $135.00 0298T PR EXT ECG > 48HR TO 21 DAY REVIEW AND INTERPRETATN 0298T $140.00 0346T PR ULTRASOUND ELASTOGRAPHY 0346T $276.00 0375T PR TOTAL DISC ARTHRP ANT APPR W/DISCECTOMY CRV 3+ 0375T $8,709.00 0376T PR ANT SEGMENT INSERT DRAIN W/O RESERVOIR EA ADDL 0376T $2,568.00 0379T PR VISUAL FIELD ASSESSMENT TECH SUPPORT W/INSTRUCT 0379T $109.00 0387T PR TRANSCATH INSERT OR REPLACE LEADLESS PM VENTR 0387T $1,124.00 0389T PR PROG DEVICE EVAL IN PERSON LEADLESS PM SYSTEM 0389T $115.00 0389T 0389T PR PROG DEVICE EVAL IN PERSON LEADLESS PM SYSTEM 26 26 $115.00 0391T PR INTERROG DEVICE EVAL IN PERSON LEADLESS PM SYST 0391T $87.00 0397T PR ERCP WITH OPTICAL ENDOMICROSCOPY ADD ON 0397T $1,002.00 $15,604.0 0398T PR MRGFUS STEREOTACTIC ABLATION LESION INTRACRANIAL 0398T 0 0399T PR MYOCARDIAL STRAIN IMAGING QUAN ASSMT 0399T $513.00 0399T 0399T PR MYOCARDIAL STRAIN IMAGING QUAN ASSMT 26 26 $513.00 0438T PR TPRNL PLMT BIODEGRADABLE MATRL PERIPROSTATIC 0438T $764.00 0442T PR ABLTJ PERC CRYOABLTJ IMG GDN NRV PLEX/TRNCL NRV 0442T $450.00 0449T PR INSJ AQUEOUS DRAIN DEV W/O EO RSVR INITIAL DEV 0449T $2,222.00 0466T PR INSRT CH WALL RESPIR ELTRD/RA & CONJ PULSE GEN 0466T $1,235.00 0474T PR CYPASS GLAUCOMA IMPLANT 0474T $3,333.00 0482T 0482T PR ABSOLUTE QUAN MYOCARD BLD FLO PET STRESS & REST 26 26 $179.00 0483T PR TMVI W/PROSTHETIC VALVE PERCUTANEOUS APPROACH 0483T $5,681.00 0484T PR TMVI W/PROSTHETIC VALVE TRANSTHORACIC EXPOSURE 0484T $8,059.00 0494T PR PREP & CANNULJ CDVR DON LNG ORGN PRFUJ SYS 0494T $812.00 0495T PR INIT & MNTR CDVR DON LNG ORGN PRFUJ SYS 1ST 2 HR 0495T $7,000.00 0496T PR MNTR CDVR DON LNG ORGN PRFUJ SYS EA ADDL HR 0496T $3,500.00 0497T PR XTRNL PT ACT ECG W/O ATTN MNTR IN-OFFICE CONN 0497T $24.00 0498T PR XTRNL PT ACT ECG W/O ATTN MNTR R&I PR 30 DAYS 0498T $65.00 0499T PR CYSTO W/DIL & URTL RX DEL F/URTL STRIX/STENOSIS 0499T $1,024.00 0504T PR COR FFR CTA DATA REVIEW W/INTERPJ & FINAL REPORT 0504T $443.00 0507T 0507T PR NEAR INFRARED DUAL IMG MEIBOMIAN GLND UNI/BI I&R 26 26 $16.00 0514T PR INTRAOPERATIVE VISUAL AXIS ID USING PT FIXATION 0514T $184.00 0537T PR CAR-T THERAPY HRVG BLD DRV T LMPHCYT PR DAY 0537T $220.00 0540T PR CAR-T THERAPY AUTOLOGOUS CELL ADMINISTRATION 0540T $500.00 0545T PR TCAT TV ANN RCNSTJ W/IMPL ADJST ANN RCNSTJ DEV 0545T $7,329.00 0569T PR TTVR PERCUTANEOUS APPROACH INITIAL PROSTHESIS 0569T $5,396.00 0570T PR TTVR PERCUTANEOUS APPROACH EACH ADDL PROSTHESIS 0570T $1,242.00 0570T 0570T PR TTVR PERCUTANEOUS APPROACH EACH ADDL PROSTHESIS 26 26 $635.00 0571T PR INSJ/RPLCMT ICDS W/SUBSTERNAL ELECTRODE 