Addendum B.-Proposed OPPS Payment by HCPCS Code for CY 

2012

HCPCS CodeShort DescriptorCI SIAPCRelative WeightPayment Rate National Unadjusted 

Copayment Minimum Unadjusted Copayment 

00100Anesth salivary 

glandN

00102Anesth repair of cleft 

lipN

00103Anesth 

blepharoplastyN

00104Anesth 

electroshockN

00120Anesth ear 

surgeryN

00124Anesth ear 

examN

00126Anesth 

tympanotomyN

00140Anesth procedures on 

eyeN

00142Anesth lens 

surgeryN

00144Anesth corneal 

transplantN

00145Anesth vitreoretinal 

surgN

00147Anesth 

iridectomyN

00148Anesth eye 

examN

00160Anesth nose/sinus 

surgeryN

00162Anesth nose/sinus 

surgeryN

00164Anesth biopsy of 

noseN

00170Anesth procedure on 

mouthN

00172Anesth cleft palate 

repairN

00174Anesth pharyngeal 

surgeryN

00176Anesth pharyngeal 
surgeryC

00190Anesth face/skull bone 

surgN

00192Anesth facial bone 

surgeryC

00210Anesth cranial surg 

nosN

00211Anesth cran surg 

hemotomaC

00212Anesth skull 

drainageN

00214Anesth skull 

drainageC

00215Anesth skull 

repair/fractC

00216Anesth head vessel 

surgeryN

00218Anesth special head 

surgeryN

00220Anesth intrcrn 

nerveN

00222Anesth head nerve 

surgeryN

00300Anesth 

head/neck/ptrunkN

00320Anesth neck organ 1 & 

overN

00322Anesth biopsy of 

thyroidN

00326Anesth larynx/trach < 1 

yrN

00350Anesth neck vessel 

surgeryN

00352Anesth neck vessel 

surgeryN

00400Anesth skin 

ext/per/atrunkN

00402Anesth surgery of 

breastN

00404Anesth surgery of 

breastN

00406Anesth surgery of 

breastN

00410Anesth correct heart 
rhythmN

00450Anesth surgery of 

shoulderN

00452Anesth surgery of 

shoulderC

00454Anesth collar bone 

biopsyN

00470Anesth removal of 

ribN

00472Anesth chest wall 

repairN

00474Anesth surgery of 

rib(s)C

00500Anesth esophageal 

surgeryN

00520Anesth chest 

procedureN

00522Anesth chest lining 

biopsyN

00524Anesth chest 

drainageC

00528Anesth chest partition 

viewN

00529Anesth chest partition 

viewN

00530Anesth pacemaker 

insertionN

00532Anesth vascular 

accessN

00534Anesth 

cardioverter/defibN

00537Anesth cardiac 

electrophysN

00539Anesth trach-bronch 

reconstN

00540Anesth chest 

surgeryC

00541Anesth one lung 

ventilationN

00542Anesth release of 

lungC

00546Anesth lung chest wall 

surgC

00548Anesth trachea bronchi 
surgN

00550Anesth sternal 

debridementN

00560Anesth heart surg w/o 

pumpC

00561Anesth heart surg < 1 

yrC

00562Anesth hrt surg w/pmp age 

1+C

00563Anesth heart surg 

w/arrestN

00566Anesth cabg w/o 

pumpN

00567Anesth cabg 

w/pumpC

00580Anesth heart/lung 

transplntC

00600Anesth spine cord 

surgeryN

00604Anesth sitting 

procedureC

00620Anesth spine cord 

surgeryN

00622Anesth removal of 

nervesC

00625Anes spine tranthor w/o 

ventN

00626Anes spine transthor 

w/ventN

00630Anesth spine cord 

surgeryN

00632Anesth removal of 

nervesC

00634Anesth for 

chemonucleolysisN

00635Anesth lumbar 

punctureN

00640Anesth spine 

manipulationN

00670Anesth spine cord 

surgeryC

00700Anesth abdominal wall 

surgN

00702Anesth for liver 
biopsyN

00730Anesth abdominal wall 

surgN

00740Anesth upper gi 

visualizeN

00750Anesth repair of 

herniaN

00752Anesth repair of 

herniaN

00754Anesth repair of 

herniaN

00756Anesth repair of 

herniaN

00770Anesth blood vessel 

repairN

00790Anesth surg upper 

abdomenN

00792Anesth hemorr/excise 

liverC

00794Anesth pancreas 

removalC

00796Anesth for liver 

transplantC

00797Anesth surgery for 

obesityN

00800Anesth abdominal wall 

surgN

00802Anesth fat layer 

removalC

00810Anesth low intestine 

scopeN

00820Anesth abdominal wall 

surgN

00830Anesth repair of 

herniaN

00832Anesth repair of 

herniaN

00834Anesth hernia repair < 1 

yrN

00836Anesth hernia repair 

preemieN

00840Anesth surg lower 

abdomenN

00842Anesth 
amniocentesisN

00844Anesth pelvis 

surgeryC

00846Anesth 

hysterectomyC

00848Anesth pelvic organ 

surgC

00851Anesth tubal 

ligationN

00860Anesth surgery of 

abdomenN

00862Anesth kidney/ureter 

surgN

00864Anesth removal of 

bladderC

00865Anesth removal of 

prostateC

00866Anesth removal of 

adrenalC

00868Anesth kidney 

transplantC

00870Anesth bladder stone 

surgN

00872Anesth kidney stone 

destructN

00873Anesth kidney stone 

destructN

00880Anesth abdomen vessel 

surgN

00882Anesth major vein 

ligationC

00902Anesth anorectal 

surgeryN

00904Anesth perineal 

surgeryC

00906Anesth removal of 

vulvaN

00908Anesth removal of 

prostateC

00910Anesth bladder 

surgeryN

00912Anesth bladder tumor 

surgN

00914Anesth removal of 
prostateN

00916Anesth bleeding 

controlN

00918Anesth stone 

removalN

00920Anesth genitalia 

surgeryN

00921Anesth 

vasectomyN

00922Anesth sperm duct 

surgeryN

00924Anesth testis 

explorationN

00926Anesth removal of 

testisN

00928Anesth removal of 

testisN

00930Anesth testis 

suspensionN

00932Anesth amputation of 

penisC

00934Anesth penis nodes 

removalC

00936Anesth penis nodes 

removalC

00938Anesth insert penis 

deviceN

00940Anesth vaginal 

proceduresN

00942Anesth surg on 

vag/urethralN

00944Anesth vaginal 

hysterectomyC

00948Anesth repair of 

cervixN

00950Anesth vaginal 

endoscopyN

00952Anesth 

hysteroscope/graphN

01112Anesth bone 

aspirate/bxN

01120Anesth pelvis 

surgeryN

01130Anesth body cast 
procedureN

01140Anesth amputation at 

pelvisC

01150Anesth pelvic tumor 

surgeryC

01160Anesth pelvis 

procedureN

01170Anesth pelvis 

surgeryN

01173Anesth fx repair 

pelvisN

01180Anesth pelvis nerve 

removalN

01190Anesth pelvis nerve 

removalN

01200Anesth hip joint 

procedureN

01202Anesth arthroscopy of 

hipN

01210Anesth hip joint 

surgeryN

01212Anesth hip 

disarticulationC

01214Anesth hip 

arthroplastyC

01215Anesth revise hip 

repairN

01220Anesth procedure on 

femurN

01230Anesth surgery of 

femurN

01232Anesth amputation of 

femurC

01234Anesth radical femur 

surgC

01250Anesth upper leg 

surgeryN

01260Anesth upper leg veins 

surgN

01270Anesth thigh arteries 

surgN

01272Anesth femoral artery 

surgC

01274Anesth femoral 
embolectomyC

01320Anesth knee area 

surgeryN

01340Anesth knee area 

procedureN

01360Anesth knee area 

surgeryN

01380Anesth knee joint 

procedureN

01382Anesth dx knee 

arthroscopyN

01390Anesth knee area 

procedureN

01392Anesth knee area 

surgeryN

01400Anesth knee joint 

surgeryN

01402Anesth knee 

arthroplastyC

01404Anesth amputation at 

kneeC

01420Anesth knee joint 

castingN

01430Anesth knee veins 

surgeryN

01432Anesth knee vessel 

surgN

01440Anesth knee arteries 

surgN

01442Anesth knee artery 

surgC

01444Anesth knee artery 

repairC

01462Anesth lower leg 

procedureN

01464Anesth ankle/ft 

arthroscopyN

01470Anesth lower leg 

surgeryN

01472Anesth achilles tendon 

surgN

01474Anesth lower leg 

surgeryN

01480Anesth lower leg bone 
surgN

01482Anesth radical leg 

surgeryN

01484Anesth lower leg 

revisionN

01486Anesth ankle 

replacementC

01490Anesth lower leg 

castingN

01500Anesth leg arteries 

surgN

01502Anesth lwr leg 

embolectomyC

01520Anesth lower leg vein 

surgN

01522Anesth lower leg vein 

surgN

01610Anesth surgery of 

shoulderN

01620Anesth shoulder 

procedureN

01622Anes dx shoulder 

arthroscopyN

01630Anesth surgery of 

shoulderN

01634Anesth shoulder joint 

amputC

01636Anesth forequarter 

amputC

01638Anesth shoulder 

replacementC

01650Anesth shoulder artery 

surgN

01652Anesth shoulder vessel 

surgC

01654Anesth shoulder vessel 

surgC

01656Anesth arm-leg vessel 

surgC

01670Anesth shoulder vein 

surgN

01680Anesth shoulder 

castingN

01682Anesth airplane 
castN

01710Anesth elbow area 

surgeryN

01712Anesth uppr arm tendon 

surgN

01714Anesth uppr arm tendon 

surgN

01716Anesth biceps tendon 

repairN

01730Anesth uppr arm 

procedureN

01732Anesth dx elbow 

arthroscopyN

01740Anesth upper arm 

surgeryN

01742Anesth humerus 

surgeryN

01744Anesth humerus 

repairN

01756Anesth radical humerus 

surgC

01758Anesth humeral lesion 

surgN

01760Anesth elbow 

replacementN

01770Anesth uppr arm artery 

surgN

01772Anesth uppr arm 

embolectomyN

01780Anesth upper arm vein 

surgN

01782Anesth uppr arm vein 

repairN

01810Anesth lower arm 

surgeryN

01820Anesth lower arm 

procedureN

01829Anesth dx wrist 

arthroscopyN

01830Anesth lower arm 

surgeryN

01832Anesth wrist 

replacementN

01840Anesth lwr arm artery 
surgN

01842Anesth lwr arm 

embolectomyN

01844Anesth vascular shunt 

surgN

01850Anesth lower arm vein 

surgN

01852Anesth lwr arm vein 

repairN

01860Anesth lower arm 

castingN

01916Anesth dx 

arteriographyN

01920Anesth catheterize 

heartN

01922Anesth cat or mri 

scanN

01924Anes ther interven rad 

artN

01925Anes ther interven rad 

carN

01926Anes tx interv rad 

hrt/cranN

01930Anes ther interven rad 

veiN

01931Anes ther interven rad 

tipN

01932Anes tx interv rad th 

veinN

01933Anes tx interv rad cran 

vN

01935Anesth perc img dx sp 

procN

01936Anesth perc img tx sp 

procN

01951Anesth burn less 4 

percentN

01952Anesth burn 4-9 

percentN

01953Anesth burn each 9 

percentN

01958Anesth antepartum 

manipulN

01960Anesth vaginal 
deliveryN

01961Anesth cs 

deliveryN

01962Anesth emer 

hysterectomyN

01963Anesth cs 

hysterectomyN

01965Anesth inc/missed ab 

procN

01966Anesth induced ab procedureN 

01967Anesth/analg vag 

deliveryN

01968Anes/analg cs deliver 

add-onN

01969Anesth/analg cs hyst 

add-onN

01990Support for organ 

donorC

01991Anesth nerve 

block/injN

01992Anesth n block/inj 

proneN

01996Hosp manage cont drug 

adminN

01999Unlisted anesth 

procedureN

10021Fna w/o 

imageT00021.7462$121.22.$24.25

10022Fna 

w/imageT00044.5956$319.03.$63.81

10040Acne 

surgeryT00130.9786$67.93.$13.59

10060Drainage of skin 

abscessT00061.4481$100.53.$20.11

10061Drainage of skin 

abscessT00061.4481$100.53.$20.11

10080Drainage of pilonidal 

cystT00061.4481$100.53.$20.11

10081Drainage of pilonidal 
cystT000713.4779$935.64.$187.13

10120Remove foreign 

bodyT00162.8248$196.10.$39.22

10121Remove foreign 

bodyT002117.1909"$1,193.39".$238.68

10140Drainage of 

hematoma/fluidT000713.4779$935.64.$187.13

10160Puncture drainage of 

lesionT00061.4481$100.53.$20.11

10180Complex drainage 

woundT000820.5401"$1,425.89".$285.18

11000Debride infected 

skinT00162.8248$196.10.$39.22

11001Debride infected skin 

add-onT00130.9786$67.93.$13.59

11004Debride genitalia & 

perineumC

11005Debride abdom 

wallC

11006Debride genit/per/abdom 

wallC

11008Remove mesh from abd 

wallC

11010Debride skin at fx 

siteT00194.8763$338.51.$67.71

11011Debride skin musc at fx 

siteT00194.8763$338.51.$67.71

11012Deb skin bone at fx 

siteT00194.8763$338.51.$67.71

11042Deb subq tissue 20 sq 

cm/<T00162.8248$196.10.$39.22

11043Deb musc/fascia 20 sq 

cm/<T00162.8248$196.10.$39.22

11044Deb bone 20 sq 

cm/<T00208.6164$598.15.$119.63
11045Deb subq tissue 

add-onT00162.8248$196.10.$39.22

11046Deb musc/fascia 

add-onT00162.8248$196.10.$39.22

11047Deb bone 

add-onT00208.6164$598.15.$119.63

11055Trim skin 

lesionT00130.9786$67.93.$13.59

11056Trim skin lesions 2 to 

4T00130.9786$67.93.$13.59

11057Trim skin lesions over 

4T00130.9786$67.93.$13.59

11100Biopsy skin 

lesionT00151.4936$103.69.$20.74

11101Biopsy skin 

add-onT00130.9786$67.93.$13.59

11200Removal of skin 

tagsT00130.9786$67.93.$13.59

11201Remove skin tags 

add-onT00130.9786$67.93.$13.59

11300Shave skin 

lesionT00130.9786$67.93.$13.59

11301Shave skin 

lesionT00130.9786$67.93.$13.59

11302Shave skin 

lesionT00130.9786$67.93.$13.59

11303Shave skin 

lesionT00151.4936$103.69.$20.74

11305Shave skin 

lesionT00130.9786$67.93.$13.59

11306Shave skin 

lesionT00130.9786$67.93.$13.59

11307Shave skin 
lesionT00130.9786$67.93.$13.59

11308Shave skin 

lesionT00130.9786$67.93.$13.59

11310Shave skin 

lesionT00130.9786$67.93.$13.59

11311Shave skin 

lesionT00130.9786$67.93.$13.59

11312Shave skin 

lesionT00130.9786$67.93.$13.59

11313Shave skin 

lesionT00130.9786$67.93.$13.59

11400Exc tr-ext b9+marg 0.5 < 

cmT00194.8763$338.51.$67.71

11401Exc tr-ext b9+marg 0.6-1 

cmT00194.8763$338.51.$67.71

11402Exc tr-ext b9+marg 1.1-2 

cmT00194.8763$338.51.$67.71

11403Exc tr-ext b9+marg 2.1-3 

cmT00208.6164$598.15.$119.63

11404Exc tr-ext b9+marg 3.1-4 

cmT002117.1909"$1,193.39".$238.68

11406Exc tr-ext b9+marg > 4.0 

cmT002117.1909"$1,193.39".$238.68

11420Exc h-f-nk-sp b9+marg 0.5 

<T00208.6164$598.15.$119.63

11421Exc h-f-nk-sp b9+marg 

0.6-1T00208.6164$598.15.$119.63

11422Exc h-f-nk-sp b9+marg 

1.1-2T00208.6164$598.15.$119.63

11423Exc h-f-nk-sp b9+marg 

2.1-3T002117.1909"$1,193.39".$238.68

11424Exc h-f-nk-sp b9+marg 

3.1-4T002117.1909"$1,193.39".$238.68
11426Exc h-f-nk-sp b9+marg > 4 

cmT002223.4169"$1,625.60"$350.05$325.12

11440Exc face-mm b9+marg 0.5 < 

cmT00194.8763$338.51.$67.71

11441Exc face-mm b9+marg 0.6-1 

cmT00194.8763$338.51.$67.71

11442Exc face-mm b9+marg 1.1-2 

cmT00208.6164$598.15.$119.63

11443Exc face-mm b9+marg 2.1-3 

cmT00208.6164$598.15.$119.63

11444Exc face-mm b9+marg 3.1-4 

cmT00208.6164$598.15.$119.63

11446Exc face-mm b9+marg > 4 

cmT002223.4169"$1,625.60"$350.05$325.12

11450Removal sweat gland 

lesionT002223.4169"$1,625.60"$350.05$325.12

11451Removal sweat gland 

lesionT002223.4169"$1,625.60"$350.05$325.12

11462Removal sweat gland 

lesionT002223.4169"$1,625.60"$350.05$325.12

11463Removal sweat gland 

lesionT002223.4169"$1,625.60"$350.05$325.12

11470Removal sweat gland 

lesionT002223.4169"$1,625.60"$350.05$325.12

11471Removal sweat gland 

lesionT002223.4169"$1,625.60"$350.05$325.12

11600Exc tr-ext mlg+marg 0.5 < 

cmT00208.6164$598.15.$119.63

11601Exc tr-ext mlg+marg 0.6-1 

cmT00194.8763$338.51.$67.71

11602Exc tr-ext mlg+marg 1.1-2 

cmT00194.8763$338.51.$67.71

11603Exc tr-ext mlg+marg 2.1-3 
cmT00208.6164$598.15.$119.63

11604Exc tr-ext mlg+marg 3.1-4 

cmT00208.6164$598.15.$119.63

11606Exc tr-ext mlg+marg > 4 

cmT002117.1909"$1,193.39".$238.68

11620Exc h-f-nk-sp mlg+marg 0.5 

<T00208.6164$598.15.$119.63

11621Exc h-f-nk-sp mlg+marg 

0.6-1T00194.8763$338.51.$67.71

11622Exc h-f-nk-sp mlg+marg 

1.1-2T00208.6164$598.15.$119.63

11623Exc h-f-nk-sp mlg+marg 

2.1-3T002117.1909"$1,193.39".$238.68

11624Exc h-f-nk-sp mlg+marg 

3.1-4T002117.1909"$1,193.39".$238.68

11626Exc h-f-nk-sp mlg+mar > 4 

cmT002223.4169"$1,625.60"$350.05$325.12

11640Exc face-mm malig+marg 0.5 

<T00194.8763$338.51.$67.71

11641Exc face-mm malig+marg 

0.6-1T00194.8763$338.51.$67.71

11642Exc face-mm malig+marg 

1.1-2T00194.8763$338.51.$67.71

11643Exc face-mm malig+marg 

2.1-3T00208.6164$598.15.$119.63

11644Exc face-mm malig+marg 

3.1-4T002117.1909"$1,193.39".$238.68

11646Exc face-mm mlg+marg > 4 

cmT002223.4169"$1,625.60"$350.05$325.12

11719Trim 

nail(s)T00120.4047$28.09.$5.62

11720Debride nail 

1-5T00130.9786$67.93.$13.59
11721Debride nail 6 or 

moreT00130.9786$67.93.$13.59

11730Removal of nail 

plateT00130.9786$67.93.$13.59

11732Remove nail plate 

add-onT00130.9786$67.93.$13.59

11740Drain blood from under 

nailT00120.4047$28.09.$5.62

11750Removal of nail 

bedT00194.8763$338.51.$67.71

11752Remove nail bed/finger 

tipT002223.4169"$1,625.60"$350.05$325.12

11755Biopsy nail 

unitT00194.8763$338.51.$67.71

11760Repair of nail 

bedT01331.2139$84.27$23.56$16.86

11762Reconstruction of nail 

bedT013617.2745"$1,199.20".$239.84

11765Excision of nail fold 

toeT00130.9786$67.93.$13.59

11770Removal of pilonidal 

lesionT002223.4169"$1,625.60"$350.05$325.12

11771Removal of pilonidal 

lesionT002223.4169"$1,625.60"$350.05$325.12

11772Removal of pilonidal 

lesionT002223.4169"$1,625.60"$350.05$325.12

11900Injection into skin 

lesionsT00130.9786$67.93.$13.59

11901Added skin lesions 

injectionT00130.9786$67.93.$13.59

11920Correct skin color 

defectsT01343.2846$228.02.$45.61

11921Correct skin color 
defectsT01343.2846$228.02.$45.61

11922Correct skin color 

defectsT01343.2846$228.02.$45.61

11950Therapy for contour defectsCH 

T01343.2846$228.02.$45.61

11951Therapy for contour defectsCH 

T01343.2846$228.02.$45.61

11952Therapy for contour defectsCH 

T01343.2846$228.02.$45.61

11954Therapy for contour 

defectsT01331.2139$84.27$23.56$16.86

11960Insert tissue 

expander(s)T013721.8041"$1,513.64".$302.73

11970Replace tissue 

expanderT005147.1841"$3,275.52".$655.11

11971Remove tissue 

expander(s)T002223.4169"$1,625.60"$350.05$325.12

11975Insert contraceptive 

capE

11976Removal of contraceptive 

capT00194.8763$338.51.$67.71

11977Removal/reinsert contra 

capE

11980Implant hormone 

pellet(s)X03400.6739$46.78.$9.36

11981Insert drug implant 

deviceX03400.6739$46.78.$9.36

11982Remove drug implant 

deviceX03400.6739$46.78.$9.36

11983Remove/insert drug 

implantX03400.6739$46.78.$9.36

12001Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12002Repair superficial 
wound(s)T01331.2139$84.27$23.56$16.86

12004Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12005Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12006Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12007Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12011Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12013Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12014Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12015Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12016Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12017Repair superficial 

wound(s)T01331.2139$84.27$23.56$16.86

12018Repair superficial wound(s)CH 

T01343.2846$228.02.$45.61

12020Closure of split 

woundT01355.1973$360.80.$72.16

12021Closure of split 

woundT01343.2846$228.02.$45.61

12031Intmd wnd repair s/tr/extCH 

T01343.2846$228.02.$45.61

12032Intmd wnd repair 

s/tr/extT01343.2846$228.02.$45.61

12034Intmd wnd repair s/tr/extCH 

T01343.2846$228.02.$45.61
12035Intmd wnd repair s/tr/extCH 

T01343.2846$228.02.$45.61

12036Intmd wnd repair 

s/tr/extT01343.2846$228.02.$45.61

12037Intmd wnd repair 

s/tr/extT01343.2846$228.02.$45.61

12041Intmd wnd repair 

n-hf/genitT01331.2139$84.27$23.56$16.86

12042Intmd wnd repair n-hg/genitCH 

T01343.2846$228.02.$45.61

12044Intmd wnd repair n-hg/genitCH 

T01343.2846$228.02.$45.61

12045Intmd wnd repair 

n-hg/genitT01343.2846$228.02.$45.61

12046Intmd wnd repair 

n-hg/genitT01343.2846$228.02.$45.61

12047Intmd wnd repair 

n-hg/genitT01343.2846$228.02.$45.61

12051Intmd wnd repair 

face/mmT01343.2846$228.02.$45.61

12052Intmd wnd repair face/mmCH 

T01343.2846$228.02.$45.61

12053Intmd wnd repair face/mmCH 

T01343.2846$228.02.$45.61

12054Intmd wnd repair 

face/mmT01331.2139$84.27$23.56$16.86

12055Intmd wnd repair 

face/mmT01343.2846$228.02.$45.61

12056Intmd wnd repair 

face/mmT01343.2846$228.02.$45.61

12057Intmd wnd repair 

face/mmT01343.2846$228.02.$45.61

13100Repair of wound or 
lesionT01355.1973$360.80.$72.16

13101Repair of wound or 

lesionT01355.1973$360.80.$72.16

13102Repair wound/lesion add-onCH 

T01343.2846$228.02.$45.61

13120Repair of wound or 

lesionT01343.2846$228.02.$45.61

13121Repair of wound or 

lesionT01343.2846$228.02.$45.61

13122Repair wound/lesion 

add-onT01331.2139$84.27$23.56$16.86

13131Repair of wound or 

lesionT01343.2846$228.02.$45.61

13132Repair of wound or 

lesionT01355.1973$360.80.$72.16

13133Repair wound/lesion 

add-onT01343.2846$228.02.$45.61

13150Repair of wound or 

lesionT01355.1973$360.80.$72.16

13151Repair of wound or 

lesionT01355.1973$360.80.$72.16

13152Repair of wound or 

lesionT01355.1973$360.80.$72.16

13153Repair wound/lesion 

add-onT01343.2846$228.02.$45.61

13160Late closure of 

woundT013721.8041"$1,513.64".$302.73

14000Skin tissue 

rearrangementT013617.2745"$1,199.20".$239.84

14001Skin tissue 

rearrangementT013617.2745"$1,199.20".$239.84

14020Skin tissue 

rearrangementT013617.2745"$1,199.20".$239.84
14021Skin tissue 

rearrangementT013617.2745"$1,199.20".$239.84

14040Skin tissue 

rearrangementT013617.2745"$1,199.20".$239.84

14041Skin tissue 

rearrangementT013617.2745"$1,199.20".$239.84

14060Skin tissue 

rearrangementT013617.2745"$1,199.20".$239.84

14061Skin tissue 

rearrangementT013617.2745"$1,199.20".$239.84

14301Skin tissue 

rearrangementT013721.8041"$1,513.64".$302.73

14302Skin tissue rearrange 

add-onT013721.8041"$1,513.64".$302.73

14350Skin tissue 

rearrangementT013721.8041"$1,513.64".$302.73

15002Wound prep 

trk/arm/legT01355.1973$360.80.$72.16

15003Wound prep addl 100 

cmT01355.1973$360.80.$72.16

15004Wound prep f/n/hf/gCH 

T01343.2846$228.02.$45.61

15005Wnd prep f/n/hf/g addl 

cmT01355.1973$360.80.$72.16

15040Harvest cultured skin 

graftT01343.2846$228.02.$45.61

15050Skin pinch graftCH 

T01343.2846$228.02.$45.61

15100Skin splt grft 

trnk/arm/legT013721.8041"$1,513.64".$302.73

15101Skin splt grft t/a/l 

add-onT013721.8041"$1,513.64".$302.73

15110Epidrm autogrft 
trnk/arm/legT01355.1973$360.80.$72.16

15111Epidrm autogrft t/a/l 

add-onT01355.1973$360.80.$72.16

15115Epidrm a-grft 

face/nck/hf/gT01355.1973$360.80.$72.16

15116Epidrm a-grft f/n/hf/g addlCH 

T01343.2846$228.02.$45.61

15120Skn splt a-grft 

fac/nck/hf/gT013721.8041"$1,513.64".$302.73

15121Skn splt a-grft f/n/hf/g 

addT013721.8041"$1,513.64".$302.73

15130Derm autograft 

trnk/arm/legT013617.2745"$1,199.20".$239.84

15131Derm autograft t/a/l 

add-onT013617.2745"$1,199.20".$239.84

15135Derm autograft 

face/nck/hf/gT013617.2745"$1,199.20".$239.84

15136Derm autograft f/n/hf/g 

addT013617.2745"$1,199.20".$239.84

15150Cult epiderm grft 

t/arm/legT01355.1973$360.80.$72.16

15151Cult epiderm grft t/a/l 

addlT01355.1973$360.80.$72.16

15152Cult epiderm graft t/a/l 

+%T01355.1973$360.80.$72.16

15155Cult epiderm graft 

f/n/hf/gT01355.1973$360.80.$72.16

15156Cult epidrm grft f/n/hfg 

addT01355.1973$360.80.$72.16

15157Cult epiderm grft f/n/hfg 

+%T01355.1973$360.80.$72.16

15170Acell graft 

trunk/arms/legsT01355.1973$360.80.$72.16
15171Acell graft t/arm/leg 

add-onT01343.2846$228.02.$45.61

15175Acellular graft 

f/n/hf/gT01355.1973$360.80.$72.16

15176Acell graft f/n/hf/g 

add-onT01355.1973$360.80.$72.16

15200Skin full graft 

trunkT013617.2745"$1,199.20".$239.84

15201Skin full graft trunk 

add-onT013617.2745"$1,199.20".$239.84

15220Skin full graft 

sclp/arm/legT013617.2745"$1,199.20".$239.84

15221Skin full graft 

add-onT01355.1973$360.80.$72.16

15240Skin full grft 

face/genit/hfT013617.2745"$1,199.20".$239.84

15241Skin full graft add-onCH 

T01343.2846$228.02.$45.61

15260Skin full graft een & 

lipsT013617.2745"$1,199.20".$239.84

15261Skin full graft 

add-onT013617.2745"$1,199.20".$239.84

15300Apply skinallogrft 

t/arm/lgT01355.1973$360.80.$72.16

15301Apply sknallogrft t/a/l 

addlT01355.1973$360.80.$72.16

15320Apply skin allogrft 

f/n/hf/gT01355.1973$360.80.$72.16

15321Aply sknallogrft f/n/hfg 

addT01355.1973$360.80.$72.16

15330Aply acell alogrft 

t/arm/legT01355.1973$360.80.$72.16

15331Aply acell grft t/a/l 
add-onT01355.1973$360.80.$72.16

15335Apply acell graft 

f/n/hf/gT01355.1973$360.80.$72.16

15336Aply acell grft f/n/hf/g 

addT01355.1973$360.80.$72.16

15340Apply cult skin 

substituteT01343.2846$228.02.$45.61

15341Apply cult skin sub 

add-onT01343.2846$228.02.$45.61

15360Apply cult derm sub 

t/a/lT01343.2846$228.02.$45.61

15361Aply cult derm sub t/a/l 

addT01343.2846$228.02.$45.61

15365Apply cult derm sub 

f/n/hf/gT01343.2846$228.02.$45.61

15366Apply cult derm f/hf/g 

addT01343.2846$228.02.$45.61

15400Apply skin xenograft 

t/a/lT01355.1973$360.80.$72.16

15401Apply skn xenogrft t/a/l 

addT01355.1973$360.80.$72.16

15420Apply skin xgraft 

f/n/hf/gT01355.1973$360.80.$72.16

15421Apply skn xgrft f/n/hf/g 

addT01355.1973$360.80.$72.16

15430Apply acellular xenograftCH 

T01343.2846$228.02.$45.61

15431Apply acellular xgraft 

addT01355.1973$360.80.$72.16

15570Form skin pedicle 

flapT013721.8041"$1,513.64".$302.73

15572Form skin pedicle 

flapT013721.8041"$1,513.64".$302.73
15574Form skin pedicle 

flapT013721.8041"$1,513.64".$302.73

15576Form skin pedicle 

flapT013721.8041"$1,513.64".$302.73

15600Skin 

graftT013721.8041"$1,513.64".$302.73

15610Skin 

graftT013721.8041"$1,513.64".$302.73

15620Skin 

graftT013721.8041"$1,513.64".$302.73

15630Skin 

graftT013721.8041"$1,513.64".$302.73

15650Transfer skin pedicle 

flapT013721.8041"$1,513.64".$302.73

15731Forehead flap w/vasc 

pedicleT013721.8041"$1,513.64".$302.73

15732Muscle-skin graft 

head/neckT013721.8041"$1,513.64".$302.73

15734Muscle-skin graft 

trunkT013721.8041"$1,513.64".$302.73

15736Muscle-skin graft 

armT013721.8041"$1,513.64".$302.73

15738Muscle-skin graft 

legT013721.8041"$1,513.64".$302.73

15740Island pedicle flap 

graftT013617.2745"$1,199.20".$239.84

15750Neurovascular pedicle 

graftT013721.8041"$1,513.64".$302.73

15756Free myo/skin flap 

microvascC

15757Free skin flap 

microvascC

15758Free fascial flap 

microvascC
15760Composite skin 

graftT013721.8041"$1,513.64".$302.73

15770Derma-fat-fascia 

graftT013721.8041"$1,513.64".$302.73

15775Hair transplant punch 

graftsT01331.2139$84.27$23.56$16.86

15776Hair transplant punch 

graftsT01331.2139$84.27$23.56$16.86

15780Abrasion treatment of 

skinT002223.4169"$1,625.60"$350.05$325.12

15781Abrasion treatment of 

skinT00194.8763$338.51.$67.71

15782Abrasion treatment of 

skinT00194.8763$338.51.$67.71

15783Abrasion treatment of 

skinT00162.8248$196.10.$39.22

15786Abrasion lesion 

singleT00130.9786$67.93.$13.59

15787Abrasion lesions 

add-onT00130.9786$67.93.$13.59

15788Chemical peel face 

epidermT00130.9786$67.93.$13.59

15789Chemical peel face 

dermalT00151.4936$103.69.$20.74

15792Chemical peel 

nonfacialT00151.4936$103.69.$20.74

15793Chemical peel 

nonfacialT00130.9786$67.93.$13.59

15819Plastic surgery 

neckT01343.2846$228.02.$45.61

15820Revision of lower 

eyelidT013721.8041"$1,513.64".$302.73

15821Revision of lower 

eyelidT013721.8041"$1,513.64".$302.73
15822Revision of upper 

eyelidT013721.8041"$1,513.64".$302.73

15823Revision of upper 

eyelidT013721.8041"$1,513.64".$302.73

15824Removal of forehead 

wrinklesT013721.8041"$1,513.64".$302.73

15825Removal of neck 

wrinklesT013721.8041"$1,513.64".$302.73

15826Removal of brow 

wrinklesT013721.8041"$1,513.64".$302.73

15828Removal of face 

wrinklesT013721.8041"$1,513.64".$302.73

15829Removal of skin 

wrinklesT013721.8041"$1,513.64".$302.73

15830Exc skin 

abdT002223.4169"$1,625.60"$350.05$325.12

15832Excise excessive skin 

tissueT002223.4169"$1,625.60"$350.05$325.12

15833Excise excessive skin 

tissueT002223.4169"$1,625.60"$350.05$325.12

15834Excise excessive skin 

tissueT002223.4169"$1,625.60"$350.05$325.12

15835Excise excessive skin 

tissueT002223.4169"$1,625.60"$350.05$325.12

15836Excise excessive skin 

tissueT002117.1909"$1,193.39".$238.68

15837Excise excessive skin 

tissueT002117.1909"$1,193.39".$238.68

15838Excise excessive skin 

tissueT002117.1909"$1,193.39".$238.68

15839Excise excessive skin 

tissueT002117.1909"$1,193.39".$238.68
15840Graft for face nerve 

palsyT013721.8041"$1,513.64".$302.73

15841Graft for face nerve 

palsyT013721.8041"$1,513.64".$302.73

15842Flap for face nerve 

palsyT013721.8041"$1,513.64".$302.73

15845Skin and muscle repair 

faceT013721.8041"$1,513.64".$302.73

15847Exc skin abd 

add-onT002223.4169"$1,625.60"$350.05$325.12

15850Removal of 

suturesT00162.8248$196.10.$39.22

15851Removal of 

suturesT00162.8248$196.10.$39.22

15852Dressing change not for 

burnX03400.6739$46.78.$9.36

15860Test for blood flow in 

graftX03400.6739$46.78.$9.36

15876Suction assisted 

lipectomyT013721.8041"$1,513.64".$302.73

15877Suction assisted 

lipectomyT013721.8041"$1,513.64".$302.73

15878Suction assisted 

lipectomyT013721.8041"$1,513.64".$302.73

15879Suction assisted 

lipectomyT013721.8041"$1,513.64".$302.73

15920Removal of tail bone 

ulcerT00194.8763$338.51.$67.71

15922Removal of tail bone 

ulcerT013721.8041"$1,513.64".$302.73

15931Remove sacrum pressure 

soreT002223.4169"$1,625.60"$350.05$325.12

15933Remove sacrum pressure 

soreT002223.4169"$1,625.60"$350.05$325.12
15934Remove sacrum pressure 

soreT013721.8041"$1,513.64".$302.73

15935Remove sacrum pressure 

soreT013721.8041"$1,513.64".$302.73

15936Remove sacrum pressure 

soreT013617.2745"$1,199.20".$239.84

15937Remove sacrum pressure 

soreT013721.8041"$1,513.64".$302.73

15940Remove hip pressure 

soreT002223.4169"$1,625.60"$350.05$325.12

15941Remove hip pressure 

soreT002223.4169"$1,625.60"$350.05$325.12

15944Remove hip pressure 

soreT013721.8041"$1,513.64".$302.73

15945Remove hip pressure 

soreT013721.8041"$1,513.64".$302.73

15946Remove hip pressure 

soreT013721.8041"$1,513.64".$302.73

15950Remove thigh pressure 

soreT002223.4169"$1,625.60"$350.05$325.12

15951Remove thigh pressure 

soreT002223.4169"$1,625.60"$350.05$325.12

15952Remove thigh pressure 

soreT013617.2745"$1,199.20".$239.84

15953Remove thigh pressure 

soreT013617.2745"$1,199.20".$239.84

15956Remove thigh pressure 

soreT013617.2745"$1,199.20".$239.84

15958Remove thigh pressure 

soreT013617.2745"$1,199.20".$239.84

15999Removal of pressure 

soreT00194.8763$338.51.$67.71
16000Initial treatment of 

burn(s)T00130.9786$67.93.$13.59

16020Dress/debrid p-thick burn 

sT00151.4936$103.69.$20.74

16025Dress/debrid p-thick burn 

mT00151.4936$103.69.$20.74

16030Dress/debrid p-thick burn 

lT00151.4936$103.69.$20.74

16035Incision of burn scab 

initiT00151.4936$103.69.$20.74

16036Escharotomy addl 

incisionC

17000Destruct premalg 

lesionT00130.9786$67.93.$13.59

17003Destruct premalg les 

2-14T00120.4047$28.09.$5.62

17004Destroy premlg lesions 

15+T00162.8248$196.10.$39.22

17106Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17107Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17108Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17110Destruct b9 lesion 

1-14T00130.9786$67.93.$13.59

17111Destruct lesion 15 or 

moreT00151.4936$103.69.$20.74

17250Chemical cautery 

tissueT00151.4936$103.69.$20.74

17260Destruction of skin 

lesionsT00151.4936$103.69.$20.74

17261Destruction of skin 

lesionsT00151.4936$103.69.$20.74
17262Destruction of skin 

lesionsT00151.4936$103.69.$20.74

17263Destruction of skin 

lesionsT00151.4936$103.69.$20.74

17264Destruction of skin 

lesionsT00151.4936$103.69.$20.74

17266Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17270Destruction of skin 

lesionsT00151.4936$103.69.$20.74

17271Destruction of skin 

lesionsT00151.4936$103.69.$20.74

17272Destruction of skin 

lesionsT00151.4936$103.69.$20.74

17273Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17274Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17276Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17280Destruction of skin 

lesionsT00151.4936$103.69.$20.74

17281Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17282Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17283Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17284Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17286Destruction of skin 

lesionsT00162.8248$196.10.$39.22

17311Mohs 1 stage 
h/n/hf/gT06945.3689$372.71$91.69$74.55

17312Mohs addl 

stageT06945.3689$372.71$91.69$74.55

17313Mohs 1 stage 

t/a/lT06945.3689$372.71$91.69$74.55

17314Mohs addl stage 

t/a/lT06945.3689$372.71$91.69$74.55

17315Mohs surg addl 

blockT06945.3689$372.71$91.69$74.55

17340Cryotherapy of 

skinT00130.9786$67.93.$13.59

17360Skin peel 

therapyT00130.9786$67.93.$13.59

17380Hair removal by 

electrolysisT00130.9786$67.93.$13.59

17999Skin tissue 

procedureT00120.4047$28.09.$5.62

19000Drainage of breast 

lesionT00044.5956$319.03.$63.81

19001Drain breast lesion 

add-onT00021.7462$121.22.$24.25

19020Incision of breast 

lesionT000820.5401"$1,425.89".$285.18

19030Injection for breast 

x-rayN

19100Bx breast percut w/o 

imageT00044.5956$319.03.$63.81

19101Biopsy of breast 

openT002825.8383"$1,793.69".$358.74

19102Bx breast percut 

w/imageT00058.1415$565.18.$113.04

19103Bx breast percut 

w/deviceT003715.3594"$1,066.25"$225.55$213.25
19105Cryosurg ablate fa 

eachT002933.8417"$2,349.29"$581.52$469.86

19110Nipple 

explorationT002825.8383"$1,793.69".$358.74

19112Excise breast duct 

fistulaT002825.8383"$1,793.69".$358.74

19120Removal of breast 

lesionT002825.8383"$1,793.69".$358.74

19125Excision breast 

lesionT002825.8383"$1,793.69".$358.74

19126Excision addl breast 

lesionT002825.8383"$1,793.69".$358.74

19260Removal of chest wall 

lesionT002117.1909"$1,193.39".$238.68

19271Revision of chest 

wallC

19272Extensive chest wall 

surgeryC

19290Place needle wire 

breastN

19291Place needle wire 

breastN

19295Place breast clip 

percutQ103400.6739$46.78.$9.36

19296Place po breast cath for 

radT064861.6690"$4,281.06".$856.22

19297Place breast cath for 

radT064861.6690"$4,281.06".$856.22

19298Place breast rad 

tube/cathsT064861.6690"$4,281.06".$856.22

19300Removal of breast 

tissueT002825.8383"$1,793.69".$358.74

19301Partical 

mastectomyT002825.8383"$1,793.69".$358.74

19302P-mastectomy w/ln 

removalT003045.0972"$3,130.65"$747.07$626.13
19303Mast simple 

completeT002933.8417"$2,349.29"$581.52$469.86

19304Mast 

subqT002933.8417"$2,349.29"$581.52$469.86

19305Mast 

radicalC

19306Mast rad urban 

typeC

19307Mast mod 

radT003045.0972"$3,130.65"$747.07$626.13

19316Suspension of 

breastT002933.8417"$2,349.29"$581.52$469.86

19318Reduction of large 

breastT003045.0972"$3,130.65"$747.07$626.13

19324Enlarge 

breastT003045.0972"$3,130.65"$747.07$626.13

19325Enlarge breast with 

implantT064861.6690"$4,281.06".$856.22

19328Removal of breast 

implantT002933.8417"$2,349.29"$581.52$469.86

19330Removal of implant 

materialT002933.8417"$2,349.29"$581.52$469.86

19340Immediate breast 

prosthesisT003045.0972"$3,130.65"$747.07$626.13

19342Delayed breast 

prosthesisT064861.6690"$4,281.06".$856.22

19350Breast 

reconstructionT002825.8383"$1,793.69".$358.74

19355Correct inverted 

nipple(s)T002933.8417"$2,349.29"$581.52$469.86

19357Breast 

reconstructionT064861.6690"$4,281.06".$856.22

19361Breast reconstr w/lat 

flapC
19364Breast 

reconstructionC

19366Breast 

reconstructionT002933.8417"$2,349.29"$581.52$469.86

19367Breast 

reconstructionC

19368Breast 

reconstructionC

19369Breast 

reconstructionC

19370Surgery of breast 

capsuleT002933.8417"$2,349.29"$581.52$469.86

19371Removal of breast 

capsuleT002933.8417"$2,349.29"$581.52$469.86

19380Revise breast 

reconstructionT003045.0972"$3,130.65"$747.07$626.13

19396Design custom breast 

implantT002933.8417"$2,349.29"$581.52$469.86

19499Breast surgery 

procedureT002825.8383"$1,793.69".$358.74

20005I&d abscess 

subfascialT00208.6164$598.15.$119.63

20100Explore wound 

neckT02528.0353$557.81.$111.57

20101Explore wound 

chestT013721.8041"$1,513.64".$302.73

20102Explore wound 

abdomenT013721.8041"$1,513.64".$302.73

20103Explore wound 

extremityT000713.4779$935.64.$187.13

20150Excise epiphyseal 

barT005147.1841"$3,275.52".$655.11

20200Muscle 

biopsyT002117.1909"$1,193.39".$238.68

20205Deep muscle 
biopsyT002117.1909"$1,193.39".$238.68

20206Needle biopsy 

muscleT00058.1415$565.18.$113.04

20220Bone biopsy 

trocar/needleT00208.6164$598.15.$119.63

20225Bone biopsy 

trocar/needleT002117.1909"$1,193.39".$238.68

20240Bone biopsy 

excisionalT002223.4169"$1,625.60"$350.05$325.12

20245Bone biopsy 

excisionalT002223.4169"$1,625.60"$350.05$325.12

20250Open bone biopsyCH 

T005032.4101"$2,249.91".$449.99

20251Open bone biopsyCH 

T005032.4101"$2,249.91".$449.99

20500Injection of sinus 

tractT02528.0353$557.81.$111.57

20501Inject sinus tract for 

x-rayN

20520Removal of foreign 

bodyT00194.8763$338.51.$67.71

20525Removal of foreign 

bodyT002223.4169"$1,625.60"$350.05$325.12

20526Ther injection carp 

tunnelT02042.7693$192.24$40.13$38.45

20550Inj tendon 

sheath/ligamentT02042.7693$192.24$40.13$38.45

20551Inj tendon 

origin/insertionT02042.7693$192.24$40.13$38.45

20552Inj trigger point 1/2 

musclT02042.7693$192.24$40.13$38.45

20553Inject trigger points =/> 

3T02042.7693$192.24$40.13$38.45
20555Place ndl musc/tis for 

rtT005032.4101"$2,249.91".$449.99

20600Drain/inject 

joint/bursaT02042.7693$192.24$40.13$38.45

20605Drain/inject 

joint/bursaT02042.7693$192.24$40.13$38.45

20610Drain/inject 

joint/bursaT02042.7693$192.24$40.13$38.45

20612Aspirate/inj ganglion 

cystT02042.7693$192.24$40.13$38.45

20615Treatment of bone 

cystT00044.5956$319.03.$63.81

20650Insert and remove bone pinCH 

T005032.4101"$2,249.91".$449.99

20660Apply rem fixation 

deviceT01384.9874$346.23.$69.25

20661Application of head 

braceC

20662Application of pelvis 

braceT004922.1674"$1,538.86".$307.78

20663Application of thigh braceCH 

T005032.4101"$2,249.91".$449.99

20664Application of 

haloC

20665Removal of fixation 

deviceX03400.6739$46.78.$9.36

20670Removal of support 

implantT002117.1909"$1,193.39".$238.68

20680Removal of support 

implantT002223.4169"$1,625.60"$350.05$325.12

20690Apply bone fixation 

deviceT005032.4101"$2,249.91".$449.99

20692Apply bone fixation 

deviceT005032.4101"$2,249.91".$449.99
20693Adjust bone fixation deviceCH 

T005032.4101"$2,249.91".$449.99

20694Remove bone fixation 

deviceT004922.1674"$1,538.86".$307.78

20696Comp multiplane ext 

fixationT005032.4101"$2,249.91".$449.99

20697Comp ext fixate strut 

changeT013918.6922"$1,297.61".$259.53

20802Replantation arm 

completeC

20805Replant forearm 

completeC

20808Replantation hand 

completeC

20816Replantation digit 

completeC

20822Replantation digit 

completeT005429.0181"$2,014.44".$402.89

20824Replantation thumb 

completeC

20827Replantation thumb 

completeC

20838Replantation foot 

completeC

20900Removal of bone for 

graftT005032.4101"$2,249.91".$449.99

20902Removal of bone for 

graftT005032.4101"$2,249.91".$449.99

20910Remove cartilage for 

graftT013721.8041"$1,513.64".$302.73

20912Remove cartilage for 

graftT013721.8041"$1,513.64".$302.73

20920Removal of fascia for 

graftT013617.2745"$1,199.20".$239.84

20922Removal of fascia for 

graftT013617.2745"$1,199.20".$239.84

20924Removal of tendon for 
graftT005032.4101"$2,249.91".$449.99

20926Removal of tissue for 

graftT01355.1973$360.80.$72.16

20930Sp bone algrft morsel 

add-onC

20931Sp bone algrft struct 

add-onC

20936Sp bone agrft local 

add-onC

20937Sp bone agrft morsel 

add-onC

20938Sp bone agrft struct 

add-onC

20950Fluid pressure 

muscleT00061.4481$100.53.$20.11

20955Fibula bone graft 

microvascC

20956Iliac bone graft 

microvascC

20957Mt bone graft 

microvascC

20962Other bone graft 

microvascC

20969Bone/skin graft 

microvascC

20970Bone/skin graft iliac 

crestC

20972Bone/skin graft 

metatarsalT005657.2099"$3,971.51".$794.31

20973Bone/skin graft great 

toeT005657.2099"$3,971.51".$794.31

20974Electrical bone 

stimulationA

20975Electrical bone stimulationN 

20979Us bone stimulationX 

03400.6739$46.78.$9.36

20982Ablate bone tumor(s) 

perqT005147.1841"$3,275.52".$655.11

20985Cptr-asst dir ms pxN 
20999Musculoskeletal 

surgeryT004922.1674"$1,538.86".$307.78

21010Incision of jaw 

jointT025425.1379"$1,745.07".$349.02

21011Exc face les sc < 2 

cmT00208.6164$598.15.$119.63

21012Exc face les sbq 2+ 

cmT00208.6164$598.15.$119.63

21013Exc face tum deep < 2 

cmT00208.6164$598.15.$119.63

21014Exc face tum deep 2+ 

cmT00208.6164$598.15.$119.63

21015Resect face tum < 2 

cmT002117.1909"$1,193.39".$238.68

21016Resect face tum + 

cmT002223.4169"$1,625.60"$350.05$325.12

21025Excision of bone lower 

jawT025645.1286"$3,132.83".$626.57

21026Excision of facial 

bone(s)T025645.1286"$3,132.83".$626.57

21029Contour of face bone 

lesionT025645.1286"$3,132.83".$626.57

21030Excise max/zygoma b9 

tumorT025425.1379"$1,745.07".$349.02

21031Remove exostosis 

mandibleT025425.1379"$1,745.07".$349.02

21032Remove exostosis 

maxillaT025425.1379"$1,745.07".$349.02

21034Excise max/zygoma mlg 

tumorT025645.1286"$3,132.83".$626.57

21040Excise mandible 

lesionT025425.1379"$1,745.07".$349.02
21044Removal of jaw bone 

lesionT025645.1286"$3,132.83".$626.57

21045Extensive jaw 

surgeryC

21046Remove mandible cyst 

complexT025645.1286"$3,132.83".$626.57

21047Excise lwr jaw cyst 

w/repairT025645.1286"$3,132.83".$626.57

21048Remove maxilla cyst 

complexT025645.1286"$3,132.83".$626.57

21049Excis uppr jaw cyst 

w/repairT025645.1286"$3,132.83".$626.57

21050Removal of jaw 

jointT025645.1286"$3,132.83".$626.57

21060Remove jaw joint 

cartilageT025645.1286"$3,132.83".$626.57

21070Remove coronoid 

processT025645.1286"$3,132.83".$626.57

21073Mnpj of tmj 

w/anesthT02528.0353$557.81.$111.57

21076Prepare face/oral 

prosthesisT025425.1379"$1,745.07".$349.02

21077Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21079Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21080Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21081Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21082Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21083Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57
21084Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21085Prepare face/oral 

prosthesisT025316.9180"$1,174.45"$277.61$234.89

21086Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21087Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21088Prepare face/oral 

prosthesisT025645.1286"$3,132.83".$626.57

21089Prepare face/oral 

prosthesisT02501.0875$75.49$24.28$15.10

21100Maxillofacial 

fixationT025645.1286"$3,132.83".$626.57

21110Interdental 

fixationT02528.0353$557.81.$111.57

21116Injection jaw joint 

x-rayN

21120Reconstruction of 

chinT025425.1379"$1,745.07".$349.02

21121Reconstruction of 

chinT025425.1379"$1,745.07".$349.02

21122Reconstruction of 

chinT025425.1379"$1,745.07".$349.02

21123Reconstruction of 

chinT025425.1379"$1,745.07".$349.02

21125Augmentation lower jaw 

boneT025425.1379"$1,745.07".$349.02

21127Augmentation lower jaw 

boneT025645.1286"$3,132.83".$626.57

21137Reduction of 

foreheadT025425.1379"$1,745.07".$349.02

21138Reduction of 

foreheadT025645.1286"$3,132.83".$626.57
21139Reduction of 

foreheadT025645.1286"$3,132.83".$626.57

21141Reconstruct midface 

lefortC

21142Reconstruct midface 

lefortC

21143Reconstruct midface 

lefortC

21145Reconstruct midface 

lefortC

21146Reconstruct midface 

lefortC

21147Reconstruct midface 

lefortC

21150Reconstruct midface 

lefortT025645.1286"$3,132.83".$626.57

21151Reconstruct midface 

lefortC

21154Reconstruct midface 

lefortC

21155Reconstruct midface 

lefortC

21159Reconstruct midface 

lefortC

21160Reconstruct midface 

lefortC

21172Reconstruct 

orbit/foreheadT025645.1286"$3,132.83".$626.57

21175Reconstruct 

orbit/foreheadT025645.1286"$3,132.83".$626.57

21179Reconstruct entire 

foreheadC

21180Reconstruct entire 

foreheadC

21181Contour cranial bone 

lesionT025425.1379"$1,745.07".$349.02

21182Reconstruct cranial 

boneC

21183Reconstruct cranial 

boneC
21184Reconstruct cranial 

boneC

21188Reconstruction of 

midfaceC

21193Reconst lwr jaw w/o 

graftT025645.1286"$3,132.83".$626.57

21194Reconst lwr jaw 

w/graftC

21195Reconst lwr jaw w/o 

fixationT025645.1286"$3,132.83".$626.57

21196Reconst lwr jaw 

w/fixationC

21198Reconstr lwr jaw 

segmentT025645.1286"$3,132.83".$626.57

21199Reconstr lwr jaw 

w/advanceT025645.1286"$3,132.83".$626.57

21206Reconstruct upper jaw 

boneT025645.1286"$3,132.83".$626.57

21208Augmentation of facial 

bonesT025645.1286"$3,132.83".$626.57

21209Reduction of facial 

bonesT025645.1286"$3,132.83".$626.57

21210Face bone 

graftT025645.1286"$3,132.83".$626.57

21215Lower jaw bone 

graftT025645.1286"$3,132.83".$626.57

21230Rib cartilage 

graftT025645.1286"$3,132.83".$626.57

21235Ear cartilage 

graftT025425.1379"$1,745.07".$349.02

21240Reconstruction of jaw 

jointT025645.1286"$3,132.83".$626.57

21242Reconstruction of jaw 

jointT025645.1286"$3,132.83".$626.57

21243Reconstruction of jaw 
jointT025645.1286"$3,132.83".$626.57

21244Reconstruction of lower 

jawT025645.1286"$3,132.83".$626.57

21245Reconstruction of 

jawT025645.1286"$3,132.83".$626.57

21246Reconstruction of 

jawT025645.1286"$3,132.83".$626.57

21247Reconstruct lower jaw 

boneC

21248Reconstruction of 

jawT025645.1286"$3,132.83".$626.57

21249Reconstruction of 

jawT025645.1286"$3,132.83".$626.57

21255Reconstruct lower jaw 

boneC

21256Reconstruction of 

orbitT025645.1286"$3,132.83".$626.57

21260Revise eye 

socketsT025645.1286"$3,132.83".$626.57

21261Revise eye 

socketsT025645.1286"$3,132.83".$626.57

21263Revise eye 

socketsT025645.1286"$3,132.83".$626.57

21267Revise eye 

socketsT025645.1286"$3,132.83".$626.57

21268Revise eye 

socketsC

21270Augmentation cheek 

boneT025645.1286"$3,132.83".$626.57

21275Revision orbitofacial 

bonesT025645.1286"$3,132.83".$626.57

21280Revision of 

eyelidT025645.1286"$3,132.83".$626.57

21282Revision of 

eyelidT025316.9180"$1,174.45"$277.61$234.89
21295Revision of jaw 

muscle/boneT02528.0353$557.81.$111.57

21296Revision of jaw 

muscle/boneT025425.1379"$1,745.07".$349.02

21299Cranio/maxillofacial 

surgeryT02501.0875$75.49$24.28$15.10

21310Treatment of nose 

fractureT02501.0875$75.49$24.28$15.10

21315Treatment of nose 

fractureT025316.9180"$1,174.45"$277.61$234.89

21320Treatment of nose 

fractureT025316.9180"$1,174.45"$277.61$234.89

21325Treatment of nose 

fractureT025425.1379"$1,745.07".$349.02

21330Treatment of nose 

fractureT025425.1379"$1,745.07".$349.02

21335Treatment of nose 

fractureT025425.1379"$1,745.07".$349.02

21336Treat nasal septal 

fractureT006226.2376"$1,821.41"$371.33$364.29

21337Treat nasal septal 

fractureT025316.9180"$1,174.45"$277.61$234.89

21338Treat nasoethmoid 

fractureT025425.1379"$1,745.07".$349.02

21339Treat nasoethmoid 

fractureT025425.1379"$1,745.07".$349.02

21340Treatment of nose 

fractureT025645.1286"$3,132.83".$626.57

21343Treatment of sinus 

fractureC

21344Treatment of sinus 

fractureC

21345Treat nose/jaw 

fractureT025425.1379"$1,745.07".$349.02
21346Treat nose/jaw 

fractureCHT025425.1379"$1,745.07".$349.02

21347Treat nose/jaw 

fractureC

21348Treat nose/jaw 

fractureC

21355Treat cheek bone 

fractureT025645.1286"$3,132.83".$626.57

21356Treat cheek bone 

fractureT025425.1379"$1,745.07".$349.02

21360Treat cheek bone 

fractureT025425.1379"$1,745.07".$349.02

21365Treat cheek bone 

fractureT025645.1286"$3,132.83".$626.57

21366Treat cheek bone 

fractureC

21385Treat eye socket 

fractureT025645.1286"$3,132.83".$626.57

21386Treat eye socket 

fractureT025645.1286"$3,132.83".$626.57

21387Treat eye socket 

fractureT025645.1286"$3,132.83".$626.57

21390Treat eye socket 

fractureT025645.1286"$3,132.83".$626.57

21395Treat eye socket 

fractureT025645.1286"$3,132.83".$626.57

21400Treat eye socket 

fractureT02528.0353$557.81.$111.57

21401Treat eye socket 

fractureT025316.9180"$1,174.45"$277.61$234.89

21406Treat eye socket 

fractureT025645.1286"$3,132.83".$626.57

21407Treat eye socket 

fractureT025645.1286"$3,132.83".$626.57
21408Treat eye socket 

fractureT025645.1286"$3,132.83".$626.57

21421Treat mouth roof 

fractureT025425.1379"$1,745.07".$349.02

21422Treat mouth roof 

fractureC

21423Treat mouth roof 

fractureC

21431Treat craniofacial 

fractureC

21432Treat craniofacial 

fractureC

21433Treat craniofacial 

fractureC

21435Treat craniofacial 

fractureC

21436Treat craniofacial 

fractureC

21440Treat dental ridge 

fractureT025425.1379"$1,745.07".$349.02

21445Treat dental ridge 

fractureT025425.1379"$1,745.07".$349.02

21450Treat lower jaw 

fractureT02513.3531$232.77.$46.56

21451Treat lower jaw 

fractureT02528.0353$557.81.$111.57

21452Treat lower jaw 

fractureT025316.9180"$1,174.45"$277.61$234.89

21453Treat lower jaw 

fractureT025645.1286"$3,132.83".$626.57

21454Treat lower jaw 

fractureT025425.1379"$1,745.07".$349.02

21461Treat lower jaw 

fractureT025645.1286"$3,132.83".$626.57

21462Treat lower jaw 

fractureT025645.1286"$3,132.83".$626.57
21465Treat lower jaw 

fractureT025645.1286"$3,132.83".$626.57

21470Treat lower jaw 

fractureT025645.1286"$3,132.83".$626.57

21480Reset dislocated 

jawT02501.0875$75.49$24.28$15.10

21485Reset dislocated 

jawT025316.9180"$1,174.45"$277.61$234.89

21490Repair dislocated 

jawT025645.1286"$3,132.83".$626.57

21495Treat hyoid bone 

fractureT025316.9180"$1,174.45"$277.61$234.89

21497Interdental 

wiringT025316.9180"$1,174.45"$277.61$234.89

21499Head surgery 

procedureT02501.0875$75.49$24.28$15.10

21501Drain neck/chest 

lesionT000820.5401"$1,425.89".$285.18

21502Drain chest 

lesionT004922.1674"$1,538.86".$307.78

21510Drainage of bone 

lesionC

21550Biopsy of 

neck/chestT002117.1909"$1,193.39".$238.68

21552Exc neck les sc 3+ 

cmT002223.4169"$1,625.60"$350.05$325.12

21554Exc neck tum deep 5+ 

cmT002223.4169"$1,625.60"$350.05$325.12

21555Exc neck les sc < 3 

cmT002117.1909"$1,193.39".$238.68

21556Exc neck tum deep < 5 

cmT002223.4169"$1,625.60"$350.05$325.12

21557Resect neck tum < 5 

cmT002117.1909"$1,193.39".$238.68
21558Resect neck tum 5+ 

cmT002223.4169"$1,625.60"$350.05$325.12

21600Partial removal of 

ribT005032.4101"$2,249.91".$449.99

21610Partial removal of 

ribT005032.4101"$2,249.91".$449.99

21615Removal of 

ribC

21616Removal of rib and 

nervesC

21620Partial removal of 

sternumC

21627Sternal 

debridementC

21630Extensive sternum 

surgeryC

21632Extensive sternum 

surgeryC

21685Hyoid myotomy & 

suspensionT02528.0353$557.81.$111.57

21700Revision of neck 

muscleT004922.1674"$1,538.86".$307.78

21705Revision of neck 

muscle/ribC

21720Revision of neck 

muscleT004922.1674"$1,538.86".$307.78

21725Revision of neck 

muscleT00061.4481$100.53.$20.11

21740Reconstruction of 

sternumC

21742Repair stern/nuss w/o 

scopeT005147.1841"$3,275.52".$655.11

21743Repair sternum/nuss 

w/scopeT005147.1841"$3,275.52".$655.11

21750Repair of sternum 

separationC

21800Treatment of rib 

fractureT01291.6063$111.51.$22.31
21805Treatment of rib 

fractureT006226.2376"$1,821.41"$371.33$364.29

21810Treatment of rib 

fracture(s)C

21820Treat sternum 

fractureT01291.6063$111.51.$22.31

21825Treat sternum 

fractureC

21899Neck/chest surgery 

procedureT02501.0875$75.49$24.28$15.10

21920Biopsy soft tissue of 

backT00208.6164$598.15.$119.63

21925Biopsy soft tissue of 

backT002223.4169"$1,625.60"$350.05$325.12

21930Exc back les sc < 3 

cmT002117.1909"$1,193.39".$238.68

21931Exc back les sc 3+ 

cmT002223.4169"$1,625.60"$350.05$325.12

21932Exc back tum deep < 5 

cmT002117.1909"$1,193.39".$238.68

21933Exc back tum deep 5+ 

cmT002223.4169"$1,625.60"$350.05$325.12

21935Resect back tum < 5 

cmT002117.1909"$1,193.39".$238.68

21936Resect back tum 5+ 

cmT002223.4169"$1,625.60"$350.05$325.12

22010I&d p-spine 

c/t/cerv-thorC

22015I&d p-spine 

l/s/lsC

22100Remove part of neck 

vertebraT020851.1173"$3,548.56".$709.72

22101Remove part thorax 

vertebraT020851.1173"$3,548.56".$709.72
22102Remove part lumbar 

vertebraT020851.1173"$3,548.56".$709.72

22103Remove extra spine 

segmentT020851.1173"$3,548.56".$709.72

22110Remove part of neck 

vertebraC

22112Remove part thorax 

vertebraC

22114Remove part lumbar 

vertebraC

22116Remove extra spine 

segmentC

22206Cut spine 3 col 

thorC

22207Cut spine 3 col 

lumbC

22208Cut spine 3 col addl 

segC

22210Revision of neck 

spineC

22212Revision of thorax 

spineC

22214Revision of lumbar 

spineC

22216Revise extra spine 

segmentC

22220Revision of neck 

spineC

22222Revision of thorax 

spineT020851.1173"$3,548.56".$709.72

22224Revision of lumbar 

spineC

22226Revise extra spine 

segmentC

22305Treat spine process 

fractureT01291.6063$111.51.$22.31

22310Treat spine 

fractureT01384.9874$346.23.$69.25

22315Treat spine 

fractureT013918.6922"$1,297.61".$259.53
22318Treat odontoid fx w/o 

graftC

22319Treat odontoid fx 

w/graftC

22325Treat spine 

fractureC

22326Treat neck spine 

fractureC

22327Treat thorax spine 

fractureC

22328Treat each add spine 

fxC

22505Manipulation of 

spineT004515.5166"$1,077.16"$268.44$215.44

22520Percut vertebroplasty 

thorT005032.4101"$2,249.91".$449.99

22521Percut vertebroplasty 

lumbT005032.4101"$2,249.91".$449.99

22522Percut vertebroplasty 

addlT005032.4101"$2,249.91".$449.99

22523Percut kyphoplasty 

thorT005287.5671"$6,078.91"."$1,215.79"

22524Percut kyphoplasty 

lumbarT005287.5671"$6,078.91"."$1,215.79"

22525Percut kyphoplasty 

add-onT005287.5671"$6,078.91"."$1,215.79"

22526Idet single 

levelE

22527Idet 1 or more 

levelsE

22532Lat thorax spine 

fusionC

22533Lat lumbar spine 

fusionC

22534Lat thor/lumb addl 

segC

22548Neck spine 

fusionC

22551Neck spine fuse&remove 

addlC
22552Addl neck spine 

fusionC

22554Neck spine 

fusionC

22556Thorax spine 

fusionC

22558Lumbar spine 

fusionC

22585Additional spinal 

fusionC

22590Spine & skull spinal 

fusionC

22595Neck spinal 

fusionC

22600Neck spine 

fusionC

22610Thorax spine 

fusionC

22612Lumbar spine 

fusionT020851.1173"$3,548.56".$709.72

22614Spine fusion extra 

segmentT020851.1173"$3,548.56".$709.72

22630Lumbar spine 

fusionC

22632Spine fusion extra 

segmentC

22800Fusion of 

spineC

22802Fusion of 

spineC

22804Fusion of 

spineC

22808Fusion of 

spineC

22810Fusion of 

spineC

22812Fusion of 

spineC

22818Kyphectomy 1-2 

segmentsC

22819Kyphectomy 3 or 

moreC
22830Exploration of spinal 

fusionC

22840Insert spine fixation 

deviceC

22841Insert spine fixation 

deviceC

22842Insert spine fixation 

deviceC

22843Insert spine fixation 

deviceC

22844Insert spine fixation 

deviceC

22845Insert spine fixation 

deviceC

22846Insert spine fixation 

deviceC

22847Insert spine fixation 

deviceC

22848Insert pelv fixation 

deviceC

22849Reinsert spinal 

fixationC

22850Remove spine fixation 

deviceC

22851Apply spine prosth deviceCH 

T005032.4101"$2,249.91".$449.99

22852Remove spine fixation 

deviceC

22855Remove spine fixation 

deviceC

22856Cerv artific 

diskectomyC

22857Lumbar artif 

diskectomyC

22861Revise cerv artific 

discC

22862Revise lumbar artif 

discC

22864Remove cerv artif 

discC

22865Remove lumb artif 

discC

22899Spine surgery procedureCH 

T005032.4101"$2,249.91".$449.99
22900Exc back tum deep < 5 

cmT002223.4169"$1,625.60"$350.05$325.12

22901Exc back tum deep 5+ 

cmT002223.4169"$1,625.60"$350.05$325.12

22902Exc abd les sc < 3 

cmT002117.1909"$1,193.39".$238.68

22903Exc abd les sc > 3 

cmT002223.4169"$1,625.60"$350.05$325.12

22904Resect abd tum < 5 

cmT002117.1909"$1,193.39".$238.68

22905Resect abd tum > 5 

cmT002223.4169"$1,625.60"$350.05$325.12

22999Abdomen surgery 

procedureT004922.1674"$1,538.86".$307.78

23000Removal of calcium 

depositsT002117.1909"$1,193.39".$238.68

23020Release shoulder jointCH 

T005032.4101"$2,249.91".$449.99

23030Drain shoulder 

lesionT000820.5401"$1,425.89".$285.18

23031Drain shoulder 

bursaT000820.5401"$1,425.89".$285.18

23035Drain shoulder bone 

lesionT004922.1674"$1,538.86".$307.78

23040Exploratory shoulder 

surgeryT005032.4101"$2,249.91".$449.99

23044Exploratory shoulder 

surgeryT005032.4101"$2,249.91".$449.99

23065Biopsy shoulder 

tissuesT00208.6164$598.15.$119.63

23066Biopsy shoulder 

tissuesT002223.4169"$1,625.60"$350.05$325.12
23071Exc shoulder les sc > 3 

cmT002223.4169"$1,625.60"$350.05$325.12

23073Exc shoulder tum deep > 5 

cmT002223.4169"$1,625.60"$350.05$325.12

23075Exc shoulder les sc < 3 

cmT002117.1909"$1,193.39".$238.68

23076Exc shoulder tum deep < 5 

cmT002117.1909"$1,193.39".$238.68

23077Resect shoulder tum < 5 

cmT002117.1909"$1,193.39".$238.68

23078Resect shoulder tum > 5 

cmT002223.4169"$1,625.60"$350.05$325.12

23100Biopsy of shoulder 

jointT004922.1674"$1,538.86".$307.78

23101Shoulder joint 

surgeryT005032.4101"$2,249.91".$449.99

23105Remove shoulder joint 

liningT005032.4101"$2,249.91".$449.99

23106Incision of collarbone 

jointT005032.4101"$2,249.91".$449.99

23107Explore treat shoulder 

jointT005032.4101"$2,249.91".$449.99

23120Partial removal collar 

boneT005032.4101"$2,249.91".$449.99

23125Removal of collar 

boneT005032.4101"$2,249.91".$449.99

23130Remove shoulder bone 

partT005147.1841"$3,275.52".$655.11

23140Removal of bone 

lesionT004922.1674"$1,538.86".$307.78

23145Removal of bone 

lesionT005032.4101"$2,249.91".$449.99

23146Removal of bone 

lesionT005032.4101"$2,249.91".$449.99
23150Removal of humerus 

lesionT005032.4101"$2,249.91".$449.99

23155Removal of humerus 

lesionT005032.4101"$2,249.91".$449.99

23156Removal of humerus 

lesionT005032.4101"$2,249.91".$449.99

23170Remove collar bone 

lesionT005032.4101"$2,249.91".$449.99

23172Remove shoulder blade 

lesionT005032.4101"$2,249.91".$449.99

23174Remove humerus 

lesionT005032.4101"$2,249.91".$449.99

23180Remove collar bone 

lesionT005032.4101"$2,249.91".$449.99

23182Remove shoulder blade 

lesionT005032.4101"$2,249.91".$449.99

23184Remove humerus 

lesionT005032.4101"$2,249.91".$449.99

23190Partial removal of 

scapulaT005032.4101"$2,249.91".$449.99

23195Removal of head of 

humerusT005032.4101"$2,249.91".$449.99

23200Resect clavicle 

tumorC

23210Resect scapula 

tumorC

23220Resect prox humerus 

tumorC

23330Remove shoulder foreign 

bodyT00208.6164$598.15.$119.63

23331Remove shoulder foreign 

bodyT002223.4169"$1,625.60"$350.05$325.12

23332Remove shoulder foreign 

bodyC
23350Injection for shoulder 

x-rayN

23395Muscle transfer 

shoulder/armT005147.1841"$3,275.52".$655.11

23397Muscle 

transfersT005287.5671"$6,078.91"."$1,215.79"

23400Fixation of shoulder 

bladeT005032.4101"$2,249.91".$449.99

23405Incision of tendon & 

muscleT005032.4101"$2,249.91".$449.99

23406Incise tendon(s) & 

muscle(s)T005032.4101"$2,249.91".$449.99

23410Repair rotator cuff 

acuteT005147.1841"$3,275.52".$655.11

23412Repair rotator cuff 

chronicT005147.1841"$3,275.52".$655.11

23415Release of shoulder 

ligamentT005147.1841"$3,275.52".$655.11

23420Repair of 

shoulderT005147.1841"$3,275.52".$655.11

23430Repair biceps 

tendonT005147.1841"$3,275.52".$655.11

23440Remove/transplant tendonCH 

T005032.4101"$2,249.91".$449.99

23450Repair shoulder 

capsuleT005287.5671"$6,078.91"."$1,215.79"

23455Repair shoulder 

capsuleT005287.5671"$6,078.91"."$1,215.79"

23460Repair shoulder 

capsuleT005287.5671"$6,078.91"."$1,215.79"

23462Repair shoulder 

capsuleT005147.1841"$3,275.52".$655.11

23465Repair shoulder 

capsuleT005287.5671"$6,078.91"."$1,215.79"
23466Repair shoulder 

capsuleT005147.1841"$3,275.52".$655.11

23470Reconstruct shoulder 

jointT0425130.4476"$9,055.67"."$1,811.14"

23472Reconstruct shoulder 

jointC

23480Revision of collar 

boneT005147.1841"$3,275.52".$655.11

23485Revision of collar 

boneT005287.5671"$6,078.91"."$1,215.79"

23490Reinforce 

clavicleT005287.5671"$6,078.91"."$1,215.79"

23491Reinforce shoulder 

bonesT005287.5671"$6,078.91"."$1,215.79"

23500Treat clavicle 

fractureT01291.6063$111.51.$22.31

23505Treat clavicle 

fractureT013918.6922"$1,297.61".$259.53

23515Treat clavicle 

fractureT006467.0623"$4,655.46".$931.10

23520Treat clavicle 

dislocationT01384.9874$346.23.$69.25

23525Treat clavicle 

dislocationT01384.9874$346.23.$69.25

23530Treat clavicle 

dislocationT006349.4864"$3,435.35".$687.07

23532Treat clavicle 

dislocationT006226.2376"$1,821.41"$371.33$364.29

23540Treat clavicle 

dislocationT01291.6063$111.51.$22.31

23545Treat clavicle 

dislocationT01384.9874$346.23.$69.25

23550Treat clavicle 

dislocationT006349.4864"$3,435.35".$687.07
23552Treat clavicle 

dislocationT006349.4864"$3,435.35".$687.07

23570Treat shoulder blade 

fxT01291.6063$111.51.$22.31

23575Treat shoulder blade 

fxT01384.9874$346.23.$69.25

23585Treat scapula 

fractureT006467.0623"$4,655.46".$931.10

23600Treat humerus 

fractureT01291.6063$111.51.$22.31

23605Treat humerus 

fractureT013918.6922"$1,297.61".$259.53

23615Treat humerus 

fractureT006467.0623"$4,655.46".$931.10

23616Treat humerus 

fractureT006467.0623"$4,655.46".$931.10

23620Treat humerus 

fractureT01291.6063$111.51.$22.31

23625Treat humerus 

fractureT013918.6922"$1,297.61".$259.53

23630Treat humerus 

fractureT006467.0623"$4,655.46".$931.10

23650Treat shoulder 

dislocationT01291.6063$111.51.$22.31

23655Treat shoulder 

dislocationT004515.5166"$1,077.16"$268.44$215.44

23660Treat shoulder 

dislocationT006349.4864"$3,435.35".$687.07

23665Treat 

dislocation/fractureT01384.9874$346.23.$69.25

23670Treat 

dislocation/fractureT006467.0623"$4,655.46".$931.10
23675Treat 

dislocation/fractureT01291.6063$111.51.$22.31

23680Treat 

dislocation/fractureT006349.4864"$3,435.35".$687.07

23700Fixation of 

shoulderT004515.5166"$1,077.16"$268.44$215.44

23800Fusion of shoulder 

jointT005287.5671"$6,078.91"."$1,215.79"

23802Fusion of shoulder 

jointT005287.5671"$6,078.91"."$1,215.79"

23900Amputation of arm & 

girdleC

23920Amputation at shoulder 

jointC

23921Amputation follow-up 

surgeryT013617.2745"$1,199.20".$239.84

23929Shoulder surgery 

procedureT01291.6063$111.51.$22.31

23930Drainage of arm 

lesionT000820.5401"$1,425.89".$285.18

23931Drainage of arm 

bursaT000820.5401"$1,425.89".$285.18

23935Drain arm/elbow bone 

lesionT004922.1674"$1,538.86".$307.78

24000Exploratory elbow 

surgeryT005032.4101"$2,249.91".$449.99

24006Release elbow 

jointT005032.4101"$2,249.91".$449.99

24065Biopsy arm/elbow soft 

tissueT002117.1909"$1,193.39".$238.68

24066Biopsy arm/elbow soft 

tissueT002117.1909"$1,193.39".$238.68

24071Exc arm/elbow les sc 3+ 

cmT002223.4169"$1,625.60"$350.05$325.12
24073Ex arm/elbow tum deep > 5 

cmT002223.4169"$1,625.60"$350.05$325.12

24075Exc arm/elbow les sc < 3 

cmT002117.1909"$1,193.39".$238.68

24076Ex arm/elbow tum deep < 5 

cmT002117.1909"$1,193.39".$238.68

24077Resect arm/elbow tum < 5 

cmT002117.1909"$1,193.39".$238.68

24079Resect arm/elbow tum > 5 

cmT002223.4169"$1,625.60"$350.05$325.12

24100Biopsy elbow joint 

liningT004922.1674"$1,538.86".$307.78

24101Explore/treat elbow 

jointT005032.4101"$2,249.91".$449.99

24102Remove elbow joint 

liningT005032.4101"$2,249.91".$449.99

24105Removal of elbow 

bursaT004922.1674"$1,538.86".$307.78

24110Remove humerus 

lesionT004922.1674"$1,538.86".$307.78

24115Remove/graft bone 

lesionT005032.4101"$2,249.91".$449.99

24116Remove/graft bone 

lesionT005032.4101"$2,249.91".$449.99

24120Remove elbow 

lesionT004922.1674"$1,538.86".$307.78

24125Remove/graft bone 

lesionT005032.4101"$2,249.91".$449.99

24126Remove/graft bone 

lesionT005032.4101"$2,249.91".$449.99

24130Removal of head of 

radiusT005032.4101"$2,249.91".$449.99

24134Removal of arm bone 

lesionT005032.4101"$2,249.91".$449.99
24136Remove radius bone 

lesionT005032.4101"$2,249.91".$449.99

24138Remove elbow bone 

lesionT005032.4101"$2,249.91".$449.99

24140Partial removal of arm 

boneT005032.4101"$2,249.91".$449.99

24145Partial removal of 

radiusT005032.4101"$2,249.91".$449.99

24147Partial removal of 

elbowT005032.4101"$2,249.91".$449.99

24149Radical resection of 

elbowT005032.4101"$2,249.91".$449.99

24150Resect distal humerus 

tumorT005147.1841"$3,275.52".$655.11

24152Resect radius 

tumorT005147.1841"$3,275.52".$655.11

24155Removal of elbow jointCH 

T005032.4101"$2,249.91".$449.99

24160Remove elbow joint 

implantT005032.4101"$2,249.91".$449.99

24164Remove radius head 

implantT005032.4101"$2,249.91".$449.99

24200Removal of arm foreign 

bodyT00194.8763$338.51.$67.71

24201Removal of arm foreign 

bodyT002117.1909"$1,193.39".$238.68

24220Injection for elbow 

x-rayN

24300Manipulate elbow 

w/anesthT004515.5166"$1,077.16"$268.44$215.44

24301Muscle/tendon 

transferT005032.4101"$2,249.91".$449.99

24305Arm tendon 
lengtheningT005032.4101"$2,249.91".$449.99

24310Revision of arm 

tendonT004922.1674"$1,538.86".$307.78

24320Repair of arm tendonCH 

T005032.4101"$2,249.91".$449.99

24330Revision of arm 

musclesT005287.5671"$6,078.91"."$1,215.79"

24331Revision of arm 

musclesT005147.1841"$3,275.52".$655.11

24332Tenolysis tricepsCH 

T005032.4101"$2,249.91".$449.99

24340Repair of biceps 

tendonT005147.1841"$3,275.52".$655.11

24341Repair arm 

tendon/muscleT005147.1841"$3,275.52".$655.11

24342Repair of ruptured 

tendonT005147.1841"$3,275.52".$655.11

24343Repr elbow lat ligmnt 

w/tissT005032.4101"$2,249.91".$449.99

24344Reconstruct elbow lat 

ligmntT005287.5671"$6,078.91"."$1,215.79"

24345Repr elbw med ligmnt 

w/tissuT005032.4101"$2,249.91".$449.99

24346Reconstruct elbow med 

ligmntT005287.5671"$6,078.91"."$1,215.79"

24357Repair elbow 

percT005032.4101"$2,249.91".$449.99

24358Repair elbow w/deb 

openT005032.4101"$2,249.91".$449.99

24359Repair elbow deb/attch 

openT005032.4101"$2,249.91".$449.99

24360Reconstruct elbow 

jointT004741.2971"$2,866.84".$573.37
24361Reconstruct elbow 

jointT0425130.4476"$9,055.67"."$1,811.14"

24362Reconstruct elbow 

jointT004860.0335"$4,167.53".$833.51

24363Replace elbow 

jointT0425130.4476"$9,055.67"."$1,811.14"

24365Reconstruct head of 

radiusT004741.2971"$2,866.84".$573.37

24366Reconstruct head of 

radiusT0425130.4476"$9,055.67"."$1,811.14"

24400Revision of 

humerusT005287.5671"$6,078.91"."$1,215.79"

24410Revision of 

humerusT005147.1841"$3,275.52".$655.11

24420Revision of 

humerusT005147.1841"$3,275.52".$655.11

24430Repair of 

humerusT005287.5671"$6,078.91"."$1,215.79"

24435Repair humerus with 

graftT005287.5671"$6,078.91"."$1,215.79"

24470Revision of elbow 

jointT005147.1841"$3,275.52".$655.11

24495Decompression of 

forearmT005032.4101"$2,249.91".$449.99

24498Reinforce 

humerusT005287.5671"$6,078.91"."$1,215.79"

24500Treat humerus 

fractureT01291.6063$111.51.$22.31

24505Treat humerus 

fractureT01291.6063$111.51.$22.31

24515Treat humerus 

fractureT006467.0623"$4,655.46".$931.10

24516Treat humerus 
fractureT006467.0623"$4,655.46".$931.10

24530Treat humerus 

fractureT01291.6063$111.51.$22.31

24535Treat humerus 

fractureT01384.9874$346.23.$69.25

24538Treat humerus 

fractureT006226.2376"$1,821.41"$371.33$364.29

24545Treat humerus 

fractureT006467.0623"$4,655.46".$931.10

24546Treat humerus 

fractureT006467.0623"$4,655.46".$931.10

24560Treat humerus 

fractureT01291.6063$111.51.$22.31

24565Treat humerus 

fractureT01291.6063$111.51.$22.31

24566Treat humerus 

fractureT006226.2376"$1,821.41"$371.33$364.29

24575Treat humerus 

fractureT006467.0623"$4,655.46".$931.10

24576Treat humerus 

fractureT01291.6063$111.51.$22.31

24577Treat humerus 

fractureT01291.6063$111.51.$22.31

24579Treat humerus 

fractureT006467.0623"$4,655.46".$931.10

24582Treat humerus 

fractureT006226.2376"$1,821.41"$371.33$364.29

24586Treat elbow 

fractureT006467.0623"$4,655.46".$931.10

24587Treat elbow 

fractureT006467.0623"$4,655.46".$931.10

24600Treat elbow 

dislocationT01291.6063$111.51.$22.31
24605Treat elbow 

dislocationT004515.5166"$1,077.16"$268.44$215.44

24615Treat elbow 

dislocationT006467.0623"$4,655.46".$931.10

24620Treat elbow 

fractureT013918.6922"$1,297.61".$259.53

24635Treat elbow 

fractureT006467.0623"$4,655.46".$931.10

24640Treat elbow 

dislocationT01291.6063$111.51.$22.31

24650Treat radius 

fractureT01291.6063$111.51.$22.31

24655Treat radius 

fractureT01384.9874$346.23.$69.25

24665Treat radius 

fractureT006349.4864"$3,435.35".$687.07

24666Treat radius 

fractureT006467.0623"$4,655.46".$931.10

24670Treat ulnar 

fractureT01291.6063$111.51.$22.31

24675Treat ulnar 

fractureT01291.6063$111.51.$22.31

24685Treat ulnar 

fractureT006349.4864"$3,435.35".$687.07

24800Fusion of elbow 

jointT005147.1841"$3,275.52".$655.11

24802Fusion/graft of elbow 

jointT005287.5671"$6,078.91"."$1,215.79"

24900Amputation of upper 

armC

24920Amputation of upper 

armC

24925Amputation follow-up 

surgeryT004922.1674"$1,538.86".$307.78
24930Amputation follow-up 

surgeryC

24931Amputate upper arm & 

implantC

24935Revision of 

amputationT005287.5671"$6,078.91"."$1,215.79"

24940Revision of upper 

armC

24999Upper arm/elbow 

surgeryT01291.6063$111.51.$22.31

25000Incision of tendon 

sheathT004922.1674"$1,538.86".$307.78

25001Incise flexor carpi 

radialisT004922.1674"$1,538.86".$307.78

25020Decompress forearm 1 

spaceT005032.4101"$2,249.91".$449.99

25023Decompress forearm 1 

spaceT005032.4101"$2,249.91".$449.99

25024Decompress forearm 2 

spacesT005032.4101"$2,249.91".$449.99

25025Decompress forearm 2 

spacesT005032.4101"$2,249.91".$449.99

25028Drainage of forearm 

lesionT004922.1674"$1,538.86".$307.78

25031Drainage of forearm 

bursaT004922.1674"$1,538.86".$307.78

25035Treat forearm bone 

lesionT004922.1674"$1,538.86".$307.78

25040Explore/treat wrist 

jointT005032.4101"$2,249.91".$449.99

25065Biopsy forearm soft 

tissuesT00208.6164$598.15.$119.63

25066Biopsy forearm soft 

tissuesT002223.4169"$1,625.60"$350.05$325.12
25071Exc forearm les sc > 3 

cmT002223.4169"$1,625.60"$350.05$325.12

25073Exc forearm tum deep 3+ 

cmT002223.4169"$1,625.60"$350.05$325.12

25075Exc forearm les sc < 3 

cmT002117.1909"$1,193.39".$238.68

25076Exc forearm tum deep < 3 

cmT002117.1909"$1,193.39".$238.68

25077Resect forearm/wrist 

tum<3cmT002117.1909"$1,193.39".$238.68

25078Resect forearm/wrist 

tum3+cmT002223.4169"$1,625.60"$350.05$325.12

25085Incision of wrist 

capsuleT004922.1674"$1,538.86".$307.78

25100Biopsy of wrist 

jointT004922.1674"$1,538.86".$307.78

25101Explore/treat wrist 

jointT005032.4101"$2,249.91".$449.99

25105Remove wrist joint 

liningT005032.4101"$2,249.91".$449.99

25107Remove wrist joint 

cartilageT005032.4101"$2,249.91".$449.99

25109Excise tendon 

forearm/wristT004922.1674"$1,538.86".$307.78

25110Remove wrist tendon 

lesionT004922.1674"$1,538.86".$307.78

25111Remove wrist tendon 

lesionT004922.1674"$1,538.86".$307.78

25112Reremove wrist tendon 

lesionT004922.1674"$1,538.86".$307.78

25115Remove wrist/forearm 

lesionT004922.1674"$1,538.86".$307.78

25116Remove wrist/forearm 

lesionT004922.1674"$1,538.86".$307.78
25118Excise wrist tendon 

sheathT005032.4101"$2,249.91".$449.99

25119Partial removal of 

ulnaT005032.4101"$2,249.91".$449.99

25120Removal of forearm 

lesionT005032.4101"$2,249.91".$449.99

25125Remove/graft forearm 

lesionT005032.4101"$2,249.91".$449.99

25126Remove/graft forearm 

lesionT005032.4101"$2,249.91".$449.99

25130Removal of wrist 

lesionT005032.4101"$2,249.91".$449.99

25135Remove & graft wrist 

lesionT005032.4101"$2,249.91".$449.99

25136Remove & graft wrist 

lesionT005032.4101"$2,249.91".$449.99

25145Remove forearm bone 

lesionT005032.4101"$2,249.91".$449.99

25150Partial removal of 

ulnaT005032.4101"$2,249.91".$449.99

25151Partial removal of 

radiusT005032.4101"$2,249.91".$449.99

25170Resect radius/ulnar tumorCH 

T005032.4101"$2,249.91".$449.99

25210Removal of wrist 

boneT005032.4101"$2,249.91".$449.99

25215Removal of wrist 

bonesT005032.4101"$2,249.91".$449.99

25230Partial removal of 

radiusT005032.4101"$2,249.91".$449.99

25240Partial removal of 

ulnaT005032.4101"$2,249.91".$449.99
25246Injection for wrist 

x-rayN

25248Remove forearm foreign 

bodyT004922.1674"$1,538.86".$307.78

25250Removal of wrist 

prosthesisT005032.4101"$2,249.91".$449.99

25251Removal of wrist 

prosthesisT005032.4101"$2,249.91".$449.99

25259Manipulate wrist 

w/anesthesT013918.6922"$1,297.61".$259.53

25260Repair forearm 

tendon/muscleT005032.4101"$2,249.91".$449.99

25263Repair forearm 

tendon/muscleT005032.4101"$2,249.91".$449.99

25265Repair forearm 

tendon/muscleT005032.4101"$2,249.91".$449.99

25270Repair forearm 

tendon/muscleT005032.4101"$2,249.91".$449.99

25272Repair forearm 

tendon/muscleT005032.4101"$2,249.91".$449.99

25274Repair forearm 

tendon/muscleT005032.4101"$2,249.91".$449.99

25275Repair forearm tendon 

sheathT005032.4101"$2,249.91".$449.99

25280Revise wrist/forearm 

tendonT005032.4101"$2,249.91".$449.99

25290Incise wrist/forearm 

tendonT005032.4101"$2,249.91".$449.99

25295Release wrist/forearm 

tendonT004922.1674"$1,538.86".$307.78

25300Fusion of tendons at 

wristT005032.4101"$2,249.91".$449.99

25301Fusion of tendons at 

wristT005032.4101"$2,249.91".$449.99
25310Transplant forearm tendonCH 

T005032.4101"$2,249.91".$449.99

25312Transplant forearm 

tendonT005147.1841"$3,275.52".$655.11

25315Revise palsy hand tendon(s)CH 

T005032.4101"$2,249.91".$449.99

25316Revise palsy hand 

tendon(s)T005287.5671"$6,078.91"."$1,215.79"

25320Repair/revise wrist 

jointT005147.1841"$3,275.52".$655.11

25332Revise wrist 

jointT004741.2971"$2,866.84".$573.37

25335Realignment of 

handT005147.1841"$3,275.52".$655.11

25337Reconstruct 

ulna/radioulnarT005147.1841"$3,275.52".$655.11

25350Revision of 

radiusT005147.1841"$3,275.52".$655.11

25355Revision of 

radiusT005147.1841"$3,275.52".$655.11

25360Revision of 

ulnaT005147.1841"$3,275.52".$655.11

25365Revise radius & 

ulnaT005287.5671"$6,078.91"."$1,215.79"

25370Revise radius or 

ulnaT005147.1841"$3,275.52".$655.11

25375Revise radius & 

ulnaT005147.1841"$3,275.52".$655.11

25390Shorten radius or 

ulnaT005147.1841"$3,275.52".$655.11

25391Lengthen radius or 

ulnaT005287.5671"$6,078.91"."$1,215.79"

25392Shorten radius & 
ulnaT005032.4101"$2,249.91".$449.99

25393Lengthen radius & 

ulnaT005147.1841"$3,275.52".$655.11

25394Repair carpal bone 

shortenT005147.1841"$3,275.52".$655.11

25400Repair radius or 

ulnaT005287.5671"$6,078.91"."$1,215.79"

25405Repair/graft radius or 

ulnaT005287.5671"$6,078.91"."$1,215.79"

25415Repair radius & 

ulnaT005287.5671"$6,078.91"."$1,215.79"

25420Repair/graft radius & 

ulnaT005287.5671"$6,078.91"."$1,215.79"

25425Repair/graft radius or 

ulnaT005287.5671"$6,078.91"."$1,215.79"

25426Repair/graft radius & 

ulnaT005147.1841"$3,275.52".$655.11

25430Vasc graft into carpal 

boneT005147.1841"$3,275.52".$655.11

25431Repair nonunion carpal 

boneT005147.1841"$3,275.52".$655.11

25440Repair/graft wrist 

boneT005287.5671"$6,078.91"."$1,215.79"

25441Reconstruct wrist 

jointT0425130.4476"$9,055.67"."$1,811.14"

25442Reconstruct wrist 

jointT0425130.4476"$9,055.67"."$1,811.14"

25443Reconstruct wrist 

jointT004860.0335"$4,167.53".$833.51

25444Reconstruct wrist 

jointT004860.0335"$4,167.53".$833.51

25445Reconstruct wrist 

jointT004860.0335"$4,167.53".$833.51
25446Wrist 

replacementT0425130.4476"$9,055.67"."$1,811.14"