0571T $1,581.00 0572T PR INSJ SUBSTERNAL IMPLANTABLE DEFIBRILLATOR ELTRD 0572T $1,258.00 0573T PR RMVL SUBSTERNAL IMPLANTABLE DEFIBRILLATOR ELTRD 0573T $1,058.00 0574T PR REPOS PREV IMPL SS IMPLTBL DFB PACING ELTRD 0574T $1,039.00 0581T PR ABLATION MAL BRST TUMOR PERQ CRTX UNILATERAL 0581T $763.00 0584T PR PERCUTANEOUS ISLET CELL TRANSPLANT 0584T $5,361.00 0585T PR LAPAROSCOPIC ISLET CELL TRANSPLANT 0585T $2,451.00 0586T PR OPEN ISLET CELL TRANSPLANT 0586T $4,045.00 0589T PR ELEC ALYS SMPL PRGRMG IINS PTN 1-3 PARAMETERS 0589T $129.00 0590T PR ELEC ALYS CPLX PRGRMG IINS PTN 4+ PARAMETERS 0590T $300.00 0600T PR IRE ABLATION 1+TUMORS PER ORGAN W/IMG GDN PERQ 0600T $2,386.00 10004 PR FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL 10004 $135.00 10005 PR FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION 10005 $342.00 10006 PR FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL 10006 $155.00 10007 PR FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION 10007 $729.00 10008 PR FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL 10008 $411.00 10009 PR FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION 10009 $1,193.00 10010 PR FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL 10010 $719.00 10011 PR FINE NEEDLE ASPIRATION BX W/MR GDN 1ST LESION 10011 $1,193.00 10012 PR FINE NEEDLE ASPIRATION BX W/MR GDN EA ADDL 10012 $719.00 10021 PR FINE NEEDLE ASP;W/O IMAGING GUIDANCE 10021 $357.00 10022 PR FINE NEEDLE ASP;W/IMAGING GUIDANCE 10022 $328.00 10030 PR IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE 10030 $1,938.00 10035 PR PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE 10035 $1,359.00 10040 PR ACNE SURGERY OF SKIN ABSCESS 10040 $276.82 10060 PR DRAIN SKIN ABSCESS SIMPLE 10060 $321.00 10061 PR DRAIN SKIN ABSCESS COMPLIC 10061 $556.00 10080 PR DRAIN PILONIDAL CYST SIMPL 10080 $558.00 10081 PR DRAIN PILONIDAL CYST COMPLIC 10081 $808.00 10120 PR REMOVE FOREIGN BODY SIMPLE 10120 $402.00 10121 PR REMOVE FOREIGN BODY COMPLIC 10121 $723.00 10140 PR DRAINAGE OF HEMATOMA/FLUID 10140 $452.00 10160 PR PUNCTURE DRAINAGE OF LESION 10160 $346.00 10180 PR COMPLEX DRAINAGE, WOUND 10180 $680.00 11000 PR DEBRIDEMENT, INFECTED SKIN, UP TO 10% BSA 11000 $150.00 11001 PR DEBRIDEMENT, INFECTED SKIN, EA ADD 10% BSA 11001 $63.00 11004 PR DEBRIDE NECROTIC SKIN/ TISSUE, GENIT & PERINM 11004 $1,554.00 11005 PR DEBRIDE NECROTIC SKIN/ TISSUE, ABD WALL 11005 $2,810.00 11006 PR DEBRIDE NECROT SKIN/ TISS, GENIT,PERI, ADB WALL 11006 $2,540.00 11008 REMOVE MESH FROM ABD WALL FOR INFECTION 11008 $745.00 11010 PR DEBRIDE ASSOC OPEN FX/DISLOC SKIN/SUBQ 11010 $1,412.00 11011 PR DEBRIDE ASSOC OPEN FX/DISLOC SKIN/MUSCLE 11011 $1,676.00 11012 PR DEBRIDE ASSOC OPEN FX/DISLO SKIN/MUS/BONE 11012 $2,446.00 11042 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,=<20 SQ CM 11042 $395.00 11043 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,=<20 SQ CM 11043 $619.00 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,=<20 SQ 11044 CM 11044 $981.00 11045 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,EACH ADD 20 SQ CM 11045 $111.00 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,EACH ADD 20 11046 SQ CM 11046 $198.00 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,EACH 11047 ADD 20 SQ CM 11047 $329.00 11055 PR TRIM HYPERKERATOTIC SKIN LESION, ONE 11055 $166.00 11056 TRIM BENIGN HYPERKERATOTIC SKIN LESION,2-4 11056 $187.09 11057 TRIM BENIGN HYPERKERATOTIC SKIN LESION,>4 11057 $226.00 11100 PR BIOPSY OF SKIN LESION 11100 $239.00 11101 PR BIOPSY, EACH ADDED LESION 11101 $74.00 11102 PR TANGENTIAL BIOPSY SKIN SINGLE LESION 11102 $265.00 11103 PR TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION 11103 $141.00 11104 PR PUNCH BIOPSY SKIN SINGLE LESION 11104 $333.00 11105 PR PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION 11105 $161.00 11106 PR INCISIONAL BIOPSY SKIN SINGLE LESION 11106 $403.00 11107 PR INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION 11107 $190.00 11200 PR REMOVAL OF SKIN TAGS, UP TO 15 11200 $235.00 11201 PR REMOVAL OF SKIN TAGS, EACH ADD 10 11201 $56.00 11300 PR SHAV SKIN LES <5MM TRUNK,ARM,LEG 11300 $265.00 11301 PR SHAV SKIN LES 6-10MM TRUNK,ARM,LEG 11301 $322.00 11302 PR SHAV SKIN LES 11-20MM TRUNK,ARM,LEG 11302 $372.00 11303 PR SHAV SKIN LES >21MM TRUNK,ARM,LEG 11303 $409.00 11305 PR SHAV SKIN LES <5MM REMAINDR BODY 11305 $279.00 11306 PR SHAV SKIN LES 6-10MM REMAINDR BODY 11306 $326.00 11307 PR SHAV SKIN LES 11-20MM REMAINDR BODY 11307 $381.00 11308 PR SHAV SKIN LES >21MM REMAINDR BODY 11308 $407.00 11310 PR SHAV SKIN LES <5MM FACE,FACIAL 11310 $307.00 11311 PR SHAV SKIN LES 6-10MM FACE,FACIAL 11311 $364.00 11312 PR SHAV SKIN LES 11-20MM FACE,FACIAL 11312 $420.00 11313 PR SHAV SKIN LES >21MM FACE,FACIAL 11313 $468.68 11400 PR EXC SKIN BENIG <5MM TRUNK,ARM,LEG 11400 $333.00 11401 PR EXC SKIN BENIG 0.6-1CM TRUNK,ARM,LEG 11401 $406.00 11402 PR EXC SKIN BENIG 1.1-2CM TRUNK,ARM,LEG 11402 $450.00 11403 PR EXC SKIN BENIG 2.1-3CM TRUNK,ARM,LEG 11403 $520.00 11404 PR EXC SKIN BENIG 3.1-4CM TRUNK,ARM,LEG 11404 $591.00 11406 PR EXC SKIN BENIG >4CM TRUNK,ARM,LEG 11406 $845.00