25447Repair wrist 

joint(s)T004741.2971"$2,866.84".$573.37

25449Remove wrist joint 

implantT004741.2971"$2,866.84".$573.37

25450Revision of wrist 

jointT005147.1841"$3,275.52".$655.11

25455Revision of wrist 

jointT005147.1841"$3,275.52".$655.11

25490Reinforce 

radiusT005147.1841"$3,275.52".$655.11

25491Reinforce 

ulnaT005147.1841"$3,275.52".$655.11

25492Reinforce radius and 

ulnaT005147.1841"$3,275.52".$655.11

25500Treat fracture of 

radiusT01291.6063$111.51.$22.31

25505Treat fracture of 

radiusT01384.9874$346.23.$69.25

25515Treat fracture of 

radiusT006349.4864"$3,435.35".$687.07

25520Treat fracture of 

radiusT01384.9874$346.23.$69.25

25525Treat fracture of 

radiusT006349.4864"$3,435.35".$687.07

25526Treat fracture of 

radiusT006349.4864"$3,435.35".$687.07

25530Treat fracture of 

ulnaT01291.6063$111.51.$22.31

25535Treat fracture of 

ulnaT01291.6063$111.51.$22.31

25545Treat fracture of 
ulnaT006349.4864"$3,435.35".$687.07

25560Treat fracture radius & 

ulnaT01291.6063$111.51.$22.31

25565Treat fracture radius & 

ulnaT01384.9874$346.23.$69.25

25574Treat fracture radius & 

ulnaT006467.0623"$4,655.46".$931.10

25575Treat fracture 

radius/ulnaT006467.0623"$4,655.46".$931.10

25600Treat fracture 

radius/ulnaT01291.6063$111.51.$22.31

25605Treat fracture 

radius/ulnaT01384.9874$346.23.$69.25

25606Treat fx distal 

radialT006226.2376"$1,821.41"$371.33$364.29

25607Treat fx rad 

extra-articulT006467.0623"$4,655.46".$931.10

25608Treat fx rad 

intra-articulT006467.0623"$4,655.46".$931.10

25609Treat fx radial 3+ 

fragT006467.0623"$4,655.46".$931.10

25622Treat wrist bone 

fractureT01291.6063$111.51.$22.31

25624Treat wrist bone 

fractureT01384.9874$346.23.$69.25

25628Treat wrist bone 

fractureT006349.4864"$3,435.35".$687.07

25630Treat wrist bone 

fractureT01291.6063$111.51.$22.31

25635Treat wrist bone 

fractureT01291.6063$111.51.$22.31

25645Treat wrist bone 

fractureT006349.4864"$3,435.35".$687.07
25650Treat wrist bone 

fractureT01291.6063$111.51.$22.31

25651Pin ulnar styloid 

fractureT006226.2376"$1,821.41"$371.33$364.29

25652Treat fracture ulnar 

styloidT006349.4864"$3,435.35".$687.07

25660Treat wrist 

dislocationT01291.6063$111.51.$22.31

25670Treat wrist 

dislocationT006226.2376"$1,821.41"$371.33$364.29

25671Pin radioulnar 

dislocationT006226.2376"$1,821.41"$371.33$364.29

25675Treat wrist 

dislocationT01291.6063$111.51.$22.31

25676Treat wrist 

dislocationT006226.2376"$1,821.41"$371.33$364.29

25680Treat wrist 

fractureT01291.6063$111.51.$22.31

25685Treat wrist 

fractureT006226.2376"$1,821.41"$371.33$364.29

25690Treat wrist 

dislocationT013918.6922"$1,297.61".$259.53

25695Treat wrist 

dislocationT006226.2376"$1,821.41"$371.33$364.29

25800Fusion of wrist 

jointT005287.5671"$6,078.91"."$1,215.79"

25805Fusion/graft of wrist 

jointT005287.5671"$6,078.91"."$1,215.79"

25810Fusion/graft of wrist 

jointT005287.5671"$6,078.91"."$1,215.79"

25820Fusion of hand 

bonesT005147.1841"$3,275.52".$655.11

25825Fuse hand bones with 
graftT005287.5671"$6,078.91"."$1,215.79"

25830Fusion radioulnar 

jnt/ulnaT005287.5671"$6,078.91"."$1,215.79"

25900Amputation of 

forearmC

25905Amputation of 

forearmC

25907Amputation follow-up 

surgeryT004922.1674"$1,538.86".$307.78

25909Amputation follow-up 

surgeryT004922.1674"$1,538.86".$307.78

25915Amputation of 

forearmC

25920Amputate hand at 

wristC

25922Amputate hand at 

wristT004922.1674"$1,538.86".$307.78

25924Amputation follow-up 

surgeryC

25927Amputation of 

handC

25929Amputation follow-up 

surgeryT013617.2745"$1,199.20".$239.84

25931Amputation follow-up 

surgeryT004922.1674"$1,538.86".$307.78

25999Forearm or wrist 

surgeryT01291.6063$111.51.$22.31

26010Drainage of finger 

abscessT00061.4481$100.53.$20.11

26011Drainage of finger 

abscessT000713.4779$935.64.$187.13

26020Drain hand tendon 

sheathT005317.4096"$1,208.57"$253.49$241.72

26025Drainage of palm 

bursaT005317.4096"$1,208.57"$253.49$241.72

26030Drainage of palm 
bursa(s)T005317.4096"$1,208.57"$253.49$241.72

26034Treat hand bone 

lesionT005317.4096"$1,208.57"$253.49$241.72

26035Decompress 

fingers/handT005317.4096"$1,208.57"$253.49$241.72

26037Decompress 

fingers/handT005317.4096"$1,208.57"$253.49$241.72

26040Release palm 

contractureT005317.4096"$1,208.57"$253.49$241.72

26045Release palm 

contractureT005429.0181"$2,014.44".$402.89

26055Incise finger tendon 

sheathT005317.4096"$1,208.57"$253.49$241.72

26060Incision of finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26070Explore/treat hand 

jointT005317.4096"$1,208.57"$253.49$241.72

26075Explore/treat finger 

jointT005317.4096"$1,208.57"$253.49$241.72

26080Explore/treat finger 

jointT005317.4096"$1,208.57"$253.49$241.72

26100Biopsy hand joint 

liningT005317.4096"$1,208.57"$253.49$241.72

26105Biopsy finger joint 

liningT005317.4096"$1,208.57"$253.49$241.72

26110Biopsy finger joint 

liningT005317.4096"$1,208.57"$253.49$241.72

26111Exc hand les sc > 1.5 

cmT002223.4169"$1,625.60"$350.05$325.12

26113Exc hand tum deep > 1.5 

cmT002223.4169"$1,625.60"$350.05$325.12

26115Exc hand les sc < 1.5 

cmT002117.1909"$1,193.39".$238.68
26116Exc hand tum deep < 1.5 

cmT002117.1909"$1,193.39".$238.68

26117Exc hand tum ra < 3 

cmT002117.1909"$1,193.39".$238.68

26118Exc hand tum ra > 3 

cmT002223.4169"$1,625.60"$350.05$325.12

26121Release palm 

contractureT005429.0181"$2,014.44".$402.89

26123Release palm 

contractureT005429.0181"$2,014.44".$402.89

26125Release palm 

contractureT005317.4096"$1,208.57"$253.49$241.72

26130Remove wrist joint 

liningT005317.4096"$1,208.57"$253.49$241.72

26135Revise finger joint 

eachT005429.0181"$2,014.44".$402.89

26140Revise finger joint 

eachT005317.4096"$1,208.57"$253.49$241.72

26145Tendon excision 

palm/fingerT005317.4096"$1,208.57"$253.49$241.72

26160Remove tendon sheath 

lesionT005317.4096"$1,208.57"$253.49$241.72

26170Removal of palm tendon 

eachT005317.4096"$1,208.57"$253.49$241.72

26180Removal of finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26185Remove finger 

boneT005317.4096"$1,208.57"$253.49$241.72

26200Remove hand bone 

lesionT005317.4096"$1,208.57"$253.49$241.72

26205Remove/graft bone 

lesionT005429.0181"$2,014.44".$402.89

26210Removal of finger 
lesionT005317.4096"$1,208.57"$253.49$241.72

26215Remove/graft finger 

lesionT005317.4096"$1,208.57"$253.49$241.72

26230Partial removal of hand 

boneT005317.4096"$1,208.57"$253.49$241.72

26235Partial removal finger 

boneT005317.4096"$1,208.57"$253.49$241.72

26236Partial removal finger 

boneT005317.4096"$1,208.57"$253.49$241.72

26250Extensive hand 

surgeryT005317.4096"$1,208.57"$253.49$241.72

26260Resect prox finger 

tumorT005317.4096"$1,208.57"$253.49$241.72

26262Resect distal finger 

tumorT005317.4096"$1,208.57"$253.49$241.72

26320Removal of implant from 

handT002117.1909"$1,193.39".$238.68

26340Manipulate finger 

w/anesthT01384.9874$346.23.$69.25

26350Repair finger/hand 

tendonT005429.0181"$2,014.44".$402.89

26352Repair/graft hand 

tendonT005429.0181"$2,014.44".$402.89

26356Repair finger/hand 

tendonT005429.0181"$2,014.44".$402.89

26357Repair finger/hand 

tendonT005429.0181"$2,014.44".$402.89

26358Repair/graft hand 

tendonT005429.0181"$2,014.44".$402.89

26370Repair finger/hand 

tendonT005429.0181"$2,014.44".$402.89

26372Repair/graft hand 

tendonT005429.0181"$2,014.44".$402.89
26373Repair finger/hand 

tendonT005429.0181"$2,014.44".$402.89

26390Revise hand/finger 

tendonT005429.0181"$2,014.44".$402.89

26392Repair/graft hand 

tendonT005429.0181"$2,014.44".$402.89

26410Repair hand 

tendonT005317.4096"$1,208.57"$253.49$241.72

26412Repair/graft hand 

tendonT005429.0181"$2,014.44".$402.89

26415Excision hand/finger 

tendonT005429.0181"$2,014.44".$402.89

26416Graft hand or finger 

tendonT005429.0181"$2,014.44".$402.89

26418Repair finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26420Repair/graft finger 

tendonT005429.0181"$2,014.44".$402.89

26426Repair finger/hand 

tendonT005429.0181"$2,014.44".$402.89

26428Repair/graft finger 

tendonT005429.0181"$2,014.44".$402.89

26432Repair finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26433Repair finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26434Repair/graft finger 

tendonT005429.0181"$2,014.44".$402.89

26437Realignment of 

tendonsT005317.4096"$1,208.57"$253.49$241.72

26440Release palm/finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26442Release palm & finger 
tendonT005429.0181"$2,014.44".$402.89

26445Release hand/finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26449Release forearm/hand 

tendonT005429.0181"$2,014.44".$402.89

26450Incision of palm 

tendonT005317.4096"$1,208.57"$253.49$241.72

26455Incision of finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26460Incise hand/finger 

tendonT005317.4096"$1,208.57"$253.49$241.72

26471Fusion of finger 

tendonsT005317.4096"$1,208.57"$253.49$241.72

26474Fusion of finger 

tendonsT005317.4096"$1,208.57"$253.49$241.72

26476Tendon 

lengtheningT005317.4096"$1,208.57"$253.49$241.72

26477Tendon 

shorteningT005317.4096"$1,208.57"$253.49$241.72

26478Lengthening of hand 

tendonT005317.4096"$1,208.57"$253.49$241.72

26479Shortening of hand 

tendonT005317.4096"$1,208.57"$253.49$241.72

26480Transplant hand 

tendonT005429.0181"$2,014.44".$402.89

26483Transplant/graft hand 

tendonT005429.0181"$2,014.44".$402.89

26485Transplant palm 

tendonT005429.0181"$2,014.44".$402.89

26489Transplant/graft palm 

tendonT005429.0181"$2,014.44".$402.89

26490Revise thumb 

tendonT005429.0181"$2,014.44".$402.89
26492Tendon transfer with 

graftT005429.0181"$2,014.44".$402.89

26494Hand tendon/muscle 

transferT005429.0181"$2,014.44".$402.89

26496Revise thumb 

tendonT005429.0181"$2,014.44".$402.89

26497Finger tendon 

transferT005429.0181"$2,014.44".$402.89

26498Finger tendon 

transferT005429.0181"$2,014.44".$402.89

26499Revision of 

fingerT005429.0181"$2,014.44".$402.89

26500Hand tendon 

reconstructionT005317.4096"$1,208.57"$253.49$241.72

26502Hand tendon 

reconstructionT005429.0181"$2,014.44".$402.89

26508Release thumb 

contractureT005317.4096"$1,208.57"$253.49$241.72

26510Thumb tendon 

transferT005429.0181"$2,014.44".$402.89

26516Fusion of knuckle 

jointT005429.0181"$2,014.44".$402.89

26517Fusion of knuckle 

jointsT005429.0181"$2,014.44".$402.89

26518Fusion of knuckle 

jointsT005429.0181"$2,014.44".$402.89

26520Release knuckle 

contractureT005317.4096"$1,208.57"$253.49$241.72

26525Release finger 

contractureT005317.4096"$1,208.57"$253.49$241.72

26530Revise knuckle 

jointT004741.2971"$2,866.84".$573.37

26531Revise knuckle with 
implantT004860.0335"$4,167.53".$833.51

26535Revise finger 

jointT004741.2971"$2,866.84".$573.37

26536Revise/implant finger 

jointT004860.0335"$4,167.53".$833.51

26540Repair hand 

jointT005317.4096"$1,208.57"$253.49$241.72

26541Repair hand joint with 

graftT005429.0181"$2,014.44".$402.89

26542Repair hand joint with 

graftT005317.4096"$1,208.57"$253.49$241.72

26545Reconstruct finger 

jointT005429.0181"$2,014.44".$402.89

26546Repair nonunion 

handT005429.0181"$2,014.44".$402.89

26548Reconstruct finger 

jointT005429.0181"$2,014.44".$402.89

26550Construct thumb 

replacementT005429.0181"$2,014.44".$402.89

26551Great toe-hand 

transferC

26553Single transfer 

toe-handC

26554Double transfer 

toe-handC

26555Positional change of 

fingerT005429.0181"$2,014.44".$402.89

26556Toe joint 

transferC

26560Repair of web 

fingerT005317.4096"$1,208.57"$253.49$241.72

26561Repair of web 

fingerT005429.0181"$2,014.44".$402.89

26562Repair of web 

fingerT005429.0181"$2,014.44".$402.89
26565Correct metacarpal 

flawT005429.0181"$2,014.44".$402.89

26567Correct finger 

deformityT005429.0181"$2,014.44".$402.89

26568Lengthen 

metacarpal/fingerT005429.0181"$2,014.44".$402.89

26580Repair hand 

deformityT005317.4096"$1,208.57"$253.49$241.72

26587Reconstruct extra 

fingerT005317.4096"$1,208.57"$253.49$241.72

26590Repair finger 

deformityT005317.4096"$1,208.57"$253.49$241.72

26591Repair muscles of 

handT005429.0181"$2,014.44".$402.89

26593Release muscles of 

handT005317.4096"$1,208.57"$253.49$241.72

26596Excision constricting 

tissueT005317.4096"$1,208.57"$253.49$241.72

26600Treat metacarpal 

fractureT01291.6063$111.51.$22.31

26605Treat metacarpal 

fractureT01291.6063$111.51.$22.31

26607Treat metacarpal 

fractureT013918.6922"$1,297.61".$259.53

26608Treat metacarpal 

fractureT006226.2376"$1,821.41"$371.33$364.29

26615Treat metacarpal 

fractureT006349.4864"$3,435.35".$687.07

26641Treat thumb 

dislocationT01291.6063$111.51.$22.31

26645Treat thumb 

fractureT01384.9874$346.23.$69.25

26650Treat thumb 
fractureT006226.2376"$1,821.41"$371.33$364.29

26665Treat thumb 

fractureT006349.4864"$3,435.35".$687.07

26670Treat hand 

dislocationT01291.6063$111.51.$22.31

26675Treat hand 

dislocationT01291.6063$111.51.$22.31

26676Pin hand 

dislocationT006226.2376"$1,821.41"$371.33$364.29

26685Treat hand 

dislocationT006226.2376"$1,821.41"$371.33$364.29

26686Treat hand 

dislocationT006467.0623"$4,655.46".$931.10

26700Treat knuckle 

dislocationT01291.6063$111.51.$22.31

26705Treat knuckle 

dislocationT01291.6063$111.51.$22.31

26706Pin knuckle 

dislocationT013918.6922"$1,297.61".$259.53

26715Treat knuckle 

dislocationT006226.2376"$1,821.41"$371.33$364.29

26720Treat finger fracture 

eachT01291.6063$111.51.$22.31

26725Treat finger fracture 

eachT01291.6063$111.51.$22.31

26727Treat finger fracture 

eachT006226.2376"$1,821.41"$371.33$364.29

26735Treat finger fracture 

eachT006226.2376"$1,821.41"$371.33$364.29

26740Treat finger fracture 

eachT01291.6063$111.51.$22.31

26742Treat finger fracture 

eachT01291.6063$111.51.$22.31
26746Treat finger fracture 

eachT006226.2376"$1,821.41"$371.33$364.29

26750Treat finger fracture 

eachT01291.6063$111.51.$22.31

26755Treat finger fracture 

eachT01291.6063$111.51.$22.31

26756Pin finger fracture 

eachT006226.2376"$1,821.41"$371.33$364.29

26765Treat finger fracture 

eachT006226.2376"$1,821.41"$371.33$364.29

26770Treat finger 

dislocationT01291.6063$111.51.$22.31

26775Treat finger 

dislocationT004515.5166"$1,077.16"$268.44$215.44

26776Pin finger 

dislocationT006226.2376"$1,821.41"$371.33$364.29

26785Treat finger 

dislocationT006226.2376"$1,821.41"$371.33$364.29

26820Thumb fusion with 

graftT005429.0181"$2,014.44".$402.89

26841Fusion of 

thumbT005429.0181"$2,014.44".$402.89

26842Thumb fusion with 

graftT005429.0181"$2,014.44".$402.89

26843Fusion of hand 

jointT005429.0181"$2,014.44".$402.89

26844Fusion/graft of hand 

jointT005429.0181"$2,014.44".$402.89

26850Fusion of 

knuckleT005429.0181"$2,014.44".$402.89

26852Fusion of knuckle with 

graftT005429.0181"$2,014.44".$402.89

26860Fusion of finger 
jointT005429.0181"$2,014.44".$402.89

26861Fusion of finger jnt 

add-onT005429.0181"$2,014.44".$402.89

26862Fusion/graft of finger 

jointT005429.0181"$2,014.44".$402.89

26863Fuse/graft added 

jointT005429.0181"$2,014.44".$402.89

26910Amputate metacarpal 

boneT005429.0181"$2,014.44".$402.89

26951Amputation of 

finger/thumbT005317.4096"$1,208.57"$253.49$241.72

26952Amputation of 

finger/thumbT005317.4096"$1,208.57"$253.49$241.72

26989Hand/finger 

surgeryT01291.6063$111.51.$22.31

26990Drainage of pelvis 

lesionT004922.1674"$1,538.86".$307.78

26991Drainage of pelvis 

bursaT004922.1674"$1,538.86".$307.78

26992Drainage of bone 

lesionC

27000Incision of hip 

tendonT004922.1674"$1,538.86".$307.78

27001Incision of hip 

tendonT005032.4101"$2,249.91".$449.99

27003Incision of hip 

tendonT005032.4101"$2,249.91".$449.99

27005Incision of hip 

tendonC

27006Incision of hip 

tendonsT005032.4101"$2,249.91".$449.99

27025Incision of hip/thigh 

fasciaC

27027Buttock fasciotomyCH 

T005032.4101"$2,249.91".$449.99
27030Drainage of hip 

jointC

27033Exploration of hip 

jointT005147.1841"$3,275.52".$655.11

27035Denervation of hip jointCH 

T005032.4101"$2,249.91".$449.99

27036Excision of hip 

joint/muscleC

27040Biopsy of soft 

tissuesT00208.6164$598.15.$119.63

27041Biopsy of soft 

tissuesT00208.6164$598.15.$119.63

27043Exc hip pelvis les sc > 3 

cmT002223.4169"$1,625.60"$350.05$325.12

27045Exc hip/pelv tum deep > 5 

cmT002223.4169"$1,625.60"$350.05$325.12

27047Exc hip/pelvis les sc < 3 

cmT002117.1909"$1,193.39".$238.68

27048Exc hip/pelv tum deep < 5 

cmT002117.1909"$1,193.39".$238.68

27049Resect hip/pelv tum < 5 

cmT002117.1909"$1,193.39".$238.68

27050Biopsy of sacroiliac 

jointT004922.1674"$1,538.86".$307.78

27052Biopsy of hip 

jointT004922.1674"$1,538.86".$307.78

27054Removal of hip joint 

liningC

27057Buttock fasciotomy 

w/dbrdmtT004922.1674"$1,538.86".$307.78

27059Resect hip/pelv tum > 5 

cmT002223.4169"$1,625.60"$350.05$325.12

27060Removal of ischial 

bursaT004922.1674"$1,538.86".$307.78
27062Remove femur 

lesion/bursaT004922.1674"$1,538.86".$307.78

27065Remove hip bone les 

superT004922.1674"$1,538.86".$307.78

27066Remove hip bone les 

deepT005032.4101"$2,249.91".$449.99

27067Remove/graft hip bone 

lesionT005032.4101"$2,249.91".$449.99

27070Part remove hip bone 

superC

27071Part removal hip bone 

deepC

27075Resect hip 

tumorC

27076Resect hip tum incl 

acetabulC

27077Resect hip tum w/innom 

boneC

27078Rsect hip tum incl 

femurC

27080Removal of tail 

boneT005032.4101"$2,249.91".$449.99

27086Remove hip foreign 

bodyT00208.6164$598.15.$119.63

27087Remove hip foreign 

bodyT004922.1674"$1,538.86".$307.78

27090Removal of hip 

prosthesisC

27091Removal of hip 

prosthesisC

27093Injection for hip 

x-rayN

27095Injection for hip 

x-rayN

27096Inject sacroiliac 

jointB

27097Revision of hip 

tendonT005032.4101"$2,249.91".$449.99
27098Transfer tendon to 

pelvisT005032.4101"$2,249.91".$449.99

27100Transfer of abdominal 

muscleT005147.1841"$3,275.52".$655.11

27105Transfer of spinal 

muscleT005147.1841"$3,275.52".$655.11

27110Transfer of iliopsoas 

muscleT005147.1841"$3,275.52".$655.11

27111Transfer of iliopsoas 

muscleT005147.1841"$3,275.52".$655.11

27120Reconstruction of hip 

socketC

27122Reconstruction of hip 

socketC

27125Partial hip 

replacementC

27130Total hip 

arthroplastyC

27132Total hip 

arthroplastyC

27134Revise hip joint 

replacementC

27137Revise hip joint 

replacementC

27138Revise hip joint 

replacementC

27140Transplant femur 

ridgeC

27146Incision of hip 

boneC

27147Revision of hip 

boneC

27151Incision of hip 

bonesC

27156Revision of hip 

bonesC

27158Revision of 

pelvisC

27161Incision of neck of 

femurC

27165Incision/fixation of 
femurC

27170Repair/graft femur 

head/neckC

27175Treat slipped 

epiphysisC

27176Treat slipped 

epiphysisC

27177Treat slipped 

epiphysisC

27178Treat slipped 

epiphysisC

27179Revise head/neck of 

femurT005287.5671"$6,078.91"."$1,215.79"

27181Treat slipped 

epiphysisC

27185Revision of femur 

epiphysisC

27187Reinforce hip 

bonesC

27193Treat pelvic ring 

fractureT01291.6063$111.51.$22.31

27194Treat pelvic ring 

fractureT004515.5166"$1,077.16"$268.44$215.44

27200Treat tail bone 

fractureT01291.6063$111.51.$22.31

27202Treat tail bone 

fractureT006349.4864"$3,435.35".$687.07

27215Treat pelvic 

fracture(s)E

27216Treat pelvic ring 

fractureE

27217Treat pelvic ring 

fractureE

27218Treat pelvic ring 

fractureE

27220Treat hip socket 

fractureT01291.6063$111.51.$22.31

27222Treat hip socket 

fractureC

27226Treat hip wall 
fractureC

27227Treat hip 

fracture(s)C

27228Treat hip 

fracture(s)C

27230Treat thigh 

fractureT01291.6063$111.51.$22.31

27232Treat thigh 

fractureC

27235Treat thigh 

fractureT005032.4101"$2,249.91".$449.99

27236Treat thigh 

fractureC

27238Treat thigh 

fractureT01384.9874$346.23.$69.25

27240Treat thigh 

fractureC

27244Treat thigh 

fractureC

27245Treat thigh 

fractureC

27246Treat thigh 

fractureT01384.9874$346.23.$69.25

27248Treat thigh 

fractureC

27250Treat hip 

dislocationT01291.6063$111.51.$22.31

27252Treat hip 

dislocationT004515.5166"$1,077.16"$268.44$215.44

27253Treat hip 

dislocationC

27254Treat hip 

dislocationC

27256Treat hip 

dislocationT01291.6063$111.51.$22.31

27257Treat hip 

dislocationT004515.5166"$1,077.16"$268.44$215.44

27258Treat hip 

dislocationC
27259Treat hip 

dislocationC

27265Treat hip 

dislocationT01291.6063$111.51.$22.31

27266Treat hip 

dislocationT004515.5166"$1,077.16"$268.44$215.44

27267Cltx thigh 

fxT01291.6063$111.51.$22.31

27268Cltx thigh fx 

w/mnpjC

27269Optx thigh 

fxC

27275Manipulation of hip 

jointT004515.5166"$1,077.16"$268.44$215.44

27280Fusion of sacroiliac 

jointC

27282Fusion of pubic 

bonesC

27284Fusion of hip 

jointC

27286Fusion of hip 

jointC

27290Amputation of leg at 

hipC

27295Amputation of leg at 

hipC

27299Pelvis/hip joint 

surgeryT01291.6063$111.51.$22.31

27301Drain thigh/knee 

lesionT000820.5401"$1,425.89".$285.18

27303Drainage of bone 

lesionC

27305Incise thigh tendon & 

fasciaT004922.1674"$1,538.86".$307.78

27306Incision of thigh 

tendonT004922.1674"$1,538.86".$307.78

27307Incision of thigh tendonsCH 

T005032.4101"$2,249.91".$449.99
27310Exploration of knee 

jointT005032.4101"$2,249.91".$449.99

27323Biopsy thigh soft 

tissuesT00208.6164$598.15.$119.63

27324Biopsy thigh soft 

tissuesT002223.4169"$1,625.60"$350.05$325.12

27325Neurectomy 

hamstringT022019.0626"$1,323.33".$264.67

27326Neurectomy 

poplitealT022019.0626"$1,323.33".$264.67

27327Exc thigh/knee les sc < 3 

cmT002223.4169"$1,625.60"$350.05$325.12

27328Exc thigh/knee tum deep 

<5cmT002117.1909"$1,193.39".$238.68

27329Resect thigh/knee tum < 5 

cmT002117.1909"$1,193.39".$238.68

27330Biopsy knee joint 

liningT005032.4101"$2,249.91".$449.99

27331Explore/treat knee 

jointT005032.4101"$2,249.91".$449.99

27332Removal of knee 

cartilageT005032.4101"$2,249.91".$449.99

27333Removal of knee 

cartilageT005032.4101"$2,249.91".$449.99

27334Remove knee joint 

liningT005032.4101"$2,249.91".$449.99

27335Remove knee joint 

liningT005032.4101"$2,249.91".$449.99

27337Exc thigh/knee les sc 3+ 

cmT002223.4169"$1,625.60"$350.05$325.12

27339Exc thigh/knee tum deep 

5+cmT002223.4169"$1,625.60"$350.05$325.12

27340Removal of kneecap 
bursaT004922.1674"$1,538.86".$307.78

27345Removal of knee 

cystT004922.1674"$1,538.86".$307.78

27347Remove knee 

cystT004922.1674"$1,538.86".$307.78

27350Removal of 

kneecapT005032.4101"$2,249.91".$449.99

27355Remove femur 

lesionT005032.4101"$2,249.91".$449.99

27356Remove femur 

lesion/graftT005032.4101"$2,249.91".$449.99

27357Remove femur 

lesion/graftT005032.4101"$2,249.91".$449.99

27358Remove femur 

lesion/fixationT005032.4101"$2,249.91".$449.99

27360Partial removal leg 

bone(s)T005032.4101"$2,249.91".$449.99

27364Resect thigh/knee tum 5+ 

cmT002223.4169"$1,625.60"$350.05$325.12

27365Resect femur/knee 

tumorC

27370Injection for knee 

x-rayN

27372Removal of foreign 

bodyT002223.4169"$1,625.60"$350.05$325.12

27380Repair of kneecap tendonCH 

T005032.4101"$2,249.91".$449.99

27381Repair/graft kneecap tendonCH 

T005032.4101"$2,249.91".$449.99

27385Repair of thigh muscleCH 

T005032.4101"$2,249.91".$449.99

27386Repair/graft of thigh muscleCH 

T005032.4101"$2,249.91".$449.99

27390Incision of thigh 
tendonT004922.1674"$1,538.86".$307.78

27391Incision of thigh 

tendonsT004922.1674"$1,538.86".$307.78

27392Incision of thigh tendonsCH 

T005032.4101"$2,249.91".$449.99

27393Lengthening of thigh 

tendonT005032.4101"$2,249.91".$449.99

27394Lengthening of thigh 

tendonsT005032.4101"$2,249.91".$449.99

27395Lengthening of thigh 

tendonsT005147.1841"$3,275.52".$655.11

27396Transplant of thigh 

tendonT005032.4101"$2,249.91".$449.99

27397Transplants of thigh 

tendonsT005147.1841"$3,275.52".$655.11

27400Revise thigh 

muscles/tendonsT005147.1841"$3,275.52".$655.11

27403Repair of knee 

cartilageT005032.4101"$2,249.91".$449.99

27405Repair of knee 

ligamentT005147.1841"$3,275.52".$655.11

27407Repair of knee 

ligamentT005287.5671"$6,078.91"."$1,215.79"

27409Repair of knee 

ligamentsT005287.5671"$6,078.91"."$1,215.79"

27412Autochondrocyte implant 

kneeT005287.5671"$6,078.91"."$1,215.79"

27415Osteochondral knee 

allograftT005287.5671"$6,078.91"."$1,215.79"

27416Osteochondral knee 

autograftT005147.1841"$3,275.52".$655.11

27418Repair degenerated 

kneecapT005147.1841"$3,275.52".$655.11
27420Revision of unstable 

kneecapT005147.1841"$3,275.52".$655.11

27422Revision of unstable 

kneecapT005147.1841"$3,275.52".$655.11

27424Revision/removal of 

kneecapT005147.1841"$3,275.52".$655.11

27425Lat retinacular release 

openT005032.4101"$2,249.91".$449.99

27427Reconstruction 

kneeT005287.5671"$6,078.91"."$1,215.79"

27428Reconstruction 

kneeT005287.5671"$6,078.91"."$1,215.79"

27429Reconstruction 

kneeT005287.5671"$6,078.91"."$1,215.79"

27430Revision of thigh 

musclesT005147.1841"$3,275.52".$655.11

27435Incision of knee jointCH 

T005032.4101"$2,249.91".$449.99

27437Revise 

kneecapT004741.2971"$2,866.84".$573.37

27438Revise kneecap with 

implantT004860.0335"$4,167.53".$833.51

27440Revision of knee 

jointT004741.2971"$2,866.84".$573.37

27441Revision of knee 

jointT004741.2971"$2,866.84".$573.37

27442Revision of knee 

jointT004741.2971"$2,866.84".$573.37

27443Revision of knee 

jointT004741.2971"$2,866.84".$573.37

27445Revision of knee 

jointC

27446Revision of knee 

jointT0425130.4476"$9,055.67"."$1,811.14"
27447Total knee 

arthroplastyC

27448Incision of 

thighC

27450Incision of 

thighC

27454Realignment of thigh 

boneC

27455Realignment of 

kneeC

27457Realignment of 

kneeC

27465Shortening of thigh 

boneC

27466Lengthening of thigh 

boneC

27468Shorten/lengthen 

thighsC

27470Repair of 

thighC

27472Repair/graft of 

thighC

27475Surgery to stop leg 

growthT005032.4101"$2,249.91".$449.99

27477Surgery to stop leg 

growthC

27479Surgery to stop leg 

growthT005032.4101"$2,249.91".$449.99

27485Surgery to stop leg 

growthC

27486Revise/replace knee 

jointC

27487Revise/replace knee 

jointC

27488Removal of knee 

prosthesisC

27495Reinforce 

thighC

27496Decompression of 

thigh/kneeT005032.4101"$2,249.91".$449.99

27497Decompression of 
thigh/kneeT004922.1674"$1,538.86".$307.78

27498Decompression of 

thigh/kneeT005032.4101"$2,249.91".$449.99

27499Decompression of 

thigh/kneeT005032.4101"$2,249.91".$449.99

27500Treatment of thigh 

fractureT01384.9874$346.23.$69.25

27501Treatment of thigh 

fractureT01291.6063$111.51.$22.31

27502Treatment of thigh 

fractureT013918.6922"$1,297.61".$259.53

27503Treatment of thigh 

fractureT01291.6063$111.51.$22.31

27506Treatment of thigh 

fractureC

27507Treatment of thigh 

fractureC

27508Treatment of thigh 

fractureT01291.6063$111.51.$22.31

27509Treatment of thigh 

fractureT006226.2376"$1,821.41"$371.33$364.29

27510Treatment of thigh 

fractureT01384.9874$346.23.$69.25

27511Treatment of thigh 

fractureC

27513Treatment of thigh 

fractureC

27514Treatment of thigh 

fractureC

27516Treat thigh fx growth 

plateT01291.6063$111.51.$22.31

27517Treat thigh fx growth 

plateT01291.6063$111.51.$22.31

27519Treat thigh fx growth 

plateC

27520Treat kneecap 
fractureT01291.6063$111.51.$22.31

27524Treat kneecap 

fractureT006349.4864"$3,435.35".$687.07

27530Treat knee 

fractureT01291.6063$111.51.$22.31

27532Treat knee 

fractureT013918.6922"$1,297.61".$259.53

27535Treat knee 

fractureC

27536Treat knee 

fractureC

27538Treat knee 

fracture(s)T01291.6063$111.51.$22.31

27540Treat knee 

fractureC

27550Treat knee 

dislocationT01291.6063$111.51.$22.31

27552Treat knee 

dislocationT004515.5166"$1,077.16"$268.44$215.44

27556Treat knee 

dislocationC

27557Treat knee 

dislocationC

27558Treat knee 

dislocationC

27560Treat kneecap 

dislocationT01291.6063$111.51.$22.31

27562Treat kneecap 

dislocationT004515.5166"$1,077.16"$268.44$215.44

27566Treat kneecap 

dislocationT006349.4864"$3,435.35".$687.07

27570Fixation of knee 

jointT004515.5166"$1,077.16"$268.44$215.44

27580Fusion of 

kneeC

27590Amputate leg at 

thighC
27591Amputate leg at 

thighC

27592Amputate leg at 

thighC

27594Amputation follow-up 

surgeryT004922.1674"$1,538.86".$307.78

27596Amputation follow-up 

surgeryC

27598Amputate lower leg at 

kneeC

27599Leg surgery 

procedureT01291.6063$111.51.$22.31

27600Decompression of lower 

legT004922.1674"$1,538.86".$307.78

27601Decompression of lower 

legT004922.1674"$1,538.86".$307.78

27602Decompression of lower legCH 

T005032.4101"$2,249.91".$449.99

27603Drain lower leg 

lesionT000820.5401"$1,425.89".$285.18

27604Drain lower leg bursaCH 

T005032.4101"$2,249.91".$449.99

27605Incision of achilles 

tendonT005522.1739"$1,539.31"$351.47$307.87

27606Incision of achilles 

tendonT004922.1674"$1,538.86".$307.78

27607Treat lower leg bone 

lesionT004922.1674"$1,538.86".$307.78

27610Explore/treat ankle 

jointT005032.4101"$2,249.91".$449.99

27612Exploration of ankle 

jointT005032.4101"$2,249.91".$449.99

27613Biopsy lower leg soft 

tissueT00208.6164$598.15.$119.63

27614Biopsy lower leg soft 
tissueT002223.4169"$1,625.60"$350.05$325.12

27615Resect leg/ankle tum < 5 

cmT002117.1909"$1,193.39".$238.68

27616Resect leg/ankle tum 5+ 

cmT002223.4169"$1,625.60"$350.05$325.12

27618Exc leg/ankle tum < 3 

cmT002117.1909"$1,193.39".$238.68

27619Exc leg/ankle tum deep <5 

cmT002117.1909"$1,193.39".$238.68

27620Explore/treat ankle 

jointT005032.4101"$2,249.91".$449.99

27625Remove ankle joint 

liningT005032.4101"$2,249.91".$449.99

27626Remove ankle joint 

liningT005032.4101"$2,249.91".$449.99

27630Removal of tendon 

lesionT004922.1674"$1,538.86".$307.78

27632Exc leg/ankle les sc 3+ 

cmT002223.4169"$1,625.60"$350.05$325.12

27634Exc leg/ankle tum deep 5+ 

cmT002223.4169"$1,625.60"$350.05$325.12

27635Remove lower leg bone 

lesionT005032.4101"$2,249.91".$449.99

27637Remove/graft leg bone 

lesionT005032.4101"$2,249.91".$449.99

27638Remove/graft leg bone 

lesionT005032.4101"$2,249.91".$449.99

27640Partial removal of tibiaCH 

T005032.4101"$2,249.91".$449.99

27641Partial removal of 

fibulaT005032.4101"$2,249.91".$449.99

27645Resect tibia 

tumorC
27646Resect fibula 

tumorC

27647Resect talus/calcaneus tumCH 

T005032.4101"$2,249.91".$449.99

27648Injection for ankle 

x-rayN

27650Repair achilles 

tendonT005147.1841"$3,275.52".$655.11

27652Repair/graft achilles 

tendonT005287.5671"$6,078.91"."$1,215.79"

27654Repair of achilles 

tendonT005147.1841"$3,275.52".$655.11

27656Repair leg fascia 

defectT004922.1674"$1,538.86".$307.78

27658Repair of leg tendon 

eachT004922.1674"$1,538.86".$307.78

27659Repair of leg tendon 

eachT004922.1674"$1,538.86".$307.78

27664Repair of leg tendon 

eachT005032.4101"$2,249.91".$449.99

27665Repair of leg tendon 

eachT005032.4101"$2,249.91".$449.99

27675Repair lower leg 

tendonsT004922.1674"$1,538.86".$307.78

27676Repair lower leg 

tendonsT005032.4101"$2,249.91".$449.99

27680Release of lower leg 

tendonT005032.4101"$2,249.91".$449.99

27681Release of lower leg 

tendonsT005032.4101"$2,249.91".$449.99

27685Revision of lower leg 

tendonT005032.4101"$2,249.91".$449.99

27686Revise lower leg 

tendonsT005032.4101"$2,249.91".$449.99
27687Revision of calf 

tendonT005032.4101"$2,249.91".$449.99

27690Revise lower leg 

tendonT005147.1841"$3,275.52".$655.11

27691Revise lower leg 

tendonT005147.1841"$3,275.52".$655.11

27692Revise additional leg 

tendonT005147.1841"$3,275.52".$655.11

27695Repair of ankle 

ligamentT005032.4101"$2,249.91".$449.99

27696Repair of ankle 

ligamentsT005032.4101"$2,249.91".$449.99

27698Repair of ankle 

ligamentT005032.4101"$2,249.91".$449.99

27700Revision of ankle 

jointT004741.2971"$2,866.84".$573.37

27702Reconstruct ankle 

jointC

27703Reconstruction ankle 

jointC

27704Removal of ankle 

implantT004922.1674"$1,538.86".$307.78

27705Incision of 

tibiaT005147.1841"$3,275.52".$655.11

27707Incision of fibulaCH 

T005032.4101"$2,249.91".$449.99

27709Incision of tibia & 

fibulaT005032.4101"$2,249.91".$449.99

27712Realignment of lower 

legC

27715Revision of lower 

legC

27720Repair of 

tibiaT006349.4864"$3,435.35".$687.07

27722Repair/graft of 

tibiaT006467.0623"$4,655.46".$931.10
27724Repair/graft of 

tibiaC

27725Repair of lower 

legC

27726Repair fibula 

nonunionT006349.4864"$3,435.35".$687.07

27727Repair of lower 

legC

27730Repair of tibia 

epiphysisT005032.4101"$2,249.91".$449.99

27732Repair of fibula 

epiphysisT005032.4101"$2,249.91".$449.99

27734Repair lower leg 

epiphysesT005032.4101"$2,249.91".$449.99

27740Repair of leg 

epiphysesT005032.4101"$2,249.91".$449.99

27742Repair of leg 

epiphysesT005147.1841"$3,275.52".$655.11

27745Reinforce 

tibiaT005287.5671"$6,078.91"."$1,215.79"

27750Treatment of tibia 

fractureT01291.6063$111.51.$22.31

27752Treatment of tibia 

fractureT013918.6922"$1,297.61".$259.53

27756Treatment of tibia 

fractureT006226.2376"$1,821.41"$371.33$364.29

27758Treatment of tibia 

fractureT006349.4864"$3,435.35".$687.07

27759Treatment of tibia 

fractureT006467.0623"$4,655.46".$931.10

27760Cltx medial ankle 

fxT01291.6063$111.51.$22.31

27762Cltx med ankle fx 

w/mnpjT013918.6922"$1,297.61".$259.53
27766Optx medial ankle 

fxT006349.4864"$3,435.35".$687.07

27767Cltx post ankle 

fxT01291.6063$111.51.$22.31

27768Cltx post ankle fx 

w/mnpjT01291.6063$111.51.$22.31

27769Optx post ankle 

fxT006349.4864"$3,435.35".$687.07

27780Treatment of fibula 

fractureT01291.6063$111.51.$22.31

27781Treatment of fibula 

fractureT013918.6922"$1,297.61".$259.53

27784Treatment of fibula 

fractureT006349.4864"$3,435.35".$687.07

27786Treatment of ankle 

fractureT01291.6063$111.51.$22.31

27788Treatment of ankle 

fractureT01291.6063$111.51.$22.31

27792Treatment of ankle 

fractureT006349.4864"$3,435.35".$687.07

27808Treatment of ankle 

fractureT01291.6063$111.51.$22.31

27810Treatment of ankle 

fractureT01291.6063$111.51.$22.31

27814Treatment of ankle 

fractureT006349.4864"$3,435.35".$687.07

27816Treatment of ankle 

fractureT01291.6063$111.51.$22.31

27818Treatment of ankle 

fractureT01384.9874$346.23.$69.25

27822Treatment of ankle 

fractureT006349.4864"$3,435.35".$687.07

27823Treatment of ankle 
fractureT006467.0623"$4,655.46".$931.10

27824Treat lower leg 

fractureT01291.6063$111.51.$22.31

27825Treat lower leg 

fractureT013918.6922"$1,297.61".$259.53

27826Treat lower leg 

fractureT006349.4864"$3,435.35".$687.07

27827Treat lower leg 

fractureT006467.0623"$4,655.46".$931.10

27828Treat lower leg 

fractureT006467.0623"$4,655.46".$931.10

27829Treat lower leg 

jointT006349.4864"$3,435.35".$687.07

27830Treat lower leg 

dislocationT01291.6063$111.51.$22.31

27831Treat lower leg 

dislocationT013918.6922"$1,297.61".$259.53

27832Treat lower leg 

dislocationT006349.4864"$3,435.35".$687.07

27840Treat ankle 

dislocationT01291.6063$111.51.$22.31

27842Treat ankle 

dislocationT004515.5166"$1,077.16"$268.44$215.44

27846Treat ankle 

dislocationT006349.4864"$3,435.35".$687.07

27848Treat ankle 

dislocationT006349.4864"$3,435.35".$687.07

27860Fixation of ankle 

jointT004515.5166"$1,077.16"$268.44$215.44

27870Fusion of ankle joint 

openT005287.5671"$6,078.91"."$1,215.79"

27871Fusion of tibiofibular 

jointT005287.5671"$6,078.91"."$1,215.79"
27880Amputation of lower 

legC

27881Amputation of lower 

legC

27882Amputation of lower 

legC

27884Amputation follow-up 

surgeryT004922.1674"$1,538.86".$307.78

27886Amputation follow-up 

surgeryC

27888Amputation of foot at 

ankleC

27889Amputation of foot at 

ankleT005032.4101"$2,249.91".$449.99

27892Decompression of 

legT005032.4101"$2,249.91".$449.99

27893Decompression of 

legT005032.4101"$2,249.91".$449.99

27894Decompression of 

legT005032.4101"$2,249.91".$449.99

27899Leg/ankle surgery 

procedureT01291.6063$111.51.$22.31

28001Drainage of bursa of 

footT000713.4779$935.64.$187.13

28002Treatment of foot 

infectionT004922.1674"$1,538.86".$307.78

28003Treatment of foot 

infectionT004922.1674"$1,538.86".$307.78

28005Treat foot bone 

lesionT005522.1739"$1,539.31"$351.47$307.87

28008Incision of foot 

fasciaT005522.1739"$1,539.31"$351.47$307.87

28010Incision of toe 

tendonT005522.1739"$1,539.31"$351.47$307.87

28011Incision of toe 

tendonsT005522.1739"$1,539.31"$351.47$307.87
28020Exploration of foot 

jointT005522.1739"$1,539.31"$351.47$307.87

28022Exploration of foot 

jointT005522.1739"$1,539.31"$351.47$307.87

28024Exploration of toe 

jointT005522.1739"$1,539.31"$351.47$307.87

28035Decompression of tibia 

nerveT022019.0626"$1,323.33".$264.67

28039Exc foot/toe tum sc > 1.5 

cmT002223.4169"$1,625.60"$350.05$325.12

28041Exc foot/toe tum deep 

1.5cm+T002223.4169"$1,625.60"$350.05$325.12

28043Exc foot/toe tum sc < 1.5 

cmT002117.1909"$1,193.39".$238.68

28045Exc foot/toe tum deep 

<1.5cmT002117.1909"$1,193.39".$238.68

28046Resect foot/toe tumor < 3 

cmT002117.1909"$1,193.39".$238.68

28047Resect foot/toe tumor > 3 

cmT002223.4169"$1,625.60"$350.05$325.12

28050Biopsy of foot joint 

liningT005522.1739"$1,539.31"$351.47$307.87

28052Biopsy of foot joint 

liningT005522.1739"$1,539.31"$351.47$307.87

28054Biopsy of toe joint 

liningT005522.1739"$1,539.31"$351.47$307.87

28055Neurectomy 

footT022019.0626"$1,323.33".$264.67

28060Partial removal foot 

fasciaT005522.1739"$1,539.31"$351.47$307.87

28062Removal of foot 

fasciaT005522.1739"$1,539.31"$351.47$307.87
28070Removal of foot joint 

liningT005522.1739"$1,539.31"$351.47$307.87

28072Removal of foot joint 

liningT005522.1739"$1,539.31"$351.47$307.87

28080Removal of foot 

lesionT005522.1739"$1,539.31"$351.47$307.87

28086Excise foot tendon 

sheathT005522.1739"$1,539.31"$351.47$307.87

28088Excise foot tendon 

sheathT005522.1739"$1,539.31"$351.47$307.87

28090Removal of foot 

lesionT005522.1739"$1,539.31"$351.47$307.87

28092Removal of toe 

lesionsT005522.1739"$1,539.31"$351.47$307.87

28100Removal of ankle/heel 

lesionT005522.1739"$1,539.31"$351.47$307.87

28102Remove/graft foot 

lesionT005657.2099"$3,971.51".$794.31

28103Remove/graft foot 

lesionT005657.2099"$3,971.51".$794.31

28104Removal of foot 

lesionT005522.1739"$1,539.31"$351.47$307.87

28106Remove/graft foot 

lesionT005657.2099"$3,971.51".$794.31

28107Remove/graft foot 

lesionT005657.2099"$3,971.51".$794.31

28108Removal of toe 

lesionsT005522.1739"$1,539.31"$351.47$307.87

28110Part removal of 

metatarsalT005522.1739"$1,539.31"$351.47$307.87

28111Part removal of 

metatarsalT005522.1739"$1,539.31"$351.47$307.87

28112Part removal of 

metatarsalT005522.1739"$1,539.31"$351.47$307.87
28113Part removal of 

metatarsalT005522.1739"$1,539.31"$351.47$307.87

28114Removal of metatarsal 

headsT005522.1739"$1,539.31"$351.47$307.87

28116Revision of 

footT005522.1739"$1,539.31"$351.47$307.87

28118Removal of heel 

boneT005522.1739"$1,539.31"$351.47$307.87

28119Removal of heel 

spurT005522.1739"$1,539.31"$351.47$307.87

28120Part removal of 

ankle/heelT005522.1739"$1,539.31"$351.47$307.87

28122Partial removal of foot 

boneT005522.1739"$1,539.31"$351.47$307.87

28124Partial removal of 

toeT005522.1739"$1,539.31"$351.47$307.87

28126Partial removal of 

toeT005522.1739"$1,539.31"$351.47$307.87

28130Removal of ankle 

boneT005522.1739"$1,539.31"$351.47$307.87

28140Removal of 

metatarsalT005522.1739"$1,539.31"$351.47$307.87

28150Removal of 

toeT005522.1739"$1,539.31"$351.47$307.87

28153Partial removal of 

toeT005522.1739"$1,539.31"$351.47$307.87

28160Partial removal of 

toeT005522.1739"$1,539.31"$351.47$307.87

28171Resect tarsal 

tumorT005522.1739"$1,539.31"$351.47$307.87

28173Resect metatarsal 

tumorT005522.1739"$1,539.31"$351.47$307.87
28175Resect phalanx of toe 

tumorT005522.1739"$1,539.31"$351.47$307.87

28190Removal of foot foreign 

bodyT00208.6164$598.15.$119.63

28192Removal of foot foreign 

bodyT002117.1909"$1,193.39".$238.68

28193Removal of foot foreign 

bodyT00208.6164$598.15.$119.63

28200Repair of foot 

tendonT005522.1739"$1,539.31"$351.47$307.87

28202Repair/graft of foot 

tendonT005522.1739"$1,539.31"$351.47$307.87

28208Repair of foot 

tendonT005522.1739"$1,539.31"$351.47$307.87

28210Repair/graft of foot 

tendonT005657.2099"$3,971.51".$794.31

28220Release of foot 

tendonT005522.1739"$1,539.31"$351.47$307.87

28222Release of foot 

tendonsT005522.1739"$1,539.31"$351.47$307.87

28225Release of foot 

tendonT005522.1739"$1,539.31"$351.47$307.87

28226Release of foot 

tendonsT005522.1739"$1,539.31"$351.47$307.87

28230Incision of foot 

tendon(s)T005522.1739"$1,539.31"$351.47$307.87

28232Incision of toe 

tendonT005522.1739"$1,539.31"$351.47$307.87

28234Incision of foot 

tendonT005522.1739"$1,539.31"$351.47$307.87

28238Revision of foot 

tendonT005657.2099"$3,971.51".$794.31

28240Release of big 

toeT005522.1739"$1,539.31"$351.47$307.87
28250Revision of foot 

fasciaT005522.1739"$1,539.31"$351.47$307.87

28260Release of midfoot 

jointT005522.1739"$1,539.31"$351.47$307.87

28261Revision of foot 

tendonT005522.1739"$1,539.31"$351.47$307.87

28262Revision of foot and 

ankleT005522.1739"$1,539.31"$351.47$307.87

28264Release of midfoot 

jointT005657.2099"$3,971.51".$794.31

28270Release of foot 

contractureT005522.1739"$1,539.31"$351.47$307.87

28272Release of toe joint 

eachT005522.1739"$1,539.31"$351.47$307.87

28280Fusion of 

toesT005522.1739"$1,539.31"$351.47$307.87

28285Repair of 

hammertoeT005522.1739"$1,539.31"$351.47$307.87

28286Repair of 

hammertoeT005522.1739"$1,539.31"$351.47$307.87

28288Partial removal of foot 

boneT005522.1739"$1,539.31"$351.47$307.87

28289Repair hallux 

rigidusT005522.1739"$1,539.31"$351.47$307.87

28290Correction of 

bunionT005732.5456"$2,259.32"$469.58$451.87

28292Correction of 

bunionT005732.5456"$2,259.32"$469.58$451.87

28293Correction of 

bunionT005732.5456"$2,259.32"$469.58$451.87

28294Correction of 

bunionT005732.5456"$2,259.32"$469.58$451.87
28296Correction of 

bunionT005732.5456"$2,259.32"$469.58$451.87

28297Correction of 

bunionT005732.5456"$2,259.32"$469.58$451.87

28298Correction of 

bunionT005732.5456"$2,259.32"$469.58$451.87

28299Correction of 

bunionT005732.5456"$2,259.32"$469.58$451.87

28300Incision of heel 

boneT005657.2099"$3,971.51".$794.31

28302Incision of ankle 

boneT005522.1739"$1,539.31"$351.47$307.87

28304Incision of midfoot 

bonesT005657.2099"$3,971.51".$794.31

28305Incise/graft midfoot 

bonesT005657.2099"$3,971.51".$794.31

28306Incision of 

metatarsalT005522.1739"$1,539.31"$351.47$307.87

28307Incision of 

metatarsalT005522.1739"$1,539.31"$351.47$307.87

28308Incision of 

metatarsalT005522.1739"$1,539.31"$351.47$307.87

28309Incision of 

metatarsalsT005657.2099"$3,971.51".$794.31

28310Revision of big 

toeT005522.1739"$1,539.31"$351.47$307.87

28312Revision of 

toeT005522.1739"$1,539.31"$351.47$307.87

28313Repair deformity of 

toeT005522.1739"$1,539.31"$351.47$307.87

28315Removal of sesamoid 

boneT005522.1739"$1,539.31"$351.47$307.87

28320Repair of foot 

bonesT005657.2099"$3,971.51".$794.31
28322Repair of 

metatarsalsT005657.2099"$3,971.51".$794.31

28340Resect enlarged toe 

tissueT005522.1739"$1,539.31"$351.47$307.87

28341Resect enlarged 

toeT005522.1739"$1,539.31"$351.47$307.87

28344Repair extra 

toe(s)T005522.1739"$1,539.31"$351.47$307.87

28345Repair webbed 

toe(s)T005522.1739"$1,539.31"$351.47$307.87

28360Reconstruct cleft 

footT005657.2099"$3,971.51".$794.31

28400Treatment of heel 

fractureT01291.6063$111.51.$22.31

28405Treatment of heel 

fractureT013918.6922"$1,297.61".$259.53

28406Treatment of heel 

fractureT006226.2376"$1,821.41"$371.33$364.29

28415Treat heel 

fractureT006467.0623"$4,655.46".$931.10

28420Treat/graft heel 

fractureT006349.4864"$3,435.35".$687.07

28430Treatment of ankle 

fractureT01291.6063$111.51.$22.31

28435Treatment of ankle 

fractureT01291.6063$111.51.$22.31

28436Treatment of ankle 

fractureT006226.2376"$1,821.41"$371.33$364.29

28445Treat ankle 

fractureT006349.4864"$3,435.35".$687.07

28446Osteochondral talus 

autogrftT005657.2099"$3,971.51".$794.31
28450Treat midfoot fracture 

eachT01291.6063$111.51.$22.31

28455Treat midfoot fracture 

eachT01291.6063$111.51.$22.31

28456Treat midfoot 

fractureT006226.2376"$1,821.41"$371.33$364.29

28465Treat midfoot fracture 

eachT006349.4864"$3,435.35".$687.07

28470Treat metatarsal 

fractureT01291.6063$111.51.$22.31

28475Treat metatarsal 

fractureT01291.6063$111.51.$22.31

28476Treat metatarsal 

fractureT006226.2376"$1,821.41"$371.33$364.29

28485Treat metatarsal 

fractureT006349.4864"$3,435.35".$687.07

28490Treat big toe 

fractureT01291.6063$111.51.$22.31

28495Treat big toe 

fractureT01291.6063$111.51.$22.31

28496Treat big toe 

fractureT006226.2376"$1,821.41"$371.33$364.29

28505Treat big toe 

fractureT006226.2376"$1,821.41"$371.33$364.29

28510Treatment of toe 

fractureT01291.6063$111.51.$22.31

28515Treatment of toe 

fractureT01291.6063$111.51.$22.31

28525Treat toe 

fractureT006226.2376"$1,821.41"$371.33$364.29

28530Treat sesamoid bone 

fractureT01291.6063$111.51.$22.31

28531Treat sesamoid bone 

fractureT006226.2376"$1,821.41"$371.33$364.29
28540Treat foot 

dislocationT01291.6063$111.51.$22.31

28545Treat foot 

dislocationT006226.2376"$1,821.41"$371.33$364.29

28546Treat foot 

dislocationT006226.2376"$1,821.41"$371.33$364.29

28555Repair foot 

dislocationT006349.4864"$3,435.35".$687.07

28570Treat foot 

dislocationT01291.6063$111.51.$22.31

28575Treat foot 

dislocationT013918.6922"$1,297.61".$259.53

28576Treat foot 

dislocationT006226.2376"$1,821.41"$371.33$364.29

28585Repair foot 

dislocationT006226.2376"$1,821.41"$371.33$364.29

28600Treat foot 

dislocationT01291.6063$111.51.$22.31

28605Treat foot 

dislocationT01291.6063$111.51.$22.31

28606Treat foot 

dislocationT006226.2376"$1,821.41"$371.33$364.29

28615Repair foot 

dislocationT006349.4864"$3,435.35".$687.07

28630Treat toe 

dislocationT01291.6063$111.51.$22.31

28635Treat toe 

dislocationT004515.5166"$1,077.16"$268.44$215.44

28636Treat toe 

dislocationT006226.2376"$1,821.41"$371.33$364.29

28645Repair toe 

dislocationT006226.2376"$1,821.41"$371.33$364.29
28660Treat toe 

dislocationT01291.6063$111.51.$22.31

28665Treat toe 

dislocationT004515.5166"$1,077.16"$268.44$215.44

28666Treat toe 

dislocationT006226.2376"$1,821.41"$371.33$364.29

28675Repair of toe 

dislocationT006226.2376"$1,821.41"$371.33$364.29

28705Fusion of foot 

bonesT005657.2099"$3,971.51".$794.31

28715Fusion of foot 

bonesT005287.5671"$6,078.91"."$1,215.79"

28725Fusion of foot 

bonesT005657.2099"$3,971.51".$794.31

28730Fusion of foot 

bonesT005657.2099"$3,971.51".$794.31

28735Fusion of foot 

bonesT005657.2099"$3,971.51".$794.31

28737Revision of foot 

bonesT005657.2099"$3,971.51".$794.31

28740Fusion of foot 

bonesT005657.2099"$3,971.51".$794.31

28750Fusion of big toe 

jointT005657.2099"$3,971.51".$794.31

28755Fusion of big toe 

jointT005522.1739"$1,539.31"$351.47$307.87

28760Fusion of big toe 

jointT005657.2099"$3,971.51".$794.31

28800Amputation of 

midfootC

28805Amputation thru 

metatarsalT005522.1739"$1,539.31"$351.47$307.87

28810Amputation toe & 

metatarsalT005522.1739"$1,539.31"$351.47$307.87
28820Amputation of 

toeT005522.1739"$1,539.31"$351.47$307.87

28825Partial amputation of 

toeT005522.1739"$1,539.31"$351.47$307.87

28890High energy eswt plantar 

fT005032.4101"$2,249.91".$449.99

28899Foot/toes surgery 

procedureT01291.6063$111.51.$22.31

29000Application of body 

castS00581.1378$78.99.$15.80

29010Application of body 

castS04262.7059$187.84.$37.57

29015Application of body 

castS04262.7059$187.84.$37.57

29020Application of body 

castS00581.1378$78.99.$15.80

29025Application of body 

castS00581.1378$78.99.$15.80

29035Application of body 

castS04262.7059$187.84.$37.57

29040Application of body 

castS00581.1378$78.99.$15.80

29044Application of body 

castS04262.7059$187.84.$37.57

29046Application of body 

castS04262.7059$187.84.$37.57

29049Application of figure 

eightS00581.1378$78.99.$15.80

29055Application of shoulder 

castS04262.7059$187.84.$37.57

29058Application of shoulder 

castS00581.1378$78.99.$15.80

29065Application of long arm 
castS04262.7059$187.84.$37.57

29075Application of forearm 

castS04262.7059$187.84.$37.57

29085Apply hand/wrist 

castS00581.1378$78.99.$15.80

29086Apply finger 

castS00581.1378$78.99.$15.80

29105Apply long arm 

splintS00581.1378$78.99.$15.80

29125Apply forearm 

splintS00581.1378$78.99.$15.80

29126Apply forearm 

splintS00581.1378$78.99.$15.80

29130Application of finger 

splintS00581.1378$78.99.$15.80

29131Application of finger 

splintS00581.1378$78.99.$15.80

29200Strapping of 

chestS00581.1378$78.99.$15.80

29240Strapping of 

shoulderS00581.1378$78.99.$15.80

29260Strapping of elbow or 

wristS00581.1378$78.99.$15.80

29280Strapping of hand or 

fingerS00581.1378$78.99.$15.80

29305Application of hip 

castS04262.7059$187.84.$37.57

29325Application of hip 

castsS04262.7059$187.84.$37.57

29345Application of long leg 

castS04262.7059$187.84.$37.57

29355Application of long leg 

castS04262.7059$187.84.$37.57
29358Apply long leg cast 

braceS04262.7059$187.84.$37.57

29365Application of long leg 

castS04262.7059$187.84.$37.57

29405Apply short leg 

castS04262.7059$187.84.$37.57

29425Apply short leg 

castS04262.7059$187.84.$37.57

29435Apply short leg 

castS04262.7059$187.84.$37.57

29440Addition of walker to 

castS00581.1378$78.99.$15.80

29445Apply rigid leg 

castS04262.7059$187.84.$37.57

29450Application of leg 

castS00581.1378$78.99.$15.80

29505Application long leg 

splintS00581.1378$78.99.$15.80

29515Application lower leg 

splintS00581.1378$78.99.$15.80

29520Strapping of 

hipS00581.1378$78.99.$15.80

29530Strapping of 

kneeS00581.1378$78.99.$15.80

29540Strapping of ankle and/or 

ftS00581.1378$78.99.$15.80

29550Strapping of 

toesS00581.1378$78.99.$15.80

29580Application of paste 

bootS00581.1378$78.99.$15.80

29581Apply multlay comprs lwr 

legS00581.1378$78.99.$15.80

29590Application of foot 
splintS00581.1378$78.99.$15.80

29700Removal/revision of 

castS00581.1378$78.99.$15.80

29705Removal/revision of 

castS00581.1378$78.99.$15.80

29710Removal/revision of 

castS04262.7059$187.84.$37.57

29715Removal/revision of 

castS00581.1378$78.99.$15.80

29720Repair of body 

castS00581.1378$78.99.$15.80

29730Windowing of 

castS00581.1378$78.99.$15.80

29740Wedging of 

castS00581.1378$78.99.$15.80

29750Wedging of clubfoot 

castS00581.1378$78.99.$15.80

29799Casting/strapping 

procedureS00581.1378$78.99.$15.80

29800Jaw 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29804Jaw 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29805Shoulder arthroscopy 

dxT004129.4235"$2,042.58".$408.52

29806Shoulder 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29807Shoulder 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29819Shoulder 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29820Shoulder 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75
29821Shoulder 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29822Shoulder 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29823Shoulder 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29824Shoulder 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29825Shoulder 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29826Shoulder 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29827Arthroscop rotator cuff 

reprT004248.4545"$3,363.71"$804.74$672.75

29828Arthroscopy biceps 

tenodesisT004248.4545"$3,363.71"$804.74$672.75

29830Elbow 

arthroscopyT004129.4235"$2,042.58".$408.52

29834Elbow 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29835Elbow 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29836Elbow 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29837Elbow 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29838Elbow 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29840Wrist 

arthroscopyT004129.4235"$2,042.58".$408.52

29843Wrist 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29844Wrist 
arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29845Wrist 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29846Wrist 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29847Wrist 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29848Wrist 

endoscopy/surgeryT004129.4235"$2,042.58".$408.52

29850Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29851Knee 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29855Tibial 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29856Tibial 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29860Hip arthroscopy 

dxT004248.4545"$3,363.71"$804.74$672.75

29861Hip arthro w/fb 

removalT004248.4545"$3,363.71"$804.74$672.75

29862Hip arthr0 

w/debridementT004248.4545"$3,363.71"$804.74$672.75

29863Hip arthr0 

w/synovectomyT004248.4545"$3,363.71"$804.74$672.75

29866Autgrft implnt knee 

w/scopeT004248.4545"$3,363.71"$804.74$672.75

29867Allgrft implnt knee 

w/scopeT004248.4545"$3,363.71"$804.74$672.75

29868Meniscal trnspl knee 

w/scpeT004248.4545"$3,363.71"$804.74$672.75

29870Knee arthroscopy 

dxT004129.4235"$2,042.58".$408.52
29871Knee 

arthroscopy/drainageT004129.4235"$2,042.58".$408.52

29873Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29874Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29875Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29876Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29877Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29879Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29880Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29881Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29882Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29883Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29884Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29885Knee 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29886Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29887Knee 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29888Knee 

arthroscopy/surgeryT005287.5671"$6,078.91"."$1,215.79"

29889Knee 
arthroscopy/surgeryT005287.5671"$6,078.91"."$1,215.79"

29891Ankle 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29892Ankle 

arthroscopy/surgeryT005287.5671"$6,078.91"."$1,215.79"

29893Scope plantar 

fasciotomyT005522.1739"$1,539.31"$351.47$307.87

29894Ankle 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29895Ankle 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29897Ankle 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29898Ankle 

arthroscopy/surgeryT004129.4235"$2,042.58".$408.52

29899Ankle 

arthroscopy/surgeryT004248.4545"$3,363.71"$804.74$672.75

29900Mcp joint arthroscopy 

dxT004129.4235"$2,042.58".$408.52

29901Mcp joint arthroscopy 

surgT004129.4235"$2,042.58".$408.52

29902Mcp joint arthroscopy 

surgT004129.4235"$2,042.58".$408.52

29904Subtalar arthro w/fb 

rmvlT004129.4235"$2,042.58".$408.52

29905Subtalar arthro 

w/excT004129.4235"$2,042.58".$408.52

29906Subtalar arthro 

w/debT004129.4235"$2,042.58".$408.52

29907Subtalar arthro 

w/fusionT004248.4545"$3,363.71"$804.74$672.75

29914Hip arthro 

w/femoroplastyT004248.4545"$3,363.71"$804.74$672.75
29915Hip arthro 

acetabuloplastyT004248.4545"$3,363.71"$804.74$672.75

29916Hip arthro w/labral 

repairT004248.4545"$3,363.71"$804.74$672.75

29999Arthroscopy of 

jointT004129.4235"$2,042.58".$408.52

30000Drainage of nose 

lesionT02513.3531$232.77.$46.56

30020Drainage of nose 

lesionT02513.3531$232.77.$46.56

30100Intranasal 

biopsyT02528.0353$557.81.$111.57

30110Removal of nose 

polyp(s)T025316.9180"$1,174.45"$277.61$234.89

30115Removal of nose 

polyp(s)T025316.9180"$1,174.45"$277.61$234.89

30117Removal of intranasal 

lesionT025316.9180"$1,174.45"$277.61$234.89

30118Removal of intranasal 

lesionT025425.1379"$1,745.07".$349.02

30120Revision of 

noseT025425.1379"$1,745.07".$349.02

30124Removal of nose 

lesionT02528.0353$557.81.$111.57

30125Removal of nose 

lesionT025645.1286"$3,132.83".$626.57

30130Excise inferior 

turbinateT025316.9180"$1,174.45"$277.61$234.89

30140Resect inferior 

turbinateT025425.1379"$1,745.07".$349.02

30150Partial removal of 

noseT025645.1286"$3,132.83".$626.57

30160Removal of 
noseT025645.1286"$3,132.83".$626.57

30200Injection treatment of 

noseT02528.0353$557.81.$111.57

30210Nasal sinus 

therapyT02528.0353$557.81.$111.57

30220Insert nasal septal 

buttonT02528.0353$557.81.$111.57

30300Remove nasal foreign 

bodyX03400.6739$46.78.$9.36

30310Remove nasal foreign 

bodyT025316.9180"$1,174.45"$277.61$234.89

30320Remove nasal foreign 

bodyT025316.9180"$1,174.45"$277.61$234.89

30400Reconstruction of 

noseT025645.1286"$3,132.83".$626.57

30410Reconstruction of 

noseT025645.1286"$3,132.83".$626.57

30420Reconstruction of 

noseT025645.1286"$3,132.83".$626.57

30430Revision of 

noseT025425.1379"$1,745.07".$349.02

30435Revision of 

noseT025645.1286"$3,132.83".$626.57

30450Revision of 

noseT025645.1286"$3,132.83".$626.57

30460Revision of 

noseT025645.1286"$3,132.83".$626.57

30462Revision of 

noseT025645.1286"$3,132.83".$626.57

30465Repair nasal 

stenosisT025645.1286"$3,132.83".$626.57

30520Repair of nasal 

septumT025425.1379"$1,745.07".$349.02
30540Repair nasal 

defectT025645.1286"$3,132.83".$626.57

30545Repair nasal 

defectT025645.1286"$3,132.83".$626.57

30560Release of nasal 

adhesionsT02513.3531$232.77.$46.56

30580Repair upper jaw 

fistulaT025645.1286"$3,132.83".$626.57

30600Repair mouth/nose 

fistulaT025645.1286"$3,132.83".$626.57

30620Intranasal 

reconstructionT025645.1286"$3,132.83".$626.57

30630Repair nasal septum 

defectT025425.1379"$1,745.07".$349.02

30801Ablate inf turbinate 

superfT02528.0353$557.81.$111.57

30802Ablate inf turbinate 

submucT025316.9180"$1,174.45"$277.61$234.89

30901Control of 

nosebleedT02501.0875$75.49$24.28$15.10

30903Control of 

nosebleedT02501.0875$75.49$24.28$15.10

30905Control of 

nosebleedT02501.0875$75.49$24.28$15.10

30906Repeat control of 

nosebleedT02501.0875$75.49$24.28$15.10

30915Ligation nasal sinus 

arteryT009226.9181"$1,868.65".$373.73

30920Ligation upper jaw 

arteryT009226.9181"$1,868.65".$373.73

30930Ther fx nasal inf 

turbinateT025316.9180"$1,174.45"$277.61$234.89

30999Nasal surgery 
procedureT02501.0875$75.49$24.28$15.10

31000Irrigation maxillary 

sinusT02513.3531$232.77.$46.56

31002Irrigation sphenoid 

sinusT02528.0353$557.81.$111.57

31020Exploration maxillary 

sinusT025425.1379"$1,745.07".$349.02

31030Exploration maxillary 

sinusT025645.1286"$3,132.83".$626.57

31032Explore sinus remove 

polypsT025645.1286"$3,132.83".$626.57

31040Exploration behind upper 

jawT025425.1379"$1,745.07".$349.02

31050Exploration sphenoid 

sinusT025645.1286"$3,132.83".$626.57

31051Sphenoid sinus 

surgeryT025645.1286"$3,132.83".$626.57

31070Exploration of frontal 

sinusT025425.1379"$1,745.07".$349.02

31075Exploration of frontal 

sinusT025645.1286"$3,132.83".$626.57

31080Removal of frontal 

sinusT025645.1286"$3,132.83".$626.57

31081Removal of frontal 

sinusT025645.1286"$3,132.83".$626.57

31084Removal of frontal 

sinusT025645.1286"$3,132.83".$626.57

31085Removal of frontal 

sinusT025645.1286"$3,132.83".$626.57

31086Removal of frontal 

sinusT025645.1286"$3,132.83".$626.57

31087Removal of frontal 

sinusT025645.1286"$3,132.83".$626.57
31090Exploration of 

sinusesT025645.1286"$3,132.83".$626.57

31200Removal of ethmoid 

sinusT025645.1286"$3,132.83".$626.57

31201Removal of ethmoid 

sinusT025645.1286"$3,132.83".$626.57

31205Removal of ethmoid 

sinusT025645.1286"$3,132.83".$626.57

31225Removal of upper 

jawC

31230Removal of upper 

jawC

31231Nasal endoscopy 

dxT00721.9475$135.20.$27.04

31233Nasal/sinus endoscopy 

dxT00721.9475$135.20.$27.04

31235Nasal/sinus endoscopy 

dxT007421.3691"$1,483.44".$296.69

31237Nasal/sinus endoscopy 

surgT007421.3691"$1,483.44".$296.69

31238Nasal/sinus endoscopy 

surgT007421.3691"$1,483.44".$296.69

31239Nasal/sinus endoscopy 

surgT007530.2222"$2,098.03"$438.93$419.61

31240Nasal/sinus endoscopy 

surgT007421.3691"$1,483.44".$296.69

31254Revision of ethmoid 

sinusT007530.2222"$2,098.03"$438.93$419.61

31255Removal of ethmoid 

sinusT007530.2222"$2,098.03"$438.93$419.61

31256Exploration maxillary 

sinusT007530.2222"$2,098.03"$438.93$419.61

31267Endoscopy maxillary 

sinusT007530.2222"$2,098.03"$438.93$419.61
31276Sinus endoscopy 

surgicalT007530.2222"$2,098.03"$438.93$419.61

31287Nasal/sinus endoscopy 

surgT007530.2222"$2,098.03"$438.93$419.61

31288Nasal/sinus endoscopy 

surgT007530.2222"$2,098.03"$438.93$419.61

31290Nasal/sinus endoscopy 

surgC

31291Nasal/sinus endoscopy 

surgC

31292Nasal/sinus endoscopy 

surgT007530.2222"$2,098.03"$438.93$419.61

31293Nasal/sinus endoscopy 

surgT007530.2222"$2,098.03"$438.93$419.61

31294Nasal/sinus endoscopy 

surgT007530.2222"$2,098.03"$438.93$419.61

31295Sinus endo w/balloon 

dilT007530.2222"$2,098.03"$438.93$419.61

31296Sinus endo w/balloon 

dilT007530.2222"$2,098.03"$438.93$419.61

31297Sinus endo w/balloon 

dilT007530.2222"$2,098.03"$438.93$419.61

31299Sinus surgery 

procedureT02501.0875$75.49$24.28$15.10

31300Removal of larynx 

lesionT025425.1379"$1,745.07".$349.02

31320Diagnostic incision 

larynxT025645.1286"$3,132.83".$626.57

31360Removal of 

larynxC

31365Removal of 

larynxC

31367Partial removal of 

larynxC

31368Partial removal of 

larynxC
31370Partial removal of 

larynxC

31375Partial removal of 

larynxC

31380Partial removal of 

larynxC

31382Partial removal of 

larynxC

31390Removal of larynx & 

pharynxC

31395Reconstruct larynx & 

pharynxC

31400Revision of 

larynxT025645.1286"$3,132.83".$626.57

31420Removal of 

epiglottisT025645.1286"$3,132.83".$626.57

31500Insert emergency 

airwayS00942.2773$158.09$44.32$31.62

31502Change of windpipe 

airwayS00781.4008$97.24.$19.45

31505Diagnostic 

laryngoscopyT00711.0521$73.04.$14.61

31510Laryngoscopy with 

biopsyT007421.3691"$1,483.44".$296.69

31511Remove foreign body 

larynxT00721.9475$135.20.$27.04

31512Removal of larynx 

lesionT007421.3691"$1,483.44".$296.69

31513Injection into vocal 

cordT00721.9475$135.20.$27.04

31515Laryngoscopy for 

aspirationT007421.3691"$1,483.44".$296.69

31520Dx laryngoscopy 

newbornT00721.9475$135.20.$27.04

31525Dx laryngoscopy excl 

nbT007421.3691"$1,483.44".$296.69
31526Dx laryngoscopy w/oper 

scopeT007421.3691"$1,483.44".$296.69

31527Laryngoscopy for 

treatmentT007530.2222"$2,098.03"$438.93$419.61

31528Laryngoscopy and 

dilationT007421.3691"$1,483.44".$296.69

31529Laryngoscopy and 

dilationT007421.3691"$1,483.44".$296.69

31530Laryngoscopy w/fb 

removalT007421.3691"$1,483.44".$296.69

31531Laryngoscopy w/fb & op 

scopeT007421.3691"$1,483.44".$296.69

31535Laryngoscopy 

w/biopsyT007421.3691"$1,483.44".$296.69

31536Laryngoscopy w/bx & op 

scopeT007421.3691"$1,483.44".$296.69

31540Laryngoscopy w/exc of 

tumorT007421.3691"$1,483.44".$296.69

31541Larynscop w/tumr exc + 

scopeT007421.3691"$1,483.44".$296.69

31545Remove vc lesion 

w/scopeT007530.2222"$2,098.03"$438.93$419.61

31546Remove vc lesion 

scope/graftT007530.2222"$2,098.03"$438.93$419.61

31560Laryngoscop 

w/arytenoidectomT007530.2222"$2,098.03"$438.93$419.61

31561Larynscop remve cart + 

scopT007530.2222"$2,098.03"$438.93$419.61

31570Laryngoscope w/vc 

injT007421.3691"$1,483.44".$296.69

31571Laryngoscop w/vc inj + 

scopeT007530.2222"$2,098.03"$438.93$419.61

31575Diagnostic 
laryngoscopyT00721.9475$135.20.$27.04

31576Laryngoscopy with 

biopsyT007421.3691"$1,483.44".$296.69

31577Remove foreign body 

larynxT00734.5122$313.24$67.83$62.65

31578Removal of larynx 

lesionT007530.2222"$2,098.03"$438.93$419.61

31579Diagnostic 

laryngoscopyT00734.5122$313.24$67.83$62.65

31580Revision of 

larynxT025645.1286"$3,132.83".$626.57

31582Revision of 

larynxT025645.1286"$3,132.83".$626.57

31584Treat larynx 

fractureC

31587Revision of 

larynxC

31588Revision of 

larynxT025645.1286"$3,132.83".$626.57

31590Reinnervate 

larynxT025645.1286"$3,132.83".$626.57

31595Larynx nerve 

surgeryT025645.1286"$3,132.83".$626.57

31599Larynx surgery 

procedureT02501.0875$75.49$24.28$15.10

31600Incision of 

windpipeT025425.1379"$1,745.07".$349.02

31601Incision of 

windpipeT025425.1379"$1,745.07".$349.02

31603Incision of 

windpipeT02528.0353$557.81.$111.57

31605Incision of 

windpipeT02528.0353$557.81.$111.57

31610Incision of 
windpipeT025425.1379"$1,745.07".$349.02

31611Surgery/speech 

prosthesisT025425.1379"$1,745.07".$349.02

31612Puncture/clear 

windpipeT025425.1379"$1,745.07".$349.02

31613Repair windpipe 

openingT025425.1379"$1,745.07".$349.02

31614Repair windpipe 

openingT025645.1286"$3,132.83".$626.57

31615Visualization of 

windpipeT02528.0353$557.81.$111.57

31620Endobronchial us add-onN 

31622Dx 

bronchoscope/washT007610.4123$722.82$189.71$144.57

31623Dx 

bronchoscope/brushT007610.4123$722.82$189.71$144.57

31624Dx 

bronchoscope/lavageT007610.4123$722.82$189.71$144.57

31625Bronchoscopy 

w/biopsy(s)T007610.4123$722.82$189.71$144.57

31626Bronchoscopy 

w/markersCHT041529.1250"$2,021.86"$459.92$404.38

31627Navigational bronchoscopyN 

31628Bronchoscopy/lung bx 

eachT007610.4123$722.82$189.71$144.57

31629Bronchoscopy/needle bx 

eachT007610.4123$722.82$189.71$144.57

31630Bronchoscopy dilate/fx 

reprT041529.1250"$2,021.86"$459.92$404.38

31631Bronchoscopy dilate 

w/stentT041529.1250"$2,021.86"$459.92$404.38

31632Bronchoscopy/lung bx 
addlT007610.4123$722.82$189.71$144.57

31633Bronchoscopy/needle bx 

addlT007610.4123$722.82$189.71$144.57

31634Bronch w/balloon 

occlusionT007610.4123$722.82$189.71$144.57

31635Bronchoscopy w/fb 

removalT007610.4123$722.82$189.71$144.57

31636Bronchoscopy bronch 

stentsT041529.1250"$2,021.86"$459.92$404.38

31637Bronchoscopy stent 

add-onT007610.4123$722.82$189.71$144.57

31638Bronchoscopy revise 

stentT041529.1250"$2,021.86"$459.92$404.38

31640Bronchoscopy w/tumor 

exciseT041529.1250"$2,021.86"$459.92$404.38

31641Bronchoscopy treat 

blockageT041529.1250"$2,021.86"$459.92$404.38

31643Diag 

bronchoscope/catheterT007610.4123$722.82$189.71$144.57

31645Bronchoscopy clear 

airwaysT007610.4123$722.82$189.71$144.57

31646Bronchoscopy reclear 

airwayT007610.4123$722.82$189.71$144.57

31656Bronchoscopy inj for 

x-rayT007610.4123$722.82$189.71$144.57

31715Injection for bronchus 

x-rayN

31717Bronchial brush 

biopsyT00734.5122$313.24$67.83$62.65

31720Clearance of 

airwaysS00770.4224$29.32$7.74$5.87

31725Clearance of 

airwaysC

31730Intro windpipe 
wire/tubeT00734.5122$313.24$67.83$62.65

31750Repair of 

windpipeT025645.1286"$3,132.83".$626.57

31755Repair of 

windpipeT025645.1286"$3,132.83".$626.57

31760Repair of 

windpipeC

31766Reconstruction of 

windpipeC

31770Repair/graft of 

bronchusC

31775Reconstruct 

bronchusC

31780Reconstruct 

windpipeC

31781Reconstruct 

windpipeC

31785Remove windpipe 

lesionT025425.1379"$1,745.07".$349.02

31786Remove windpipe 

lesionC

31800Repair of windpipe 

injuryC

31805Repair of windpipe 

injuryC

31820Closure of windpipe 

lesionT025425.1379"$1,745.07".$349.02

31825Repair of windpipe 

defectT025425.1379"$1,745.07".$349.02

31830Revise windpipe 

scarT025425.1379"$1,745.07".$349.02

31899Airways surgical 

procedureT007610.4123$722.82$189.71$144.57

32035Exploration of 

chestC

32036Exploration of 

chestC

32095Biopsy through chest 

wallC
32100Exploration/biopsy of 

chestC

32110Explore/repair 

chestC

32120Re-exploration of 

chestC

32124Explore chest free 

adhesionsC

32140Removal of lung 

lesion(s)C

32141Remove/treat lung 

lesionsC

32150Removal of lung 

lesion(s)C

32151Remove lung foreign 

bodyC

32160Open chest heart 

massageC

32200Drain open lung 

lesionC

32201Drain percut lung 

lesionT00705.5572$385.78.$77.16

32215Treat chest 

liningC

32220Release of 

lungC

32225Partial release of 

lungC

32310Removal of chest 

liningC

32320Free/remove chest 

liningC

32400Needle biopsy chest 

liningT06859.7281$675.32.$135.07

32402Open biopsy chest 

liningC

32405Biopsy lung or 

mediastinumT06859.7281$675.32.$135.07

32420Puncture/clear 

lungT00705.5572$385.78.$77.16

32421Thoracentesis for 
aspirationT00705.5572$385.78.$77.16

32422Thoracentesis w/tube 

insertT00705.5572$385.78.$77.16

32440Removal of 

lungC

32442Sleeve 

pneumonectomyC

32445Removal of 

lungC

32480Partial removal of 

lungC

32482BilobectomyC

32484SegmentectomyC

32486Sleeve 

lobectomyC

32488Completion 

pneumonectomyC

32491Lung volume 

reductionC

32500Partial removal of 

lungC

32501Repair bronchus 

add-onC

32503Resect apical lung 

tumorC

32504Resect apical lung 

tum/chestC

32540Removal of lung 

lesionC

32550Insert pleural 

cathT065230.6257"$2,126.04".$425.21

32551Insertion of chest 

tubeT00705.5572$385.78.$77.16

32552Remove lung 

catheterS00781.4008$97.24.$19.45

32553Ins mark thor for rt 

perqX031013.2460$919.54$322.74$183.91

32560Treat pleurodesis 

w/agentT00705.5572$385.78.$77.16
32561Lyse chest fibrin init 

dayT00705.5572$385.78.$77.16

32562Lyse chest fibrin subq 

dayT00705.5572$385.78.$77.16

32601Thoracoscopy 

diagnosticT006934.9007"$2,422.81"$591.64$484.57

32602Thoracoscopy 

diagnosticT006934.9007"$2,422.81"$591.64$484.57

32603Thoracoscopy 

diagnosticT006934.9007"$2,422.81"$591.64$484.57

32604Thoracoscopy 

diagnosticT006934.9007"$2,422.81"$591.64$484.57

32605Thoracoscopy 

diagnosticT006934.9007"$2,422.81"$591.64$484.57

32606Thoracoscopy 

diagnosticT006934.9007"$2,422.81"$591.64$484.57

32650Thoracoscopy 

surgicalC

32651Thoracoscopy 

surgicalC

32652Thoracoscopy 

surgicalC

32653Thoracoscopy 

surgicalC

32654Thoracoscopy 

surgicalC

32655Thoracoscopy 

surgicalC

32656Thoracoscopy 

surgicalC

32657Thoracoscopy 

surgicalC

32658Thoracoscopy 

surgicalC

32659Thoracoscopy 

surgicalC

32660Thoracoscopy 

surgicalC
32661Thoracoscopy 

surgicalC

32662Thoracoscopy 

surgicalC

32663Thoracoscopy 

surgicalC

32664Thoracoscopy 

surgicalC

32665Thoracoscopy 

surgicalC

32800Repair lung 

herniaC

32810Close chest after 

drainageC

32815Close bronchial 

fistulaC

32820Reconstruct injured 

chestC

32850Donor 

pneumonectomyC

32851Lung transplant 

singleC

32852Lung transplant with 

bypassC

32853Lung transplant 

doubleC

32854Lung transplant with 

bypassC

32855Prepare donor lung 

singleC

32856Prepare donor lung 

doubleC

32900Removal of 

rib(s)C

32905Revise & repair chest 

wallC

32906Revise & repair chest 

wallC

32940Revision of 

lungC

32960Therapeutic 

pneumothoraxT00705.5572$385.78.$77.16

32997Total lung 

lavageC
32998Perq rf ablate tx pul 

tumorT042357.1703"$3,968.76".$793.76

32999Chest surgery 

procedureT00705.5572$385.78.$77.16

33010Drainage of heart 

sacT00705.5572$385.78.$77.16

33011Repeat drainage of heart 

sacT00705.5572$385.78.$77.16

33015Incision of heart 

sacC

33020Incision of heart 

sacC

33025Incision of heart 

sacC

33030Partial removal of heart 

sacC

33031Partial removal of heart 

sacC

33050Removal of heart sac 

lesionC

33120Removal of heart 

lesionC

33130Removal of heart 

lesionC

33140Heart revascularize 

(tmr)C

33141Heart tmr w/other 

procedureC

33202Insert epicard eltrd 

openC

33203Insert epicard eltrd 

endoC

33206Insertion of heart 

pacemakerT0089110.9465"$7,701.91""$1,620.86""$1,540.39"

33207Insertion of heart 

pacemakerT0089110.9465"$7,701.91""$1,620.86""$1,540.39"

33208Insertion of heart 

pacemakerT0655136.0608"$9,445.34"."$1,889.07"

33210Insertion of heart 
electrodeT010648.5765"$3,372.18".$674.44

33211Insertion of heart 

electrodeT010648.5765"$3,372.18".$674.44

33212Insertion of pulse 

generatorT009093.4566"$6,487.76""$1,570.21""$1,297.56"

33213Insertion of pulse 

generatorT0654100.4629"$6,974.13"."$1,394.83"

33214Upgrade of pacemaker 

systemT0655136.0608"$9,445.34"."$1,889.07"

33215Reposition pacing-defib 

leadT010523.2424"$1,613.49".$322.70

33216Insert 1 electrode 

pm-defibT010648.5765"$3,372.18".$674.44

33217Insert 2 electrode 

pm-defibT010648.5765"$3,372.18".$674.44

33218Repair lead pace-defib 

oneT010523.2424"$1,613.49".$322.70

33220Repair lead pace-defib 

dualT010523.2424"$1,613.49".$322.70

33222Revise pocket 

pacemakerT013617.2745"$1,199.20".$239.84

33223Revise pocket for 

defibT013617.2745"$1,199.20".$239.84

33224Insert pacing lead & 

connectCHT0655136.0608"$9,445.34"."$1,889.07"

33225L ventric pacing lead add-onCHQ3 

0108379.7887"$26,364.93"."$5,272.99"

33226Reposition l ventric 

leadT010523.2424"$1,613.49".$322.70

33233Removal of pacemaker 

systemT010523.2424"$1,613.49".$322.70

33234Removal of pacemaker 

systemT010523.2424"$1,613.49".$322.70
33235Removal pacemaker 

electrodeT010523.2424"$1,613.49".$322.70

33236Remove 

electrode/thoracotomyC

33237Remove 

electrode/thoracotomyC

33238Remove 

electrode/thoracotomyC

33240Insert pulse generatorT 

0107329.3230"$22,861.60"."$4,572.32"

33241Remove pulse 

generatorT010523.2424"$1,613.49".$322.70

33243Remove 

eltrd/thoracotomyC

33244Remove eltrd 

transvenT010523.2424"$1,613.49".$322.70

33249Eltrd/insert pace-defibCHQ3 

0108379.7887"$26,364.93"."$5,272.99"

33250Ablate heart dysrhythm 

focusC

33251Ablate heart dysrhythm 

focusC

33254Ablate atria 

lmtdC

33255Ablate atria w/o bypass 

extC

33256Ablate atria w/bypass 

extenC

33257Ablate atria lmtd 

add-onC

33258Ablate atria x10sv 

add-onC

33259Ablate atria w/bypass 

add-onC

33261Ablate heart dysrhythm 

focusC

33265Ablate atria lmtd 

endoC
33266Ablate atria x10sv 

endoC

33282Implant pat-active ht 

recordS068078.4050"$5,442.88"."$1,088.58"

33284Remove pat-active ht 

recordT00208.6164$598.15.$119.63

33300Repair of heart 

woundC

33305Repair of heart 

woundC

33310Exploratory heart 

surgeryC

33315Exploratory heart 

surgeryC

33320Repair major blood 

vessel(s)C

33321Repair major 

vesselC

33322Repair major blood 

vessel(s)C

33330Insert major vessel 

graftC

33332Insert major vessel 

graftC

33335Insert major vessel 

graftC

33400Repair of aortic 

valveC

33401Valvuloplasty 

openC

33403Valvuloplasty w/cp 

bypassC

33404Prepare heart-aorta 

conduitC

33405Replacement of aortic 

valveC

33406Replacement of aortic 

valveC

33410Replacement of aortic 

valveC

33411Replacement of aortic 

valveC

33412Replacement of aortic 
valveC

33413Replacement of aortic 

valveC

33414Repair of aortic 

valveC

33415Revision subvalvular 

tissueC

33416Revise ventricle 

muscleC

33417Repair of aortic 

valveC

33420Revision of mitral 

valveC

33422Revision of mitral 

valveC

33425Repair of mitral 

valveC

33426Repair of mitral 

valveC

33427Repair of mitral 

valveC

33430Replacement of mitral 

valveC

33460Revision of tricuspid 

valveC

33463Valvuloplasty 

tricuspidC

33464Valvuloplasty 

tricuspidC

33465Replace tricuspid 

valveC

33468Revision of tricuspid 

valveC

33470Revision of pulmonary 

valveC

33471Valvotomy pulmonary 

valveC

33472Revision of pulmonary 

valveC

33474Revision of pulmonary 

valveC

33475Replacement pulmonary 

valveC

33476Revision of heart 
chamberC

33478Revision of heart 

chamberC

33496Repair prosth valve 

clotC

33500Repair heart vessel 

fistulaC

33501Repair heart vessel 

fistulaC

33502Coronary artery 

correctionC

33503Coronary artery 

graftC

33504Coronary artery 

graftC

33505Repair artery 

w/tunnelC

33506Repair artery 

translocationC

33507Repair art 

intramuralC

33508Endoscopic vein 

harvestN

33510Cabg vein 

singleC

33511Cabg vein 

twoC

33512Cabg vein 

threeC

33513Cabg vein 

fourC

33514Cabg vein 

fiveC

33516Cabg vein six or 

moreC

33517Cabg artery-vein 

singleC

33518Cabg artery-vein 

twoC

33519Cabg artery-vein 

threeC

33521Cabg artery-vein 

fourC

33522Cabg artery-vein 
fiveC

33523Cabg art-vein six or 

moreC

33530Coronary artery 

bypass/reopC

33533Cabg arterial 

singleC

33534Cabg arterial 

twoC

33535Cabg arterial 

threeC

33536Cabg arterial four or 

moreC

33542Removal of heart 

lesionC

33545Repair of heart 

damageC

33548Restore/remodel 

ventricleC

33572Open coronary 

endarterectomyC

33600Closure of 

valveC

33602Closure of 

valveC

33606Anastomosis/artery-aortaC

33608Repair anomaly 

w/conduitC

33610Repair by 

enlargementC

33611Repair double 

ventricleC

33612Repair double 

ventricleC

33615Repair modified 

fontanC

33617Repair single 

ventricleC

33619Repair single 

ventricleC

33620Apply r&l pulm art 

bandsC

33621Transthor cath for 
stentC

33622Redo compl cardiac 

anomalyC

33641Repair heart septum 

defectC

33645Revision of heart 

veinsC

33647Repair heart septum 

defectsC

33660Repair of heart 

defectsC

33665Repair of heart 

defectsC

33670Repair of heart 

chambersC

33675Close mult 

vsdC

33676Close mult vsd 

w/resectionC

33677Cl mult vsd w/rem pul 

bandC

33681Repair heart septum 

defectC

33684Repair heart septum 

defectC

33688Repair heart septum 

defectC

33690Reinforce pulmonary 

arteryC

33692Repair of heart 

defectsC

33694Repair of heart 

defectsC

33697Repair of heart 

defectsC

33702Repair of heart 

defectsC

33710Repair of heart 

defectsC

33720Repair of heart 

defectC

33722Repair of heart 

defectC

33724Repair venous 
anomalyC

33726Repair pul venous 

stenosisC

33730Repair heart-vein 

defect(s)C

33732Repair heart-vein 

defectC

33735Revision of heart 

chamberC

33736Revision of heart 

chamberC

33737Revision of heart 

chamberC

33750Major vessel 

shuntC

33755Major vessel 

shuntC

33762Major vessel 

shuntC

33764Major vessel shunt & 

graftC

33766Major vessel 

shuntC

33767Major vessel 

shuntC

33768Cavopulmonary 

shuntingC

33770Repair great vessels 

defectC

33771Repair great vessels 

defectC

33774Repair great vessels 

defectC

33775Repair great vessels 

defectC

33776Repair great vessels 

defectC

33777Repair great vessels 

defectC

33778Repair great vessels 

defectC

33779Repair great vessels 

defectC

33780Repair great vessels 
defectC

33781Repair great vessels 

defectC

33782Nikaidoh 

procC

33783Nikaidoh proc w/ostia 

impltC

33786Repair arterial 

trunkC

33788Revision of pulmonary 

arteryC

33800Aortic 

suspensionC

33802Repair vessel 

defectC

33803Repair vessel 

defectC

33813Repair septal 

defectC

33814Repair septal 

defectC

33820Revise major 

vesselC

33822Revise major 

vesselC

33824Revise major 

vesselC

33840Remove aorta 

constrictionC

33845Remove aorta 

constrictionC

33851Remove aorta 

constrictionC

33852Repair septal 

defectC

33853Repair septal 

defectC

33860Ascending aortic 

graftC

33863Ascending aortic 

graftC

33864Ascending aortic 

graftC

33870Transverse aortic arch 
graftC

33875Thoracic aortic 

graftC

33877Thoracoabdominal 

graftC

33880Endovasc taa repr incl 

subclC

33881Endovasc taa repr w/o 

subclC

33883Insert endovasc prosth 

taaC

33884Endovasc prosth taa 

add-onC

33886Endovasc prosth 

delayedC

33889Artery transpose/endovas 

taaC

33891Car-car bp grft/endovas 

taaC

33910Remove lung artery 

emboliC

33915Remove lung artery 

emboliC

33916Surgery of great 

vesselC

33917Repair pulmonary 

arteryC

33920Repair pulmonary 

atresiaC

33922Transect pulmonary 

arteryC

33924Remove pulmonary 

shuntC

33925Rpr pul art unifocal w/o 

cpbC

33926Repr pul art unifocal 

w/cpbC

33930Removal of donor 

heart/lungC

33933Prepare donor 

heart/lungC

33935Transplantation 

heart/lungC

33940Removal of donor 
heartC

33944Prepare donor 

heartC

33945Transplantation of 

heartC

33960External circulation 

assistC

33961External circulation 

assistC

33967Insert ia percut 

deviceC

33968Remove aortic assist 

deviceC

33970Aortic circulation 

assistC

33971Aortic circulation 

assistC

33973Insert balloon 

deviceC

33974Remove intra-aortic 

balloonC

33975Implant ventricular 

deviceC

33976Implant ventricular 

deviceC

33977Remove ventricular 

deviceC

33978Remove ventricular 

deviceC

33979Insert intracorporeal 

deviceC

33980Remove intracorporeal 

deviceC

33981Replace vad pump 

extC

33982Replace vad intra w/o 

bpC

33983Replace vad intra 

w/bpC

33999Cardiac surgery 

procedureT00705.5572$385.78.$77.16

34001Removal of artery 

clotC
34051Removal of artery 

clotC

34101Removal of artery 

clotT008841.2260"$2,861.91"$652.56$572.39

34111Removal of arm artery 

clotT008841.2260"$2,861.91"$652.56$572.39

34151Removal of artery 

clotC

34201Removal of artery 

clotT008841.2260"$2,861.91"$652.56$572.39

34203Removal of leg artery 

clotT008841.2260"$2,861.91"$652.56$572.39

34401Removal of vein 

clotC

34421Removal of vein 

clotT008841.2260"$2,861.91"$652.56$572.39

34451Removal of vein 

clotC

34471Removal of vein 

clotT008841.2260"$2,861.91"$652.56$572.39

34490Removal of vein 

clotT008841.2260"$2,861.91"$652.56$572.39

34501Repair valve femoral 

veinT008841.2260"$2,861.91"$652.56$572.39

34502Reconstruct vena 

cavaC

34510Transposition of vein 

valveT008841.2260"$2,861.91"$652.56$572.39

34520Cross-over vein 

graftT008841.2260"$2,861.91"$652.56$572.39

34530Leg vein 

fusionT008841.2260"$2,861.91"$652.56$572.39

34800Endovas aaa repr w/sm 

tubeC

34802Endovas aaa repr w/2-p 

partC

34803Endovas aaa repr w/3-p 
partC

34804Endovas aaa repr w/1-p 

partC

34805Endovas aaa repr w/long 

tubeC

34806Aneurysm press sensor 

add-onC

34808Endovas iliac a device 

addonC

34812Xpose for endoprosth 

femorlC

34813Femoral endovas graft 

add-onC

34820Xpose for endoprosth 

iliacC

34825Endovasc extend prosth 

initC

34826Endovasc exten prosth 

addlC

34830Open aortic tube prosth 

reprC

34831Open aortoiliac prosth 

reprC

34832Open aortofemor prosth 

reprC

34833Xpose for endoprosth 

iliacC

34834Xpose endoprosth 

brachialC

34900Endovasc iliac repr 

w/graftC

35001Repair defect of 

arteryC

35002Repair artery rupture 

neckC

35005Repair defect of 

arteryC

35011Repair defect of 

arteryT065343.1404"$2,994.81".$598.97

35013Repair artery rupture 

armC

35021Repair defect of 

arteryC
35022Repair artery rupture 

chestC

35045Repair defect of arm 

arteryCHT009330.7767"$2,136.52".$427.31

35081Repair defect of 

arteryC

35082Repair artery rupture 

aortaC

35091Repair defect of 

arteryC

35092Repair artery rupture 

aortaC

35102Repair defect of 

arteryC

35103Repair artery rupture 

groinC

35111Repair defect of 

arteryC

35112Repair artery rupture 

spleenC

35121Repair defect of 

arteryC

35122Repair artery rupture 

bellyC

35131Repair defect of 

arteryC

35132Repair artery rupture 

groinC

35141Repair defect of 

arteryC

35142Repair artery rupture 

thighC

35151Repair defect of 

arteryC

35152Repair artery rupture 

kneeC

35180Repair blood vessel 

lesionT009330.7767"$2,136.52".$427.31

35182Repair blood vessel 

lesionC

35184Repair blood vessel 

lesionT009330.7767"$2,136.52".$427.31
35188Repair blood vessel 

lesionT008841.2260"$2,861.91"$652.56$572.39

35189Repair blood vessel 

lesionC

35190Repair blood vessel 

lesionT009330.7767"$2,136.52".$427.31

35201Repair blood vessel 

lesionT009330.7767"$2,136.52".$427.31

35206Repair blood vessel 

lesionT009330.7767"$2,136.52".$427.31

35207Repair blood vessel 

lesionT008841.2260"$2,861.91"$652.56$572.39

35211Repair blood vessel 

lesionC

35216Repair blood vessel 

lesionC

35221Repair blood vessel 

lesionC

35226Repair blood vessel 

lesionT00208.6164$598.15.$119.63

35231Repair blood vessel 

lesionT009330.7767"$2,136.52".$427.31

35236Repair blood vessel 

lesionT009330.7767"$2,136.52".$427.31

35241Repair blood vessel 

lesionC

35246Repair blood vessel 

lesionC

35251Repair blood vessel 

lesionC

35256Repair blood vessel 

lesionT009330.7767"$2,136.52".$427.31

35261Repair blood vessel 

lesionT065343.1404"$2,994.81".$598.97

35266Repair blood vessel 

lesionT065343.1404"$2,994.81".$598.97

35271Repair blood vessel 
lesionC

35276Repair blood vessel 

lesionC

35281Repair blood vessel 

lesionC

35286Repair blood vessel 

lesionT065343.1404"$2,994.81".$598.97

35301Rechanneling of 

arteryC

35302Rechanneling of 

arteryC

35303Rechanneling of 

arteryC

35304Rechanneling of 

arteryC

35305Rechanneling of 

arteryC

35306Rechanneling of 

arteryC

35311Rechanneling of 

arteryC

35321Rechanneling of 

arteryT009330.7767"$2,136.52".$427.31

35331Rechanneling of 

arteryC

35341Rechanneling of 

arteryC

35351Rechanneling of 

arteryC

35355Rechanneling of 

arteryC

35361Rechanneling of 

arteryC

35363Rechanneling of 

arteryC

35371Rechanneling of 

arteryC

35372Rechanneling of 

arteryC

35390Reoperation carotid 

add-onC

35400AngioscopyC
35450Repair arterial 

blockageC

35452Repair arterial 

blockageC

35458Repair arterial 

blockageT008365.1118"$4,520.06".$904.02

35460Repair venous 

blockageT008365.1118"$4,520.06".$904.02

35471Repair arterial 

blockageT008365.1118"$4,520.06".$904.02

35472Repair arterial 

blockageT008365.1118"$4,520.06".$904.02

35475Repair arterial 

blockageT008365.1118"$4,520.06".$904.02

35476Repair venous 

blockageT008365.1118"$4,520.06".$904.02

35500Harvest vein for 

bypassT010316.7686"$1,164.08".$232.82

35501Artery bypass 

graftC

35506Artery bypass 

graftC

35508Artery bypass 

graftC

35509Artery bypass 

graftC

35510Artery bypass 

graftC

35511Artery bypass 

graftC

35512Artery bypass 

graftC

35515Artery bypass 

graftC

35516Artery bypass 

graftC

35518Artery bypass 

graftC

35521Artery bypass 

graftC
35522Artery bypass 

graftC

35523Artery bypass 

graftC

35525Artery bypass 

graftC

35526Artery bypass 

graftC

35531Artery bypass 

graftC

35533Artery bypass 

graftC

35535Artery bypass 

graftC

35536Artery bypass 

graftC

35537Artery bypass 

graftC

35538Artery bypass 

graftC

35539Artery bypass 

graftC

35540Artery bypass 

graftC

35548Artery bypass 

graftC

35549Artery bypass 

graftC

35551Artery bypass 

graftC

35556Artery bypass 

graftC

35558Artery bypass 

graftC

35560Artery bypass 

graftC

35563Artery bypass 

graftC

35565Artery bypass 

graftC

35566Artery bypass 

graftC

35570Artery bypass 

graftC
35571Artery bypass 

graftC

35572Harvest femoropopliteal 

veinN

35583Vein bypass 

graftC

35585Vein bypass 

graftC

35587Vein bypass 

graftC

35600Harvest art for cabg 

add-onC

35601Artery bypass 

graftC

35606Artery bypass 

graftC

35612Artery bypass 

graftC

35616Artery bypass 

graftC

35621Artery bypass 

graftC

35623Bypass graft not 

veinC

35626Artery bypass 

graftC

35631Artery bypass 

graftC

35632Artery bypass 

graftC

35633Artery bypass 

graftC

35634Artery bypass 

graftC

35636Artery bypass 

graftC

35637Artery bypass 

graftC

35638Artery bypass 

graftC

35642Artery bypass 

graftC

35645Artery bypass 

graftC
35646Artery bypass 

graftC

35647Artery bypass 

graftC

35650Artery bypass 

graftC

35651Artery bypass 

graftC

35654Artery bypass 

graftC

35656Artery bypass 

graftC

35661Artery bypass 

graftC

35663Artery bypass 

graftC

35665Artery bypass 

graftC

35666Artery bypass 

graftC

35671Artery bypass 

graftC

35681Composite bypass 

graftC

35682Composite bypass 

graftC

35683Composite bypass 

graftC

35685Bypass graft 

patency/patchT009330.7767"$2,136.52".$427.31

35686Bypass graft/av fist 

patencyT009330.7767"$2,136.52".$427.31

35691Arterial 

transpositionC

35693Arterial 

transpositionC

35694Arterial 

transpositionC

35695Arterial 

transpositionC

35697Reimplant artery 

eachC
35700Reoperation bypass 

graftC

35701Exploration carotid 

arteryC

35721Exploration femoral 

arteryC

35741Exploration popliteal 

arteryC

35761Exploration of 

artery/veinT009330.7767"$2,136.52".$427.31

35800Explore neck 

vesselsC

35820Explore chest 

vesselsC

35840Explore abdominal 

vesselsC

35860Explore limb 

vesselsT009330.7767"$2,136.52".$427.31

35870Repair vessel graft 

defectC

35875Removal of clot in 

graftT008841.2260"$2,861.91"$652.56$572.39

35876Removal of clot in 

graftT008841.2260"$2,861.91"$652.56$572.39

35879Revise graft 

w/veinT008841.2260"$2,861.91"$652.56$572.39

35881Revise graft 

w/veinT008841.2260"$2,861.91"$652.56$572.39

35883Revise graft w/nonauto 

graftT008841.2260"$2,861.91"$652.56$572.39

35884Revise graft 

w/veinT008841.2260"$2,861.91"$652.56$572.39

35901Excision graft 

neckC

35903Excision graft 

extremityT009330.7767"$2,136.52".$427.31

35905Excision graft 

thoraxC
35907Excision graft 

abdomenC

36000Place needle in 

veinN

36002Pseudoaneurysm injection 

trtS02672.1881$151.90$59.41$30.38

36005Injection ext 

venographyN

36010Place catheter in 

veinN

36011Place catheter in 

veinN

36012Place catheter in 

veinN

36013Place catheter in 

arteryN

36014Place catheter in 

arteryN

36015Place catheter in 

arteryN

36100Establish access to 

arteryN

36120Establish access to 

arteryN

36140Establish access to 

arteryN

36147Access av dial grft for 

evalCHT06689.4312$654.71.$130.95

36148Access av dial grft for 

procN

36160Establish access to 

aortaN

36200Place catheter in 

aortaN

36215Place catheter in 

arteryN

36216Place catheter in 

arteryN

36217Place catheter in 

arteryN

36218Place catheter in 

arteryN

36245Place catheter in 
arteryN

36246Place catheter in 

arteryN

36247Place catheter in 

arteryN

36248Place catheter in 

arteryN

36260Insertion of infusion 

pumpT062330.2967"$2,103.20".$420.64

36261Revision of infusion 

pumpT010523.2424"$1,613.49".$322.70

36262Removal of infusion 

pumpT010523.2424"$1,613.49".$322.70

36299Vessel injection 

procedureN

36400Bl draw < 3 yrs 

fem/jugularN

36405Bl draw < 3 yrs scalp 

veinN

36406Bl draw < 3 yrs other 

veinN

36410Non-routine bl draw > 3 

yrsN

36415Routine 

venipunctureA

36416Capillary blood 

drawN

36420Vein access cutdown < 1 yrX 

00350.2717$18.86.$3.78

36425Vein access cutdown > 1 yrX 

00350.2717$18.86.$3.78

36430Blood transfusion 

serviceS01103.3671$233.74.$46.75

36440Bl push transfuse 2 yr or 

<S01103.3671$233.74.$46.75

36450Bl exchange/transfuse 

nbS01103.3671$233.74.$46.75

36455Bl exchange/transfuse 

non-nbS01103.3671$233.74.$46.75
36460Transfusion service 

fetalS01103.3671$233.74.$46.75

36468Injection(s) spider 

veinsT00130.9786$67.93.$13.59

36469Injection(s) spider 

veinsT00130.9786$67.93.$13.59

36470Injection therapy of 

veinT00130.9786$67.93.$13.59

36471Injection therapy of 

veinsT00130.9786$67.93.$13.59

36475Endovenous rf 1st 

veinT009143.6864"$3,032.71".$606.55

36476Endovenous rf vein 

add-onT009226.9181"$1,868.65".$373.73

36478Endovenous laser 1st 

veinT009226.9181"$1,868.65".$373.73

36479Endovenous laser vein 

addonT009226.9181"$1,868.65".$373.73

36481Insertion of catheter 

veinN

36500Insertion of catheter 

veinN

36510Insertion of catheter 

veinN

36511Apheresis 

wbcS011111.7368$814.77$189.47$162.96

36512Apheresis 

rbcS011111.7368$814.77$189.47$162.96

36513Apheresis 

plateletsS011111.7368$814.77$189.47$162.96

36514Apheresis 

plasmaS011111.7368$814.77$189.47$162.96

36515Apheresis 

adsorp/reinfuseS011232.6016"$2,263.20".$452.64

36516Apheresis 
selectiveS011232.6016"$2,263.20".$452.64

36522PhotopheresisS011232.6016"$2,263.20".$452.64

36555Insert non-tunnel cv 

cathT062111.1622$774.88.$154.98

36556Insert non-tunnel cv 

cathT062111.1622$774.88.$154.98

36557Insert tunneled cv 

cathT062225.1290"$1,744.46".$348.90

36558Insert tunneled cv 

cathT062225.1290"$1,744.46".$348.90

36560Insert tunneled cv 

cathT062330.2967"$2,103.20".$420.64

36561Insert tunneled cv 

cathT062330.2967"$2,103.20".$420.64

36563Insert tunneled cv 

cathT062330.2967"$2,103.20".$420.64

36565Insert tunneled cv 

cathT062330.2967"$2,103.20".$420.64

36566Insert tunneled cv 

cathT062330.2967"$2,103.20".$420.64

36568Insert picc 

cathT062111.1622$774.88.$154.98

36569Insert picc 

cathT062111.1622$774.88.$154.98

36570Insert picvad 

cathT062225.1290"$1,744.46".$348.90

36571Insert picvad 

cathT062225.1290"$1,744.46".$348.90

36575Repair tunneled cv 

cathT01216.3178$438.58.$87.72

36576Repair tunneled cv 

cathT062111.1622$774.88.$154.98
36578Replace tunneled cv 

cathT062225.1290"$1,744.46".$348.90

36580Replace cvad 

cathT062111.1622$774.88.$154.98

36581Replace tunneled cv 

cathT062225.1290"$1,744.46".$348.90

36582Replace tunneled cv 

cathT062330.2967"$2,103.20".$420.64

36583Replace tunneled cv 

cathT062330.2967"$2,103.20".$420.64

36584Replace picc 

cathT062111.1622$774.88.$154.98

36585Replace picvad 

cathT062225.1290"$1,744.46".$348.90

36589Removal tunneled cv 

cathT01216.3178$438.58.$87.72

36590Removal tunneled cv 

cathT062111.1622$774.88.$154.98

36591Draw blood off venous 

deviceQ106240.6235$43.28$12.56$8.66

36592Collect blood from 

piccQ106240.6235$43.28$12.56$8.66

36593Declot vascular 

deviceT06762.3410$162.51.$32.51

36595Mech remov tunneled cv 

cathT062225.1290"$1,744.46".$348.90

36596Mech remov tunneled cv 

cathT062111.1622$774.88.$154.98

36597Reposition venous 

catheterT062111.1622$774.88.$154.98

36598Inj w/fluor eval cv 

deviceT06762.3410$162.51.$32.51

36600Withdrawal of arterial bloodQ3 

00350.2717$18.86.$3.78
36620Insertion catheter 

arteryN

36625Insertion catheter 

arteryN

36640Insertion catheter 

arteryT062330.2967"$2,103.20".$420.64

36660Insertion catheter 

arteryC

36680Insert needle bone 

cavityT00021.7462$121.22.$24.25

36800Insertion of 

cannulaT011536.8791"$2,560.15".$512.03

36810Insertion of 

cannulaT011536.8791"$2,560.15".$512.03

36815Insertion of 

cannulaT011536.8791"$2,560.15".$512.03

36818Av fuse uppr arm 

cephalicT008841.2260"$2,861.91"$652.56$572.39

36819Av fuse uppr arm 

basilicT008841.2260"$2,861.91"$652.56$572.39

36820Av fusion/forearm 

veinT008841.2260"$2,861.91"$652.56$572.39

36821Av fusion direct any 

siteT008841.2260"$2,861.91"$652.56$572.39

36822Insertion of 

cannula(s)C

36823Insertion of 

cannula(s)C

36825Artery-vein 

autograftT008841.2260"$2,861.91"$652.56$572.39

36830Artery-vein 

nonautograftT008841.2260"$2,861.91"$652.56$572.39

36831Open thrombect av 

fistulaT008841.2260"$2,861.91"$652.56$572.39

36832Av fistula revision 

openT008841.2260"$2,861.91"$652.56$572.39
36833Av fistula 

revisionT008841.2260"$2,861.91"$652.56$572.39

36835Artery to vein 

shuntT011536.8791"$2,560.15".$512.03

36838Dist revas ligation 

hemoT008841.2260"$2,861.91"$652.56$572.39

36860External cannula 

declottingT06762.3410$162.51.$32.51

36861Cannula 

declottingT011536.8791"$2,560.15".$512.03

36870Percut thrombect av 

fistulaT065343.1404"$2,994.81".$598.97

37140Revision of 

circulationC

37145Revision of 

circulationC

37160Revision of 

circulationC

37180Revision of 

circulationC

37181Splice spleen/kidney 

veinsC

37182Insert hepatic shunt 

(tips)C

37183Remove hepatic shunt 

(tips)T0229114.2626"$7,932.11"."$1,586.43"

37184Prim art mech 

thrombectomyT008841.2260"$2,861.91"$652.56$572.39

37185Prim art m-thrombect 

add-onT008841.2260"$2,861.91"$652.56$572.39

37186Sec art m-thrombect 

add-onT008841.2260"$2,861.91"$652.56$572.39

37187Venous mech 

thrombectomyT008841.2260"$2,861.91"$652.56$572.39

37188Venous m-thrombectomy 

add-onT008841.2260"$2,861.91"$652.56$572.39
37195Thrombolytic therapy 

strokeT06762.3410$162.51.$32.51

37200Transcatheter 

biopsyT062330.2967"$2,103.20".$420.64

37201Transcatheter therapy 

infuseT010316.7686"$1,164.08".$232.82

37202Transcatheter therapy 

infuseT010316.7686"$1,164.08".$232.82

37203Transcatheter 

retrievalT062330.2967"$2,103.20".$420.64

37204Transcatheter 

occlusionT0082104.8857"$7,281.17"."$1,456.24"

37205Transcath iv stent 

percutT0229114.2626"$7,932.11"."$1,586.43"

37206Transcath iv stent/perc 

addlT0229114.2626"$7,932.11"."$1,586.43"

37207Transcath iv stent 

openT0229114.2626"$7,932.11"."$1,586.43"

37208Transcath iv stent/open 

addlT0229114.2626"$7,932.11"."$1,586.43"

37209Change iv cath at thromb 

txT062330.2967"$2,103.20".$420.64

37210Embolization uterine 

fibroidT0229114.2626"$7,932.11"."$1,586.43"

37215Transcath stent cca 

w/epsC

37216Transcath stent cca w/o epsE 

37220Iliac 

revascT008365.1118"$4,520.06".$904.02

37221Iliac revasc 

w/stentCHT0229114.2626"$7,932.11"."$1,586.43"

37222Iliac revasc 

add-onT008365.1118"$4,520.06".$904.02
37223Iliac revasc w/stent 

add-onT008365.1118"$4,520.06".$904.02

37224Fem/popl revas 

w/tlaT008365.1118"$4,520.06".$904.02

37225Fem/popl revas 

w/atherT0229114.2626"$7,932.11"."$1,586.43"

37226Fem/popl revasc 

w/stentT0229114.2626"$7,932.11"."$1,586.43"

37227Fem/popl revasc stnt & 

atherT0319202.3898"$14,049.90""$5,559.48""$2,809.98"

37228Tib/per revasc 

w/tlaT008365.1118"$4,520.06".$904.02

37229Tib/per revasc 

w/atherT0229114.2626"$7,932.11"."$1,586.43"

37230Tib/per revasc 

w/stentT0229114.2626"$7,932.11"."$1,586.43"

37231Tib/per revasc stent & 

atherT0319202.3898"$14,049.90""$5,559.48""$2,809.98"

37232Tib/per revasc 

add-onT008365.1118"$4,520.06".$904.02

37233Tibper revasc w/ather 

add-onT0229114.2626"$7,932.11"."$1,586.43"

37234Revsc opn/prq tib/pero 

stentT008365.1118"$4,520.06".$904.02

37235Tib/per revasc stnt & 

atherT008365.1118"$4,520.06".$904.02

37250Iv us first vessel add-onN 

37251Iv us each add vessel add-onN 

37500Endoscopy ligate perf 

veinsT009143.6864"$3,032.71".$606.55

37501Vascular endoscopy 

procedureT009226.9181"$1,868.65".$373.73
37565Ligation of neck 

veinT009330.7767"$2,136.52".$427.31

37600Ligation of neck 

arteryT009330.7767"$2,136.52".$427.31

37605Ligation of neck 

arteryT009143.6864"$3,032.71".$606.55

37606Ligation of neck 

arteryT009226.9181"$1,868.65".$373.73

37607Ligation of a-v 

fistulaT009226.9181"$1,868.65".$373.73

37609Temporal artery 

procedureT002117.1909"$1,193.39".$238.68

37615Ligation of neck 

arteryT009226.9181"$1,868.65".$373.73

37616Ligation of chest 

arteryC

37617Ligation of abdomen 

arteryC

37618Ligation of extremity 

arteryC

37620Revision of major 

veinT009143.6864"$3,032.71".$606.55

37650Revision of major 

veinT009226.9181"$1,868.65".$373.73

37660Revision of major 

veinC

37700Revise leg 

veinT009226.9181"$1,868.65".$373.73

37718Ligate/strip short leg 

veinT009226.9181"$1,868.65".$373.73

37722Ligate/strip long leg 

veinT009143.6864"$3,032.71".$606.55

37735Removal of leg 

veins/lesionT009143.6864"$3,032.71".$606.55
37760Ligate leg veins 

radicalT009226.9181"$1,868.65".$373.73

37761Ligate leg veins 

openT009226.9181"$1,868.65".$373.73

37765Stab phleb veins xtr 

10-20T009226.9181"$1,868.65".$373.73

37766Phleb veins - extrem 

20+T009226.9181"$1,868.65".$373.73

37780Revision of leg 

veinT009226.9181"$1,868.65".$373.73

37785Ligate/divide/excise 

veinT009226.9181"$1,868.65".$373.73

37788Revascularization 

penisC

37790Penile venous 

occlusionT018134.3803"$2,386.68"$598.48$477.34

37799Vascular surgery 

procedureX06240.6235$43.28$12.56$8.66

38100Removal of spleen 

totalC

38101Removal of spleen 

partialC

38102Removal of spleen 

totalC

38115Repair of ruptured 

spleenC

38120Laparoscopy 

splenectomyT013147.7164"$3,312.47""$1,001.89"$662.50

38129Laparoscope proc 

spleenT013039.0865"$2,713.38"$659.53$542.68

38200Injection for spleen 

x-rayN

38204Bl donor search managementN 

38205Harvest allogenic stem 

cellsB

38206Harvest auto stem 

cellsS011111.7368$814.77$189.47$162.96
38207Cryopreserve stem cellsS 

01103.3671$233.74.$46.75

38208Thaw preserved stem cellsS 

01103.3671$233.74.$46.75

38209Wash harvest stem cellsS 

01103.3671$233.74.$46.75

38210T-cell depletion of harvestS 

03936.3038$437.61.$87.53

38211Tumor cell deplete of harvstS 

03936.3038$437.61.$87.53

38212Rbc depletion of harvestS 

03936.3038$437.61.$87.53

38213Platelet deplete of harvestS 

03936.3038$437.61.$87.53

38214Volume deplete of harvestS 

03936.3038$437.61.$87.53

38215Harvest stem cell concentrteS 

03936.3038$437.61.$87.53

38220Bone marrow 

aspirationT00033.9075$271.26.$54.26

38221Bone marrow 

biopsyT00033.9075$271.26.$54.26

38230Bone marrow 

collectionS011232.6016"$2,263.20".$452.64

38240Bone marrow/stem 

transplantS011232.6016"$2,263.20".$452.64

38241Bone marrow/stem 

transplantS011232.6016"$2,263.20".$452.64

38242Lymphocyte infuse 

transplantS011111.7368$814.77$189.47$162.96

38300Drainage lymph node 

lesionT000713.4779$935.64.$187.13
38305Drainage lymph node 

lesionT000820.5401"$1,425.89".$285.18

38308Incision of lymph 

channelsT011325.4874"$1,769.34".$353.87

38380Thoracic duct 

procedureC

38381Thoracic duct 

procedureC

38382Thoracic duct 

procedureC

38500Biopsy/removal lymph 

nodesT011325.4874"$1,769.34".$353.87

38505Needle biopsy lymph 

nodesT00058.1415$565.18.$113.04

38510Biopsy/removal lymph 

nodesT011325.4874"$1,769.34".$353.87

38520Biopsy/removal lymph 

nodesT011325.4874"$1,769.34".$353.87

38525Biopsy/removal lymph 

nodesT011325.4874"$1,769.34".$353.87

38530Biopsy/removal lymph 

nodesT011325.4874"$1,769.34".$353.87

38542Explore deep node(s) 

neckT011451.2321"$3,556.53".$711.31

38550Removal neck/armpit 

lesionT011325.4874"$1,769.34".$353.87

38555Removal neck/armpit 

lesionT011325.4874"$1,769.34".$353.87

38562Removal pelvic lymph 

nodesC

38564Removal abdomen lymph 

nodesC

38570Laparoscopy lymph node 

biopT013147.7164"$3,312.47""$1,001.89"$662.50

38571Laparoscopy 

lymphadenectomyT013271.0451"$4,931.95""$1,236.99"$986.39
38572Laparoscopy 

lymphadenectomyT013147.7164"$3,312.47""$1,001.89"$662.50

38589Laparoscope proc 

lymphaticT013039.0865"$2,713.38"$659.53$542.68

38700Removal of lymph nodes 

neckT011325.4874"$1,769.34".$353.87

38720Removal of lymph nodes 

neckT011325.4874"$1,769.34".$353.87

38724Removal of lymph nodes 

neckC

38740Remove armpit lymph 

nodesT011451.2321"$3,556.53".$711.31

38745Remove armpit lymph 

nodesT011451.2321"$3,556.53".$711.31

38746Remove thoracic lymph 

nodesC

38747Remove abdominal lymph 

nodesC

38760Remove groin lymph 

nodesT011325.4874"$1,769.34".$353.87

38765Remove groin lymph 

nodesC

38770Remove pelvis lymph 

nodesC

38780Remove abdomen lymph 

nodesC

38790Inject for lymphatic 

x-rayN

38792Identify sentinel nodeQ1 

03922.5360$176.05$42.39$35.21

38794Access thoracic lymph 

ductN

38900Io map of sent lymph 

nodeN

38999Blood/lymph system 

procedureS01103.3671$233.74.$46.75

39000Exploration of 

chestC
39010Exploration of 

chestC

39200Removal chest 

lesionC

39220Removal chest 

lesionC

39400Visualization of 

chestT006934.9007"$2,422.81"$591.64$484.57

39499Chest 

procedureC

39501Repair diaphragm 

lacerationC

39503Repair of diaphragm 

herniaC

39540Repair of diaphragm 

herniaC

39541Repair of diaphragm 

herniaC

39545Revision of 

diaphragmC

39560Resect diaphragm 

simpleC

39561Resect diaphragm 

complexC

39599Diaphragm surgery 

procedureC

40490Biopsy of 

lipT02513.3531$232.77.$46.56

40500Partial excision of 

lipT025316.9180"$1,174.45"$277.61$234.89

40510Partial excision of 

lipT025425.1379"$1,745.07".$349.02

40520Partial excision of 

lipT025316.9180"$1,174.45"$277.61$234.89

40525Reconstruct lip with 

flapT025425.1379"$1,745.07".$349.02

40527Reconstruct lip with 

flapT025425.1379"$1,745.07".$349.02

40530Partial removal of 
lipT025425.1379"$1,745.07".$349.02

40650Repair 

lipT02528.0353$557.81.$111.57

40652Repair 

lipT02528.0353$557.81.$111.57

40654Repair 

lipT02528.0353$557.81.$111.57

40700Repair cleft 

lip/nasalT025645.1286"$3,132.83".$626.57

40701Repair cleft 

lip/nasalT025645.1286"$3,132.83".$626.57

40702Repair cleft 

lip/nasalT025645.1286"$3,132.83".$626.57

40720Repair cleft 

lip/nasalT025645.1286"$3,132.83".$626.57

40761Repair cleft 

lip/nasalT025645.1286"$3,132.83".$626.57

40799Lip surgery 

procedureT02501.0875$75.49$24.28$15.10

40800Drainage of mouth 

lesionT00061.4481$100.53.$20.11

40801Drainage of mouth 

lesionT02528.0353$557.81.$111.57

40804Removal foreign body 

mouthX03400.6739$46.78.$9.36

40805Removal foreign body 

mouthT02528.0353$557.81.$111.57

40806Incision of lip 

foldT02513.3531$232.77.$46.56

40808Biopsy of mouth 

lesionT02513.3531$232.77.$46.56

40810Excision of mouth 

lesionT025316.9180"$1,174.45"$277.61$234.89
40812Excise/repair mouth 

lesionT025316.9180"$1,174.45"$277.61$234.89

40814Excise/repair mouth 

lesionT025316.9180"$1,174.45"$277.61$234.89

40816Excision of mouth 

lesionT025425.1379"$1,745.07".$349.02

40818Excise oral mucosa for 

graftT02513.3531$232.77.$46.56

40819Excise lip or cheek 

foldT02528.0353$557.81.$111.57

40820Treatment of mouth 

lesionT025316.9180"$1,174.45"$277.61$234.89

40830Repair mouth 

lacerationT02513.3531$232.77.$46.56

40831Repair mouth 

lacerationT02528.0353$557.81.$111.57

40840Reconstruction of 

mouthT025425.1379"$1,745.07".$349.02

40842Reconstruction of 

mouthT025425.1379"$1,745.07".$349.02

40843Reconstruction of 

mouthT025425.1379"$1,745.07".$349.02

40844Reconstruction of 

mouthT025645.1286"$3,132.83".$626.57

40845Reconstruction of 

mouthT025645.1286"$3,132.83".$626.57

40899Mouth surgery 

procedureT02501.0875$75.49$24.28$15.10

41000Drainage of mouth 

lesionT025316.9180"$1,174.45"$277.61$234.89

41005Drainage of mouth 

lesionT02513.3531$232.77.$46.56

41006Drainage of mouth 
lesionT025425.1379"$1,745.07".$349.02

41007Drainage of mouth 

lesionT025316.9180"$1,174.45"$277.61$234.89

41008Drainage of mouth 

lesionT025316.9180"$1,174.45"$277.61$234.89

41009Drainage of mouth 

lesionT02513.3531$232.77.$46.56

41010Incision of tongue 

foldT02528.0353$557.81.$111.57

41015Drainage of mouth 

lesionT02513.3531$232.77.$46.56

41016Drainage of mouth 

lesionT02528.0353$557.81.$111.57

41017Drainage of mouth 

lesionT02528.0353$557.81.$111.57

41018Drainage of mouth 

lesionT02528.0353$557.81.$111.57

41019Place needles h&n for 

rtT025425.1379"$1,745.07".$349.02

41100Biopsy of 

tongueT02528.0353$557.81.$111.57

41105Biopsy of 

tongueT025316.9180"$1,174.45"$277.61$234.89

41108Biopsy of floor of 

mouthT00194.8763$338.51.$67.71

41110Excision of tongue 

lesionT025316.9180"$1,174.45"$277.61$234.89

41112Excision of tongue 

lesionT025316.9180"$1,174.45"$277.61$234.89

41113Excision of tongue 

lesionT025316.9180"$1,174.45"$277.61$234.89

41114Excision of tongue 

lesionT025425.1379"$1,745.07".$349.02
41115Excision of tongue 

foldT02528.0353$557.81.$111.57

41116Excision of mouth 

lesionT025316.9180"$1,174.45"$277.61$234.89

41120Partial removal of 

tongueT025425.1379"$1,745.07".$349.02

41130Partial removal of 

tongueC

41135Tongue and neck 

surgeryC

41140Removal of 

tongueC

41145Tongue removal neck 

surgeryC

41150Tongue mouth jaw 

surgeryC

41153Tongue mouth neck 

surgeryC

41155Tongue jaw & neck 

surgeryC

41250Repair tongue 

lacerationT02501.0875$75.49$24.28$15.10

41251Repair tongue 

lacerationT02513.3531$232.77.$46.56

41252Repair tongue 

lacerationT02528.0353$557.81.$111.57

41500Fixation of 

tongueT025425.1379"$1,745.07".$349.02

41510Tongue to lip 

surgeryT025316.9180"$1,174.45"$277.61$234.89

41512Tongue 

suspensionT02528.0353$557.81.$111.57

41520Reconstruction tongue 

foldT02528.0353$557.81.$111.57

41530Tongue base vol 

reductionT025425.1379"$1,745.07".$349.02
41599Tongue and mouth 

surgeryT02501.0875$75.49$24.28$15.10

41800Drainage of gum 

lesionT00061.4481$100.53.$20.11

41805Removal foreign body 

gumT025425.1379"$1,745.07".$349.02

41806Removal foreign body 

jawboneT025316.9180"$1,174.45"$277.61$234.89

41820Excision gum each 

quadrantT02528.0353$557.81.$111.57

41821Excision of gum 

flapT02528.0353$557.81.$111.57

41822Excision of gum 

lesionT025316.9180"$1,174.45"$277.61$234.89

41823Excision of gum 

lesionT025425.1379"$1,745.07".$349.02

41825Excision of gum 

lesionT025316.9180"$1,174.45"$277.61$234.89

41826Excision of gum 

lesionT025425.1379"$1,745.07".$349.02

41827Excision of gum 

lesionT025425.1379"$1,745.07".$349.02

41828Excision of gum 

lesionT025316.9180"$1,174.45"$277.61$234.89

41830Removal of gum 

tissueT025316.9180"$1,174.45"$277.61$234.89

41850Treatment of gum 

lesionT025316.9180"$1,174.45"$277.61$234.89

41870Gum 

graftT025425.1379"$1,745.07".$349.02

41872Repair 

gumT025316.9180"$1,174.45"$277.61$234.89

41874Repair tooth 

socketT025425.1379"$1,745.07".$349.02
41899Dental surgery 

procedureT02501.0875$75.49$24.28$15.10

42000Drainage mouth roof 

lesionT02513.3531$232.77.$46.56

42100Biopsy roof of 

mouthT02528.0353$557.81.$111.57

42104Excision lesion mouth 

roofT025316.9180"$1,174.45"$277.61$234.89

42106Excision lesion mouth 

roofT025316.9180"$1,174.45"$277.61$234.89

42107Excision lesion mouth 

roofT025425.1379"$1,745.07".$349.02

42120Remove 

palate/lesionT025645.1286"$3,132.83".$626.57

42140Excision of 

uvulaT02528.0353$557.81.$111.57

42145Repair palate 

pharynx/uvulaT025425.1379"$1,745.07".$349.02

42160Treatment mouth roof 

lesionT025316.9180"$1,174.45"$277.61$234.89

42180Repair 

palateT02513.3531$232.77.$46.56

42182Repair 

palateT025645.1286"$3,132.83".$626.57

42200Reconstruct cleft 

palateT025645.1286"$3,132.83".$626.57

42205Reconstruct cleft 

palateT025645.1286"$3,132.83".$626.57

42210Reconstruct cleft 

palateT025645.1286"$3,132.83".$626.57

42215Reconstruct cleft 

palateT025645.1286"$3,132.83".$626.57
42220Reconstruct cleft 

palateT025645.1286"$3,132.83".$626.57

42225Reconstruct cleft 

palateT025645.1286"$3,132.83".$626.57

42226Lengthening of 

palateT025645.1286"$3,132.83".$626.57

42227Lengthening of 

palateT025645.1286"$3,132.83".$626.57

42235Repair 

palateT025316.9180"$1,174.45"$277.61$234.89

42260Repair nose to lip 

fistulaT025425.1379"$1,745.07".$349.02

42280Preparation palate 

moldT02513.3531$232.77.$46.56

42281Insertion palate 

prosthesisT025316.9180"$1,174.45"$277.61$234.89

42299Palate/uvula 

surgeryT02501.0875$75.49$24.28$15.10

42300Drainage of salivary 

glandT025316.9180"$1,174.45"$277.61$234.89

42305Drainage of salivary 

glandT025316.9180"$1,174.45"$277.61$234.89

42310Drainage of salivary 

glandT02513.3531$232.77.$46.56

42320Drainage of salivary 

glandT02513.3531$232.77.$46.56

42330Removal of salivary 

stoneT025316.9180"$1,174.45"$277.61$234.89

42335Removal of salivary 

stoneT025316.9180"$1,174.45"$277.61$234.89

42340Removal of salivary 

stoneT025316.9180"$1,174.45"$277.61$234.89

42400Biopsy of salivary 

glandT00058.1415$565.18.$113.04
42405Biopsy of salivary 

glandT025425.1379"$1,745.07".$349.02

42408Excision of salivary 

cystT025316.9180"$1,174.45"$277.61$234.89

42409Drainage of salivary 

cystT025316.9180"$1,174.45"$277.61$234.89

42410Excise parotid 

gland/lesionT025645.1286"$3,132.83".$626.57

42415Excise parotid 

gland/lesionT025645.1286"$3,132.83".$626.57

42420Excise parotid 

gland/lesionT025645.1286"$3,132.83".$626.57

42425Excise parotid 

gland/lesionT025645.1286"$3,132.83".$626.57

42426Excise parotid 

gland/lesionC

42440Excise submaxillary 

glandT025645.1286"$3,132.83".$626.57

42450Excise sublingual 

glandT025425.1379"$1,745.07".$349.02

42500Repair salivary 

ductT025425.1379"$1,745.07".$349.02

42505Repair salivary 

ductT025645.1286"$3,132.83".$626.57

42507Parotid duct 

diversionT025645.1286"$3,132.83".$626.57

42508Parotid duct 

diversionT025645.1286"$3,132.83".$626.57

42509Parotid duct 

diversionT025645.1286"$3,132.83".$626.57

42510Parotid duct 

diversionT025645.1286"$3,132.83".$626.57

42550Injection for salivary 
x-rayN

42600Closure of salivary 

fistulaT025316.9180"$1,174.45"$277.61$234.89

42650Dilation of salivary 

ductT02528.0353$557.81.$111.57

42660Dilation of salivary 

ductT02513.3531$232.77.$46.56

42665Ligation of salivary 

ductT025425.1379"$1,745.07".$349.02

42699Salivary surgery 

procedureT02501.0875$75.49$24.28$15.10

42700Drainage of tonsil 

abscessT02513.3531$232.77.$46.56

42720Drainage of throat 

abscessT025316.9180"$1,174.45"$277.61$234.89

42725Drainage of throat 

abscessT025645.1286"$3,132.83".$626.57

42800Biopsy of 

throatT02528.0353$557.81.$111.57

42802Biopsy of 

throatT025316.9180"$1,174.45"$277.61$234.89

42804Biopsy of upper 

nose/throatT025316.9180"$1,174.45"$277.61$234.89

42806Biopsy of upper 

nose/throatT025425.1379"$1,745.07".$349.02

42808Excise pharynx 

lesionT025425.1379"$1,745.07".$349.02

42809Remove pharynx foreign 

bodyX03400.6739$46.78.$9.36

42810Excision of neck 

cystT025425.1379"$1,745.07".$349.02

42815Excision of neck 

cystT025645.1286"$3,132.83".$626.57
42820Remove tonsils and 

adenoidsT025425.1379"$1,745.07".$349.02

42821Remove tonsils and 

adenoidsT025425.1379"$1,745.07".$349.02

42825Removal of 

tonsilsT025425.1379"$1,745.07".$349.02

42826Removal of 

tonsilsT025425.1379"$1,745.07".$349.02

42830Removal of 

adenoidsT025425.1379"$1,745.07".$349.02

42831Removal of 

adenoidsT025425.1379"$1,745.07".$349.02

42835Removal of 

adenoidsT025425.1379"$1,745.07".$349.02

42836Removal of 

adenoidsT025425.1379"$1,745.07".$349.02

42842Extensive surgery of 

throatT025425.1379"$1,745.07".$349.02

42844Extensive surgery of 

throatT025645.1286"$3,132.83".$626.57

42845Extensive surgery of 

throatC

42860Excision of tonsil 

tagsT025425.1379"$1,745.07".$349.02

42870Excision of lingual 

tonsilT025425.1379"$1,745.07".$349.02

42890Partial removal of 

pharynxT025645.1286"$3,132.83".$626.57

42892Revision of pharyngeal 

wallsT025645.1286"$3,132.83".$626.57

42894Revision of pharyngeal 

wallsC

42900Repair throat 

woundT02528.0353$557.81.$111.57
42950Reconstruction of 

throatT025425.1379"$1,745.07".$349.02

42953Repair throat 

esophagusC

42955Surgical opening of 

throatT025425.1379"$1,745.07".$349.02

42960Control throat 

bleedingT02501.0875$75.49$24.28$15.10

42961Control throat 

bleedingC

42962Control throat 

bleedingT025645.1286"$3,132.83".$626.57

42970Control nose/throat 

bleedingT02501.0875$75.49$24.28$15.10

42971Control nose/throat 

bleedingC

42972Control nose/throat 

bleedingT025316.9180"$1,174.45"$277.61$234.89

42999Throat surgery 

procedureT02501.0875$75.49$24.28$15.10

43020Incision of 

esophagusT02528.0353$557.81.$111.57

43030Throat muscle 

surgeryT025316.9180"$1,174.45"$277.61$234.89

43045Incision of 

esophagusC

43100Excision of esophagus 

lesionC

43101Excision of esophagus 

lesionC

43107Removal of 

esophagusC

43108Removal of 

esophagusC

43112Removal of 

esophagusC

43113Removal of 

esophagusC
43116Partial removal of 

esophagusC

43117Partial removal of 

esophagusC

43118Partial removal of 

esophagusC

43121Partial removal of 

esophagusC

43122Partial removal of 

esophagusC

43123Partial removal of 

esophagusC

43124Removal of 

esophagusC

43130Removal of esophagus 

pouchT025645.1286"$3,132.83".$626.57

43135Removal of esophagus 

pouchC

43200Esophagus 

endoscopyT01418.3787$581.65$136.33$116.33

43201Esoph scope w/submucous 

injCHT041912.5693$872.56$204.51$174.52

43202Esophagus endoscopy 

biopsyT01418.3787$581.65$136.33$116.33

43204Esoph scope w/sclerosis 

injT01418.3787$581.65$136.33$116.33

43205Esophagus 

endoscopy/ligationCHT041912.5693$872.56$204.51$174.52

43215Esophagus 

endoscopyCHT041912.5693$872.56$204.51$174.52

43216Esophagus 

endoscopy/lesionT042225.4890"$1,769.45".$353.89

43217Esophagus 

endoscopyCHT041912.5693$872.56$204.51$174.52

43219Esophagus 

endoscopyT038429.0233"$2,014.80".$402.96

43220Esoph endoscopy 

dilationCHT041912.5693$872.56$204.51$174.52
43226Esoph endoscopy 

dilationCHT041912.5693$872.56$204.51$174.52

43227Esoph endoscopy 

repairCHT041912.5693$872.56$204.51$174.52

43228Esoph endoscopy 

ablationT042225.4890"$1,769.45".$353.89

43231Esoph endoscopy w/us 

examCHT041912.5693$872.56$204.51$174.52

43232Esoph endoscopy w/us fn 

bxCHT041912.5693$872.56$204.51$174.52

43234Upper gi endoscopy 

examT01418.3787$581.65$136.33$116.33

43235Uppr gi endoscopy 

diagnosisT01418.3787$581.65$136.33$116.33

43236Uppr gi scope w/submuc 

injT01418.3787$581.65$136.33$116.33

43237Endoscopic us exam 

esophCHT041912.5693$872.56$204.51$174.52

43238Uppr gi endoscopy w/us fn 

bxCHT041912.5693$872.56$204.51$174.52

43239Upper gi endoscopy 

biopsyT01418.3787$581.65$136.33$116.33

43240Esoph endoscope w/drain 

cystCHT041912.5693$872.56$204.51$174.52

43241Upper GI endoscopy with 

tubeT01418.3787$581.65$136.33$116.33

43242Uppr gi endoscopy w/us fn 

bxCHT041912.5693$872.56$204.51$174.52

43243Upper gi endoscopy & 

injectT01418.3787$581.65$136.33$116.33

43244Upper GI 

endoscopy/ligationCHT041912.5693$872.56$204.51$174.52
43245Uppr gi scope dilate 

strictrCHT041912.5693$872.56$204.51$174.52

43246Place gastrostomy 

tubeCHT041912.5693$872.56$204.51$174.52

43247Operative upper GI 

endoscopyT01418.3787$581.65$136.33$116.33

43248Uppr gi endoscopy/guide 

wireT01418.3787$581.65$136.33$116.33

43249Esoph endoscopy 

dilationCHT041912.5693$872.56$204.51$174.52

43250Upper GI 

endoscopy/tumorCHT041912.5693$872.56$204.51$174.52

43251Operative upper GI 

endoscopyCHT041912.5693$872.56$204.51$174.52

43255Operative upper GI 

endoscopyCHT041912.5693$872.56$204.51$174.52

43256Uppr gi endoscopy 

w/stentT038429.0233"$2,014.80".$402.96

43257Uppr gi scope w/thrml 

txmntT042225.4890"$1,769.45".$353.89

43258Operative upper GI 

endoscopyCHT041912.5693$872.56$204.51$174.52

43259Endoscopic ultrasound 

examCHT041912.5693$872.56$204.51$174.52

43260Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79

43261Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79

43262Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79

43263Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79

43264Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79
43265Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79

43267Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79

43268Endo 

cholangiopancreatographT038429.0233"$2,014.80".$402.96

43269Endo 

cholangiopancreatographT038429.0233"$2,014.80".$402.96

43271Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79

43272Endo 

cholangiopancreatographT015124.4009"$1,693.91".$338.79

43273Endoscopic 

pancreatoscopyT015124.4009"$1,693.91".$338.79

43279Lap myotomy 

hellerC

43280Laparoscopy 

fundoplastyT013271.0451"$4,931.95""$1,236.99"$986.39

43281Lap paraesophag hern 

repairC

43282Lap paraesoph her rpr 

w/meshC

43283Lap esoph 

lengtheningC

43289Laparoscope proc 

esophT013039.0865"$2,713.38"$659.53$542.68

43300Repair of 

esophagusC

43305Repair esophagus and 

fistulaC

43310Repair of 

esophagusC

43312Repair esophagus and 

fistulaC

43313Esophagoplasty 

congenitalC

43314Tracheo-esophagoplasty 
congC

43320Fuse esophagus & 

stomachC

43325Revise esophagus & 

stomachC

43327Esoph fundoplasty 

lapC

43328Esoph fundoplasty 

thorC

43330Esophagomyotomy 

abdominalC

43331Esophagomyotomy 

thoracicC

43332Transab esoph hiat hern 

rprC

43333Transab esoph hiat hern 

rprC

43334Transthor diaphrag hern 

rprC

43335Transthor diaphrag hern 

rprC

43336Thorabd diaphr hern 

repairC

43337Thorabd diaphr hern 

repairC

43338Esoph 

lengtheningC

43340Fuse esophagus & 

intestineC

43341Fuse esophagus & 

intestineC

43350Surgical opening 

esophagusC

43351Surgical opening 

esophagusC

43352Surgical opening 

esophagusC

43360Gastrointestinal 

repairC

43361Gastrointestinal 

repairC

43400Ligate esophagus 

veinsC

43401Esophagus surgery for 
veinsC

43405Ligate/staple 

esophagusC

43410Repair esophagus 

woundC

43415Repair esophagus 

woundC

43420Repair esophagus 

openingT025425.1379"$1,745.07".$349.02

43425Repair esophagus 

openingC

43450Dilate 

esophagusT01406.5430$454.22.$90.85

43453Dilate 

esophagusT01406.5430$454.22.$90.85

43456Dilate 

esophagusT01406.5430$454.22.$90.85

43458Dilate esophagusCH 

T041912.5693$872.56$204.51$174.52

43460Pressure treatment 

esophagusC

43496Free jejunum flap 

microvascC

43499Esophagus surgery 

procedureT01418.3787$581.65$136.33$116.33

43500Surgical opening of 

stomachC

43501Surgical repair of 

stomachC

43502Surgical repair of 

stomachC

43510Surgical opening of stomachCH 

T01418.3787$581.65$136.33$116.33

43520Incision of pyloric 

muscleC

43605Biopsy of 

stomachC

43610Excision of stomach 

lesionC
43611Excision of stomach 

lesionC

43620Removal of 

stomachC

43621Removal of 

stomachC

43622Removal of 

stomachC

43631Removal of stomach 

partialC

43632Removal of stomach 

partialC

43633Removal of stomach 

partialC

43634Removal of stomach 

partialC

43635Removal of stomach 

partialC

43640Vagotomy & pylorus 

repairC

43641Vagotomy & pylorus 

repairC

43644Lap gastric 

bypass/roux-en-yC

43645Lap gastr bypass incl smll 

iC

43647Lap impl electrode 

antrumS006186.9786"$6,038.05"."$1,207.61"

43648Lap revise/remv eltrd 

antrumT013039.0865"$2,713.38"$659.53$542.68

43651Laparoscopy vagus 

nerveT013271.0451"$4,931.95""$1,236.99"$986.39

43652Laparoscopy vagus 

nerveT013271.0451"$4,931.95""$1,236.99"$986.39

43653Laparoscopy 

gastrostomyT013147.7164"$3,312.47""$1,001.89"$662.50

43659Laparoscope proc 

stomT013039.0865"$2,713.38"$659.53$542.68

43752Nasal/orogastric 

w/stentQ302721.2481$86.64$30.47$17.33
43753Tx gastro intub 

w/aspX03400.6739$46.78.$9.36

43754Dx gastr intub w/asp 

specX03400.6739$46.78.$9.36

43755Dx gastr intub w/asp 

specsS00970.9478$65.80$23.63$13.16

43756Dx duod intub w/asp 

specX02721.2481$86.64$30.47$17.33

43757Dx duod intub w/asp 

specsX02721.2481$86.64$30.47$17.33

43760Change gastrostomy 

tubeT06762.3410$162.51.$32.51

43761Reposition gastrostomy 

tubeT01418.3787$581.65$136.33$116.33

43770Lap place gastr adj 

deviceC

43771Lap revise gastr adj 

deviceC

43772Lap rmvl gastr adj 

deviceC

43773Lap replace gastr adj 

deviceC

43774Lap rmvl gastr adj all 

partsC

43775Lap sleeve 

gastrectomyE

43800Reconstruction of 

pylorusC

43810Fusion of stomach and 

bowelC

43820Fusion of stomach and 

bowelC

43825Fusion of stomach and 

bowelC

43830Place gastrostomy tubeCH 

T041912.5693$872.56$204.51$174.52

43831Place gastrostomy 

tubeT01418.3787$581.65$136.33$116.33
43832Place gastrostomy 

tubeC

43840Repair of stomach 

lesionC

43842V-band 

gastroplastyE

43843Gastroplasty w/o 

v-bandC

43845Gastroplasty duodenal 

switchC

43846Gastric bypass for 

obesityC

43847Gastric bypass incl small 

iC

43848Revision 

gastroplastyC

43850Revise stomach-bowel 

fusionC

43855Revise stomach-bowel 

fusionC

43860Revise stomach-bowel 

fusionC

43865Revise stomach-bowel 

fusionC

43870Repair stomach 

openingT042225.4890"$1,769.45".$353.89

43880Repair stomach-bowel 

fistulaC

43881Impl/redo electrd 

antrumC

43882Revise/remove electrd 

antrumC

43886Revise gastric port 

openT013721.8041"$1,513.64".$302.73

43887Remove gastric port 

openT01355.1973$360.80.$72.16

43888Change gastric port 

openT013721.8041"$1,513.64".$302.73

43999Stomach surgery 

procedureT01418.3787$581.65$136.33$116.33
44005Freeing of bowel 

adhesionC

44010Incision of small 

bowelC

44015Insert needle cath 

bowelC

44020Explore small 

intestineC

44021Decompress small 

bowelC

44025Incision of large 

bowelC

44050Reduce bowel 

obstructionC

44055Correct malrotation of 

bowelC

44100Biopsy of 

bowelCHT041912.5693$872.56$204.51$174.52

44110Excise intestine 

lesion(s)C

44111Excision of bowel 

lesion(s)C

44120Removal of small 

intestineC

44121Removal of small 

intestineC

44125Removal of small 

intestineC

44126Enterectomy w/o taper 

congC

44127Enterectomy w/taper 

congC

44128Enterectomy cong 

add-onC

44130Bowel to bowel 

fusionC

44132Enterectomy cadaver 

donorC

44133Enterectomy live 

donorC

44135Intestine transplnt 

cadaverC

44136Intestine transplant 

liveC
44137Remove intestinal 

allograftC

44139Mobilization of 

colonC

44140Partial removal of 

colonC

44141Partial removal of 

colonC

44143Partial removal of 

colonC

44144Partial removal of 

colonC

44145Partial removal of 

colonC

44146Partial removal of 

colonC

44147Partial removal of 

colonC

44150Removal of 

colonC

44151Removal of 

colon/ileostomyC

44155Removal of 

colon/ileostomyC

44156Removal of 

colon/ileostomyC

44157Colectomy w/ileoanal 

anastC

44158Colectomy w/neo-rectum 

pouchC

44160Removal of 

colonC

44180Lap 

enterolysisT013147.7164"$3,312.47""$1,001.89"$662.50

44186Lap 

jejunostomyT013147.7164"$3,312.47""$1,001.89"$662.50

44187Lap 

ileo/jejuno-stomyC

44188Lap 

colostomyC

44202Lap 

enterectomyC
44203Lap resect s/intestine 

addlC

44204Laparo partial 

colectomyC

44205Lap colectomy part 

w/ileumC

44206Lap part colectomy 

w/stomaT013271.0451"$4,931.95""$1,236.99"$986.39

44207L 

colectomy/coloproctostomyT013271.0451"$4,931.95""$1,236.99"$986.39

44208L 

colectomy/coloproctostomyT013271.0451"$4,931.95""$1,236.99"$986.39

44210Laparo total 

proctocolectomyC

44211Lap colectomy 

w/proctectomyC

44212Laparo total 

proctocolectomyC

44213Lap mobil splenic fl 

add-onT013039.0865"$2,713.38"$659.53$542.68

44227Lap close 

enterostomyC

44238Laparoscope proc 

intestineT013039.0865"$2,713.38"$659.53$542.68

44300Open bowel to 

skinC

44310Ileostomy/jejunostomyC

44312Revision of 

ileostomyT013721.8041"$1,513.64".$302.73

44314Revision of 

ileostomyC

44316Devise bowel 

pouchC

44320ColostomyC

44322Colostomy with 

biopsiesC

44340Revision of 

colostomyT013721.8041"$1,513.64".$302.73
44345Revision of 

colostomyC

44346Revision of 

colostomyC

44360Small bowel 

endoscopyT014210.1643$705.61$152.78$141.13

44361Small bowel 

endoscopy/biopsyT014210.1643$705.61$152.78$141.13

44363Small bowel 

endoscopyT014210.1643$705.61$152.78$141.13

44364Small bowel 

endoscopyCHT042415.8412"$1,099.70"$239.49$219.94

44365Small bowel 

endoscopyCHT042415.8412"$1,099.70"$239.49$219.94

44366Small bowel 

endoscopyCHT042415.8412"$1,099.70"$239.49$219.94

44369Small bowel 

endoscopyCHT042415.8412"$1,099.70"$239.49$219.94

44370Small bowel 

endoscopy/stentT038429.0233"$2,014.80".$402.96

44372Small bowel 

endoscopyCHT042415.8412"$1,099.70"$239.49$219.94

44373Small bowel 

endoscopyCHT042415.8412"$1,099.70"$239.49$219.94

44376Small bowel 

endoscopyT014210.1643$705.61$152.78$141.13

44377Small bowel 

endoscopy/biopsyT014210.1643$705.61$152.78$141.13

44378Small bowel 

endoscopyCHT042415.8412"$1,099.70"$239.49$219.94

44379S bowel endoscope 

w/stentT038429.0233"$2,014.80".$402.96

44380Small bowel 

endoscopyT014210.1643$705.61$152.78$141.13
44382Small bowel 

endoscopyT014210.1643$705.61$152.78$141.13

44383Ileoscopy 

w/stentT038429.0233"$2,014.80".$402.96

44385Endoscopy of bowel 

pouchT01439.3183$646.88$186.06$129.38

44386Endoscopy bowel 

pouch/biopT01439.3183$646.88$186.06$129.38

44388ColonoscopyT01439.3183$646.88$186.06$129.38

44389Colonoscopy with 

biopsyT01439.3183$646.88$186.06$129.38

44390Colonoscopy for foreign 

bodyT01439.3183$646.88$186.06$129.38

44391Colonoscopy for 

bleedingT01439.3183$646.88$186.06$129.38

44392Colonoscopy & 

polypectomyT01439.3183$646.88$186.06$129.38

44393Colonoscopy lesion 

removalT01439.3183$646.88$186.06$129.38

44394Colonoscopy 

w/snareT01439.3183$646.88$186.06$129.38

44397Colonoscopy 

w/stentT038429.0233"$2,014.80".$402.96

44500Intro gastrointestinal 

tubeT01216.3178$438.58.$87.72

44602Suture small 

intestineC

44603Suture small 

intestineC

44604Suture large 

intestineC

44605Repair of bowel 

lesionC

44615Intestinal 

stricturoplastyC
44620Repair bowel 

openingC

44625Repair bowel 

openingC

44626Repair bowel 

openingC

44640Repair bowel-skin 

fistulaC

44650Repair bowel 

fistulaC

44660Repair bowel-bladder 

fistulaC

44661Repair bowel-bladder 

fistulaC

44680Surgical revision 

intestineC

44700Suspend bowel 

w/prosthesisC

44701Intraop colon lavage 

add-onN

44715Prepare donor 

intestineC

44720Prep donor 

intestine/venousC

44721Prep donor 

intestine/arteryC

44799Unlisted procedure 

intestineT015326.6476"$1,849.88"$375.24$369.98

44800Excision of bowel 

pouchC

44820Excision of mesentery 

lesionC

44850Repair of 

mesenteryC

44899Bowel surgery 

procedureC

44900Drain app abscess 

openC

44901Drain app abscess 

percutT003715.3594"$1,066.25"$225.55$213.25

44950AppendectomyT015326.6476"$1,849.88"$375.24$369.98

44955Appendectomy 
add-onT015326.6476"$1,849.88"$375.24$369.98

44960AppendectomyC

44970Laparoscopy 

appendectomyT013147.7164"$3,312.47""$1,001.89"$662.50

44979Laparoscope proc 

appT013039.0865"$2,713.38"$659.53$542.68

45000Drainage of pelvic abscessCH 

T014924.4472"$1,697.12".$339.43

45005Drainage of rectal abscessCH 

T014924.4472"$1,697.12".$339.43

45020Drainage of rectal 

abscessT015516.0235"$1,112.35".$222.47

45100Biopsy of 

rectumT014924.4472"$1,697.12".$339.43

45108Removal of anorectal 

lesionT014924.4472"$1,697.12".$339.43

45110Removal of 

rectumC

45111Partial removal of 

rectumC

45112Removal of 

rectumC

45113Partial 

proctectomyC

45114Partial removal of 

rectumC

45116Partial removal of 

rectumC

45119Remove rectum 

w/reservoirC

45120Removal of 

rectumC

45121Removal of rectum and 

colonC

45123Partial 

proctectomyC

45126Pelvic 

exenterationC
45130Excision of rectal 

prolapseC

45135Excision of rectal 

prolapseC

45136Excise ileoanal 

reserviorC

45150Excision of rectal 

strictureT014924.4472"$1,697.12".$339.43

45160Excision of rectal 

lesionT014924.4472"$1,697.12".$339.43

45171Exc rect tum transanal partCH 

T014924.4472"$1,697.12".$339.43

45172Exc rect tum transanal 

fullT014924.4472"$1,697.12".$339.43

45190Destruction rectal 

tumorT014924.4472"$1,697.12".$339.43

45300Proctosigmoidoscopy 

dxT01466.3038$437.61.$87.53

45303Proctosigmoidoscopy 

dilateT014711.0219$765.14.$153.03

45305Proctosigmoidoscopy 

w/bxT014711.0219$765.14.$153.03

45307Proctosigmoidoscopy 

fbT042823.9719"$1,664.13".$332.83

45308Proctosigmoidoscopy 

removalT014711.0219$765.14.$153.03

45309Proctosigmoidoscopy 

removalT014711.0219$765.14.$153.03

45315Proctosigmoidoscopy 

removalT014711.0219$765.14.$153.03

45317Proctosigmoidoscopy 

bleedT014711.0219$765.14.$153.03

45320Proctosigmoidoscopy 

ablateT042823.9719"$1,664.13".$332.83

45321Proctosigmoidoscopy 
volvulT042823.9719"$1,664.13".$332.83

45327Proctosigmoidoscopy 

w/stentT038429.0233"$2,014.80".$402.96

45330Diagnostic 

sigmoidoscopyT01466.3038$437.61.$87.53

45331Sigmoidoscopy and 

biopsyT01466.3038$437.61.$87.53

45332Sigmoidoscopy w/fb 

removalT01466.3038$437.61.$87.53

45333Sigmoidoscopy & polypectomyCH 

T01466.3038$437.61.$87.53

45334Sigmoidoscopy for 

bleedingT014711.0219$765.14.$153.03

45335Sigmoidoscopy w/submuc 

injT01466.3038$437.61.$87.53

45337Sigmoidoscopy & 

decompressT01466.3038$437.61.$87.53

45338Sigmoidoscopy w/tumr removeCH 

T01466.3038$437.61.$87.53

45339Sigmoidoscopy w/ablate 

tumrT014711.0219$765.14.$153.03

45340Sig w/balloon 

dilationT014711.0219$765.14.$153.03

45341Sigmoidoscopy w/ultrasoundCH 

T01466.3038$437.61.$87.53

45342Sigmoidoscopy w/us guide 

bxT014711.0219$765.14.$153.03

45345Sigmoidoscopy 

w/stentT038429.0233"$2,014.80".$402.96

45355Surgical 

colonoscopyT01439.3183$646.88$186.06$129.38

45378Diagnostic 

colonoscopyT01439.3183$646.88$186.06$129.38
45379Colonoscopy w/fb 

removalT01439.3183$646.88$186.06$129.38

45380Colonoscopy and 

biopsyT01439.3183$646.88$186.06$129.38

45381Colonoscopy submucous 

injT01439.3183$646.88$186.06$129.38

45382Colonoscopy/control 

bleedingT01439.3183$646.88$186.06$129.38

45383Lesion removal 

colonoscopyT01439.3183$646.88$186.06$129.38

45384Lesion remove 

colonoscopyT01439.3183$646.88$186.06$129.38

45385Lesion removal 

colonoscopyT01439.3183$646.88$186.06$129.38

45386Colonoscopy dilate 

strictureT01439.3183$646.88$186.06$129.38

45387Colonoscopy 

w/stentT038429.0233"$2,014.80".$402.96

45391Colonoscopy w/endoscope 

usT01439.3183$646.88$186.06$129.38

45392Colonoscopy w/endoscopic 

fnbT01439.3183$646.88$186.06$129.38

45395Lap removal of 

rectumC

45397Lap remove rectum 

w/pouchC

45400Laparoscopic 

procC

45402Lap proctopexy w/sig 

resectC

45499Laparoscope proc 

rectumT013039.0865"$2,713.38"$659.53$542.68

45500Repair of 

rectumT014924.4472"$1,697.12".$339.43

45505Repair of 
rectumT015032.9730"$2,288.99".$457.80

45520Treatment of rectal 

prolapseT00130.9786$67.93.$13.59

45540Correct rectal 

prolapseC

45541Correct rectal 

prolapseT015032.9730"$2,288.99".$457.80

45550Repair rectum/remove 

sigmoidC

45560Repair of 

rectoceleT015032.9730"$2,288.99".$457.80

45562Exploration/repair of 

rectumC

45563Exploration/repair of 

rectumC

45800Repair rect/bladder 

fistulaC

45805Repair fistula 

w/colostomyC

45820Repair rectourethral 

fistulaC

45825Repair fistula 

w/colostomyC

45900Reduction of rectal 

prolapseT01486.1052$423.82.$84.77

45905Dilation of anal 

sphincterT014924.4472"$1,697.12".$339.43

45910Dilation of rectal 

narrowingT014924.4472"$1,697.12".$339.43

45915Remove rectal 

obstructionT015516.0235"$1,112.35".$222.47

45990Surg dx exam 

anorectalT014924.4472"$1,697.12".$339.43

45999Rectum surgery 

procedureT01486.1052$423.82.$84.77

46020Placement of 

setonT014924.4472"$1,697.12".$339.43
46030Removal of rectal 

markerT01486.1052$423.82.$84.77

46040Incision of rectal 

abscessT014924.4472"$1,697.12".$339.43

46045Incision of rectal 

abscessT014924.4472"$1,697.12".$339.43

46050Incision of anal 

abscessCHT01486.1052$423.82.$84.77

46060Incision of rectal 

abscessT014924.4472"$1,697.12".$339.43

46070Incision of anal 

septumT015516.0235"$1,112.35".$222.47

46080Incision of anal 

sphincterT014924.4472"$1,697.12".$339.43

46083Incise external 

hemorrhoidT01642.0973$145.59.$29.12

46200Removal of anal 

fissureT014924.4472"$1,697.12".$339.43

46220Excise anal ext 

tag/papillaT015516.0235"$1,112.35".$222.47

46221Ligation of 

hemorrhoid(s)T01486.1052$423.82.$84.77

46230Removal of anal 

tagsT014924.4472"$1,697.12".$339.43

46250Remove ext hem groups 

2+T014924.4472"$1,697.12".$339.43

46255Remove int/ext hem 1 

groupT014924.4472"$1,697.12".$339.43

46257Remove in/ex hem grp & 

fissT014924.4472"$1,697.12".$339.43

46258Remove in/ex hem grp 

w/fistuT014924.4472"$1,697.12".$339.43

46260Remove in/ex hem groups 
2+T014924.4472"$1,697.12".$339.43

46261Remove in/ex hem grps & 

fissT014924.4472"$1,697.12".$339.43

46262Remove in/ex hem grps 

w/fistT014924.4472"$1,697.12".$339.43

46270Remove anal fist 

subqT014924.4472"$1,697.12".$339.43

46275Remove anal fist 

interT014924.4472"$1,697.12".$339.43

46280Remove anal fist 

complexT014924.4472"$1,697.12".$339.43

46285Remove anal fist 2 

stageT014924.4472"$1,697.12".$339.43

46288Repair anal 

fistulaT014924.4472"$1,697.12".$339.43

46320Removal of hemorrhoid 

clotT014924.4472"$1,697.12".$339.43

46500Injection into hemorrhoid(s)CH 

T01486.1052$423.82.$84.77

46505Chemodenervation anal 

muscT014924.4472"$1,697.12".$339.43

46600Diagnostic 

anoscopyX03400.6739$46.78.$9.36

46604Anoscopy and 

dilationT014711.0219$765.14.$153.03

46606Anoscopy and 

biopsyT01466.3038$437.61.$87.53

46608Anoscopy remove for bodyCH 

T01466.3038$437.61.$87.53

46610Anoscopy remove 

lesionT042823.9719"$1,664.13".$332.83

46611AnoscopyT014711.0219$765.14.$153.03
46612Anoscopy remove 

lesionsT042823.9719"$1,664.13".$332.83

46614Anoscopy control 

bleedingT01466.3038$437.61.$87.53

46615AnoscopyT042823.9719"$1,664.13".$332.83

46700Repair of anal 

strictureT014924.4472"$1,697.12".$339.43

46705Repair of anal 

strictureC

46706Repr of anal fistula 

w/glueT015032.9730"$2,288.99".$457.80

46707Repair anorectal fist 

w/plugT015032.9730"$2,288.99".$457.80

46710Repr per/vag pouch sngl 

procC

46712Repr per/vag pouch dbl 

procC

46715Rep perf anoper 

fistuC

46716Rep perf anoper/vestib 

fistuC

46730Construction of absent 

anusC

46735Construction of absent 

anusC

46740Construction of absent 

anusC

46742Repair of imperforated 

anusC

46744Repair of cloacal 

anomalyC

46746Repair of cloacal 

anomalyC

46748Repair of cloacal 

anomalyC

46750Repair of anal 

sphincterT015032.9730"$2,288.99".$457.80

46751Repair of anal 

sphincterC
46753Reconstruction of 

anusT014924.4472"$1,697.12".$339.43

46754Removal of suture from 

anusT014924.4472"$1,697.12".$339.43

46760Repair of anal 

sphincterT015032.9730"$2,288.99".$457.80

46761Repair of anal 

sphincterT015032.9730"$2,288.99".$457.80

46762Implant artificial 

sphincterT015032.9730"$2,288.99".$457.80

46900Destruction anal 

lesion(s)T00162.8248$196.10.$39.22

46910Destruction anal 

lesion(s)T001722.0631"$1,531.62".$306.33

46916Cryosurgery anal 

lesion(s)T00151.4936$103.69.$20.74

46917Laser surgery anal 

lesionsT001722.0631"$1,531.62".$306.33

46922Excision of anal 

lesion(s)T001722.0631"$1,531.62".$306.33

46924Destruction anal 

lesion(s)T001722.0631"$1,531.62".$306.33

46930Destroy internal 

hemorrhoidsT01486.1052$423.82.$84.77

46940Treatment of anal 

fissureT014924.4472"$1,697.12".$339.43

46942Treatment of anal 

fissureT01486.1052$423.82.$84.77

46945Remove by ligat int hem grpCH 

T014924.4472"$1,697.12".$339.43

46946Remove by ligat int hem grpsCH 

T014924.4472"$1,697.12".$339.43

46947Hemorrhoidopexy by 

staplingT015032.9730"$2,288.99".$457.80
46999Anus surgery 

procedureT01486.1052$423.82.$84.77

47000Needle biopsy of 

liverT06859.7281$675.32.$135.07

47001Needle biopsy liver 

add-onN

47010Open drainage liver 

lesionC

47011Percut drain liver 

lesionT003715.3594"$1,066.25"$225.55$213.25

47015Inject/aspirate liver 

cystC

47100Wedge biopsy of 

liverC

47120Partial removal of 

liverC

47122Extensive removal of 

liverC

47125Partial removal of 

liverC

47130Partial removal of 

liverC

47133Removal of donor 

liverC

47135Transplantation of 

liverC

47136Transplantation of 

liverC

47140Partial removal donor 

liverC

47141Partial removal donor 

liverC

47142Partial removal donor 

liverC

47143Prep donor liver 

wholeC

47144Prep donor liver 

3-segmentC

47145Prep donor liver lobe 

splitC

47146Prep donor 
liver/venousC

47147Prep donor 

liver/arterialC

47300Surgery for liver 

lesionC

47350Repair liver 

woundC

47360Repair liver 

woundC

47361Repair liver 

woundC

47362Repair liver 

woundC

47370Laparo ablate liver tumor 

rfT0174107.5115"$7,463.45""$1,962.55""$1,492.69"

47371Laparo ablate liver 

cryosurgT0174107.5115"$7,463.45""$1,962.55""$1,492.69"

47379Laparoscope procedure 

liverT013039.0865"$2,713.38"$659.53$542.68

47380Open ablate liver tumor 

rfC

47381Open ablate liver tumor 

cryoC

47382Percut ablate liver 

rfT042357.1703"$3,968.76".$793.76

47399Liver surgery 

procedureT00044.5956$319.03.$63.81

47400Incision of liver 

ductC

47420Incision of bile 

ductC

47425Incision of bile 

ductC

47460Incise bile duct 

sphincterC

47480Incision of 

gallbladderC

47490Incision of 

gallbladderT015231.2779"$2,171.31".$434.27

47500Injection for liver 
x-raysN

47505Injection for liver 

x-raysN

47510Insert catheter bile 

ductT015231.2779"$2,171.31".$434.27

47511Insert bile duct 

drainT015231.2779"$2,171.31".$434.27

47525Change bile duct 

catheterT042716.2153"$1,125.67".$225.14

47530Revise/reinsert bile 

tubeT042716.2153"$1,125.67".$225.14

47550Bile duct endoscopy 

add-onC

47552Biliary endoscopy thru 

skinT015231.2779"$2,171.31".$434.27

47553Biliary endoscopy thru 

skinT015231.2779"$2,171.31".$434.27

47554Biliary endoscopy thru 

skinT015231.2779"$2,171.31".$434.27

47555Biliary endoscopy thru 

skinT015231.2779"$2,171.31".$434.27

47556Biliary endoscopy thru 

skinT015231.2779"$2,171.31".$434.27

47560Laparoscopy 

w/cholangioT013039.0865"$2,713.38"$659.53$542.68

47561Laparo 

w/cholangio/biopsyT013039.0865"$2,713.38"$659.53$542.68

47562Laparoscopic 

cholecystectomyT013147.7164"$3,312.47""$1,001.89"$662.50

47563Laparo 

cholecystectomy/graphT013147.7164"$3,312.47""$1,001.89"$662.50

47564Laparo 

cholecystectomy/explrT013147.7164"$3,312.47""$1,001.89"$662.50

47570Laparo 

cholecystoenterostomyC
47579Laparoscope proc 

biliaryT013039.0865"$2,713.38"$659.53$542.68

47600Removal of 

gallbladderC

47605Removal of 

gallbladderC

47610Removal of 

gallbladderC

47612Removal of 

gallbladderC

47620Removal of 

gallbladderC

47630Remove bile duct 

stoneT015231.2779"$2,171.31".$434.27

47700Exploration of bile 

ductsC

47701Bile duct 

revisionC

47711Excision of bile duct 

tumorC

47712Excision of bile duct 

tumorC

47715Excision of bile duct 

cystC

47720Fuse gallbladder & 

bowelC

47721Fuse upper gi 

structuresC

47740Fuse gallbladder & 

bowelC

47741Fuse gallbladder & 

bowelC

47760Fuse bile ducts and 

bowelC

47765Fuse liver ducts & 

bowelC

47780Fuse bile ducts and 

bowelC

47785Fuse bile ducts and 

bowelC

47800Reconstruction of bile 

ductsC
47801Placement bile duct 

supportC

47802Fuse liver duct & 

intestineC

47900Suture bile duct 

injuryC

47999Bile tract surgery 

procedureT015231.2779"$2,171.31".$434.27

48000Drainage of 

abdomenC

48001Placement of drain 

pancreasC

48020Removal of pancreatic 

stoneC

48100Biopsy of pancreas 

openC

48102Needle biopsy 

pancreasT06859.7281$675.32.$135.07

48105Resect/debride 

pancreasC

48120Removal of pancreas 

lesionC

48140Partial removal of 

pancreasC

48145Partial removal of 

pancreasC

48146PancreatectomyC

48148Removal of pancreatic 

ductC

48150Partial removal of 

pancreasC

48152PancreatectomyC

48153PancreatectomyC

48154PancreatectomyC

48155Removal of 

pancreasC

48160Pancreas 

removal/transplantE
48400Injection intraop 

add-onC

48500Surgery of pancreatic 

cystC

48510Drain pancreatic 

pseudocystC

48511Drain pancreatic 

pseudocystT003715.3594"$1,066.25"$225.55$213.25

48520Fuse pancreas cyst and 

bowelC

48540Fuse pancreas cyst and 

bowelC

48545PancreatorrhaphyC

48547Duodenal 

exclusionC

48548Fuse pancreas and 

bowelC

48550Donor 

pancreatectomyE

48551Prep donor 

pancreasC

48552Prep donor 

pancreas/venousC

48554Transpl allograft 

pancreasC

48556Removal allograft 

pancreasC

48999Pancreas surgery 

procedureT00044.5956$319.03.$63.81

49000Exploration of 

abdomenC

49002Reopening of 

abdomenC

49010Exploration behind 

abdomenC

49020Drain abdominal 

abscessC

49021Drain abdominal 

abscessT003715.3594"$1,066.25"$225.55$213.25

49040Drain open abdom 

abscessC
49041Drain percut abdom 

abscessT003715.3594"$1,066.25"$225.55$213.25

49060Drain open retrop 

abscessC

49061Drain percut retroper 

abscT003715.3594"$1,066.25"$225.55$213.25

49062Drain to peritoneal 

cavityC

49080Puncture peritoneal 

cavityT00705.5572$385.78.$77.16

49081Removal of abdominal 

fluidT00705.5572$385.78.$77.16

49180Biopsy abdominal 

massT06859.7281$675.32.$135.07

49203Exc abd tum 5 cm or 

lessC

49204Exc abd tum over 5 

cmC

49205Exc abd tum over 10 

cmC

49215Excise sacral spine 

tumorC

49220Multiple surgery 

abdomenC

49250Excision of 

umbilicusT015326.6476"$1,849.88"$375.24$369.98

49255Removal of 

omentumC

49320Diag laparo separate 

procT013039.0865"$2,713.38"$659.53$542.68

49321Laparoscopy 

biopsyT013039.0865"$2,713.38"$659.53$542.68

49322Laparoscopy 

aspirationT013039.0865"$2,713.38"$659.53$542.68

49323Laparo drain 

lymphoceleT013039.0865"$2,713.38"$659.53$542.68

49324Lap insert tunnel ip 

cathT013039.0865"$2,713.38"$659.53$542.68
49325Lap revision perm ip 

cathT013039.0865"$2,713.38"$659.53$542.68

49326Lap w/omentopexy 

add-onT013039.0865"$2,713.38"$659.53$542.68

49327Lap ins device for 

rtT013039.0865"$2,713.38"$659.53$542.68

49329Laparo proc 

abdm/per/omentT013039.0865"$2,713.38"$659.53$542.68

49400Air injection into 

abdomenN

49402Remove foreign body 

adbomenT015326.6476"$1,849.88"$375.24$369.98

49411Ins mark abd/pel for rt 

perqX031013.2460$919.54$322.74$183.91

49412Ins device for rt guide openC 

49418Insert tun ip cath 

percT065230.6257"$2,126.04".$425.21

49419Insert tun ip cath 

w/portT011536.8791"$2,560.15".$512.03

49421Ins tun ip cath for dial 

opnT065230.6257"$2,126.04".$425.21

49422Remove tunneled ip 

cathT010523.2424"$1,613.49".$322.70

49423Exchange drainage 

catheterT042716.2153"$1,125.67".$225.14

49424Assess cyst contrast 

injectN

49425Insert abdomen-venous 

drainC

49426Revise abdomen-venous 

shuntT015326.6476"$1,849.88"$375.24$369.98

49427Injection abdominal 

shuntN

49428Ligation of 
shuntC

49429Removal of 

shuntT010523.2424"$1,613.49".$322.70

49435Insert subq exten to ip 

cathT042716.2153"$1,125.67".$225.14

49436Embedded ip cath 

exit-siteT042716.2153"$1,125.67".$225.14

49440Place gastrostomy tube 

percCHT041912.5693$872.56$204.51$174.52

49441Place duod/jej tube 

percCHT041912.5693$872.56$204.51$174.52

49442Place cecostomy tube 

percCHT014924.4472"$1,697.12".$339.43

49446Change g-tube to g-j 

percCHT041912.5693$872.56$204.51$174.52

49450Replace g/c tube 

percT01216.3178$438.58.$87.72

49451Replace duod/jej tube 

percT01216.3178$438.58.$87.72

49452Replace g-j tube 

percT01216.3178$438.58.$87.72

49460Fix g/colon tube 

w/deviceT01216.3178$438.58.$87.72

49465Fluoro exam of g/colon 

tubeQ102772.0083$139.42$52.93$27.89

49491Rpr hern preemie 

reducT015432.9744"$2,289.08"$464.85$457.82

49492Rpr ing hern premie 

blockedT015432.9744"$2,289.08"$464.85$457.82

49495Rpr ing hernia baby 

reducT015432.9744"$2,289.08"$464.85$457.82

49496Rpr ing hernia baby 

blockedT015432.9744"$2,289.08"$464.85$457.82
49500Rpr ing hernia init 

reduceT015432.9744"$2,289.08"$464.85$457.82

49501Rpr ing hernia init 

blockedT015432.9744"$2,289.08"$464.85$457.82

49505Prp i/hern init reduc >5 

yrT015432.9744"$2,289.08"$464.85$457.82

49507Prp i/hern init block >5 

yrT015432.9744"$2,289.08"$464.85$457.82

49520Rerepair ing hernia 

reduceT015432.9744"$2,289.08"$464.85$457.82

49521Rerepair ing hernia 

blockedT015432.9744"$2,289.08"$464.85$457.82

49525Repair ing hernia 

slidingT015432.9744"$2,289.08"$464.85$457.82

49540Repair lumbar 

herniaT015432.9744"$2,289.08"$464.85$457.82

49550Rpr rem hernia init 

reduceT015432.9744"$2,289.08"$464.85$457.82

49553Rpr fem hernia init 

blockedT015432.9744"$2,289.08"$464.85$457.82

49555Rerepair fem hernia 

reduceT015432.9744"$2,289.08"$464.85$457.82

49557Rerepair fem hernia 

blockedT015432.9744"$2,289.08"$464.85$457.82

49560Rpr ventral hern init 

reducT015432.9744"$2,289.08"$464.85$457.82

49561Rpr ventral hern init 

blockT015432.9744"$2,289.08"$464.85$457.82

49565Rerepair ventrl hern 

reduceT015432.9744"$2,289.08"$464.85$457.82

49566Rerepair ventrl hern 

blockT015432.9744"$2,289.08"$464.85$457.82

49568Hernia repair 

w/meshT015432.9744"$2,289.08"$464.85$457.82
49570Rpr epigastric hern 

reduceT015432.9744"$2,289.08"$464.85$457.82

49572Rpr epigastric hern 

blockedT015432.9744"$2,289.08"$464.85$457.82

49580Rpr umbil hern reduc < 5 

yrT015432.9744"$2,289.08"$464.85$457.82

49582Rpr umbil hern block < 5 

yrT015432.9744"$2,289.08"$464.85$457.82

49585Rpr umbil hern reduc > 5 

yrT015432.9744"$2,289.08"$464.85$457.82

49587Rpr umbil hern block > 5 

yrT015432.9744"$2,289.08"$464.85$457.82

49590Repair spigelian 

herniaT015432.9744"$2,289.08"$464.85$457.82

49600Repair umbilical 

lesionT015432.9744"$2,289.08"$464.85$457.82

49605Repair umbilical 

lesionC

49606Repair umbilical 

lesionC

49610Repair umbilical 

lesionC

49611Repair umbilical 

lesionC

49650Lap ing hernia repair 

initT013147.7164"$3,312.47""$1,001.89"$662.50

49651Lap ing hernia repair 

recurT013147.7164"$3,312.47""$1,001.89"$662.50

49652Lap vent/abd hernia 

repairT013271.0451"$4,931.95""$1,236.99"$986.39

49653Lap vent/abd hern proc 

compT013271.0451"$4,931.95""$1,236.99"$986.39

49654Lap inc hernia 

repairT013271.0451"$4,931.95""$1,236.99"$986.39
49655Lap inc hern repair 

compT013271.0451"$4,931.95""$1,236.99"$986.39

49656Lap inc hernia repair 

recurT013271.0451"$4,931.95""$1,236.99"$986.39

49657Lap inc hern recur 

compT013271.0451"$4,931.95""$1,236.99"$986.39

49659Laparo proc hernia 

repairT013039.0865"$2,713.38"$659.53$542.68

49900Repair of abdominal 

wallC

49904Omental flap 

extra-abdomC

49905Omental flap 

intra-abdomC

49906Free omental flap 

microvascC

49999Abdomen surgery 

procedureT015326.6476"$1,849.88"$375.24$369.98

50010Exploration of 

kidneyC

50020Renal abscess open 

drainT016226.2690"$1,823.59".$364.72

50021Renal abscess percut 

drainT003715.3594"$1,066.25"$225.55$213.25

50040Drainage of 

kidneyC

50045Exploration of 

kidneyC

50060Removal of kidney 

stoneC

50065Incision of 

kidneyC

50070Incision of 

kidneyC

50075Removal of kidney 

stoneC

50080Removal of kidney 

stoneT042945.8647"$3,183.93".$636.79

50081Removal of kidney 
stoneT042945.8647"$3,183.93".$636.79

50100Revise kidney blood 

vesselsC

50120Exploration of 

kidneyC

50125Explore and drain 

kidneyC

50130Removal of kidney 

stoneC

50135Exploration of 

kidneyC

50200Renal biopsy 

perqT06859.7281$675.32.$135.07

50205Renal biopsy 

openC

50220Remove kidney 

openC

50225Removal kidney open 

complexC

50230Removal kidney open 

radicalC

50234Removal of kidney & 

ureterC

50236Removal of kidney & 

ureterC

50240Partial removal of 

kidneyC

50250Cryoablate renal mass 

openC

50280Removal of kidney 

lesionC

50290Removal of kidney 

lesionC

50300Remove cadaver donor 

kidneyC

50320Remove kidney living 

donorC

50323Prep cadaver renal 

allograftC

50325Prep donor renal 

graftC

50327Prep renal 

graft/venousC
50328Prep renal 

graft/arterialC

50329Prep renal 

graft/ureteralC

50340Removal of 

kidneyC

50360Transplantation of 

kidneyC

50365Transplantation of 

kidneyC

50370Remove transplanted 

kidneyC

50380Reimplantation of 

kidneyC

50382Change ureter stent 

percutT016226.2690"$1,823.59".$364.72

50384Remove ureter stent 

percutT016117.6738"$1,226.92".$245.39

50385Change stent via 

transurethT016226.2690"$1,823.59".$364.72

50386Remove stent via 

transurethT01607.3594$510.89.$102.18

50387Change ext/int ureter 

stentT042716.2153"$1,125.67".$225.14

50389Remove renal tube 

w/fluoroT01607.3594$510.89.$102.18

50390Drainage of kidney 

lesionT06859.7281$675.32.$135.07

50391Instll rx agnt into rnal 

tubT01261.1699$81.21.$16.25

50392Insert kidney 

drainT016117.6738"$1,226.92".$245.39

50393Insert ureteral 

tubeT016226.2690"$1,823.59".$364.72

50394Injection for kidney 

x-rayN

50395Create passage to 
kidneyT016226.2690"$1,823.59".$364.72

50396Measure kidney 

pressureT01642.0973$145.59.$29.12

50398Change kidney 

tubeT042716.2153"$1,125.67".$225.14

50400Revision of 

kidney/ureterC

50405Revision of 

kidney/ureterC

50500Repair of kidney 

woundC

50520Close kidney-skin 

fistulaC

50525Repair renal-abdomen 

fistulaC

50526Repair renal-abdomen 

fistulaC

50540Revision of horseshoe 

kidneyC

50541Laparo ablate renal 

cystT013039.0865"$2,713.38"$659.53$542.68

50542Laparo ablate renal 

massT0174107.5115"$7,463.45""$1,962.55""$1,492.69"

50543Laparo partial 

nephrectomyT013147.7164"$3,312.47""$1,001.89"$662.50

50544Laparoscopy pyeloplastyCH 

T013147.7164"$3,312.47""$1,001.89"$662.50

50545Laparo radical 

nephrectomyC

50546Laparoscopic 

nephrectomyC

50547Laparo removal donor 

kidneyC

50548Laparo remove 

w/ureterC

50549Laparoscope proc 

renalT013039.0865"$2,713.38"$659.53$542.68

50551Kidney 

endoscopyT01607.3594$510.89.$102.18
50553Kidney 

endoscopyT016226.2690"$1,823.59".$364.72

50555Kidney endoscopy & 

biopsyT01607.3594$510.89.$102.18

50557Kidney endoscopy & 

treatmentT016226.2690"$1,823.59".$364.72

50561Kidney endoscopy & 

treatmentT016226.2690"$1,823.59".$364.72

50562Renal scope w/tumor 

resectT01607.3594$510.89.$102.18

50570Kidney 

endoscopyT01607.3594$510.89.$102.18

50572Kidney 

endoscopyT01607.3594$510.89.$102.18

50574Kidney endoscopy & 

biopsyT01607.3594$510.89.$102.18

50575Kidney 

endoscopyT016336.9605"$2,565.80".$513.16

50576Kidney endoscopy & 

treatmentT016117.6738"$1,226.92".$245.39

50580Kidney endoscopy & 

treatmentT016117.6738"$1,226.92".$245.39

50590Fragmenting of kidney 

stoneT016951.4038"$3,568.45"$997.74$713.69

50592Perc rf ablate renal 

tumorT042357.1703"$3,968.76".$793.76

50593Perc cryo ablate renal 

tumT042357.1703"$3,968.76".$793.76

50600Exploration of 

ureterC

50605Insert ureteral 

supportC

50610Removal of ureter 

stoneC
50620Removal of ureter 

stoneC

50630Removal of ureter 

stoneC

50650Removal of 

ureterC

50660Removal of 

ureterC

50684Injection for ureter 

x-rayN

50686Measure ureter 

pressureT01261.1699$81.21.$16.25

50688Change of ureter 

tube/stentT042716.2153"$1,125.67".$225.14

50690Injection for ureter 

x-rayN

50700Revision of 

ureterC

50715Release of 

ureterC

50722Release of 

ureterC

50725Release/revise 

ureterC

50727Revise 

ureterT016520.1960"$1,402.01".$280.41

50728Revise 

ureterC

50740Fusion of ureter & 

kidneyC

50750Fusion of ureter & 

kidneyC

50760Fusion of 

uretersC

50770Splicing of 

uretersC

50780Reimplant ureter in 

bladderC

50782Reimplant ureter in 

bladderC

50783Reimplant ureter in 

bladderC
50785Reimplant ureter in 

bladderC

50800Implant ureter in 

bowelC

50810Fusion of ureter & 

bowelC

50815Urine shunt to 

intestineC

50820Construct bowel 

bladderC

50825Construct bowel 

bladderC

50830Revise urine 

flowC

50840Replace ureter by 

bowelC

50845Appendico-vesicostomyC

50860Transplant ureter to 

skinC

50900Repair of 

ureterC

50920Closure ureter/skin 

fistulaC

50930Closure ureter/bowel 

fistulaC

50940Release of 

ureterC

50945Laparoscopy 

ureterolithotomyT013147.7164"$3,312.47""$1,001.89"$662.50

50947Laparo new 

ureter/bladderT013147.7164"$3,312.47""$1,001.89"$662.50

50948Laparo new 

ureter/bladderT013147.7164"$3,312.47""$1,001.89"$662.50

50949Laparoscope proc 

ureterT013039.0865"$2,713.38"$659.53$542.68

50951Endoscopy of 

ureterT01607.3594$510.89.$102.18

50953Endoscopy of 

ureterT01607.3594$510.89.$102.18
50955Ureter endoscopy & 

biopsyT016226.2690"$1,823.59".$364.72

50957Ureter endoscopy & 

treatmentT016226.2690"$1,823.59".$364.72

50961Ureter endoscopy & 

treatmentT016226.2690"$1,823.59".$364.72

50970Ureter 

endoscopyT01607.3594$510.89.$102.18

50972Ureter endoscopy & 

catheterT01607.3594$510.89.$102.18

50974Ureter endoscopy & 

biopsyT016117.6738"$1,226.92".$245.39

50976Ureter endoscopy & 

treatmentT016117.6738"$1,226.92".$245.39

50980Ureter endoscopy & 

treatmentT016226.2690"$1,823.59".$364.72

51020Incise & treat 

bladderT016226.2690"$1,823.59".$364.72

51030Incise & treat 

bladderT016226.2690"$1,823.59".$364.72

51040Incise & drain 

bladderT016226.2690"$1,823.59".$364.72

51045Incise bladder/drain 

ureterT01607.3594$510.89.$102.18

51050Removal of bladder 

stoneT016226.2690"$1,823.59".$364.72

51060Removal of ureter 

stoneT016336.9605"$2,565.80".$513.16

51065Remove ureter 

calculusT016226.2690"$1,823.59".$364.72

51080Drainage of bladder 

abscessT000820.5401"$1,425.89".$285.18

51100Drain bladder by 
needleT01642.0973$145.59.$29.12

51101Drain bladder by 

trocar/cathT01261.1699$81.21.$16.25

51102Drain bl w/cath 

insertionT016520.1960"$1,402.01".$280.41

51500Removal of bladder 

cystT015432.9744"$2,289.08"$464.85$457.82

51520Removal of bladder 

lesionT016226.2690"$1,823.59".$364.72

51525Removal of bladder 

lesionC

51530Removal of bladder 

lesionC

51535Repair of ureter 

lesionT016226.2690"$1,823.59".$364.72

51550Partial removal of 

bladderC

51555Partial removal of 

bladderC

51565Revise bladder & 

ureter(s)C

51570Removal of 

bladderC

51575Removal of bladder & 

nodesC

51580Remove bladder/revise 

tractC

51585Removal of bladder & 

nodesC

51590Remove bladder/revise 

tractC

51595Remove bladder/revise 

tractC

51596Remove bladder/create 

pouchC

51597Removal of pelvic 

structuresC

51600Injection for bladder 

x-rayN

51605Preparation for bladder 
xrayN

51610Injection for bladder 

x-rayN

51700Irrigation of 

bladderT01642.0973$145.59.$29.12

51701Insert bladder 

catheterX03400.6739$46.78.$9.36

51702Insert temp bladder 

cathX03400.6739$46.78.$9.36

51703Insert bladder cath 

complexT01261.1699$81.21.$16.25

51705Change of bladder 

tubeT01642.0973$145.59.$29.12

51710Change of bladder 

tubeT01216.3178$438.58.$87.72

51715Endoscopic 

injection/implantT016832.1043"$2,228.68".$445.74

51720Treatment of bladder 

lesionT01563.1976$221.98.$44.40

51725Simple 

cystometrogramT01563.1976$221.98.$44.40

51726Complex 

cystometrogramT01563.1976$221.98.$44.40

51727Cystometrogram 

w/upT01563.1976$221.98.$44.40

51728Cystometrogram 

w/vpT01563.1976$221.98.$44.40

51729Cystometrogram 

w/vp&upT01563.1976$221.98.$44.40

51736Urine flow 

measurementX03400.6739$46.78.$9.36

51741Electro-uroflowmetry 

firstT01261.1699$81.21.$16.25

51784Anal/urinary muscle 
studyT01261.1699$81.21.$16.25

51785Anal/urinary muscle 

studyT01642.0973$145.59.$29.12

51792Urinary reflex 

studyT01261.1699$81.21.$16.25

51797Intraabdominal pressure 

testT01642.0973$145.59.$29.12

51798Us urine capacity 

measureX03400.6739$46.78.$9.36

51800Revision of 

bladder/urethraC

51820Revision of urinary 

tractC

51840Attach 

bladder/urethraC

51841Attach 

bladder/urethraC

51845Repair bladder 

neckT020245.5816"$3,164.27"$981.50$632.86

51860Repair of bladder 

woundT016226.2690"$1,823.59".$364.72

51865Repair of bladder 

woundC

51880Repair of bladder 

openingT016226.2690"$1,823.59".$364.72

51900Repair bladder/vagina 

lesionC

51920Close bladder-uterus 

fistulaC

51925Hysterectomy/bladder 

repairC

51940Correction of bladder 

defectC

51960Revision of bladder & 

bowelC

51980Construct bladder 

openingC

51990Laparo urethral 

suspensionT013147.7164"$3,312.47""$1,001.89"$662.50
51992Laparo sling 

operationT013147.7164"$3,312.47""$1,001.89"$662.50

51999Laparoscope proc 

blaT013039.0865"$2,713.38"$659.53$542.68

52000CystoscopyT01607.3594$510.89.$102.18

52001Cystoscopy removal of 

clotsT016117.6738"$1,226.92".$245.39

52005Cystoscopy & ureter 

catheterT016226.2690"$1,823.59".$364.72

52007Cystoscopy and 

biopsyT016226.2690"$1,823.59".$364.72

52010Cystoscopy & duct 

catheterT01607.3594$510.89.$102.18

52204Cystoscopy 

w/biopsy(s)T016226.2690"$1,823.59".$364.72

52214Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52224Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52234Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52235Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52240Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52250Cystoscopy and 

radiotracerT016226.2690"$1,823.59".$364.72

52260Cystoscopy and 

treatmentT016117.6738"$1,226.92".$245.39

52265Cystoscopy and 

treatmentT01607.3594$510.89.$102.18

52270Cystoscopy & revise 
urethraT016117.6738"$1,226.92".$245.39

52275Cystoscopy & revise 

urethraT016226.2690"$1,823.59".$364.72

52276Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52277Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52281Cystoscopy and 

treatmentT016117.6738"$1,226.92".$245.39

52282Cystoscopy implant 

stentT016336.9605"$2,565.80".$513.16

52283Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52285Cystoscopy and 

treatmentT016117.6738"$1,226.92".$245.39

52290Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52300Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52301Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52305Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52310Cystoscopy and 

treatmentT016117.6738"$1,226.92".$245.39

52315Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52317Remove bladder 

stoneT016226.2690"$1,823.59".$364.72

52318Remove bladder 

stoneT016226.2690"$1,823.59".$364.72

52320Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72
52325Cystoscopy stone 

removalT016226.2690"$1,823.59".$364.72

52327Cystoscopy inject 

materialT016336.9605"$2,565.80".$513.16

52330Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52332Cystoscopy and 

treatmentT016226.2690"$1,823.59".$364.72

52334Create passage to 

kidneyT016226.2690"$1,823.59".$364.72

52341Cysto w/ureter stricture 

txT016226.2690"$1,823.59".$364.72

52342Cysto w/up stricture 

txT016226.2690"$1,823.59".$364.72

52343Cysto w/renal stricture 

txT016226.2690"$1,823.59".$364.72

52344Cysto/uretero stricture 

txT016226.2690"$1,823.59".$364.72

52345Cysto/uretero w/up 

strictureT016226.2690"$1,823.59".$364.72

52346Cystouretero w/renal 

strictT016226.2690"$1,823.59".$364.72

52351Cystouretero & or 

pyeloscopeT016226.2690"$1,823.59".$364.72

52352Cystouretero w/stone 

removeT016226.2690"$1,823.59".$364.72

52353Cystouretero 

w/lithotripsyT016336.9605"$2,565.80".$513.16

52354Cystouretero 

w/biopsyT016226.2690"$1,823.59".$364.72

52355Cystouretero w/excise 

tumorT016226.2690"$1,823.59".$364.72

52400Cystouretero w/congen 
reprT016226.2690"$1,823.59".$364.72

52402Cystourethro cut ejacul 

ductT016226.2690"$1,823.59".$364.72

52450Incision of 

prostateT016226.2690"$1,823.59".$364.72

52500Revision of bladder 

neckT016226.2690"$1,823.59".$364.72

52601Prostatectomy 

(TURP)T016336.9605"$2,565.80".$513.16

52630Remove prostate 

regrowthT016336.9605"$2,565.80".$513.16

52640Relieve bladder 

contractureT016226.2690"$1,823.59".$364.72

52647Laser surgery of 

prostateT042945.8647"$3,183.93".$636.79

52648Laser surgery of 

prostateT042945.8647"$3,183.93".$636.79

52649Prostate laser 

enucleationT042945.8647"$3,183.93".$636.79

52700Drainage of prostate 

abscessT016226.2690"$1,823.59".$364.72

53000Incision of 

urethraT016620.7987"$1,443.85".$288.77

53010Incision of 

urethraT016620.7987"$1,443.85".$288.77

53020Incision of 

urethraT016620.7987"$1,443.85".$288.77

53025Incision of 

urethraT016620.7987"$1,443.85".$288.77

53040Drainage of urethra 

abscessT016620.7987"$1,443.85".$288.77

53060Drainage of urethra 

abscessT016620.7987"$1,443.85".$288.77
53080Drainage of urinary 

leakageT016620.7987"$1,443.85".$288.77

53085Drainage of urinary 

leakageT016620.7987"$1,443.85".$288.77

53200Biopsy of 

urethraT016620.7987"$1,443.85".$288.77

53210Removal of 

urethraT016832.1043"$2,228.68".$445.74

53215Removal of 

urethraT016620.7987"$1,443.85".$288.77

53220Treatment of urethra 

lesionT016832.1043"$2,228.68".$445.74

53230Removal of urethra 

lesionT016832.1043"$2,228.68".$445.74

53235Removal of urethra 

lesionT016620.7987"$1,443.85".$288.77

53240Surgery for urethra 

pouchT016832.1043"$2,228.68".$445.74

53250Removal of urethra 

glandT016620.7987"$1,443.85".$288.77

53260Treatment of urethra 

lesionT016620.7987"$1,443.85".$288.77

53265Treatment of urethra 

lesionT016620.7987"$1,443.85".$288.77

53270Removal of urethra 

glandT016620.7987"$1,443.85".$288.77

53275Repair of urethra 

defectT016620.7987"$1,443.85".$288.77

53400Revise urethra stage 

1T016832.1043"$2,228.68".$445.74

53405Revise urethra stage 

2T016832.1043"$2,228.68".$445.74

53410Reconstruction of 
urethraT016832.1043"$2,228.68".$445.74

53415Reconstruction of 

urethraC

53420Reconstruct urethra stage 

1T016832.1043"$2,228.68".$445.74

53425Reconstruct urethra stage 

2T016832.1043"$2,228.68".$445.74

53430Reconstruction of 

urethraT016832.1043"$2,228.68".$445.74

53431Reconstruct 

urethra/bladderT016832.1043"$2,228.68".$445.74

53440Male sling 

procedureS0385103.8680"$7,210.52"."$1,442.11"

53442Remove/revise male 

slingT016832.1043"$2,228.68".$445.74

53444Insert tandem 

cuffS0385103.8680"$7,210.52"."$1,442.11"

53445Insert uro/ves nck 

sphincterS0386168.5335"$11,699.60"."$2,339.92"

53446Remove uro 

sphincterT016832.1043"$2,228.68".$445.74

53447Remove/replace ur 

sphincterS0386168.5335"$11,699.60"."$2,339.92"

53448Remov/replc ur sphinctr 

compC

53449Repair uro 

sphincterT016832.1043"$2,228.68".$445.74

53450Revision of 

urethraT016832.1043"$2,228.68".$445.74

53460Revision of 

urethraT016620.7987"$1,443.85".$288.77

53500Urethrlys transvag w/ 

scopeT016832.1043"$2,228.68".$445.74

53502Repair of urethra 
injuryT016620.7987"$1,443.85".$288.77

53505Repair of urethra 

injuryT016832.1043"$2,228.68".$445.74

53510Repair of urethra 

injuryT016620.7987"$1,443.85".$288.77

53515Repair of urethra 

injuryT016832.1043"$2,228.68".$445.74

53520Repair of urethra 

defectT016832.1043"$2,228.68".$445.74

53600Dilate urethra 

strictureT01563.1976$221.98.$44.40

53601Dilate urethra 

strictureT01261.1699$81.21.$16.25

53605Dilate urethra 

strictureT016117.6738"$1,226.92".$245.39

53620Dilate urethra 

strictureT016520.1960"$1,402.01".$280.41

53621Dilate urethra 

strictureT01642.0973$145.59.$29.12

53660Dilation of 

urethraT01261.1699$81.21.$16.25

53661Dilation of 

urethraT01261.1699$81.21.$16.25

53665Dilation of 

urethraT016620.7987"$1,443.85".$288.77

53850Prostatic microwave 

thermotxT042945.8647"$3,183.93".$636.79

53852Prostatic rf 

thermotxT042945.8647"$3,183.93".$636.79

53855Insert prost urethral 

stentT01642.0973$145.59.$29.12

53860Transurethral rf 

treatmentT016520.1960"$1,402.01".$280.41
53899Urology surgery 

procedureT01261.1699$81.21.$16.25

54000Slitting of 

prepuceT016620.7987"$1,443.85".$288.77

54001Slitting of 

prepuceT016620.7987"$1,443.85".$288.77

54015Drain penis 

lesionT000820.5401"$1,425.89".$285.18

54050Destruction penis 

lesion(s)T00130.9786$67.93.$13.59

54055Destruction penis 

lesion(s)T001722.0631"$1,531.62".$306.33

54056Cryosurgery penis 

lesion(s)T00130.9786$67.93.$13.59

54057Laser surg penis 

lesion(s)T001722.0631"$1,531.62".$306.33

54060Excision of penis 

lesion(s)T001722.0631"$1,531.62".$306.33

54065Destruction penis 

lesion(s)T001722.0631"$1,531.62".$306.33

54100Biopsy of 

penisT002117.1909"$1,193.39".$238.68

54105Biopsy of 

penisT002223.4169"$1,625.60"$350.05$325.12

54110Treatment of penis 

lesionT018134.3803"$2,386.68"$598.48$477.34

54111Treat penis lesion 

graftT018134.3803"$2,386.68"$598.48$477.34

54112Treat penis lesion 

graftT018134.3803"$2,386.68"$598.48$477.34

54115Treatment of penis 

lesionT000820.5401"$1,425.89".$285.18

54120Partial removal of 
penisT018134.3803"$2,386.68"$598.48$477.34

54125Removal of 

penisC

54130Remove penis & 

nodesC

54135Remove penis & 

nodesC

54150Circumcision w/regionl 

blockT018323.7235"$1,646.89".$329.38

54160Circumcision 

neonateT018323.7235"$1,646.89".$329.38

54161Circum 28 days or 

olderT018323.7235"$1,646.89".$329.38

54162Lysis penil circumic 

lesionT018323.7235"$1,646.89".$329.38

54163Repair of 

circumcisionT018323.7235"$1,646.89".$329.38

54164Frenulotomy of 

penisT018323.7235"$1,646.89".$329.38

54200Treatment of penis 

lesionT01642.0973$145.59.$29.12

54205Treatment of penis 

lesionT018134.3803"$2,386.68"$598.48$477.34

54220Treatment of penis 

lesionT01642.0973$145.59.$29.12

54230Prepare penis 

studyN

54231Dynamic 

cavernosometryT016520.1960"$1,402.01".$280.41

54235Penile 

injectionCHT01642.0973$145.59.$29.12

54240Penis 

studyT01261.1699$81.21.$16.25

54250Penis 

studyT01642.0973$145.59.$29.12
54300Revision of 

penisT018134.3803"$2,386.68"$598.48$477.34

54304Revision of 

penisT018134.3803"$2,386.68"$598.48$477.34

54308Reconstruction of 

urethraT018134.3803"$2,386.68"$598.48$477.34

54312Reconstruction of 

urethraT018134.3803"$2,386.68"$598.48$477.34

54316Reconstruction of 

urethraT018134.3803"$2,386.68"$598.48$477.34

54318Reconstruction of 

urethraT018134.3803"$2,386.68"$598.48$477.34

54322Reconstruction of 

urethraT018134.3803"$2,386.68"$598.48$477.34

54324Reconstruction of 

urethraT018134.3803"$2,386.68"$598.48$477.34

54326Reconstruction of 

urethraT018134.3803"$2,386.68"$598.48$477.34

54328Revise 

penis/urethraT018134.3803"$2,386.68"$598.48$477.34

54332Revise 

penis/urethraT018134.3803"$2,386.68"$598.48$477.34

54336Revise 

penis/urethraT018134.3803"$2,386.68"$598.48$477.34

54340Secondary urethral 

surgeryT018134.3803"$2,386.68"$598.48$477.34

54344Secondary urethral 

surgeryT018134.3803"$2,386.68"$598.48$477.34

54348Secondary urethral 

surgeryT018134.3803"$2,386.68"$598.48$477.34

54352Reconstruct 

urethra/penisT018134.3803"$2,386.68"$598.48$477.34

54360Penis plastic 
surgeryT018134.3803"$2,386.68"$598.48$477.34

54380Repair 

penisT018134.3803"$2,386.68"$598.48$477.34

54385Repair 

penisT018134.3803"$2,386.68"$598.48$477.34

54390Repair penis and 

bladderC

54400Insert semi-rigid 

prosthesisS0385103.8680"$7,210.52"."$1,442.11"

54401Insert self-contd 

prosthesisS0386168.5335"$11,699.60"."$2,339.92"

54405Insert multi-comp penis 

prosS0386168.5335"$11,699.60"."$2,339.92"

54406Remove muti-comp penis 

prosT018134.3803"$2,386.68"$598.48$477.34

54408Repair multi-comp penis 

prosT018134.3803"$2,386.68"$598.48$477.34

54410Remove/replace penis 

prosthS0386168.5335"$11,699.60"."$2,339.92"

54411Remov/replc penis pros 

compC

54415Remove self-contd penis 

prosT018134.3803"$2,386.68"$598.48$477.34

54416Remv/repl penis contain 

prosS0386168.5335"$11,699.60"."$2,339.92"

54417Remv/replc penis pros 

complC

54420Revision of 

penisT018134.3803"$2,386.68"$598.48$477.34

54430Revision of 

penisC

54435Revision of 

penisT018134.3803"$2,386.68"$598.48$477.34

54440Repair of 

penisT018134.3803"$2,386.68"$598.48$477.34
54450Preputial 

stretchingT01563.1976$221.98.$44.40

54500Biopsy of 

testisT003715.3594"$1,066.25"$225.55$213.25

54505Biopsy of 

testisT018323.7235"$1,646.89".$329.38

54512Excise lesion 

testisT018323.7235"$1,646.89".$329.38

54520Removal of 

testisT018323.7235"$1,646.89".$329.38

54522Orchiectomy 

partialT018323.7235"$1,646.89".$329.38

54530Removal of 

testisT015432.9744"$2,289.08"$464.85$457.82

54535Extensive testis 

surgeryT018134.3803"$2,386.68"$598.48$477.34

54550Exploration for 

testisT015432.9744"$2,289.08"$464.85$457.82

54560Exploration for 

testisT018323.7235"$1,646.89".$329.38

54600Reduce testis 

torsionT018323.7235"$1,646.89".$329.38

54620Suspension of 

testisT018323.7235"$1,646.89".$329.38

54640Suspension of 

testisT015432.9744"$2,289.08"$464.85$457.82

54650Orchiopexy 

(Fowler-Stephens)CHT015432.9744"$2,289.08"$464.85$457.82

54660Revision of 

testisT018323.7235"$1,646.89".$329.38

54670Repair testis 

injuryT018323.7235"$1,646.89".$329.38

54680Relocation of 
testis(es)T018323.7235"$1,646.89".$329.38

54690Laparoscopy 

orchiectomyT013147.7164"$3,312.47""$1,001.89"$662.50

54692Laparoscopy 

orchiopexyT013271.0451"$4,931.95""$1,236.99"$986.39

54699Laparoscope proc 

testisT013039.0865"$2,713.38"$659.53$542.68

54700Drainage of 

scrotumT018323.7235"$1,646.89".$329.38

54800Biopsy of 

epididymisT00044.5956$319.03.$63.81

54830Remove epididymis 

lesionT018323.7235"$1,646.89".$329.38

54840Remove epididymis 

lesionT018323.7235"$1,646.89".$329.38

54860Removal of 

epididymisT018323.7235"$1,646.89".$329.38

54861Removal of 

epididymisT018323.7235"$1,646.89".$329.38

54865Explore 

epididymisT018323.7235"$1,646.89".$329.38

54900Fusion of spermatic 

ductsT018323.7235"$1,646.89".$329.38

54901Fusion of spermatic 

ductsT018323.7235"$1,646.89".$329.38

55000Drainage of 

hydroceleT00044.5956$319.03.$63.81

55040Removal of 

hydroceleT015432.9744"$2,289.08"$464.85$457.82

55041Removal of 

hydrocelesT015432.9744"$2,289.08"$464.85$457.82

55060Repair of 

hydroceleT018323.7235"$1,646.89".$329.38
55100Drainage of scrotum 

abscessT000713.4779$935.64.$187.13

55110Explore 

scrotumT018323.7235"$1,646.89".$329.38

55120Removal of scrotum 

lesionT018323.7235"$1,646.89".$329.38

55150Removal of 

scrotumT018323.7235"$1,646.89".$329.38

55175Revision of 

scrotumT018323.7235"$1,646.89".$329.38

55180Revision of 

scrotumT018323.7235"$1,646.89".$329.38

55200Incision of sperm 

ductT018323.7235"$1,646.89".$329.38

55250Removal of sperm 

duct(s)T018323.7235"$1,646.89".$329.38

55300Prepare sperm duct 

x-rayN

55400Repair of sperm 

ductT018323.7235"$1,646.89".$329.38

55450Ligation of sperm 

ductT018323.7235"$1,646.89".$329.38

55500Removal of 

hydroceleT018323.7235"$1,646.89".$329.38

55520Removal of sperm cord 

lesionT018323.7235"$1,646.89".$329.38

55530Revise spermatic cord 

veinsT018323.7235"$1,646.89".$329.38

55535Revise spermatic cord 

veinsT015432.9744"$2,289.08"$464.85$457.82

55540Revise hernia & sperm 

veinsT015432.9744"$2,289.08"$464.85$457.82

55550Laparo ligate spermatic 

veinT013147.7164"$3,312.47""$1,001.89"$662.50
55559Laparo proc spermatic 

cordT013039.0865"$2,713.38"$659.53$542.68

55600Incise sperm duct 

pouchT018323.7235"$1,646.89".$329.38

55605Incise sperm duct 

pouchC

55650Remove sperm duct 

pouchC

55680Remove sperm pouch 

lesionT018323.7235"$1,646.89".$329.38

55700Biopsy of 

prostateT018414.2476$989.07.$197.82

55705Biopsy of 

prostateT018414.2476$989.07.$197.82

55706Prostate saturation 

samplingT018414.2476$989.07.$197.82

55720Drainage of prostate 

abscessT016226.2690"$1,823.59".$364.72

55725Drainage of prostate 

abscessT016226.2690"$1,823.59".$364.72

55801Removal of 

prostateC

55810Extensive prostate 

surgeryC

55812Extensive prostate 

surgeryC

55815Extensive prostate 

surgeryC

55821Removal of 

prostateC

55831Removal of 

prostateC

55840Extensive prostate 

surgeryC

55842Extensive prostate 

surgeryC

55845Extensive prostate 

surgeryC
55860Surgical exposure 

prostateT016520.1960"$1,402.01".$280.41

55862Extensive prostate 

surgeryC

55865Extensive prostate 

surgeryC

55866Laparo radical 

prostatectomyC

55870ElectroejaculationT01893.6121$250.75.$50.15

55873Cryoablate 

prostateT0674111.0864"$7,711.62"."$1,542.33"

55875Transperi needle place 

prosQ3016336.9605"$2,565.80".$513.16

55876Place rt device/marker prosX 

031013.2460$919.54$322.74$183.91

55899Genital surgery 

procedureT01261.1699$81.21.$16.25

55920Place needles pelvic for 

rtT015326.6476"$1,849.88"$375.24$369.98

55970Sex transformation m to 

fE

55980Sex transformation f to 

mE

56405I & D of 

vulva/perineumT01881.6099$111.76.$22.36

56420Drainage of gland 

abscessT01881.6099$111.76.$22.36

56440Surgery for vulva 

lesionT019320.7771"$1,442.35".$288.47

56441Lysis of labial 

lesion(s)T019320.7771"$1,442.35".$288.47

56442HymenotomyT019320.7771"$1,442.35".$288.47

56501Destroy vulva lesions 

simT001722.0631"$1,531.62".$306.33
56515Destroy vulva lesion/s 

complT001722.0631"$1,531.62".$306.33

56605Biopsy of 

vulva/perineumT01893.6121$250.75.$50.15

56606Biopsy of 

vulva/perineumT01881.6099$111.76.$22.36

56620Partial removal of 

vulvaT019320.7771"$1,442.35".$288.47

56625Complete removal of 

vulvaT019320.7771"$1,442.35".$288.47

56630Extensive vulva 

surgeryC

56631Extensive vulva 

surgeryC

56632Extensive vulva 

surgeryC

56633Extensive vulva 

surgeryC

56634Extensive vulva 

surgeryC

56637Extensive vulva 

surgeryC

56640Extensive vulva 

surgeryC

56700Partial removal of 

hymenT019320.7771"$1,442.35".$288.47

56740Remove vagina gland 

lesionT019320.7771"$1,442.35".$288.47

56800Repair of 

vaginaT019320.7771"$1,442.35".$288.47

56805Repair 

clitorisT019320.7771"$1,442.35".$288.47

56810Repair of 

perineumT019320.7771"$1,442.35".$288.47

56820Exam of vulva 

w/scopeT01881.6099$111.76.$22.36

56821Exam/biopsy of vulva 
w/scopeT01881.6099$111.76.$22.36

57000Exploration of 

vaginaT019320.7771"$1,442.35".$288.47

57010Drainage of pelvic 

abscessT019320.7771"$1,442.35".$288.47

57020Drainage of pelvic 

fluidT01927.0332$488.24.$97.65

57022I & d vaginal hematoma 

ppT000713.4779$935.64.$187.13

57023I & d vag hematoma 

non-obT000820.5401"$1,425.89".$285.18

57061Destroy vag lesions 

simpleT019320.7771"$1,442.35".$288.47

57065Destroy vag lesions 

complexT019320.7771"$1,442.35".$288.47

57100Biopsy of 

vaginaT01927.0332$488.24.$97.65

57105Biopsy of 

vaginaT019320.7771"$1,442.35".$288.47

57106Remove vagina wall 

partialT019320.7771"$1,442.35".$288.47

57107Remove vagina tissue 

partT019535.9320"$2,494.40".$498.88

57109Vaginectomy partial 

w/nodesT019535.9320"$2,494.40".$498.88

57110Remove vagina wall 

completeC

57111Remove vagina tissue 

complC

57112Vaginectomy w/nodes 

complC

57120Closure of 

vaginaT019535.9320"$2,494.40".$498.88

57130Remove vagina 

lesionT019320.7771"$1,442.35".$288.47
57135Remove vagina 

lesionT019320.7771"$1,442.35".$288.47

57150Treat vagina 

infectionT01881.6099$111.76.$22.36

57155Insert uteri 

tandems/ovoidsT01927.0332$488.24.$97.65

57156Ins vag brachytx 

deviceT01893.6121$250.75.$50.15

57160Insert pessary/other 

deviceT01881.6099$111.76.$22.36

57170Fitting of 

diaphragm/capT01910.1274$8.84$1.85$1.77

57180Treat vaginal 

bleedingT01881.6099$111.76.$22.36

57200Repair of 

vaginaT019320.7771"$1,442.35".$288.47

57210Repair 

vagina/perineumT019320.7771"$1,442.35".$288.47

57220Revision of 

urethraT020245.5816"$3,164.27"$981.50$632.86

57230Repair of urethral 

lesionT019535.9320"$2,494.40".$498.88

57240Repair bladder & 

vaginaT019535.9320"$2,494.40".$498.88

57250Repair rectum & 

vaginaT019535.9320"$2,494.40".$498.88

57260Repair of 

vaginaT019535.9320"$2,494.40".$498.88

57265Extensive repair of 

vaginaT020245.5816"$3,164.27"$981.50$632.86

57267Insert mesh/pelvic flr 

addonT019535.9320"$2,494.40".$498.88
57268Repair of bowel 

bulgeT019535.9320"$2,494.40".$498.88

57270Repair of bowel 

pouchC

57280Suspension of 

vaginaC

57282Colpopexy 

extraperitonealT020245.5816"$3,164.27"$981.50$632.86

57283Colpopexy 

intraperitonealT020245.5816"$3,164.27"$981.50$632.86

57284Repair paravag defect 

openT020245.5816"$3,164.27"$981.50$632.86

57285Repair paravag defect 

vagT020245.5816"$3,164.27"$981.50$632.86

57287Revise/remove sling 

repairT019535.9320"$2,494.40".$498.88

57288Repair bladder 

defectT020245.5816"$3,164.27"$981.50$632.86

57289Repair bladder & 

vaginaT019535.9320"$2,494.40".$498.88

57291Construction of 

vaginaT019535.9320"$2,494.40".$498.88

57292Construct vagina with 

graftT019535.9320"$2,494.40".$498.88

57295Revise vag graft via 

vaginaT019320.7771"$1,442.35".$288.47

57296Revise vag graft open 

abdC

57300Repair rectum-vagina 

fistulaT019535.9320"$2,494.40".$498.88

57305Repair rectum-vagina 

fistulaC

57307Fistula repair & 

colostomyC

57308Fistula repair 

transperineC
57310Repair urethrovaginal 

lesionT020245.5816"$3,164.27"$981.50$632.86

57311Repair urethrovaginal 

lesionC

57320Repair bladder-vagina 

lesionT019535.9320"$2,494.40".$498.88

57330Repair bladder-vagina 

lesionT019535.9320"$2,494.40".$498.88

57335Repair 

vaginaT019535.9320"$2,494.40".$498.88

57400Dilation of 

vaginaT019320.7771"$1,442.35".$288.47

57410Pelvic 

examinationT019320.7771"$1,442.35".$288.47

57415Remove vaginal foreign 

bodyT019320.7771"$1,442.35".$288.47

57420Exam of vagina 

w/scopeT01893.6121$250.75.$50.15

57421Exam/biopsy of vag 

w/scopeT01893.6121$250.75.$50.15

57423Repair paravag defect 

lapT020245.5816"$3,164.27"$981.50$632.86

57425Laparoscopy surg colpopexyCH 

T013147.7164"$3,312.47""$1,001.89"$662.50

57426Revise prosth vag graft 

lapT019320.7771"$1,442.35".$288.47

57452Exam of cervix 

w/scopeT01881.6099$111.76.$22.36

57454Bx/curett of cervix 

w/scopeT01893.6121$250.75.$50.15

57455Biopsy of cervix 

w/scopeT01893.6121$250.75.$50.15

57456Endocerv curettage 

w/scopeT01893.6121$250.75.$50.15
57460Bx of cervix w/scope 

leepT019320.7771"$1,442.35".$288.47

57461Conz of cervix w/scope 

leepT019320.7771"$1,442.35".$288.47

57500Biopsy of 

cervixT01927.0332$488.24.$97.65

57505Endocervical 

curettageT01927.0332$488.24.$97.65

57510Cauterization of 

cervixT019320.7771"$1,442.35".$288.47

57511Cryocautery of 

cervixT01881.6099$111.76.$22.36

57513Laser surgery of 

cervixT019320.7771"$1,442.35".$288.47

57520Conization of 

cervixT019320.7771"$1,442.35".$288.47

57522Conization of 

cervixT019320.7771"$1,442.35".$288.47

57530Removal of 

cervixT019535.9320"$2,494.40".$498.88

57531Removal of cervix 

radicalC

57540Removal of residual 

cervixC

57545Remove cervix/repair 

pelvisC

57550Removal of residual 

cervixT019535.9320"$2,494.40".$498.88

57555Remove cervix/repair 

vaginaT019535.9320"$2,494.40".$498.88

57556Remove cervix repair 

bowelT020245.5816"$3,164.27"$981.50$632.86

57558D&c of cervical 

stumpT019320.7771"$1,442.35".$288.47
57700Revision of 

cervixT019320.7771"$1,442.35".$288.47

57720Revision of 

cervixT019320.7771"$1,442.35".$288.47

57800Dilation of cervical 

canalT019320.7771"$1,442.35".$288.47

58100Biopsy of uterus 

liningT01881.6099$111.76.$22.36

58110Bx done w/colposcopy add-onN 

58120Dilation and 

curettageT019320.7771"$1,442.35".$288.47

58140Myomectomy abdom 

methodC

58145Myomectomy vag 

methodT019535.9320"$2,494.40".$498.88

58146Myomectomy abdom 

complexC

58150Total 

hysterectomyC

58152Total 

hysterectomyC

58180Partial 

hysterectomyC

58200Extensive 

hysterectomyC

58210Extensive 

hysterectomyC

58240Removal of pelvis 

contentsC

58260Vaginal hysterectomyT 

019535.9320"$2,494.40".$498.88

58262Vag hyst including t/oT 

019535.9320"$2,494.40".$498.88

58263Vag hyst w/t/o & vag repairT 

019535.9320"$2,494.40".$498.88

58267Vag hyst w/urinary 

repairC
58270Vag hyst w/enterocele repairT 

019535.9320"$2,494.40".$498.88

58275Hysterectomy/revise 

vaginaC

58280Hysterectomy/revise 

vaginaC

58285Extensive 

hysterectomyC

58290Vag hyst complexT 

020245.5816"$3,164.27"$981.50$632.86

58291Vag hyst incl t/o complexT 

020245.5816"$3,164.27"$981.50$632.86

58292Vag hyst t/o & repair complT 

020245.5816"$3,164.27"$981.50$632.86

58293Vag hyst w/uro repair 

complC

58294Vag hyst w/enterocele complT 

020245.5816"$3,164.27"$981.50$632.86

58300Insert intrauterine 

deviceE

58301Remove intrauterine 

deviceT01881.6099$111.76.$22.36

58321Artificial 

inseminationT01893.6121$250.75.$50.15

58322Artificial 

inseminationT01893.6121$250.75.$50.15

58323Sperm 

washingT01893.6121$250.75.$50.15

58340Catheter for 

hysterographyN

58345Reopen fallopian 

tubeT019320.7771"$1,442.35".$288.47

58346Insert heyman uteri 

capsuleT019320.7771"$1,442.35".$288.47

58350Reopen fallopian 

tubeT019535.9320"$2,494.40".$498.88
58353Endometr ablate 

thermalT019535.9320"$2,494.40".$498.88

58356Endometrial 

cryoablationT020245.5816"$3,164.27"$981.50$632.86

58400Suspension of 

uterusC

58410Suspension of 

uterusC

58520Repair of ruptured 

uterusC

58540Revision of 

uterusC

58541Lsh uterus 250 g or 

lessT013271.0451"$4,931.95""$1,236.99"$986.39

58542Lsh w/t/o ut 250 g or 

lessT013271.0451"$4,931.95""$1,236.99"$986.39

58543Lsh uterus above 250 

gT013271.0451"$4,931.95""$1,236.99"$986.39

58544Lsh w/t/o uterus above 250 

gT013271.0451"$4,931.95""$1,236.99"$986.39

58545Laparoscopic 

myomectomyT013039.0865"$2,713.38"$659.53$542.68

58546Laparo-myomectomy 

complexT013147.7164"$3,312.47""$1,001.89"$662.50

58548Lap radical 

hystC

58550Laparo-asst vag 

hysterectomyT013271.0451"$4,931.95""$1,236.99"$986.39

58552Laparo-vag hyst incl 

t/oT013147.7164"$3,312.47""$1,001.89"$662.50

58553Laparo-vag hyst 

complexT013147.7164"$3,312.47""$1,001.89"$662.50

58554Laparo-vag hyst w/t/o 

complT013147.7164"$3,312.47""$1,001.89"$662.50

58555Hysteroscopy dx sep 

procT019023.1868"$1,609.63"$424.28$321.93
58558Hysteroscopy 

biopsyT019023.1868"$1,609.63"$424.28$321.93

58559Hysteroscopy 

lysisT019023.1868"$1,609.63"$424.28$321.93

58560Hysteroscopy resect 

septumT038737.9124"$2,631.88"$650.74$526.38

58561Hysteroscopy remove 

myomaT038737.9124"$2,631.88"$650.74$526.38

58562Hysteroscopy remove 

fbT019023.1868"$1,609.63"$424.28$321.93

58563Hysteroscopy 

ablationT038737.9124"$2,631.88"$650.74$526.38

58565Hysteroscopy 

sterilizationT020245.5816"$3,164.27"$981.50$632.86

58570Tlh uterus 250 g or 

lessT013147.7164"$3,312.47""$1,001.89"$662.50

58571Tlh w/t/o 250 g or 

lessT013147.7164"$3,312.47""$1,001.89"$662.50

58572Tlh uterus over 250 

gT013147.7164"$3,312.47""$1,001.89"$662.50

58573Tlh w/t/o uterus over 250 

gT013147.7164"$3,312.47""$1,001.89"$662.50

58578Laparo proc 

uterusT013039.0865"$2,713.38"$659.53$542.68

58579Hysteroscope 

procedureT019023.1868"$1,609.63"$424.28$321.93

58600Division of fallopian 

tubeT019535.9320"$2,494.40".$498.88

58605Division of fallopian 

tubeC

58611Ligate oviduct(s) 

add-onC

58615Occlude fallopian 

tube(s)T019320.7771"$1,442.35".$288.47
58660Laparoscopy 

lysisT013147.7164"$3,312.47""$1,001.89"$662.50

58661Laparoscopy remove 

adnexaT013147.7164"$3,312.47""$1,001.89"$662.50

58662Laparoscopy excise 

lesionsT013147.7164"$3,312.47""$1,001.89"$662.50

58670Laparoscopy tubal 

cauteryT013147.7164"$3,312.47""$1,001.89"$662.50

58671Laparoscopy tubal 

blockT013147.7164"$3,312.47""$1,001.89"$662.50

58672Laparoscopy 

fimbrioplastyT013147.7164"$3,312.47""$1,001.89"$662.50

58673Laparoscopy 

salpingostomyT013147.7164"$3,312.47""$1,001.89"$662.50

58679Laparo proc 

oviduct-ovaryT013039.0865"$2,713.38"$659.53$542.68

58700Removal of fallopian 

tubeC

58720Removal of 

ovary/tube(s)C

58740Adhesiolysis tube 

ovaryC

58750Repair 

oviductC

58752Revise ovarian 

tube(s)C

58760FimbrioplastyC

58770Create new tubal 

openingT019535.9320"$2,494.40".$498.88

58800Drainage of ovarian 

cyst(s)T019320.7771"$1,442.35".$288.47

58805Drainage of ovarian 

cyst(s)T019535.9320"$2,494.40".$498.88

58820Drain ovary abscess 

openT019535.9320"$2,494.40".$498.88
58822Drain ovary abscess 

percutC

58823Drain pelvic abscess 

percutT019320.7771"$1,442.35".$288.47

58825Transposition 

ovary(s)C

58900Biopsy of 

ovary(s)T019320.7771"$1,442.35".$288.47

58920Partial removal of 

ovary(s)T019535.9320"$2,494.40".$498.88

58925Removal of ovarian 

cyst(s)T019535.9320"$2,494.40".$498.88

58940Removal of 

ovary(s)C

58943Removal of 

ovary(s)C

58950Resect ovarian 

malignancyC

58951Resect ovarian 

malignancyC

58952Resect ovarian 

malignancyC

58953Tah rad dissect for 

debulkC

58954Tah rad debulk/lymph 

removeC

58956Bso omentectomy 

w/tahC

58957Resect recurrent gyn 

malC

58958Resect recur gyn mal 

w/lymC

58960Exploration of 

abdomenC

58970Retrieval of 

oocyteT01893.6121$250.75.$50.15

58974Transfer of 

embryoT01893.6121$250.75.$50.15

58976Transfer of 

embryoT01893.6121$250.75.$50.15
58999Genital surgery 

procedureT01910.1274$8.84$1.85$1.77

59000Amniocentesis 

diagnosticT01893.6121$250.75.$50.15

59001Amniocentesis 

therapeuticT01927.0332$488.24.$97.65

59012Fetal cord puncture 

prenatalT01893.6121$250.75.$50.15

59015Chorion 

biopsyT01893.6121$250.75.$50.15

59020Fetal contract stress 

testT01881.6099$111.76.$22.36

59025Fetal non-stress 

testT01881.6099$111.76.$22.36

59030Fetal scalp blood 

sampleT01893.6121$250.75.$50.15

59050Fetal monitor w/reportM 

59051Fetal monitor/interpret 

onlyB

59070Transabdom amnioinfus 

w/usT01881.6099$111.76.$22.36

59072Umbilical cord occlud 

w/usT01893.6121$250.75.$50.15

59074Fetal fluid drainage 

w/usT01893.6121$250.75.$50.15

59076Fetal shunt placement 

w/usT01893.6121$250.75.$50.15

59100Remove uterus 

lesionT019535.9320"$2,494.40".$498.88

59120Treat ectopic 

pregnancyC

59121Treat ectopic 

pregnancyC

59130Treat ectopic 
pregnancyC

59135Treat ectopic 

pregnancyC

59136Treat ectopic 

pregnancyC

59140Treat ectopic 

pregnancyC

59150Treat ectopic 

pregnancyT013147.7164"$3,312.47""$1,001.89"$662.50

59151Treat ectopic 

pregnancyT013147.7164"$3,312.47""$1,001.89"$662.50

59160D & c after 

deliveryT019320.7771"$1,442.35".$288.47

59200Insert cervical 

dilatorT01881.6099$111.76.$22.36

59300Episiotomy or vaginal 

repairT019320.7771"$1,442.35".$288.47

59320Revision of 

cervixT019320.7771"$1,442.35".$288.47

59325Revision of 

cervixC

59350Repair of 

uterusC

59400Obstetrical 

careB

59409Obstetrical 

careT019320.7771"$1,442.35".$288.47

59410Obstetrical 

careB

59412Antepartum 

manipulationT019320.7771"$1,442.35".$288.47

59414Deliver 

placentaT019320.7771"$1,442.35".$288.47

59425Antepartum care 

onlyB

59426Antepartum care 

onlyB

59430Care after 
deliveryB

59510Cesarean 

deliveryB

59514Cesarean delivery 

onlyC

59515Cesarean 

deliveryB

59525Remove uterus after 

cesareanC

59610Vbac 

deliveryB

59612Vbac delivery 

onlyT019320.7771"$1,442.35".$288.47

59614Vbac care after 

deliveryB

59618Attempted vbac 

deliveryB

59620Attempted vbac delivery 

onlyC

59622Attempted vbac after 

careB

59812Treatment of 

miscarriageT019320.7771"$1,442.35".$288.47

59820Care of 

miscarriageT019320.7771"$1,442.35".$288.47

59821Treatment of 

miscarriageT019320.7771"$1,442.35".$288.47

59830Treat uterus 

infectionC

59840AbortionT019320.7771"$1,442.35".$288.47

59841AbortionT019320.7771"$1,442.35".$288.47

59850AbortionC

59851AbortionC

59852AbortionC

59855AbortionC

59856AbortionC

59857AbortionC
59866Abortion 

(mpr)T01893.6121$250.75.$50.15

59870Evacuate mole of 

uterusT019320.7771"$1,442.35".$288.47

59871Remove cerclage 

sutureT019320.7771"$1,442.35".$288.47

59897Fetal invas px 

w/usT01910.1274$8.84$1.85$1.77

59898Laparo proc ob 

care/deliverT013039.0865"$2,713.38"$659.53$542.68

59899Maternity care 

procedureT01910.1274$8.84$1.85$1.77

60000Drain thyroid/tongue 

cystT02528.0353$557.81.$111.57

60100Biopsy of 

thyroidT00044.5956$319.03.$63.81

60200Remove thyroid 

lesionT011451.2321"$3,556.53".$711.31

60210Partial thyroid 

excisionT011451.2321"$3,556.53".$711.31

60212Partial thyroid 

excisionT011451.2321"$3,556.53".$711.31

60220Partial removal of 

thyroidT011451.2321"$3,556.53".$711.31

60225Partial removal of 

thyroidT011451.2321"$3,556.53".$711.31

60240Removal of 

thyroidT011451.2321"$3,556.53".$711.31

60252Removal of 

thyroidT025645.1286"$3,132.83".$626.57

60254Extensive thyroid 

surgeryC

60260Repeat thyroid 

surgeryT025645.1286"$3,132.83".$626.57
60270Removal of 

thyroidC

60271Removal of 

thyroidT025645.1286"$3,132.83".$626.57

60280Remove thyroid duct 

lesionT011451.2321"$3,556.53".$711.31

60281Remove thyroid duct 

lesionT011451.2321"$3,556.53".$711.31

60300Aspir/inj thyroid 

cystT00044.5956$319.03.$63.81

60500Explore parathyroid 

glandsT025645.1286"$3,132.83".$626.57

60502Re-explore 

parathyroidsT025645.1286"$3,132.83".$626.57

60505Explore parathyroid 

glandsC

60512Autotransplant 

parathyroidT002223.4169"$1,625.60"$350.05$325.12

60520Removal of thymus 

glandT025645.1286"$3,132.83".$626.57

60521Removal of thymus 

glandC

60522Removal of thymus 

glandC

60540Explore adrenal 

glandC

60545Explore adrenal 

glandC

60600Remove carotid body 

lesionC

60605Remove carotid body 

lesionC

60650Laparoscopy 

adrenalectomyC

60659Laparo proc 

endocrineT013039.0865"$2,713.38"$659.53$542.68

60699Endocrine surgery 

procedureT011451.2321"$3,556.53".$711.31
61000Remove cranial cavity 

fluidT02077.5480$523.98.$104.80

61001Remove cranial cavity 

fluidT02077.5480$523.98.$104.80

61020Remove brain cavity 

fluidT02077.5480$523.98.$104.80

61026Injection into brain 

canalT02077.5480$523.98.$104.80

61050Remove brain canal 

fluidT02077.5480$523.98.$104.80

61055Injection into brain 

canalT02077.5480$523.98.$104.80

61070Brain canal shunt 

procedureT01216.3178$438.58.$87.72

61105Twist drill 

holeC

61107Drill skull for 

implantationC

61108Drill skull for 

drainageC

61120Burr hole for 

punctureC

61140Pierce skull for 

biopsyC

61150Pierce skull for 

drainageC

61151Pierce skull for 

drainageC

61154Pierce skull & remove 

clotC

61156Pierce skull for 

drainageC

61210Pierce skull implant 

deviceC

61215Insert brain-fluid 

deviceT022442.5188"$2,951.66".$590.34

61250Pierce skull & 

exploreC
61253Pierce skull & 

exploreC

61304Open skull for 

explorationC

61305Open skull for 

explorationC

61312Open skull for 

drainageC

61313Open skull for 

drainageC

61314Open skull for 

drainageC

61315Open skull for 

drainageC

61316Implt cran bone flap to 

abdoC

61320Open skull for 

drainageC

61321Open skull for 

drainageC

61322Decompressive 

craniotomyC

61323Decompressive 

lobectomyC

61330Decompress eye 

socketT025645.1286"$3,132.83".$626.57

61332Explore/biopsy eye 

socketC

61333Explore orbit/remove 

lesionC

61334Explore orbit/remove 

objectT025645.1286"$3,132.83".$626.57

61340Subtemporal 

decompressionC

61343Incise skull (press 

relief)C

61345Relieve cranial 

pressureC

61440Incise skull for 

surgeryC

61450Incise skull for 

surgeryC
61458Incise skull for brain 

woundC

61460Incise skull for 

surgeryC

61470Incise skull for 

surgeryC

61480Incise skull for 

surgeryC

61490Incise skull for 

surgeryC

61500Removal of skull 

lesionC

61501Remove infected skull 

boneC

61510Removal of brain 

lesionC

61512Remove brain lining 

lesionC

61514Removal of brain 

abscessC

61516Removal of brain 

lesionC

61517Implt brain chemotx 

add-onC

61518Removal of brain 

lesionC

61519Remove brain lining 

lesionC

61520Removal of brain 

lesionC

61521Removal of brain 

lesionC

61522Removal of brain 

abscessC

61524Removal of brain 

lesionC

61526Removal of brain 

lesionC

61530Removal of brain 

lesionC

61531Implant brain 

electrodesC

61533Implant brain 

electrodesC
61534Removal of brain 

lesionC

61535Remove brain 

electrodesC

61536Removal of brain 

lesionC

61537Removal of brain 

tissueC

61538Removal of brain 

tissueC

61539Removal of brain 

tissueC

61540Removal of brain 

tissueC

61541Incision of brain 

tissueC

61542Removal of brain 

tissueC

61543Removal of brain 

tissueC

61544Remove & treat brain 

lesionC

61545Excision of brain 

tumorC

61546Removal of pituitary 

glandC

61548Removal of pituitary 

glandC

61550Release of skull 

seamsC

61552Release of skull 

seamsC

61556Incise 

skull/suturesC

61557Incise 

skull/suturesC

61558Excision of 

skull/suturesC

61559Excision of 

skull/suturesC

61563Excision of skull 

tumorC

61564Excision of skull 

tumorC
61566Removal of brain 

tissueC

61567Incision of brain 

tissueC

61570Remove foreign body 

brainC

61571Incise skull for brain 

woundC

61575Skull base/brainstem 

surgeryC

61576Skull base/brainstem 

surgeryC

61580Craniofacial approach 

skullC

61581Craniofacial approach 

skullC

61582Craniofacial approach 

skullC

61583Craniofacial approach 

skullC

61584Orbitocranial 

approach/skullC

61585Orbitocranial 

approach/skullC

61586Resect nasopharynx 

skullC

61590Infratemporal 

approach/skullC

61591Infratemporal 

approach/skullC

61592Orbitocranial 

approach/skullC

61595Transtemporal 

approach/skullC

61596Transcochlear 

approach/skullC

61597Transcondylar 

approach/skullC

61598Transpetrosal 

approach/skullC

61600Resect/excise cranial 

lesionC

61601Resect/excise cranial 

lesionC
61605Resect/excise cranial 

lesionC

61606Resect/excise cranial 

lesionC

61607Resect/excise cranial 

lesionC

61608Resect/excise cranial 

lesionC

61609Transect artery 

sinusC

61610Transect artery 

sinusC

61611Transect artery 

sinusC

61612Transect artery 

sinusC

61613Remove aneurysm 

sinusC

61615Resect/excise lesion 

skullC

61616Resect/excise lesion 

skullC

61618Repair 

duraC

61619Repair 

duraC

61623Endovasc tempory vessel 

occlT0082104.8857"$7,281.17"."$1,456.24"

61624Transcath occlusion 

cnsC

61626Transcath occlusion 

non-cnsT0082104.8857"$7,281.17"."$1,456.24"

61630Intracranial 

angioplastyC

61635Intracran angioplsty 

w/stentC

61640Dilate ic vasospasm initE 

61641Dilate ic vasospasm add-onE 

61642Dilate ic vasospasm add-onE 

61680Intracranial vessel 
surgeryC

61682Intracranial vessel 

surgeryC

61684Intracranial vessel 

surgeryC

61686Intracranial vessel 

surgeryC

61690Intracranial vessel 

surgeryC

61692Intracranial vessel 

surgeryC

61697Brain aneurysm repr 

complxC

61698Brain aneurysm repr 

complxC

61700Brain aneurysm repr 

simpleC

61702Inner skull vessel 

surgeryC

61703Clamp neck 

arteryC

61705Revise circulation to 

headC

61708Revise circulation to 

headC

61710Revise circulation to 

headC

61711Fusion of skull 

arteriesC

61720Incise skull/brain 

surgeryT022137.4067"$2,596.77".$519.36

61735Incise skull/brain 

surgeryC

61750Incise skull/brain 

biopsyC

61751Brain biopsy w/ct/mr 

guideC

61760Implant brain 

electrodesC

61770Incise skull for 

treatmentT022137.4067"$2,596.77".$519.36

61781Scan proc cranial 

intraN
61782Scan proc cranial 

extraN

61783Scan proc 

spinalN

61790Treat trigeminal 

nerveT022019.0626"$1,323.33".$264.67

61791Treat trigeminal 

tractT020312.9066$895.98.$179.20

61796Srs cranial lesion 

simpleB

61797Srs cran les simple 

addlB

61798Srs cranial lesion 

complexB

61799Srs cran les complex 

addlB

61800Apply srs headframe 

add-onB

61850Implant 

neuroelectrodesC

61860Implant 

neuroelectrodesC

61863Implant 

neuroelectrodeC

61864Implant neuroelectrde 

addlC

61867Implant 

neuroelectrodeC

61868Implant neuroelectrde 

addlC

61870Implant 

neuroelectrodesC

61875Implant 

neuroelectrodesC

61880Revise/remove 

neuroelectrodeT068720.7466"$1,440.23"$382.52$288.05

61885Insrt/redo neurostim 1 

arrayS0039209.6958"$14,557.08"."$2,911.42"

61886Implant neurostim arraysS 

0315284.8462"$19,774.02"."$3,954.81"
61888Revise/remove 

neuroreceiverT068831.3873"$2,178.91"$768.94$435.79

62000Treat skull 

fractureT025425.1379"$1,745.07".$349.02

62005Treat skull 

fractureC

62010Treatment of head 

injuryC

62100Repair brain fluid 

leakageC

62115Reduction of skull 

defectC

62116Reduction of skull 

defectC

62117Reduction of skull 

defectC

62120Repair skull cavity 

lesionC

62121Incise skull 

repairC

62140Repair of skull 

defectC

62141Repair of skull 

defectC

62142Remove skull 

plate/flapC

62143Replace skull 

plate/flapC

62145Repair of skull & 

brainC

62146Repair of skull with 

graftC

62147Repair of skull with 

graftC

62148Retr bone flap to fix 

skullC

62160Neuroendoscopy add-onN 

62161Dissect brain 

w/scopeC

62162Remove colloid cyst 

w/scopeC

62163Neuroendoscopy w/fb 
removalC

62164Remove brain tumor 

w/scopeC

62165Remove pituit tumor 

w/scopeC

62180Establish brain cavity 

shuntC

62190Establish brain cavity 

shuntC

62192Establish brain cavity 

shuntC

62194Replace/irrigate 

catheterT02077.5480$523.98.$104.80

62200Establish brain cavity 

shuntC

62201Brain cavity shunt 

w/scopeC

62220Establish brain cavity 

shuntC

62223Establish brain cavity 

shuntC

62225Replace/irrigate 

catheterT042716.2153"$1,125.67".$225.14

62230Replace/revise brain 

shuntT022442.5188"$2,951.66".$590.34

62252Csf shunt 

reprogramS06912.4153$167.67.$33.54

62256Remove brain cavity 

shuntC

62258Replace brain cavity 

shuntC

62263Epidural lysis mult sessionsCH 

T020312.9066$895.98.$179.20

62264Epidural lysis on single 

dayT020312.9066$895.98.$179.20

62267Interdiscal perq aspir 

dxT00044.5956$319.03.$63.81

62268Drain spinal cord 

cystT02077.5480$523.98.$104.80
62269Needle biopsy spinal 

cordT06859.7281$675.32.$135.07

62270Spinal fluid tap 

diagnosticT02063.9371$273.31.$54.67

62272Drain cerebro spinal 

fluidT02063.9371$273.31.$54.67

62273Inject epidural 

patchT02077.5480$523.98.$104.80

62280Treat spinal cord 

lesionT02077.5480$523.98.$104.80

62281Treat spinal cord lesionCH 

T020312.9066$895.98.$179.20

62282Treat spinal canal lesionCH 

T020312.9066$895.98.$179.20

62284Injection for 

myelogramN

62287Percutaneous 

diskectomyT022137.4067"$2,596.77".$519.36

62290Inject for spine disk 

x-rayN

62291Inject for spine disk 

x-rayN

62292Injection into disk 

lesionT02077.5480$523.98.$104.80

62294Injection into spinal 

arteryT02077.5480$523.98.$104.80

62310Inject spine 

c/tT02077.5480$523.98.$104.80

62311Inject spine l/s 

(cd)T02077.5480$523.98.$104.80

62318Inject spine w/cath 

c/tT02077.5480$523.98.$104.80

62319Inject spine w/cath l/s 

(cd)T020312.9066$895.98.$179.20
62350Implant spinal canal 

cathT022442.5188"$2,951.66".$590.34

62351Implant spinal canal 

cathT020851.1173"$3,548.56".$709.72

62355Remove spinal canal 

catheterT020312.9066$895.98.$179.20

62360Insert spine infusion 

deviceT022442.5188"$2,951.66".$590.34

62361Implant spine infusion 

pumpT0227190.0513"$13,193.36"."$2,638.68"

62362Implant spine infusion 

pumpT0227190.0513"$13,193.36"."$2,638.68"

62365Remove spine infusion 

deviceT022137.4067"$2,596.77".$519.36

62367Analyze spine infusion 

pumpS06912.4153$167.67.$33.54

62368Analyze spine infusion 

pumpS06912.4153$167.67.$33.54

63001Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63003Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63005Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63011Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63012Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63015Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63016Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63017Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72
63020Neck spine disk 

surgeryT020851.1173"$3,548.56".$709.72

63030Low back disk 

surgeryT020851.1173"$3,548.56".$709.72

63035Spinal disk surgery 

add-onT020851.1173"$3,548.56".$709.72

63040Laminotomy single 

cervicalT020851.1173"$3,548.56".$709.72

63042Laminotomy single 

lumbarT020851.1173"$3,548.56".$709.72

63043Laminotomy addl 

cervicalC

63044Laminotomy addl 

lumbarC

63045Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63046Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63047Removal of spinal 

laminaT020851.1173"$3,548.56".$709.72

63048Remove spinal lamina 

add-onT020851.1173"$3,548.56".$709.72

63050Cervical 

laminoplastyC

63051C-laminoplasty 

w/graft/plateC

63055Decompress spinal 

cordT020851.1173"$3,548.56".$709.72

63056Decompress spinal 

cordT020851.1173"$3,548.56".$709.72

63057Decompress spine cord 

add-onT020851.1173"$3,548.56".$709.72

63064Decompress spinal 

cordT020851.1173"$3,548.56".$709.72
63066Decompress spine cord 

add-onT020851.1173"$3,548.56".$709.72

63075Neck spine disk 

surgeryT020851.1173"$3,548.56".$709.72

63076Neck spine disk 

surgeryT020851.1173"$3,548.56".$709.72

63077Spine disk surgery 

thoraxC

63078Spine disk surgery 

thoraxC

63081Removal of vertebral 

bodyC

63082Remove vertebral body 

add-onC

63085Removal of vertebral 

bodyC

63086Remove vertebral body 

add-onC

63087Removal of vertebral 

bodyC

63088Remove vertebral body 

add-onC

63090Removal of vertebral 

bodyC

63091Remove vertebral body 

add-onC

63101Removal of vertebral 

bodyC

63102Removal of vertebral 

bodyC

63103Remove vertebral body 

add-onC

63170Incise spinal cord 

tract(s)C

63172Drainage of spinal 

cystC

63173Drainage of spinal 

cystC

63180Revise spinal cord 

ligamentsC

63182Revise spinal cord 

ligamentsC
63185Incise spinal 

column/nervesC

63190Incise spinal 

column/nervesC

63191Incise spinal 

column/nervesC

63194Incise spinal column & 

cordC

63195Incise spinal column & 

cordC

63196Incise spinal column & 

cordC

63197Incise spinal column & 

cordC

63198Incise spinal column & 

cordC

63199Incise spinal column & 

cordC

63200Release of spinal 

cordC

63250Revise spinal cord 

vesselsC

63251Revise spinal cord 

vesselsC

63252Revise spinal cord 

vesselsC

63265Excise intraspinal 

lesionC

63266Excise intraspinal 

lesionC

63267Excise intraspinal 

lesionC

63268Excise intraspinal 

lesionC

63270Excise intraspinal 

lesionC

63271Excise intraspinal 

lesionC

63272Excise intraspinal 

lesionC

63273Excise intraspinal 

lesionC

63275Biopsy/excise spinal 

tumorC
63276Biopsy/excise spinal 

tumorC

63277Biopsy/excise spinal 

tumorC

63278Biopsy/excise spinal 

tumorC

63280Biopsy/excise spinal 

tumorC

63281Biopsy/excise spinal 

tumorC

63282Biopsy/excise spinal 

tumorC

63283Biopsy/excise spinal 

tumorC

63285Biopsy/excise spinal 

tumorC

63286Biopsy/excise spinal 

tumorC

63287Biopsy/excise spinal 

tumorC

63290Biopsy/excise spinal 

tumorC

63295Repair of laminectomy 

defectC

63300Removal of vertebral 

bodyC

63301Removal of vertebral 

bodyC

63302Removal of vertebral 

bodyC

63303Removal of vertebral 

bodyC

63304Removal of vertebral 

bodyC

63305Removal of vertebral 

bodyC

63306Removal of vertebral 

bodyC

63307Removal of vertebral 

bodyC

63308Remove vertebral body 

add-onC

63600Remove spinal cord 

lesionT022019.0626"$1,323.33".$264.67
63610Stimulation of spinal 

cordT022019.0626"$1,323.33".$264.67

63615Remove lesion of spinal 

cordT022019.0626"$1,323.33".$264.67

63620Srs spinal 

lesionB

63621Srs spinal lesion 

addlB

63650Implant 

neuroelectrodesS004062.7889"$4,358.81".$871.77

63655Implant 

neuroelectrodesS006186.9786"$6,038.05"."$1,207.61"

63661Remove spine eltrd perq 

arayT068720.7466"$1,440.23"$382.52$288.05

63662Remove spine eltrd 

plateT068720.7466"$1,440.23"$382.52$288.05

63663Revise spine eltrd perq arayCH 

T004062.7889"$4,358.81".$871.77

63664Revise spine eltrd plateCH 

T004062.7889"$4,358.81".$871.77

63685Insrt/redo spine n generatorS 

0039209.6958"$14,557.08"."$2,911.42"

63688Revise/remove 

neuroreceiverT068831.3873"$2,178.91"$768.94$435.79

63700Repair of spinal 

herniationC

63702Repair of spinal 

herniationC

63704Repair of spinal 

herniationC

63706Repair of spinal 

herniationC

63707Repair spinal fluid 

leakageC

63709Repair spinal fluid 

leakageC

63710Graft repair of spine 
defectC

63740Install spinal 

shuntC

63741Install spinal 

shuntT022442.5188"$2,951.66".$590.34

63744Revision of spinal 

shuntT022442.5188"$2,951.66".$590.34

63746Removal of spinal 

shuntT020312.9066$895.98.$179.20

64400N block inj 

trigeminalT02042.7693$192.24$40.13$38.45

64402N block inj 

facialT02042.7693$192.24$40.13$38.45

64405N block inj 

occipitalT02063.9371$273.31.$54.67

64408N block inj 

vagusCHT02042.7693$192.24$40.13$38.45

64410N block inj 

phrenicCHT02042.7693$192.24$40.13$38.45

64412N block inj spinal 

accessorCHT02063.9371$273.31.$54.67

64413N block inj cervical 

plexusT02063.9371$273.31.$54.67

64415N block inj brachial 

plexusT02063.9371$273.31.$54.67

64416N block cont infuse b 

plexT02077.5480$523.98.$104.80

64417N block inj 

axillaryT02063.9371$273.31.$54.67

64418N block inj 

suprascapularT02063.9371$273.31.$54.67

64420N block inj intercost 

sngT02063.9371$273.31.$54.67

64421N block inj intercost 
mltT02077.5480$523.98.$104.80

64425N block inj 

ilio-ing/hypogiT02063.9371$273.31.$54.67

64430N block inj 

pudendalT02077.5480$523.98.$104.80

64435N block inj 

paracervicalT02063.9371$273.31.$54.67

64445N block inj sciatic 

sngT02077.5480$523.98.$104.80

64446N blk inj sciatic cont 

infT02077.5480$523.98.$104.80

64447N block inj fem 

singleT02063.9371$273.31.$54.67

64448N block inj fem cont 

infT02077.5480$523.98.$104.80

64449N block inj lumbar 

plexusT02077.5480$523.98.$104.80

64450N block other 

peripheralT02063.9371$273.31.$54.67

64455N block inj plantar 

digitT02042.7693$192.24$40.13$38.45

64479Inj foramen epidural 

c/tT02077.5480$523.98.$104.80

64480Inj foramen epidural 

add-onT02063.9371$273.31.$54.67

64483Inj foramen epidural 

l/sT02077.5480$523.98.$104.80

64484Inj foramen epidural 

add-onT02063.9371$273.31.$54.67

64490Inj paravert f jnt c/t 1 

levT02077.5480$523.98.$104.80

64491Inj paravert f jnt c/t 2 

levT02042.7693$192.24$40.13$38.45
64492Inj paravert f jnt c/t 3 

levT02042.7693$192.24$40.13$38.45

64493Inj paravert f jnt l/s 1 

levT02077.5480$523.98.$104.80

64494Inj paravert f jnt l/s 2 

levT02042.7693$192.24$40.13$38.45

64495Inj paravert f jnt l/s 3 

levT02042.7693$192.24$40.13$38.45

64505N block spenopalatine 

ganglT02042.7693$192.24$40.13$38.45

64508N block carotid sinus 

s/pT02042.7693$192.24$40.13$38.45

64510N block stellate 

ganglionT02077.5480$523.98.$104.80

64517N block inj hypogas 

plxsT02077.5480$523.98.$104.80

64520N block 

lumbar/thoracicT02077.5480$523.98.$104.80

64530N block inj celiac 

pelusT02077.5480$523.98.$104.80

64550Apply 

neurostimulatorA

64553Implant 

neuroelectrodesS004062.7889"$4,358.81".$871.77

64555Implant 

neuroelectrodesS004062.7889"$4,358.81".$871.77

64560Implant 

neuroelectrodesS004062.7889"$4,358.81".$871.77

64561Implant 

neuroelectrodesS004062.7889"$4,358.81".$871.77

64565Implant 

neuroelectrodesS004062.7889"$4,358.81".$871.77

64566Neuroeltrd stim post 

tibialT02042.7693$192.24$40.13$38.45
64568Inc for vagus n elect 

implS0318337.4240"$23,423.97""$9,121.76""$4,684.80"

64569Revise/repl vagus n 

eltrdT068720.7466"$1,440.23"$382.52$288.05

64570Remove vagus n 

eltrdT022137.4067"$2,596.77".$519.36

64575Implant 

neuroelectrodesS006186.9786"$6,038.05"."$1,207.61"

64577Implant 

neuroelectrodesS006186.9786"$6,038.05"."$1,207.61"

64580Implant 

neuroelectrodesS006186.9786"$6,038.05"."$1,207.61"

64581Implant 

neuroelectrodesS006186.9786"$6,038.05"."$1,207.61"

64585Revise/remove 

neuroelectrodeT068720.7466"$1,440.23"$382.52$288.05

64590Insrt/redo pn/gastr stimulS 

0039209.6958"$14,557.08"."$2,911.42"

64595Revise/rmv pn/gastr 

stimulT068831.3873"$2,178.91"$768.94$435.79

64600Injection treatment of 

nerveT020312.9066$895.98.$179.20

64605Injection treatment of 

nerveT022019.0626"$1,323.33".$264.67

64610Injection treatment of 

nerveT022019.0626"$1,323.33".$264.67

64611Chemodenerv saliv 

glandsT02042.7693$192.24$40.13$38.45

64612Destroy nerve face 

muscleT02042.7693$192.24$40.13$38.45

64613Destroy nerve neck 

muscleT02063.9371$273.31.$54.67
64614Destroy nerve extrem 

muscT02063.9371$273.31.$54.67

64620Injection treatment of 

nerveCHT020312.9066$895.98.$179.20

64622Destr paravertebrl nerve 

l/sT020312.9066$895.98.$179.20

64623Destr paravertebral n 

add-onT02077.5480$523.98.$104.80

64626Destr paravertebrl nerve 

c/tCHT020312.9066$895.98.$179.20

64627Destr paravertebral n 

add-onT02042.7693$192.24$40.13$38.45

64630Injection treatment of 

nerveT02077.5480$523.98.$104.80

64632N block inj common 

digitT02042.7693$192.24$40.13$38.45

64640Injection treatment of 

nerveT02077.5480$523.98.$104.80

64650Chemodenerv eccrine 

glandsT02042.7693$192.24$40.13$38.45

64653Chemodenerv eccrine 

glandsT02042.7693$192.24$40.13$38.45

64680Injection treatment of 

nerveCHT020312.9066$895.98.$179.20

64681Injection treatment of 

nerveT020312.9066$895.98.$179.20

64702Revise finger/toe 

nerveT022019.0626"$1,323.33".$264.67

64704Revise hand/foot 

nerveT022019.0626"$1,323.33".$264.67

64708Revise arm/leg 

nerveT022019.0626"$1,323.33".$264.67

64712Revision of sciatic 

nerveT022019.0626"$1,323.33".$264.67
64713Revision of arm 

nerve(s)T022019.0626"$1,323.33".$264.67

64714Revise low back 

nerve(s)T022019.0626"$1,323.33".$264.67

64716Revision of cranial 

nerveT022019.0626"$1,323.33".$264.67

64718Revise ulnar nerve at 

elbowT022019.0626"$1,323.33".$264.67

64719Revise ulnar nerve at 

wristT022019.0626"$1,323.33".$264.67

64721Carpal tunnel 

surgeryT022019.0626"$1,323.33".$264.67

64722Relieve pressure on 

nerve(s)T022019.0626"$1,323.33".$264.67

64726Release foot/toe 

nerveT022019.0626"$1,323.33".$264.67

64727Internal nerve 

revisionT022019.0626"$1,323.33".$264.67

64732Incision of brow 

nerveT022019.0626"$1,323.33".$264.67

64734Incision of cheek 

nerveT022019.0626"$1,323.33".$264.67

64736Incision of chin 

nerveT022019.0626"$1,323.33".$264.67

64738Incision of jaw 

nerveT022019.0626"$1,323.33".$264.67

64740Incision of tongue 

nerveT022019.0626"$1,323.33".$264.67

64742Incision of facial 

nerveT022019.0626"$1,323.33".$264.67

64744Incise nerve back of 

headT022019.0626"$1,323.33".$264.67
64746Incise diaphragm 

nerveT022019.0626"$1,323.33".$264.67

64752Incision of vagus 

nerveC

64755Incision of stomach 

nervesC

64760Incision of vagus 

nerveC

64761Incision of pelvis 

nerveT022019.0626"$1,323.33".$264.67

64763Incise hip/thigh 

nerveT022019.0626"$1,323.33".$264.67

64766Incise hip/thigh 

nerveT022137.4067"$2,596.77".$519.36

64771Sever cranial 

nerveT022019.0626"$1,323.33".$264.67

64772Incision of spinal 

nerveT022019.0626"$1,323.33".$264.67

64774Remove skin nerve 

lesionT022019.0626"$1,323.33".$264.67

64776Remove digit nerve 

lesionT022019.0626"$1,323.33".$264.67

64778Digit nerve surgery 

add-onT022019.0626"$1,323.33".$264.67

64782Remove limb nerve 

lesionT022019.0626"$1,323.33".$264.67

64783Limb nerve surgery 

add-onT022019.0626"$1,323.33".$264.67

64784Remove nerve 

lesionT022019.0626"$1,323.33".$264.67

64786Remove sciatic nerve 

lesionT022137.4067"$2,596.77".$519.36

64787Implant nerve 

endT022019.0626"$1,323.33".$264.67

64788Remove skin nerve 
lesionT022019.0626"$1,323.33".$264.67

64790Removal of nerve 

lesionT022019.0626"$1,323.33".$264.67

64792Removal of nerve 

lesionT022137.4067"$2,596.77".$519.36

64795Biopsy of 

nerveT022019.0626"$1,323.33".$264.67

64802Remove sympathetic 

nervesT022019.0626"$1,323.33".$264.67

64804Remove sympathetic 

nervesT022019.0626"$1,323.33".$264.67

64809Remove sympathetic 

nervesC

64818Remove sympathetic 

nervesC

64820Remove sympathetic 

nervesT022019.0626"$1,323.33".$264.67

64821Remove sympathetic 

nervesT005429.0181"$2,014.44".$402.89

64822Remove sympathetic 

nervesT005429.0181"$2,014.44".$402.89

64823Remove sympathetic 

nervesT005429.0181"$2,014.44".$402.89

64831Repair of digit 

nerveT022137.4067"$2,596.77".$519.36

64832Repair nerve 

add-onT022137.4067"$2,596.77".$519.36

64834Repair of hand or foot 

nerveT022137.4067"$2,596.77".$519.36

64835Repair of hand or foot 

nerveT022137.4067"$2,596.77".$519.36

64836Repair of hand or foot 

nerveT022137.4067"$2,596.77".$519.36

64837Repair nerve 
add-onT022137.4067"$2,596.77".$519.36

64840Repair of leg 

nerveT022137.4067"$2,596.77".$519.36

64856Repair/transpose 

nerveT022137.4067"$2,596.77".$519.36

64857Repair arm/leg 

nerveT022137.4067"$2,596.77".$519.36

64858Repair sciatic 

nerveT022137.4067"$2,596.77".$519.36

64859Nerve 

surgeryT022137.4067"$2,596.77".$519.36

64861Repair of arm 

nervesT022137.4067"$2,596.77".$519.36

64862Repair of low back 

nervesT022137.4067"$2,596.77".$519.36

64864Repair of facial 

nerveT022137.4067"$2,596.77".$519.36

64865Repair of facial 

nerveT022137.4067"$2,596.77".$519.36

64866Fusion of facial/other 

nerveC

64868Fusion of facial/other 

nerveC

64870Fusion of facial/other 

nerveT022137.4067"$2,596.77".$519.36

64872Subsequent repair of 

nerveT022137.4067"$2,596.77".$519.36

64874Repair & revise nerve 

add-onT022137.4067"$2,596.77".$519.36

64876Repair nerve/shorten 

boneT022137.4067"$2,596.77".$519.36

64885Nerve graft head or 

neckT022137.4067"$2,596.77".$519.36

64886Nerve graft head or 
neckT022137.4067"$2,596.77".$519.36

64890Nerve graft hand or 

footT022137.4067"$2,596.77".$519.36

64891Nerve graft hand or 

footT022137.4067"$2,596.77".$519.36

64892Nerve graft arm or 

legT022137.4067"$2,596.77".$519.36

64893Nerve graft arm or 

legT022137.4067"$2,596.77".$519.36

64895Nerve graft hand or 

footT022137.4067"$2,596.77".$519.36

64896Nerve graft hand or 

footT022137.4067"$2,596.77".$519.36

64897Nerve graft arm or 

legT022137.4067"$2,596.77".$519.36

64898Nerve graft arm or 

legT022137.4067"$2,596.77".$519.36

64901Nerve graft 

add-onT022137.4067"$2,596.77".$519.36

64902Nerve graft 

add-onT022137.4067"$2,596.77".$519.36

64905Nerve pedicle 

transferT022137.4067"$2,596.77".$519.36

64907Nerve pedicle 

transferT022137.4067"$2,596.77".$519.36

64910Nerve repair 

w/allograftT022137.4067"$2,596.77".$519.36

64911Neurorraphy w/vein 

autograftT022137.4067"$2,596.77".$519.36

64999Nervous system 

surgeryT02042.7693$192.24$40.13$38.45

65091Revise 

eyeT024240.9376"$2,841.89"$597.36$568.38
65093Revise eye with 

implantT024240.9376"$2,841.89"$597.36$568.38

65101Removal of 

eyeT024240.9376"$2,841.89"$597.36$568.38

65103Remove eye/insert 

implantT024240.9376"$2,841.89"$597.36$568.38

65105Remove eye/attach 

implantT024240.9376"$2,841.89"$597.36$568.38

65110Removal of 

eyeT024240.9376"$2,841.89"$597.36$568.38

65112Remove eye/revise 

socketT024240.9376"$2,841.89"$597.36$568.38

65114Remove eye/revise 

socketT024240.9376"$2,841.89"$597.36$568.38

65125Revise ocular 

implantT024127.0493"$1,877.76"$383.45$375.56

65130Insert ocular 

implantT024127.0493"$1,877.76"$383.45$375.56

65135Insert ocular 

implantT024127.0493"$1,877.76"$383.45$375.56

65140Attach ocular 

implantT024240.9376"$2,841.89"$597.36$568.38

65150Revise ocular 

implantT024127.0493"$1,877.76"$383.45$375.56

65155Reinsert ocular 

implantT024240.9376"$2,841.89"$597.36$568.38

65175Removal of ocular 

implantT024020.3065"$1,409.68"$296.20$281.94

65205Remove foreign body from 

eyeS06981.4030$97.40.$19.48

65210Remove foreign body from 

eyeS06981.4030$97.40.$19.48

65220Remove foreign body from 
eyeS06981.4030$97.40.$19.48

65222Remove foreign body from 

eyeS06981.4030$97.40.$19.48

65235Remove foreign body from 

eyeT023316.8777"$1,171.65".$234.33

65260Remove foreign body from 

eyeT02354.9132$341.07.$68.22

65265Remove foreign body from 

eyeT023722.7865"$1,581.84".$316.37

65270Repair of eye 

woundT024020.3065"$1,409.68"$296.20$281.94

65272Repair of eye 

woundT023425.2649"$1,753.89"$511.31$350.78

65273Repair of eye 

woundC

65275Repair of eye 

woundT023425.2649"$1,753.89"$511.31$350.78

65280Repair of eye 

woundT023722.7865"$1,581.84".$316.37

65285Repair of eye 

woundT067241.3248"$2,868.77".$573.76

65286Repair of eye 

woundT02557.8512$545.03$124.97$109.01

65290Repair of eye socket 

woundT024325.2851"$1,755.29"$415.27$351.06

65400Removal of eye 

lesionT023316.8777"$1,171.65".$234.33

65410Biopsy of 

corneaT023316.8777"$1,171.65".$234.33

65420Removal of eye 

lesionT023316.8777"$1,171.65".$234.33

65426Removal of eye 

lesionT023425.2649"$1,753.89"$511.31$350.78
65430Corneal 

smearS06981.4030$97.40.$19.48

65435Curette/treat 

corneaT02398.3090$576.81.$115.37

65436Curette/treat 

corneaT023316.8777"$1,171.65".$234.33

65450Treatment of corneal 

lesionS02312.3088$160.28.$32.06

65600Revision of 

corneaT024020.3065"$1,409.68"$296.20$281.94

65710Corneal 

transplantT024438.4709"$2,670.65"$800.09$534.13

65730Corneal 

transplantT024438.4709"$2,670.65"$800.09$534.13

65750Corneal 

transplantT024438.4709"$2,670.65"$800.09$534.13

65755Corneal 

transplantT024438.4709"$2,670.65"$800.09$534.13

65756Corneal trnspl 

endothelialT024438.4709"$2,670.65"$800.09$534.13

65757Prep corneal endo 

allograftN

65760Revision of 

corneaE

65765Revision of 

corneaE

65767Corneal tissue 

transplantE

65770Revise cornea with 

implantT0293117.7956"$8,177.37"."$1,635.48"

65771Radial 

keratotomyE

65772Correction of 

astigmatismT023316.8777"$1,171.65".$234.33

65775Correction of 

astigmatismT023316.8777"$1,171.65".$234.33
65778Cover eye 

w/membraneCHQ2023316.8777"$1,171.65".$234.33

65779Cover eye w/membrane 

sutureCHT023316.8777"$1,171.65".$234.33

65780Ocular reconst 

transplantT024438.4709"$2,670.65"$800.09$534.13

65781Ocular reconst 

transplantT024438.4709"$2,670.65"$800.09$534.13

65782Ocular reconst 

transplantT024438.4709"$2,670.65"$800.09$534.13

65800Drainage of 

eyeT02557.8512$545.03$124.97$109.01

65805Drainage of 

eyeCHT023425.2649"$1,753.89"$511.31$350.78

65810Drainage of 

eyeT023425.2649"$1,753.89"$511.31$350.78

65815Drainage of 

eyeT023425.2649"$1,753.89"$511.31$350.78

65820Relieve inner eye 

pressureT023425.2649"$1,753.89"$511.31$350.78

65850Incision of 

eyeT023425.2649"$1,753.89"$511.31$350.78

65855Laser surgery of 

eyeT02475.5801$387.37$104.31$77.48

65860Incise inner eye 

adhesionsT02475.5801$387.37$104.31$77.48

65865Incise inner eye 

adhesionsT023316.8777"$1,171.65".$234.33

65870Incise inner eye 

adhesionsT023425.2649"$1,753.89"$511.31$350.78

65875Incise inner eye 

adhesionsT023425.2649"$1,753.89"$511.31$350.78

65880Incise inner eye 
adhesionsT023316.8777"$1,171.65".$234.33

65900Remove eye 

lesionT02322.9435$204.34$42.27$40.87

65920Remove implant of 

eyeT023425.2649"$1,753.89"$511.31$350.78

65930Remove blood clot from 

eyeT023425.2649"$1,753.89"$511.31$350.78

66020Injection treatment of 

eyeT023316.8777"$1,171.65".$234.33

66030Injection treatment of 

eyeT023316.8777"$1,171.65".$234.33

66130Remove eye 

lesionT023425.2649"$1,753.89"$511.31$350.78

66150Glaucoma 

surgeryT023425.2649"$1,753.89"$511.31$350.78

66155Glaucoma 

surgeryT023425.2649"$1,753.89"$511.31$350.78

66160Glaucoma 

surgeryT023425.2649"$1,753.89"$511.31$350.78

66165Glaucoma 

surgeryT023425.2649"$1,753.89"$511.31$350.78

66170Glaucoma 

surgeryT023425.2649"$1,753.89"$511.31$350.78

66172Incision of 

eyeT023425.2649"$1,753.89"$511.31$350.78

66174Translum dil eye 

canalT067341.7832"$2,900.59"$632.65$580.12

66175Trnslum dil eye canal 

w/stntT067341.7832"$2,900.59"$632.65$580.12

66180Implant eye 

shuntT067341.7832"$2,900.59"$632.65$580.12

66185Revise eye 

shuntT023425.2649"$1,753.89"$511.31$350.78
66220Repair eye 

lesionT067241.3248"$2,868.77".$573.76

66225Repair/graft eye 

lesionT067341.7832"$2,900.59"$632.65$580.12

66250Follow-up surgery of 

eyeT023316.8777"$1,171.65".$234.33

66500Incision of 

irisT02322.9435$204.34$42.27$40.87

66505Incision of 

irisT02557.8512$545.03$124.97$109.01

66600Remove iris and 

lesionT023425.2649"$1,753.89"$511.31$350.78

66605Removal of 

irisT023425.2649"$1,753.89"$511.31$350.78

66625Removal of 

irisT02557.8512$545.03$124.97$109.01

66630Removal of 

irisT023425.2649"$1,753.89"$511.31$350.78

66635Removal of 

irisT023425.2649"$1,753.89"$511.31$350.78

66680Repair iris & ciliary 

bodyT023425.2649"$1,753.89"$511.31$350.78

66682Repair iris & ciliary 

bodyT023425.2649"$1,753.89"$511.31$350.78

66700Destruction ciliary 

bodyT023316.8777"$1,171.65".$234.33

66710Ciliary transsleral 

therapyT023316.8777"$1,171.65".$234.33

66711Ciliary endoscopic 

ablationT023316.8777"$1,171.65".$234.33

66720Destruction ciliary 

bodyT023316.8777"$1,171.65".$234.33

66740Destruction ciliary 
bodyT023425.2649"$1,753.89"$511.31$350.78

66761Revision of 

irisT02475.5801$387.37$104.31$77.48

66762Revision of 

irisT02475.5801$387.37$104.31$77.48

66770Removal of inner eye 

lesionT02475.5801$387.37$104.31$77.48

66820Incision secondary 

cataractT02557.8512$545.03$124.97$109.01

66821After cataract laser 

surgeryT02475.5801$387.37$104.31$77.48

66825Reposition intraocular 

lensT023425.2649"$1,753.89"$511.31$350.78

66830Removal of lens 

lesionT02557.8512$545.03$124.97$109.01

66840Removal of lens 

materialT024515.2776"$1,060.57".$212.12

66850Removal of lens 

materialT024930.7811"$2,136.82"$516.99$427.37

66852Removal of lens 

materialT024930.7811"$2,136.82"$516.99$427.37

66920Extraction of 

lensT024930.7811"$2,136.82"$516.99$427.37

66930Extraction of 

lensT024930.7811"$2,136.82"$516.99$427.37

66940Extraction of 

lensT024515.2776"$1,060.57".$212.12

66982Cataract surgery 

complexT024624.0158"$1,667.18"$488.94$333.44

66983Cataract surg w/iol 1 

stageT024624.0158"$1,667.18"$488.94$333.44

66984Cataract surg w/iol 1 

stageT024624.0158"$1,667.18"$488.94$333.44
66985Insert lens 

prosthesisT024624.0158"$1,667.18"$488.94$333.44

66986Exchange lens 

prosthesisT024624.0158"$1,667.18"$488.94$333.44

66990Ophthalmic endoscope 

add-onN

66999Eye surgery 

procedureT02322.9435$204.34$42.27$40.87

67005Partial removal of eye 

fluidT023722.7865"$1,581.84".$316.37

67010Partial removal of eye 

fluidT067241.3248"$2,868.77".$573.76

67015Release of eye 

fluidT067241.3248"$2,868.77".$573.76

67025Replace eye 

fluidT067241.3248"$2,868.77".$573.76

67027Implant eye drug 

systemT067241.3248"$2,868.77".$573.76

67028Injection eye 

drugT02383.3278$231.02.$46.21

67030Incise inner eye 

strandsT023722.7865"$1,581.84".$316.37

67031Laser surgery eye 

strandsT02475.5801$387.37$104.31$77.48

67036Removal of inner eye 

fluidT067241.3248"$2,868.77".$573.76

67039Laser treatment of 

retinaT067241.3248"$2,868.77".$573.76

67040Laser treatment of 

retinaT067241.3248"$2,868.77".$573.76

67041Vit for macular 

puckerT067241.3248"$2,868.77".$573.76

67042Vit for macular 

holeT067241.3248"$2,868.77".$573.76
67043Vit for membrane 

dissectT067241.3248"$2,868.77".$573.76

67101Repair detached 

retinaT023722.7865"$1,581.84".$316.37

67105Repair detached 

retinaT02475.5801$387.37$104.31$77.48

67107Repair detached 

retinaT067241.3248"$2,868.77".$573.76

67108Repair detached 

retinaT067241.3248"$2,868.77".$573.76

67110Repair detached 

retinaT023722.7865"$1,581.84".$316.37

67112Rerepair detached 

retinaT067241.3248"$2,868.77".$573.76

67113Repair retinal detach 

cplxT067241.3248"$2,868.77".$573.76

67115Release encircling 

materialT023722.7865"$1,581.84".$316.37

67120Remove eye implant 

materialT023722.7865"$1,581.84".$316.37

67121Remove eye implant 

materialT067241.3248"$2,868.77".$573.76

67141Treatment of 

retinaT02354.9132$341.07.$68.22

67145Treatment of 

retinaT02475.5801$387.37$104.31$77.48

67208Treatment of retinal 

lesionT02354.9132$341.07.$68.22

67210Treatment of retinal 

lesionT02475.5801$387.37$104.31$77.48

67218Treatment of retinal 

lesionT023722.7865"$1,581.84".$316.37
67220Treatment of choroid 

lesionT02354.9132$341.07.$68.22

67221Ocular photodynamic 

therT02354.9132$341.07.$68.22

67225Eye photodynamic ther 

add-onT02354.9132$341.07.$68.22

67227Treatment of retinal 

lesionT023722.7865"$1,581.84".$316.37

67228Treatment of retinal 

lesionT02475.5801$387.37$104.31$77.48

67229Tr retinal les preterm 

infT02475.5801$387.37$104.31$77.48

67250Reinforce eye 

wallT024020.3065"$1,409.68"$296.20$281.94

67255Reinforce/graft eye 

wallT023722.7865"$1,581.84".$316.37

67299Eye surgery 

procedureT02354.9132$341.07.$68.22

67311Revise eye 

muscleT024325.2851"$1,755.29"$415.27$351.06

67312Revise two eye 

musclesT024325.2851"$1,755.29"$415.27$351.06

67314Revise eye 

muscleT024325.2851"$1,755.29"$415.27$351.06

67316Revise two eye 

musclesT024325.2851"$1,755.29"$415.27$351.06

67318Revise eye 

muscle(s)T024325.2851"$1,755.29"$415.27$351.06

67320Revise eye muscle(s) 

add-onT024325.2851"$1,755.29"$415.27$351.06

67331Eye surgery follow-up 

add-onT024325.2851"$1,755.29"$415.27$351.06

67332Rerevise eye muscles 

add-onT024325.2851"$1,755.29"$415.27$351.06
67334Revise eye muscle 

w/sutureT024325.2851"$1,755.29"$415.27$351.06

67335Eye suture during 

surgeryT024325.2851"$1,755.29"$415.27$351.06

67340Revise eye muscle 

add-onT024325.2851"$1,755.29"$415.27$351.06

67343Release eye 

tissueT024325.2851"$1,755.29"$415.27$351.06

67345Destroy nerve of eye 

muscleT02383.3278$231.02.$46.21

67346Biopsy eye 

muscleT069915.6140"$1,083.92".$216.79

67399Eye muscle surgery 

procedureT024325.2851"$1,755.29"$415.27$351.06

67400Explore/biopsy eye 

socketT024020.3065"$1,409.68"$296.20$281.94

67405Explore/drain eye 

socketT024127.0493"$1,877.76"$383.45$375.56

67412Explore/treat eye 

socketT024020.3065"$1,409.68"$296.20$281.94

67413Explore/treat eye 

socketT024127.0493"$1,877.76"$383.45$375.56

67414Explr/decompress eye 

socketT024240.9376"$2,841.89"$597.36$568.38

67415Aspiration orbital 

contentsT024020.3065"$1,409.68"$296.20$281.94

67420Explore/treat eye 

socketT024240.9376"$2,841.89"$597.36$568.38

67430Explore/treat eye 

socketT024240.9376"$2,841.89"$597.36$568.38

67440Explore/drain eye 

socketT024240.9376"$2,841.89"$597.36$568.38
67445Explr/decompress eye 

socketT024240.9376"$2,841.89"$597.36$568.38

67450Explore/biopsy eye 

socketT024240.9376"$2,841.89"$597.36$568.38

67500Inject/treat eye 

socketS02312.3088$160.28.$32.06

67505Inject/treat eye 

socketT02383.3278$231.02.$46.21

67515Inject/treat eye 

socketT02383.3278$231.02.$46.21

67550Insert eye socket 

implantT024240.9376"$2,841.89"$597.36$568.38

67560Revise eye socket 

implantT024127.0493"$1,877.76"$383.45$375.56

67570Decompress optic 

nerveT024240.9376"$2,841.89"$597.36$568.38

67599Orbit surgery 

procedureT02383.3278$231.02.$46.21

67700Drainage of eyelid 

abscessT02383.3278$231.02.$46.21

67710Incision of 

eyelidT02398.3090$576.81.$115.37

67715Incision of eyelid 

foldT024020.3065"$1,409.68"$296.20$281.94

67800Remove eyelid 

lesionT02383.3278$231.02.$46.21

67801Remove eyelid 

lesionsT02398.3090$576.81.$115.37

67805Remove eyelid 

lesionsT02383.3278$231.02.$46.21

67808Remove eyelid 

lesion(s)T024020.3065"$1,409.68"$296.20$281.94

67810Biopsy of 

eyelidT02383.3278$231.02.$46.21
67820Revise 

eyelashesS06981.4030$97.40.$19.48

67825Revise 

eyelashesT02383.3278$231.02.$46.21

67830Revise 

eyelashesT02398.3090$576.81.$115.37

67835Revise 

eyelashesT024020.3065"$1,409.68"$296.20$281.94

67840Remove eyelid 

lesionT02398.3090$576.81.$115.37

67850Treat eyelid 

lesionT02398.3090$576.81.$115.37

67875Closure of eyelid by 

sutureT02398.3090$576.81.$115.37

67880Revision of 

eyelidT023316.8777"$1,171.65".$234.33

67882Revision of 

eyelidT024020.3065"$1,409.68"$296.20$281.94

67900Repair brow 

defectT024127.0493"$1,877.76"$383.45$375.56

67901Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67902Repair eyelid 

defectT024127.0493"$1,877.76"$383.45$375.56

67903Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67904Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67906Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67908Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94
67909Revise eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67911Revise eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67912Correction eyelid 

w/implantT024020.3065"$1,409.68"$296.20$281.94

67914Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67915Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67916Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67917Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67921Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67922Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67923Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67924Repair eyelid 

defectT024020.3065"$1,409.68"$296.20$281.94

67930Repair eyelid 

woundT024020.3065"$1,409.68"$296.20$281.94

67935Repair eyelid 

woundT024020.3065"$1,409.68"$296.20$281.94

67938Remove eyelid foreign 

bodyS02312.3088$160.28.$32.06

67950Revision of 

eyelidT024020.3065"$1,409.68"$296.20$281.94

67961Revision of 

eyelidT024020.3065"$1,409.68"$296.20$281.94

67966Revision of 

eyelidT024020.3065"$1,409.68"$296.20$281.94
67971Reconstruction of 

eyelidT024020.3065"$1,409.68"$296.20$281.94

67973Reconstruction of 

eyelidT024127.0493"$1,877.76"$383.45$375.56

67974Reconstruction of 

eyelidT024020.3065"$1,409.68"$296.20$281.94

67975Reconstruction of 

eyelidT024020.3065"$1,409.68"$296.20$281.94

67999Revision of 

eyelidT02383.3278$231.02.$46.21

68020Incise/drain eyelid 

liningT02383.3278$231.02.$46.21

68040Treatment of eyelid 

lesionsS06981.4030$97.40.$19.48

68100Biopsy of eyelid liningCH 

T02398.3090$576.81.$115.37

68110Remove eyelid lining 

lesionT069915.6140"$1,083.92".$216.79

68115Remove eyelid lining 

lesionT024020.3065"$1,409.68"$296.20$281.94

68130Remove eyelid lining 

lesionT023316.8777"$1,171.65".$234.33

68135Remove eyelid lining 

lesionT02398.3090$576.81.$115.37

68200Treat eyelid by 

injectionCHS02300.6929$48.10.$9.62

68320Revise/graft eyelid 

liningT024127.0493"$1,877.76"$383.45$375.56

68325Revise/graft eyelid 

liningT024127.0493"$1,877.76"$383.45$375.56

68326Revise/graft eyelid 

liningT024020.3065"$1,409.68"$296.20$281.94
68328Revise/graft eyelid 

liningT024127.0493"$1,877.76"$383.45$375.56

68330Revise eyelid 

liningT023425.2649"$1,753.89"$511.31$350.78

68335Revise/graft eyelid 

liningT024127.0493"$1,877.76"$383.45$375.56

68340Separate eyelid 

adhesionsT024020.3065"$1,409.68"$296.20$281.94

68360Revise eyelid 

liningT023425.2649"$1,753.89"$511.31$350.78

68362Revise eyelid 

liningT023425.2649"$1,753.89"$511.31$350.78

68371Harvest eye tissue 

alograftCHT023425.2649"$1,753.89"$511.31$350.78

68399Eyelid lining 

surgeryT02383.3278$231.02.$46.21

68400Incise/drain tear 

glandT02383.3278$231.02.$46.21

68420Incise/drain tear 

sacT024020.3065"$1,409.68"$296.20$281.94

68440Incise tear duct 

openingT02383.3278$231.02.$46.21

68500Removal of tear 

glandT024127.0493"$1,877.76"$383.45$375.56

68505Partial removal tear 

glandT024127.0493"$1,877.76"$383.45$375.56

68510Biopsy of tear 

glandT024020.3065"$1,409.68"$296.20$281.94

68520Removal of tear 

sacT024127.0493"$1,877.76"$383.45$375.56

68525Biopsy of tear 

sacT024020.3065"$1,409.68"$296.20$281.94

68530Clearance of tear 

ductT02383.3278$231.02.$46.21
68540Remove tear gland 

lesionT024020.3065"$1,409.68"$296.20$281.94

68550Remove tear gland 

lesionT024127.0493"$1,877.76"$383.45$375.56

68700Repair tear 

ductsT024020.3065"$1,409.68"$296.20$281.94

68705Revise tear duct 

openingT02383.3278$231.02.$46.21

68720Create tear sac 

drainT024127.0493"$1,877.76"$383.45$375.56

68745Create tear duct 

drainT024127.0493"$1,877.76"$383.45$375.56

68750Create tear duct 

drainT024127.0493"$1,877.76"$383.45$375.56

68760Close tear duct 

openingT02383.3278$231.02.$46.21

68761Close tear duct 

openingT02383.3278$231.02.$46.21

68770Close tear system 

fistulaT024127.0493"$1,877.76"$383.45$375.56

68801Dilate tear duct 

openingS06981.4030$97.40.$19.48

68810Probe nasolacrimal 

ductT02383.3278$231.02.$46.21

68811Probe nasolacrimal 

ductT024020.3065"$1,409.68"$296.20$281.94

68815Probe nasolacrimal 

ductT024020.3065"$1,409.68"$296.20$281.94

68816Probe nl duct 

w/balloonT024020.3065"$1,409.68"$296.20$281.94

68840Explore/irrigate tear 

ductsS02312.3088$160.28.$32.06
68850Injection for tear sac 

x-rayN

68899Tear duct system 

surgeryT02383.3278$231.02.$46.21

69000Drain external ear 

lesionT00061.4481$100.53.$20.11

69005Drain external ear 

lesionT000820.5401"$1,425.89".$285.18

69020Drain outer ear canal 

lesionT00061.4481$100.53.$20.11

69090Pierce 

earlobesE

69100Biopsy of external 

earT02513.3531$232.77.$46.56

69105Biopsy of external ear 

canalT025316.9180"$1,174.45"$277.61$234.89

69110Remove external ear 

partialT002117.1909"$1,193.39".$238.68

69120Removal of external 

earT025425.1379"$1,745.07".$349.02

69140Remove ear canal 

lesion(s)T025425.1379"$1,745.07".$349.02

69145Remove ear canal 

lesion(s)T002117.1909"$1,193.39".$238.68

69150Extensive ear canal 

surgeryT02528.0353$557.81.$111.57

69155Extensive ear/neck 

surgeryC

69200Clear outer ear 

canalX03400.6739$46.78.$9.36

69205Clear outer ear 

canalT002223.4169"$1,625.60"$350.05$325.12

69210Remove impacted ear 

waxX03400.6739$46.78.$9.36

69220Clean out mastoid 
cavityT00130.9786$67.93.$13.59

69222Clean out mastoid 

cavityT025316.9180"$1,174.45"$277.61$234.89

69300Revise external 

earT025425.1379"$1,745.07".$349.02

69310Rebuild outer ear 

canalT025645.1286"$3,132.83".$626.57

69320Rebuild outer ear 

canalT025645.1286"$3,132.83".$626.57

69399Outer ear surgery 

procedureT02501.0875$75.49$24.28$15.10

69400Inflate middle ear 

canalT02513.3531$232.77.$46.56

69401Inflate middle ear 

canalT02513.3531$232.77.$46.56

69405Catheterize middle ear 

canalT02528.0353$557.81.$111.57

69420Incision of 

eardrumT02513.3531$232.77.$46.56

69421Incision of 

eardrumT025316.9180"$1,174.45"$277.61$234.89

69424Remove ventilating 

tubeT025316.9180"$1,174.45"$277.61$234.89

69433Create eardrum 

openingT02528.0353$557.81.$111.57

69436Create eardrum 

openingT025316.9180"$1,174.45"$277.61$234.89

69440Exploration of middle 

earT025425.1379"$1,745.07".$349.02

69450Eardrum 

revisionT025645.1286"$3,132.83".$626.57

69501MastoidectomyT025645.1286"$3,132.83".$626.57
69502MastoidectomyT025425.1379"$1,745.07".$349.02

69505Remove mastoid 

structuresT025645.1286"$3,132.83".$626.57

69511Extensive mastoid 

surgeryT025645.1286"$3,132.83".$626.57

69530Extensive mastoid 

surgeryT025645.1286"$3,132.83".$626.57

69535Remove part of temporal 

boneC

69540Remove ear 

lesionT025316.9180"$1,174.45"$277.61$234.89

69550Remove ear 

lesionT025645.1286"$3,132.83".$626.57

69552Remove ear 

lesionT025645.1286"$3,132.83".$626.57

69554Remove ear 

lesionC

69601Mastoid surgery 

revisionT025645.1286"$3,132.83".$626.57

69602Mastoid surgery 

revisionT025645.1286"$3,132.83".$626.57

69603Mastoid surgery 

revisionT025645.1286"$3,132.83".$626.57

69604Mastoid surgery 

revisionT025645.1286"$3,132.83".$626.57

69605Mastoid surgery 

revisionT025645.1286"$3,132.83".$626.57

69610Repair of 

eardrumT025425.1379"$1,745.07".$349.02

69620Repair of 

eardrumT025425.1379"$1,745.07".$349.02

69631Repair eardrum 

structuresT025645.1286"$3,132.83".$626.57

69632Rebuild eardrum 
structuresT025645.1286"$3,132.83".$626.57

69633Rebuild eardrum 

structuresT025645.1286"$3,132.83".$626.57

69635Repair eardrum 

structuresT025645.1286"$3,132.83".$626.57

69636Rebuild eardrum 

structuresT025645.1286"$3,132.83".$626.57

69637Rebuild eardrum 

structuresT025645.1286"$3,132.83".$626.57

69641Revise middle ear & 

mastoidT025645.1286"$3,132.83".$626.57

69642Revise middle ear & 

mastoidT025645.1286"$3,132.83".$626.57

69643Revise middle ear & 

mastoidT025645.1286"$3,132.83".$626.57

69644Revise middle ear & 

mastoidT025645.1286"$3,132.83".$626.57

69645Revise middle ear & 

mastoidT025645.1286"$3,132.83".$626.57

69646Revise middle ear & 

mastoidT025645.1286"$3,132.83".$626.57

69650Release middle ear 

boneT025425.1379"$1,745.07".$349.02

69660Revise middle ear 

boneT025645.1286"$3,132.83".$626.57

69661Revise middle ear 

boneT025645.1286"$3,132.83".$626.57

69662Revise middle ear 

boneT025645.1286"$3,132.83".$626.57

69666Repair middle ear 

structuresT025645.1286"$3,132.83".$626.57

69667Repair middle ear 

structuresT025645.1286"$3,132.83".$626.57
69670Remove mastoid air 

cellsT025645.1286"$3,132.83".$626.57

69676Remove middle ear 

nerveT025645.1286"$3,132.83".$626.57

69700Close mastoid 

fistulaT025645.1286"$3,132.83".$626.57

69710Implant/replace hearing 

aidE

69711Remove/repair hearing 

aidT025645.1286"$3,132.83".$626.57

69714Implant temple bone 

w/stimulT0425130.4476"$9,055.67"."$1,811.14"

69715Temple bne implnt 

w/stimulatT0425130.4476"$9,055.67"."$1,811.14"

69717Temple bone implant 

revisionT0425130.4476"$9,055.67"."$1,811.14"

69718Revise temple bone 

implantT0425130.4476"$9,055.67"."$1,811.14"

69720Release facial 

nerveT025645.1286"$3,132.83".$626.57

69725Release facial 

nerveT025645.1286"$3,132.83".$626.57

69740Repair facial 

nerveT025645.1286"$3,132.83".$626.57

69745Repair facial 

nerveT025645.1286"$3,132.83".$626.57

69799Middle ear surgery 

procedureT02501.0875$75.49$24.28$15.10

69801Incise inner 

earT025316.9180"$1,174.45"$277.61$234.89

69802Incise inner 

earT025425.1379"$1,745.07".$349.02

69805Explore inner 

earT025645.1286"$3,132.83".$626.57
69806Explore inner 

earT025645.1286"$3,132.83".$626.57

69820Establish inner ear 

windowT025645.1286"$3,132.83".$626.57

69840Revise inner ear 

windowT025645.1286"$3,132.83".$626.57

69905Remove inner 

earT025645.1286"$3,132.83".$626.57

69910Remove inner ear & 

mastoidT025645.1286"$3,132.83".$626.57

69915Incise inner ear 

nerveT025645.1286"$3,132.83".$626.57

69930Implant cochlear 

deviceT0259395.1320"$27,430.06""$7,545.06""$5,486.02"

69949Inner ear surgery 

procedureT02501.0875$75.49$24.28$15.10

69950Incise inner ear 

nerveC

69955Release facial 

nerveT025645.1286"$3,132.83".$626.57

69960Release inner ear 

canalT025645.1286"$3,132.83".$626.57

69970Remove inner ear 

lesionT025645.1286"$3,132.83".$626.57

69979Temporal bone 

surgeryT02501.0875$75.49$24.28$15.10

69990Microsurgery 

add-onN

70010Contrast x-ray of 

brainQ202746.9677$483.70.$96.74

70015Contrast x-ray of 

brainQ202746.9677$483.70.$96.74

70030X-ray eye for foreign 

bodyX02600.6418$44.55.$8.91
70100X-ray exam of 

jawX02600.6418$44.55.$8.91

70110X-ray exam of 

jawX02600.6418$44.55.$8.91

70120X-ray exam of 

mastoidsX02600.6418$44.55.$8.91

70130X-ray exam of 

mastoidsX02600.6418$44.55.$8.91

70134X-ray exam of middle 

earX02611.0831$75.19.$15.04

70140X-ray exam of facial 

bonesX02600.6418$44.55.$8.91

70150X-ray exam of facial 

bonesX02600.6418$44.55.$8.91

70160X-ray exam of nasal 

bonesX02600.6418$44.55.$8.91

70170X-ray exam of tear 

ductQ202633.3928$235.53.$47.11

70190X-ray exam of eye 

socketsX02600.6418$44.55.$8.91

70200X-ray exam of eye 

socketsX02600.6418$44.55.$8.91

70210X-ray exam of 

sinusesX02600.6418$44.55.$8.91

70220X-ray exam of 

sinusesX02600.6418$44.55.$8.91

70240X-ray exam pituitary 

saddleX02600.6418$44.55.$8.91

70250X-ray exam of 

skullX02600.6418$44.55.$8.91

70260X-ray exam of 

skullX02611.0831$75.19.$15.04
70300X-ray exam of 

teethX02620.4650$32.28.$6.46

70310X-ray exam of 

teethX02620.4650$32.28.$6.46

70320Full mouth x-ray of 

teethX02620.4650$32.28.$6.46

70328X-ray exam of jaw 

jointX02600.6418$44.55.$8.91

70330X-ray exam of jaw 

jointsX02600.6418$44.55.$8.91

70332X-ray exam of jaw jointQ2 

02753.9868$276.76$68.90$55.36

70336Magnetic image jaw 

jointQ303364.8219$334.74$131.90$66.95

70350X-ray head for 

orthodontiaX02600.6418$44.55.$8.91

70355Panoramic x-ray of 

jawsX02620.4650$32.28.$6.46

70360X-ray exam of 

neckX02600.6418$44.55.$8.91

70370Throat x-ray & 

fluoroscopyX02721.2481$86.64$30.47$17.33

70371Speech evaluation 

complexX02721.2481$86.64$30.47$17.33

70373Contrast x-ray of 

larynxQ202633.3928$235.53.$47.11

70380X-ray exam of salivary 

glandX02600.6418$44.55.$8.91

70390X-ray exam of salivary ductQ2 

02633.3928$235.53.$47.11

70450Ct head/brain w/o 

dyeQ303322.7424$190.38$73.61$38.08

70460Ct head/brain 

w/dyeQ302834.2806$297.16$95.77$59.44
70470Ct head/brain w/o & 

w/dyeQ303334.7716$331.24$115.09$66.25

70480Ct orbit/ear/fossa w/o 

dyeQ303322.7424$190.38$73.61$38.08

70481Ct orbit/ear/fossa 

w/dyeQ302834.2806$297.16$95.77$59.44

70482Ct orbit/ear/fossa 

w/o&w/dyeQ303334.7716$331.24$115.09$66.25

70486Ct maxillofacial w/o 

dyeQ303322.7424$190.38$73.61$38.08

70487Ct maxillofacial 

w/dyeQ302834.2806$297.16$95.77$59.44

70488Ct maxillofacial w/o & 

w/dyeQ303334.7716$331.24$115.09$66.25

70490Ct soft tissue neck w/o 

dyeQ303322.7424$190.38$73.61$38.08

70491Ct soft tissue neck 

w/dyeQ302834.2806$297.16$95.77$59.44

70492Ct sft tsue nck w/o & 

w/dyeQ303334.7716$331.24$115.09$66.25

70496Ct angiography 

headQ306624.8432$336.21$113.59$67.25

70498Ct angiography 

neckQ306624.8432$336.21$113.59$67.25

70540Mri orbit/face/neck w/o 

dyeQ303364.8219$334.74$131.90$66.95

70542Mri orbit/face/neck 

w/dyeQ302846.1872$429.52$144.34$85.91

70543Mri orbt/fac/nck w/o & 

w/dyeQ303377.6393$530.32$196.43$106.07

70544Mr angiography head w/o 

dyeQ303364.8219$334.74$131.90$66.95
70545Mr angiography head 

w/dyeQ302846.1872$429.52$144.34$85.91

70546Mr angiograph head 

w/o&w/dyeQ303377.6393$530.32$196.43$106.07

70547Mr angiography neck w/o 

dyeQ303364.8219$334.74$131.90$66.95

70548Mr angiography neck 

w/dyeQ302846.1872$429.52$144.34$85.91

70549Mr angiograph neck 

w/o&w/dyeQ303377.6393$530.32$196.43$106.07

70551Mri brain w/o 

dyeQ303364.8219$334.74$131.90$66.95

70552Mri brain 

w/dyeQ302846.1872$429.52$144.34$85.91

70553Mri brain w/o & 

w/dyeQ303377.6393$530.32$196.43$106.07

70554Fmri brain by 

techQ303364.8219$334.74$131.90$66.95

70555Fmri brain by 

phys/psychS03364.8219$334.74$131.90$66.95

70557Mri brain w/o 

dyeS03364.8219$334.74$131.90$66.95

70558Mri brain 

w/dyeS02846.1872$429.52$144.34$85.91

70559Mri brain w/o & 

w/dyeS03377.6393$530.32$196.43$106.07

71010Chest 

x-rayQ302600.6418$44.55.$8.91

71015Chest 

x-rayQ302600.6418$44.55.$8.91

71020Chest 

x-rayQ302600.6418$44.55.$8.91

71021Chest 

x-rayX02600.6418$44.55.$8.91
71022Chest 

x-rayX02600.6418$44.55.$8.91

71023Chest x-ray and 

fluoroscopyX02721.2481$86.64$30.47$17.33

71030Chest 

x-rayX02600.6418$44.55.$8.91

71034Chest x-ray and 

fluoroscopyX02721.2481$86.64$30.47$17.33

71035Chest 

x-rayX02600.6418$44.55.$8.91

71040Contrast x-ray of bronchiQ2 

02633.3928$235.53.$47.11

71060Contrast x-ray of bronchiQ2 

02633.3928$235.53.$47.11

71090X-ray & pacemaker insertionN 

71100X-ray exam of 

ribsX02600.6418$44.55.$8.91

71101X-ray exam of 

ribs/chestX02600.6418$44.55.$8.91

71110X-ray exam of 

ribsX02600.6418$44.55.$8.91

71111X-ray exam of 

ribs/chestX02611.0831$75.19.$15.04

71120X-ray exam of 

breastboneX02600.6418$44.55.$8.91

71130X-ray exam of 

breastboneX02600.6418$44.55.$8.91

71250Ct thorax w/o 

dyeQ303322.7424$190.38$73.61$38.08

71260Ct thorax 

w/dyeQ302834.2806$297.16$95.77$59.44

71270Ct thorax w/o & 
w/dyeQ303334.7716$331.24$115.09$66.25

71275Ct angiography 

chestQ306624.8432$336.21$113.59$67.25

71550Mri chest w/o 

dyeQ303364.8219$334.74$131.90$66.95

71551Mri chest 

w/dyeQ302846.1872$429.52$144.34$85.91

71552Mri chest w/o & 

w/dyeQ303377.6393$530.32$196.43$106.07

71555Mri angio chest w or w/o 

dyeB

72010X-ray exam of 

spineX02611.0831$75.19.$15.04

72020X-ray exam of 

spineX02600.6418$44.55.$8.91

72040X-ray exam of neck 

spineX02600.6418$44.55.$8.91

72050X-ray exam of neck 

spineX02611.0831$75.19.$15.04

72052X-ray exam of neck 

spineX02611.0831$75.19.$15.04

72069X-ray exam of trunk 

spineX02600.6418$44.55.$8.91

72070X-ray exam of thoracic 

spineX02600.6418$44.55.$8.91

72072X-ray exam of thoracic 

spineX02600.6418$44.55.$8.91

72074X-ray exam of thoracic 

spineX02600.6418$44.55.$8.91

72080X-ray exam of trunk 

spineX02600.6418$44.55.$8.91

72090X-ray exam of trunk 

spineX02611.0831$75.19.$15.04
72100X-ray exam of lower 

spineX02600.6418$44.55.$8.91

72110X-ray exam of lower 

spineX02611.0831$75.19.$15.04

72114X-ray exam of lower 

spineX02611.0831$75.19.$15.04

72120X-ray exam of lower 

spineX02600.6418$44.55.$8.91

72125Ct neck spine w/o 

dyeQ303322.7424$190.38$73.61$38.08

72126Ct neck spine 

w/dyeQ302834.2806$297.16$95.77$59.44

72127Ct neck spine w/o & 

w/dyeQ303334.7716$331.24$115.09$66.25

72128Ct chest spine w/o 

dyeQ303322.7424$190.38$73.61$38.08

72129Ct chest spine 

w/dyeQ302834.2806$297.16$95.77$59.44

72130Ct chest spine w/o & 

w/dyeQ303334.7716$331.24$115.09$66.25

72131Ct lumbar spine w/o 

dyeQ303322.7424$190.38$73.61$38.08

72132Ct lumbar spine 

w/dyeQ302834.2806$297.16$95.77$59.44

72133Ct lumbar spine w/o & 

w/dyeQ303334.7716$331.24$115.09$66.25

72141Mri neck spine w/o 

dyeQ303364.8219$334.74$131.90$66.95

72142Mri neck spine 

w/dyeQ302846.1872$429.52$144.34$85.91

72146Mri chest spine w/o 

dyeQ303364.8219$334.74$131.90$66.95

72147Mri chest spine 

w/dyeQ302846.1872$429.52$144.34$85.91
72148Mri lumbar spine w/o 

dyeQ303364.8219$334.74$131.90$66.95

72149Mri lumbar spine 

w/dyeQ302846.1872$429.52$144.34$85.91

72156Mri neck spine w/o & 

w/dyeQ303377.6393$530.32$196.43$106.07

72157Mri chest spine w/o & 

w/dyeQ303377.6393$530.32$196.43$106.07

72158Mri lumbar spine w/o & 

w/dyeQ303377.6393$530.32$196.43$106.07

72159Mr angio spine 

w/o&w/dyeB

72170X-ray exam of 

pelvisX02600.6418$44.55.$8.91

72190X-ray exam of 

pelvisX02600.6418$44.55.$8.91

72191Ct angiograph pelv 

w/o&w/dyeQ306624.8432$336.21$113.59$67.25

72192Ct pelvis w/o 

dyeQ303322.7424$190.38$73.61$38.08

72193Ct pelvis 

w/dyeQ302834.2806$297.16$95.77$59.44

72194Ct pelvis w/o & 

w/dyeQ303334.7716$331.24$115.09$66.25

72195Mri pelvis w/o 

dyeQ303364.8219$334.74$131.90$66.95

72196Mri pelvis 

w/dyeQ302846.1872$429.52$144.34$85.91

72197Mri pelvis w/o & 

w/dyeQ303377.6393$530.32$196.43$106.07

72198Mr angio pelvis w/o & 

w/dyeB

72200X-ray exam sacroiliac 

jointsX02600.6418$44.55.$8.91
72202X-ray exam sacroiliac 

jointsX02600.6418$44.55.$8.91

72220X-ray exam of 

tailboneX02600.6418$44.55.$8.91

72240Contrast x-ray of neck spineQ2 

02746.9677$483.70.$96.74

72255Contrast x-ray thorax spineQ2 

02746.9677$483.70.$96.74

72265Contrast x-ray lower spineQ2 

02746.9677$483.70.$96.74

72270Contrast x-ray spineQ2 

02746.9677$483.70.$96.74

72275EpidurographyN 

72285X-ray c/t spine diskQ2 

038823.0551"$1,600.49".$320.10

72291Perq verte/sacroplsty fluorN 

72292Perq verte/sacroplsty ctN 

72295X-ray of lower spine diskQ2 

038823.0551"$1,600.49".$320.10

73000X-ray exam of collar 

boneX02600.6418$44.55.$8.91

73010X-ray exam of shoulder 

bladeX02600.6418$44.55.$8.91

73020X-ray exam of 

shoulderX02600.6418$44.55.$8.91

73030X-ray exam of 

shoulderX02600.6418$44.55.$8.91

73040Contrast x-ray of shoulderQ2 

02753.9868$276.76$68.90$55.36

73050X-ray exam of 

shouldersX02600.6418$44.55.$8.91
73060X-ray exam of 

humerusX02600.6418$44.55.$8.91

73070X-ray exam of 

elbowX02600.6418$44.55.$8.91

73080X-ray exam of 

elbowX02600.6418$44.55.$8.91

73085Contrast x-ray of elbowQ2 

02753.9868$276.76$68.90$55.36

73090X-ray exam of 

forearmX02600.6418$44.55.$8.91

73092X-ray exam of arm 

infantX02600.6418$44.55.$8.91

73100X-ray exam of 

wristX02600.6418$44.55.$8.91

73110X-ray exam of 

wristX02600.6418$44.55.$8.91

73115Contrast x-ray of wristQ2 

02753.9868$276.76$68.90$55.36

73120X-ray exam of 

handX02600.6418$44.55.$8.91

73130X-ray exam of 

handX02600.6418$44.55.$8.91

73140X-ray exam of 

finger(s)X02600.6418$44.55.$8.91

73200Ct upper extremity w/o 

dyeQ303322.7424$190.38$73.61$38.08

73201Ct upper extremity 

w/dyeQ302834.2806$297.16$95.77$59.44

73202Ct uppr extremity 

w/o&w/dyeQ303334.7716$331.24$115.09$66.25

73206Ct angio upr extrm 

w/o&w/dyeQ306624.8432$336.21$113.59$67.25

73218Mri upper extremity w/o 
dyeQ303364.8219$334.74$131.90$66.95

73219Mri upper extremity 

w/dyeQ302846.1872$429.52$144.34$85.91

73220Mri uppr extremity 

w/o&w/dyeQ303377.6393$530.32$196.43$106.07

73221Mri joint upr extrem w/o 

dyeQ303364.8219$334.74$131.90$66.95

73222Mri joint upr extrem 

w/dyeQ302846.1872$429.52$144.34$85.91

73223Mri joint upr extr 

w/o&w/dyeQ303377.6393$530.32$196.43$106.07

73225Mr angio upr extr 

w/o&w/dyeB

73500X-ray exam of 

hipX02600.6418$44.55.$8.91

73510X-ray exam of 

hipX02600.6418$44.55.$8.91

73520X-ray exam of 

hipsX02600.6418$44.55.$8.91

73525Contrast x-ray of hipQ2 

02753.9868$276.76$68.90$55.36

73530X-ray exam of hipN 

73540X-ray exam of pelvis & 

hipsX02600.6418$44.55.$8.91

73542X-ray exam sacroiliac jointQ2 

02753.9868$276.76$68.90$55.36

73550X-ray exam of 

thighX02600.6418$44.55.$8.91

73560X-ray exam of knee 1 or 

2X02600.6418$44.55.$8.91

73562X-ray exam of knee 

3X02600.6418$44.55.$8.91

73564X-ray exam knee 4 or 
moreX02600.6418$44.55.$8.91

73565X-ray exam of 

kneesX02600.6418$44.55.$8.91

73580Contrast x-ray of knee jointQ2 

02753.9868$276.76$68.90$55.36

73590X-ray exam of lower 

legX02600.6418$44.55.$8.91

73592X-ray exam of leg 

infantX02600.6418$44.55.$8.91

73600X-ray exam of 

ankleX02600.6418$44.55.$8.91

73610X-ray exam of 

ankleX02600.6418$44.55.$8.91

73615Contrast x-ray of ankleQ2 

02753.9868$276.76$68.90$55.36

73620X-ray exam of 

footX02600.6418$44.55.$8.91

73630X-ray exam of 

footX02600.6418$44.55.$8.91

73650X-ray exam of 

heelX02600.6418$44.55.$8.91

73660X-ray exam of 

toe(s)X02600.6418$44.55.$8.91

73700Ct lower extremity w/o 

dyeQ303322.7424$190.38$73.61$38.08

73701Ct lower extremity 

w/dyeQ302834.2806$297.16$95.77$59.44

73702Ct lwr extremity 

w/o&w/dyeQ303334.7716$331.24$115.09$66.25

73706Ct angio lwr extr 

w/o&w/dyeQ306624.8432$336.21$113.59$67.25

73718Mri lower extremity w/o 

dyeQ303364.8219$334.74$131.90$66.95
73719Mri lower extremity 

w/dyeQ302846.1872$429.52$144.34$85.91

73720Mri lwr extremity 

w/o&w/dyeQ303377.6393$530.32$196.43$106.07

73721Mri jnt of lwr extre w/o 

dyeQ303364.8219$334.74$131.90$66.95

73722Mri joint of lwr extr 

w/dyeQ302846.1872$429.52$144.34$85.91

73723Mri joint lwr extr 

w/o&w/dyeQ303377.6393$530.32$196.43$106.07

73725Mr ang lwr ext w or w/o 

dyeB

74000X-ray exam of 

abdomenX02600.6418$44.55.$8.91

74010X-ray exam of 

abdomenX02600.6418$44.55.$8.91

74020X-ray exam of 

abdomenX02600.6418$44.55.$8.91

74022X-ray exam series 

abdomenX02611.0831$75.19.$15.04

74150Ct abdomen w/o 

dyeQ303322.7424$190.38$73.61$38.08

74160Ct abdomen 

w/dyeQ302834.2806$297.16$95.77$59.44

74170Ct abdomen w/o & 

w/dyeQ303334.7716$331.24$115.09$66.25

74175Ct angio abdom w/o & 

w/dyeQ306624.8432$336.21$113.59$67.25

74176Ct abd & pelvis w/o 

contrastCHQ303315.8040$402.91$155.78$80.59

74177Ct abdomen&pelvis 

w/contrastCHQ303348.2338$571.59$184.21$114.32

74178Ct abd&pelv 1+ 

section/regnsCHQ303348.2338$571.59$184.21$114.32
74181Mri abdomen w/o 

dyeQ303364.8219$334.74$131.90$66.95

74182Mri abdomen 

w/dyeQ302846.1872$429.52$144.34$85.91

74183Mri abdomen w/o & 

w/dyeQ303377.6393$530.32$196.43$106.07

74185Mri angio abdom w orw/o 

dyeB

74190X-ray exam of peritoneumQ2 

02633.3928$235.53.$47.11

74210Contrst x-ray exam of 

throatS02761.2290$85.32$33.87$17.07

74220Contrast x-ray 

esophagusS02761.2290$85.32$33.87$17.07

74230Cine/vid x-ray 

throat/esophS02761.2290$85.32$33.87$17.07

74235Remove esophagus obstructionN 

74240X-ray exam upper gi 

tractS02761.2290$85.32$33.87$17.07

74241X-ray exam upper gi 

tractS02761.2290$85.32$33.87$17.07

74245X-ray exam upper gi 

tractS02772.0083$139.42$52.93$27.89

74246Contrst x-ray uppr gi 

tractS02761.2290$85.32$33.87$17.07

74247Contrst x-ray uppr gi 

tractS02761.2290$85.32$33.87$17.07

74249Contrst x-ray uppr gi 

tractS02772.0083$139.42$52.93$27.89

74250X-ray exam of small 

bowelS02761.2290$85.32$33.87$17.07

74251X-ray exam of small 

bowelS02772.0083$139.42$52.93$27.89
74260X-ray exam of small 

bowelS02761.2290$85.32$33.87$17.07

74261Ct colonography 

dxQ303322.7424$190.38$73.61$38.08

74262Ct colonography dx 

w/dyeQ302834.2806$297.16$95.77$59.44

74263Ct colonography 

screeningE

74270Contrast x-ray exam of 

colonS02761.2290$85.32$33.87$17.07

74280Contrast x-ray exam of 

colonS02772.0083$139.42$52.93$27.89

74283Contrast x-ray exam of 

colonS02761.2290$85.32$33.87$17.07

74290Contrast x-ray 

gallbladderS02761.2290$85.32$33.87$17.07

74291Contrast x-rays 

gallbladderS02761.2290$85.32$33.87$17.07

74300X-ray bile ducts/pancreasN 

74301X-rays at surgery add-onN 

74305X-ray bile ducts/pancreasQ2 

02633.3928$235.53.$47.11

74320Contrast x-ray of bile ductsQ2 

03176.2675$435.09.$87.02

74327X-ray bile stone removalN 

74328X-ray bile duct 

endoscopyN

74329X-ray for pancreas 

endoscopyN

74330X-ray bile/panc 

endoscopyN

74340X-ray guide for GI 

tubeN
74355X-ray guide intestinal 

tubeN

74360X-ray guide gi 

dilationN

74363X-ray bile duct 

dilationN

74400Contrst x-ray urinary 

tractS02782.5896$179.77$58.44$35.96

74410Contrst x-ray urinary 

tractS02782.5896$179.77$58.44$35.96

74415Contrst x-ray urinary 

tractS02782.5896$179.77$58.44$35.96

74420Contrst x-ray urinary 

tractS02782.5896$179.77$58.44$35.96

74425Contrst x-ray urinary tractQ2 

02782.5896$179.77$58.44$35.96

74430Contrast x-ray bladderQ2 

02782.5896$179.77$58.44$35.96

74440X-ray male genital tractQ2 

02782.5896$179.77$58.44$35.96

74445X-ray exam of penisQ2 

02782.5896$179.77$58.44$35.96

74450X-ray urethra/bladderQ2 

02782.5896$179.77$58.44$35.96

74455X-ray urethra/bladderQ2 

02782.5896$179.77$58.44$35.96

74470X-ray exam of kidney lesionQ2 

02633.3928$235.53.$47.11

74475X-ray control cath insertQ2 

016117.6738"$1,226.92".$245.39

74480X-ray control cath insertQ2 

016117.6738"$1,226.92".$245.39

74485X-ray guide gu dilationQ2 

016117.6738"$1,226.92".$245.39

74710X-ray measurement of 
pelvisX02611.0831$75.19.$15.04

74740X-ray female genital tractQ2 

02633.3928$235.53.$47.11

74742X-ray fallopian tubeN 

74775X-ray exam of 

perineumS02782.5896$179.77$58.44$35.96

75557Cardiac mri for 

morphQ303364.8219$334.74$131.90$66.95

75559Cardiac mri w/stress 

imgQ303364.8219$334.74$131.90$66.95

75561Cardiac mri for morph 

w/dyeQ303377.6393$530.32$196.43$106.07

75563Card mri w/stress img & 

dyeQ303377.6393$530.32$196.43$106.07

75565Card mri veloc flow mappingN 

75571Ct hrt w/o dye w/ca 

testX03400.6739$46.78.$9.36

75572Ct hrt w/3d 

imageS03833.7294$258.89.$51.78

75573Ct hrt w/3d image 

congenS03833.7294$258.89.$51.78

75574Ct angio hrt w/3d 

imageS03833.7294$258.89.$51.78

75600Contrast x-ray exam of aortaQ2 

027929.6734"$2,059.93".$411.99

75605Contrast x-ray exam of aortaQ2 

027929.6734"$2,059.93".$411.99

75625Contrast x-ray exam of aortaQ2 

027929.6734"$2,059.93".$411.99

75630X-ray aorta leg arteriesQ2 

027929.6734"$2,059.93".$411.99

75635Ct angio abdominal arteriesQ2 
06624.8432$336.21$113.59$67.25

75650Artery x-rays head & neckQ2 

028049.6711"$3,448.17".$689.64

75658Artery x-rays armQ2 

027929.6734"$2,059.93".$411.99

75660Artery x-rays head & neckQ2 

028049.6711"$3,448.17".$689.64

75662Artery x-rays head & neckQ2 

028049.6711"$3,448.17".$689.64

75665Artery x-rays head & neckQ2 

027929.6734"$2,059.93".$411.99

75671Artery x-rays head & neckQ2 

028049.6711"$3,448.17".$689.64

75676Artery x-rays neckQ2 

027929.6734"$2,059.93".$411.99

75680Artery x-rays neckQ2 

027929.6734"$2,059.93".$411.99

75685Artery x-rays spineQ2 

027929.6734"$2,059.93".$411.99

75705Artery x-rays spineQ2 

027929.6734"$2,059.93".$411.99

75710Artery x-rays arm/legQ2 

027929.6734"$2,059.93".$411.99

75716Artery x-rays arms/legsQ2 

027929.6734"$2,059.93".$411.99

75722Artery x-rays kidneyQ2 

027929.6734"$2,059.93".$411.99

75724Artery x-rays kidneysQ2 

027929.6734"$2,059.93".$411.99

75726Artery x-rays abdomenQ2 

027929.6734"$2,059.93".$411.99

75731Artery x-rays adrenal glandQ2 

027929.6734"$2,059.93".$411.99
75733Artery x-rays adrenalsQ2 

027929.6734"$2,059.93".$411.99

75736Artery x-rays pelvisQ2 

027929.6734"$2,059.93".$411.99

75741Artery x-rays lungQ2 

027929.6734"$2,059.93".$411.99

75743Artery x-rays lungsQ2 

027929.6734"$2,059.93".$411.99

75746Artery x-rays lungQ2 

06689.4312$654.71.$130.95

75756Artery x-rays chestQ2 

06689.4312$654.71.$130.95

75774Artery x-ray each vesselN 

75791Av dialysis shunt 

imagingCHQ206689.4312$654.71.$130.95

75801Lymph vessel x-ray arm/legQ2 

03176.2675$435.09.$87.02

75803Lymph vessel x-ray arms/legsQ2 

03176.2675$435.09.$87.02

75805Lymph vessel x-ray trunkQ2 

03176.2675$435.09.$87.02

75807Lymph vessel x-ray trunkQ2 

03176.2675$435.09.$87.02

75809Nonvascular shunt x-rayQ2 

02611.0831$75.19.$15.04

75810Vein x-ray spleen/liverQ2 

027929.6734"$2,059.93".$411.99

75820Vein x-ray arm/legQ2 

06689.4312$654.71.$130.95

75822Vein x-ray arms/legsQ2 

06689.4312$654.71.$130.95

75825Vein x-ray trunkQ2 

027929.6734"$2,059.93".$411.99
75827Vein x-ray chestQ2 

06689.4312$654.71.$130.95

75831Vein x-ray kidneyQ2 

027929.6734"$2,059.93".$411.99

75833Vein x-ray kidneysQ2 

027929.6734"$2,059.93".$411.99

75840Vein x-ray adrenal glandQ2 

027929.6734"$2,059.93".$411.99

75842Vein x-ray adrenal glandsQ2 

027929.6734"$2,059.93".$411.99

75860Vein x-ray neckQ2 

06689.4312$654.71.$130.95

75870Vein x-ray skullQ2 

06689.4312$654.71.$130.95

75872Vein x-ray skullQ2 

06689.4312$654.71.$130.95

75880Vein x-ray eye socketQ2 

06689.4312$654.71.$130.95

75885Vein x-ray liverQ2 

027929.6734"$2,059.93".$411.99

75887Vein x-ray liverQ2 

06689.4312$654.71.$130.95

75889Vein x-ray liverQ2 

027929.6734"$2,059.93".$411.99

75891Vein x-ray liverQ2 

027929.6734"$2,059.93".$411.99

75893Venous sampling by catheterQ2 

027929.6734"$2,059.93".$411.99

75894X-rays transcath 

therapyN

75896X-rays transcath 

therapyN

75898Follow-up angiographyQ1 

02611.0831$75.19.$15.04
75900Intravascular cath 

exchangeC

75901Remove cva device obstructN 

75902Remove cva lumen obstructN 

75940X-ray placement vein filterN 

75945Intravascular usQ2 

02672.1881$151.90$59.41$30.38

75946Intravascular us add-onN 

75952Endovasc repair abdom 

aortaC

75953Abdom aneurysm endovas 

rprC

75954Iliac aneurysm endovas 

rprC

75956Xray endovasc thor ao 

reprC

75957Xray endovasc thor ao 

reprC

75958Xray place prox ext thor 

aoC

75959Xray place dist ext thor 

aoC

75960Transcath iv stent rs&iN 

75961Retrieval broken catheterN 

75962Repair arterial blockageQ2 

008365.1118"$4,520.06".$904.02

75964Repair artery blockage eachN 

75966Repair arterial blockageQ2 

008365.1118"$4,520.06".$904.02

75968Repair artery blockage eachN 

75970Vascular biopsyN 

75978Repair venous blockageQ2 
009330.7767"$2,136.52".$427.31

75980Contrast xray exam bile ductN 

75982Contrast xray exam bile ductN 

75984Xray control catheter changeN 

75989Abscess drainage under 

x-rayN

76000Fluoroscope examinationQ1 

02721.2481$86.64$30.47$17.33

76001Fluoroscope exam 

extensiveN

76010X-ray nose to 

rectumX02600.6418$44.55.$8.91

76080X-ray exam of fistulaQ2 

02633.3928$235.53.$47.11

76098X-ray exam breast specimenQ2 

03176.2675$435.09.$87.02

76100X-ray exam of body 

sectionX02611.0831$75.19.$15.04

76101Complex body section 

x-rayX02633.3928$235.53.$47.11

76102Complex body section 

x-raysX02633.3928$235.53.$47.11

76120Cine/video 

x-raysX02721.2481$86.64$30.47$17.33

76125Cine/video x-rays add-onN 

76140X-ray 

consultationE

763763d render w/o postprocessN 

763773d rendering w/postprocessN 

76380CAT scan follow-up 

studyS02821.5453$107.27$35.74$21.46
76390Mr 

spectroscopyE

76496Fluoroscopic 

procedureX02721.2481$86.64$30.47$17.33

76497Ct 

procedureS02821.5453$107.27$35.74$21.46

76498Mri 

procedureS03364.8219$334.74$131.90$66.95

76499Radiographic 

procedureX02600.6418$44.55.$8.91

76506Echo exam of 

headS02650.8995$62.44$22.26$12.49

76510Ophth us b & quant 

aT02322.9435$204.34$42.27$40.87

76511Ophth us quant a 

onlyS02661.3711$95.18$36.80$19.04

76512Ophth us b w/non-quant 

aS02661.3711$95.18$36.80$19.04

76513Echo exam of eye water 

bathS02661.3711$95.18$36.80$19.04

76514Echo exam of eye thicknessX 

00350.2717$18.86.$3.78

76516Echo exam of 

eyeS02650.8995$62.44$22.26$12.49

76519Echo exam of 

eyeS02661.3711$95.18$36.80$19.04

76529Echo exam of 

eyeS02650.8995$62.44$22.26$12.49

76536Us exam of head and 

neckS02661.3711$95.18$36.80$19.04

76604Us exam 

chestQ302650.8995$62.44$22.26$12.49

76645Us exam 

breast(s)S02650.8995$62.44$22.26$12.49
76700Us exam abdom 

completeQ302661.3711$95.18$36.80$19.04

76705Echo exam of 

abdomenQ302661.3711$95.18$36.80$19.04

76770Us exam abdo back wall 

compQ302661.3711$95.18$36.80$19.04

76775Us exam abdo back wall 

limQ302661.3711$95.18$36.80$19.04

76776Us exam k transpl 

w/dopplerQ302661.3711$95.18$36.80$19.04

76800Us exam spinal 

canalS02661.3711$95.18$36.80$19.04

76801Ob us < 14 wks single 

fetusS02661.3711$95.18$36.80$19.04

76802Ob us < 14 wks addl 

fetusS02650.8995$62.44$22.26$12.49

76805Ob us >/= 14 wks sngl 

fetusS02661.3711$95.18$36.80$19.04

76810Ob us >/= 14 wks addl 

fetusS02661.3711$95.18$36.80$19.04

76811Ob us detailed sngl 

fetusS02672.1881$151.90$59.41$30.38

76812Ob us detailed addl 

fetusS02650.8995$62.44$22.26$12.49

76813Ob us nuchal meas 1 

gestS02650.8995$62.44$22.26$12.49

76814Ob us nuchal meas 

add-onS02650.8995$62.44$22.26$12.49

76815Ob us limited 

fetus(s)S02650.8995$62.44$22.26$12.49

76816Ob us follow-up per 

fetusS02650.8995$62.44$22.26$12.49

76817Transvaginal us 

obstetricS02650.8995$62.44$22.26$12.49
76818Fetal biophys profile 

w/nstS02661.3711$95.18$36.80$19.04

76819Fetal biophys profil w/o 

nstS02661.3711$95.18$36.80$19.04

76820Umbilical artery 

echoS02650.8995$62.44$22.26$12.49

76821Middle cerebral artery 

echoS02650.8995$62.44$22.26$12.49

76825Echo exam of fetal heartCH 

S06973.1535$218.92.$43.79

76826Echo exam of fetal heartCH 

S06973.1535$218.92.$43.79

76827Echo exam of fetal 

heartS02650.8995$62.44$22.26$12.49

76828Echo exam of fetal 

heartS02650.8995$62.44$22.26$12.49

76830Transvaginal us 

non-obS02661.3711$95.18$36.80$19.04

76831Echo exam 

uterusQ302672.1881$151.90$59.41$30.38

76856Us exam pelvic 

completeQ302661.3711$95.18$36.80$19.04

76857Us exam pelvic 

limitedQ302650.8995$62.44$22.26$12.49

76870Us exam 

scrotumQ302661.3711$95.18$36.80$19.04

76872Us 

transrectalS02661.3711$95.18$36.80$19.04

76873Echograp trans r pros 

studyS02661.3711$95.18$36.80$19.04

76881Us xtr non-vasc 

completeS02661.3711$95.18$36.80$19.04
76882Us xtr non-vasc 

lmtdS02650.8995$62.44$22.26$12.49

76885Us exam infant hips 

dynamicS02650.8995$62.44$22.26$12.49

76886Us exam infant hips 

staticS02650.8995$62.44$22.26$12.49

76930Echo guide cardiocentesisN 

76932Echo guide for heart biopsyN 

76936Echo guide for artery 

repairS00961.5324$106.38$36.83$21.28

76937Us guide vascular 

accessN

76940Us guide tissue 

ablationN

76941Echo guide for 

transfusionN

76942Echo guide for 

biopsyN

76945Echo guide villus 

samplingN

76946Echo guide for 

amniocentesisN

76948Echo guide ova 

aspirationN

76950Echo guidance 

radiotherapyN

76965Echo guidance 

radiotherapyN

76970Ultrasound exam 

follow-upS02650.8995$62.44$22.26$12.49

76975GI endoscopic ultrasoundQ2 

02672.1881$151.90$59.41$30.38

76977Us bone density 

measureX03400.6739$46.78$0.00$0.00

76998Us guide intraopN 

76999Echo examination 

procedureS02650.8995$62.44$22.26$12.49
77001Fluoroguide for vein deviceN 

77002Needle localization by xrayN 

77003Fluoroguide for spine injectN 

77011Ct scan for localizationN 

77012Ct scan for needle biopsyN 

77013Ct guide for tissue ablationN 

77014Ct scan for therapy guideN 

77021Mr guidance for needle placeN 

77022Mri for tissue ablationN 

77031Stereotact guide for brst bxN 

77032Guidance for needle breastN 

77051Computer dx mammogram 

add-onA

77052Comp screen mammogram 

add-onA

77053X-ray of mammary ductQ2 

02633.3928$235.53.$47.11

77054X-ray of mammary ductsQ2 

02633.3928$235.53.$47.11

77055Mammogram one 

breastA

77056Mammogram both 

breastsA

77057Mammogram 

screeningA

77058Mri one 

breastB

77059Mri both 

breastsB

77071X-ray stress viewX 

02600.6418$44.55.$8.91
77072X-rays for bone ageX 

02600.6418$44.55.$8.91

77073X-rays bone length studiesX 

02600.6418$44.55.$8.91

77074X-rays bone survey limitedX 

02611.0831$75.19.$15.04

77075X-rays bone survey completeX 

02611.0831$75.19.$15.04

77076X-rays bone survey infantX 

02611.0831$75.19.$15.04

77077Joint survey single viewX 

02600.6418$44.55.$8.91

77078Ct bone density 

axialS02881.0215$70.91$0.00$0.00

77079Ct bone density 

peripheralS02821.5453$107.27$0.00$0.00

77080Dxa bone density 

axialS02881.0215$70.91$0.00$0.00

77081Dxa bone 

density/peripheralS06650.4570$31.72$0.00$0.00

77082Dxa bone density vert fxX 

02600.6418$44.55.$8.91

77083Radiographic absorptiometryX 

02611.0831$75.19$0.00$0.00

77084Magnetic image bone marrowS 

03364.8219$334.74$131.90$66.95

77261Radiation therapy 

planningB

77262Radiation therapy 

planningB

77263Radiation therapy 

planningB

77280Set radiation therapy 

fieldX03041.4946$103.76$34.39$20.76

77285Set radiation therapy 

fieldX03053.7009$256.92$86.44$51.39
77290Set radiation therapy 

fieldX03053.7009$256.92$86.44$51.39

77295Set radiation therapy 

fieldX031013.2460$919.54$322.74$183.91

77299Radiation therapy 

planningX03041.4946$103.76$34.39$20.76

77300Radiation therapy dose 

planX03041.4946$103.76$34.39$20.76

77301Radiotherapy dose plan 

imrtX031013.2460$919.54$322.74$183.91

77305Teletx isodose plan 

simpleX03041.4946$103.76$34.39$20.76

77310Teletx isodose plan 

intermedX03041.4946$103.76$34.39$20.76

77315Teletx isodose plan 

complexX03053.7009$256.92$86.44$51.39

77321Special teletx port 

planX03053.7009$256.92$86.44$51.39

77326Brachytx isodose calc 

simpX03041.4946$103.76$34.39$20.76

77327Brachytx isodose calc 

intermX03053.7009$256.92$86.44$51.39

77328Brachytx isodose plan 

complX03053.7009$256.92$86.44$51.39

77331Special radiation 

dosimetryX03041.4946$103.76$34.39$20.76

77332Radiation treatment 

aid(s)X03032.7910$193.75$64.95$38.75

77333Radiation treatment 

aid(s)X03032.7910$193.75$64.95$38.75

77334Radiation treatment 

aid(s)X03032.7910$193.75$64.95$38.75

77336Radiation physics 

consultX03041.4946$103.76$34.39$20.76
77338Design mlc device for 

imrtCHX03053.7009$256.92$86.44$51.39

77370Radiation physics 

consultX03041.4946$103.76$34.39$20.76

77371Srs 

multisourceS0127106.1294"$7,367.50"."$1,473.50"

77372Srs linear 

basedB

77373Sbrt 

deliveryB

77399External radiation 

dosimetryX03041.4946$103.76$34.39$20.76

77401Radiation treatment 

deliveryS03001.3628$94.61.$18.93

77402Radiation treatment 

deliveryS03001.3628$94.61.$18.93

77403Radiation treatment 

deliveryS03001.3628$94.61.$18.93

77404Radiation treatment 

deliveryS03001.3628$94.61.$18.93

77406Radiation treatment 

deliveryS03001.3628$94.61.$18.93

77407Radiation treatment 

deliveryS03001.3628$94.61.$18.93

77408Radiation treatment 

deliveryCHS03012.3680$164.39.$32.88

77409Radiation treatment 

deliveryCHS03012.3680$164.39.$32.88

77411Radiation treatment 

deliveryS03012.3680$164.39.$32.88

77412Radiation treatment 

deliveryS03012.3680$164.39.$32.88

77413Radiation treatment 

deliveryS03012.3680$164.39.$32.88
77414Radiation treatment 

deliveryS03012.3680$164.39.$32.88

77416Radiation treatment 

deliveryS03012.3680$164.39.$32.88

77417Radiology port film(s)N 

77418Radiation tx delivery 

imrtS04126.4422$447.22.$89.45

77421Stereoscopic x-ray 

guidanceN

77422Neutron beam tx 

simpleS03012.3680$164.39.$32.88

77423Neutron beam tx 

complexS03012.3680$164.39.$32.88

77427Radiation tx management 

x5B

77431Radiation therapy 

managementB

77432Stereotactic radiation 

trmtB

77435Sbrt managementN 

77470Special radiation 

treatmentS02995.6094$389.40.$77.88

77499Radiation therapy 

managementB

77520Proton trmt simple w/o 

compS066414.2952$992.37.$198.48

77522Proton trmt simple 

w/compS066414.2952$992.37.$198.48

77523Proton trmt 

intermediateS066718.7001"$1,298.16".$259.64

77525Proton treatment 

complexS066718.7001"$1,298.16".$259.64

77600Hyperthermia 

treatmentS02995.6094$389.40.$77.88
77605Hyperthermia 

treatmentS02995.6094$389.40.$77.88

77610Hyperthermia 

treatmentS02995.6094$389.40.$77.88

77615Hyperthermia 

treatmentS02995.6094$389.40.$77.88

77620Hyperthermia 

treatmentS02995.6094$389.40.$77.88

77750Infuse radioactive 

materialsS03012.3680$164.39.$32.88

77761Apply intrcav radiat 

simpleS03124.7014$326.37.$65.28

77762Apply intrcav radiat 

intermS03124.7014$326.37.$65.28

77763Apply intrcav radiat 

complS03124.7014$326.37.$65.28

77776Apply interstit radiat 

simplS03124.7014$326.37.$65.28

77777Apply interstit radiat 

interS03124.7014$326.37.$65.28

77778Apply interstit radiat 

complQ3065112.4760$866.08.$173.22

77785Hdr brachytx 1 

channelS03139.8659$684.89$258.98$136.98

77786Hdr brachytx 2-12 

channelS03139.8659$684.89$258.98$136.98

77787Hdr brachytx over 12 

chanS03139.8659$684.89$258.98$136.98

77789Apply surface 

radiationS03001.3628$94.61.$18.93

77790Radiation 

handlingN

77799Radium/radioisotope 

therapyS03124.7014$326.37.$65.28
78000Thyroid single 

uptakeS03891.5133$105.05$26.88$21.01

78001Thyroid multiple 

uptakesS03891.5133$105.05$26.88$21.01

78003Thyroid 

suppress/stimulS03891.5133$105.05$26.88$21.01

78006Thyroid imaging with 

uptakeS03913.1750$220.41$65.46$44.09

78007Thyroid image mult 

uptakesS03913.1750$220.41$65.46$44.09

78010Thyroid 

imagingS03901.8660$129.54$46.52$25.91

78011Thyroid imaging with 

flowS03901.8660$129.54$46.52$25.91

78015Thyroid met 

imagingS04064.0374$280.28$85.03$56.06

78016Thyroid met 

imaging/studiesS04064.0374$280.28$85.03$56.06

78018Thyroid met imaging 

bodyS04064.0374$280.28$85.03$56.06

78020Thyroid met uptakeN 

78070Parathyroid nuclear 

imagingS03913.1750$220.41$65.46$44.09

78075Adrenal nuclear 

imagingCHS04146.9811$484.63.$96.93

78099Endocrine nuclear 

procedureS03901.8660$129.54$46.52$25.91

78102Bone marrow imaging 

ltdS04003.7132$257.77$91.24$51.56

78103Bone marrow imaging 

multS04003.7132$257.77$91.24$51.56

78104Bone marrow imaging 
bodyS04003.7132$257.77$91.24$51.56

78110Plasma volume 

singleS03936.3038$437.61.$87.53

78111Plasma volume 

multipleS03936.3038$437.61.$87.53

78120Red cell mass 

singleS03936.3038$437.61.$87.53

78121Red cell mass 

multipleS03936.3038$437.61.$87.53

78122Blood 

volumeS03936.3038$437.61.$87.53

78130Red cell survival 

studyS03936.3038$437.61.$87.53

78135Red cell survival 

kineticsS03936.3038$437.61.$87.53

78140Red cell 

sequestrationS03936.3038$437.61.$87.53

78185Spleen 

imagingS04003.7132$257.77$91.24$51.56

78190Platelet survival 

kineticsS03922.5360$176.05$42.39$35.21

78191Platelet 

survivalS03922.5360$176.05$42.39$35.21

78195Lymph system 

imagingS04003.7132$257.77$91.24$51.56

78199Blood/lymph nuclear 

examS04003.7132$257.77$91.24$51.56

78201Liver 

imagingS03944.1587$288.70$90.78$57.74

78202Liver imaging with 

flowS03944.1587$288.70$90.78$57.74

78205Liver imaging 

(3D)S03944.1587$288.70$90.78$57.74
78206Liver image (3d) with 

flowS03944.1587$288.70$90.78$57.74

78215Liver and spleen 

imagingS03944.1587$288.70$90.78$57.74

78216Liver & spleen 

image/flowS03944.1587$288.70$90.78$57.74

78220Liver function 

studyS03944.1587$288.70$90.78$57.74

78223Hepatobiliary 

imagingS03944.1587$288.70$90.78$57.74

78230Salivary gland 

imagingS03953.4576$240.03$87.01$48.01

78231Serial salivary 

imagingS03953.4576$240.03$87.01$48.01

78232Salivary gland function 

examS03953.4576$240.03$87.01$48.01

78258Esophageal motility 

studyS03953.4576$240.03$87.01$48.01

78261Gastric mucosa 

imagingS03953.4576$240.03$87.01$48.01

78262Gastroesophageal reflux 

examS03953.4576$240.03$87.01$48.01

78264Gastric emptying 

studyS03953.4576$240.03$87.01$48.01

78267Breath tst attain/anal 

c-14A

78268Breath test analysis 

c-14A

78270Vit B-12 absorption 

examS03922.5360$176.05$42.39$35.21

78271Vit b-12 absrp exam int 

facS03922.5360$176.05$42.39$35.21

78272Vit b-12 absorp 

combinedS03922.5360$176.05$42.39$35.21
78278Acute GI blood loss 

imagingS03953.4576$240.03$87.01$48.01

78282GI protein loss 

examS03953.4576$240.03$87.01$48.01

78290Meckels divert 

examS03953.4576$240.03$87.01$48.01

78291Leveen/shunt patency 

examS03953.4576$240.03$87.01$48.01

78299GI nuclear 

procedureS03953.4576$240.03$87.01$48.01

78300Bone imaging limited 

areaS03963.5140$243.94$93.91$48.79

78305Bone imaging multiple 

areasS03963.5140$243.94$93.91$48.79

78306Bone imaging whole 

bodyS03963.5140$243.94$93.91$48.79

78315Bone imaging 3 

phaseS03963.5140$243.94$93.91$48.79

78320Bone imaging 

(3D)S03963.5140$243.94$93.91$48.79

78350Bone mineral single 

photonE

78351Bone mineral dual 

photonE

78399Musculoskeletal nuclear 

examS03963.5140$243.94$93.91$48.79

78414Non-imaging heart 

functionS03984.2252$293.31$93.33$58.67

78428Cardiac shunt 

imagingS03984.2252$293.31$93.33$58.67

78445Vascular flow 

imagingS03972.4220$168.14$38.85$33.63

78451Ht muscle image spect 

singS03779.7483$676.73.$135.35
78452Ht muscle image spect 

multS03779.7483$676.73.$135.35

78453Ht muscle image planar 

singS03779.7483$676.73.$135.35

78454Ht musc image planar 

multS03779.7483$676.73.$135.35

78456Acute venous thrombus 

imageS03972.4220$168.14$38.85$33.63

78457Venous thrombosis 

imagingS03972.4220$168.14$38.85$33.63

78458Ven thrombosis images 

bilatS03972.4220$168.14$38.85$33.63

78459Heart muscle imaging 

(PET)S030713.2711$921.28.$184.26

78466Heart infarct 

imageS03984.2252$293.31$93.33$58.67

78468Heart infarct image 

(ef)S03984.2252$293.31$93.33$58.67

78469Heart infarct image 

(3D)S03984.2252$293.31$93.33$58.67

78472Gated heart planar 

singleS03984.2252$293.31$93.33$58.67

78473Gated heart 

multipleS03984.2252$293.31$93.33$58.67

78481Heart first pass 

singleS03984.2252$293.31$93.33$58.67

78483Heart first pass 

multipleS03984.2252$293.31$93.33$58.67

78491Heart image (pet) 

singleS030713.2711$921.28.$184.26

78492Heart image (pet) 

multipleS030713.2711$921.28.$184.26

78494Heart image 
spectS03984.2252$293.31$93.33$58.67

78496Heart first pass add-onN 

78499Cardiovascular nuclear 

examS03984.2252$293.31$93.33$58.67

78580Lung perfusion 

imagingS04012.8425$197.33$71.16$39.47

78584Lung V/Q image single 

breathS03784.5059$312.80$120.71$62.56

78585Lung V/Q 

imagingS03784.5059$312.80$120.71$62.56

78586Aerosol lung image 

singleS04012.8425$197.33$71.16$39.47

78587Aerosol lung image 

multipleS04012.8425$197.33$71.16$39.47

78588Perfusion lung 

imageS03784.5059$312.80$120.71$62.56

78591Vent image 1 breath 1 

projS04012.8425$197.33$71.16$39.47

78593Vent image 1 proj 

gasS04012.8425$197.33$71.16$39.47

78594Vent image mult proj 

gasS04012.8425$197.33$71.16$39.47

78596Lung differential 

functionS03784.5059$312.80$120.71$62.56

78599Respiratory nuclear 

examS04012.8425$197.33$71.16$39.47

78600Brain image < 4 

viewsS04033.3656$233.64$70.43$46.73

78601Brain image w/flow < 4 

viewsS04028.7081$604.52.$120.91

78605Brain image 4+ 

viewsS04033.3656$233.64$70.43$46.73
78606Brain image w/flow 4 + 

viewsS04028.7081$604.52.$120.91

78607Brain imaging 

(3D)S04028.7081$604.52.$120.91

78608Brain imaging 

(PET)S030814.6171"$1,014.72".$202.95

78609Brain imaging 

(PET)E

78610Brain flow imaging 

onlyS04033.3656$233.64$70.43$46.73

78630Cerebrospinal fluid 

scanS04028.7081$604.52.$120.91

78635CSF 

ventriculographyS04028.7081$604.52.$120.91

78645CSF shunt 

evaluationS04033.3656$233.64$70.43$46.73

78647Cerebrospinal fluid 

scanS04028.7081$604.52.$120.91

78650CSF leakage 

imagingS04028.7081$604.52.$120.91

78660Nuclear exam of tear 

flowS04033.3656$233.64$70.43$46.73

78699Nervous system nuclear 

examS04033.3656$233.64$70.43$46.73

78700Kidney imaging 

morpholS04044.5715$317.35$81.14$63.47

78701Kidney imaging with 

flowS04044.5715$317.35$81.14$63.47

78707K flow/funct image w/o 

drugS04044.5715$317.35$81.14$63.47

78708K flow/funct image 

w/drugS04044.5715$317.35$81.14$63.47

78709K flow/funct image 

multipleS04044.5715$317.35$81.14$63.47
78710Kidney imaging 

(3D)S04044.5715$317.35$81.14$63.47

78725Kidney function 

studyS03922.5360$176.05$42.39$35.21

78730Urinary bladder 

retentionS03891.5133$105.05$26.88$21.01

78740Ureteral reflux 

studyS04044.5715$317.35$81.14$63.47

78761Testicular imaging 

w/flowS04044.5715$317.35$81.14$63.47

78799Genitourinary nuclear 

examS04044.5715$317.35$81.14$63.47

78800Tumor imaging limited 

areaS04064.0374$280.28$85.03$56.06

78801Tumor imaging mult 

areasS04146.9811$484.63.$96.93

78802Tumor imaging whole 

bodyS04146.9811$484.63.$96.93

78803Tumor imaging 

(3D)S04146.9811$484.63.$96.93

78804Tumor imaging whole 

bodyS040813.7263$952.88.$190.58

78805Abscess imaging ltd 

areaS04146.9811$484.63.$96.93

78806Abscess imaging whole 

bodyS04146.9811$484.63.$96.93

78807Nuclear 

localization/abscessS04146.9811$484.63.$96.93

78808Iv inj ra drug dx studyQ1 

03922.5360$176.05$42.39$35.21

78811Pet image ltd 

areaS030814.6171"$1,014.72".$202.95

78812Pet image 
skull-thighS030814.6171"$1,014.72".$202.95

78813Pet image full 

bodyS030814.6171"$1,014.72".$202.95

78814Pet image w/ct 

lmtdS030814.6171"$1,014.72".$202.95

78815Pet image w/ct 

skull-thighS030814.6171"$1,014.72".$202.95

78816Pet image w/ct full 

bodyS030814.6171"$1,014.72".$202.95

78999Nuclear diagnostic 

examS03891.5133$105.05$26.88$21.01

79005Nuclear rx oral 

adminS04073.2808$227.75$78.13$45.55

79101Nuclear rx iv 

adminS04073.2808$227.75$78.13$45.55

79200Nuclear rx intracav 

adminS04134.0894$283.89.$56.78

79300Nuclr rx interstit 

colloidS04073.2808$227.75$78.13$45.55

79403Hematopoietic nuclear 

txS04134.0894$283.89.$56.78

79440Nuclear rx 

intra-articularS04134.0894$283.89.$56.78

79445Nuclear rx 

intra-arterialS04073.2808$227.75$78.13$45.55

79999Nuclear medicine 

therapyS04073.2808$227.75$78.13$45.55

80047Metabolic panel ionized 

caA

80048Metabolic panel total 

caA

80050General health 

panelE

80051Electrolyte 

panelA
80053Comprehen metabolic 

panelA

80055Obstetric 

panelE

80061Lipid 

panelA

80069Renal function 

panelA

80074Acute hepatitis 

panelA

80076Hepatic function 

panelA

80100Drug screen 

qualitate/multiE

80101Drug screen 

singleE

80102Drug 

confirmationA

80103Drug analysis tissue 

prepN

80104Drug scrn 1+ class 

nonchromoE

80150Assay of 

amikacinA

80152Assay of 

amitriptylineA

80154Assay of 

benzodiazepinesA

80156Assay carbamazepine 

totalA

80157Assay carbamazepine 

freeA

80158Assay of 

cyclosporineA

80160Assay of 

desipramineA

80162Assay of 

digoxinA

80164Assay dipropylacetic 

acidA

80166Assay of 

doxepinA

80168Assay of 

ethosuximideA
80170Assay of 

gentamicinA

80172Assay of 

goldA

80173Assay of 

haloperidolA

80174Assay of 

imipramineA

80176Assay of 

lidocaineA

80178Assay of 

lithiumA

80182Assay of 

nortriptylineA

80184Assay of 

phenobarbitalA

80185Assay of phenytoin 

totalA

80186Assay of phenytoin 

freeA

80188Assay of 

primidoneA

80190Assay of 

procainamideA

80192Assay of 

procainamideA

80194Assay of 

quinidineA

80195Assay of 

sirolimusA

80196Assay of 

salicylateA

80197Assay of 

tacrolimusA

80198Assay of 

theophyllineA

80200Assay of 

tobramycinA

80201Assay of 

topiramateA

80202Assay of 

vancomycinA

80299Quantitative assay 

drugA
80400Acth stimulation 

panelA

80402Acth stimulation 

panelA

80406Acth stimulation 

panelA

80408Aldosterone suppression 

evalA

80410Calcitonin stimul 

panelA

80412CRH stimulation 

panelA

80414Testosterone 

responseA

80415Estradiol response 

panelA

80416Renin stimulation 

panelA

80417Renin stimulation 

panelA

80418Pituitary evaluation 

panelA

80420Dexamethasone 

panelA

80422Glucagon tolerance 

panelA

80424Glucagon tolerance 

panelA

80426Gonadotropin hormone 

panelA

80428Growth hormone 

panelA

80430Growth hormone 

panelA

80432Insulin suppression 

panelA

80434Insulin tolerance 

panelA

80435Insulin tolerance 

panelA

80436Metyrapone 

panelA

80438TRH stimulation 

panelA
80439TRH stimulation 

panelA

80440TRH stimulation 

panelA

80500Lab pathology 

consultationCHX03420.1639$11.38.$2.28

80502Lab pathology 

consultationX03420.1639$11.38.$2.28

81000Urinalysis nonauto 

w/scopeA

81001Urinalysis auto 

w/scopeA

81002Urinalysis nonauto w/o 

scopeA

81003Urinalysis auto w/o 

scopeA

81005UrinalysisA

81007Urine screen for 

bacteriaA

81015Microscopic exam of 

urineA

81020Urinalysis glass 

testA

81025Urine pregnancy 

testA

81050Urinalysis volume 

measureA

81099Urinalysis test 

procedureA

82000Assay of blood 

acetaldehydeA

82003Assay of 

acetaminophenA

82009Test for 

acetone/ketonesA

82010Acetone 

assayA

82013Acetylcholinesterase 

assayA

82016Acylcarnitines 

qualA

82017Acylcarnitines 
quantA

82024Assay of 

acthA

82030Assay of adp & 

ampA

82040Assay of serum 

albuminA

82042Assay of urine 

albuminA

82043Microalbumin 

quantitativeA

82044Microalbumin 

semiquantA

82045Albumin ischemia 

modifiedA

82055Assay of 

ethanolA

82075Assay of breath 

ethanolA

82085Assay of 

aldolaseA

82088Assay of 

aldosteroneA

82101Assay of urine 

alkaloidsA

82103Alpha-1-antitrypsin 

totalA

82104Alpha-1-antitrypsin 

phenoA

82105Alpha-fetoprotein 

serumA

82106Alpha-fetoprotein 

amnioticA

82107Alpha-fetoprotein 

l3A

82108Assay of 

aluminumA

82120Amines vaginal fluid 

qualA

82127Amino acid single 

qualA

82128Amino acids mult 

qualA

82131Amino acids single 
quantA

82135Assay aminolevulinic 

acidA

82136Amino acids quant 

2-5A

82139Amino acids quan 6 or 

moreA

82140Assay of 

ammoniaA

82143Amniotic fluid 

scanA

82145Assay of 

amphetaminesA

82150Assay of 

amylaseA

82154Androstanediol 

glucuronideA

82157Assay of 

androstenedioneA

82160Assay of 

androsteroneA

82163Assay of angiotensin 

IIA

82164Angiotensin I enzyme 

testA

82172Assay of 

apolipoproteinA

82175Assay of 

arsenicA

82180Assay of ascorbic 

acidA

82190Atomic 

absorptionA

82205Assay of 

barbituratesA

82232Assay of beta-2 

proteinA

82239Bile acids 

totalA

82240Bile acids 

cholylglycineA

82247Bilirubin 

totalA

82248Bilirubin 
directA

82252Fecal bilirubin 

testA

82261Assay of 

biotinidaseA

82270Occult blood 

fecesA

82271Occult blood other 

sourcesA

82272Occult bld feces 1-3 

testsA

82274Assay test for blood 

fecalA

82286Assay of 

bradykininA

82300Assay of 

cadmiumA

82306Vitamin d 25 

hydroxyA

82308Assay of 

calcitoninA

82310Assay of 

calciumA

82330Assay of 

calciumA

82331Calcium infusion 

testA

82340Assay of calcium in 

urineA

82355Calculus analysis 

qualA

82360Calculus assay 

quantA

82365Calculus 

spectroscopyA

82370X-ray assay 

calculusA

82373Assay c-d transfer 

measureA

82374Assay blood carbon 

dioxideA

82375Assay carboxyhb 

quantA

82376Assay carboxyhb 
qualA

82378Carcinoembryonic 

antigenA

82379Assay of 

carnitineA

82380Assay of 

caroteneA

82382Assay urine 

catecholaminesA

82383Assay blood 

catecholaminesA

82384Assay three 

catecholaminesA

82387Assay of 

cathepsin-dA

82390Assay of 

ceruloplasminA

82397Chemiluminescent 

assayA

82415Assay of 

chloramphenicolA

82435Assay of blood 

chlorideA

82436Assay of urine 

chlorideA

82438Assay other fluid 

chloridesA

82441Test for 

chlorohydrocarbonsA

82465Assay bld/serum 

cholesterolA

82480Assay serum 

cholinesteraseA

82482Assay rbc 

cholinesteraseA

82485Assay chondroitin 

sulfateA

82486Gas/liquid 

chromatographyA

82487Paper 

chromatographyA

82488Paper 

chromatographyA

82489Thin layer 
chromatographyA

82491Chromotography quant 

singA

82492Chromotography quant 

multA

82495Assay of 

chromiumA

82507Assay of 

citrateA

82520Assay of 

cocaineA

82523Collagen 

crosslinksA

82525Assay of 

copperA

82528Assay of 

corticosteroneA

82530Cortisol 

freeA

82533Total 

cortisolA

82540Assay of 

creatineA

82541Column chromotography 

qualA

82542Column chromotography 

quantA

82543Column 

chromotograph/isotopeA

82544Column 

chromotograph/isotopeA

82550Assay of ck 

(cpk)A

82552Assay of cpk in 

bloodA

82553Creatine mb 

fractionA

82554Creatine 

isoformsA

82565Assay of 

creatinineA

82570Assay of urine 

creatinineA
82575Creatinine clearance 

testA

82585Assay of 

cryofibrinogenA

82595Assay of 

cryoglobulinA

82600Assay of 

cyanideA

82607Vitamin 

B-12A

82608B-12 binding 

capacityA

82610Cystatin 

cA

82615Test for urine 

cystinesA

82626DehydroepiandrosteroneA

82627DehydroepiandrosteroneA

82633DesoxycorticosteroneA

82634DeoxycortisolA

82638Assay of dibucaine 

numberA

82646Assay of 

dihydrocodeinoneA

82649Assay of 

dihydromorphinoneA

82651Assay of 

dihydrotestosteroneA

82652Vit d 1 

25-dihydroxyA

82654Assay of 

dimethadioneA

82656Pancreatic elastase 

fecalA

82657Enzyme cell 

activityA

82658Enzyme cell activity 

raA

82664Electrophoretic 

testA
82666Assay of 

epiandrosteroneA

82668Assay of 

erythropoietinA

82670Assay of 

estradiolA

82671Assay of 

estrogensA

82672Assay of 

estrogenA

82677Assay of 

estriolA

82679Assay of 

estroneA

82690Assay of 

ethchlorvynolA

82693Assay of ethylene 

glycolA

82696Assay of 

etiocholanoloneA

82705Fats/lipids feces 

qualA

82710Fats/lipids feces 

quantA

82715Assay of fecal 

fatA

82725Assay of blood fatty 

acidsA

82726Long chain fatty 

acidsA

82728Assay of 

ferritinA

82731Assay of fetal 

fibronectinA

82735Assay of 

fluorideA

82742Assay of 

flurazepamA

82746Blood folic acid 

serumA

82747Assay of folic acid 

rbcA

82757Assay of semen 

fructoseA
82759Assay of rbc 

galactokinaseA

82760Assay of 

galactoseA

82775Assay galactose 

transferaseA

82776Galactose transferase 

testA

82784Assay iga/igd/igg/igm 

eachA

82785Assay of 

igeA

82787Igg 1 2 3 or 4 

eachA

82800Blood 

pHA

82803Blood gases any 

combinationA

82805Blood gases w/o2 

saturationA

82810Blood gases o2 sat 

onlyA

82820Hemoglobin-oxygen 

affinityA

82930Gastric analy w/ph ea 

specA

82938Gastrin 

testA

82941Assay of 

gastrinA

82943Assay of 

glucagonA

82945Glucose other 

fluidA

82946Glucagon tolerance 

testA

82947Assay glucose blood 

quantA

82948Reagent strip/blood 

glucoseA

82950Glucose 

testA

82951Glucose tolerance test 

(GTT)A
82952GTT-added 

samplesA

82953Glucose-tolbutamide 

testA

82955Assay of g6pd 

enzymeA

82960Test for G6PD 

enzymeA

82962Glucose blood 

testA

82963Assay of 

glucosidaseA

82965Assay of gdh 

enzymeA

82975Assay of 

glutamineA

82977Assay of 

GGTA

82978Assay of 

glutathioneA

82979Assay rbc 

glutathioneA

82980Assay of 

glutethimideA

82985Glycated 

proteinA

83001Gonadotropin 

(FSH)A

83002Gonadotropin 

(LH)A

83003Assay growth hormone 

(hgh)A

83008Assay of 

guanosineA

83009H pylori (c-13) 

bloodA

83010Assay of haptoglobin 

quantA

83012Assay of 

haptoglobinsA

83013H pylori (c-13) 

breathA

83014H pylori drug 

adminA
83015Heavy metal 

screenA

83018Quantitative screen 

metalsA

83020Hemoglobin 

electrophoresisA

83021Hemoglobin 

chromotographyA

83026Hemoglobin copper 

sulfateA

83030Fetal hemoglobin 

chemicalA

83033Fetal hemoglobin assay 

qualA

83036Glycosylated hemoglobin 

testA

83037Glycosylated hb home 

deviceA

83045Blood methemoglobin 

testA

83050Blood methemoglobin 

assayA

83051Assay of plasma 

hemoglobinA

83055Blood sulfhemoglobin 

testA

83060Blood sulfhemoglobin 

assayA

83065Assay of hemoglobin 

heatA

83068Hemoglobin stability 

screenA

83069Assay of urine 

hemoglobinA

83070Assay of hemosiderin 

qualA

83071Assay of hemosiderin 

quantA

83080Assay of b 

hexosaminidaseA

83088Assay of 

histamineA

83090Assay of 

homocystineA
83150Assay of for 

hvaA

83491Assay of 

corticosteroidsA

83497Assay of 

5-hiaaA

83498Assay of 

progesteroneA

83499Assay of 

progesteroneA

83500Assay free 

hydroxyprolineA

83505Assay total 

hydroxyprolineA

83516Immunoassay 

nonantibodyA

83518Immunoassay 

dipstickA

83519Ria 

nonantibodyA

83520Immunoassay quant nos 

nonabA

83525Assay of 

insulinA

83527Assay of 

insulinA

83528Assay of intrinsic 

factorA

83540Assay of 

ironA

83550Iron binding 

testA

83570Assay of idh 

enzymeA

83582Assay of ketogenic 

steroidsA

83586Assay 17- 

ketosteroidsA

83593Fractionation 

ketosteroidsA

83605Assay of lactic 

acidA

83615Lactate (LD) (LDH) 

enzymeA
83625Assay of ldh 

enzymesA

83630Lactoferrin fecal 

(qual)A

83631Lactoferrin fecal 

(quant)A

83632Placental 

lactogenA

83633Test urine for 

lactoseA

83634Assay of urine for 

lactoseA

83655Assay of 

leadA

83661L/s ratio fetal 

lungA

83662Foam stability fetal 

lungA

83663Fluoro polarize fetal 

lungA

83664Lamellar bdy fetal 

lungA

83670Assay of lap 

enzymeA

83690Assay of 

lipaseA

83695Assay of 

lipoprotein(a)A

83698Assay lipoprotein 

pla2A

83700Lipopro bld 

electrophoreticA

83701Lipoprotein bld hr 

fractionA

83704Lipoprotein bld by 

nmrA

83718Assay of 

lipoproteinA

83719Assay of blood 

lipoproteinA

83721Assay of blood 

lipoproteinA

83727Assay of lrh 

hormoneA
83735Assay of 

magnesiumA

83775Assay of md 

enzymeA

83785Assay of 

manganeseA

83788Mass spectrometry 

qualA

83789Mass spectrometry 

quantA

83805Assay of 

meprobamateA

83825Assay of 

mercuryA

83835Assay of 

metanephrinesA

83840Assay of 

methadoneA

83857Assay of 

methemalbuminA

83858Assay of 

methsuximideA

83861Microfluid analy 

tearsA

83864MucopolysaccharidesA

83866Mucopolysaccharides 

screenA

83872Assay synovial fluid 

mucinA

83873Assay of csf 

proteinA

83874Assay of 

myoglobinA

83876Assay 

myeloperoxidaseA

83880Natriuretic 

peptideA

83883Assay nephelometry not 

specA

83885Assay of 

nickelA

83887Assay of 

nicotineA
83890Molecule 

isolateA

83891Molecule isolate 

nucleicA

83892Molecular 

diagnosticsA

83893Molecule 

dot/slot/blotA

83894Molecule gel 

electrophorA

83896Molecular 

diagnosticsA

83897Molecule nucleic 

transferA

83898Molecule nucleic ampli 

eachA

83900Molecule nucleic ampli 2 

seqA

83901Molecule nucleic ampli 

addonA

83902Molecular 

diagnosticsA

83903Molecule mutation 

scanA

83904Molecule mutation 

identifyA

83905Molecule mutation 

identifyA

83906Molecule mutation 

identifyA

83907Lyse cells for nucleic 

extA

83908Nucleic acid signal 

ampliA

83909Nucleic acid high 

resoluteA

83912Genetic 

examinationA

83913Molecular rna 

stabilizationA

83914Mutation ident 

ola/sbce/aspeA

83915Assay of 

nucleotidaseA
83916Oligoclonal 

bandsA

83918Organic acids total 

quantA

83919Organic acids qual 

eachA

83921Organic acid single 

quantA

83925Assay of 

opiatesA

83930Assay of blood 

osmolalityA

83935Assay of urine 

osmolalityA

83937Assay of 

osteocalcinA

83945Assay of 

oxalateA

83950Oncoprotein 

her-2/neuA

83951Oncoprotein 

dcpA

83970Assay of 

parathormoneA

83986Assay ph body fluid 

nosA

83987Exhaled breath 

condensateA

83992Assay for 

phencyclidineA

83993Assay for calprotectin 

fecalA

84022Assay of 

phenothiazineA

84030Assay of blood 

pkuA

84035Assay of 

phenylketonesA

84060Assay acid 

phosphataseA

84061Phosphatase forensic 

examA

84066Assay prostate 

phosphataseA
84075Assay alkaline 

phosphataseA

84078Assay alkaline 

phosphataseA

84080Assay alkaline 

phosphatasesA

84081Amniotic fluid enzyme 

testA

84085Assay of rbc pg6d 

enzymeA

84087Assay phosphohexose 

enzymesA

84100Assay of 

phosphorusA

84105Assay of urine 

phosphorusA

84106Test for 

porphobilinogenA

84110Assay of 

porphobilinogenA

84112Placenta alpha micro ig 

c/vA

84119Test urine for 

porphyrinsA

84120Assay of urine 

porphyrinsA

84126Assay of feces 

porphyrinsA

84127Assay of feces 

porphyrinsA

84132Assay of serum 

potassiumA

84133Assay of urine 

potassiumA

84134Assay of 

prealbuminA

84135Assay of 

pregnanediolA

84138Assay of 

pregnanetriolA

84140Assay of 

pregnenoloneA

84143Assay of 

17-hydroxypregnenoA
84144Assay of 

progesteroneA

84145Procalcitonin 

(pct)A

84146Assay of 

prolactinA

84150Assay of 

prostaglandinA

84152Assay of psa 

complexedA

84153Assay of psa 

totalA

84154Assay of psa 

freeA

84155Assay of protein 

serumA

84156Assay of protein 

urineA

84157Assay of protein 

otherA

84160Assay of protein any 

sourceA

84163Pappa 

serumA

84165Protein e-phoresis 

serumA

84166Protein 

e-phoresis/urine/csfA

84181Western blot 

testA

84182Protein western blot 

testA

84202Assay RBC 

protoporphyrinA

84203Test RBC 

protoporphyrinA

84206Assay of 

proinsulinA

84207Assay of vitamin 

b-6A

84210Assay of 

pyruvateA

84220Assay of pyruvate 

kinaseA
84228Assay of 

quinineA

84233Assay of 

estrogenA

84234Assay of 

progesteroneA

84235Assay of endocrine 

hormoneA

84238Assay nonendocrine 

receptorA

84244Assay of 

reninA

84252Assay of vitamin 

b-2A

84255Assay of 

seleniumA

84260Assay of 

serotoninA

84270Assay of sex hormone 

globulA

84275Assay of sialic 

acidA

84285Assay of 

silicaA

84295Assay of serum 

sodiumA

84300Assay of urine 

sodiumA

84302Assay of sweat 

sodiumA

84305Assay of 

somatomedinA

84307Assay of 

somatostatinA

84311SpectrophotometryA

84315Body fluid specific 

gravityA

84375Chromatogram assay 

sugarsA

84376Sugars single 

qualA

84377Sugars multiple 

qualA
84378Sugars single 

quantA

84379Sugars multiple 

quantA

84392Assay of urine 

sulfateA

84402Assay of 

testosteroneA

84403Assay of total 

testosteroneA

84425Assay of vitamin 

b-1A

84430Assay of 

thiocyanateA

84431Thromboxane 

urineA

84432Assay of 

thyroglobulinA

84436Assay of total 

thyroxineA

84437Assay of neonatal 

thyroxineA

84439Assay of free 

thyroxineA

84442Assay of thyroid 

activityA

84443Assay thyroid stim 

hormoneA

84445Assay of 

tsiA

84446Assay of vitamin 

eA

84449Assay of 

transcortinA

84450Transferase (AST) 

(SGOT)A

84460Alanine amino (ALT) 

(SGPT)A

84466Assay of 

transferrinA

84478Assay of 

triglyceridesA

84479Assay of thyroid (t3 or 

t4)A
84480Assay triiodothyronine 

(t3)A

84481Free assay 

(FT-3)A

84482T3 

reverseA

84484Assay of troponin 

quantA

84485Assay duodenal fluid 

trypsinA

84488Test feces for 

trypsinA

84490Assay of feces for 

trypsinA

84510Assay of 

tyrosineA

84512Assay of troponin 

qualA

84520Assay of urea 

nitrogenA

84525Urea nitrogen 

semi-quantA

84540Assay of 

urine/urea-nA

84545Urea-N clearance 

testA

84550Assay of blood/uric 

acidA

84560Assay of urine/uric 

acidA

84577Assay of 

feces/urobilinogenA

84578Test urine 

urobilinogenA

84580Assay of urine 

urobilinogenA

84583Assay of urine 

urobilinogenA

84585Assay of urine 

vmaA

84586Assay of 

vipA

84588Assay of 

vasopressinA
84590Assay of vitamin 

aA

84591Assay of nos 

vitaminA

84597Assay of vitamin 

kA

84600Assay of 

volatilesA

84620Xylose tolerance 

testA

84630Assay of 

zincA

84681Assay of 

c-peptideA

84702Chorionic gonadotropin 

testA

84703Chorionic gonadotropin 

assayA

84704Hcg free betachain 

testA

84830Ovulation 

testsA

84999Clinical chemistry 

testA

85002Bleeding time 

testA

85004Automated diff wbc 

countA

85007Bl smear w/diff wbc 

countA

85008Bl smear w/o diff wbc 

countA

85009Manual diff wbc count 

b-coatA

85013Spun 

microhematocritA

85014HematocritA

85018HemoglobinA

85025Complete cbc w/auto diff 

wbcA

85027Complete cbc 

automatedA

85032Manual cell count 
eachA

85041Automated rbc 

countA

85044Manual reticulocyte 

countA

85045Automated reticulocyte 

countA

85046Reticyte/hgb 

concentrateA

85048Automated leukocyte 

countA

85049Automated platelet 

countA

85055Reticulated platelet 

assayA

85060Blood smear 

interpretationB

85097Bone marrow 

interpretationX03430.5225$36.27$10.78$7.26

85130Chromogenic substrate 

assayA

85170Blood clot 

retractionA

85175Blood clot lysis 

timeA

85210Blood clot factor II 

testA

85220Blood clot factor V 

testA

85230Blood clot factor VII 

testA

85240Blood clot factor VIII 

testA

85244Blood clot factor VIII 

testA

85245Blood clot factor VIII 

testA

85246Blood clot factor VIII 

testA

85247Blood clot factor VIII 

testA

85250Blood clot factor IX 

testA
85260Blood clot factor X 

testA

85270Blood clot factor XI 

testA

85280Blood clot factor XII 

testA

85290Blood clot factor XIII 

testA

85291Blood clot factor XIII 

testA

85292Blood clot factor 

assayA

85293Blood clot factor 

assayA

85300Antithrombin III 

testA

85301Antithrombin III 

testA

85302Blood clot inhibitor 

antigenA

85303Blood clot inhibitor 

testA

85305Blood clot inhibitor 

assayA

85306Blood clot inhibitor 

testA

85307Assay activated protein 

cA

85335Factor inhibitor 

testA

85337ThrombomodulinA

85345Coagulation 

timeA

85347Coagulation 

timeA

85348Coagulation 

timeA

85360Euglobulin 

lysisA

85362Fibrin degradation 

productsA

85366Fibrinogen 

testA
85370Fibrinogen 

testA

85378Fibrin degrade 

semiquantA

85379Fibrin degradation 

quantA

85380Fibrin degradation 

vteA

85384FibrinogenA

85385FibrinogenA

85390Fibrinolysins 

screenA

85396Clotting assay whole 

bloodN

85397Clotting funct 

activityA

85400Fibrinolytic 

plasminA

85410Fibrinolytic 

antiplasminA

85415Fibrinolytic 

plasminogenA

85420Fibrinolytic 

plasminogenA

85421Fibrinolytic 

plasminogenA

85441Heinz bodies 

directA

85445Heinz bodies 

inducedA

85460Hemoglobin 

fetalA

85461Hemoglobin 

fetalA

85475HemolysinA

85520Heparin 

assayA

85525Heparin 

neutralizationA

85530Heparin-protamine 

toleranceA

85536Iron stain peripheral 

bloodA
85540Wbc alkaline 

phosphataseA

85547RBC mechanical 

fragilityA

85549MuramidaseA

85555RBC osmotic 

fragilityA

85557RBC osmotic 

fragilityA

85576Blood platelet 

aggregationA

85597Phospholipid pltlt 

neutralizA

85598Hexagnal phosph pltlt 

neutrlA

85610Prothrombin 

timeA

85611Prothrombin 

testA

85612Viper venom prothrombin 

timeA

85613Russell viper venom 

dilutedA

85635Reptilase 

testA

85651Rbc sed rate 

nonautomatedA

85652Rbc sed rate 

automatedA

85660RBC sickle cell 

testA

85670Thrombin time 

plasmaA

85675Thrombin time 

titerA

85705Thromboplastin 

inhibitionA

85730Thromboplastin time 

partialA

85732Thromboplastin time 

partialA

85810Blood viscosity 

examinationA

85999Hematology 
procedureA

86000Agglutinins 

febrileA

86001Allergen specific 

iggA

86003Allergen specific 

IgEA

86005Allergen specific 

IgEA

86021WBC antibody 

identificationA

86022Platelet 

antibodiesA

86023Immunoglobulin 

assayA

86038Antinuclear 

antibodiesA

86039Antinuclear antibodies 

(ANA)A

86060Antistreptolysin o 

titerA

86063Antistreptolysin o 

screenA

86077Physician blood bank 

serviceCHX03420.1639$11.38.$2.28

86078Physician blood bank 

serviceX03430.5225$36.27$10.78$7.26

86079Physician blood bank 

serviceCHX03420.1639$11.38.$2.28

86140C-reactive 

proteinA

86141C-reactive protein 

hsA

86146Glycoprotein 

antibodyA

86147Cardiolipin 

antibodyA

86148Phospholipid 

antibodyA

86155Chemotaxis 

assayA

86156Cold agglutinin 
screenA

86157Cold agglutinin 

titerA

86160Complement 

antigenA

86161Complement/function 

activityA

86162Complement total 

(ch50)A

86171Complement fixation 

eachA

86185CounterimmunoelectrophoresisA

86200Ccp 

antibodyA

86215Deoxyribonuclease 

antibodyA

86225DNA 

antibodyA

86226Dna antibody single 

strandA

86235Nuclear antigen 

antibodyA

86243Fc 

receptorA

86255Fluorescent antibody 

screenA

86256Fluorescent antibody 

titerA

86277Growth hormone 

antibodyA

86280Hemagglutination 

inhibitionA

86294Immunoassay tumor 

qualA

86300Immunoassay tumor ca 

15-3A

86301Immunoassay tumor ca 

19-9A

86304Immunoassay tumor ca 

125A

86305Human epididymis protein 

4A

86308Heterophile 
antibodiesA

86309Heterophile 

antibodiesA

86310Heterophile 

antibodiesA

86316Immunoassay tumor 

otherA

86317Immunoassay infectious 

agentA

86318Immunoassay infectious 

agentA

86320Serum 

immunoelectrophoresisA

86325Other 

immunoelectrophoresisA

86327Immunoelectrophoresis 

assayA

86329ImmunodiffusionA

86331Immunodiffusion 

ouchterlonyA

86332Immune complex 

assayA

86334Immunofix e-phoresis 

serumA

86335Immunfix 

e-phorsis/urine/csfA

86336Inhibin 

AA

86337Insulin 

antibodiesA

86340Intrinsic factor 

antibodyA

86341Islet cell 

antibodyA

86343Leukocyte histamine 

releaseA

86344Leukocyte 

phagocytosisA

86352Cell function assay 

w/stimA

86353Lymphocyte 

transformationA
86355B cells total 

countA

86356Mononuclear cell 

antigenA

86357Nk cells total 

countA

86359T cells total 

countA

86360T cell absolute 

count/ratioA

86361T cell absolute 

countA

86367Stem cells total 

countA

86376Microsomal 

antibodyA

86378Migration inhibitory 

factorA

86382Neutralization test 

viralA

86384Nitroblue tetrazolium 

dyeA

86403Particle agglutination 

testA

86406Particle agglutination 

testA

86430Rheumatoid factor 

testA

86431Rheumatoid factor 

quantA

86480Tb test cell immun 

measureA

86481Tb ag response t-cell 

suspA

86485Skin test 

candidaX03410.0776$5.39$2.02$1.08

86486Skin test nos 

antigenX03410.0776$5.39$2.02$1.08

86490Coccidioidomycosis skin 

testX03410.0776$5.39$2.02$1.08

86510Histoplasmosis skin 

testX03410.0776$5.39$2.02$1.08
86580TB intradermal 

testX03410.0776$5.39$2.02$1.08

86590Streptokinase 

antibodyA

86592Syphilis test non-trep 

qualA

86593Syphilis test non-trep 

quantA

86602Antinomyces 

antibodyA

86603Adenovirus 

antibodyA

86606Aspergillus 

antibodyA

86609Bacterium 

antibodyA

86611Bartonella 

antibodyA

86612Blastomyces 

antibodyA

86615Bordetella 

antibodyA

86617Lyme disease 

antibodyA

86618Lyme disease 

antibodyA

86619Borrelia 

antibodyA

86622Brucella 

antibodyA

86625Campylobacter 

antibodyA

86628Candida 

antibodyA

86631Chlamydia 

antibodyA

86632Chlamydia igm 

antibodyA

86635Coccidioides 

antibodyA

86638Q fever 

antibodyA
86641Cryptococcus 

antibodyA

86644CMV 

antibodyA

86645Cmv antibody 

igmA

86648Diphtheria 

antibodyA

86651Encephalitis 

antibodyA

86652Encephalitis 

antibodyA

86653Encephalitis 

antibodyA

86654Encephalitis 

antibodyA

86658Enterovirus 

antibodyA

86663Epstein-barr 

antibodyA

86664Epstein-barr 

antibodyA

86665Epstein-barr 

antibodyA

86666Ehrlichia 

antibodyA

86668Francisella 

tularensisA

86671Fungus 

antibodyA

86674Giardia lamblia 

antibodyA

86677Helicobacter 

pyloriA

86682Helminth 

antibodyA

86684Hemophilus 

influenzaA

86687Htlv-i 

antibodyA

86688Htlv-ii 

antibodyA

86689HTLV/HIV confirmatory 

testA
86692Hepatitis delta 

agentA

86694Herpes simplex 

testA

86695Herpes simplex 

testA

86696Herpes simplex type 

2A

86698HistoplasmaA

86701HIV-1A

86702HIV-2A

86703Hiv-1/hiv-2 single 

assayA

86704Hep b core antibody 

totalA

86705Hep b core antibody 

igmA

86706Hep b surface 

antibodyA

86707Hep be 

antibodyA

86708Hep a antibody 

totalA

86709Hep a antibody 

igmA

86710Influenza virus 

antibodyA

86713Legionella 

antibodyA

86717Leishmania 

antibodyA

86720Leptospira 

antibodyA

86723Listeria monocytogenes 

abA

86727Lymph choriomeningitis 

abA

86729Lympho venereum 

antibodyA

86732Mucormycosis 

antibodyA

86735Mumps 

antibodyA
86738Mycoplasma 

antibodyA

86741Neisseria 

meningitidisA

86744Nocardia 

antibodyA

86747Parvovirus 

antibodyA

86750Malaria 

antibodyA

86753Protozoa antibody 

nosA

86756Respiratory virus 

antibodyA

86757Rickettsia 

antibodyA

86759Rotavirus 

antibodyA

86762Rubella 

antibodyA

86765Rubeola 

antibodyA

86768Salmonella 

antibodyA

86771Shigella 

antibodyA

86774Tetanus 

antibodyA

86777Toxoplasma 

antibodyA

86778Toxoplasma antibody 

igmA

86780Treponema 

pallidumA

86784Trichinella 

antibodyA

86787Varicella-zoster 

antibodyA

86788West nile virus ab 

igmA

86789West nile virus 

antibodyA

86790Virus antibody 

nosA
86793Yersinia 

antibodyA

86800Thyroglobulin 

antibodyA

86803Hepatitis c ab 

testA

86804Hep c ab test 

confirmA

86805Lymphocytotoxicity 

assayA

86806Lymphocytotoxicity 

assayA

86807Cytotoxic antibody 

screeningA

86808Cytotoxic antibody 

screeningA

86812Hla typing a b or 

cA

86813Hla typing a b or 

cA

86816Hla typing 

dr/dqA

86817Hla typing 

dr/dqA

86821Lymphocyte culture 

mixedA

86822Lymphocyte culture 

primedA

86825Hla x-math 

non-cytotoxicA

86826Hla x-match noncytotoxc 

addlA

86849Immunology 

procedureA

86850RBC antibody 

screenX03450.2109$14.64.$2.93

86860RBC antibody 

elutionX03460.3580$24.85.$4.97

86870RBC antibody 

identificationX03460.3580$24.85.$4.97

86880Coombs test 

directX04090.1103$7.66$2.16$1.54
86885Coombs test indirect 

qualX04090.1103$7.66$2.16$1.54

86886Coombs test indirect 

titerX04090.1103$7.66$2.16$1.54

86890Autologous blood 

processX03470.6541$45.41.$9.09

86891Autologous blood op 

salvageX03450.2109$14.64.$2.93

86900Blood typing 

aboX04090.1103$7.66$2.16$1.54

86901Blood typing rh 

(d)X04090.1103$7.66$2.16$1.54

86902Blood type antigen donor 

eaX03450.2109$14.64.$2.93

86904Blood typing patient 

serumX03450.2109$14.64.$2.93

86905Blood typing rbc 

antigensX03450.2109$14.64.$2.93

86906Blood typing rh 

phenotypeX03450.2109$14.64.$2.93

86910Blood typing paternity 

testE

86911Blood typing antigen 

systemE

86920Compatibility test 

spinX03450.2109$14.64.$2.93

86921Compatibility test 

incubateX03450.2109$14.64.$2.93

86922Compatibility test 

antiglobX03460.3580$24.85.$4.97

86923Compatibility test 

electricX03450.2109$14.64.$2.93

86927Plasma fresh 

frozenX03450.2109$14.64.$2.93
86930Frozen blood 

prepX03470.6541$45.41.$9.09

86931Frozen blood 

thawX03470.6541$45.41.$9.09

86932Frozen blood 

freeze/thawX03470.6541$45.41.$9.09

86940Hemolysins/agglutinins 

autoA

86941Hemolysins/agglutininsA

86945Blood 

product/irradiationX03450.2109$14.64.$2.93

86950Leukacyte 

transfusionX03450.2109$14.64.$2.93

86960Vol reduction of 

blood/prodX03450.2109$14.64.$2.93

86965Pooling blood 

plateletsX03460.3580$24.85.$4.97

86970RBC 

pretreatmentX03450.2109$14.64.$2.93

86971RBC 

pretreatmentX03450.2109$14.64.$2.93

86972RBC 

pretreatmentX03450.2109$14.64.$2.93

86975Rbc pretreatment 

serumX03460.3580$24.85.$4.97

86976Rbc pretreatment 

serumX03450.2109$14.64.$2.93

86977Rbc pretreatment 

serumX03470.6541$45.41.$9.09

86978Rbc pretreatment 

serumX03460.3580$24.85.$4.97

86985Split blood or 

productsX03450.2109$14.64.$2.93
86999Transfusion 

procedureX03450.2109$14.64.$2.93

87001Small animal 

inoculationA

87003Small animal 

inoculationA

87015Specimen 

concentrationA

87040Blood culture for 

bacteriaA

87045Feces culture 

bacteriaA

87046Stool cultr bacteria 

eachA

87070Culture bacteria 

otherA

87071Culture bacteri aerobic 

othrA

87073Culture bacteria 

anaerobicA

87075Cultr bacteria except 

bloodA

87076Culture anaerobe ident 

eachA

87077Culture aerobic 

identifyA

87081Culture screen 

onlyA

87084Culture of specimen by 

kitA

87086Urine culture/colony 

countA

87088Urine bacteria 

cultureA

87101Skin fungi 

cultureA

87102Fungus isolation 

cultureA

87103Blood fungus 

cultureA

87106Fungi identification 

yeastA

87107Fungi identification 
moldA

87109MycoplasmaA

87110Chlamydia 

cultureA

87116Mycobacteria 

cultureA

87118Mycobacteric 

identificationA

87140Culture type 

immunofluorescA

87143Culture typing 

glc/hplcA

87147Culture type 

immunologicA

87149Dna/rna direct 

probeA

87150Dna/rna amplified 

probeA

87152Culture type pulse field 

gelA

87153Dna/rna 

sequencingA

87158Culture typing added 

methodA

87164Dark field 

examinationA

87166Dark field 

examinationA

87168Macroscopic exam 

arthropodA

87169Macroscopic exam 

parasiteA

87172Pinworm 

examA

87176Tissue homogenization 

cultrA

87177Ova and parasites 

smearsA

87181Microbe susceptible 

diffuseA

87184Microbe susceptible 

diskA

87185Microbe susceptible 

enzymeA
87186Microbe susceptible 

micA

87187Microbe susceptible 

mlcA

87188Microbe suscept 

macrobrothA

87190Microbe suscept 

mycobacteriA

87197Bactericidal level 

serumA

87205Smear gram 

stainA

87206Smear fluorescent/acid 

staiA

87207Smear special 

stainA

87209Smear complex 

stainA

87210Smear wet mount 

saline/inkA

87220Tissue exam for 

fungiA

87230Assay toxin or 

antitoxinA

87250Virus inoculate 

eggs/animalA

87252Virus inoculation 

tissueA

87253Virus inoculate tissue 

addlA

87254Virus inoculation shell 

viaA

87255Genet virus isolate 

hsvA

87260Adenovirus ag 

ifA

87265Pertussis ag 

ifA

87267Enterovirus antibody 

dfaA

87269Giardia ag 

ifA

87270Chlamydia trachomatis ag 

ifA
87271Cytomegalovirus 

dfaA

87272Cryptosporidium ag 

ifA

87273Herpes simplex 2 ag 

ifA

87274Herpes simplex 1 ag 

ifA

87275Influenza b ag 

ifA

87276Influenza a ag 

ifA

87277Legionella micdadei ag 

ifA

87278Legion pneumophilia ag 

ifA

87279Parainfluenza ag 

ifA

87280Respiratory syncytial ag 

ifA

87281Pneumocystis carinii ag 

ifA

87283Rubeola ag 

ifA

87285Treponema pallidum ag 

ifA

87290Varicella zoster ag 

ifA

87299Antibody detection nos 

ifA

87300Ag detection polyval 

ifA

87301Adenovirus ag 

eiaA

87305Aspergillus ag 

eiaA

87320Chylmd trach ag 

eiaA

87324Clostridium ag 

eiaA

87327Cryptococcus neoform ag 

eiaA

87328Cryptosporidium ag 

eiaA
87329Giardia ag 

eiaA

87332Cytomegalovirus ag 

eiaA

87335E coli 0157 ag 

eiaA

87336Entamoeb hist dispr ag 

eiaA

87337Entamoeb hist group ag 

eiaA

87338Hpylori stool 

eiaA

87339H pylori ag 

eiaA

87340Hepatitis b surface ag 

eiaA

87341Hepatitis b surface ag 

eiaA

87350Hepatitis be ag 

eiaA

87380Hepatitis delta ag 

eiaA

87385Histoplasma capsul ag 

eiaA

87390Hiv-1 ag 

eiaA

87391Hiv-2 ag 

eiaA

87400Influenza a/b ag 

eiaA

87420Resp syncytial ag 

eiaA

87425Rotavirus ag 

eiaA

87427Shiga-like toxin ag 

eiaA

87430Strep a ag 

eiaA

87449Ag detect nos eia 

multA

87450Ag detect nos eia 

singleA

87451Ag detect polyval eia 

multA
87470Bartonella dna dir 

probeA

87471Bartonella dna amp 

probeA

87472Bartonella dna 

quantA

87475Lyme dis dna dir 

probeA

87476Lyme dis dna amp 

probeA

87477Lyme dis dna 

quantA

87480Candida dna dir 

probeA

87481Candida dna amp 

probeA

87482Candida dna 

quantA

87485Chylmd pneum dna dir 

probeA

87486Chylmd pneum dna amp 

probeA

87487Chylmd pneum dna 

quantA

87490Chylmd trach dna dir 

probeA

87491Chylmd trach dna amp 

probeA

87492Chylmd trach dna 

quantA

87493C diff amplified 

probeA

87495Cytomeg dna dir 

probeA

87496Cytomeg dna amp 

probeA

87497Cytomeg dna 

quantA

87498Enterovirus dna amp 

probeA

87500Vanomycin dna amp 

probeA

87501Influenza dna amp prob 

1+A
87502Influenza dna amp 

probeA

87503Influenza dna amp prob 

addlA

87510Gardner vag dna dir 

probeA

87511Gardner vag dna amp 

probeA

87512Gardner vag dna 

quantA

87515Hepatitis b dna dir 

probeA

87516Hepatitis b dna amp 

probeA

87517Hepatitis b dna 

quantA

87520Hepatitis c rna dir 

probeA

87521Hepatitis c rna amp 

probeA

87522Hepatitis c rna 

quantA

87525Hepatitis g dna dir 

probeA

87526Hepatitis g dna amp 

probeA

87527Hepatitis g dna 

quantA

87528Hsv dna dir 

probeA

87529Hsv dna amp 

probeA

87530Hsv dna 

quantA

87531Hhv-6 dna dir 

probeA

87532Hhv-6 dna amp 

probeA

87533Hhv-6 dna 

quantA

87534Hiv-1 dna dir 

probeA

87535Hiv-1 dna amp 

probeA
87536Hiv-1 dna 

quantA

87537Hiv-2 dna dir 

probeA

87538Hiv-2 dna amp 

probeA

87539Hiv-2 dna 

quantA

87540Legion pneumo dna dir 

probA

87541Legion pneumo dna amp 

probA

87542Legion pneumo dna 

quantA

87550Mycobacteria dna dir 

probeA

87551Mycobacteria dna amp 

probeA

87552Mycobacteria dna 

quantA

87555M.tuberculo dna dir 

probeA

87556M.tuberculo dna amp 

probeA

87557M.tuberculo dna 

quantA

87560M.avium-intra dna dir 

probA

87561M.avium-intra dna amp 

probA

87562M.avium-intra dna 

quantA

87580M.pneumon dna dir 

probeA

87581M.pneumon dna amp 

probeA

87582M.pneumon dna 

quantA

87590N.gonorrhoeae dna dir 

probA

87591N.gonorrhoeae dna amp 

probA

87592N.gonorrhoeae dna 

quantA
87620Hpv dna dir 

probeA

87621Hpv dna amp 

probeA

87622Hpv dna 

quantA

87640Staph a dna amp 

probeA

87641Mr-staph dna amp 

probeA

87650Strep a dna dir 

probeA

87651Strep a dna amp 

probeA

87652Strep a dna 

quantA

87653Strep b dna amp 

probeA

87660Trichomonas vagin dir 

probeA

87797Detect agent nos dna 

dirA

87798Detect agent nos dna 

ampA

87799Detect agent nos dna 

quantA

87800Detect agnt mult dna 

direcA

87801Detect agnt mult dna 

ampliA

87802Strep b assay 

w/opticA

87803Clostridium toxin a 

w/opticA

87804Influenza assay 

w/opticA

87807Rsv assay 

w/opticA

87808Trichomonas assay 

w/opticA

87809Adenovirus assay 

w/opticA

87810Chylmd trach assay 

w/opticA
87850N. gonorrhoeae assay 

w/opticA

87880Strep a assay 

w/opticA

87899Agent nos assay 

w/opticA

87900Phenotype infect agent 

drugA

87901Genotype dna hiv reverse 

tA

87902Genotype dna hepatitis 

cA

87903Phenotype dna hiv 

w/cultureA

87904Phenotype dna hiv w/clt 

addA

87905Sialidase enzyme 

assayA

87906Genotype dna hiv reverse 

tA

87999Microbiology 

procedureA

88000Autopsy (necropsy) 

grossE

88005Autopsy (necropsy) 

grossE

88007Autopsy (necropsy) 

grossE

88012Autopsy (necropsy) 

grossE

88014Autopsy (necropsy) 

grossE

88016Autopsy (necropsy) 

grossE

88020Autopsy (necropsy) 

completeE

88025Autopsy (necropsy) 

completeE

88027Autopsy (necropsy) 

completeE

88028Autopsy (necropsy) 

completeE

88029Autopsy (necropsy) 

completeE
88036Limited 

autopsyE

88037Limited 

autopsyE

88040Forensic autopsy 

(necropsy)E

88045Coroners autopsy 

(necropsy)E

88099Necropsy (autopsy) 

procedureE

88104Cytopath fl nongyn 

smearsX04330.2464$17.11$5.17$3.43

88106Cytopath fl nongyn 

filterX04330.2464$17.11$5.17$3.43

88107Cytopath fl nongyn 

sm/fltrCHX04330.2464$17.11$5.17$3.43

88108Cytopath concentrate 

techX04330.2464$17.11$5.17$3.43

88112Cytopath cell enhance 

techX03430.5225$36.27$10.78$7.26

88120Cytp urne 3-5 probes ea 

specX03440.8204$56.95$15.56$11.39

88121Cytp urine 3-5 probes 

cmptrX03440.8204$56.95$15.56$11.39

88125Forensic 

cytopathologyX04330.2464$17.11$5.17$3.43

88130Sex chromatin 

identificationA

88140Sex chromatin 

identificationA

88141Cytopath c/v 

interpretN

88142Cytopath c/v thin 

layerA

88143Cytopath c/v thin layer 

redoA

88147Cytopath c/v 

automatedA
88148Cytopath c/v auto 

rescreenA

88150Cytopath c/v 

manualA

88152Cytopath c/v auto 

redoA

88153Cytopath c/v 

redoA

88154Cytopath c/v 

selectA

88155Cytopath c/v index 

add-onA

88160Cytopath smear other 

sourceX04330.2464$17.11$5.17$3.43

88161Cytopath smear other 

sourceX04330.2464$17.11$5.17$3.43

88162Cytopath smear other 

sourceX03430.5225$36.27$10.78$7.26

88164Cytopath tbs c/v 

manualA

88165Cytopath tbs c/v 

redoA

88166Cytopath tbs c/v auto 

redoA

88167Cytopath tbs c/v 

selectA

88172Cytp dx eval fna 1st ea 

siteX04330.2464$17.11$5.17$3.43

88173Cytopath eval fna 

reportX03430.5225$36.27$10.78$7.26

88174Cytopath c/v auto in 

fluidA

88175Cytopath c/v auto fluid 

redoA

88177Cytp c/v auto thin lyr 

addlX03420.1639$11.38.$2.28

88182Cell marker 

studyX03430.5225$36.27$10.78$7.26

88184Flowcytometry/ tc 1 

markerX04330.2464$17.11$5.17$3.43
88185Flowcytometry/tc 

add-onX04330.2464$17.11$5.17$3.43

88187Flowcytometry/read 

2-8X03420.1639$11.38.$2.28

88188Flowcytometry/read 

9-15X03430.5225$36.27$10.78$7.26

88189Flowcytometry/read 16 & 

>X03430.5225$36.27$10.78$7.26

88199Cytopathology 

procedureX03420.1639$11.38.$2.28

88230Tissue culture 

lymphocyteA

88233Tissue culture 

skin/biopsyA

88235Tissue culture 

placentaA

88237Tissue culture bone 

marrowA

88239Tissue culture 

tumorA

88240Cell 

cryopreserve/storageA

88241Frozen cell 

preparationA

88245Chromosome analysis 

20-25A

88248Chromosome analysis 

50-100A

88249Chromosome analysis 

100A

88261Chromosome analysis 

5A

88262Chromosome analysis 

15-20A

88263Chromosome analysis 

45A

88264Chromosome analysis 

20-25A

88267Chromosome analys 
placentaA

88269Chromosome analys 

amnioticA

88271Cytogenetics dna 

probeA

88272Cytogenetics 

3-5A

88273Cytogenetics 

10-30A

88274Cytogenetics 

25-99A

88275Cytogenetics 

100-300A

88280Chromosome karyotype 

studyA

88283Chromosome banding 

studyA

88285Chromosome count 

additionalA

88289Chromosome study 

additionalA

88291Cyto/molecular 

reportM

88299Cytogenetic 

studyX03420.1639$11.38.$2.28

88300Surgical path 

grossCHX03420.1639$11.38.$2.28

88302Tissue exam by 

pathologistX04330.2464$17.11$5.17$3.43

88304Tissue exam by 

pathologistX03430.5225$36.27$10.78$7.26

88305Tissue exam by 

pathologistX03430.5225$36.27$10.78$7.26

88307Tissue exam by 

pathologistX03440.8204$56.95$15.56$11.39

88309Tissue exam by 

pathologistX03440.8204$56.95$15.56$11.39

88311Decalcify 

tissueX03420.1639$11.38.$2.28
88312Special stains group 

1X04330.2464$17.11$5.17$3.43

88313Special stains group 

2X04330.2464$17.11$5.17$3.43

88314Histochemical stains 

add-onX04330.2464$17.11$5.17$3.43

88318Chemical 

histochemistryX04330.2464$17.11$5.17$3.43

88319Enzyme 

histochemistryX03430.5225$36.27$10.78$7.26

88321Microslide 

consultationX04330.2464$17.11$5.17$3.43

88323Microslide 

consultationX03430.5225$36.27$10.78$7.26

88325Comprehensive review of 

dataX03440.8204$56.95$15.56$11.39

88329Path consult 

intropX04330.2464$17.11$5.17$3.43

88331Path consult intraop 1 

blocX03430.5225$36.27$10.78$7.26

88332Path consult intraop 

addlCHX03420.1639$11.38.$2.28

88333Intraop cyto path consult 

1X04330.2464$17.11$5.17$3.43

88334Intraop cyto path consult 

2X04330.2464$17.11$5.17$3.43

88342ImmunohistochemistryX03430.5225$36.27$10.78$7.26

88346Immunofluorescent 

studyX03430.5225$36.27$10.78$7.26

88347Immunofluorescent 

studyX03430.5225$36.27$10.78$7.26

88348Electron 

microscopyX06612.3755$164.91.$32.99
88349Scanning electron 

microscopyX06612.3755$164.91.$32.99

88355Analysis skeletal 

muscleX03430.5225$36.27$10.78$7.26

88356Analysis 

nerveX03440.8204$56.95$15.56$11.39

88358Analysis 

tumorX03430.5225$36.27$10.78$7.26

88360Tumor 

immunohistochem/manualX03430.5225$36.27$10.78$7.26

88361Tumor 

immunohistochem/computX03440.8204$56.95$15.56$11.39

88362Nerve teasing 

preparationsX03440.8204$56.95$15.56$11.39

88363Xm archive tissue molec 

analX03420.1639$11.38.$2.28

88365Insitu hybridization 

(fish)X03440.8204$56.95$15.56$11.39

88367Insitu hybridization 

autoX03430.5225$36.27$10.78$7.26

88368Insitu hybridization 

manualX03440.8204$56.95$15.56$11.39

88371Protein western blot 

tissueA

88372Protein analysis 

w/probeA

88380Microdissection 

laserN

88381Microdissection 

manualN

88384Eval molecular probes 

11-50X04330.2464$17.11$5.17$3.43

88385Eval molecul probes 

51-250X03430.5225$36.27$10.78$7.26
88386Eval molecul probes 

251-500X03440.8204$56.95$15.56$11.39

88387Tiss exam molecular 

studyN

88388Tiss ex molecul study 

add-onN

88399Surgical pathology 

procedureX03420.1639$11.38.$2.28

88720Bilirubin total 

transcutA

88738Hgb quant 

transcutaneousA

88740Transcutaneous 

carboxyhbA

88741Transcutaneous 

methbA

88749In vivo lab 

serviceA

89049Chct for mal 

hyperthermiaX03420.1639$11.38.$2.28

89050Body fluid cell 

countA

89051Body fluid cell 

countA

89055Leukocyte assessment 

fecalA

89060Exam synovial fluid 

crystalsA

89125Specimen fat 

stainA

89160Exam feces for meat 

fibersA

89190Nasal smear for 

eosinophilsA

89220Sputum specimen 

collectionX04330.2464$17.11$5.17$3.43

89230Collect sweat for 

testX03430.5225$36.27$10.78$7.26

89240Pathology lab procedureX 

03420.1639$11.38.$2.28

89250Cultr oocyte/embryo <4 
daysX03440.8204$56.95$15.56$11.39

89251Cultr oocyte/embryo <4 

daysX03440.8204$56.95$15.56$11.39

89253Embryo 

hatchingX03440.8204$56.95$15.56$11.39

89254Oocyte 

identificationX03440.8204$56.95$15.56$11.39

89255Prepare embryo for 

transferX03440.8204$56.95$15.56$11.39

89257Sperm 

identificationX03430.5225$36.27$10.78$7.26

89258Cryopreservation 

embryo(s)X03440.8204$56.95$15.56$11.39

89259Cryopreservation 

spermCHX04330.2464$17.11$5.17$3.43

89260Sperm isolation 

simpleX03430.5225$36.27$10.78$7.26

89261Sperm isolation 

complexX03430.5225$36.27$10.78$7.26

89264Identify sperm 

tissueX03440.8204$56.95$15.56$11.39

89268Insemination of 

oocytesX03440.8204$56.95$15.56$11.39

89272Extended culture of 

oocytesX03440.8204$56.95$15.56$11.39

89280Assist oocyte 

fertilizationX03440.8204$56.95$15.56$11.39

89281Assist oocyte 

fertilizationX03440.8204$56.95$15.56$11.39

89290Biopsy oocyte polar 

bodyX03440.8204$56.95$15.56$11.39

89291Biopsy oocyte polar 

bodyX03440.8204$56.95$15.56$11.39
89300Semen analysis 

w/huhnerA

89310Semen analysis 

w/countA

89320Semen anal 

vol/count/motA

89321Semen anal sperm 

detectionA

89322Semen anal strict 

criteriaA

89325Sperm antibody 

testA

89329Sperm evaluation 

testA

89330Evaluation cervical 

mucusA

89331Retrograde ejaculation 

analA

89335Cryopreserve testicular 

tissX03440.8204$56.95$15.56$11.39

89342Storage/year 

embryo(s)X03440.8204$56.95$15.56$11.39

89343Storage/year 

sperm/semenX03440.8204$56.95$15.56$11.39

89344Storage/year reprod 

tissueX03440.8204$56.95$15.56$11.39

89346Storage/year 

oocyte(s)X03440.8204$56.95$15.56$11.39

89352Thawing cryopresrved 

embryoX03440.8204$56.95$15.56$11.39

89353Thawing cryopresrved 

spermX03440.8204$56.95$15.56$11.39

89354Thaw cryoprsvrd reprod 

tissX03440.8204$56.95$15.56$11.39

89356Thawing cryopresrved 

oocyteX03440.8204$56.95$15.56$11.39

89398Unlisted reprod med lab 

procX03420.1639$11.38.$2.28
90281Human ig 

imE

90283Human ig 

ivE

90284Human ig 

scE

90287Botulinum 

antitoxinE

90288Botulism ig 

ivE

90291Cmv ig 

ivE

90296Diphtheria 

antitoxinE

90371Hep b ig 

imK1630$112.16.$22.44

90375Rabies ig 

im/scK9133$159.86.$31.98

90376Rabies ig heat 

treatedK9134$154.18.$30.84

90378Rsv mab im 50mgCH 

N

90384Rh ig full-dose 

imE

90385Rh ig minidose 

imN

90386Rh ig 

ivE

90389Tetanus ig 

imE

90393Vaccina ig 

imE

90396Varicella-zoster ig 

imK9135$129.48.$25.90

90399Immune 

globulinE

90460Imadm any route 1st 

vac/toxB

90461Inadm any route addl 

vac/toxB
90471Immunization 

adminS04360.3780$26.24.$5.25

90472Immunization admin each 

addS04360.3780$26.24.$5.25

90473Immune admin 

oral/nasalS04360.3780$26.24.$5.25

90474Immune admin oral/nasal 

addlS04360.3780$26.24.$5.25

90476Adenovirus vaccine type 4CH 

N

90477Adenovirus vaccine type 7E 

90581Anthrax vaccine scE 

90585Bcg vaccine 

percutK9137$112.46.$22.50

90586Bcg vaccine 

intravesicalB

90632Hep a vaccine adult 

imN

90633Hep a vacc ped/adol 2 

doseN

90634Hep a vacc ped/adol 3 

doseN

90636Hep a/hep b vacc adult 

imN

90644Meningoccl hib vac 4 dose 

imE

90645Hib vaccine hboc 

imN

90646Hib vaccine prp-d 

imN

90647Hib vaccine prp-omp 

imN

90648Hib vaccine prp-t 

imN

90649Hpv vaccine 4 valent 

imM

90650Hpv vaccine 2 valent 

imM

90654"Flu vaccine no preserv, ID"E 
90655Flu vaccine no preserv 

6-35mL

90656Flu vaccine no preserv 3 & 

>L

90657Flu vaccine 3 yrs 

imL

90658Flu vaccine 3 yrs & > imE 

90660Flu vaccine 

nasalL

90661Flu vacc cell cult prsv freeE 

90662Flu vacc prsv free inc 

antigL

90664Flu vacc pandemic 

intranasalE

90665Lyme disease vaccine 

imN

90666Flu vac pandem prsrv free 

imE

90667Flu vac pandemic adjuvant 

imE

90668Flu vac pandemic splt 

imE

90669Pneumococcal vacc 7 val imL 

90670Pneumococcal vacc 13 val imL 

90675Rabies vaccine 

imK9139$190.82.$38.17

90676Rabies vaccine 

idK9140$107.83.$21.57

90680Rotovirus vacc 3 dose oralCH 

N

90681Rotavirus vacc 2 dose 

oralK1239$100.56.$20.12

90690Typhoid vaccine 

oralN

90691Typhoid vaccine imN 

90692Typhoid vaccine h-p 
sc/idN

90693Typhoid vaccine akd 

scB

90696Dtap-ipv vacc 4-6 yr 

imN

90698Dtap-hib-ip vaccine 

imN

90700Dtap vaccine < 7 yrs 

imN

90701Dtp vaccine 

imN

90702Dt vaccine < 7 

imN

90703Tetanus vaccine 

imN

90704Mumps vaccine 

scN

90705Measles vaccine 

scN

90706Rubella vaccine 

scN

90707Mmr vaccine 

scN

90708Measles-rubella vaccine 

scN

90710Mmrv vaccine scN 

90712Oral poliovirus 

vaccineN

90713Poliovirus ipv 

sc/imN

90714Td vaccine no prsrv >/= 7 

imN

90715Tdap vaccine >7 

imN

90716Chicken pox vaccine 

scM

90717Yellow fever vaccine 

scN

90718Td vaccine > 7 

imN

90719Diphtheria vaccine 

imN

90720Dtp/hib vaccine 
imN

90721Dtap/hib vaccine 

imN

90723Dtap-hep b-ipv vaccine 

imE

90725Cholera vaccine 

injectableE

90727Plague vaccine imE 

90732Pneumococcal 

vaccineL

90733Meningococcal vaccine scK 

9143$104.49.$20.90

90734Meningococcal vaccine 

imK9145$83.39.$16.68

90735Encephalitis vaccine 

scK9144$100.16.$20.04

90736Zoster vacc scM 

90738Inactivated je vacc imM 

90740Hepb vacc ill pat 3 dose 

imF

90743Hep b vacc adol 2 dose 

imF

90744Hepb vacc ped/adol 3 dose 

imF

90746Hep b vaccine adult 

imF

90747Hepb vacc ill pat 4 dose 

imF

90748Hep b/hib vaccine 

imE

90749Vaccine 

toxoidN

90801Psy dx 

interviewQ303231.5885$110.27.$22.06

90802Intac psy dx 

interviewQ303231.5885$110.27.$22.06

90804Psytx office 20-30 

minQ303221.0957$76.06.$15.22
90805Psytx off 20-30 min 

w/e&mQ303221.0957$76.06.$15.22

90806Psytx off 45-50 

minQ303231.5885$110.27.$22.06

90807Psytx off 45-50 min 

w/e&mQ303231.5885$110.27.$22.06

90808Psytx office 75-80 

minQ303231.5885$110.27.$22.06

90809Psytx off 75-80 

w/e&mQ303231.5885$110.27.$22.06

90810Intac psytx off 20-30 

minQ303221.0957$76.06.$15.22

90811Intac psytx 20-30 

w/e&mQ303221.0957$76.06.$15.22

90812Intac psytx off 45-50 

minQ303231.5885$110.27.$22.06

90813Intac psytx 45-50 min 

w/e&mQ303231.5885$110.27.$22.06

90814Intac psytx off 75-80 

minQ303231.5885$110.27.$22.06

90815Intac psytx 75-80 

w/e&mQ303231.5885$110.27.$22.06

90816Psytx hosp 20-30 

minP

90817Psytx hosp 20-30 min 

w/e&mP

90818Psytx hosp 45-50 

minP

90819Psytx hosp 45-50 min 

w/e&mP

90821Psytx hosp 75-80 

minP

90822Psytx hosp 75-80 min 

w/e&mP

90823Intac psytx hosp 20-30 

minP

90824Intac psytx hsp 20-30 
w/e&mP

90826Intac psytx hosp 45-50 

minP

90827Intac psytx hsp 45-50 

w/e&mP

90828Intac psytx hosp 75-80 

minP

90829Intac psytx hsp 75-80 

w/e&mP

90845PsychoanalysisQ303231.5885$110.27.$22.06

90846Family psytx w/o 

patientQ303241.8739$130.09.$26.02

90847Family psytx 

w/patientQ303241.8739$130.09.$26.02

90849Multiple family group 

psytxQ303250.7798$54.13$11.54$10.83

90853Group 

psychotherapyQ303250.7798$54.13$11.54$10.83

90857Intac group 

psytxQ303250.7798$54.13$11.54$10.83

90862Medication 

managementQ306051.0430$72.41.$14.49

90865NarcosynthesisQ303231.5885$110.27.$22.06

90867Tcranial magn stim tx 

planS02162.6231$182.10.$36.42

90868Tcranial magn stim tx 

deliS02162.6231$182.10.$36.42

90870Electroconvulsive 

therapyS03205.9679$414.29.$82.86

90875Psychophysiological 

therapyE

90876Psychophysiological 

therapyE

90880HypnotherapyQ303231.5885$110.27.$22.06

90882Environmental 
manipulationE

90885Psy evaluation of 

recordsN

90887Consultation with 

familyN

90889Preparation of 

reportN

90899Psychiatric 

service/therapyQ303221.0957$76.06.$15.22

90901Biofeedback train any 

methA

90911Biofeedback peri/uro/rectalT 

01261.1699$81.21.$16.25

90935Hemodialysis one 

evaluationS01705.9462$412.79.$82.56

90937Hemodialysis repeated evalB 

90940Hemodialysis access 

studyN

90945Dialysis one 

evaluationV06082.4718$171.59.$34.32

90947Dialysis repeated 

evalB

90951Esrd serv 4 visits p mo 

<2M

90952Esrd serv 2-3 vsts p mo 

<2M

90953Esrd serv 1 visit p mo 

<2M

90954Esrd serv 4 vsts p mo 

2-11M

90955Esrd srv 2-3 vsts p mo 

2-11M

90956Esrd srv 1 visit p mo 

2-11M

90957Esrd srv 4 vsts p mo 

12-19M

90958Esrd srv 2-3 vsts p mo 

12-19M

90959Esrd serv 1 vst p mo 

12-19M
90960Esrd srv 4 visits p mo 

20+M

90961Esrd srv 2-3 vsts p mo 

20+M

90962Esrd serv 1 visit p mo 

20+M

90963Esrd home pt serv p mo 

<2M

90964Esrd home pt serv p mo 

2-11M

90965Esrd home pt serv p mo 

12-19M

90966Esrd home pt serv p mo 

20+M

90967Esrd home pt serv p day 

<2M

90968Esrd home pt srv p day 

2-11M

90969Esrd home pt srv p day 

12-19M

90970Esrd home pt serv p day 

20+M

90989Dialysis training 

completeB

90993Dialysis training 

incomplB

90997HemoperfusionB 

90999Dialysis 

procedureB

91010Esophagus motility 

studyX03614.1026$284.80$83.23$56.96

91013Esophgl motil 

w/stim/perfusX03614.1026$284.80$83.23$56.96

91020Gastric motility 

studiesX03614.1026$284.80$83.23$56.96

91022Duodenal motility 

studyX03614.1026$284.80$83.23$56.96

91030Acid perfusion of 

esophagusX03614.1026$284.80$83.23$56.96

91034Gastroesophageal reflux 
testX03614.1026$284.80$83.23$56.96

91035G-esoph reflx tst 

w/electrodX03614.1026$284.80$83.23$56.96

91037Esoph imped function 

testX03601.7147$119.03$33.57$23.81

91038Esoph imped funct test > 

1hX03614.1026$284.80$83.23$56.96

91040Esoph balloon distension 

tstX03601.7147$119.03$33.57$23.81

91065Breath hydrogen 

testX03601.7147$119.03$33.57$23.81

91110Gi tract capsule 

endoscopyT014210.1643$705.61$152.78$141.13

91111Esophageal capsule 

endoscopyCHT041912.5693$872.56$204.51$174.52

91117Colon motility 6 hr 

studyT01563.1976$221.98.$44.40

91120Rectal sensation 

testT01261.1699$81.21.$16.25

91122Anal pressure 

recordT01563.1976$221.98.$44.40

91132ElectrogastrographyX03601.7147$119.03$33.57$23.81

91133Electrogastrography 

w/testX03601.7147$119.03$33.57$23.81

91299Gastroenterology 

procedureX03601.7147$119.03$33.57$23.81

92002Eye exam new 

patientV06061.4647$101.68.$20.34

92004Eye exam new 

patientV06061.4647$101.68.$20.34

92012Eye exam established 

patV06051.0430$72.41.$14.49
92014Eye exam & 

treatmentV06051.0430$72.41.$14.49

92015RefractionE

92018New eye exam & 

treatmentT069915.6140"$1,083.92".$216.79

92019Eye exam & 

treatmentT069915.6140"$1,083.92".$216.79

92020Special eye 

evaluationS02300.6929$48.10.$9.62

92025Corneal 

topographyCHS02300.6929$48.10.$9.62

92060Special eye 

evaluationCHS02300.6929$48.10.$9.62

92065Orthoptic/pleoptic 

trainingCHS02300.6929$48.10.$9.62

92070Fitting of contact 

lensN

92081Visual field 

examination(s)S02300.6929$48.10.$9.62

92082Visual field 

examination(s)CHS02300.6929$48.10.$9.62

92083Visual field 

examination(s)CHS02300.6929$48.10.$9.62

92100Serial tonometry 

exam(s)N

92120Tonography & eye 

evaluationCHS02300.6929$48.10.$9.62

92130Water provocation 

tonographyS02300.6929$48.10.$9.62

92132Cmptr ophth dx img ant 

segmtS02300.6929$48.10.$9.62

92133Cmptr ophth img optic 

nerveS02300.6929$48.10.$9.62

92134Cptr ophth dx img post 

segmtS02300.6929$48.10.$9.62
92136Ophthalmic 

biometryCHS02300.6929$48.10.$9.62

92140Glaucoma provocative 

testsS02300.6929$48.10.$9.62

92225Special eye exam 

initialS02300.6929$48.10.$9.62

92226Special eye exam 

subsequentCHS02300.6929$48.10.$9.62

92227Remote dx retinal 

imagingX00350.2717$18.86.$3.78

92228Remote retinal imaging 

mgmtX00350.2717$18.86.$3.78

92230Eye exam with photosCH 

S06981.4030$97.40.$19.48

92235Eye exam with 

photosS02312.3088$160.28.$32.06

92240Icg 

angiographyS02312.3088$160.28.$32.06

92250Eye exam with 

photosCHS02300.6929$48.10.$9.62

92260Ophthalmoscopy/dynamometryS02300.6929$48.10.$9.62

92265Eye muscle 

evaluationCHS02300.6929$48.10.$9.62

92270Electro-oculographyS02300.6929$48.10.$9.62

92275ElectroretinographyS02312.3088$160.28.$32.06

92283Color vision 

examinationS02300.6929$48.10.$9.62

92284Dark adaptation eye 

examCHS02300.6929$48.10.$9.62

92285Eye 

photographyCHS02300.6929$48.10.$9.62
92286Internal eye photographyCH 

S06981.4030$97.40.$19.48

92287Internal eye photographyCH 

S06981.4030$97.40.$19.48

92310Contact lens 

fittingE

92311Contact lens 

fittingS06981.4030$97.40.$19.48

92312Contact lens 

fittingCHS02300.6929$48.10.$9.62

92313Contact lens 

fittingS02300.6929$48.10.$9.62

92314Prescription of contact 

lensE

92315Prescription of contact 

lensS02300.6929$48.10.$9.62

92316Prescription of contact 

lensS06981.4030$97.40.$19.48

92317Prescription of contact 

lensS02300.6929$48.10.$9.62

92325Modification of contact 

lensS02300.6929$48.10.$9.62

92326Replacement of contact 

lensCHS02300.6929$48.10.$9.62

92340Fitting of 

spectaclesE

92341Fitting of 

spectaclesE

92342Fitting of 

spectaclesE

92352Special spectacles 

fittingS06981.4030$97.40.$19.48

92353Special spectacles 

fittingS02300.6929$48.10.$9.62

92354Special spectacles 

fittingS02300.6929$48.10.$9.62
92355Special spectacles 

fittingS02300.6929$48.10.$9.62

92358Eye prosthesis 

serviceS02300.6929$48.10.$9.62

92370Repair & adjust 

spectaclesE

92371Repair & adjust 

spectaclesS02300.6929$48.10.$9.62

92499Eye service or 

procedureS02300.6929$48.10.$9.62

92502Ear and throat 

examinationT02513.3531$232.77.$46.56

92504Ear microscopy 

examinationN

92506Speech/hearing 

evaluationA

92507Speech/hearing 

therapyA

92508Speech/hearing 

therapyA

92511NasopharyngoscopyT00711.0521$73.04.$14.61

92512Nasal function 

studiesX03630.9462$65.69$17.10$13.14

92516Facial nerve function 

testX06601.8827$130.70$27.10$26.14

92520Laryngeal function 

studiesX06601.8827$130.70$27.10$26.14

92526Oral function 

therapyA

92531Spontaneous nystagmus 

studyN

92532Positional nystagmus 

testN

92533Caloric vestibular 

testN

92534Optokinetic nystagmus 

testN
92540Basic vestibular 

evaluationX06601.8827$130.70$27.10$26.14

92541Spontaneous nystagmus 

testX03630.9462$65.69$17.10$13.14

92542Positional nystagmus 

testX03630.9462$65.69$17.10$13.14

92543Caloric vestibular 

testX06601.8827$130.70$27.10$26.14

92544Optokinetic nystagmus 

testX03630.9462$65.69$17.10$13.14

92545Oscillating tracking 

testX03630.9462$65.69$17.10$13.14

92546Sinusoidal rotational 

testX06601.8827$130.70$27.10$26.14

92547Supplemental electrical testN 

92548PosturographyX06601.8827$130.70$27.10$26.14

92550Tympanometry & reflex 

threshX03640.4896$33.99$7.06$6.80

92551Pure tone hearing test 

airE

92552Pure tone audiometry 

airX03640.4896$33.99$7.06$6.80

92553Audiometry air & 

boneX03651.2340$85.66$18.14$17.14

92555Speech threshold 

audiometryX03640.4896$33.99$7.06$6.80

92556Speech audiometry 

completeX03640.4896$33.99$7.06$6.80

92557Comprehensive hearing 

testX03651.2340$85.66$18.14$17.14

92559Group audiometric 

testingE

92560Bekesy audiometry 
screenE

92561Bekesy audiometry 

diagnosisCHX03651.2340$85.66$18.14$17.14

92562Loudness balance 

testX03640.4896$33.99$7.06$6.80

92563Tone decay hearing 

testX03640.4896$33.99$7.06$6.80

92564Sisi hearing 

testX03640.4896$33.99$7.06$6.80

92565Stenger test pure 

toneX03640.4896$33.99$7.06$6.80

92567TympanometryX03640.4896$33.99$7.06$6.80

92568Acoustic refl threshold 

tstX03640.4896$33.99$7.06$6.80

92570Acoustic immitance 

testingCHX03651.2340$85.66$18.14$17.14

92571Filtered speech hearing 

testX03640.4896$33.99$7.06$6.80

92572Staggered spondaic word 

testX03661.6976$117.85$23.61$23.57

92575Sensorineural acuity 

testX03640.4896$33.99$7.06$6.80

92576Synthetic sentence 

testX03640.4896$33.99$7.06$6.80

92577Stenger test 

speechX03661.6976$117.85$23.61$23.57

92579Visual audiometry 

(vra)X03651.2340$85.66$18.14$17.14

92582Conditioning play 

audiometryX03651.2340$85.66$18.14$17.14

92583Select picture 

audiometryX03640.4896$33.99$7.06$6.80

92584ElectrocochleographyS02162.6231$182.10.$36.42
92585Auditor evoke potent 

compreS02162.6231$182.10.$36.42

92586Auditor evoke potent 

limitS02181.1945$82.92.$16.59

92587Evoked auditory 

testX03630.9462$65.69$17.10$13.14

92588Evoked auditory 

testX03630.9462$65.69$17.10$13.14

92590Hearing aid exam one 

earE

92591Hearing aid exam both 

earsE

92592Hearing aid check one 

earE

92593Hearing aid check both 

earsE

92594Electro hearng aid test 

oneE

92595Electro hearng aid tst 

bothE

92596Ear protector 

evaluationX03640.4896$33.99$7.06$6.80

92597Oral speech device 

evalA

92601Cochlear implt f/up exam < 

7X03661.6976$117.85$23.61$23.57

92602Reprogram cochlear implt < 

7X03661.6976$117.85$23.61$23.57

92603Cochlear implt f/up exam 7 

>X03661.6976$117.85$23.61$23.57

92604Reprogram cochlear implt 7 

>X03661.6976$117.85$23.61$23.57

92605Eval for nonspeech device 

rxA

92606Non-speech device 

serviceA

92607Ex for speech device rx 
1hrA

92608Ex for speech device rx 

addlA

92609Use of speech device 

serviceA

92610Evaluate swallowing 

functionA

92611Motion 

fluoroscopy/swallowA

92612Endoscopy swallow tst 

(fees)A

92613Endoscopy swallow tst (fees)B 

92614Laryngoscopic sensory 

testA

92615Eval laryngoscopy sense 

tstE

92616Fees w/laryngeal sense 

testA

92617Interprt fees/laryngeal 

testE

92620Auditory function 60 

minX03651.2340$85.66$18.14$17.14

92621Auditory function + 15 

minN

92625Tinnitus 

assessmentX03651.2340$85.66$18.14$17.14

92626Eval aud rehab 

statusX03661.6976$117.85$23.61$23.57

92627Eval aud status rehab 

add-onN

92630Aud rehab pre-ling hear 

lossE

92633Aud rehab postling hear 

lossE

92640Aud brainstem implt 

programgX03651.2340$85.66$18.14$17.14

92700Ent 

procedure/serviceX03640.4896$33.99$7.06$6.80

92950Heart/lung resuscitation 

cprS00942.2773$158.09$44.32$31.62
92953Temporary external 

pacingQ300942.2773$158.09$44.32$31.62

92960Cardioversion electric 

extS06795.3123$368.78$94.48$73.76

92961Cardioversion electric 

intS06795.3123$368.78$94.48$73.76

92970Cardioassist 

internalC

92971Cardioassist 

externalC

92973Percut coronary 

thrombectomyT008841.2260"$2,861.91"$652.56$572.39

92974Cath place cardio 

brachytxT010316.7686"$1,164.08".$232.82

92975Dissolve clot heart 

vesselC

92977Dissolve clot heart 

vesselT06762.3410$162.51.$32.51

92978Intravasc us heart 

add-onN

92979Intravasc us heart 

add-onN

92980Insert intracoronary 

stentT010479.9047"$5,546.98"."$1,109.40"

92981Insert intracoronary 

stentT010479.9047"$5,546.98"."$1,109.40"

92982Coronary artery 

dilationT008365.1118"$4,520.06".$904.02

92984Coronary artery 

dilationT008365.1118"$4,520.06".$904.02

92986Revision of aortic 

valveT008365.1118"$4,520.06".$904.02

92987Revision of mitral 

valveT008365.1118"$4,520.06".$904.02

92990Revision of pulmonary 
valveT008365.1118"$4,520.06".$904.02

92992Revision of heart 

chamberC

92993Revision of heart 

chamberC

92995Coronary 

atherectomyT0082104.8857"$7,281.17"."$1,456.24"

92996Coronary atherectomy 

add-onT0082104.8857"$7,281.17"."$1,456.24"

92997Pul art balloon repr 

percutT008365.1118"$4,520.06".$904.02

92998Pul art balloon repr 

percutT008365.1118"$4,520.06".$904.02

93000Electrocardiogram completeM 

93005Electrocardiogram 

tracingS00990.3895$27.04.$5.41

93010Electrocardiogram 

reportB

93015Cardiovascular stress 

testB

93016Cardiovascular stress 

testB

93017Cardiovascular stress 

testX01002.5348$175.97$40.87$35.20

93018Cardiovascular stress 

testB

93024Cardiac drug stress 

testX01002.5348$175.97$40.87$35.20

93025Microvolt t-wave 

assessX01002.5348$175.97$40.87$35.20

93040Rhythm ECG with 

reportB

93041Rhythm ecg 

tracingX00350.2717$18.86.$3.78

93042Rhythm ecg 

reportB
93224Ecg monit/reprt up to 48 

hrsM

93225Ecg monit/reprt up to 48 

hrsS00970.9478$65.80$23.63$13.16

93226Ecg monit/reprt up to 48 

hrsS00970.9478$65.80$23.63$13.16

93227Ecg monit/reprt up to 48 

hrsM

93228Remote 30 day ecg 

rev/reportM

93229Remote 30 day ecg tech 

suppS020911.3894$790.65$268.73$158.13

93268ECG 

record/reviewM

93270Remote 30 day ecg 

rev/reportS00970.9478$65.80$23.63$13.16

93271Ecg/monitoring and analysisS 

06921.6659$115.65.$23.13

93272Ecg/review interpret 

onlyM

93278ECG/signal-averagedX00350.2717$18.86.$3.78

93279Pm device progr eval 

snglS06900.5148$35.74$8.67$7.15

93280Pm device progr eval 

dualS06900.5148$35.74$8.67$7.15

93281Pm device progr eval 

multiS06900.5148$35.74$8.67$7.15

93282Icd device prog eval 1 

snglS06900.5148$35.74$8.67$7.15

93283Icd device progr eval 

dualS06900.5148$35.74$8.67$7.15

93284Icd device progr eval 

multS06900.5148$35.74$8.67$7.15

93285Ilr device eval 

progrS06900.5148$35.74$8.67$7.15
93286Pre-op pm device 

evalN

93287Pre-op icd device 

evalN

93288Pm device eval in 

personS06900.5148$35.74$8.67$7.15

93289Icd device 

interrogateS06900.5148$35.74$8.67$7.15

93290Icm device evalX 

00350.2717$18.86.$3.78

93291Ilr device 

interrogateS06900.5148$35.74$8.67$7.15

93292Wcd device 

interrogateS06900.5148$35.74$8.67$7.15

93293Pm phone r-strip device 

evalS06900.5148$35.74$8.67$7.15

93294Pm device interrogate remoteM 

93295Icd device interrogat remoteM 

93296Pm/icd remote tech 

servS06900.5148$35.74$8.67$7.15

93297Icm device interrogat remoteM 

93298Ilr device interrogat remoteM 

93299Icm/ilr remote tech 

servCHS06900.5148$35.74$8.67$7.15

93303Echo 

transthoracicS02708.1675$566.99$133.61$113.40

93304Echo 

transthoracicS02695.5306$383.93.$76.79

93306Tte w/doppler 

completeS02695.5306$383.93.$76.79

93307Tte w/o doppler 

completeS02695.5306$383.93.$76.79

93308Tte f-up or 
lmtdS06973.1535$218.92.$43.79

93312Echo 

transesophagealS02708.1675$566.99$133.61$113.40

93313Echo 

transesophagealS02695.5306$383.93.$76.79

93314Echo 

transesophagealN

93315Echo transesophagealCH 

S02695.5306$383.93.$76.79

93316Echo 

transesophagealS02708.1675$566.99$133.61$113.40

93317Echo 

transesophagealN

93318Echo transesophageal 

intraopS02708.1675$566.99$133.61$113.40

93320Doppler echo exam heartN 

93321Doppler echo exam heartN 

93325Doppler color flow add-onN 

93350Stress tte 

onlyS02695.5306$383.93.$76.79

93351Stress tte 

completeS02708.1675$566.99$133.61$113.40

93352Admin ecg contrast agentM 

93451Right heart 

cathT008039.2392"$2,723.99"$838.04$544.80

93452Left hrt cath 

w/ventrclgrphyT008039.2392"$2,723.99"$838.04$544.80

93453R&l hrt cath 

w/ventriclgrphyT008039.2392"$2,723.99"$838.04$544.80

93454Coronary artery angio 

s&iT008039.2392"$2,723.99"$838.04$544.80

93455Coronary art/grft angio 
s&iT008039.2392"$2,723.99"$838.04$544.80

93456R hrt coronary artery 

angioT008039.2392"$2,723.99"$838.04$544.80

93457R hrt art/grft 

angioT008039.2392"$2,723.99"$838.04$544.80

93458L hrt artery/ventricle 

angioT008039.2392"$2,723.99"$838.04$544.80

93459L hrt art/grft 

angioT008039.2392"$2,723.99"$838.04$544.80

93460R&l hrt art/ventricle 

angioT008039.2392"$2,723.99"$838.04$544.80

93461R&l hrt art/ventricle 

angioT008039.2392"$2,723.99"$838.04$544.80

93462L hrt cath trnsptl 

punctureT008039.2392"$2,723.99"$838.04$544.80

93463Drug admin & hemodynmic 

measN

93464Exercise w/hemodynamic 

measN

93503Insert/place heart 

catheterT010316.7686"$1,164.08".$232.82

93505Biopsy of heart 

liningT010316.7686"$1,164.08".$232.82

93530Rt heart cath 

congenitalT008039.2392"$2,723.99"$838.04$544.80

93531R & l heart cath 

congenitalT008039.2392"$2,723.99"$838.04$544.80

93532R & l heart cath 

congenitalT008039.2392"$2,723.99"$838.04$544.80

93533R & l heart cath 

congenitalT008039.2392"$2,723.99"$838.04$544.80

93561Cardiac output 

measurementN

93562Cardiac output 

measurementN
93563Inject congenital card 

cathN

93564Inject hrt congntl 

art/grftN

93565Inject l ventr/atrial 

angioN

93566Inject r ventr/atrial 

angioN

93567Inject suprvlv 

aortographyN

93568Inject pulm art hrt 

cathN

93571Heart flow reserve 

measureN

93572Heart flow reserve 

measureN

93580Transcath closure of 

asdT0434166.2005"$11,537.64"."$2,307.53"

93581Transcath closure of 

vsdT0434166.2005"$11,537.64"."$2,307.53"

93600Bundle of His 

recordingS00849.6404$669.24.$133.85

93602Intra-atrial 

recordingS00849.6404$669.24.$133.85

93603Right ventricular 

recordingS00849.6404$669.24.$133.85

93609Map tachycardia add-onN 

93610Intra-atrial 

pacingS00849.6404$669.24.$133.85

93612Intraventricular 

pacingS00849.6404$669.24.$133.85

93613Electrophys map 3d add-onN 

93615Esophageal 

recordingS00849.6404$669.24.$133.85

93616Esophageal 

recordingS00849.6404$669.24.$133.85
93618Heart rhythm 

pacingS00849.6404$669.24.$133.85

93619Electrophysiology 

evaluationQ3008552.8540"$3,669.12".$733.83

93620Electrophysiology 

evaluationQ3008552.8540"$3,669.12".$733.83

93621Electrophysiology evaluationN 

93622Electrophysiology evaluationN 

93623Stimulation pacing heartN 

93624Electrophysiologic 

studyT008552.8540"$3,669.12".$733.83

93631Heart pacing mappingN 

93640Evaluation heart deviceN 

93641Electrophysiology evaluationN 

93642Electrophysiology 

evaluationS00849.6404$669.24.$133.85

93650Ablate heart dysrhythm 

focusQ3008552.8540"$3,669.12".$733.83

93651Ablate heart dysrhythm 

focusQ30086133.7624"$9,285.79"."$1,857.16"

93652Ablate heart dysrhythm 

focusQ30086133.7624"$9,285.79"."$1,857.16"

93660Tilt table 

evaluationS01014.2610$295.80$100.24$59.16

93662Intracardiac ecg (ice)N 

93668Peripheral vascular 

rehabE

93701Bioimpedance cv 

analysisS00990.3895$27.04.$5.41

93720Total body 
plethysmographyB

93721Plethysmography 

tracingCHX03670.7369$51.16$13.76$10.24

93722Plethysmography 

reportB

93724Analyze pacemaker 

systemS06900.5148$35.74$8.67$7.15

93740Temperature gradient 

studiesCHX03670.7369$51.16$13.76$10.24

93745Set-up 

cardiovert-defibrillS06900.5148$35.74$8.67$7.15

93750Interrogation vad in 

personS06921.6659$115.65.$23.13

93770Measure venous 

pressureN

93784Ambulatory BP 

monitoringE

93786Ambulatory BP 

recordingS00970.9478$65.80$23.63$13.16

93788Ambulatory BP 

analysisS00970.9478$65.80$23.63$13.16

93790Review/report BP recordingM 

93797Cardiac 

rehabS00950.9648$66.98$13.49$13.40

93798Cardiac 

rehab/monitorS00950.9648$66.98$13.49$13.40

93799Cardiovascular 

procedureS00970.9478$65.80$23.63$13.16

93875Extracranial 

studyS00961.5324$106.38$36.83$21.28

93880Extracranial 

studyS02672.1881$151.90$59.41$30.38

93882Extracranial 

studyS02672.1881$151.90$59.41$30.38
93886Intracranial 

studyS02672.1881$151.90$59.41$30.38

93888Intracranial 

studyS02650.8995$62.44$22.26$12.49

93890Tcd vasoreactivity 

studyS02661.3711$95.18$36.80$19.04

93892Tcd emboli detect w/o 

injS02661.3711$95.18$36.80$19.04

93893Tcd emboli detect 

w/injS02661.3711$95.18$36.80$19.04

93922Upr/l xtremity art 2 

levelsS00970.9478$65.80$23.63$13.16

93923Upr/lxtr art stdy 3+ 

lvlsS00961.5324$106.38$36.83$21.28

93924Lwr xtr vasc stdy 

bilatS00961.5324$106.38$36.83$21.28

93925Lower extremity 

studyS02672.1881$151.90$59.41$30.38

93926Lower extremity 

studyS02661.3711$95.18$36.80$19.04

93930Upper extremity 

studyS02672.1881$151.90$59.41$30.38

93931Upper extremity 

studyS02661.3711$95.18$36.80$19.04

93965Extremity 

studyS00961.5324$106.38$36.83$21.28

93970Extremity 

studyS02672.1881$151.90$59.41$30.38

93971Extremity 

studyS02661.3711$95.18$36.80$19.04

93975Vascular 

studyS02672.1881$151.90$59.41$30.38

93976Vascular 

studyS02672.1881$151.90$59.41$30.38
93978Vascular 

studyS02672.1881$151.90$59.41$30.38

93979Vascular 

studyS02661.3711$95.18$36.80$19.04

93980Penile vascular 

studyS02672.1881$151.90$59.41$30.38

93981Penile vascular 

studyS02672.1881$151.90$59.41$30.38

93982Aneurysm pressure sens 

studyS00970.9478$65.80$23.63$13.16

93990Doppler flow 

testingS02661.3711$95.18$36.80$19.04

94002Vent mgmt inpat init 

dayQ300793.0221$209.79.$41.96

94003Vent mgmt inpat subq 

dayQ300793.0221$209.79.$41.96

94004Vent mgmt nf per 

dayB

94005Home vent mgmt supervisionM 

94010Breathing capacity 

testCHX03670.7369$51.16$13.76$10.24

94011Spirometry up to 2 yrs 

oldCHX03670.7369$51.16$13.76$10.24

94012Spirmtry w/brnchdil inf-2 

yrCHX03670.7369$51.16$13.76$10.24

94013Meas lung vol thru 2 

yrsX03692.6420$183.41$37.27$36.69

94014Patient recorded 

spirometryX03670.7369$51.16$13.76$10.24

94015Patient recorded 

spirometryX03670.7369$51.16$13.76$10.24

94016Review patient 

spirometryA
94060Evaluation of wheezingS 

00781.4008$97.24.$19.45

94070Evaluation of 

wheezingX03692.6420$183.41$37.27$36.69

94150Vital capacity 

testX03670.7369$51.16$13.76$10.24

94200Lung function test 

(MBC/MVV)X03670.7369$51.16$13.76$10.24

94240Residual lung 

capacityX03680.8927$61.97$20.93$12.40

94250Expired gas 

collectionX03670.7369$51.16$13.76$10.24

94260Thoracic gas 

volumeCHX03670.7369$51.16$13.76$10.24

94350Lung nitrogen washout 

curveCHX03670.7369$51.16$13.76$10.24

94360Measure airflow 

resistanceX03670.7369$51.16$13.76$10.24

94370Breath airway closing 

volumeCHX03670.7369$51.16$13.76$10.24

94375Respiratory flow volume 

loopCHX03670.7369$51.16$13.76$10.24

94400CO2 breathing response 

curveX03670.7369$51.16$13.76$10.24

94450Hypoxia response 

curveX03680.8927$61.97$20.93$12.40

94452Hast 

w/reportX03680.8927$61.97$20.93$12.40

94453Hast w/oxygen 

titrateCHX03670.7369$51.16$13.76$10.24

94610Surfactant admin thru tubeS 

00770.4224$29.32$7.74$5.87

94620Pulmonary stress 
test/simpleX03680.8927$61.97$20.93$12.40

94621Pulm stress 

test/complexX03692.6420$183.41$37.27$36.69

94640Airway inhalation 

treatmentS00770.4224$29.32$7.74$5.87

94642Aerosol inhalation 

treatmentS00781.4008$97.24.$19.45

94644Cbt 1st 

hourX03400.6739$46.78.$9.36

94645Cbt each addl 

hourX03400.6739$46.78.$9.36

94660Pos airway pressure 

cpapQ300781.4008$97.24.$19.45

94662Neg press ventilation 

cnpQ300793.0221$209.79.$41.96

94664Evaluate pt use of 

inhalerS00770.4224$29.32$7.74$5.87

94667Chest wall 

manipulationS00770.4224$29.32$7.74$5.87

94668Chest wall 

manipulationS00770.4224$29.32$7.74$5.87

94680Exhaled air analysis 

o2X03680.8927$61.97$20.93$12.40

94681Exhaled air analysis 

o2/co2CHX03692.6420$183.41$37.27$36.69

94690Exhaled air 

analysisX03670.7369$51.16$13.76$10.24

94720Monoxide diffusing 

capacityX03680.8927$61.97$20.93$12.40

94725Membrane diffusion 

capacityCHX03670.7369$51.16$13.76$10.24

94750Pulmonary compliance 

studyX03670.7369$51.16$13.76$10.24
94760Measure blood oxygen 

levelN

94761Measure blood oxygen 

levelN

94762Measure blood oxygen 

levelQ300970.9478$65.80$23.63$13.16

94770Exhaled carbon dioxide 

testX03680.8927$61.97$20.93$12.40

94772Breath recording 

infantX03692.6420$183.41$37.27$36.69

94774Ped home apnea rec complB 

94775Ped home apnea rec 

hk-upS00970.9478$65.80$23.63$13.16

94776Ped home apnea rec 

downldS00970.9478$65.80$23.63$13.16

94777Ped home apnea rec reportB 

94799Pulmonary 

service/procedureX03670.7369$51.16$13.76$10.24

95004Percut allergy skin 

testsX03810.4731$32.84.$6.57

95010Percut allergy titrate 

testX03810.4731$32.84.$6.57

95012Exhaled nitric oxide 

measX03670.7369$51.16$13.76$10.24

95015Id allergy 

titrate-drug/bugX03810.4731$32.84.$6.57

95024Id allergy test 

drug/bugX03810.4731$32.84.$6.57

95027Id allergy 

titrate-airborneX03810.4731$32.84.$6.57

95028Id allergy test-delayed 

typeX03810.4731$32.84.$6.57

95044Allergy patch 
testsX03810.4731$32.84.$6.57

95052Photo patch 

testX03810.4731$32.84.$6.57

95056Photosensitivity 

testsX03701.3506$93.76.$18.76

95060Eye allergy 

testsX03701.3506$93.76.$18.76

95065Nose allergy 

testX03810.4731$32.84.$6.57

95070Bronchial allergy 

testsX03692.6420$183.41$37.27$36.69

95071Bronchial allergy 

testsCHX03680.8927$61.97$20.93$12.40

95075Ingestion challenge 

testX03614.1026$284.80$83.23$56.96

95115Immunotherapy one 

injectionS04360.3780$26.24.$5.25

95117Immunotherapy injectionsS 

04360.3780$26.24.$5.25

95120Immunotherapy one injectionE 

95125Immunotherapy many antigensE 

95130Immunotherapy insect venomE 

95131Immunotherapy insect venomsE 

95132Immunotherapy insect venomsE 

95133Immunotherapy insect venomsE 

95134Immunotherapy insect venomsE 

95144Antigen therapy 

servicesS04370.5280$36.65.$7.33

95145Antigen therapy 

servicesS04370.5280$36.65.$7.33
95146Antigen therapy 

servicesS04381.0547$73.22.$14.65

95147Antigen therapy 

servicesS04381.0547$73.22.$14.65

95148Antigen therapy 

servicesS04370.5280$36.65.$7.33

95149Antigen therapy 

servicesS04370.5280$36.65.$7.33

95165Antigen therapy 

servicesS04360.3780$26.24.$5.25

95170Antigen therapy 

servicesS04370.5280$36.65.$7.33

95180Rapid 

desensitizationX03701.3506$93.76.$18.76

95199Allergy immunology 

servicesX03810.4731$32.84.$6.57

95250Glucose monitoring 

contV06071.9242$133.58.$26.72

95251Gluc monitor cont phys 

i&rB

95800Slp stdy 

unattendedS02132.3958$166.32$53.48$33.27

95801Slp stdy unatnd 

w/analS02132.3958$166.32$53.48$33.27

95803Actigraphy 

testingS02181.1945$82.92.$16.59

95805Multiple sleep latency 

testS020911.3894$790.65$268.73$158.13

95806Sleep study unatt&resp 

efftS02132.3958$166.32$53.48$33.27

95807Sleep study 

attendedS020911.3894$790.65$268.73$158.13

95808Polysomnography 

1-3S020911.3894$790.65$268.73$158.13
95810Polysomnography 4 or 

moreS020911.3894$790.65$268.73$158.13

95811Polysomnography 

w/cpapS020911.3894$790.65$268.73$158.13

95812Eeg 41-60 

minutesS02132.3958$166.32$53.48$33.27

95813Eeg over 1 

hourS02132.3958$166.32$53.48$33.27

95816Eeg awake and 

drowsyS02132.3958$166.32$53.48$33.27

95819Eeg awake and 

asleepS02132.3958$166.32$53.48$33.27

95822Eeg coma or sleep 

onlyS02132.3958$166.32$53.48$33.27

95824Eeg cerebral death 

onlyS02162.6231$182.10.$36.42

95827Eeg all night 

recordingS02132.3958$166.32$53.48$33.27

95829Surgery electrocorticogramN 

95830Insert electrodes for 

EEGB

95831Limb muscle testing 

manualA

95832Hand muscle testing 

manualA

95833Body muscle testing 

manualA

95834Body muscle testing 

manualA

95851Range of motion 

measurementsA

95852Range of motion 

measurementsA

95857Cholinesterase 

challengeS02181.1945$82.92.$16.59
95860Muscle test one 

limbS02181.1945$82.92.$16.59

95861Muscle test 2 

limbsS02181.1945$82.92.$16.59

95863Muscle test 3 

limbsS02181.1945$82.92.$16.59

95864Muscle test 4 

limbsS02181.1945$82.92.$16.59

95865Muscle test 

larynxS02181.1945$82.92.$16.59

95866Muscle test 

hemidiaphragmS02181.1945$82.92.$16.59

95867Muscle test cran nerv 

unilatS02181.1945$82.92.$16.59

95868Muscle test cran nerve 

bilatS02181.1945$82.92.$16.59

95869Muscle test thor 

paraspinalS02150.6352$44.10.$8.82

95870Muscle test 

nonparaspinalS02150.6352$44.10.$8.82

95872Muscle test one 

fiberS02181.1945$82.92.$16.59

95873Guide nerv destr elec stimN 

95874Guide nerv destr needle emgN 

95875Limb exercise 

testS02181.1945$82.92.$16.59

95900Motor nerve conduction 

testS02150.6352$44.10.$8.82

95903Motor nerve conduction 

testS02150.6352$44.10.$8.82

95904Sense nerve conduction 

testS02150.6352$44.10.$8.82
95905Motor/sens nrve conduct 

testS02150.6352$44.10.$8.82

95920Intraop nerve test add-onN 

95921Autonomic nerv function 

testS02181.1945$82.92.$16.59

95922Autonomic nerv function 

testS02181.1945$82.92.$16.59

95923Autonomic nerv function 

testS02181.1945$82.92.$16.59

95925Somatosensory 

testingS02162.6231$182.10.$36.42

95926Somatosensory 

testingS02162.6231$182.10.$36.42

95927Somatosensory 

testingS02162.6231$182.10.$36.42

95928C motor evoked uppr 

limbsS02181.1945$82.92.$16.59

95929C motor evoked lwr 

limbsS02181.1945$82.92.$16.59

95930Visual evoked potential 

testS02162.6231$182.10.$36.42

95933Blink reflex 

testS02150.6352$44.10.$8.82

95934H-reflex 

testS02150.6352$44.10.$8.82

95936H-reflex 

testS02150.6352$44.10.$8.82

95937Neuromuscular junction 

testS02181.1945$82.92.$16.59

95950Ambulatory eeg 

monitoringS020911.3894$790.65$268.73$158.13

95951EEG 

monitoring/videorecordS020911.3894$790.65$268.73$158.13
95953EEG 

monitoring/computerS020911.3894$790.65$268.73$158.13

95954EEG monitoring/giving 

drugsS02181.1945$82.92.$16.59

95955EEG during surgeryN 

95956Eeg monitor technol 

attendedS020911.3894$790.65$268.73$158.13

95957EEG digital analysisN 

95958EEG monitoring/function 

testS02132.3958$166.32$53.48$33.27

95961Electrode stimulation 

brainS02162.6231$182.10.$36.42

95962Electrode stim brain 

add-onS02162.6231$182.10.$36.42

95965Meg spontaneousS 

006746.8279"$3,250.79".$650.16

95966Meg evoked singleS 

006512.4513$864.37.$172.88

95967Meg evoked each addlS 

006512.4513$864.37.$172.88

95970Analyze neurostim no 

progS02181.1945$82.92.$16.59

95971Analyze neurostim 

simpleS06921.6659$115.65.$23.13

95972Analyze neurostim 

complexS06921.6659$115.65.$23.13

95973Analyze neurostim 

complexS06921.6659$115.65.$23.13

95974Cranial neurostim 

complexS06921.6659$115.65.$23.13

95975Cranial neurostim 

complexS06921.6659$115.65.$23.13
95978Analyze neurostim 

brain/1hS06921.6659$115.65.$23.13

95979Analyz neurostim brain 

addonS06921.6659$115.65.$23.13

95980Io anal gast n-stim 

initN

95981Io anal gast n-stim 

subsqS02181.1945$82.92.$16.59

95982Io ga n-stim subsq 

w/reprogS06921.6659$115.65.$23.13

95990Spin/brain pump refil & 

mainS04391.9117$132.71.$26.55

95991Spin/brain pump refil & 

mainS04391.9117$132.71.$26.55

95992Canalith repositioning 

procA

95999Neurological 

procedureS02150.6352$44.10.$8.82

96000Motion analysis 

video/3dS02162.6231$182.10.$36.42

96001Motion test w/ft press 

measS02162.6231$182.10.$36.42

96002Dynamic surface 

emgS02181.1945$82.92.$16.59

96003Dynamic fine wire 

emgS02181.1945$82.92.$16.59

96004Phys review of motion testsB 

96020Functional brain mappingN 

96040Genetic counseling 30 minB 

96101Psycho testing by 

psych/physQ303822.6658$185.06.$37.02

96102Psycho testing by 

technicianQ303822.6658$185.06.$37.02
96103Psycho testing admin by 

compQ303731.3767$95.57.$19.12

96105Assessment of 

aphasiaA

96110Developmental test 

limQ303731.3767$95.57.$19.12

96111Developmental test 

extendQ303731.3767$95.57.$19.12

96116Neurobehavioral status 

examQ303822.6658$185.06.$37.02

96118Neuropsych tst by 

psych/physQ303822.6658$185.06.$37.02

96119Neuropsych testing by 

tecQ303822.6658$185.06.$37.02

96120Neuropsych tst admin 

w/compQ303822.6658$185.06.$37.02

96125Cognitive test by hc proA 

96150Assess hlth/behave 

initQ304320.4940$34.29.$6.86

96151Assess hlth/behave 

subseqQ304320.4940$34.29.$6.86

96152Intervene hlth/behave 

indivQ304320.4940$34.29.$6.86

96153Intervene hlth/behave 

groupQ304320.4940$34.29.$6.86

96154Interv hlth/behav fam 

w/ptQ304320.4940$34.29.$6.86

96155Interv hlth/behav fam no 

ptE

96360Hydration iv infusion 

initS04381.0547$73.22.$14.65

96361Hydrate iv infusion 

add-onS04360.3780$26.24.$5.25
96365Ther/proph/diag iv inf 

initS04391.9117$132.71.$26.55

96366Ther/proph/diag iv inf 

addonS04360.3780$26.24.$5.25

96367Tx/proph/dg addl seq iv 

infS04370.5280$36.65.$7.33

96368Ther/diag concurrent 

infN

96369Sc ther infusion up to 1 

hrS04391.9117$132.71.$26.55

96370Sc ther infusion addl 

hrS04370.5280$36.65.$7.33

96371Sc ther infusion reset 

pumpS04360.3780$26.24.$5.25

96372Ther/proph/diag inj 

sc/imS04360.3780$26.24.$5.25

96373Ther/proph/diag inj 

iaS04370.5280$36.65.$7.33

96374Ther/proph/diag inj iv 

pushS04370.5280$36.65.$7.33

96375Tx/pro/dx inj new drug 

addonS04370.5280$36.65.$7.33

96376Tx/pro/dx inj same drug 

adonN

96379Ther/prop/diag inj/inf 

procS04360.3780$26.24.$5.25

96401Chemo anti-neopl 

sq/imS04370.5280$36.65.$7.33

96402Chemo hormon antineopl 

sq/imS04370.5280$36.65.$7.33

96405Chemo intralesional up to 

7S04370.5280$36.65.$7.33

96406Chemo intralesional over 

7S04391.9117$132.71.$26.55
96409Chemo iv push sngl drugS 

04391.9117$132.71.$26.55

96411Chemo iv push addl drugS 

04381.0547$73.22.$14.65

96413Chemo iv infusion 1 hrS 

04403.0395$211.00.$42.20

96415Chemo iv infusion addl 

hrS04370.5280$36.65.$7.33

96416Chemo prolong infuse 

w/pumpS04403.0395$211.00.$42.20

96417Chemo iv infus each addl 

seqS04381.0547$73.22.$14.65

96420Chemo ia push 

tecniqueS04381.0547$73.22.$14.65

96422Chemo ia infusion up to 1 

hrS04403.0395$211.00.$42.20

96423Chemo ia infuse each addl hrS 

04381.0547$73.22.$14.65

96425Chemotherapy infusion 

methodS04403.0395$211.00.$42.20

96440Chemotherapy 

intracavitaryS04391.9117$132.71.$26.55

96446Chemotx admn prtl 

cavityS04391.9117$132.71.$26.55

96450Chemotherapy into 

cnsS04403.0395$211.00.$42.20

96521Refill/maint portable 

pumpS04391.9117$132.71.$26.55

96522Refill/maint pump/resvr 

systS04391.9117$132.71.$26.55

96523Irrig drug delivery deviceQ1 

06240.6235$43.28$12.56$8.66

96542Chemotherapy 
injectionS04381.0547$73.22.$14.65

96549Chemotherapy 

unspecifiedS04360.3780$26.24.$5.25

96567Photodynamic tx 

skinT00151.4936$103.69.$20.74

96570Photodynmc tx 30 min 

add-onT00151.4936$103.69.$20.74

96571Photodynamic tx addl 15 

minT00151.4936$103.69.$20.74

96900Ultraviolet light 

therapyS00010.5025$34.88.$6.98

96902TrichogramN

96904Whole body 

photographyN

96910Photochemotherapy with 

UV-BS00010.5025$34.88.$6.98

96912Photochemotherapy with 

UV-AS00010.5025$34.88.$6.98

96913Photochemotherapy uv-a or 

bS06832.9704$206.21.$41.25

96920Laser tx skin < 250 sq 

cmT00151.4936$103.69.$20.74

96921Laser tx skin 250-500 sq 

cmT00151.4936$103.69.$20.74

96922Laser tx skin > 500 sq 

cmT00151.4936$103.69.$20.74

96999Dermatological 

procedureT00120.4047$28.09.$5.62

97001Pt 

evaluationA

97002Pt 

re-evaluationA

97003Ot 

evaluationA

97004Ot 
re-evaluationA

97005Athletic train 

evalE

97006Athletic train 

reevalE

97010Hot or cold packs 

therapyA

97012Mechanical traction 

therapyA

97014Electric stimulation 

therapyE

97016Vasopneumatic device 

therapyA

97018Paraffin bath 

therapyA

97022Whirlpool 

therapyA

97024Diathermy eg 

microwaveA

97026Infrared 

therapyA

97028Ultraviolet 

therapyA

97032Electrical 

stimulationA

97033Electric current 

therapyA

97034Contrast bath 

therapyA

97035Ultrasound 

therapyA

97036HydrotherapyA

97039Physical therapy 

treatmentA

97110Therapeutic 

exercisesA

97112Neuromuscular 

reeducationA

97113Aquatic 

therapy/exercisesA

97116Gait training 

therapyA

97124Massage 

therapyA
97139Physical medicine 

procedureA

97140Manual 

therapyA

97150Group therapeutic 

proceduresA

97530Therapeutic 

activitiesA

97532Cognitive skills 

developmentA

97533Sensory 

integrationA

97535Self care mngment 

trainingA

97537Community/work 

reintegrationA

97542Wheelchair mngment 

trainingA

97545Work 

hardeningA

97546Work hardening 

add-onA

97597Rmvl devital tis 20 

cm/<T00151.4936$103.69.$20.74

97598Rmvl devital tis addl 20 

cm<T00151.4936$103.69.$20.74

97602Wound(s) care 

non-selectiveT00130.9786$67.93.$13.59

97605Neg press wound tx < 50 

cmT00130.9786$67.93.$13.59

97606Neg press wound tx > 50 

cmT00151.4936$103.69.$20.74

97750Physical performance 

testA

97755Assistive technology 

assessA

97760Orthotic mgmt and 

trainingA

97761Prosthetic 

trainingA
97762C/o for orthotic/prosth 

useA

97799Physical medicine 

procedureA

97802Medical nutrition indiv 

inA

97803Med nutrition indiv 

subseqA

97804Medical nutrition 

groupA

97810Acupunct w/o stimul 15 

minE

97811Acupunct w/o stimul addl 

15mE

97813Acupunct w/stimul 15 

minE

97814Acupunct w/stimul addl 

15mE

98925Osteopathic 

manipulationS00600.3234$22.45.$4.49

98926Osteopathic 

manipulationS00600.3234$22.45.$4.49

98927Osteopathic 

manipulationS00600.3234$22.45.$4.49

98928Osteopathic 

manipulationS00600.3234$22.45.$4.49

98929Osteopathic 

manipulationS00600.3234$22.45.$4.49

98940Chiropractic 

manipulationS00600.3234$22.45.$4.49

98941Chiropractic 

manipulationS00600.3234$22.45.$4.49

98942Chiropractic 

manipulationS00600.3234$22.45.$4.49

98943Chiropractic 

manipulationE

98960Self-mgmt educ & train 1 

ptE

98961Self-mgmt educ/train 2-4 
ptE

98962Self-mgmt educ/train 5-8 

ptE

98966Hc pro phone call 5-10 

minE

98967Hc pro phone call 11-20 

minE

98968Hc pro phone call 21-30 

minE

98969Online service by hc 

proE

99000Specimen handlingE 

99001Specimen handlingE 

99002Device 

handlingB

99024Postop follow-up 

visitB

99026In-hospital on call 

serviceE

99027Out-of-hosp on call 

serviceE

99050Medical services after 

hrsB

99051Med serv 

eve/wkend/holidayB

99053Med serv 10pm-8am 24 hr 

facB

99056Med service out of 

officeB

99058Office emergency 

careB

99060Out of office emerg med 

servB

99070Special 

suppliesB

99071Patient education 

materialsB

99075Medical 

testimonyE

99078Group health 

educationN

99080Special reports or 
formsB

99082Unusual physician 

travelB

99090Computer data 

analysisB

99091Collect/review data from 

ptN

99100Special anesthesia 

serviceB

99116Anesthesia with 

hypothermiaB

99135Special anesthesia 

procedureB

99140Emergency 

anesthesiaB

99143Mod cs by same phys < 5 

yrsN

99144Mod cs by same phys 5 yrs 

+N

99145Mod cs by same phys 

add-onN

99148Mod cs diff phys < 5 

yrsN

99149Mod cs diff phys 5 yrs 

+N

99150Mod cs diff phys 

add-onN

99170Anogenital exam 

childT01910.1274$8.84$1.85$1.77

99172Ocular function 

screenE

99173Visual acuity 

screenE

99174Ocular 

photoscreeningE

99175Induction of 

vomitingN

99183Hyperbaric oxygen 

therapyB

99190Special pump 

servicesC

99191Special pump 

servicesC
99192Special pump 

servicesC

99195PhlebotomyX06240.6235$43.28$12.56$8.66

99199Special 

service/proc/reportB

99201Office/outpatient visit 

newV06040.6941$48.18.$9.64

99202Office/outpatient visit 

newV06051.0430$72.41.$14.49

99203Office/outpatient visit 

newV06061.4647$101.68.$20.34

99204Office/outpatient visit 

newV06071.9242$133.58.$26.72

99205Office/outpatient visit newQ3 

06082.4718$171.59.$34.32

99211Office/outpatient visit 

estV06040.6941$48.18.$9.64

99212Office/outpatient visit 

estV06051.0430$72.41.$14.49

99213Office/outpatient visit 

estV06051.0430$72.41.$14.49

99214Office/outpatient visit 

estV06061.4647$101.68.$20.34

99215Office/outpatient visit estQ3 

06071.9242$133.58.$26.72

99217Observation care 

dischargeB

99218Initial observation 

careB

99219Initial observation 

careB

99220Initial observation 

careB

99221Initial hospital careB 

99222Initial hospital careB 
99223Initial hospital careB 

99224Subsequent observation careB 

99225Subsequent observation careB 

99226Subsequent observation careB 

99231Subsequent hospital careB 

99232Subsequent hospital careB 

99233Subsequent hospital careB 

99234Observ/hosp same 

dateB

99235Observ/hosp same 

dateB

99236Observ/hosp same 

dateB

99238Hospital discharge dayB 

99239Hospital discharge dayB 

99241Office 

consultationE

99242Office 

consultationE

99243Office 

consultationE

99244Office 

consultationE

99245Office 

consultationE

99251Inpatient 

consultationE

99252Inpatient 

consultationE

99253Inpatient 

consultationE

99254Inpatient 

consultationE

99255Inpatient 

consultationE
99281Emergency dept 

visitV06090.7290$50.61$12.12$10.13

99282Emergency dept 

visitV06131.2424$86.25$20.73$17.25

99283Emergency dept 

visitV06141.9769$137.24$33.86$27.45

99284Emergency dept visitQ3 

06153.1815$220.86$48.11$44.18

99285Emergency dept visitQ3 

06164.7283$328.24$72.57$65.65

99288Direct advanced life 

supportB

99291Critical care first hourQ3 

06176.8172$473.25$104.95$94.65

99292Critical care addl 30 

minN

99304Nursing facility care 

initB

99305Nursing facility care 

initB

99306Nursing facility care 

initB

99307Nursing fac care 

subseqB

99308Nursing fac care 

subseqB

99309Nursing fac care 

subseqB

99310Nursing fac care 

subseqB

99315Nursing fac discharge 

dayB

99316Nursing fac discharge 

dayB

99318Annual nursing fac 

assessmntB

99324Domicil/r-home visit new 

patB

99325Domicil/r-home visit new 

patB
99326Domicil/r-home visit new 

patB

99327Domicil/r-home visit new 

patB

99328Domicil/r-home visit new 

patB

99334Domicil/r-home visit est 

patB

99335Domicil/r-home visit est 

patB

99336Domicil/r-home visit est 

patB

99337Domicil/r-home visit est 

patB

99339Domicil/r-home care 

supervisB

99340Domicil/r-home care 

supervisB

99341Home visit new 

patientB

99342Home visit new 

patientB

99343Home visit new 

patientB

99344Home visit new 

patientB

99345Home visit new 

patientB

99347Home visit est 

patientB

99348Home visit est 

patientB

99349Home visit est 

patientB

99350Home visit est 

patientB

99354Prolonged service 

officeN

99355Prolonged service 

officeN

99356Prolonged service 

inpatientC

99357Prolonged service 

inpatientC
99358Prolong service w/o 

contactN

99359Prolong serv w/o contact 

addN

99360Physician standby 

servicesB

99363Anticoag mgmt 

initB

99364Anticoag mgmt 

subseqB

99366Team conf w/pat by hc 

proN

99367Team conf w/o pat by 

physN

99368Team conf w/o pat by hc 

proN

99374Home health care 

supervisionB

99375Home health care 

supervisionE

99377Hospice care 

supervisionB

99378Hospice care 

supervisionE

99379Nursing fac care 

supervisionB

99380Nursing fac care 

supervisionB

99381Init pm e/m new pat 

infE

99382Init pm e/m new pat 1-4 

yrsE

99383Prev visit new age 

5-11E

99384Prev visit new age 

12-17E

99385Prev visit new age 

18-39E

99386Prev visit new age 

40-64E

99387Init pm e/m new pat 65+ 

yrsE

99391Per pm reeval est pat 

infE
99392Prev visit est age 

1-4E

99393Prev visit est age 

5-11E

99394Prev visit est age 

12-17E

99395Prev visit est age 

18-39E

99396Prev visit est age 

40-64E

99397Per pm reeval est pat 65+ 

yrE

99401Preventive counseling 

indivE

99402Preventive counseling 

indivE

99403Preventive counseling 

indivE

99404Preventive counseling 

indivE

99406Behav chng smoking 3-10 

minX00310.2941$20.42.$4.09

99407Behav chng smoking > 10 

minX00310.2941$20.42.$4.09

99408Audit/dast 15-30 minE 

99409Audit/dast over 30 

minE

99411Preventive counseling 

groupE

99412Preventive counseling 

groupE

99420Health risk assessment 

testE

99429Unlisted preventive 

serviceE

99441Phone e/m by phys 5-10 

minE

99442Phone e/m by phys 11-20 

minE

99443Phone e/m by phys 21-30 

minE
99444Online e/m by 

physE

99450Basic life disability 

examE

99455Work related disability 

examB

99456Disability 

examinationB

99460Init nb em per day 

hospV06051.0430$72.41.$14.49

99461Init nb em per day 

non-facM

99462Sbsq nb em per day 

hospC

99463Same day nb 

dischargeV06051.0430$72.41.$14.49

99464Attendance at 

deliveryN

99465Nb 

resuscitationS00942.2773$158.09$44.32$31.62

99466Ped crit care 

transportN

99467Ped crit care transport 

addlN

99468Neonate crit care 

initialC

99469Neonate crit care 

subsqC

99471Ped critical care 

initialC

99472Ped critical care 

subsqC

99475Ped crit care age 2-5 

initC

99476Ped crit care age 2-5 

subsqC

99477Init day hosp neonate 

careC

99478Ic lbw inf < 1500 gm 

subsqC

99479Ic lbw inf 1500-2500 g 

subsqC
99480Ic inf pbw 2501-5000 g 

subsqC

99499Unlisted e&m 

serviceB

99500Home visit 

prenatalE

99501Home visit 

postnatalE

99502Home visit nb 

careE

99503Home visit resp 

therapyE

99504Home visit mech 

ventilatorE

99505Home visit stoma 

careE

99506Home visit im 

injectionE

99507Home visit cath 

maintainE

99509Home visit day life 

activityE

99510Home visit sing/m/fam 

counsE

99511Home visit fecal/enema 

mgmtE

99512Home visit for 

hemodialysisE

99600Home visit 

nosE

99601Home infusion/visit 2 

hrsE

99602Home infusion each addtl 

hrE

99605Mtms by pharm np 15 

minE

99606Mtms by pharm est 15 

minE

99607Mtms by pharm addl 15 

minE

0001FHeart failure 

compositeE

0005FOsteoarthritis 

compositeE
0012FCap bacterial 

assessE

0014FComp preop assess cat 

surgE

0015FMelan follow-up 

completeE

0019TExtracorp shock wv tx ms nosA 

0030TAntiprothrombin 

antibodyA

0042TCt perfusion w/contrast 

cbfN

0048TImplant ventricular 

deviceC

0050TRemoval circulation 

assistC

0051TImplant total heart 

systemC

0052TReplace component heart 

systC

0053TReplace component heart 

systC

0054TBone surgery using 

computerN

0055TBone surgery using 

computerN

0058TCryopreservation ovary 

tissX03440.8204$56.95$15.56$11.39

0059TCryopreservation 

oocyteX03440.8204$56.95$15.56$11.39

0071TU/s leiomyomata ablate 

<200S006746.8279"$3,250.79".$650.16

0072TU/s leiomyomata ablate 

>200S006746.8279"$3,250.79".$650.16

0073TDelivery comp 

imrtS04126.4422$447.22.$89.45

0075TPerq stent/chest vert 

artC

0076TS&i stent/chest vert 

artC

0078TEndovasc aort repr 
w/deviceC

0079TEndovasc visc extnsn 

reprC

0080TEndovasc aort repr rad 

s&iC

0081TEndovasc visc extnsn 

s&iC

0085TBreath test heart 

rejectE

0092TArtific disc 

addlC

0095TArtific diskectomy addlC 

0098TRev artific disc 

addlC

0099TImplant corneal 

ringCHT023425.2649"$1,753.89"$511.31$350.78

0100TProsth retina 

receive&genT067241.3248"$2,868.77".$573.76

0101TExtracorp shockwv tx hi 

enrgT005032.4101"$2,249.91".$449.99

0102TExtracorp shockwv tx 

anesthT005032.4101"$2,249.91".$449.99

0103THolotranscobalaminA

0106TTouch quant sensory testX 

03410.0776$5.39$2.02$1.08

0107TVibrate quant sensory testX 

03410.0776$5.39$2.02$1.08

0108TCool quant sensory testX 

03410.0776$5.39$2.02$1.08

0109THeat quant sensory testX 

03410.0776$5.39$2.02$1.08

0110TNos quant sensory 

testX03410.0776$5.39$2.02$1.08

0111TRbc membranes fatty 

acidsA

0123TScleral 
fistulizationT023425.2649"$1,753.89"$511.31$350.78

0124TConjunctival drug 

placementT02322.9435$204.34$42.27$40.87

0126TChd risk imt 

studyQ103400.6739$46.78.$9.36

0141TPerq islet 

transplantE

0142TOpen islet 

transplantE

0143TLaparoscopic islet 

transplntE

0155TLap impl gast curve 

electrdT013039.0865"$2,713.38"$659.53$542.68

0156TLap remv gast curve 

electrdT013039.0865"$2,713.38"$659.53$542.68

0157TOpen impl gast curve 

electrdC

0158TOpen remv gast curve 

electrdC

0159TCad breast 

mriN

0163TLumb artif diskectomy 

addlC

0164TRemove lumb artif disc 

addlC

0165TRevise lumb artif disc 

addlC

0166TTcath vsd close w/o 

bypassC

0167TTcath vsd close 

w/bypassC

0168TRhinophototx light app bilatT 

02513.3531$232.77.$46.56

0169TPlace stereo cath 

brainC

0171TLumbar spine proces 

distractT005287.5671"$6,078.91"."$1,215.79"

0172TLumbar spine process 

addlT005287.5671"$6,078.91"."$1,215.79"
0173TIop monit io 

pressureN

0174TCad cxr with 

interpN

0175TCad cxr 

remoteN

0178T64 lead ecg w/i&rB 

0179T64 lead ecg 

w/tracingX01002.5348$175.97$40.87$35.20

0180T64 lead ecg w/i&r onlyB 

0181TCorneal 

hysteresisS02300.6929$48.10.$9.62

0182THdr elect 

brachytherapyS03139.8659$684.89$258.98$136.98

0183TWound 

ultrasoundT00151.4936$103.69.$20.74

0184TExc rectal tumor 

endoscopicC

0185TComptr probability 

analysisN

0186TSuprachoroidal drug 

deliveryT023722.7865"$1,581.84".$316.37

0188TVideoconf crit care 74 

minM

0189TVideoconf crit care addl 

30M

0190TPlace intraoc radiation 

srcT023722.7865"$1,581.84".$316.37

0191TInsert ant segment drain 

intT067341.7832"$2,900.59"$632.65$580.12

0192TInsert ant segment drain 

extT067341.7832"$2,900.59"$632.65$580.12

0195TArthrod presac 

interbodyC

0196TArthrod presac interbody 

eacC
0197TIntrafraction track 

motionN

0198TOcular blood flow 

measureS02300.6929$48.10.$9.62

0199TPhysiologic tremor 

recordS02150.6352$44.10.$8.82

0200TPerq sacral augmt unilat injCH 

T005032.4101"$2,249.91".$449.99

0201TPerq sacral augmt bilat 

injT005032.4101"$2,249.91".$449.99

0202TPost vert arthrplst 1 

lumbarC

0205TInirs each vessel 

add-onN

0206TRemote algorithm analys 

ecgQ103400.6739$46.78.$9.36

0207TClear eyelid gland 

w/heatS02300.6929$48.10.$9.62

0208TAudiometry air 

onlyX00350.2717$18.86.$3.78

0209TAudiometry air & 

boneX00350.2717$18.86.$3.78

0210TSpeech audiometry 

thresholdX00350.2717$18.86.$3.78

0211TSpeech audiom thresh & 

recogX00350.2717$18.86.$3.78

0212TCompre audiometry 

evaluationCHX03651.2340$85.66$18.14$17.14

0213TNjx paravert w/us 

cer/thorT02077.5480$523.98.$104.80

0214TNjx paravert w/us 

cer/thorT02042.7693$192.24$40.13$38.45

0215TNjx paravert w/us 

cer/thorT02042.7693$192.24$40.13$38.45

0216TNjx paravert w/us 
lumb/sacT02077.5480$523.98.$104.80

0217TNjx paravert w/us 

lumb/sacT02042.7693$192.24$40.13$38.45

0218TNjx paravert w/us 

lumb/sacT02042.7693$192.24$40.13$38.45

0219TPlmt post facet implt 

cervC

0220TPlmt post facet implt 

thorC

0221TPlmt post facet implt 

lumbT005032.4101"$2,249.91".$449.99

0222TPlmt post facet implt 

addlT005032.4101"$2,249.91".$449.99

0223TAcoustic ecg 

w/i&rS00990.3895$27.04.$5.41

0224TAcoustic ecg 1+ 

analysisS06900.5148$35.74$8.67$7.15

0225TAcoustic ecg analy & 

reprogS06900.5148$35.74$8.67$7.15

0226TAnoscopy hra w/spec 

collectX03400.6739$46.78.$9.36

0227TAnoscopy hra 

w/biopsyT01466.3038$437.61.$87.53

0228TNjx tfrml eprl w/us 

cer/thorT02077.5480$523.98.$104.80

0229TNjx tfrml eprl w/us 

cer/thorT02063.9371$273.31.$54.67

0230TNjx tfrml eprl w/us 

lumb/sacT02077.5480$523.98.$104.80

0231TNjx tfrml eprl w/us 

lumb/sacT02063.9371$273.31.$54.67

0232TNjx platelet 

plasmaX03400.6739$46.78.$9.36

0233TSkin glycation 
spectroscopyA

0234TTrluml perip athrc renal 

artT0082104.8857"$7,281.17"."$1,456.24"

0235TTrluml perip athrc 

visceralC

0236TTrluml perip athrc abd 

aortaT0082104.8857"$7,281.17"."$1,456.24"

0237TTrluml perip athrc 

brchiocphT0082104.8857"$7,281.17"."$1,456.24"

0238TTrluml perip athrc iliac 

artT0082104.8857"$7,281.17"."$1,456.24"

0239TBioimpedance 

spectroscopyS00990.3895$27.04.$5.41

0240TEsoph motility 3d 

topographyX03614.1026$284.80$83.23$56.96

0241TEsoph motility 

w/stim/perfX03614.1026$284.80$83.23$56.96

0242TGi tract transit & pres 

measX03614.1026$284.80$83.23$56.96

0243TIntm msr bronchodil 

wheezeS00781.4008$97.24.$19.45

0244TCont msr bronchodil 

wheezeX03692.6420$183.41$37.27$36.69

0245TOpn tx rib fx 1-2 

ribsT006226.2376"$1,821.41"$371.33$364.29

0246TOpn tx rib fx 3-4 

ribsT006226.2376"$1,821.41"$371.33$364.29

0247TOpn tx rib fx 5-6 

ribsT006226.2376"$1,821.41"$371.33$364.29

0248TOpn tx rib fx 7+ 

ribsT006226.2376"$1,821.41"$371.33$364.29

0249TLigation hemorrhoid 

w/usT015516.0235"$1,112.35".$222.47

0250TInsert bronchial 
valveT041529.1250"$2,021.86"$459.92$404.38

0251TRemov bronchial valve 

addlT007610.4123$722.82$189.71$144.57

0252TBronchscpc rmvl bronch 

valveT007610.4123$722.82$189.71$144.57

0253TInsert aqueous drain 

deviceT023425.2649"$1,753.89"$511.31$350.78

0254TEvasc rpr iliac art 

bifurC

0255TEvasc rpr iliac art bifr 

s&iC

0256TEvasc aortic hrt 

valveC

0257TOpn tthrc aortic hrt 

valveC

0258TAortic hrt valv w/o card 

bypC

0259TAortic hrt valve w/card 

bypC

0260THypthrm bdy neonate 

28d/<N

0261THypthrm head neonate 

28d/<N

0500FInitial prenatal care 

visitE

0501FPrenatal flow 

sheetE

0502FSubsequent prenatal 

careE

0503FPostpartum care 

visitE

0505FHemodialysis plan docdM 

0507FPeriton dialysis plan docdM 

0509FUrine incon plan docdM 

0513FElev bp plan of care docdM 

0514FCare plan hgb docd esa ptM 
0516FAnemia plan of care 

docdE

0517FGlaucoma plan of care docdM 

0518FFall plan of care docdM 

0519FPland chemo docd b/4 

txmntE

0520FRad dos limts b/4 3d radM 

0521FPlan of care 4 pain docdM 

0525FInitial visit for 

episodeE

0526FSubs visit for episodeM 

0528FRcmnd flw-up 10 yrs 

docdE

0529FIntrvl 3+yrs pts clnscp docdM 

0535FDyspnea mngmnt plan 

docdE

0540FGluco mngmnt plan docdM 

0545FFollow up care plan mdd 

docdE

0575FHIV rna plan care docdM 

1000FTobacco use 

assessedE

1002FAssess anginal symptom/levelM 

1003FLevel of activity 

assessE

1004FClin symp vol ovrld 

assessE

1005FAsthma symptoms evaluateM 

1006FOsteoarthritis assessM 

1007FAnti-inflm/anlgsc otc assessM 

1008FGi/renal risk 

assessE
1015FCopd symptoms 

assessE

1018FAssess dyspnea not 

presentE

1019FAssess dyspnea 

presentE

1022FPneumo imm status 

assessE

1026FCo-morbid condition 

assessE

1030FInfluenza imm status 

assessE

1034FCurrent tobacco 

smokerE

1035FSmokeless tobacco 

userE

1036FTobacco non-userM 

1038FPersistent asthmaM 

1039FIntermittent asthmaM 

1040FDsm-iv info mdd docdM 

1050FHistory of mole 

changesE

1055FVisual funct status 

assessE

1060FDoc perm/cont/parox atr 

fibE

1061FDoc lack perm+cont+parox 

fibE

1065FIschm stroke symp lt3 

hrsb/4E

1066FIschm stroke symp ge3 

hrsb/4E

1070FAlarm symp 

assessed-absentE

1071FAlarm symp assessed-1+ 

prsntE

1090FPres/absn urine incon assessM 

1091FUrine incon characterizedM 
1100FPtfalls assess-docd ge2+/yrM 

1101FPt falls assess-docd le1/yrM 

1110FPt lft inpt fac w/in 60 daysM 

1111FDschrg med/current med mergeM 

1116FAuric/peri pain assessedM 

1118FGERD symps assessed 12 

monthE

1119FInit eval for conditionM 

1121FSubs eval for conditionM 

1123FAcp discuss/dscn mkr docdM 

1124FAcp discuss-no dscnmkr docdM 

1125FAmnt pain noted pain prsntM 

1126FAmnt pain noted none prsntM 

1130FBk pain + fxn assessedM 

1134FEpsd bk pain for =< 6 

wksE

1135FEpsd bk pain for > 6 

wksE

1136FEpsd bk pain for <= 12 

wksE

1137FEpsd bk pain for > 12 

wksE

1150FDoc pt rsk death w/in 

1yrE

1151FDoc no pt rsk death w/in 

1yrE

1152FDoc advncd dis comfort 

1stE

1153FDoc advncd dis cmfrt not 

1stE

1157FAdvnc care plan in 

rcrdE
1158FAdvnc care plan tlk docdM 

1159FMed list docd in 

rcrdE

1160FRvw meds by rx/dr in 

rcrdE

1170FFxnl status assessedM 

1180FThromboemb risk 

assessedE

1200FSeizure type& frequ 

docdE

1205FEPI etiol synd rvwd and 

docdE

1220FPt screened for 

depressionE

1400FPrkns diag 

rviewedE

2000FBlood pressure measureM 

2001FWeight 

recordE

2002FClin sign vol ovrld 

assessE

2004FInitial exam involved 

jointsE

2010FVital signs recordedM 

2014FMental status assessM 

2018FHydration status 

assessE

2019FDilated macul exam doneM 

2020FDilated fundus eval 

doneE

2021FDilat macul+ exam doneM 

2022FDil retina exam interp revM 

2024F7 field photo interp doc revM 

2026FEye image valid to dx revM 
2027FOptic nerve head eval doneM 

2028FFoot exam performedM 

2029FComplete phys skin exam 

doneE

2030FH2o stat docd 

normalE

2031FH2o stat docd 

dehydratedE

2035FTymp memb motion examdM 

2040FBk pn xm on init visit dateM 

2044FDoc mntl tst b/4 bk 

trxmntE

2050FWound char size etc docdE 

2060FPt talk eval hlthwkr re 

mddE

3006FCxr doc 

revE

3008FBody mass index 

docdE

3011FLipid panel doc 

revE

3014FScreen mammo doc revM 

3015FCerv cancer screen 

docdE

3016FPt scrnd unhlthy OH useM 

3017FColorectal ca screen doc revM 

3018FPre-prxd rsk et al docdE 

3020FLvf assessM 

3021FLvef mod/sever deprs systM 

3022FLvef >=40% systolicM 

3023FSpirom doc revM 
3025FSpirom fev/fvc<70% w/copdM 

3027FSpirom fev/fvc>=70%/w/o copdM 

3028FO2 saturation doc revM 

3035FO2 saturation<=88% /pao<=55E 

3037FO2 saturation> 88% /pao>55E 

3038FPulm fx w/in 12 mon b/4 surgM 

3040FFev<40% predicted valueE 

3042FFev>=40% predicted valueE 

3044FHg a1c level lt 7.0%M 

3045FHg a1c level 7.0-9.0%M 

3046FHemoglobin a1c level > 9.0%M 

3048FLdl-c <100 mg/dlM 

3049FLdl-c 100-129 mg/dlM 

3050FLdl-c >= 130 mg/dlM 

3060FPos microalbuminuria revM 

3061FNeg microalbuminuria revM 

3062FPos macroalbuminuria revM 

3066FNephropathy doc txM 

3072FLow risk for retinopathyM 

3073FPre-surg eye measures docdE 

3074FSyst bp lt 130 mm hgM 

3075FSyst bp ge 130 - 139mm hgM 
3077FSyst bp >= 140 mm hgM 

3078FDiast bp < 80 mm hgM 

3079FDiast bp 80-89 mm hgM 

3080FDiast bp >= 90 mm hgM 

3082FKt/v <1.2M 

3083FKt/v > 1.2 <1.7M 

3084FKt/v ge 1.7M 

3085FSuicide risk assessedM 

3088FMdd mildE 

3089FMdd moderateE 

3090FMdd severe w/o psychE 

3091FMdd severe w/psychE 

3092FMdd in remissionM 

3093FDoc new diag 1st/addl mddE 

3095FCentral dexa results docdM 

3096FCentral dexa orderedM 

3100FImage test ref carot diamM 

3110FPres/absn hmrhg/lesion docdM 

3111FCt/mri brain done w/in 24hrsM 

3112FCt/mri brain done >24 hrsM 

3120F12-lead ecg performedM 

3130FUpper gi endoscopy performedE 
3132FDoc ref upper gi endoscopyE 

3140FUpper gi endo shows barrttsE 

3141FUpper gi endo not barrttsE 

3142FBarium swallow test orderedE 

3150FForceps esoph biopsy doneE 

3155FCytogen test marrow b/4 txM 

3160FDoc fe+ stores b/4 epo thxM 

3170FFlow cyto done b/4 txM 

3200FBarium swallow test not reqE 

3210FGrp a strep test performedM 

3215FPt immunity to hep a docdM 

3216FPt immunity to hep b docdM 

3218FRna tstng hep c docd doneM 

3220FHep c quant rna tstng docdM 

3230FNote hring tst w/in 6 monE 

3250FNonprim loc anat bx site tumM 

3260FPt cat/pn cat/hist grd docdM 

3265FRna tstng hepc vir ord/docdM 

3266FHepc gn tstng docd b/4txmntM 

3268FPsa/t/glsc docd b/4 txmntE 

3269FBone scn b/4 txmnt/aftr DxM 

3270FNo bone scn b/4 txmnt/aftrDxM 
3271FLow risk prostate cancerM 

3272FMed risk prostate cancerM 

3273FHigh risk prostate cancerM 

3274FProst Cncr rsk not lw/md/hghM 

3278FSerum lvls CA/iPTH/lpd ordM 

3279FHgb lvl >/= 13 g/dlM 

3280FHgb lvl 11-12.9 g/dLM 

3281FHgb lvl < 11 g/dlM 

3284FIop down >15% of pre-svc lvlM 

3285FIOP down <15% of pre-svc lvlM 

3288FFall risk assessment docdM 

3290FPt=D(Rh)- and unsensitizedE 

3291FPt=d(rh)+ or sensitizedE 

3292FHiv tstng asked/docd/revwdE 

3293FAbo rh blood typing 

docdE

3294FGrp b strep screening 

docdE

3300FAJCC stage docd b/4 thxpyM 

3301FCancer stage docd metastM 

3315FEr+ or pr+ breast cancerM 

3316FER- or PR- breast cancerM 

3317FPath rpt malig cancer docdE 

3318FPath rpt malig cancer docdE 
3319FX-ray/ct/ultrsnd et al ordM 

3320FNo xray/ct/ et al orddM 

3321FAJCC cncr 0/IA melan docdM 

3322FMelanoma>ajcc stage 0 or iaM 

3323FClin node stgng docdb/4 surgM 

3324FMri ct scan ord rvwd 

rqstdE

3325FPreop asses 4 cataract surgE 

3328FPrfrmnc docd 2 wks b/4 surgM 

3330FImaging study ordered (bkp)E 

3331FBk imaging tst not orderedE 

3340FMammo assess inc xray docdM 

3341FMammo assess negative docdM 

3342FMammo assess bengn docdM 

3343FMammo probably bengn docdM 

3344FMammo assess susp docdM 

3345FMammo assess hghlymalig docM 

3350FMammo bx proven malig docdM 

3351FNeg scrn dep symp by 

deptoolE

3352FNo sig dep symp by dep 

toolE

3353FMild-mod dep symp by 

deptoolE

3354FClin sig dep sym by dep 

toolE

3370FAJCC brst cncr stage 0 docdM 
3372FAjcc brst cncr stage 1 docdM 

3374FAjcc brst cncr stage 1 docdM 

3376FAJCC brstcncr stage 2 docdM 

3378FAJCC brstcncr stage 3 docdM 

3380FAJCC brstcncr stage 4 docdM 

3382FAJCC cln cncr stage 0 docdM 

3384FAJCC cln cncr stage 1 docdM 

3386FAJCC cln cncr stage 2 docdM 

3388FAJCC cln cncr stage 3 docdM 

3390FAJCC cln cncr stage 4 docdM 

3450FDyspnea scrnd no-mild dyspE 

3451FDyspnea scrnd mod-high dyspE 

3452FDyspnea not screenedE 

3455FTB scrng done-interpd 6monM 

3470FRa disease activity lowM 

3471FRa disease activity modM 

3472FRa disease activity highM 

3475FDisease progn RA poor docdM 

3476FDisease progn RA good docdM 

3490FHistory aids-defining condM 

3491FHIV unsure baby of HIV+momsE 

3492FHistory cd4+ cell count <350M 
3493FNo hist cd4+ cell count<350M 

3494FCD4+cell count <200cells/mm3M 

3495FCd4+cell cnt 200-499 cellsM 

3496FCd4+ cell count + 500 cellsM 

3497FCD4+ cell percentage <15%E 

3498FCd4+ cell % >=15% (hiv)E 

3500FCd4+cell cnt/% docd as doneM 

3502FHIV rna vrl ld <lmts quantifM 

3503FHIV rna vrl ldnot<lmts quntfM 

3510FDoc tb scrng-rslts interpdE 

3511FChlmyd/gonrh tsts docd doneM 

3512FSyph scrng docd as doneM 

3513FHep B scrng docd as doneE 

3514FHep C scrng docd as doneE 

3515FPt has docd immun to hep CE 

3550FLow rsk thromboembolismE 

3551FIntrmed rsk thromboembolismE 

3552FHgh risk for thromboembolismE 

3555FPt inr measurement performedE 

3570FRprt bone scint xref w xrayM 

3572FPt consid poss risk fxE 

3573FPt not consid poss risk fxE 
3650FEeg ordered rvwd reqstdE 

3700FPsych disorders assessedE 

3720FCognit impairment assessedE 

4000FTobacco use txmnt counselingM 

4001FTobacco use txmnt pharmacolM 

4002FStatin therapy rxM 

4003FPt ed write/oral pts w/ hfM 

4004FPt tobacco screen rcvd tlkM 

4005FPharm thx for op rxdM 

4006FBeta-blocker therapy rxM 

4009FAce/arb inhibitor therapy rxM 

4011FOral antiplatelet therapy rxM 

4012FWarfarin therapy rxM 

4014FWritten discharge instr prvdE 

4015FPersist asthma medicine ctrlM 

4016FAnti-inflm/anlgsc agent rxE 

4017FGi prophylaxis for nsaid rxE 

4018FTherapy exercise joint rxE 

4019FDoc recpt counsl vit d/calc+E 

4025FInhaled bronchodilator rxM 

4030FOxygen therapy rxE 

4033FPulmonary rehab recE 
4035FInfluenza imm recE 

4037FInfluenza imm order/adminM 

4040FPneumoc vac/admin/rcvdM 

4041FDoc order cefazolin/cefuroxM 

4042FDoc antibio not givenM 

4043FDoc order given stop antibioM 

4044FDoc order given vte prophylxM 

4045FEmpiric antibiotic rxM 

4046FDoc antibio given b/4 surgM 

4047FDoc antibio given b/4 surgM 

4048FDoc antibio given b/4 surgM 

4049FDoc order given stop antibioM 

4050FHt care plan docM 

4051FReferred for an AV fistulaM 

4052FHemodialysis via AV fistulaE 

4053FHemodialysis via AV graftE 

4054FHemodialysis via catheterE 

4055FPt rcvng periton dialysisE 

4056FApprop oral rehyd recommdE 

4058FPed gastro ed given caregvrE 

4060FPsych svcs providedE 

4062FPt referral psych docdE 
4063FAntidepres rxthxpy not 

rxdE

4064FAntidepressant rxE 

4065FAntipsychotic rxE 

4066FECT providedE 

4067FPt referral for ect docdE 

4070FDvt prophylx recvd day 2M 

4073FOral antiplat thx rx dischrgM 

4075FAnticoag thx rx at dischrgM 

4077FDoc t-pa admin consideredE 

4079FDoc rehab svcs consideredM 

4084FAspirin recvd w/in 24 hrsM 

4090FPt rcvng epo thxpyM 

4095FPt not rcvng epo thxpyM 

4100FBiphos thxpy vein ord/recvdM 

4110FInt mam art used for cabgM 

4115FBeta blckr admin w/in 24 hrsM 

4120FAntibiot rxd/givenM 

4124FAntibiot not rxd/givenM 

4130FTopical prep rx aoeM 

4131FSyst antimicrobial thx rxM 

4132FNo syst antimicrobial thx rxM 

4133FAntihist/decong rx/recomE 
4134FNo antihist/decong rx/recomE 

4135FSystemic corticosteroids rxE 

4136FSyst corticosteroids not rxE 

4148FHep A vac injxn admin/recvdM 

4149FHep B vac injxn admin/recvdM 

4150FPt recvng antivir txmnt hepcM 

4151FPt not recvng antiv hep cM 

4153FCombo pegintf/rib rxM 

4155FHep A vac series prev recvdE 

4157FHep B vac series prev recvdE 

4158FPt edu re alcoh drnkng doneM 

4159FContrcp talk b/4 antiv txmntM 

4163FPt couns 4 txmnt opt prostE 

4164FAdjv hrmnl thxpy rxdM 

4165F3d-crt/imrt receivedM 

4167FHd bed tilted 1st day ventE 

4168FPt care icu&vent w/in 24hrsE 

4169FNo pt care ICU/vent in 24hrsE 

4171FPt rcvng esa thxpyM 

4172FPt not rcvng esa thxpyM 

4174FCouns potent glauc impctE 

4175FVis of >= 20/40 w/in 90 daysM 
4176FTalk re uv light pt/crgvrE 

4177FTalk pt/crgvr re areds prevM 

4178FAntid glbln rcvd w/in 26wksE 

4179FTamoxifen/AI prescribedM 

4180FAdjv thxpyrxd/rcvd colon caM 

4181FConformal radn thxpy rcvdE 

4182FNo conformal radn thxpyE 

4185FContinuous ppi or h2ra rcvdE 

4186FNo cont ppi or h2ra rcvdE 

4187FAnti rheum drugthxpyrxd/gvnM 

4188FApprop ACE/ARB tstng doneE 

4189FApprop digoxin tstng doneE 

4190FApprop diuretic tstng doneE 

4191FApprop anticonvuls tstngE 

4192FPt not rcvng glucoco thxpyM 

4193FPt rcvng<10mg daily prednisoM 

4194FPt rcvng>10mg daily prednisoM 

4195FPt rcvng anti-rheum thxpy RAM 

4196FPtnot rcvng anti-rhm thxpyRAM 

4200FExternal beam to prost onlyM 

4201FExtrnl beam other than prostM 

4210FACE/ARB thxpy for >= 6 monsE 
4220FDigoxin thxpy for >= 6 monsE 

4221FDiuretic thxpy for >= 6 monsE 

4230FAnticonv thxpy for >= 6 monsE 

4240FInstr xrcz 4bk pn >12 weeksE 

4242FSprvsd xrcz bk pn >12 weeksE 

4245FPt instr nrml lifestM 

4248FPt instr no bd rest>= 4 daysM 

4250FWrmng 4 surg normothermiaM 

4255FAnesth 60+ min as docdM 

4256FAnesthe <60 min as docdM 

4260FWound srfc culturetech usedE 

4261FTech other than surfc cultrE 

4265FWet-dry dressings rx recmdE 

4266FNo wet-dry drssings rx recmdE 

4267FComprssion thxpy prescribedM 

4268FPt ed re comp thxpy rcvdE 

4269FAppropos mthd offloading RxdE 

4270FPt rcvng anti r-viral thxpyM 

4271FPt rcvng anti r-viral thxpyM 

4274FFlu immuno admind rcvdM 

4275FHep b vac inj admin/rcvdE 

4276FPotent antivir thxpy RxdM 
4279FPCP prophylaxis RxdE 

4280FPCP prophylax Rxd 3mon low %M 

4290FPt scrned for inj drug useM 

4293FPt scrnd hgh-risk sex behavM 

4300FPt rcvng warf thxpyE 

4301FPt not rcvng warf thxpyE 

4305FPt ed re ft care inspct rcvdE 

4306FPt tlk psych & Rx opd addicE 

4320FPt talk psychsoc&rx oh dpndE 

4324FPt queried prkns complicE 

4325FMed txmnt options rvwd w/ptE 

4326FPt asked re symp auto dysfxnE 

4328FPt asked re sleep disturbE 

4330FCnslng epi spec sfty 

issuesE

4340FCnslng chldbrng women 

epiE

4400FRehab thxpy options w/ptE 

5005FPt counsld on exam for molesE 

5010FMacul result to phy mng dmM 

5015FDoc fx & test/txmnt for opM 

5020FTxmnts 2 main Dr by 1 monE 

5050FPlan 2 main dr by 1 monthM 

5060FFndngs mammo 2pt w/in 3 daysE 
5062FMammo result com to pt 5 dayE 

5100FRsk fx ref w/n 24 hrs xrayE 

5200FEval appros surg thxpy 

epiE

6005FCare level rationale docE 

6010FDysphag test done b/4 eatingM 

6015FDysphag test done b/4 eatingM 

6020FNpo (nothing-mouth) orderedM 

6030FMax sterile barriers follwdM 

6040FAppro rad ds dvcs techs docdE 

6045FRadxps in end rprt4fluro pxdM 

6070FPt asked/cnsld aed 

effectsE

6080FPt/caregiver queried fallsE 

6090FPt/caregiver counsel safetyE 

7010FPt info into recall systemM 

7020FMammo assess cat in dbaseE 

7025FPt infosys alarm 4 nxt mammo M 

A0021Outside state ambulance 

servE

A0080Noninterest escort in non 

erE

A0090Interest escort in non 

erE

A0100Nonemergency transport 

taxiE

A0110Nonemergency transport 

busE

A0120Noner transport 

mini-busE
A0130Noner transport wheelch 

vanE

A0140Nonemergency transport 

airE

A0160Noner transport case 

workerE

A0170Transport parking 

fees/tollsE

A0180Noner transport lodgng 

recipE

A0190Noner transport meals 

recipE

A0200Noner transport lodgng 

escrtE

A0210Noner transport meals 

escortE

A0225Neonatal emergency 

transportE

A0380Basic life support 

mileageE

A0382Basic support routine 

supplsA

A0384Bls defibrillation 

suppliesA

A0390Advanced life support 

mileagE

A0392Als defibrillation 

suppliesA

A0394Als IV drug therapy 

suppliesA

A0396Als esophageal intub 

supplsA

A0398Als routine disposble 

supplsA

A0420Ambulance waiting 1/2 

hrA

A0422Ambulance 02 life 

sustainingA

A0424Extra ambulance 

attendantA

A0425Ground 

mileageA

A0426Als 

1A
A0427ALS1-emergencyA

A0428blsA

A0429BLS-emergencyA

A0430Fixed wing air 

transportA

A0431Rotary wing air 

transportA

A0432PI volunteer ambulance 

coA

A0433als 

2A

A0434Specialty care 

transportA

A0435Fixed wing air 

mileageA

A0436Rotary wing air 

mileageA

A0888Noncovered ambulance 

mileageE

A0998Ambulance 

response/treatmentE

A0999Unlisted ambulance 

serviceA

A42061 CC sterile 

syringe&needleE

A42072 CC sterile 

syringe&needleE

A42083 CC sterile 

syringe&needleE

A42095+ CC sterile 

syringe&needleE

A4210Nonneedle injection 

deviceE

A4211Supp for self-adm injectionsE 

A4212Non coring needle or 

styletB

A421320+ CC syringe 

onlyE

A4215Sterile 

needleE

A4216"Sterile water/saline, 10 

ml"A
A4217"Sterile water/saline, 500 

ml"A

A4218Sterile saline or waterN 

A4220Infusion pump refill 

kitN

A4221Maint drug infus cath per 

wkY

A4222Infusion supplies with 

pumpY

A4223Infusion supplies w/o 

pumpE

A4230Infus insulin pump non needlN 

A4231Infusion insulin pump needleN 

A4232Syringe w/needle insulin 

3ccE

A4233Alkalin batt for glucose 

monY

A4234J-cell batt for glucose 

monY

A4235Lithium batt for glucose 

monY

A4236Silvr oxide batt glucose 

monY

A4244Alcohol or peroxide per 

pintE

A4245Alcohol wipes per 

boxE

A4246Betadine/phisohex 

solutionE

A4247Betadine/iodine 

swabs/wipesE

A4248Chlorhexidine 

antiseptN

A4250Urine reagent 

strips/tabletsE

A4252Blood ketone test or 

stripE

A4253Blood glucose/reagent 

stripsY

A4255Glucose monitor 

platformsY
A4256Calibrator 

solution/chipsY

A4257Replace Lensshield 

CartridgeY

A4258Lancet device 

eachY

A4259Lancets per 

boxY

A4261Cervical cap 

contraceptiveE

A4262Temporary tear duct 

plugN

A4263Permanent tear duct 

plugN

A4264Intratubal occlusion 

deviceE

A4265ParaffinY

A4266DiaphragmE

A4267Male 

condomE

A4268Female 

condomE

A4269SpermicideE

A4270Disposable endoscope sheathN 

A4280Brst prsths adhsv 

attchmntA

A4281Replacement breastpump 

tubeE

A4282Replacement breastpump 

adptE

A4283Replacement breastpump 

capE

A4284Replcmnt breast pump 

shieldE

A4285Replcmnt breast pump 

bottleE

A4286Replcmnt breastpump lok 

ringE

A4290Sacral nerve stim test 

leadB

A4300Cath impl vasc access 

portalN
A4301Implantable access syst 

percN

A4305Drug delivery system >=50 

MLN

A4306Drug delivery system <=50 

mlN

A4310Insert tray w/o 

bag/cathA

A4311Catheter w/o bag 2-way 

latexA

A4312Cath w/o bag 2-way 

siliconeA

A4313Catheter w/bag 

3-wayA

A4314Cath w/drainage 2-way 

latexA

A4315Cath w/drainage 2-way 

silcneA

A4316Cath w/drainage 

3-wayA

A4320Irrigation 

trayA

A4321Cath therapeutic irrig 

agentA

A4322Irrigation 

syringeA

A4326Male external 

catheterA

A4327Fem urinary collect dev 

cupA

A4328Fem urinary collect 

pouchA

A4330Stool collection 

pouchA

A4331Extension drainage 

tubingA

A4332Lube sterile 

packetA

A4333Urinary cath anchor 

deviceA

A4334Urinary cath leg 

strapA

A4335Incontinence 

supplyA
A4336Urethral 

insertA

A4338Indwelling catheter 

latexA

A4340Indwelling catheter 

specialA

A4344Cath indw foley 2 way 

silicnA

A4346Cath indw foley 3 

wayA

A4349Disposable male external 

catA

A4351Straight tip urine 

catheterA

A4352Coude tip urinary 

catheterA

A4353Intermittent urinary 

cathA

A4354Cath insertion tray 

w/bagA

A4355Bladder irrigation 

tubingA

A4356Ext ureth clmp or compr 

dvcA

A4357Bedside drainage 

bagA

A4358Urinary leg or abdomen 

bagA

A4360Disposable ext urethral 

devA

A4361Ostomy face 

plateA

A4362Solid skin 

barrierA

A4363"Ostomy clamp, 

replacement"A

A4364"Adhesive, liquid or 

equal"A

A4366Ostomy 

ventA

A4367Ostomy 

beltA

A4368Ostomy 

filterA
A4369Skin barrier liquid per 

ozA

A4371Skin barrier powder per 

ozA

A4372Skin barrier solid 4x4 

equivA

A4373Skin barrier with 

flangeA

A4375Drainable plastic pch w 

fcplA

A4376Drainable rubber pch w 

fcpltA

A4377Drainable plstic pch w/o 

fpA

A4378Drainable rubber pch w/o 

fpA

A4379Urinary plastic pouch w 

fcplA

A4380Urinary rubber pouch w 

fcpltA

A4381Urinary plastic pouch w/o 

fpA

A4382Urinary hvy plstc pch w/o 

fpA

A4383Urinary rubber pouch w/o 

fpA

A4384Ostomy faceplt/silicone 

ringA

A4385Ost skn barrier sld ext 

wearA

A4387Ost clsd pouch w att st 

barrA

A4388Drainable pch w ex wear 

barrA

A4389Drainable pch w st wear 

barrA

A4390Drainable pch ex wear 

convexA

A4391Urinary pouch w ex wear 

barrA

A4392Urinary pouch w st wear 

barrA

A4393Urine pch w ex wear bar 

convA
A4394Ostomy pouch liq 

deodorantA

A4395Ostomy pouch solid 

deodorantA

A4396Peristomal hernia supprt 

bltA

A4397Irrigation supply 

sleeveA

A4398Ostomy irrigation 

bagA

A4399Ostomy irrig cone/cath w 

brsA

A4400Ostomy irrigation 

setA

A4402Lubricant per 

ounceA

A4404Ostomy ring 

eachA

A4405Nonpectin based ostomy 

pasteA

A4406Pectin based ostomy 

pasteA

A4407"Ext wear ost skn barr 

<=4sq"""A

A4408"Ext wear ost skn barr 

>4sq"""A

A4409Ost skn barr convex <=4 sq 

iA

A4410Ost skn barr extnd >4 

sqA

A4411Ost skn barr extnd 

=4sqA

A4412Ost pouch drain high 

outputA

A44132 pc drainable ost 

pouchA

A4414Ost sknbar w/o conv<=4 sq 

inA

A4415Ost skn barr w/o conv >4 

sqiA

A4416Ost pch clsd w 

barrier/filtrA

A4417Ost pch w 

bar/bltinconv/fltrA
A4418Ost pch clsd w/o bar w 

filtrA

A4419Ost pch for bar w 

flange/fltA

A4420Ost pch clsd for bar w lk 

flA

A4421Ostomy supply 

miscE

A4422Ost pouch absorbent 

materialA

A4423Ost pch for bar w lk 

fl/fltrA

A4424Ost pch drain w bar & 

filterA

A4425Ost pch drain for barrier 

flA

A4426Ost pch drain 2 piece 

systemA

A4427Ost pch drain/barr lk 

flng/fA

A4428Urine ost pouch w 

faucet/tapA

A4429Urine ost pouch w 

bltinconvA

A4430Ost urine pch w b/bltin 

convA

A4431Ost pch urine w 

barrier/tapvA

A4432Os pch urine w 

bar/fange/tapA

A4433Urine ost pch bar w lock 

flnA

A4434Ost pch urine w lock 

flng/ftA

A4450Non-waterproof 

tapeA

A4452Waterproof 

tapeA

A4455Adhesive remover per 

ounceA

A4456"Adhesive remover, 

wipes"A

A4458Reusable enema 

bagE
A4461Surgicl dress hold 

non-reuseA

A4463Surgical dress holder 

reuseA

A4465Non-elastic extremity 

binderN

A4466Elastic 

garment/coveringE

A4470Gravlee jet 

washerN

A4480Vabra 

aspiratorN

A4481Tracheostoma 

filterA

A4483Moisture 

exchangerA

A4490Above knee surgical 

stockingE

A4495Thigh length surg 

stockingE

A4500Below knee surgical 

stockingE

A4510Full length surg 

stockingE

A4520Incontinence garment 

anytypeE

A4550Surgical 

traysB

A4554Disposable 

underpadsE

A4556"Electrodes, 

pair"Y

A4557"Lead wires, 

pair"Y

A4558Conductive gel or 

pasteY

A4559Coupling gel or 

pasteY

A4561"Pessary rubber, any 

type"N

A4562"Pessary, non rubber,any 

type"N

A4565SlingsN
A4566Should 

sling/vest/abrestrainE

A4570SplintE

A4575Hyperbaric o2 chamber 

dispsE

A4580Cast supplies 

(plaster)E

A4590Special casting 

materialE

A4595TENS suppl 2 lead per 

monthY

A4600"Sleeve, inter limb comp 

dev"Y

A4601"Lith ion batt, non-pros use 

"Y

A4604Tubing with heating 

elementY

A4605Trach suction cath close 

sysY

A4606Oxygen probe used w 

oximeterA

A4608Transtracheal oxygen 

cathY

A4611Heavy duty 

batteryY

A4612Battery 

cablesY

A4613Battery chargerY 

A4614Hand-held PEFR meterY 

A4615Cannula 

nasalY

A4616Tubing (oxygen) per 

footY

A4617Mouth 

pieceY

A4618Breathing 

circuitsY

A4619Face 

tentY

A4620Variable concentration 

maskY
A4623Tracheostomy inner 

cannulaA

A4624Tracheal suction 

tubeY

A4625Trach care kit for new 

trachA

A4626Tracheostomy cleaning 

brushA

A4627Spacer 

bag/reservoirE

A4628Oropharyngeal suction 

cathY

A4629Tracheostomy care 

kitA

A4630Repl bat t.e.n.s. own by 

ptY

A4633Uvl replacement 

bulbY

A4634Replacement bulb th 

lightboxA

A4635Underarm crutch 

padY

A4636Handgrip for cane 

etcY

A4637Repl tip 

cane/crutch/walkerY

A4638Repl batt pulse gen 

sysY

A4639Infrared ht sys replcmnt 

padY

A4640Alternating pressure 

padY

A4641Radiopharm dx agent 

nocN

A4642In111 

satumomabN

A4648Implantable tissue 

markerN

A4649Surgical 

suppliesN

A4650Implant radiation 

dosimeterN

A4651Calibrated microcap 

tubeA
A4652Microcapillary tube 

sealantA

A4653PD catheter anchor 

beltA

A4657Syringe w/wo 

needleN

A4660Sphyg/bp app w cuff and 

stetN

A4663Dialysis blood pressure 

cuffN

A4670"Automatic bp monitor, 

dial"E

A4671Disposable cycler 

setB

A4672"Drainage ext line, 

dialysis"B

A4673Ext line w easy lock 

connectB

A4674"Chem/antisept solution, 

8oz"B

A4680"Activated carbon filter, 

ea"N

A4690"Dialyzer, 

each"N

A4706Bicarbonate conc sol per 

galN

A4707Bicarbonate conc pow per 

pacN

A4708Acetate conc sol per 

gallonN

A4709Acid conc sol per 

gallonN

A4714Treated water per 

gallonN

A4719"""Y set"" 

tubing"N

A4720Dialysat sol fld vol > 

249ccN

A4721Dialysat sol fld vol > 

999ccN

A4722Dialys sol fld vol > 

1999ccN

A4723Dialys sol fld vol > 

2999ccN
A4724Dialys sol fld vol > 

3999ccN

A4725Dialys sol fld vol > 

4999ccN

A4726Dialys sol fld vol > 

5999ccN

A4728"Dialysate solution, 

non-dex"B

A4730"Fistula cannulation set, 

ea"N

A4736"Topical anesthetic, per 

gram"N

A4737Inj anesthetic per 10 

mlN

A4740Shunt 

accessoryN

A4750Art or venous blood 

tubingN

A4755Comb art/venous blood 

tubingN

A4760"Dialysate sol test kit, 

each"N

A4765Dialysate conc pow per 

packN

A4766Dialysate conc sol add 10 

mlN

A4770Blood collection 

tube/vacuumN

A4771Serum clotting time 

tubeN

A4772Blood glucose test 

stripsN

A4773Occult blood test 

stripsN

A4774Ammonia test 

stripsN

A4802Protamine sulfate per 50 

mgN

A4860Disposable catheter 

tipsN

A4870Plumb/elec wk hm hemo 

equipN

A4890Repair/maint cont hemo 

equipN
A4911Drain 

bag/bottleN

A4913Misc dialysis supplies 

nocN

A4918Venous pressure 

clampN

A4927Non-sterile 

glovesN

A4928Surgical 

maskN

A4929"Tourniquet for dialysis, 

ea"N

A4930"Sterile, gloves per 

pair"N

A4931Reusable oral 

thermometerN

A4932Reusable rectal 

thermometerE

A5051Pouch clsd w barr 

attachedA

A5052Clsd ostomy pouch w/o 

barrA

A5053Clsd ostomy pouch 

faceplateA

A5054Clsd ostomy pouch 

w/flangeA

A5055Stoma 

capA

A5061Pouch drainable w barrier 

atA

A5062Drnble ostomy pouch w/o 

barrA

A5063Drain ostomy pouch 

w/flangeA

A5071Urinary pouch 

w/barrierA

A5072Urinary pouch w/o 

barrierA

A5073Urinary pouch on barr 

w/flngA

A5081Continent stoma 

plugA

A5082Continent stoma 

catheterA
A5083Stoma absorptive 

coverA

A5093Ostomy accessory convex 

inseA

A5102Bedside drain btl w/wo 

tubeA

A5105Urinary 

suspensoryA

A5112Urinary leg 

bagA

A5113Latex leg 

strapA

A5114Foam/fabric leg 

strapA

A5120"Skin barrier, wipe or 

swab"A

A5121Solid skin barrier 

6x6A

A5122Solid skin barrier 

8x8A

A5126Disk/foam pad +oradhesiveA

A5131Appliance 

cleanerA

A5200Percutaneous catheter 

anchorA

A5500Diab shoe for density 

insertY

A5501Diabetic custom molded 

shoeY

A5503Diabetic shoe 

w/roller/rockrY

A5504Diabetic shoe with 

wedgeY

A5505Diab shoe w/metatarsal 

barY

A5506Diabetic shoe w/off set 

heelY

A5507Modification diabetic 

shoeY

A5508Diabetic deluxe 

shoeY

A5510Compression form shoe 

insertE
A5512Multi den insert direct formY 

A5513Multi den insert custom moldY 

A6000Wound warming wound 

coverE

A6010Collagen based wound 

fillerA

A6011Collagen gel/paste wound 

filA

A6021Collagen dressing <=16 sq 

inA

A6022Collagen drsg>16<=48 sq 

inA

A6023Collagen dressing >48 sq 

inA

A6024Collagen dsg wound 

fillerA

A6025"Silicone gel sheet, 

each"E

A6154Wound pouch 

eachA

A6196Alginate dressing <=16 sq 

inA

A6197Alginate drsg >16 <=48 sq 

inA

A6198alginate dressing > 48 sq 

inA

A6199Alginate drsg wound 

fillerA

A6203Composite drsg <= 16 sq 

inA

A6204Composite drsg >16<=48 sq 

inA

A6205Composite drsg > 48 sq 

inA

A6206Contact layer <= 16 sq 

inA

A6207Contact layer >16<= 48 sq 

inA

A6208Contact layer > 48 sq 

inA

A6209Foam drsg <=16 sq in w/o 

bdrA
A6210Foam drg >16<=48 sq in w/o 

bA

A6211Foam drg > 48 sq in w/o 

brdrA

A6212Foam drg <=16 sq in 

w/borderA

A6213Foam drg >16<=48 sq in 

w/bdrA

A6214Foam drg > 48 sq in 

w/borderA

A6215Foam dressing wound 

fillerA

A6216Non-sterile gauze<=16 sq 

inA

A6217Non-sterile gauze>16<=48 

sqA

A6218Non-sterile gauze > 48 sq 

inA

A6219Gauze <= 16 sq in 

w/borderA

A6220Gauze >16 <=48 sq in 

w/bordrA

A6221Gauze > 48 sq in 

w/borderA

A6222Gauze <=16 in no w/sal w/o 

bA

A6223Gauze >16<=48 no w/sal w/o 

bA

A6224Gauze > 48 in no w/sal w/o 

bA

A6228Gauze <= 16 sq in 

water/salA

A6229Gauze >16<=48 sq in 

watr/salA

A6230Gauze > 48 sq in 

water/salneA

A6231Hydrogel dsg<=16 sq 

inA

A6232Hydrogel dsg>16<=48 sq 

inA

A6233Hydrogel dressing >48 sq 

inA

A6234Hydrocolld drg <=16 w/o 

bdrA
A6235Hydrocolld drg >16<=48 w/o 

bA

A6236Hydrocolld drg > 48 in w/o 

bA

A6237Hydrocolld drg <=16 in 

w/bdrA

A6238Hydrocolld drg >16<=48 

w/bdrA

A6239Hydrocolld drg > 48 in 

w/bdrA

A6240Hydrocolld drg filler 

pasteA

A6241Hydrocolloid drg filler 

dryA

A6242Hydrogel drg <=16 in w/o 

bdrA

A6243Hydrogel drg >16<=48 w/o 

bdrA

A6244Hydrogel drg >48 in w/o 

bdrA

A6245Hydrogel drg <= 16 in 

w/bdrA

A6246Hydrogel drg >16<=48 in 

w/bA

A6247Hydrogel drg > 48 sq in 

w/bA

A6248Hydrogel drsg gel 

fillerA

A6250Skin seal protect 

moisturizrA

A6251Absorpt drg <=16 sq in w/o 

bA

A6252Absorpt drg >16 <=48 w/o 

bdrA

A6253Absorpt drg > 48 sq in w/o 

bA

A6254Absorpt drg <=16 sq in 

w/bdrA

A6255Absorpt drg >16<=48 in 

w/bdrA

A6256Absorpt drg > 48 sq in 

w/bdrA

A6257Transparent film <= 16 sq 

inA
A6258Transparent film >16<=48 

inA

A6259Transparent film > 48 sq 

inA

A6260Wound cleanser any 

type/sizeA

A6261Wound filler gel/paste 

/ozA

A6262Wound filler dry form / 

gramA

A6266Impreg gauze no 

h20/sal/yardA

A6402Sterile gauze <= 16 sq 

inA

A6403Sterile gauze>16 <= 48 sq 

inA

A6404Sterile gauze > 48 sq 

inA

A6407"Packing strips, 

non-impreg"A

A6410Sterile eye 

padA

A6411Non-sterile eye 

padA

A6412Occlusive eye 

patchA

A6413"Adhesive bandage, first-aid"E 

A6441"Pad band w>=3"" 

<5""/yd"A

A6442"Conform band n/s 

w<3""/yd"A

A6443"Conform band n/s 

w>=3""<5""/yd"A

A6444"Conform band n/s 

w>=5""/yd"A

A6445"Conform band s w 

<3""/yd"A

A6446"Conform band s w>=3"" 

<5""/yd"A

A6447"Conform band s w 

>=5""/yd"A

A6448"Lt compres band 

<3""/yd"A
A6449"Lt compres band >=3"" 

<5""/yd"A

A6450"Lt compres band 

>=5""/yd"A

A6451"Mod compres band 

w>=3""<5""/yd"A

A6452"High compres band 

w>=3""<5""yd"A

A6453"Self-adher band w 

<3""/yd"A

A6454"Self-adher band w>=3"" 

<5""/yd"A

A6455"Self-adher band 

>=5""/yd"A

A6456"Zinc paste band w 

>=3""<5""/yd"A

A6457Tubular 

dressingA

A6501Compres burngarment 

bodysuitA

A6502Compres burngarment 

chinstrpA

A6503Compres burngarment 

facehoodA

A6504Cmprsburngarment 

glove-wristA

A6505Cmprsburngarment 

glove-elbowA

A6506Cmprsburngrmnt 

glove-axillaA

A6507Cmprs burngarment 

foot-kneeA

A6508Cmprs burngarment 

foot-thighA

A6509Compres burn garment 

jacketA

A6510Compres burn garment 

leotardA

A6511Compres burn garment 

pantyA

A6512"Compres burn garment, 

noc"A

A6513Compress burn mask 

face/neckB
A6530Compression stocking 

BK18-30E

A6531Compression stocking 

BK30-40A

A6532Compression stocking 

BK40-50A

A6533Gc stocking thighlngth 

18-30E

A6534Gc stocking thighlngth 

30-40E

A6535Gc stocking thighlngth 

40-50E

A6536Gc stocking full lngth 

18-30E

A6537Gc stocking full lngth 

30-40E

A6538Gc stocking full lngth 

40-50E

A6539Gc stocking waistlngth 

18-30E

A6540Gc stocking waistlngth 

30-40E

A6541Gc stocking waistlngth 

40-50E

A6544Gc stocking garter 

beltE

A6545Grad comp non-elastic 

BKA

A6549G compression 

stockingE

A6550Neg pres wound ther drsg 

setY

A7000Disposable canister for 

pumpY

A7001Nondisposable pump 

canisterY

A7002Tubing used w suction 

pumpY

A7003Nebulizer administration 

setY

A7004Disposable nebulizer sml 

volY

A7005Nondisposable nebulizer 

setY
A7006Filtered nebulizer admin 

setY

A7007Lg vol nebulizer 

disposableY

A7008Disposable nebulizer 

prefillY

A7009Nebulizer reservoir 

bottleY

A7010Disposable corrugated 

tubingY

A7011Nondispos corrugated 

tubingY

A7012Nebulizer water collec 

devicY

A7013Disposable compressor 

filterY

A7014Compressor nondispos 

filterY

A7015Aerosol mask used w 

nebulizeY

A7016Nebulizer dome & 

mouthpieceY

A7017Nebulizer not used w 

oxygenY

A7018Water distilled 

w/nebulizerY

A7020"Interface, cough stim 

device"Y

A7025Replace chest compress 

vestY

A7026Replace chst cmprss sys 

hoseY

A7027Combination oral/nasal 

maskY

A7028Repl oral cushion combo 

maskY

A7029Repl nasal pillow comb 

maskY

A7030CPAP full face 

maskY

A7031Replacement facemask 

interfaY

A7032Replacement nasal 

cushionY
A7033Replacement nasal 

pillowsY

A7034Nasal application 

deviceY

A7035Pos airway press 

headgearY

A7036Pos airway press 

chinstrapY

A7037Pos airway pressure 

tubingY

A7038Pos airway pressure 

filterY

A7039"Filter, non disposable w 

pap"Y

A7040One way chest drain 

valveA

A7041Water seal drain 

containerA

A7042Implanted pleural 

catheterN

A7043Vacuum 

drainagebottle/tubingA

A7044PAP oral 

interfaceY

A7045Repl exhalation port for 

PAPY

A7046"Repl water chamber, PAP 

dev"Y

A7501Tracheostoma valve w 

diaphraA

A7502Replacement 

diaphragm/fplateA

A7503HMES filter holder or 

capA

A7504Tracheostoma HMES 

filterA

A7505HMES or trach valve 

housingA

A7506HMES/trachvalve 

adhesivediskA

A7507Integrated filter & 

holderA

A7508Housing & Integrated 

AdhesivA
A7509Heat & moisture exchange 

sysA

A7520Trach/laryn tube 

non-cuffedA

A7521Trach/laryn tube 

cuffedA

A7522Trach/laryn tube 

stainlessA

A7523Tracheostomy shower 

protectA

A7524Tracheostoma 

stent/stud/bttnA

A7525Tracheostomy 

maskA

A7526Tracheostomy tube 

collarA

A7527Trach/laryn tube 

plug/stopA

A8000Soft protect helmet prefabY 

A8001Hard protect helmet prefabY 

A8002Soft protect helmet customY 

A8003Hard protect helmet customY 

A8004"Repl soft interface, helmet"Y 

A9150Misc/exper non-prescript 

druB

A9152Single vitamin 

nosE

A9153Multi-vitamin 

nosE

A9155Artificial salivaB 

A9180"Lice treatment, 

topical"E

A9270Non-covered item or 

serviceE

A9273Hot/cold h2obot/cap/col/wrapY 

A9274Ext amb insulin delivery 

sysE
A9275Disp home glucose monitor 

E

A9276"Disposable sensor, CGM 

sys"E

A9277"External transmitter, 

CGM"E

A9278"External receiver, CGM 

sys"E

A9279Monitoring 

feature/deviceNOCE

A9280"Alert device, 

noc"E

A9281Reaching/grabbing 

deviceE

A9282Wig any 

typeE

A9283Foot press off load supp 

devE

A9284Non-electronic 

spirometerN

A9300Exercise 

equipmentE

A9500Tc99m 

sestamibiN

A9501Technetium TC-99m 

teboroximeN

A9502Tc99m 

tetrofosminN

A9503Tc99m 

medronateN

A9504Tc99m 

apcitideN

A9505TL201 

thalliumN

A9507In111 

capromabN

A9508"I131 iodobenguate, 

dx"N

A9509Iodine I-123 sod iodide 

milN

A9510Tc99m disofeninN 

A9512Tc99m 

pertechnetateN
A9516Iodine I-123 sod iodide 

micN

A9517"I131 iodide cap, rx"K 

1064$17.58.$3.52

A9521Tc99m 

exametazimeN

A9524"I131 serum albumin, 

dx"N

A9526Nitrogen N-13 

ammoniaN

A9527Iodine I-125 sodium 

iodideU26320.2868$19.91.$3.99

A9528"Iodine I-131 iodide cap, 

dx"N

A9529"I131 iodide sol, dx"N 

A9530"I131 iodide sol, rx"K 

1150$13.26.$2.66

A9531I131 max 100uCiN 

A9532"I125 serum albumin, dx"N 

A9536Tc99m depreotideN 

A9537Tc99m 

mebrofeninN

A9538Tc99m 

pyrophosphateN

A9539Tc99m pentetateN 

A9540Tc99m 

MAAN

A9541Tc99m sulfur 

colloidN

A9542"In111 ibritumomab, dx"N 

A9543"Y90 ibritumomab, rx"K 

1643"$32,078.39"."$6,415.68"

A9544"I131 tositumomab, dx"N 

A9545"I131 tositumomab, rx"K 

1645"$29,460.02"."$5,892.01"
A9546Co57/58N 

A9547In111 oxyquinolineN 

A9548In111 pentetateN 

A9550Tc99m gluceptateN 

A9551Tc99m succimerN 

A9552F18 fdgN 

A9553Cr51 chromateN 

A9554"I125 iothalamate, dx"N 

A9555Rb82 rubidium N 

A9556Ga67 galliumN 

A9557Tc99m bicisateN 

A9558Xe133 xenon 10mciN 

A9559Co57 

cyanoN

A9560Tc99m labeled 

rbcN

A9561Tc99m oxidronateN 

A9562Tc99m mertiatideN 

A9563P32 Na phosphateK 

1675$162.87.$32.58

A9564P32 chromic phosphateK 

1676$154.15.$30.83

A9566Tc99m fanolesomabN 

A9567Technetium TC-99m 

aerosolN

A9568Technetium tc99m 

arcitumomabN

A9569Technetium TC-99m auto 

WBCN
A9570Indium In-111 auto 

WBCN

A9571Indium IN-111 auto 

plateletN

A9572Indium In-111 

pentetreotideN

A9576Inj prohance 

multipackN

A9577Inj 

multihanceN

A9578Inj multihance 

multipackN

A9579"Gad-base MR contrast NOS,1ml 

"N

A9580Sodium fluoride 

F-18N

A9581Gadoxetate disodium 

injN

A9582Iodine I-123 

iobenguaneCHN

A9583Gadofosveset trisodium 

injCHN

A9600Sr89 strontiumK 

0701$641.83.$128.37

A9604Sm 153 

lexidronamK1295"$7,555.71"."$1,511.15"

A9698Non-rad contrast 

materialNOCN

A9699Radiopharm rx agent 

nocN

A9700Echocardiography 

ContrastB

A9900Supply/accessory/serviceY 

A9901Delivery/set 

up/dispensingA

A9999"DME supply or accessory, 

nos"Y

B4034Enter feed supkit syr by 

dayY

B4035Enteral feed supp pump per 

dY

B4036Enteral feed sup kit grav 
byY

B4081Enteral ng tubing w/ 

styletY

B4082Enteral ng tubing w/o 

styletY

B4083Enteral stomach tube 

levineY

B4087"Gastro/jejuno tube, 

std"A

B4088"Gastro/jejuno tube, 

low-pro"A

B4100Food thickener 

oralE

B4102EF adult fluids and 

electroY

B4103EF ped fluid and 

electrolyteY

B4104Additive for enteral 

formulaE

B4149EF blenderized 

foodsY

B4150EF complet w/intact 

nutrientY

B4152EF calorie 

dense>/=1.5KcalY

B4153EF hydrolyzed/amino 

acidsY

B4154EF spec metabolic 

noninheritY

B4155EF 

incomplete/modularY

B4157EF special metabolic 

inheritY

B4158EF ped complete intact 

nutY

B4159EF ped complete soy 

basedY

B4160EF ped caloric 

dense>/=0.7kcY

B4161EF ped hydrolyzed/amino 

acidY

B4162EF ped specmetabolic 

inheritY

B4164Parenteral 50% dextrose 
soluY

B4168Parenteral sol amino acid 

3.Y

B4172Parenteral sol amino acid 

5.Y

B4176Parenteral sol amino acid 

7-Y

B4178Parenteral sol amino acid 

>Y

B4180Parenteral sol carb > 

50%Y

B4185Parenteral sol 10 gm 

lipidsB

B4189Parenteral sol amino acid &Y 

B4193Parenteral sol 52-73 gm protY 

B4197Parenteral sol 74-100 gm proY 

B4199Parenteral sol > 100gm proteY 

B4216Parenteral nutrition additivY 

B4220Parenteral supply kit premixY 

B4222Parenteral supply kit homemiY 

B4224Parenteral administration kiY 

B5000Parenteral sol renal-amirosyY 

B5100Parenteral sol hepatic-freamY 

B5200Parenteral sol stres-brnch cY 

B9000Enter infusion pump w/o alrmY 

B9002Enteral infusion pump w/ alaY 

B9004Parenteral infus pump portabY 

B9006Parenteral infus pump statioY 

B9998Enteral supp not otherwise cY 
B9999Parenteral supp not othrws cY 

C1300HYPERBARIC 

OxygenS06591.4834$102.98.$20.60

C1713"Anchor/screw 

bn/bn,tis/bn"N

C1714"Cath, trans atherectomy, 

dir"N

C1715Brachytherapy 

needleN

C1716"Brachytx, non-str, 

Gold-198"U17161.0120$70.25.$14.05

C1717"Brachytx, non-str,HDR 

Ir-192"U17173.1681$219.93.$43.99

C1719"Brachytx, NS, 

Non-HDRIr-192"U17190.4486$31.14.$6.23

C1721"AICD, dual 

chamber"N

C1722"AICD, single 

chamber"N

C1724"Cath, trans 

atherec,rotation"N

C1725"Cath, translumin 

non-laser"N

C1726"Cath, bal dil, 

non-vascular"N

C1727"Cath, bal tis dis, 

non-vas"N

C1728"Cath, brachytx seed 

adm"N

C1729"Cath, 

drainage"N

C1730"Cath, EP, 19 or few 

elect"N

C1731"Cath, EP, 20 or more 

elec"N

C1732"Cath, EP, diag/abl, 

3D/vect"N

C1733"Cath, EP, othr than 

cool-tip"N
C1749"Endo, colon, retro 

imaging"H1749

C1750"Cath, 

hemodialysis,long-term"N

C1751"Cath, inf, 

per/cent/midline"N

C1752"Cath,hemodialysis,short-term"N

C1753"Cath, intravas 

ultrasound"N

C1754"Catheter, 

intradiscal"N

C1755"Catheter, 

intraspinal"N

C1756"Cath, pacing, 

transesoph"N

C1757"Cath, 

thrombectomy/embolect"N

C1758"Catheter, 

ureteral"N

C1759"Cath, intra 

echocardiography"N

C1760"Closure dev, 

vasc"N

C1762"Conn tiss, human(inc 

fascia)"N

C1763"Conn tiss, 

non-human"N

C1764"Event recorder, 

cardiac"N

C1765Adhesion 

barrierN

C1766"Intro/sheath,strble,non-peel"N

C1767"Generator, neuro 

non-recharg"N

C1768"Graft, 

vascular"N

C1769Guide 

wireN

C1770"Imaging coil, MR, 

insertable"N

C1771"Rep dev, urinary, 
w/sling"N

C1772"Infusion pump, 

programmable"N

C1773"Ret dev, 

insertable"N

C1776Joint device 

(implantable)N

C1777"Lead, AICD, endo single 

coil"N

C1778"Lead, 

neurostimulator"N

C1779"Lead, pmkr, transvenous 

VDD"N

C1780"Lens, intraocular (new 

tech)"N

C1781Mesh 

(implantable)N

C1782MorcellatorN

C1783"Ocular imp, aqueous drain 

de"N

C1784"Ocular dev, intraop, det 

ret"N

C1785"Pmkr, dual, 

rate-resp"N

C1786"Pmkr, single, 

rate-resp"N

C1787"Patient progr, 

neurostim"N

C1788"Port, indwelling, 

imp"N

C1789"Prosthesis, breast, 

imp"N

C1813"Prosthesis, penile, 

inflatab"N

C1814"Retinal tamp, silicone 

oil"N

C1815"Pros, urinary sph, 

imp"N

C1816"Receiver/transmitter, 

neuro"N

C1817Septal defect imp 

sysN

C1818Integrated 

keratoprosthesisN
C1819Tissue 

localization-excisionN

C1820Generator neuro rechg bat syN 

C1821Interspinous implantN 

C1874"Stent, coated/cov w/del 

sys"N

C1875"Stent, coated/cov w/o del 

sy"N

C1876"Stent, non-coa/non-cov 

w/del"N

C1877"Stent, non-coat/cov w/o 

del"N

C1878Matrl for vocal 

cordN

C1879"Tissue marker, 

implantable"N

C1880Vena cava 

filterN

C1881Dialysis access 

systemN

C1882"AICD, other than 

sing/dual"N

C1883"Adapt/ext, pacing/neuro 

lead"N

C1884Embolization Protect 

systN

C1885"Cath, translumin angio 

laser"N

C1887"Catheter, 

guiding"N

C1888Endovas non-cardiac abl 

cathN

C1891"Infusion pump,non-prog, 

perm"N

C1892"Intro/sheath,fixed,peel-away"N

C1893"Intro/sheath, 

fixed,non-peel"N

C1894"Intro/sheath, 

non-laser"N

C1895"Lead, AICD, endo dual 
coil"N

C1896"Lead, AICD, non 

sing/dual"N

C1897"Lead, neurostim test 

kit"N

C1898"Lead, pmkr, other than 

trans"N

C1899"Lead, pmkr/AICD 

combination"N

C1900"Lead, coronary 

venous"N

C2614"Probe, perc lumb 

disc"N

C2615"Sealant, pulmonary, 

liquid"N

C2616"Brachytx, 

non-str,Yttrium-90"U2616232.3017"$16,126.38"."$3,225.28"

C2617"Stent, non-cor, tem w/o 

del"N

C2618"Probe, 

cryoablation"N

C2619"Pmkr, dual, non 

rate-resp"N

C2620"Pmkr, single, non 

rate-resp"N

C2621"Pmkr, other than 

sing/dual"N

C2622"Prosthesis, penile, 

non-inf"N

C2625"Stent, non-cor, tem w/del 

sy"N

C2626"Infusion pump, 

non-prog,temp"N

C2627"Cath, 

suprapubic/cystoscopic"N

C2628"Catheter, 

occlusion"N

C2629"Intro/sheath, 

laser"N

C2630"Cath, EP, 

cool-tip"N

C2631"Rep dev, urinary, w/o 

sling"N
C2634"Brachytx, non-str, HA, 

I-125"U26340.7908$54.90.$10.98

C2635"Brachytx, non-str, HA, 

P-103"U26350.3438$23.87.$4.78

C2636"Brachy linear, 

non-str,P-103"U26360.5112$35.49.$7.10

C2637"Brachy,non-str,Ytterbium-169"B 

C2638"Brachytx, stranded, 

I-125"U26380.6225$43.21.$8.65

C2639"Brachytx, 

non-stranded,I-125"U26390.4992$34.65.$6.93

C2640"Brachytx, stranded, 

P-103"U26401.0610$73.65.$14.73

C2641"Brachytx, 

non-stranded,P-103"U26410.9263$64.30.$12.86

C2642"Brachytx, stranded, 

C-131"U26421.6922$117.47.$23.50

C2643"Brachytx, 

non-stranded,C-131"U26431.0735$74.52.$14.91

C2698"Brachytx, stranded, 

NOS"U26980.6225$43.21.$8.65

C2699"Brachytx, non-stranded, 

NOS"U26990.3438$23.87.$4.78

C8900"MRA w/cont, 

abd"Q302846.1872$429.52$144.34$85.91

C8901"MRA w/o cont, 

abd"Q303364.8219$334.74$131.90$66.95

C8902"MRA w/o fol w/cont, 

abd"Q303377.6393$530.32$196.43$106.07

C8903"MRI w/cont, breast, 

uni"Q302846.1872$429.52$144.34$85.91

C8904"MRI w/o cont, breast, 

uni"Q303364.8219$334.74$131.90$66.95
C8905"MRI w/o fol w/cont, brst, 

un"Q303377.6393$530.32$196.43$106.07

C8906"MRI w/cont, breast, 

bi"Q302846.1872$429.52$144.34$85.91

C8907"MRI w/o cont, breast, 

bi"Q303364.8219$334.74$131.90$66.95

C8908"MRI w/o fol w/cont, 

breast,"Q303377.6393$530.32$196.43$106.07

C8909"MRA w/cont, 

chest"Q302846.1872$429.52$144.34$85.91

C8910"MRA w/o cont, 

chest"Q303364.8219$334.74$131.90$66.95

C8911"MRA w/o fol w/cont, 

chest"Q303377.6393$530.32$196.43$106.07

C8912"MRA w/cont, lwr 

ext"Q302846.1872$429.52$144.34$85.91

C8913"MRA w/o cont, lwr 

ext"Q303364.8219$334.74$131.90$66.95

C8914"MRA w/o fol w/cont, lwr 

ext"Q303377.6393$530.32$196.43$106.07

C8918"MRA w/cont, 

pelvis"Q302846.1872$429.52$144.34$85.91

C8919"MRA w/o cont, 

pelvis"Q303364.8219$334.74$131.90$66.95

C8920"MRA w/o fol w/cont, 

pelvis"Q303377.6393$530.32$196.43$106.07

C8921"TTE w or w/o fol w/cont, 

com"S01288.1207$563.74$166.16$112.75

C8922"TTE w or w/o fol w/cont, 

f/u"S01288.1207$563.74$166.16$112.75

C8923"2D TTE w or w/o fol 

w/con,co"S01288.1207$563.74$166.16$112.75
C8924"2D TTE w or w/o fol 

w/con,fu"S01288.1207$563.74$166.16$112.75

C8925"2D TEE w or w/o fol 

w/con,in"S01288.1207$563.74$166.16$112.75

C8926"TEE w or w/o fol 

w/cont,cong"S01288.1207$563.74$166.16$112.75

C8927"TEE w or w/o fol w/cont, 

mon"S01288.1207$563.74$166.16$112.75

C8928"TTE w or w/o fol 

w/con,stres"S01288.1207$563.74$166.16$112.75

C8929"TTE w or wo fol 

wcon,Doppler"S01288.1207$563.74$166.16$112.75

C8930"TTE w or w/o contr, cont 

ECG"S01288.1207$563.74$166.16$112.75

C8931"MRA, w/dye, spinal 

canal"Q302846.1872$429.52$144.34$85.91

C8932"MRA, w/o dye, spinal canal 

"Q303364.8219$334.74$131.90$66.95

C8933"MRA, w/o&w/dye, spinal 

canal"Q303377.6393$530.32$196.43$106.07

C8934"MRA, w/dye, upper 

extremity"Q302846.1872$429.52$144.34$85.91

C8935"MRA, w/o dye, upper 

extr"Q303364.8219$334.74$131.90$66.95

C8936"MRA, w/o&w/dye, upper 

extr"Q303377.6393$530.32$196.43$106.07

C8957"Prolonged IV inf, req 

pump"S04403.0395$211.00.$42.20

C9113"Inj pantoprazole sodium, 

via"N

C9121"Injection, 

argatroban"K9121$18.71.$3.75

C9248"Inj, clevidipine 

butyrate"K9248$6.03.$1.21
C9250Artiss fibrin 

sealantCHK9250$121.80.$24.36

C9254"Injection, 

lacosamide"K9254$0.15.$0.03

C9257Bevacizumab 

injectionK1281$1.47.$0.30

C9270Gammaplex 

IVIGG9270$37.29.$7.39

C9272"Inj, 

denosumab"G9272$14.52.$2.88

C9273"Sipuleucel-T, per 

infusion"G9273"$32,860.00"."$6,510.00"

C9274Crotalidae Poly Immune 

FabG9274"$2,111.36".$418.29

C9275Hexaminolevulinate 

HClG9275$636.00$0.00$0.00

C9276Cabazitaxel 

injectionG9276$135.05.$26.76

C9277"Lumizyme, 1 

mg"G9277$14.83.$2.94

C9279"Injection, 

ibuprofen"G9279$1.39.$0.28

C9280"Injection, eribulin 

mesylate"G9280$901.00.$178.50

C9281"Injection, pegloticase 

"G9281$304.75.$60.38

C9282"Injection, ceftaroline fosamil 

"G9282$0.72.$0.14

C9352"Neuragen nerve guide, per cm"N 

C9353"Neurawrap nerve protector,cm"N 

C9354"Veritas collagen matrix, cm2"N 

C9355"Neuromatrix nerve cuff, cm"N 
C9356"TenoGlide tendon prot, cm2"N 

C9358"SurgiMend, 

fetal"K9358$11.09.$2.22

C9359"Implnt,bon void filler-putty"N 

C9360"SurgiMend, 

neonatal"CHK9360$11.59.$2.32

C9361NeuroMend nerve wrapCHN 

C9362"Implnt,bon void filler-strip"CHN 

C9363Integra Meshed Bil Wound 

MatCHK9363$19.17.$3.84

C9364"Porcine implant, Permacol"CHN 

C9367Endoform Dermal 

TemplateG9367$4.35.$0.86

C9399Unclassified drugs or 

biologA

C9716Radiofrequency energy to 

anuT015032.9730"$2,288.99".$457.80

C9724EPS gast cardia 

plicT042225.4890"$1,769.45".$353.89

C9725Place endorectal 

appT01486.1052$423.82.$84.77

C9726Rxt breast appl 

place/removT002825.8383"$1,793.69".$358.74

C9727Insert palate implantsT 

02528.0353$557.81.$111.57

C9728"Place device/marker, non pro"X 

031013.2460$919.54$322.74$183.91

C9729Percut lumbar 

lamiT020851.1173"$3,548.56".$709.72

C9800Dermal filler inj px/supplT 

01355.1973$360.80.$72.16
C9898Inpnt stay radiolabeled 

itemN

C9899"Inpt implant pros dev,no 

cov"A

D0120Periodic oral 

evaluationE

D0140Limit oral eval problm 

focusE

D0145"Oral evaluation, pt < 3yrs"E 

D0150Comprehensve oral 

evaluationS03309.5583$663.54.$132.71

D0160Extensv oral eval prob 

focusE

D0170"Re-eval,est pt,problem 

focus"E

D0180Comp periodontal 

evaluationE

D0210Intraor complete film 

seriesE

D0220Intraoral periapical first 

fE

D0230Intraoral periapical ea 

addE

D0240Intraoral occlusal 

filmS03309.5583$663.54.$132.71

D0250Extraoral first 

filmS03309.5583$663.54.$132.71

D0260Extraoral ea additional 

filmS03309.5583$663.54.$132.71

D0270Dental bitewing single 

filmS03309.5583$663.54.$132.71

D0272Dental bitewings two 

filmsS03309.5583$663.54.$132.71

D0273Bitewings - three filmsE 

D0274Dental bitewings four 

filmsS03309.5583$663.54.$132.71

D0277Vert bitewings-sev to 

eightS03309.5583$663.54.$132.71
D0290Dental film skull/facial 

bonE

D0310Dental 

saliographyE

D0320Dental tmj arthrogram incl 

iE

D0321Dental other tmj 

filmsE

D0322Dental tomographic 

surveyE

D0330Dental panoramic 

filmE

D0340Dental cephalometric 

filmE

D0350Oral/facial photo 

imagesE

D0360Cone beam 

ctE

D0362"Cone beam, two 

dimensional"E

D0363"Cone beam, three 

dimensional"E

D0415Collection of 

microorganismsE

D0416Viral 

cultureB

D0417Collect & prep saliva 

sampleE

D0418Analysis of saliva 

sampleE

D0421Gen tst suscept oral 

diseaseB

D0425Caries susceptibility 

testE

D0431Diag tst detect mucos 

abnormB

D0460Pulp vitality 

testS03309.5583$663.54.$132.71

D0470Diagnostic 

castsE

D0472"Gross exam, prep & 

report"B
D0473"Micro exam, prep & 

report"B

D0474Micro w exam of surg 

marginsB

D0475Decalcification 

procedureB

D0476Spec stains for 

microorganisB

D0477Spec stains not for 

microorgB

D0478Immunohistochemical 

stainsB

D0479Tissue in-situ 

hybridizationB

D0480Cytopath smear prep & 

reportB

D0481Electron microscopy 

diagnostB

D0482Direct 

immunofluorescenceB

D0483Indirect 

immunofluorescenceB

D0484Consult slides prep 

elsewherB

D0485Consult inc prep of 

slidesB

D0486Access of transep cytol sampE 

D0502Other oral pathology 

proceduB

D0999Unspecified diagnostic 

proceB

D1110Dental prophylaxis 

adultE

D1120Dental prophylaxis 

childE

D1203Topical app fluoride 

childE

D1204Topical app fluoride 

adultE

D1206Topical fluoride 

varnishE

D1310Nutri counsel-control 

cariesE
D1320Tobacco 

counselingE

D1330Oral hygiene 

instructionE

D1351Dental sealant per 

toothE

D1352"Prev resin rest, perm 

tooth"E

D1510Space maintainer fxd 

unilatS03309.5583$663.54.$132.71

D1515Fixed bilat space 

maintainerS03309.5583$663.54.$132.71

D1520Remove unilat space 

maintainS03309.5583$663.54.$132.71

D1525Remove bilat space 

maintainS03309.5583$663.54.$132.71

D1550Recement space 

maintainerS03309.5583$663.54.$132.71

D1555Remove fix space 

maintainerE

D2140Amalgam one surface 

permanenE

D2150Amalgam two surfaces 

permaneE

D2160Amalgam three surfaces 

permaE

D2161Amalgam 4 or > surfaces 

permE

D2330Resin one 

surface-anteriorE

D2331Resin two 

surfaces-anteriorE

D2332Resin three 

surfaces-anterioE

D2335Resin 4/> surf or w incis 

anE

D2390Ant resin-based cmpst 

crownE

D2391Post 1 srfc resinbased 

cmpstE

D2392Post 2 srfc resinbased 
cmpstE

D2393Post 3 srfc resinbased 

cmpstE

D2394Post >=4srfc resinbase 

cmpstE

D2410Dental gold foil one 

surfaceE

D2420Dental gold foil two 

surfaceE

D2430Dental gold foil three 

surfaE

D2510Dental inlay metalic 1 

surfE

D2520Dental inlay metallic 2 

surfE

D2530Dental inlay metl 3/more 

surE

D2542Dental onlay metallic 2 

surfE

D2543Dental onlay metallic 3 

surfE

D2544Dental onlay metl 4/more 

surE

D2610Inlay porcelain/ceramic 1 

suE

D2620Inlay porcelain/ceramic 2 

suE

D2630Dental onlay porc 3/more 

surE

D2642Dental onlay porcelin 2 

surfE

D2643Dental onlay porcelin 3 

surfE

D2644Dental onlay porc 4/more 

surE

D2650Inlay composite/resin one 

suE

D2651Inlay composite/resin two 

suE

D2652Dental inlay resin 3/mre 

surE

D2662Dental onlay resin 2 

surfaceE

D2663Dental onlay resin 3 
surfaceE

D2664Dental onlay resin 4/mre 

surE

D2710Crown resin-based 

indirectE

D2712Crown 3/4 resin-based 

composE

D2720Crown resin w/ high noble 

meE

D2721Crown resin w/ base 

metalE

D2722Crown resin w/ noble 

metalE

D2740Crown porcelain/ceramic 

subsE

D2750Crown porcelain w/ h noble 

mE

D2751Crown porcelain fused base 

mE

D2752Crown porcelain w/ noble 

metE

D2780Crown 3/4 cast hi noble 

metE

D2781Crown 3/4 cast base 

metalE

D2782Crown 3/4 cast noble 

metalE

D2783Crown 3/4 

porcelain/ceramicE

D2790Crown full cast high noble 

mE

D2791Crown full cast base 

metalE

D2792Crown full cast noble 

metalE

D2794Crown-titaniumE

D2799Provisional 

crownE

D2910Recement inlay onlay or 

partE

D2915Recement cast or prefab 

postE

D2920Dental recement 
crownE

D2930Prefab stnlss steel crwn 

priE

D2931Prefab stnlss steel crown 

peE

D2932Prefabricated resin 

crownE

D2933Prefab stainless steel 

crownE

D2934Prefab steel crown 

primaryE

D2940Protective 

restorationE

D2950Core build-up incl any 

pinsE

D2951Tooth pin 

retentionE

D2952Post and core cast + 

crownE

D2953Each addtnl cast 

postE

D2954Prefab post/core + 

crownE

D2955Post 

removalE

D2957Each addtnl prefab 

postE

D2960Laminate labial 

veneerE

D2961Lab labial veneer 

resinE

D2962Lab labial veneer 

porcelainE

D2970Temp crown (fractured tooth)E 

D2971Add proc construct new 

crownE

D2975CopingE

D2980Crown 

repairE

D2999Dental unspec restorative 

prS03309.5583$663.54.$132.71

D3110Pulp cap 
directE

D3120Pulp cap 

indirectE

D3220Therapeutic 

pulpotomyE

D3221Gross pulpal 

debridementE

D3222Part pulp for 

apexogenesisE

D3230Pulpal therapy anterior 

primE

D3240Pulpal therapy posterior 

priE

D3310"End thxpy, anterior 

tooth"E

D3320"End thxpy, bicuspid 

tooth"E

D3330"End thxpy, 

molar"E

D3331Non-surg tx root canal 

obsE

D3332Incomplete endodontic 

txE

D3333Internal root 

repairE

D3346Retreat root canal 

anteriorE

D3347Retreat root canal 

bicuspidE

D3348Retreat root canal 

molarE

D3351Apexification/recalc 

initialE

D3352Apexification/recalc 

interimE

D3353Apexification/recalc 

finalE

D3354Pulpal regeneration 

E

D3410Apicoect/perirad surg 

anterE

D3421Root surgery 

bicuspidE

D3425Root surgery 
molarE

D3426Root surgery ea add 

rootE

D3430Retrograde 

fillingE

D3450Root 

amputationE

D3460Endodontic endosseous 

implanS03309.5583$663.54.$132.71

D3470Intentional 

replantationE

D3910Isolation- tooth w rubb 

damE

D3920Tooth 

splittingE

D3950Canal prep/fitting of 

dowelE

D3999Endodontic 

procedureS03309.5583$663.54.$132.71

D4210Gingivectomy/plasty per 

quadE

D4211Gingivectomy/plasty per 

tootE

D4230Ana crown exp 4 or> per 

quadE

D4231Ana crown exp 1-3 per 

quadE

D4240Gingival flap proc w/ 

planinE

D4241Gngvl flap w rootplan 1-3 

thE

D4245Apically positioned 

flapE

D4249Crown lengthen hard 

tissueE

D4260Osseous surgery per 

quadrantS03309.5583$663.54.$132.71

D4261Osseous 

surgl-3teethperquadE

D4263Bone replce graft first 

siteS03309.5583$663.54.$132.71
D4264Bone replce graft each 

addS03309.5583$663.54.$132.71

D4265Bio mtrls to aid soft/os 

regE

D4266Guided tiss regen 

resorbleE

D4267Guided tiss regen 

nonresorbE

D4268Surgical revision 

procedureS03309.5583$663.54.$132.71

D4270Pedicle soft tissue graft 

prS03309.5583$663.54.$132.71

D4271Free soft tissue graft 

procS03309.5583$663.54.$132.71

D4273Subepithelial tissue 

graftS03309.5583$663.54.$132.71

D4274Distal/proximal wedge 

procE

D4275Soft tissue 

allograftE

D4276Con tissue w dble ped 

graftE

D4320Provision splnt 

intracoronalE

D4321Provisional splint 

extracoroE

D4341Periodontal scaling & 

rootE

D4342Periodontal scaling 

1-3teethE

D4355Full mouth 

debridementS03309.5583$663.54.$132.71

D4381Localized delivery 

antimicroS03309.5583$663.54.$132.71

D4910Periodontal maint 

proceduresE

D4920Unscheduled dressing 

changeE

D4999Unspecified periodontal 

procE
D5110Dentures complete 

maxillaryE

D5120Dentures complete 

mandibleE

D5130Dentures immediat 

maxillaryE

D5140Dentures immediat 

mandibleE

D5211Dentures maxill part 

resinE

D5212Dentures mand part 

resinE

D5213Dentures maxill part 

metalE

D5214Dentures mandibl part 

metalE

D5225Maxillary part denture 

flexE

D5226Mandibular part denture 

flexE

D5281Removable partial 

dentureE

D5410Dentures adjust cmplt 

maxilE

D5411Dentures adjust cmplt 

mandE

D5421Dentures adjust part 

maxillE

D5422Dentures adjust part 

mandblE

D5510Dentur repr broken compl 

basE

D5520Replace denture teeth 

compltE

D5610Dentures repair resin 

baseE

D5620Rep part denture cast 

frameE

D5630Rep partial denture 

claspE

D5640Replace part denture 

teethE

D5650Add tooth to partial 

dentureE
D5660Add clasp to partial 

dentureE

D5670Replc tth&acrlc on mtl 

frmwkE

D5671Replc tth&acrlc 

mandibularE

D5710Dentures rebase cmplt 

maxilE

D5711Dentures rebase cmplt 

mandE

D5720Dentures rebase part 

maxillE

D5721Dentures rebase part 

mandblE

D5730Denture reln cmplt maxil 

chE

D5731Denture reln cmplt mand 

chrE

D5740Denture reln part maxil 

chrE

D5741Denture reln part mand 

chrE

D5750Denture reln cmplt max 

labE

D5751Denture reln cmplt mand 

labE

D5760Denture reln part maxil 

labE

D5761Denture reln part mand 

labE

D5810Denture interm cmplt 

maxillE

D5811Denture interm cmplt 

mandblE

D5820Denture interm part 

maxillE

D5821Denture interm part 

mandblE

D5850Denture tiss conditn 

maxillE

D5851Denture tiss condtin 

mandblE

D5860Overdenture 

completeE
D5861Overdenture 

partialE

D5862Precision 

attachmentE

D5867Replacement of precision 

attE

D5875Prosthesis 

modificationE

D5899Removable prosthodontic 

procE

D5911Facial moulage 

sectionalS03309.5583$663.54.$132.71

D5912Facial moulage 

completeS03309.5583$663.54.$132.71

D5913Nasal 

prosthesisE

D5914Auricular 

prosthesisE

D5915Orbital 

prosthesisE

D5916Ocular 

prosthesisE

D5919Facial 

prosthesisE

D5922Nasal septal 

prosthesisE

D5923Ocular prosthesis 

interimE

D5924Cranial 

prosthesisE

D5925Facial augmentation 

implantE

D5926Replacement nasal 

prosthesisE

D5927Auricular 

replacementE

D5928Orbital 

replacementE

D5929Facial 

replacementE

D5931Surgical 

obturatorE
D5932Postsurgical 

obturatorE

D5933Refitting of 

obturatorE

D5934Mandibular flange 

prosthesisE

D5935Mandibular denture 

prosthE

D5936Temp obturator 

prosthesisE

D5937Trismus 

applianceE

D5951Feeding 

aidE

D5952Pediatric speech 

aidE

D5953Adult speech 

aidE

D5954Superimposed 

prosthesisE

D5955Palatal lift 

prosthesisE

D5958Intraoral con def inter 

pltE

D5959Intraoral con def mod 

palatE

D5960Modify speech aid 

prosthesisE

D5982Surgical 

stentE

D5983Radiation 

applicatorS03309.5583$663.54.$132.71

D5984Radiation 

shieldS03309.5583$663.54.$132.71

D5985Radiation cone 

locatorS03309.5583$663.54.$132.71

D5986Fluoride 

applicatorE

D5987Commissure 

splintS03309.5583$663.54.$132.71

D5988Surgical 

splintE
D5991Topical medicament 

carrierE

D5992Adjust max prost appliance 

E

D5993Main/clean max prosthesis 

E

D5999Maxillofacial 

prosthesisE

D6010Odontics endosteal 

implantE

D6012Endosteal 

implantE

D6040Odontics eposteal 

implantE

D6050Odontics transosteal 

implntE

D6053Implnt/abtmnt spprt remv 

dntE

D6054Implnt/abtmnt spprt 

remvprtlE

D6055Implant connecting 

barE

D6056Prefabricated 

abutmentE

D6057Custom 

abutmentE

D6058Abutment supported 

crownE

D6059Abutment supported mtl 

crownE

D6060Abutment supported mtl 

crownE

D6061Abutment supported mtl 

crownE

D6062Abutment supported mtl 

crownE

D6063Abutment supported mtl 

crownE

D6064Abutment supported mtl 

crownE

D6065Implant supported 

crownE

D6066Implant supported mtl 

crownE
D6067Implant supported mtl 

crownE

D6068Abutment supported 

retainerE

D6069Abutment supported 

retainerE

D6070Abutment supported 

retainerE

D6071Abutment supported 

retainerE

D6072Abutment supported 

retainerE

D6073Abutment supported 

retainerE

D6074Abutment supported 

retainerE

D6075Implant supported 

retainerE

D6076Implant supported 

retainerE

D6077Implant supported 

retainerE

D6078Implnt/abut suprtd fixd 

dentE

D6079Implnt/abut suprtd fixd 

dentE

D6080Implant 

maintenanceE

D6090Repair 

implantE

D6091Repl semi/precision 

attachE

D6092Recement supp 

crownE

D6093Recement supp part 

dentureE

D6094Abut support crown 

titaniumE

D6095Odontics repr 

abutmentE

D6100Removal of 

implantE

D6190Radio/surgical implant 

indexE
D6194Abut support retainer 

titaniE

D6199Implant 

procedureE

D6205Pontic-indirect resin 

basedE

D6210Prosthodont high noble 

metalE

D6211Bridge base metal 

castE

D6212Bridge noble metal 

castE

D6214Pontic 

titaniumE

D6240Bridge porcelain high 

nobleE

D6241Bridge porcelain base 

metalE

D6242Bridge porcelain nobel 

metalE

D6245Bridge 

porcelain/ceramicE

D6250Bridge resin w/high 

nobleE

D6251Bridge resin base 

metalE

D6252Bridge resin w/noble 

metalE

D6253Provisional 

ponticE

D6254Interim pontic 

E

D6545Dental retainr cast 

metlE

D6548Porcelain/ceramic 

retainerE

D6600Porcelain/ceramic inlay 

2srfE

D6601Porc/ceram inlay >= 3 

surfacE

D6602Cst hgh nble mtl inlay 2 

srfE

D6603Cst hgh nble mtl inlay 

>=3srE
D6604Cst bse mtl inlay 2 

surfacesE

D6605Cst bse mtl inlay >= 3 

surfaE

D6606Cast noble metal inlay 2 

surE

D6607Cst noble mtl inlay >=3 

surfE

D6608Onlay porc/crmc 2 

surfacesE

D6609Onlay porc/crmc >=3 

surfacesE

D6610Onlay cst hgh nbl mtl 2 

srfcE

D6611Onlay cst hgh nbl mtl 

>=3srfE

D6612Onlay cst base mtl 2 

surfaceE

D6613Onlay cst base mtl >=3 

surfaE

D6614Onlay cst nbl mtl 2 

surfacesE

D6615Onlay cst nbl mtl >=3 

surfacE

D6624Inlay 

titaniumE

D6634Onlay 

titaniumE

D6710Crown-indirect resin 

basedE

D6720Retain crown resin w hi 

nbleE

D6721Crown resin w/base 

metalE

D6722Crown resin w/noble 

metalE

D6740Crown 

porcelain/ceramicE

D6750Crown porcelain high 

nobleE

D6751Crown porcelain base 

metalE

D6752Crown porcelain noble 

metalE
D6780Crown 3/4 high noble 

metalE

D6781Crown 3/4 cast based 

metalE

D6782Crown 3/4 cast noble 

metalE

D6783Crown 3/4 

porcelain/ceramicE

D6790Crown full high noble 

metalE

D6791Crown full base metal 

castE

D6792Crown full noble metal 

castE

D6793Provisional retainer 

crownE

D6794Crown 

titaniumE

D6795Interim retainer crown 

E

D6920Dental connector 

barS03309.5583$663.54.$132.71

D6930Dental recement 

bridgeE

D6940Stress 

breakerE

D6950Precision 

attachmentE

D6970Post & core plus 

retainerE

D6972Prefab post & core plus 

retaE

D6973Core build up for 

retainerE

D6975Coping 

metalE

D6976Each addtnl cast 

postE

D6977Each addtl prefab 

postE

D6980Bridge 

repairE

D6985Pediatric partial denture 
fxE

D6999Fixed prosthodontic 

procE

D7111Extraction coronal 

remnantsS03309.5583$663.54.$132.71

D7140Extraction erupted 

tooth/exrS03309.5583$663.54.$132.71

D7210Rem imp tooth w mucoper 

flpS03309.5583$663.54.$132.71

D7220Impact tooth remov soft 

tissS03309.5583$663.54.$132.71

D7230Impact tooth remov part 

bonyS03309.5583$663.54.$132.71

D7240Impact tooth remov comp 

bonyS03309.5583$663.54.$132.71

D7241Impact tooth rem bony 

w/compS03309.5583$663.54.$132.71

D7250Tooth root 

removalS03309.5583$663.54.$132.71

D7251CoronectomyE

D7260Oral antral fistula 

closureS03309.5583$663.54.$132.71

D7261Primary closure sinus 

perfS03309.5583$663.54.$132.71

D7270Tooth 

reimplantationE

D7272Tooth 

transplantationE

D7280Exposure impact tooth 

orthodE

D7282Mobilize erupted/malpos 

tootE

D7283Place device impacted 

toothB

D7285Biopsy of oral tissue 

hardE

D7286Biopsy of oral tissue 
softE

D7287Exfoliative cytolog 

collectE

D7288Brush 

biopsyB

D7290Repositioning of 

teethE

D7291Transseptal 

fiberotomyS03309.5583$663.54.$132.71

D7292Screw retained 

plateE

D7293Temp anchorage dev w 

flapE

D7294Temp anchorage dev w/o 

flapE

D7295"Bone harvest,auto graft proc 

"E

D7310Alveoplasty w/ 

extractionE

D7311Alveoloplasty w/extract 

1-3E

D7320Alveoplasty w/o 

extractionE

D7321Alveoloplasty not 

w/extractsB

D7340Vestibuloplasty ridge 

extensE

D7350Vestibuloplasty exten 

graftE

D7410Rad exc lesion up to 1.25 

cmE

D7411Excision benign 

lesion>1.25cE

D7412Excision benign lesion 

complE

D7413Excision malig 

lesion<=1.25cE

D7414Excision malig 

lesion>1.25cmE

D7415Excision malig les 

complicatE

D7440Malig tumor exc to 1.25 

cmE
D7441Malig tumor > 1.25 

cmE

D7450Rem odontogen cyst to 

1.25cmE

D7451Rem odontogen cyst > 1.25 

cmE

D7460Rem nonodonto cyst to 

1.25cmE

D7461Rem nonodonto cyst > 1.25 

cmE

D7465Lesion 

destructionE

D7471Rem exostosis any 

siteE

D7472Removal of torus 

palatinusE

D7473Remove torus 

mandibularisE

D7485Surg reduct 

osseoustuberositE

D7490Maxilla or mandible 

resectioE

D7510I&d absc intraoral soft 

tissE

D7511Incision/drain abscess 

intraB

D7520I&d abscess 

extraoralE

D7521Incision/drain abscess 

extraB

D7530Removal fb skin/areolar 

tissE

D7540Removal of fb 

reactionE

D7550Removal of sloughed off 

boneE

D7560Maxillary 

sinusotomyE

D7610Maxilla open reduct 

simpleE

D7620Clsd reduct simpl maxilla 

fxE

D7630Open red simpl mandible 

fxE
D7640Clsd red simpl mandible 

fxE

D7650Open red simp malar/zygom 

fxE

D7660Clsd red simp malar/zygom 

fxE

D7670Closd rductn splint 

alveolusE

D7671Alveolus open 

reductionE

D7680Reduct simple facial bone 

fxE

D7710Maxilla open reduct 

compoundE

D7720Clsd reduct compd maxilla 

fxE

D7730Open reduct compd mandble 

fxE

D7740Clsd reduct compd mandble 

fxE

D7750Open red comp malar/zygma 

fxE

D7760Clsd red comp malar/zygma 

fxE

D7770Open reduc compd alveolus 

fxE

D7771Alveolus clsd reduc stblz 

teE

D7780Reduct compnd facial bone 

fxE

D7810Tmj open 

reduct-dislocationE

D7820Closed tmp 

manipulationE

D7830Tmj manipulation under 

anestE

D7840Removal of tmj 

condyleE

D7850Tmj 

meniscectomyE

D7852Tmj repair of joint 

discE

D7854Tmj excisn of joint 

membraneE
D7856Tmj cutting of a 

muscleE

D7858Tmj 

reconstructionE

D7860Tmj cutting into 

jointE

D7865Tmj reshaping 

componentsE

D7870Tmj aspiration joint 

fluidE

D7871Lysis + lavage w 

cathetersE

D7872Tmj diagnostic 

arthroscopyE

D7873Tmj arthroscopy lysis 

adhesnE

D7874Tmj arthroscopy disc 

repositE

D7875Tmj arthroscopy 

synovectomyE

D7876Tmj arthroscopy 

discectomyE

D7877Tmj arthroscopy 

debridementE

D7880Occlusal orthotic 

applianceE

D7899Tmj unspecified 

therapyE

D7910Dent sutur recent wnd to 

5cmE

D7911Dental suture wound to 5 

cmE

D7912Suture complicate wnd > 5 

cmE

D7920Dental skin 

graftE

D7940Reshaping bone 

orthognathicS03309.5583$663.54.$132.71

D7941Bone cutting ramus 

closedE

D7943Cutting ramus open 

w/graftE

D7944Bone cutting 

segmentedE
D7945Bone cutting body 

mandibleE

D7946Reconstruction maxilla 

totalE

D7947Reconstruct maxilla 

segmentE

D7948Reconstruct midface no 

graftE

D7949Reconstruct midface 

w/graftE

D7950Mandible 

graftE

D7951Sinus aug w bone/bone 

supE

D7953Bone replacement 

graftE

D7955Repair maxillofacial 

defectsE

D7960Frenulectomy/frenectomyE

D7963FrenuloplastyE

D7970Excision hyperplastic 

tissueE

D7971Excision pericoronal 

gingivaE

D7972Surg redct fibrous 

tuberositE

D7980SialolithotomyE

D7981Excision of salivary 

glandE

D7982SialodochoplastyE

D7983Closure of salivary 

fistulaE

D7990Emergency 

tracheotomyE

D7991Dental 

coronoidectomyE

D7995Synthetic graft facial 

bonesE

D7996Implant mandible for 

augmentE
D7997Appliance 

removalE

D7998Intraoral place of fix 

devE

D7999Oral surgery 

procedureE

D8010Limited dental tx 

primaryE

D8020Limited dental tx 

transitionE

D8030Limited dental tx 

adolescentE

D8040Limited dental tx 

adultE

D8050Intercep dental tx 

primaryE

D8060Intercep dental tx 

transitnE

D8070Compre dental tx 

transitionE

D8080Compre dental tx 

adolescentE

D8090Compre dental tx 

adultE

D8210Orthodontic rem appliance 

txE

D8220Fixed appliance therapy 

habtE

D8660Preorthodontic tx 

visitE

D8670Periodic orthodontc tx 

visitE

D8680Orthodontic 

retentionE

D8690Orthodontic 

treatmentE

D8691Repair ortho 

applianceE

D8692Replacement 

retainerE

D8693Rebond/cement/repair 

retainE

D8999Orthodontic 

procedureE
D9110Tx dental pain minor 

procN

D9120Fix partial denture 

sectionE

D9210Dent anesthesia w/o 

surgeryE

D9211Regional block 

anesthesiaE

D9212Trigeminal block 

anesthesiaE

D9215Local 

anesthesiaE

D9220General 

anesthesiaE

D9221General anesthesia ea ad 

15mE

D9230AnalgesiaN

D9241Intravenous 

sedationE

D9242IV sedation ea ad 30 

mE

D9248Sedation 

(non-iv)N

D9310Dental 

consultationE

D9410Dental house 

callE

D9420Hospital/ASC 

callE

D9430Office visit during 

hoursE

D9440Office visit after 

hoursE

D9450Case presentation tx 

planE

D9610Dent therapeutic drug 

injectE

D9612Thera par drugs 2 or > 

adminE

D9630Other 

drugs/medicamentsS03309.5583$663.54.$132.71

D9910Dent appl desensitizing 

medE
D9911Appl desensitizing 

resinE

D9920Behavior 

managementE

D9930Treatment of 

complicationsS03309.5583$663.54.$132.71

D9940Dental occlusal 

guardS03309.5583$663.54.$132.71

D9941Fabrication athletic 

guardE

D9942Repair/reline occlusal 

guardE

D9950Occlusion 

analysisS03309.5583$663.54.$132.71

D9951Limited occlusal 

adjustmentS03309.5583$663.54.$132.71

D9952Complete occlusal 

adjustmentS03309.5583$663.54.$132.71

D9970Enamel 

microabrasionE

D9971Odontoplasty 1-2 

teethE

D9972Extrnl bleaching per 

archE

D9973Extrnl bleaching per 

toothE

D9974Intrnl bleaching per 

toothE

D9999Adjunctive 

procedureE

E0100Cane adjust/fixed with 

tipY

E0105Cane adjust/fixed quad/3 

proY

E0110Crutch forearm 

pairY

E0111Crutch forearm 

eachY

E0112Crutch underarm pair 

woodY

E0113Crutch underarm each 
woodY

E0114Crutch underarm pair no 

woodY

E0116Crutch underarm each no 

woodY

E0117Underarm springassist 

crutchY

E0118Crutch 

substituteE

E0130Walker rigid adjust/fixed 

htY

E0135Walker folding 

adjust/fixedY

E0140Walker w trunk 

supportY

E0141Rigid wheeled walker 

adj/fixY

E0143Walker folding wheeled w/o 

sY

E0144Enclosed walker w rear 

seatY

E0147Walker variable wheel 

resistY

E0148Heavyduty walker no 

wheelsY

E0149Heavy duty wheeled 

walkerY

E0153Forearm crutch platform 

attaY

E0154Walker platform 

attachmentY

E0155"Walker wheel 

attachment,pair"Y

E0156Walker seat 

attachmentY

E0157Walker crutch 

attachmentY

E0158Walker leg extenders set 

of4Y

E0159Brake for wheeled 

walkerY

E0160Sitz type bath or 

equipmentY

E0161Sitz bath/equipment 
w/faucetY

E0162Sitz bath 

chairY

E0163Commode chair with fixed 

armY

E0165Commode chair with 

detacharmY

E0167Commode chair pail or 

panY

E0168Heavyduty/wide commode 

chairY

E0170Commode chair 

electricY

E0171Commode chair 

non-electricY

E0172Seat lift mechanism 

toiletE

E0175Commode chair foot 

restY

E0181Press pad alternating w/ 

pumY

E0182"Replace pump, alt press 

pad"Y

E0184Dry pressure 

mattressY

E0185Gel pressure mattress 

padY

E0186Air pressure 

mattressY

E0187Water pressure 

mattressY

E0188Synthetic sheepskin 

padY

E0189Lambswool sheepskin 

padY

E0190Positioning 

cushionE

E0191Protector heel or 

elbowY

E0193Powered air flotation 

bedY

E0194Air fluidized 

bedY

E0196Gel pressure 
mattressY

E0197Air pressure pad for 

mattresY

E0198Water pressure pad for 

mattrY

E0199Dry pressure pad for 

mattresY

E0200Heat lamp without 

standY

E0202Phototherapy light w/ 

photomY

E0203Therapeutic lightbox tabletpE 

E0205Heat lamp with 

standY

E0210Electric heat pad 

standardY

E0215Electric heat pad 

moistY

E0217Water circ heat pad w 

pumpY

E0218Water circ cold pad w 

pumpY

E0221Infrared heating pad 

systemY

E0225Hydrocollator 

unitY

E0231Wound warming 

deviceE

E0232Warming card for 

NWTE

E0235Paraffin bath unit 

portableY

E0236Pump for water circulating 

pY

E0239Hydrocollator unit 

portableY

E0240Bath/shower 

chairE

E0241Bath tub wall 

railE

E0242Bath tub rail 

floorE

E0243Toilet 
railE

E0244Toilet seat 

raisedE

E0245Tub stool or 

benchE

E0246Transfer tub rail 

attachmentE

E0247Trans bench w/wo comm 

openE

E0248HDtrans bench w/wo comm 

openE

E0249Pad water circulating heat 

uY

E0250Hosp bed fixed ht w/ 

mattresY

E0251Hosp bed fixd ht w/o 

mattresY

E0255Hospital bed var ht w/ 

mattrY

E0256Hospital bed var ht w/o 

mattY

E0260Hosp bed semi-electr w/ 

mattY

E0261Hosp bed semi-electr w/o 

matY

E0265Hosp bed total electr w/ 

matY

E0266Hosp bed total elec w/o 

mattY

E0270Hospital bed institutional 

tE

E0271Mattress 

innerspringY

E0272Mattress foam 

rubberY

E0273Bed 

boardE

E0274Over-bed 

tableE

E0275Bed pan 

standardY

E0276Bed pan 

fractureY

E0277Powered pres-redu air 
mattrsY

E0280Bed 

cradleY

E0290Hosp bed fx ht w/o rails 

w/mY

E0291Hosp bed fx ht w/o rail 

w/oY

E0292Hosp bed var ht w/o rail 

w/oY

E0293Hosp bed var ht w/o rail 

w/Y

E0294Hosp bed semi-elect w/ 

mattrY

E0295Hosp bed semi-elect w/o 

mattY

E0296Hosp bed total elect w/ 

mattY

E0297Hosp bed total elect w/o 

matY

E0300Enclosed ped crib hosp 

gradeY

E0301"HD hosp bed, 350-600 

lbs"Y

E0302Ex hd hosp bed > 600 

lbsY

E0303Hosp bed hvy dty xtra 

wideY

E0304Hosp bed xtra hvy dty x 

wideY

E0305Rails bed side half 

lengthY

E0310Rails bed side full 

lengthY

E0315Bed accessory 

brd/tbl/supprtE

E0316Bed safety 

enclosureY

E0325Urinal male 

jug-typeY

E0326Urinal female 

jug-typeY

E0328"Ped hospital bed, 

manual"Y

E0329Ped hospital bed 
semi/electY

E0350Control unit bowel 

systemE

E0352Disposable pack w/bowel 

systE

E0370Air elevator for 

heelE

E0371Nonpower mattress 

overlayY

E0372Powered air mattress 

overlayY

E0373Nonpowered pressure 

mattressY

E0424Stationary compressed gas 

02Y

E0425Gas system stationary 

compreE

E0430Oxygen system gas 

portableE

E0431Portable gaseous 

02Y

E0433Portable liquid oxygen 

sysY

E0434Portable liquid 

02Y

E0435Oxygen system liquid 

portablE

E0439Stationary liquid 

02Y

E0440Oxygen system liquid 

stationE

E0441"Stationary O2 contents, 

gas"Y

E0442"Stationary O2 contents, 

liq"Y

E0443"Portable 02 contents, 

gas"Y

E0444"Portable 02 contents, 

liquid"Y

E0445Oximeter 

non-invasiveN

E0446"Topical Ox Deliver sys, 

nos"E

E0450Vol control vent invasiv 
intY

E0455Oxygen tent excl croup/ped 

tY

E0457Chest 

shellY

E0459Chest 

wrapY

E0460Neg press vent 

portabl/statnY

E0461Vol control vent noninv 

intY

E0462Rocking bed w/ or w/o side 

rY

E0463Press supp vent invasive 

intY

E0464Press supp vent noninv 

intY

E0470RAD w/o backup non-inv 

intfcY

E0471RAD w/backup non inv 

intrfcY

E0472RAD w backup invasive 

intrfcY

E0480Percussor elect/pneum home 

mY

E0481Intrpulmnry percuss vent 

sysE

E0482Cough stimulating 

deviceY

E0483Chest compression gen 

systemY

E0484Non-elec oscillatory pep 

dvcY

E0485Oral device/appliance 

prefabY

E0486Oral device/appliance 

cusfabY

E0487Electronic spirometer 

N

E0500Ippb all 

typesY

E0550Humidif extens supple w 

ippbY

E0555Humidifier for use w/ 
regulaY

E0560Humidifier supplemental w/ 

iY

E0561Humidifier nonheated w 

PAPY

E0562Humidifier heated used w 

PAPY

E0565Compressor air power 

sourceY

E0570Nebulizer with 

compressionY

E0571Aerosol compressor for 

svnebY

E0572Aerosol compressor adjust 

prY

E0574Ultrasonic generator w 

svnebY

E0575Nebulizer 

ultrasonicY

E0580Nebulizer for use w/ 

regulatY

E0585Nebulizer w/ compressor & 

heY

E0600Suction pump portab hom 

modlY

E0601Cont airway pressure 

deviceY

E0602Manual breast 

pumpY

E0603Electric breast 

pumpN

E0604Hosp grade elec breast 

pumpA

E0605Vaporizer room 

typeY

E0606Drainage board 

posturalY

E0607Blood glucose monitor 

homeY

E0610Pacemaker monitr 

audible/visY

E0615Pacemaker monitr 

digital/visY

E0616Cardiac event 
recorderN

E0617Automatic ext 

defibrillatorY

E0618Apnea 

monitorY

E0619Apnea monitor w 

recorderY

E0620Cap bld skin piercing 

laserY

E0621Patient lift sling or 

seatY

E0625Patient lift bathroom or 

toiE

E0627Seat lift incorp 

lift-chairY

E0628Seat lift for pt 

furn-electrY

E0629Seat lift for pt 

furn-non-elY

E0630Patient lift 

hydraulicY

E0635Patient lift 

electricY

E0636PT support & positioning 

sysY

E0637Combination sit to stand 

sysE

E0638Standing frame 

sysE

E0639Moveable patient lift 

systemE

E0640Fixed patient lift 

systemE

E0641Multi-position stnd fram 

sysE

E0642Dynamic standing 

frameE

E0650Pneuma compresor 

non-segmentY

E0651Pneum compressor 

segmentalY

E0652Pneum compres w/cal 

pressureY

E0655Pneumatic appliance half 
armY

E0656Segmental pneumatic 

trunkY

E0657Segmental pneumatic 

chestY

E0660Pneumatic appliance full 

legY

E0665Pneumatic appliance full 

armY

E0666Pneumatic appliance half 

legY

E0667Seg pneumatic appl full 

legY

E0668Seg pneumatic appl full 

armY

E0669Seg pneumatic appli half 

legY

E0671Pressure pneum appl full 

legY

E0672Pressure pneum appl full 

armY

E0673Pressure pneum appl half 

legY

E0675Pneumatic compression 

deviceY

E0676Inter limb compress dev 

NOSY

E0691Uvl pnl 2 sq ft or 

lessY

E0692Uvl sys panel 4 

ftY

E0693Uvl sys panel 6 

ftY

E0694Uvl md cabinet sys 6 

ftY

E0700Safety 

equipmentE

E0705Transfer 

deviceB

E0710Restraints any 

typeE

E0720Tens two 

leadY

E0730Tens four 
leadY

E0731Conductive garment for 

tens/Y

E0740Incontinence treatment 

systmY

E0744Neuromuscular stim for 

scoliY

E0745Neuromuscular stim for 

shockY

E0746Electromyograph 

biofeedbackN

E0747Elec osteogen stim not 

spineY

E0748Elec osteogen stim 

spinalY

E0749Elec osteogen stim 

implantedN

E0755Electronic salivary reflex 

sE

E0760Osteogen ultrasound 

stimltorY

E0761Nontherm electromgntc 

deviceE

E0762Trans elec jt stim dev 

sysB

E0764Functional 

neuromuscularstimY

E0765Nerve stimulator for tx 

n&vY

E0769Electric wound treatment 

devB

E0770Functional electric stim 

NOSY

E0776Iv 

poleY

E0779Amb infusion pump 

mechanicalY

E0780Mech amb infusion pump 

<8hrsY

E0781External ambulatory infus 

puY

E0782Non-programble infusion 

pumpN

E0783Programmable infusion 
pumpN

E0784Ext amb infusn pump 

insulinY

E0785Replacement impl pump 

cathetN

E0786Implantable pump 

replacementN

E0791Parenteral infusion pump 

staY

E0830Ambulatory traction 

deviceN

E0840Tract frame attach 

headboardY

E0849Cervical pneum trac 

equipY

E0850Traction stand free 

standingY

E0855Cervical traction 

equipmentY

E0856Cervic collar w air 

bladderY

E0860Tract equip cervical 

tractY

E0870Tract frame attach 

footboardY

E0880Trac stand free stand 

extremY

E0890Traction frame attach 

pelvicY

E0900Trac stand free stand 

pelvicY

E0910Trapeze bar attached to 

bedY

E0911HD trapeze bar attach to 

bedY

E0912HD trapeze bar free 

standingY

E0920Fracture frame attached to 

bY

E0930Fracture frame free 

standingY

E0935Cont pas motion exercise 

devY

E0936"CPM device, other than 
knee"E

E0940Trapeze bar free 

standingY

E0941Gravity assisted traction 

deY

E0942Cervical head 

harness/halterY

E0944Pelvic 

belt/harness/bootY

E0945Belt/harness 

extremityY

E0946Fracture frame dual w 

crossY

E0947Fracture frame attachmnts 

peY

E0948Fracture frame attachmnts 

ceY

E0950TrayY

E0951Loop 

heelY

E0952"Toe loop/holder, 

each"Y

E0955Cushioned 

headrestY

E0956W/c lateral trunk/hip 

supporY

E0957W/c medial thigh 

supportY

E0958Whlchr att- conv 1 arm 

driveY

E0959Amputee 

adapterB

E0960W/c shoulder 

harness/strapsY

E0961Wheelchair brake 

extensionB

E0966Wheelchair head rest 

extensiB

E0967Manual wc hand rim w 

projectY

E0968Wheelchair commode 

seatY

E0969Wheelchair narrowing 

deviceY
E0970Wheelchair no. 2 footplatesE 

E0971Wheelchair anti-tipping 

deviB

E0973W/Ch access det adj 

armrestB

E0974W/Ch access 

anti-rollbackB

E0978"W/C acc,saf belt pelv 

strap"B

E0980Wheelchair safety 

vestY

E0981"Seat upholstery, 

replacement"Y

E0982"Back upholstery, 

replacement"Y

E0983Add pwr 

joystickY

E0984Add pwr 

tillerY

E0985W/c seat lift 

mechanismY

E0986Man w/c push-rim pow 

assistY

E0990Wheelchair elevating leg 

resB

E0992Wheelchair solid seat 

insertB

E0994Wheelchair arm 

restY

E0995Wheelchair calf 

restB

E1002Pwr seat 

tiltY

E1003Pwr seat 

reclineY

E1004Pwr seat recline 

mechY

E1005Pwr seat recline 

pwrY

E1006Pwr seat combo w/o 

shearY

E1007Pwr seat combo 

w/shearY
E1008Pwr seat combo pwr 

shearY

E1009Add mech leg 

elevationY

E1010Add pwr leg 

elevationY

E1011Ped wc modify width 

adjustmY

E1014Reclining back add ped 

w/cY

E1015Shock absorber for man 

w/cY

E1016Shock absorber for power 

w/cY

E1017HD shck absrbr for hd man 

wcY

E1018HD shck absrber for hd 

powwcY

E1020Residual limb support 

systemY

E1028W/c manual 

swingawayY

E1029W/c vent tray 

fixedY

E1030W/c vent tray 

gimbaledY

E1031Rollabout chair with 

castersY

E1035Patient transfer system 

<300Y

E1036Patient transfer system 

>300Y

E1037"Transport chair, ped 

size"Y

E1038Transport chair pt 

wt<=300lbY

E1039Transport chair pt wt 

>300lbY

E1050Whelchr fxd full length 

armsY

E1060Wheelchair detachable 

armsY

E1070Wheelchair detachable foot 

rY
E1083Hemi-wheelchair fixed 

armsY

E1084Hemi-wheelchair detachable 

aY

E1085Hemi-wheelchair fixed armsE 

E1086Hemi-wheelchair detachable aE 

E1087Wheelchair lightwt fixed 

armY

E1088Wheelchair lightweight det 

aY

E1089Wheelchair lightwt fixed armE 

E1090Wheelchair lightweight det aE 

E1092Wheelchair wide w/ leg 

restsY

E1093Wheelchair wide w/ foot 

restY

E1100Whchr s-recl fxd arm leg 

resY

E1110Wheelchair semi-recl 

detachY

E1130Whlchr stand fxd arm ft restE 

E1140Wheelchair standard detach aE 

E1150Wheelchair standard w/ leg 

rY

E1160Wheelchair fixed 

armsY

E1161Manual adult wc w 

tiltinspacY

E1170Whlchr ampu fxd arm leg 

restY

E1171Wheelchair amputee w/o leg 

rY

E1172Wheelchair amputee detach 

arY

E1180Wheelchair amputee w/ foot 

rY

E1190Wheelchair amputee w/ leg 

reY
E1195Wheelchair amputee heavy 

dutY

E1200Wheelchair amputee fixed 

armY

E1220Whlchr special 

size/constrcY

E1221Wheelchair spec size w 

footY

E1222Wheelchair spec size w/ 

legY

E1223Wheelchair spec size w 

footY

E1224Wheelchair spec size w/ 

legY

E1225Manual semi-reclining 

backY

E1226Manual fully reclining 

backB

E1227Wheelchair spec sz spec ht 

aY

E1228Wheelchair spec sz spec ht 

bY

E1229Pediatric wheelchair 

NOSY

E1230Power operated 

vehicleY

E1231Rigid ped w/c 

tilt-in-spaceY

E1232Folding ped wc 

tilt-in-spaceY

E1233Rig ped wc tltnspc w/o 

seatY

E1234Fld ped wc tltnspc w/o 

seatY

E1235Rigid ped wc 

adjustableY

E1236Folding ped wc 

adjustableY

E1237Rgd ped wc adjstabl w/o 

seatY

E1238Fld ped wc adjstabl w/o 

seatY

E1239Ped power wheelchair NOSY 
E1240Whchr litwt det arm leg 

restY

E1250Wheelchair lightwt fixed armE 

E1260Wheelchair lightwt foot restE 

E1270Wheelchair lightweight leg 

rY

E1280Whchr h-duty det arm leg 

resY

E1285Wheelchair heavy duty fixedE 

E1290Wheelchair hvy duty detach aE 

E1295Wheelchair heavy duty 

fixedY

E1296Wheelchair special seat 

heigY

E1297Wheelchair special seat 

deptY

E1298Wheelchair spec seat 

depth/wY

E1300Whirlpool 

portableE

E1310Whirlpool 

non-portableY

E1353Oxygen supplies 

regulatorY

E1354"Wheeled cart, port 

cyl/conc"Y

E1355Oxygen supplies 

stand/rackY

E1356"Batt pack/cart, port 

conc"Y

E1357"Battery charger, port 

conc"Y

E1358"DC power adapter, port 

conc"Y

E1372Oxy suppl heater for 

nebulizY

E1390Oxygen 

concentratorY

E1391"Oxygen concentrator, 

dual"Y
E1392Portable oxygen 

concentratorY

E1399Durable medical equipment 

miY

E1405O2/water vapor enrich 

w/heatY

E1406O2/water vapor enrich w/o 

heY

E1500CentrifugeA

E1510Kidney dialysate delivry 

sysA

E1520Heparin infusion 

pumpA

E1530Replacement air bubble 

detecA

E1540Replacement pressure 

alarmA

E1550Bath conductivity 

meterA

E1560Replace blood leak 

detectorA

E1570Adjustable chair for esrd 

ptA

E1575Transducer protect/fld 

barA

E1580Unipuncture control 

systemA

E1590Hemodialysis 

machineA

E1592Auto interm peritoneal 

dialyA

E1594Cycler dialysis 

machineA

E1600Deli/install chrg hemo 

equipA

E1610Reverse osmosis h2o puri 

sysA

E1615Deionizer H2O puri 

systemA

E1620Replacement blood 

pumpA

E1625Water softening 

systemA
E1630Reciprocating peritoneal 

diaA

E1632Wearable artificial 

kidneyA

E1634Peritoneal dialysis 

clampB

E1635Compact travel 

hemodialyzerA

E1636Sorbent cartridges per 

10A

E1637"Hemostats for dialysis, 

each"A

E1639Dialysis 

scaleA

E1699Dialysis equipment 

nocA

E1700Jaw motion rehab 

systemY

E1701Repl cushions for jaw 

motionY

E1702Repl measr scales jaw 

motionY

E1800Adjust elbow ext/flex 

deviceY

E1801SPS elbow 

deviceY

E1802Adjst forearm pro/sup 

deviceY

E1805Adjust wrist ext/flex 

deviceY

E1806SPS wrist 

deviceY

E1810Adjust knee ext/flex 

deviceY

E1811SPS knee 

deviceY

E1812Knee ext/flex w act res 

ctrlY

E1815Adjust ankle ext/flex 

deviceY

E1816SPS ankle 

deviceY

E1818SPS forearm 

deviceY
E1820Soft interface 

materialY

E1821Replacement interface 

SPSDY

E1825Adjust finger ext/flex 

devcY

E1830Adjust toe ext/flex 

deviceY

E1831Static str toe dev 

ext/flexY

E1840Adj shoulder ext/flex 

deviceY

E1841Static str shldr dev rom 

adjY

E1902AAC non-electronic 

boardY

E2000Gastric suction pump hme 

mdlY

E2100Bld glucose monitor w 

voiceY

E2101Bld glucose monitor w 

lanceY

E2120Pulse gen sys tx endolymp 

flY

E2201"Man w/ch acc seat 

w>=20""<24"""Y

E2202Seat width 24-27 

inY

E2203Frame depth less than 22 

inY

E2204Frame depth 22 to 25 

inY

E2205"Manual wc accessory, 

handrim"Y

E2206Complete wheel lock 

assemblyY

E2207Crutch and cane 

holderY

E2208Cylinder tank 

carrierY

E2209Arm trough 

eachY

E2210Wheelchair 

bearingsY
E2211Pneumatic propulsion 

tireY

E2212Pneumatic prop tire 

tubeY

E2213Pneumatic prop tire 

insertY

E2214Pneumatic caster tire 

eachY

E2215Pneumatic caster tire 

tubeY

E2216Foam filled propulsion 

tireY

E2217Foam filled caster tire 

eachY

E2218Foam propulsion tire 

eachY

E2219Foam caster tire any size 

eaY

E2220Solid propulsion tire 

eachY

E2221Solid caster tire 

eachY

E2222Solid caster integrated 

whlY

E2224Propulsion whl excludes 

tireY

E2225Caster wheel excludes 

tireY

E2226Caster fork replacement 

onlyY

E2227Gear reduction drive 

wheelY

E2228"Mwc acc, wheelchair 

brake"Y

E2230Manual standing 

systemE

E2231Solid seat support 

baseY

E2291Planar back for ped size 

wcY

E2292Planar seat for ped size 

wcY

E2293Contour back for ped size 

wcY
E2294Contour seat for ped size 

wcY

E2295Ped dynamic seating 

frameY

E2300Pwr seat elevation 

sysY

E2301Pwr 

standingY

E2310Electro connect btw 

controlY

E2311Electro connect btw 2 

sysY

E2312Mini-prop remote 

joystickY

E2313"PWC harness, expand 

control"Y

E2321Hand interface 

joystickY

E2322Mult mech 

switchesY

E2323Special joystick 

handleY

E2324Chin cup 

interfaceY

E2325Sip and puff 

interfaceY

E2326Breath tube 

kitY

E2327Head control interface 

mechY

E2328Head/extremity control 

interY

E2329Head control 

nonproportionalY

E2330Head control proximity 

switcY

E2331Attendant 

controlY

E2340W/c wdth 20-23 in seat 

frameY

E2341W/c wdth 24-27 in seat 

frameY

E2342W/c dpth 20-21 in seat 

frameY
E2343W/c dpth 22-25 in seat 

frameY

E2351Electronic SGD 

interfaceY

E236022nf nonsealed 

leadacidY

E236122nf sealed leadacid 

batteryY

E2362Gr24 nonsealed 

leadacidY

E2363Gr24 sealed leadacid 

batteryY

E2364U1nonsealed leadacid 

batteryY

E2365U1 sealed leadacid 

batteryY

E2366"Battery charger, single 

mode"Y

E2367"Battery charger, dual 

mode"Y

E2368Power wc motor 

replacementY

E2369Pwr wc gear box 

replacementY

E2370Pwr wc motor/gear box 

comboY

E2371Gr27 sealed leadacid 

batteryY

E2372Gr27 non-sealed 

leadacidY

E2373Hand/chin ctrl spec 

joystickY

E2374Hand/chin ctrl std 

joystickY

E2375Non-expandable 

controllerY

E2376"Expandable controller, 

repl"Y

E2377"Expandable controller, 

initl"Y

E2381Pneum drive wheel 

tireY

E2382"Tube, pneum wheel drive 

tire"Y
E2383"Insert, pneum wheel drive 

"Y

E2384Pneumatic caster 

tireY

E2385"Tube, pneumatic caster 

tire"Y

E2386Foam filled drive wheel 

tireY

E2387Foam filled caster 

tireY

E2388Foam drive wheel 

tireY

E2389Foam caster 

tireY

E2390Solid drive wheel 

tireY

E2391Solid caster 

tireY

E2392"Solid caster tire, 

integrate"Y

E2394Drive wheel excludes 

tireY

E2395Caster wheel excludes 

tireY

E2396Caster 

forkY

E2397"Pwc acc, lith-based 

battery"Y

E2402Neg press wound therapy 

pumpY

E2500SGD digitized pre-rec 

<=8minY

E2502SGD prerec msg >8min 

<=20minY

E2504SGD prerec msg>20min 

<=40minY

E2506SGD prerec msg > 40 

minY

E2508SGD spelling phys 

contactY

E2510SGD w multi methods 

msg/accsY

E2511SGD sftwre prgrm for 

PC/PDAY
E2512"SGD accessory, mounting 

sys"Y

E2599SGD accessory 

nocY

E2601Gen w/c cushion wdth < 22 

inY

E2602Gen w/c cushion wdth >=22 

inY

E2603Skin protect wc cus wd 

<22inY

E2604Skin protect wc cus 

wd>=22inY

E2605Position wc cush wdth <22 

inY

E2606Position wc cush wdth>=22 

inY

E2607Skin pro/pos wc cus wd 

<22inY

E2608Skin pro/pos wc cus 

wd>=22inY

E2609Custom fabricate w/c 

cushionY

E2610Powered w/c 

cushionB

E2611Gen use back cush wdth 

<22inY

E2612Gen use back cush 

wdth>=22inY

E2613Position back cush wd 

<22inY

E2614Position back cush 

wd>=22inY

E2615Pos back post/lat wdth 

<22inY

E2616Pos back post/lat 

wdth>=22inY

E2617Custom fab w/c back 

cushionY

E2619Replace cover w/c seat 

cushY

E2620WC planar back cush wd 

<22inY

E2621WC planar back cush 

wd>=22inY
E2622Adj skin pro w/c cus 

wd<22inY

E2623Adj skin pro wc cus 

wd>=22inY

E2624Adj skin pro/pos 

cus<22inY

E2625Adj skin pro/pos wc 

cus>=22Y

E8000Posterior gait 

trainerE

E8001Upright gait 

trainerE

E8002Anterior gait 

trainerE

G0008Admin influenza virus vacS 

03500.3780$26.24$0.00$0.00

G0009Admin pneumococcal vaccineS 

03500.3780$26.24$0.00$0.00

G0010Admin hepatitis b 

vaccineS04360.3780$26.24$0.00$0.00

G0027Semen 

analysisA

G0101CA screen;pelvic/breast 

examV06040.6941$48.18$0.00$0.00

G0102Prostate ca screening; 

dreN

G0103PSA screening 

A

G0104CA screen;flexi 

sigmoidscopeS01595.4345$377.26$0.00$0.00

G0105Colorectal scrn; hi risk 

indT01588.3174$577.39$0.00$0.00

G0106Colon CA screen;barium 

enemaS01572.2553$156.56.$31.32

G0108Diab manage trn per 

indivA

G0109Diab manage trn 

ind/groupA

G0117Glaucoma scrn hgh risk 

direcS06981.4030$97.40.$19.48
G0118Glaucoma scrn hgh risk 

direcS02300.6929$48.10.$9.62

G0120Colon ca scrn; barium 

enemaS01572.2553$156.56.$31.32

G0121Colon ca scrn not hi rsk 

indT01588.3174$577.39$0.00$0.00

G0122Colon ca scrn; barium 

enemaE

G0123Screen cerv/vag thin 

layerA

G0124Screen c/v thin layer by MDB 

G0127Trim 

nail(s)T00120.4047$28.09.$5.62

G0128CORF skilled nursing 

serviceB

G0129Partial hosp prog 

serviceP

G0130Single energy x-ray 

studyX02600.6418$44.55$0.00$0.00

G0141"Scr c/v cyto,autosys and md"B 

G0143"Scr c/v 

cyto,thinlayer,rescr"A

G0144"Scr c/v 

cyto,thinlayer,rescr"A

G0145"Scr c/v 

cyto,thinlayer,rescr"A

G0147"Scr c/v cyto, automated 

sys"A

G0148"Scr c/v cyto, autosys, 

rescr"A

G0151"HHCP-serv of pt,ea 15 

min"B

G0152"HHCP-serv of ot,ea 15 

min"B

G0153"HHCP-svs of s/l path,ea 

15mn"B
G0154"HHCP-svs of rn,ea 15 

min"B

G0155"HHCP-svs of csw,ea 15 

min"B

G0156"HHCP-svs of aide,ea 15 

min"B

G0157HHC PT assistant ea 15 

B

G0158HHC OT assistant ea 

15B

G0159HHC PT maint ea 15 

minB

G0160HHC Occup Therapy ea 

15B

G0161HHC SLP ea 15 

minB

G0162"HHC RN E&M plan svs, 15 

min"B

G0163HHC LPN/RN obs/asses ea 

15B

G0164HHC lis nurse train ea 

15B

G0166"Extrnl counterpulse, per 

tx"T06781.3160$91.36.$18.28

G0168Wound closure by adhesiveB 

G0173Linear acc stereo radsur 

comS006746.8279"$3,250.79".$650.16

G0175"OPPS Service,sched team 

conf"V06071.9242$133.58.$26.72

G0176OPPS/PHP;activity 

therapyP

G0177OPPS/PHP; train & educ servN 

G0179MD recertification HHA PTM 

G0180MD certification HHA patientM 

G0181Home health care supervisionM 

G0182Hospice care supervisionM 
G0186"Dstry eye lesn,fdr vssl 

tech"T02354.9132$341.07.$68.22

G0202ScreeningmammographydigitalA

G0204DiagnosticmammographydigitalA

G0206DiagnosticmammographydigitalA

G0219PET img wholbod melano 

noncoE

G0235PET not otherwise 

specifiedE

G0237Therapeutic procd strg 

endurS00770.4224$29.32$7.74$5.87

G0238"Oth resp proc, 

indiv"S00770.4224$29.32$7.74$5.87

G0239"Oth resp proc, 

group"S00770.4224$29.32$7.74$5.87

G0245Initial foot exam pt 

lopsV06040.6941$48.18.$9.64

G0246Followup eval of foot pt 

lopV06051.0430$72.41.$14.49

G0247Routine footcare pt w 

lopsT00130.9786$67.93.$13.59

G0248Demonstrate use home inr 

monV06071.9242$133.58.$26.72

G0249Provide INR test 

mater/equipV06071.9242$133.58.$26.72

G0250MD INR test revie inter 

mgmtM

G0251Linear acc based stero 

radioS006512.4513$864.37.$172.88

G0252PET imaging initial 

dxE

G0255Current percep threshold 

tstE

G0257Unsched dialysis ESRD pt 
hosS01705.9462$412.79.$82.56

G0259Inject for sacroiliac 

jointN

G0260Inj for sacroiliac jt 

anesthT02077.5480$523.98.$104.80

G0268Removal of impacted wax mdN 

G0269Occlusive device in vein 

artN

G0270MNT subs tx for change 

dxA

G0271Group MNT 2 or more 30 

minsA

G0275"Renal angio, cardiac 

cath"N

G0278"Iliac art angio,cardiac 

cath"N

G0281Elec stim unattend for 

pressA

G0282Elect stim wound care not 

pdE

G0283Elec stim other than 

woundA

G0288"Recon, CTA for surg 

plan"N

G0289"Arthro, loose body + 

chondro"N

G0290"Drug-eluting stents, 

single"T0656104.4584"$7,251.50"."$1,450.30"

G0291"Drug-eluting stents,each 

add"T0656104.4584"$7,251.50"."$1,450.30"

G0293"Non-cov surg proc,clin trial"X 

03400.6739$46.78.$9.36

G0294"Non-cov proc, clinical trial"X 

03400.6739$46.78.$9.36

G0295Electromagnetic therapy 

oncE

G0302Pre-op service LVRS 

completeS020911.3894$790.65$268.73$158.13

G0303Pre-op service LVRS 

10-15dosS020911.3894$790.65$268.73$158.13
G0304Pre-op service LVRS 1-9 

dosS02132.3958$166.32$53.48$33.27

G0305Post op service LVRS min 

6S02132.3958$166.32$53.48$33.27

G0306CBC/diffwbc w/o 

plateletA

G0307CBC without 

plateletA

G0328Fecal blood scrn 

immunoassayA

G0329Electromagntic tx for 

ulcersA

G0333Dispense fee initial 30 

dayM

G0337Hospice evaluation 

preelectiB

G0339"Robot lin-radsurg com, 

first"S006746.8279"$3,250.79".$650.16

G0340Robt lin-radsurg fractx 

2-5S006635.2457"$2,446.76".$489.36

G0341Percutaneous islet 

celltransC

G0342Laparoscopy islet cell 

transC

G0343Laparotomy islet cell 

transpC

G0364Bone marrow aspirate &biopsyX 

03400.6739$46.78.$9.36

G0365Vessel mapping hemo 

accessS02672.1881$151.90$59.41$30.38

G0372MD service required for 

PMDM

G0378Hospital observation per hr 

N

G0379Direct refer hospital 

observQ306040.6941$48.18.$9.64

G0380Lev 1 hosp type B ED visitV 

06260.5673$39.38.$7.88

G0381Lev 2 hosp type B ED visitV 
06270.8183$56.81.$11.37

G0382Lev 3 hosp type B ED visitV 

06281.3027$90.43.$18.09

G0383Lev 4 hosp type B ED visitV 

06291.9652$136.42.$27.29

G0384Lev 5 hosp type B ED 

visitQ306303.7640$261.30.$52.26

G0389Ultrasound exam AAA 

screenS02661.3711$95.18$0.00$0.00

G0390Trauma Respons w/hosp 

critiS061811.6401$808.06.$161.62

G0396Alcohol/subs interv 15-30mnS 

04320.4940$34.29.$6.86

G0397Alcohol/subs interv >30 minS 

04320.4940$34.29.$6.86

G0398Home sleep test/type 2 PortaS 

02132.3958$166.32$53.48$33.27

G0399Home sleep test/type 3 PortaS 

02132.3958$166.32$53.48$33.27

G0400Home sleep test/type 4 PortaS 

02132.3958$166.32$53.48$33.27

G0402Initial preventive 

examV06061.4647$101.68$0.00$0.00

G0403EKG for initial prevent 

examM

G0404EKG tracing for initial prev 

S00990.3895$27.04.$5.41

G0405EKG interpret & report preve B 

G0406Telhealth inpt consult 

15minC

G0407Telheath inpt consult 

25minC

G0408Telhealth inpt consult 

35minC

G0409CORF related serv 15 mins 

eaM
G0410Grp psych partial hosp 

45-50P

G0411Inter active grp psych 

partiP

G0412Open tx iliac spine 

uni/bilC

G0413Pelvic ring fracture uni/bilT 

005032.4101"$2,249.91".$449.99

G0414Pelvic ring fx treat int 

fixC

G0415Open tx post pelvic 

fxctureC

G0416Sat biopsy prostate 1-20 

spcX06612.3755$164.91.$32.99

G0417Sat biopsy prostate 

21-40CHS1505$350.00.$70.00

G0418Sat biopsy prostate 

41-60CHS1506$450.00.$90.00

G0419Sat biopsy prostate: 

>60CHS1508$650.00.$130.00

G0420Ed svc CKD ind per 

sessionA

G0421Ed svc CKD grp per 

sessionA

G0422Intens cardiac rehab 

w/exercS00950.9648$66.98$13.49$13.40

G0423Intens cardiac rehab no 

exerS00950.9648$66.98$13.49$13.40

G0424Pulmonary rehab w 

exerS01020.5308$36.85.$7.37

G0425Inpt telehealth consult 

30mC

G0426Inpt telehealth consult 

50mC

G0427Inpt telehealth con 

70/>mC

G0428Collagen Meniscus 

ImplantE
G0429Dermal filler injection(s)B 

G0431drug screen multiple 

classA

G0432EIA HIV-1/HIV-2 

screenA

G0433ELISA HIV-1/HIV-2 

screenA

G0434Drug screen multi drug 

classA

G0435Oral HIV-1/HIV-2 

screenA

G0436Tobacco-use counsel 3-10 

minX00310.2941$20.42$0.00$0.00

G0437Tobacco-use 

counsel>10minX00310.2941$20.42$0.00$0.00

G0438"PPPS, initial 

visit"A

G0439"PPPS, subseq 

visit"A

G0440Skin/dermal subs init 25or<B 

G0441Skin/dermal subs each additionB 

G3001"Admin + supply, 

tositumomab"S044222.9208"$1,591.16".$318.24

G8126Pt treat 

w/antidepress12wksM

G8127Pt not treat 

w/antidepres12wM

G8128Pt inelig for antidepres 

medM

G8395LVEF>=40% doc normal or mildM 

G8396LVEF not performedM 

G8397Dil macula/fundus exam/w docM 

G8398Dil macular/fundus not perfoM 

G8399Pt w/DXA document or orderM 
G8400Pt w/DXA no document or ordeM 

G8401Pt inelig osteo screen measuM 

G8404Low extemity neur exam documM 

G8405Low extemity neur not perforM 

G8406Pt inelig lower extrem neuroM 

G8410Eval on foot documentedM 

G8415Eval on foot not performedM 

G8416Pt inelig footwear evaluatioM 

G8417Calc BMI abv up param f/uM 

G8418Calc BMI blw low param f/uM 

G8419Calc BMI out nrm param nof/uM 

G8420Calc BMI norm parametersM 

G8421BMI not calculatedM 

G8422Pt inelig BMI calculationM 

G8427Doc cur meds by provM 

G8428Cur meds not document M 

G8430Pt inelig med checkM 

G8431Pos clin depres scrn f/u docM 

G8432Clin depression screen not dM 

G8433Pt inelig; scrn clin depM 

G8440Pain assess f/u pln documentM 

G8441No document of pain assessM 
G8442Pt inelig pain assessmentM 

G8447Pt vis doc use EHR cer ATCBM 

G8448Pt vis doc w/PQRI qual EHR M 

G8450Beta-bloc rx pt w/abn lvefM 

G8451Pt w/abn lvef inelig b-blocM 

G8452Pt w/abn lvef b-bloc no rxM 

G8458Pt inelig geno no antvir txM 

G8459Doc pt rec antivir treatM 

G8460Pt inelig RNA no antvir txM 

G8461Pt rec antivir treat hep cM 

G8462Pt inelig couns no antvir txM 

G8463Pt rec antiviral treat docM 

G8464Pt inelig; lo to no dter rskM 

G8465High risk recurrence pro caM 

G8468ACE/ARB rx pt w/abn lvefM 

G8469Pt w/abn lvef inelig ACE/ARBM 

G8470Pt w/ normal lvefM 

G8471LVEF not performed/docM 

G8472ACE/ARB no rx pt w/abn lvefM 

G8473ACE/ARB thxpy rx'dM 

G8474ACE/ARB not rx'd; doc reasM 

G8475ACE/ARB thxpy not rx'dM 
G8476BP sys <130 and dias <80M 

G8477BP sys>=130 and/or dias >=80M 

G8478BP not performed/docM 

G8482Flu immunize order/adminM 

G8483Flu imm no ord/admin doc reaM 

G8484Flu immunize no order/adminM 

G8485"Report, Diabetes measures"M 

G8486"Report, Prev Care Measures"M 

G8487Report CKD MeasuresM 

G8489CAD measures grpM 

G8490RA measures grpM 

G8491HIV/AIDS measures grpM 

G8492Periop Care measures grpM 

G8493Back pain measures grpM 

G8494DM meas qual act performM 

G8495CKD meas qual act performM 

G8496Prev Care MG qual act perfrmM 

G8497CABG meas qual act performM 

G8498CAD meas qual act performM 

G8499RA meas qual act performM 

G8500HIV meas qual act performM 

G8501Perio meas qual act performM 
G8502Back Pain MG qual act perfrmM 

G8506Pt rec ACE/ARBM 

G8508Pt inelig; pain asses no f/uM 

G8509Pain assess no f/u pln docM 

G8510Pt inelig neg scrn depresM 

G8511Clin depres scrn no f/u docM 

G8524Patch closure conv CEAM 

G8525No patch closure CEAM 

G8526No patch closure conv CEAM 

G8530Auto AV fistula recdM 

G8531Pt inelig; auto AV fistulaM 

G8532No auto AV fistula; no reasM 

G8534Doc elder mal scrn f/u planM 

G8535Pt inelig no eld mal scrnM 

G8536No doc elder mal scrnM 

G8537Pt inelig eldmal scrn no f/uM 

G8538Eld mal scrn no f/u plnM 

G8539Cur funct assess & care plnM 

G8540Pt inelig funct assessM 

G8541No doc cur funct assessM 

G8542Pt inelig func asses no plnM 

G8543Cur funct asses; no care plnM 
G8544CABG measures grpM 

G8545HepC measures grpM 

G8546CAP measures grpM 

G8547IVD measures grpM 

G8548HF measures grpM 

G8549HepC MG qual act performM 

G8550CAP MG qual act performM 

G8551HF MG qual act performM 

G8552IVD MG qual act performM 

G85531 Rx via qualified eRx sysM 

G8556Ref to doc otolog evalM 

G8557Pt inelig ref otolog evalM 

G8558No ref to doc otolog evalM 

G8559Pt ref doc oto evalM 

G8560Pt hx act drain prev 90 daysM 

G8561Pt inelig for ref oto evalM 

G8562Pt no hx act drain 90 dM 

G8563Pt no ref oto reas no specM 

G8564Pt ref oto evalM 

G8565Ver doc hear lossM 

G8566Pt inelig ref oto evalM 

G8567Pt no doc hear lossM 
G8568Pt no ref otolo no specM 

G8569Prol intubation reqM 

G8570No prol intub reqM 

G8571Ster wd ifx 30 d postopM 

G8572No ster wd ifxM 

G8573Stk/CVA CABGM 

G8574No strk/CVA CABGM 

G8575Postop ren insufM 

G8576No postop ren insufM 

G8577Reop req bld grft othM 

G8578No reop req bld grft othM 

G8579Antplt med dischM 

G8580Antplt med contraindM 

G8581no antplt med dischM 

G8582Bblock dischM 

G8583Bblock contraindM 

G8584No bblock dischM 

G8585Antilipid treat dischM 

G8586Antlip disch contraM 

G8587No antlipid treat dischM 

G8588Sys BP <140M 

G8589Sys BP >= 140M 
G8590Dia BP < 90M 

G8591Dia BP >= 90M 

G8592No BP measureM 

G8593Lipid pn resultsM 

G8594No lipid prof perfM 

G8595Ldl < 100M 

G8596No LDL perfM 

G8597Ldl >= 100M 

G8598Asp therp usedM 

G8599No asp therp usedM 

G8600tPA initi w/in 3 hrsM 

G8601No elig tPA init w/in 3 hrsM 

G8602No tPA init w/in 3 hrsM 

G8603Spok lang comp scoreM 

G8604No high score spok langM 

G8605No spok lang comp scoreM 

G8606Attention scoreM 

G8607No high score attentionM 

G8608No attention scoreM 

G8609Memory scoreM 

G8610No high score memoryM 

G8611No memory scoreM 
G8612Moto speech scoreM 

G8613No high score moto speech M 

G8614No moto speech scoreM 

G8615Reading scoreM 

G8616No high score readingM 

G8617No reading scoreM 

G8618Spok lang exp scoreM 

G8619No high score spok lang expM 

G8620No spok lang exp scoreM 

G8621Writing scoreM 

G8622No high score writingM 

G8623No writing scoreM 

G8624Swallowing scoreM 

G8625No high score swallowingM 

G8626No swallowing scoreM 

G8627Surg proc w/in 30 daysM 

G8628No surg proc w/in 30 daysM 

G8629Doc antibio order b/4 surgM 

G8630Doc antibio given b/4 surgM 

G8631Pt no elg 4 order antbi giveM 

G8632Doc no antibi order b/4 surgM 

G8633Pharm ther osteo rxM 
G8634Pt no elg phar ther osteoM 

G8635No pharm ther osteo rxM 

G8636Flu immun admin/prev recM 

G8637Pt no elg receiv flu immunM 

G8638Flu immun no admin/prev recM 

G8639Flu immun admin or prev recM 

G8640Pt no elg rec flu immunM 

G8641Flu immun not admin/pre recM 

G8642Hrdshp rural w/o internetM 

G8643Hrdshp w/o suff pharm w/eRxM 

G8644EP no prescribe privM 

G8645Asthma measures grpM 

G8646Asthma MG qual act performM 

G8647Fun stat score knee >= 0M 

G8648Fun stat score knee < 0M 

G8649Fun stat score knee pt noelgM 

G8650Fun stat score knee not doneM 

G8651Fun stat score hip >= 0M 

G8652Fun stat score hip < 0M 

G8653Fun stat score hip pt no elgM 

G8654Fun stat score hip not doneM 

G8655Fun stat score LE >= 0M 
G8656Fun stat score LE < 0M 

G8657Fun stat score LE pt no elgM 

G8658Fun stat score LE not doneM 

G8659Fun stat score LS >= 0M 

G8660Fun stat score LS < 0M 

G8661Fun stat score LS pt no elgM 

G8662Fun stat score LS not doneM 

G8663Fun stat score shdl >=0M 

G8664Fun stat score shdl < 0M 

G8665Fun stat score shdl pt no elgM 

G8666Fun stat score shdl not doneM 

G8667Fun stat score UE >=0M 

G8668Fun stat score UE < 0M 

G8669Fun stat score UE pt no elgM 

G8670Fun stat score UE not doneM 

G8671Fun stat score neck/TS >=0M 

G8672Fun stat score neck/TS < 0M 

G8673Fun stat scor nek/TS pt no elgM 

G8674Fun stat scor nek/TS not donM 

G8675BP Syst >= 140 mmHgM 

G8676BP Diast >= 90 mmHgM 

G8677BP Syst < 130 mmHgM 
G8678BP Syst >=130 - 139 mmHgM 

G8679BP Diast < 80 mmHgM 

G8680BP Diast 80-89 mmHgM 

G8681Pt hosp w/HFM 

G8682LVG test perfM 

G8683Pt not elig for LVF testM 

G8684Pt not hosp w/HFM 

G8685LVF test not perfM 

G8686Toba smkr curr or 2 hand expM 

G8687No tob smkr cur no 2 hnd expM 

G8688Smkls tob cur; no 2 hnd expM 

G8689Toba use not assessM 

G8690Curr toba smkr or 2 hand expM 

G8691No cur tob smkr no 2 hnd expM 

G8692Curr smkls tob; no 2 hnd expM 

G8693Tobacco no assessM 

G9001"MCCD, initial 

rate"B

G9002"MCCD,maintenance 

rate"B

G9003"MCCD, risk adj hi, 

initial"B

G9004"MCCD, risk adj lo, 

initial"B

G9005"MCCD, risk adj, 

maintenance"B

G9006"MCCD, Home 

monitoring"B
G9007"MCCD, sch team 

conf"B

G9008"Mccd,phys coor-care 

ovrsght"B

G9009"MCCD, risk adj, level 

3"B

G9010"MCCD, risk adj, level 

4"B

G9011"MCCD, risk adj, level 

5"B

G9012Other Specified Case 

MgmtB

G9013ESRD demo bundle level 

IE

G9014ESRD demo bundle-level 

IIE

G9016Demo-smoking cessation 

counE

G9017Amantadine HCL 100mg 

oralA

G9018"Zanamivir,inhalation pwd 

10m"A

G9019Oseltamivir phosphate 

75mgA

G9020Rimantadine HCL 100mg 

oralA

G9033Amantadine HCL oral 

brandA

G9034"Zanamivir, inh pwdr, 

brand"A

G9035"Oseltamivir phosp, 

brand"A

G9036"Rimantadine HCL, 

brand"A

G9041Low vision rehab occupationaA 

G9042Low vision rehab orient/mobiA 

G9043Low vision lowvision therapiA 

G9044Low vision rehabilate teacheA 

G9050Oncology work-up evaluationE 
G9051Oncology tx decision-mgmtE 

G9052Onc surveillance for diseaseE 

G9053Onc expectant management ptE 

G9054Onc supervision palliativeE 

G9055Onc visit unspecified NOSE 

G9056Onc prac mgmt adheres guideE 

G9057Onc pract mgmt differs trialE 

G9058Onc prac mgmt disagree w/guiE 

G9059Onc prac mgmt pt opt alternaE 

G9060Onc prac mgmt dif pt comorbE 

G9061Onc prac cond noadd by guideE 

G9062Onc prac guide differs nosE 

G9063Onc dx nsclc stgI no progresM 

G9064Onc dx nsclc stg2 no progresM 

G9065Onc dx nsclc stg3A no progreM 

G9066Onc dx nsclc stg3B-4 metastaM 

G9067Onc dx nsclc dx unknown nosM 

G9068Onc dx sclc/nsclc limitedM 

G9069Onc dx sclc/nsclc ext at dxM 

G9070Onc dx sclc/nsclc ext unknwnM 

G9071"Onc dx brst stg1-2B HR,nopro"M 

G9072Onc dx brst stg1-2 noprogresM 
G9073"Onc dx brst stg3-HR, no pro"M 

G9074Onc dx brst stg3-noprogressM 

G9075Onc dx brst metastic/ recurM 

G9077Onc dx prostate T1no progresM 

G9078Onc dx prostate T2no progresM 

G9079Onc dx prostate T3b-T4noprogM 

G9080Onc dx prostate w/rise PSAM 

G9083Onc dx prostate unknwn nosM 

G9084"Onc dx colon t1-3,n1-2,no pr"M 

G9085"Onc dx colon T4, N0 w/o prog"M 

G9086Onc dx colon T1-4 no dx progM 

G9087Onc dx colon metas evid dxM 

G9088Onc dx colon metas noevid dxM 

G9089Onc dx colon extent unknownM 

G9090Onc dx rectal T1-2 no progrM 

G9091Onc dx rectal T3 N0 no progM 

G9092"Onc dx rectal T1-3,N1-2noprg"M 

G9093"Onc dx rectal T4,N,M0 no prg"M 

G9094Onc dx rectal M1 w/mets progM 

G9095Onc dx rectal extent unknwnM 

G9096Onc dx esophag T1-T3 noprogM 

G9097Onc dx esophageal T4 no progM 
G9098Onc dx esophageal mets recurM 

G9099Onc dx esophageal unknownM 

G9100Onc dx gastric no recurrenceM 

G9101Onc dx gastric p R1-R2noprogM 

G9102Onc dx gastric unresectableM 

G9103Onc dx gastric recurrentM 

G9104Onc dx gastric unknown NOSM 

G9105Onc dx pancreatc p R0 res noM 

G9106Onc dx pancreatc p R1/R2 noM 

G9107Onc dx pancreatic unresectabM 

G9108Onc dx pancreatic unknwn NOSM 

G9109Onc dx head/neck T1-T2no prgM 

G9110Onc dx head/neck T3-4 noprogM 

G9111Onc dx head/neck M1 mets recM 

G9112Onc dx head/neck ext unknownM 

G9113Onc dx ovarian stg1A-B no prM 

G9114Onc dx ovarian stg1A-B or 2M 

G9115Onc dx ovarian stg3/4 noprogM 

G9116Onc dx ovarian recurrenceM 

G9117Onc dx ovarian unknown NOSM 

G9123Onc dx CML chronic phaseM 

G9124Onc dx CML acceler phaseM 
G9125Onc dx CML blast phaseM 

G9126Onc dx CML remissionM 

G9128Onc dx multi myeloma stage IM 

G9129Onc dx mult myeloma stg2 higM 

G9130Onc dx multi myeloma unknownM 

G9131Onc dx brst unknown NOSM 

G9132Onc dx prostate mets no castM 

G9133Onc dx prostate clinical metM 

G9134Onc NHLstg 1-2 no relap noM 

G9135Onc dx NHL stg 3-4 not relapM 

G9136Onc dx NHL trans to lg BcellM 

G9137Onc dx NHL relapse/refractorM 

G9138Onc dx NHL stg unknownM 

G9139Onc dx CML dx status unknownM 

G9140Frontier extended stay demoA 

G9141"Influenza A H1N1,admin w 

cou"S03500.3780$26.24$0.00$0.00

G9142"Influenza A H1N1, 

vaccine"E

G9143Warfarin respon genetic testA 

G9147Outpt IV insulin tx any 

meaE

J0120Tetracyclin injectionN 

J0129Abatacept injectionK 

9230$20.26.$4.06

J0130Abciximab 

injectionK1605$515.32.$103.07
J0132Acetylcysteine 

injectionK1272$2.67.$0.54

J0133Acyclovir injectionN 

J0135Adalimumab 

injectionK1083$394.16.$78.84

J0150Injection adenosine 6 MGN 

J0152Adenosine 

injectionK0917$89.99.$18.00

J0171Adrenalin epinephrine 

injectN

J0180Agalsidase beta 

injectionK9208$133.65.$26.73

J0190Inj biperiden lactate/5 

mgE

J0200Alatrofloxacin 

mesylateN

J0205Alglucerase 

injectionK0900$41.19.$8.24

J0207AmifostineK7000$314.05.$62.81

J0210Methyldopate hcl 

injectionK2210$39.24.$7.85

J0215AlefaceptK 

1633$35.86.$7.18

J0220Alglucosidase alfa injectionK 

9234$155.84.$31.17

J0256Alpha 1 proteinase 

inhibitorK0901$3.79.$0.76

J0270Alprostadil for 

injectionB

J0275Alprostadil urethral 

supposB

J0278Amikacin sulfate injectionN 

J0280Aminophyllin 250 MG 

injN
J0282Amiodarone 

HClN

J0285Amphotericin BN 

J0287Amphotericin b lipid 

complexK9024$8.76.$1.76

J0288Ampho b cholesteryl 

sulfateK0735$13.74.$2.75

J0289Amphotericin b liposome 

injK0736$14.77.$2.96

J0290Ampicillin 500 MG 

injN

J0295Ampicillin sodium per 1.5 

gmN

J0300Amobarbital 125 MG injCH 

K1341$23.38.$4.68

J0330Succinycholine chloride 

injN

J0348Anidulafungin 

injectionK1349$1.29.$0.26

J0350Injection anistreplase 30 uE 

J0360Hydralazine hcl 

injectionN

J0364Apomorphine 

hydrochlorideN

J0365"Aprotonin, 10,000 

kiu"N

J0380Inj metaraminol bitartrateN 

J0390Chloroquine 

injectionN

J0395Arbutamine hcl injectionE 

J0400Aripiprazole injectionN 

J0456AzithromycinN

J0461Atropine sulfate 

injectionN

J0470Dimecaprol 

injectionN

J0475Baclofen 10 MG 
injectionK9032$200.54.$40.11

J0476Baclofen intrathecal trialK 

1631$72.18.$14.44

J0480BasiliximabK 

1683"$2,027.27".$405.46

J0500Dicyclomine 

injectionN

J0515Inj benztropine mesylateCH 

N

J0520Bethanechol chloride 

injectN

J0558PenG benzathine/procaine 

injN

J0561Penicillin g benzathine 

injN

J0583BivalirudinK 

3041$2.54.$0.51

J0585"Injection,onabotulinumtoxinA"K0902$5.38.$1.08

J0586AbobotulinumtoxinAK1289$7.41.$1.49

J0587"Inj, 

rimabotulinumtoxinB"K9018$10.33.$2.07

J0592Buprenorphine 

hydrochlorideN

J0594Busulfan 

injectionK1178$16.29.$3.26

J0595Butorphanol tartrate 1 

mgN

J0597"C-1 esterase, 

berinert"G9269$27.53.$5.45

J0598"C-1 esterase, 

cinryze"CHK9251$43.78.$8.76

J0600Edetate calcium disodium 

injK1274$192.07.$38.42

J0610Calcium gluconate 

injectionN

J0620Calcium glycer & lact/10 

MLN
J0630Calcitonin salmon 

injectionCHN

J0636Inj calcitriol per 0.1 

mcgN

J0637Caspofungin 

acetateK9019$12.13.$2.43

J0638Canakinumab 

injectionK1311$87.45.$17.49

J0640Leucovorin calcium 

injectionN

J0641Levoleucovorin 

injectionCHK1236$1.78.$0.36

J0670Inj mepivacaine HCL/10 

mlN

J0690Cefazolin sodium 

injectionN

J0692Cefepime HCl for 

injectionN

J0694Cefoxitin sodium 

injectionN

J0696Ceftriaxone sodium 

injectionN

J0697Sterile cefuroxime 

injectionN

J0698Cefotaxime sodium 

injectionN

J0702Betamethasone acet&sod 

phospN

J0706Caffeine citrate injectionN 

J0710Cephapirin sodium 

injectionN

J0713Inj ceftazidime per 500 

mgN

J0715Ceftizoxime sodium / 500 

MGN

J0718Certolizumab pegol injCH 

K9249$3.99.$0.80

J0720Chloramphenicol sodium 

injecN

J0725Chorionic 

gonadotropin/1000uN
J0735Clonidine hydrochlorideCH 

N

J0740Cidofovir 

injectionK9033$740.09.$148.02

J0743Cilastatin sodium 

injectionN

J0744Ciprofloxacin 

ivN

J0745Inj codeine phosphate /30 

MGN

J0760Colchicine 

injectionN

J0770Colistimethate sodium 

injN

J0775"Collagenase, clost hist 

inj"G1340$37.51.$7.43

J0780Prochlorperazine 

injectionN

J0795Corticorelin ovine triflutalK 

1684$5.06.$1.02

J0800Corticotropin 

injectionK1280"$2,395.22".$479.05

J0833Cosyntropin injection 

NOSK0835$99.76.$19.96

J0834Cosyntropin cortrosyn 

injCHN

J0850Cytomegalovirus imm IV 

/vialK0903$922.07.$184.42

J0878Daptomycin 

injectionK9124$0.45.$0.09

J0881"Darbepoetin alfa, non-esrd"K 

1685$2.98.$0.60

J0882"Darbepoetin alfa, esrd 

use"A

J0885"Epoetin alfa, non-esrd"K 

1686$9.57.$1.92

J0886Epoetin alfa 1000 units 

ESRDA

J0894Decitabine injectionK 

9231$30.71.$6.15
J0895Deferoxamine mesylate injN 

J0900Testosterone enanthate 

injN

J0945Brompheniramine maleate injCH 

N

J1000Depo-estradiol cypionate 

injN

J1020Methylprednisolone 20 MG 

injN

J1030Methylprednisolone 40 MG 

injN

J1040Methylprednisolone 80 MG 

injN

J1051Medroxyprogesterone 

injN

J1055Medrxyprogester acetate 

injE

J1056MA/EC 

contraceptiveinjectionE

J1060Testosterone cypionate 1 

MLN

J1070Testosterone cypionat 100 

MGN

J1080Testosterone cypionat 200 

MGN

J1094Inj dexamethasone 

acetateN

J1100Dexamethasone sodium 

phosN

J1110Inj dihydroergotamine 

mesyltN

J1120Acetazolamid sodium 

injectioN

J1160Digoxin 

injectionN

J1162Digoxin immune fab (ovine)K 

1687$583.90.$116.78

J1165Phenytoin sodium 

injectionN

J1170Hydromorphone 

injectionN

J1180Dyphylline 

injectionN
J1190Dexrazoxane HCl 

injectionK0726$274.42.$54.89

J1200Diphenhydramine hcl 

injectioN

J1205Chlorothiazide sodium injK 

0747$272.64.$54.53

J1212Dimethyl sulfoxide 50% 50 MLK 

1221$82.68.$16.54

J1230Methadone 

injectionN

J1240Dimenhydrinate 

injectionN

J1245Dipyridamole 

injectionN

J1250Inj dobutamine HCL/250 

mgN

J1260Dolasetron 

mesylateN

J1265Dopamine injectionN 

J1267Doripenem injectionN 

J1270"Injection, 

doxercalciferol"N

J1290Ecallantide 

injectionG9263$275.28.$54.54

J1300Eculizumab 

injectionK9236$183.71.$36.75

J1320Amitriptyline 

injectionN

J1324Enfuvirtide 

injectionN

J1325Epoprostenol 

injectionN

J1327Eptifibatide 

injectionK1607$20.31.$4.07

J1330Ergonovine maleate injectionN 

J1335Ertapenem 

injectionN

J1364Erythro lactobionate /500 
MGN

J1380Estradiol valerate 10 MG 

injN

J1410Inj estrogen conjugate 25 

MGK9038$94.03.$18.81

J1430Ethanolamine oleate 100 mgK 

1688$147.14.$29.43

J1435Injection estrone per 1 

MGE

J1436Etidronate disodium 

injN

J1438Etanercept 

injectionK1608$203.01.$40.61

J1440Filgrastim 300 mcg 

injectionK0728$238.72.$47.75

J1441Filgrastim 480 mcg 

injectionK7049$376.20.$75.24

J1450FluconazoleN

J1451"Fomepizole, 15 mg"K 

1689$6.76.$1.36

J1452Intraocular Fomivirsen 

naE

J1453Fosaprepitant injectionK 

9242$1.71.$0.35

J1455Foscarnet sodium injectionCH K 

1359$13.06.$2.62

J1457Gallium nitrate injectionCH 

N

J1458Galsulfase injectionK 

9224$338.26.$67.66

J1459Inj IVIG privigen 500 mgK 

1214$34.45.$6.89

J1460Gamma globulin 1 CC injK 

3043$17.91.$3.59

J1559Hizentra injectionK 

1312$7.15.$1.43

J1560Gamma globulin > 10 CC injK 

0933$179.06.$35.82

J1561Gamunex injectionK 

0948$36.91.$7.39

J1562"Vivaglobin, inj"K 

1275$7.11.$1.43
J1566"Immune globulin, 

powder"K2731$30.62.$6.13

J1568Octagam 

injectionK0943$55.80.$11.16

J1569Gammagard liquid 

injectionK0944$37.67.$7.54

J1570Ganciclovir sodium injectionCH 

K1343$62.51.$12.51

J1571Hepagam b im 

injectionK0946$57.07.$11.42

J1572Flebogamma 

injectionK0947$35.04.$7.01

J1573"Hepagam b intravenous, 

inj"K1138$57.07.$11.42

J1580Garamycin gentamicin 

injN

J1590Gatifloxacin 

injectionN

J1595Injection glatiramer acetateK 

1015$95.57.$19.12

J1599"Ivig non-lyophilized, 

NOS"N

J1600Gold sodium thiomaleate 

injN

J1610Glucagon hydrochloride/1 

MGK9042$95.59.$19.12

J1620Gonadorelin hydroch/ 100 mcgCH 

K1344$94.82.$18.97

J1626Granisetron hcl 

injectionN

J1630Haloperidol 

injectionN

J1631Haloperidol decanoate 

injN

J1640"Hemin, 1 mg"K 

1690$8.33.$1.67

J1642Inj heparin sodium per 10 

uN

J1644Inj heparin sodium per 

1000uN
J1645Dalteparin 

sodiumN

J1650Inj enoxaparin 

sodiumN

J1652Fondaparinux 

sodiumN

J1655Tinzaparin sodium 

injectionN

J1670Tetanus immune globulin 

injK1670$222.97.$44.60

J1675Histrelin 

acetateB

J1680Human fibrinogen conc 

injCHK1290$71.52.$14.31

J1700Hydrocortisone acetate 

injN

J1710Hydrocortisone sodium ph 

injN

J1720Hydrocortisone sodium succ 

iN

J1730Diazoxide injectionCH 

N

J1740Ibandronate sodium 

injectionK9229$144.36.$28.88

J1742Ibutilide fumarate 

injectionK9044$129.32.$25.87

J1743Idursulfase 

injectionK9232$446.45.$89.29

J1745Infliximab 

injectionK7043$58.90.$11.78

J1750Inj iron 

dextranK1237$11.59.$2.32

J1756Iron sucrose injectionCH 

N

J1786Imuglucerase 

injectionK1327$41.19.$8.24

J1790Droperidol 

injectionN
J1800Propranolol 

injectionN

J1810Droperidol/fentanyl 

injE

J1815Insulin 

injectionN

J1817Insulin for insulin pump 

useN

J1826Interferon Beta-1A 

injE

J1830Interferon beta-1b / .25 

MGK0910$197.14.$39.43

J1835Itraconazole injectionCH 

K1355$359.59.$71.92

J1840Kanamycin sulfate 500 MG 

injN

J1850Kanamycin sulfate 75 MG 

injN

J1885Ketorolac tromethamine 

injN

J1890Cephalothin sodium 

injectionN

J1930Lanreotide 

injectionK9237$29.92.$5.99

J1931Laronidase 

injectionK9209$25.08.$5.02

J1940Furosemide 

injectionN

J1945LepirudinK 

1693$299.56.$59.92

J1950Leuprolide acetate /3.75 

MGK0800$547.54.$109.51

J1953Levetiracetam 

injectionN

J1955Inj levocarnitine per 1 

gmB

J1956Levofloxacin 

injectionN

J1960Levorphanol tartrate 

injN

J1980Hyoscyamine sulfate 

injN
J1990Chlordiazepoxide 

injectionN

J2001Lidocaine 

injectionN

J2010Lincomycin 

injectionN

J2020Linezolid 

injectionK9001$33.99.$6.80

J2060Lorazepam 

injectionN

J2150Mannitol 

injectionN

J2170Mecasermin 

injectionK1308$20.18.$4.04

J2175Meperidine hydrochl /100 

MGN

J2180Meperidine/promethazine 

injN

J2185MeropenemN

J2210Methylergonovin maleate 

injN

J2248Micafungin sodium injectionK 

9227$1.02.$0.21

J2250Inj midazolam 

hydrochlorideN

J2260Inj milrinone lactate / 5 

MGN

J2270Morphine sulfate 

injectionN

J2271Morphine so4 injection 

100mgN

J2275Morphine sulfate 

injectionN

J2278Ziconotide injectionK 

1694$6.48.$1.30

J2280"Inj, moxifloxacin 100 

mg"N

J2300Inj nalbuphine 

hydrochlorideN

J2310Inj naloxone 

hydrochlorideN

J2315"Naltrexone, depot form"K 
0759$2.77.$0.56

J2320Nandrolone decanoate 50 MGCH 

N

J2323Natalizumab injectionK 

9126$9.88.$1.98

J2325Nesiritide injectionK 

1695$43.93.$8.79

J2353"Octreotide injection, 

depot"K1207$113.48.$22.70

J2354"Octreotide inj, non-depot"N 

J2355Oprelvekin 

injectionK7011$240.88.$48.18

J2357Omalizumab 

injectionK9300$20.64.$4.13

J2358Olanzapine long-acting 

injK1331$2.70.$0.54

J2360Orphenadrine 

injectionN

J2370Phenylephrine hcl 

injectionN

J2400Chloroprocaine hcl 

injectionN

J2405Ondansetron hcl 

injectionN

J2410Oxymorphone hcl 

injectionN

J2425Palifermin injectionK 

1696$11.15.$2.23

J2426Paliperidone palmitate injCHK 

9255$6.45.$1.29

J2430Pamidronate disodium /30 

MGN

J2440Papaverin hcl 

injectionN

J2460Oxytetracycline 

injectionE

J2469Palonosetron 

hclK9210$18.51.$3.71

J2501ParicalcitolN

J2503Pegaptanib sodium 

injectionK1697"$1,002.20".$200.44
J2504"Pegademase bovine, 25 iu"K 

1739$242.67.$48.54

J2505"Injection, pegfilgrastim 

6mg"K9119"$2,527.87".$505.58

J2510Penicillin g procaine injCH 

N

J2513Pentastarch 10% 

solutionK1222$158.76.$31.76

J2515Pentobarbital sodium 

injN

J2540Penicillin g potassium 

injN

J2543Piperacillin/tazobactamN

J2545Pentamidine non-comp 

unitB

J2550Promethazine hcl 

injectionN

J2560Phenobarbital sodium 

injN

J2562Plerixafor 

injectionCHK9252$278.36.$55.68

J2590Oxytocin 

injectionN

J2597Inj desmopressin 

acetateCHK1356$3.93.$0.79

J2650Prednisolone acetate 

injN

J2670Totazoline hcl 

injectionN

J2675Inj progesterone per 50 

MGN

J2680Fluphenazine decanoate 25 

MGN

J2690Procainamide hcl 

injectionN

J2700Oxacillin sodium 

injecitonCHN

J2710Neostigmine methylslfte 

injN
J2720Inj protamine sulfate/10 

MGN

J2724Protein c 

concentrateK1139$12.50.$2.50

J2725Inj protirelin per 250 

mcgCHK1357$27.03.$5.41

J2730Pralidoxime chloride injK 

1023$88.57.$17.72

J2760Phentolaine mesylate injCHK 

1358$56.35.$11.27

J2765Metoclopramide hcl 

injectionN

J2770Quinupristin/dalfopristinK2770$157.23.$31.45

J2778Ranibizumab 

injectionK9233$398.10.$79.62

J2780Ranitidine hydrochloride 

injN

J2783RasburicaseK0738$183.08.$36.62

J2785Regadenoson 

injectionK9244$51.36.$10.28

J2788Rho d immune globulin 50 

mcgK9023$24.81.$4.97

J2790Rho d immune globulin 

injK0884$82.16.$16.44

J2791Rhophylac 

injectionK0945$5.09.$1.02

J2792"Rho(D) immune globulin h, 

sd"K1609$18.83.$3.77

J2793Rilonacept 

injectionK1291$23.63.$4.73

J2794"Risperidone, long 

acting"K9125$4.93.$0.99

J2795Ropivacaine HCl 

injectionN

J2796Romiplostim 

injectionK9245$44.84.$8.97
J2800Methocarbamol 

injectionN

J2805Sincalide injectionCH 

N

J2810Inj theophylline per 40 

MGN

J2820Sargramostim 

injectionK0731$23.62.$4.73

J2850Inj secretin synthetic humanK 

1700$26.97.$5.40

J2910Aurothioglucose 

injecitonN

J2916Na ferric gluconate 

complexN

J2920Methylprednisolone 

injectionN

J2930Methylprednisolone 

injectionN

J2940Somatrem injectionCH 

E

J2941Somatropin 

injectionK7034$56.09.$11.22

J2950Promazine hcl 

injectionN

J2993Reteplase 

injectionK9005"$1,332.35".$266.47

J2995Inj streptokinase /250000 

IUK1226$47.57.$9.52

J2997Alteplase 

recombinantK7048$39.22.$7.85

J3000Streptomycin 

injectionN

J3010Fentanyl citrate 

injecitonN

J3030Sumatriptan succinate / 6 

MGN

J3070Pentazocine 

injectionN

J3095Telavancin 

injectionG9258$1.96.$0.39

J3101Tenecteplase 
injectionK9002$51.95.$10.39

J3105Terbutaline sulfate 

injN

J3110Teriparatide 

injectionB

J3120Testosterone enanthate 

injN

J3130Testosterone enanthate 

injN

J3140Testosterone suspension 

injN

J3150Testosteron propionate 

injN

J3230Chlorpromazine hcl 

injectionN

J3240Thyrotropin 

injectionK9108"$1,034.03".$206.81

J3243Tigecycline 

injectionK9228$1.22.$0.25

J3246Tirofiban 

HClK7041$8.83.$1.77

J3250Trimethobenzamide hcl 

injN

J3260Tobramycin sulfate 

injectionN

J3262Tocilizumab 

injectionG9264$3.47.$0.69

J3265Injection torsemide 10 

mg/mlN

J3280Thiethylperazine maleate 

injN

J3285Treprostinil injectionK 

1701$60.08.$12.02

J3300Triamcinolone A inj PRS-freeK 

1253$3.17.$0.64

J3301Triamcinolone acet inj 

NOSN

J3302Triamcinolone diacetate 

injN

J3303Triamcinolone hexacetonl 

injN
J3305Inj trimetrexate glucoronateCH 

E

J3310Perphenazine 

injecitonK1304$30.91.$6.19

J3315Triptorelin 

pamoateK9122$193.59.$38.72

J3320Spectinomycn di-hcl 

injE

J3350Urea 

injectionK1306$82.18.$16.44

J3355"Urofollitropin, 75 iu"K 

1741$63.60.$12.72

J3357Ustekinumab 

injectionG9261$112.30.$22.25

J3360Diazepam 

injectionN

J3364Urokinase 5000 IU 

injectionN

J3365"Urokinase 250,000 IU 

inj"K7036$449.09.$89.82

J3370Vancomycin hcl 

injectionN

J3385Velaglucerase 

alfaG9271$349.88.$69.32

J3396Verteporfin 

injectionK1203$9.55.$1.91

J3400Triflupromazine hcl 

injE

J3410Hydroxyzine hcl 

injectionN

J3411Thiamine hcl 100 

mgN

J3415Pyridoxine hcl 100 

mgN

J3420Vitamin b12 

injectionN

J3430Vitamin k phytonadione 

injN

J3465"Injection, 

voriconazole"K1052$6.02.$1.21
J3470Hyaluronidase 

injectionN

J3471"Ovine, up to 999 USP 

units"N

J3472"Ovine, 1000 USP 

units"N

J3473Hyaluronidase 

recombinantN

J3475Inj magnesium 

sulfateN

J3480Inj potassium 

chlorideN

J3485ZidovudineN

J3486Ziprasidone 

mesylateN

J3487Zoledronic 

acidK9115$219.00.$43.80

J3488Reclast 

injectionK0951$218.47.$43.70

J3490Drugs unclassified 

injectionN

J3520Edetate disodium per 150 

mgE

J3530Nasal vaccine 

inhalationN

J3535Metered dose inhaler 

drugE

J3570Laetrile amygdalin vit 

B17E

J3590Unclassified 

biologicsN

J7030Normal saline solution 

infusN

J7040Normal saline solution 

infusN

J70425% dextrose/normal 

salineN

J7050Normal saline solution 

infusN

J70605% 

dextrose/waterN
J7070D5w 

infusionN

J7100Dextran 40 

infusionN

J7110Dextran 75 

infusionN

J7120Ringers lactate 

infusionN

J7130Hypertonic saline 

solutionN

J7184Wilate 

injectionG9267$70.14.$13.90

J7185Xyntha 

injK1268$1.05.$0.21

J7186Antihemophilic viii/vwf compK 

1213$0.90.$0.18

J7187"Humate-P, inj"K 

1704$0.87.$0.18

J7189Factor viiaK 

1705$1.50.$0.30

J7190Factor 

viiiK0925$0.87.$0.18

J7191Factor VIII 

(porcine)K1279$1.17.$0.24

J7192Factor viii recombinant 

NOSK0927$1.09.$0.22

J7193Factor IX 

non-recombinantK0931$0.88.$0.18

J7194Factor ix 

complexK0928$0.85.$0.17

J7195Factor IX 

recombinantK0932$1.13.$0.23

J7196Antithrombin 

recombinantK1332$101.40.$20.28

J7197Antithrombin iii 

injectionK1263$2.48.$0.50

J7198Anti-inhibitorK0929$1.57.$0.32

J7199Hemophilia clot factor 

nocB
J7300Intraut copper 

contraceptiveE

J7302Levonorgestrel iu 

contraceptE

J7303Contraceptive vaginal 

ringE

J7304Contraceptive hormone 

patchE

J7306Levonorgestrel implant 

sysE

J7307Etonogestrel implant 

systemE

J7308Aminolevulinic acid hcl 

topK7308$138.70.$27.74

J7309"Methyl aminolevulinate, 

top"K1338$68.27.$13.66

J7310Ganciclovir long act 

implantK0913"$16,640.00"."$3,328.00"

J7311Fluocinolone acetonide 

impltK9225"$18,980.00"."$3,796.00"

J7312Dexamethasone intra 

implantCHK9256$194.17.$38.84

J7321Hyalgan/supartz inj per 

doseK0873$88.80.$17.76

J7323Euflexxa inj per 

doseK0875$147.16.$29.44

J7324Orthovisc inj per 

doseK0877$167.00.$33.40

J7325Synvisc or 

Synvisc-OneK0874$11.81.$2.37

J7330Cultured chondrocytes 

implntB

J7335Capsaicin 8% 

patchG9268$25.55.$5.06

J7500Azathioprine oral 

50mgN

J7501Azathioprine 
parenteralK0887$104.77.$20.96

J7502Cyclosporine oral 100 

mgN

J7504Lymphocyte immune 

globulinK0890$542.36.$108.48

J7505Monoclonal 

antibodiesK7038"$1,112.14".$222.43

J7506Prednisone 

oralN

J7507Tacrolimus oral per 1 

MGN

J7509Methylprednisolone 

oralN

J7510Prednisolone oral per 5 

mgN

J7511Antithymocyte globuln 

rabbitK9104$387.17.$77.44

J7513"Daclizumab, 

parenteral"K1612$516.41.$103.29

J7515Cyclosporine oral 25 

mgN

J7516Cyclosporin parenteral 

250mgN

J7517Mycophenolate mofetil 

oralN

J7518Mycophenolic acidN 

J7520"Sirolimus, oral"N 

J7525Tacrolimus 

injectionK9006$136.85.$27.37

J7599Immunosuppressive drug 

nocN

J7604Acetylcysteine comp unitM 

J7605Arformoterol non-comp unitM 

J7606"Formoterol fumarate, inh"M 

J7607Levalbuterol comp conM 
J7608Acetylcysteine non-comp unitM 

J7609Albuterol comp unitM 

J7610Albuterol comp conM 

J7611Albuterol non-comp conM 

J7612Levalbuterol non-comp conM 

J7613Albuterol non-comp unitM 

J7614Levalbuterol non-comp unitM 

J7615Levalbuterol comp unitM 

J7620Albuterol ipratrop non-compM 

J7622Beclomethasone comp unit M 

J7624Betamethasone comp unitM 

J7626Budesonide non-comp unit M 

J7627Budesonide comp unit M 

J7628Bitolterol mesylate comp con M 

J7629Bitolterol mesylate comp unt M 

J7631Cromolyn sodium noncomp unitM 

J7632Cromolyn sodium comp unitM 

J7633Budesonide non-comp conM 

J7634Budesonide comp conM 

J7635Atropine comp con M 

J7636Atropine comp unit M 

J7637Dexamethasone comp con M 
J7638Dexamethasone comp unit M 

J7639Dornase alfa non-comp unitM 

J7640Formoterol comp unit 

E

J7641Flunisolide comp unit M 

J7642Glycopyrrolate comp con M 

J7643Glycopyrrolate comp unit M 

J7644Ipratropium bromide non-comp M 

J7645Ipratropium bromide compM 

J7647Isoetharine comp conM 

J7648Isoetharine non-comp con M 

J7649Isoetharine non-comp unit M 

J7650Isoetharine comp unitM 

J7657Isoproterenol comp conM 

J7658Isoproterenol non-comp con M 

J7659Isoproterenol non-comp unit M 

J7660Isoproterenol comp unitM 

J7667Metaproterenol comp conM 

J7668Metaproterenol non-comp con M 

J7669Metaproterenol non-comp unit M 

J7670Metaproterenol comp unitM 

J7674"Methacholine chloride, 

neb"N

J7676Pentamidine comp unit doseM 
J7680Terbutaline sulf comp con M 

J7681Terbutaline sulf comp unit M 

J7682Tobramycin non-comp unit M 

J7683Triamcinolone comp con M 

J7684Triamcinolone comp unit M 

J7685Tobramycin comp unitM 

J7686"Treprostinil, non-comp 

unit"M

J7699Inhalation solution for DMEM 

J7799Non-inhalation drug for DMEN 

J8498Antiemetic rectal/supp 

NOSB

J8499Oral prescrip drug non 

chemoE

J8501Oral 

aprepitantK0868$5.90.$1.18

J8510Oral 

busulfanK1307$3.59.$0.72

J8515"Cabergoline, oral 

0.25mg"E

J8520"Capecitabine, oral, 150 

mg"K7042$6.81.$1.37

J8521"Capecitabine, oral, 500 

mg"K0934$22.48.$4.50

J8530Cyclophosphamide oral 25 

MGN

J8540Oral 

dexamethasoneN

J8560Etoposide oral 50 

MGK0802$34.34.$6.87

J8562Oral fludarabine 

phosphateG1339$79.44.$15.74

J8565Gefitinib 
oralE

J8597Antiemetic drug oral 

NOSN

J8600Melphalan oral 2 

MGN

J8610Methotrexate oral 2.5 

MGN

J8650Nabilone oralCH 

E

J8700TemozolomideK1086$9.31.$1.87

J8705Topotecan oralCH 

K1238$76.40.$15.28

J8999Oral prescription drug 

chemoB

J9000Doxorubicin hcl injectionN 

J9001Doxorubicin hcl liposome 

injK7046$504.27.$100.86

J9010Alemtuzumab 

injectionK9110$577.60.$115.52

J9015Aldesleukin 

injectionK0807$915.45.$183.09

J9017Arsenic trioxide 

injectionK9012$40.13.$8.03

J9020Asparaginase 

injectionK0814$62.07.$12.42

J9025Azacitidine 

injectionK1709$5.16.$1.04

J9027Clofarabine 

injectionK1710$114.37.$22.88

J9031Bcg live intravesical 

vacK0809$114.38.$22.88

J9033Bendamustine 

injectionK9243$18.15.$3.63

J9035Bevacizumab 

injectionK9214$58.72.$11.75
J9040Bleomycin sulfate injectionN 

J9041Bortezomib 

injectionK9207$39.60.$7.92

J9045Carboplatin injectionN 

J9050Carmustine 

injectionK0812$172.56.$34.52

J9055Cetuximab 

injectionK9215$49.52.$9.91

J9060Cisplatin 10 MG 

injectionN

J9065Inj cladribine per 1 

MGK0858$23.59.$4.72

J9070Cyclophosphamide 100 MG 

injN

J9098Cytarabine liposome 

injK1166$479.02.$95.81

J9100Cytarabine hcl 100 MG 

injN

J9120Dactinomycin injectionK 

0752$529.42.$105.89

J9130Dacarbazine 100 mg injN 

J9150Daunorubicin 

injectionK0820$13.16.$2.64

J9151Daunorubicin citrate 

injK0821$56.58.$11.32

J9155Degarelix injectionCH 

K1296$2.79.$0.56

J9160Denileukin diftitox 

injK1084"$1,559.54".$311.91

J9165Diethylstilbestrol injectionCH 

E

J9171Docetaxel 

injectionK0823$20.84.$4.17

J9175Elliotts b solution per mlN 

J9178"Inj, epirubicin hcl, 2 
mg"K1167$1.87.$0.38

J9181Etoposide injectionN 

J9185Fludarabine phosphate injCH N 

J9190Fluorouracil 

injectionN

J9200Floxuridine 

injectionK0827$36.60.$7.32

J9201Gemcitabine hcl 

injectionK0828$111.40.$22.28

J9202Goserelin acetate 

implantK0810$195.16.$39.04

J9206Irinotecan injectionCH 

N

J9207Ixabepilone 

injectionK9240$62.53.$12.51

J9208Ifosfomide 

injectionK0831$31.21.$6.25

J9209Mesna 

injectionN

J9211Idarubicin hcl 

injectionK0832$46.43.$9.29

J9212Interferon alfacon-1 injCH 

N

J9213Interferon alfa-2a injCH 

E

J9214Interferon alfa-2b 

injK0836$16.19.$3.24

J9215Interferon alfa-n3 

injK0865$20.87.$4.18

J9216Interferon gamma 1-b 

injK0838$549.62.$109.93

J9217Leuprolide acetate 

suspnsionK9217$210.96.$42.20

J9218Leuprolide acetate 

injecitonK0861$4.88.$0.98

J9219Leuprolide acetate 
implantK7051"$4,728.88".$945.78

J9225Vantas 

implantK1711"$3,223.57".$644.72

J9226Supprelin LA 

implantK1142"$15,184.53"."$3,036.91"

J9230Mechlorethamine hcl 

injK0751$154.88.$30.98

J9245Inj melphalan hydrochl 50 

MGK0840"$1,272.01".$254.41

J9250Methotrexate sodium 

injN

J9260Methotrexate sodium 

injN

J9261Nelarabine injection 

K0825$110.19.$22.04

J9263OxaliplatinK1738$8.36.$1.68

J9264Paclitaxel protein 

boundK1712$9.21.$1.85

J9265Paclitaxel injectionCH 

N

J9266Pegaspargase injection 

K0843"$2,675.40".$535.08

J9268Pentostatin 

injectionK0844"$1,068.16".$213.64

J9270Plicamycin (mithramycin) 

injN

J9280Mitomycin 5 MG 

injK1232$20.36.$4.08

J9293Mitoxantrone hydrochl / 5 

MGK0864$33.95.$6.79

J9300Gemtuzumab ozogamicin 

injK9004"$2,637.02".$527.41

J9302Ofatumumab 

injectionG9260$45.41.$9.00

J9303Panitumumab 

injectionK9235$85.62.$17.13
J9305Pemetrexed 

injectionK9213$51.37.$10.28

J9307Pralatrexate 

injectionG9259$165.63.$32.81

J9310Rituximab 

injectionK0849$599.16.$119.84

J9315Romidepsin 

injectionG9265$219.30.$43.45

J9320Streptozocin 

injectionK0850$264.81.$52.97

J9328Temozolomide 

injectionCHK9253$4.86.$0.98

J9330Temsirolimus 

injectionK1168$49.87.$9.98

J9340Thiotepa 

injectionK0851$106.54.$21.31

J9351Topotecan 

injectionK1350$19.30.$3.86

J9355Trastuzumab 

injectionK1613$69.06.$13.82

J9357Valrubicin 

injectionK1235$946.64.$189.33

J9360Vinblastine sulfate 

injN

J9370Vincristine sulfate 1 MG 

injN

J9390Vinorelbine tartrate 

injN

J9395"Injection, 

Fulvestrant"K9120$81.81.$16.37

J9600Porfimer sodium 

injectionK0856"$3,017.82".$603.57

J9999Chemotherapy 

drugN

K0001Standard 
wheelchairY

K0002Stnd hemi (low seat) 

whlchrY

K0003Lightweight 

wheelchairY

K0004High strength ltwt 

whlchrY

K0005Ultralightweight 

wheelchairY

K0006Heavy duty 

wheelchairY

K0007Extra heavy duty 

wheelchairY

K0009Other manual 

wheelchair/baseY

K0010Stnd wt frame power 

whlchrY

K0011Stnd wt pwr whlchr w 

controlY

K0012Ltwt portbl power 

whlchrY

K0014Other power whlchr 

baseY

K0015Detach non-adjus hght 

armrstY

K0017Detach adjust armrest 

baseY

K0018Detach adjust armrst 

upperY

K0019Arm pad 

eachY

K0020Fixed adjust armrest 

pairY

K0037High mount flip-up 

footrestY

K0038Leg strap 

eachY

K0039Leg strap h style 

eachY

K0040Adjustable angle 

footplateY

K0041Large size footplate 

eachY

K0042Standard size footplate 
eachY

K0043Ftrst lower extension 

tubeY

K0044Ftrst upper hanger 

bracketY

K0045Footrest complete 

assemblyY

K0046Elevat legrst low 

extensionY

K0047Elevat legrst up hangr 

brackY

K0050Ratchet 

assemblyY

K0051Cam relese assem 

ftrst/lgrstY

K0052Swingaway detach 

footrestY

K0053Elevate footrest 

articulateY

K0056Seat ht <17 or >=21 ltwt 

wcY

K0065Spoke 

protectorsY

K0069Rear whl complete solid 

tireY

K0070Rear whl compl pneum 

tireY

K0071Front castr compl pneum 

tireY

K0072Frnt cstr cmpl sem-pneum 

tirY

K0073Caster pin lock 

eachY

K0077Front caster assem 

completeY

K0098Drive belt power 

wheelchairY

K0105Iv hangerY 

K0108W/c component-accessory 

NOSY

K0195Elevating whlchair leg 

restsY

K0455Pump uninterrupted 
infusionY

K0462Temporary replacement 

eqpmntY

K0552Supply/ext inf pump syr 

typeY

K0601Repl batt silver oxide 1.5 

vY

K0602Repl batt silver oxide 3 v 

Y

K0603Repl batt alkaline 1.5 

vY

K0604Repl batt lithium 3.6 

vY

K0605Repl batt lithium 4.5 

vY

K0606AED garment w elec 

analysisY

K0607Repl batt for 

AEDY

K0608Repl garment for 

AEDY

K0609Repl electrode for 

AEDY

K0669Seat/back cus no dmepdac 

verY

K0672Removable soft interface LEA 

K0730Ctrl dose inh drug deliv sysY 

K073312-24hr sealed lead acidY 

K0738Portable gas oxygen systemY 

K0739Repair/svc DME non-oxygen eqY 

K0740Repair/svc oxygen 

equipmentE

K0800POV group 1 std up to 300lbsY 

K0801POV group 1 hd 301-450 lbsY 

K0802POV group 1 vhd 451-600 lbsY 

K0806POV group 2 std up to 300lbsY 
K0807POV group 2 hd 301-450 lbsY 

K0808POV group 2 vhd 451-600 lbsY 

K0812Power operated vehicle NOCY 

K0813PWC gp 1 std port seat/backY 

K0814PWC gp 1 std port cap chairY 

K0815PWC gp 1 std seat/backY 

K0816PWC gp 1 std cap chairY 

K0820PWC gp 2 std port seat/backY 

K0821PWC gp 2 std port cap chairY 

K0822PWC gp 2 std seat/backY 

K0823PWC gp 2 std cap chairY 

K0824PWC gp 2 hd seat/backY 

K0825PWC gp 2 hd cap chairY 

K0826PWC gp 2 vhd seat/backY 

K0827PWC gp vhd cap chairY 

K0828PWC gp 2 xtra hd seat/backY 

K0829PWC gp 2 xtra hd cap chairY 

K0830PWC gp2 std seat elevate s/bY 

K0831PWC gp2 std seat elevate capY 

K0835PWC gp2 std sing pow opt s/bY 

K0836PWC gp2 std sing pow opt capY 

K0837PWC gp 2 hd sing pow opt s/bY 
K0838PWC gp 2 hd sing pow opt capY 

K0839PWC gp2 vhd sing pow opt s/bY 

K0840PWC gp2 xhd sing pow opt s/bY 

K0841PWC gp2 std mult pow opt s/bY 

K0842PWC gp2 std mult pow opt capY 

K0843PWC gp2 hd mult pow opt s/bY 

K0848PWC gp 3 std seat/backY 

K0849PWC gp 3 std cap chairY 

K0850PWC gp 3 hd seat/backY 

K0851PWC gp 3 hd cap chairY 

K0852PWC gp 3 vhd seat/backY 

K0853PWC gp 3 vhd cap chairY 

K0854PWC gp 3 xhd seat/backY 

K0855PWC gp 3 xhd cap chairY 

K0856PWC gp3 std sing pow opt s/bY 

K0857PWC gp3 std sing pow opt capY 

K0858PWC gp3 hd sing pow opt s/bY 

K0859PWC gp3 hd sing pow opt capY 

K0860PWC gp3 vhd sing pow opt s/bY 

K0861PWC gp3 std mult pow opt s/bY 

K0862PWC gp3 hd mult pow opt s/bY 

K0863PWC gp3 vhd mult pow opt s/bY 
K0864PWC gp3 xhd mult pow opt s/bY 

K0868PWC gp 4 std seat/backY 

K0869PWC gp 4 std cap chairY 

K0870PWC gp 4 hd seat/backY 

K0871PWC gp 4 vhd seat/backY 

K0877PWC gp4 std sing pow opt s/bY 

K0878PWC gp4 std sing pow opt capY 

K0879PWC gp4 hd sing pow opt s/bY 

K0880PWC gp4 vhd sing pow opt s/bY 

K0884PWC gp4 std mult pow opt s/bY 

K0885PWC gp4 std mult pow opt capY 

K0886PWC gp4 hd mult pow s/bY 

K0890PWC gp5 ped sing pow opt s/bY 

K0891PWC gp5 ped mult pow opt s/bY 

K0898Power wheelchair NOCY 

K0899Pow mobil dev no dmepdacY 

L0112Cranial cervical 

orthosisA

L0113Cranial cervical 

torticollisA

L0120Cerv flexible 

non-adjustableA

L0130Flex thermoplastic collar 

moA

L0140Cervical semi-rigid 

adjustabA

L0150Cerv semi-rig adj molded 
chnA

L0160Cerv semi-rig wire 

occ/mandA

L0170Cervical collar molded to 

ptA

L0172Cerv col thermplas foam 2 

piA

L0174Cerv col foam 2 piece w 

thorA

L0180Cer post col occ/man sup 

adjA

L0190Cerv collar supp adj cerv 

baA

L0200Cerv col supp adj bar & 

thorA

L0220Thor rib belt custom 

fabricaA

L0430Dewall posture 

protectorA

L0450TLSO flex prefab 

thoracicA

L0452tlso flex custom fab 

thoraciA

L0454TLSO flex prefab 

sacrococ-T9A

L0456TLSO flex 

prefabA

L0458TLSO 2Mod symphis-xipho 

preA

L0460TLSO2Mod symphysis-stern 

preA

L0462TLSO 3Mod sacro-scap 

preA

L0464TLSO 4Mod sacro-scap 

preA

L0466TLSO rigid frame pre soft 

apA

L0468TLSO rigid frame prefab 

pelvA

L0470TLSO rigid frame pre 

subclavA

L0472TLSO rigid frame hyperex 

preA

L0480TLSO rigid plastic custom 
faA

L0482TLSO rigid lined custom 

fabA

L0484TLSO rigid plastic cust 

fabA

L0486TLSO rigidlined cust fab 

twoA

L0488TLSO rigid lined pre one 

pieA

L0490TLSO rigid plastic pre 

oneA

L0491TLSO 2 piece rigid 

shellA

L0492TLSO 3 piece rigid 

shellA

L0621SIO flex pelvisacral 

prefabA

L0622SIO flex pelvisacral 

customA

L0623SIO panel 

prefabA

L0624SIO panel 

customA

L0625LO flexibl L1-below L5 

preA

L0626LO sag stays/panels 

pre-fabA

L0627LO sagitt rigid panel 

prefabA

L0628LO flex w/o rigid stays 

preA

L0629LSO flex w/rigid stays 

custA

L0630LSO post rigid panel 

preA

L0631LSO sag-coro rigid frame 

preA

L0632LSO sag rigid frame 

custA

L0633LSO flexion control 

prefabA

L0634LSO flexion control 

customA

L0635LSO sagit rigid panel 
prefabA

L0636LSO sagittal rigid panel 

cusA

L0637LSO sag-coronal panel 

prefabA

L0638LSO sag-coronal panel 

customA

L0639LSO s/c shell/panel 

prefabA

L0640LSO s/c shell/panel 

customA

L0700Ctlso a-p-l control 

moldedA

L0710Ctlso a-p-l control w/ 

interA

L0810Halo cervical into jckt 

vestA

L0820Halo cervical into body 

jackA

L0830Halo cerv into milwaukee 

typA

L0859MRI compatible 

systemA

L0861Halo repl 

liner/interfaceA

L0970Tlso corset 

frontA

L0972Lso corset 

frontA

L0974Tlso full 

corsetA

L0976Lso full 

corsetA

L0978Axillary crutch 

extensionA

L0980Peroneal straps 

pairA

L0982Stocking supp grips set of 

fA

L0984Protective body sock 

eachA

L0999Add to spinal orthosis 

NOSA

L1000Ctlso milwauke initial 
modelA

L1001CTLSO infant 

immobilizerA

L1005Tension based scoliosis 

orthA

L1010Ctlso axilla 

slingA

L1020Kyphosis 

padA

L1025Kyphosis pad 

floatingA

L1030Lumbar bolster 

padA

L1040Lumbar or lumbar rib 

padA

L1050Sternal 

padA

L1060Thoracic 

padA

L1070Trapezius 

slingA

L1080OutriggerA

L1085Outrigger bil w/ vert 

extensA

L1090Lumbar 

slingA

L1100Ring flange 

plastic/leatherA

L1110Ring flange plas/leather 

molA

L1120Covers for upright 

eachA

L1200Furnsh initial orthosis 

onlyA

L1210Lateral thoracic 

extensionA

L1220Anterior thoracic 

extensionA

L1230Milwaukee type 

superstructurA

L1240Lumbar derotation 

padA

L1250Anterior asis 

padA
L1260Anterior thoracic 

derotationA

L1270Abdominal 

padA

L1280Rib gusset (elastic) 

eachA

L1290Lateral trochanteric 

padA

L1300Body jacket mold to 

patientA

L1310Post-operative body 

jacketA

L1499Spinal orthosis 

NOSA

L1500Thkao mobility 

frameA

L1510Thkao standing 

frameA

L1520Thkao swivel 

walkerA

L1600Abduct hip flex frejka w 

cvrA

L1610Abduct hip flex frejka 

covrA

L1620Abduct hip flex pavlik 

harneA

L1630Abduct control hip 

semi-flexA

L1640Pelv band/spread bar thigh 

cA

L1650HO abduction hip 

adjustableA

L1652HO bi thighcuffs w sprdr 

barA

L1660HO abduction static 

plasticA

L1680Pelvic & hip control thigh 

cA

L1685Post-op hip abduct custom 

faA

L1686HO post-op hip 

abductionA

L1690Combination bilateral 

HOA
L1700Leg perthes orth toronto 

typA

L1710Legg perthes orth 

newingtonA

L1720Legg perthes orthosis 

trilatA

L1730Legg perthes orth scottish 

rA

L1755Legg perthes patten bottom 

tA

L1810Ko elastic with 

jointsA

L1820Ko elas w/ condyle pads & 

joA

L1830Ko immobilizer canvas 

longitA

L1831Knee orth pos locking 

jointA

L1832KO adj jnt pos rigid 

supportA

L1834Ko w/0 joint rigid molded 

toA

L1836Rigid KO wo 

jointsA

L1840Ko derot ant cruciate 

customA

L1843KO single upright custom 

fitA

L1844Ko w/adj jt rot cntrl 

moldedA

L1845Ko w/ adj flex/ext rotat 

cusA

L1846Ko w adj flex/ext rotat 

moldA

L1847KO adjustable w air 

chambersA

L1850Ko swedish 

typeA

L1860Ko supracondylar socket 

moldA

L1900Afo sprng wir drsflx calf 

bdA

L1902Afo ankle 

gauntletA
L1904Afo molded ankle 

gauntletA

L1906Afo multiligamentus ankle 

suA

L1907AFO supramalleolar 

customA

L1910Afo sing bar clasp attach 

shA

L1920Afo sing upright w/ adjust 

sA

L1930Afo 

plasticA

L1932Afo rig ant tib prefab 

TCF/=A

L1940Afo molded to patient 

plastiA

L1945Afo molded plas rig ant 

tibA

L1950Afo spiral molded to pt 

plasA

L1951AFO spiral 

prefabricatedA

L1960Afo pos solid ank plastic 

moA

L1970Afo plastic molded w/ankle 

jA

L1971"AFO w/ankle joint, 

prefab"A

L1980Afo sing solid stirrup 

calfA

L1990Afo doub solid stirrup 

calfA

L2000Kafo sing fre stirr 

thi/calfA

L2005KAFO sng/dbl mechanical 

actA

L2010Kafo sng solid stirrup w/o 

jA

L2020Kafo dbl solid stirrup 

band/A

L2030Kafo dbl solid stirrup w/o 

jA

L2034KAFO pla sin up w/wo k/a 

cusA
L2035KAFO plastic pediatric 

sizeA

L2036Kafo plas doub free knee 

molA

L2037Kafo plas sing free knee 

molA

L2038Kafo w/o joint multi-axis 

anA

L2040Hkafo torsion bil rot 

strapsA

L2050Hkafo torsion cable hip 

pelvA

L2060Hkafo torsion ball bearing 

jA

L2070Hkafo torsion unilat rot 

strA

L2080Hkafo unilat torsion 

cableA

L2090Hkafo unilat torsion ball 

brA

L2106Afo tib fx cast plaster 

moldA

L2108Afo tib fx cast molded to 

ptA

L2112Afo tibial fracture 

softA

L2114Afo tib fx 

semi-rigidA

L2116Afo tibial fracture 

rigidA

L2126Kafo fem fx cast 

thermoplasA

L2128Kafo fem fx cast molded to 

pA

L2132Kafo femoral fx cast 

softA

L2134Kafo fem fx cast 

semi-rigidA

L2136Kafo femoral fx cast 

rigidA

L2180Plas shoe insert w ank 

jointA

L2182Drop lock 

kneeA
L2184Limited motion knee 

jointA

L2186Adj motion knee jnt lerman 

tA

L2188Quadrilateral 

brimA

L2190Waist 

beltA

L2192Pelvic band & belt thigh 

flaA

L2200Limited ankle motion ea 

jntA

L2210Dorsiflexion assist each 

joiA

L2220Dorsi & plantar flex 

ass/resA

L2230Split flat caliper stirr & 

pA

L2232"Rocker bottom, contact 

AFO"A

L2240Round caliper and plate 

attaA

L2250Foot plate molded stirrup 

atA

L2260Reinforced solid 

stirrupA

L2265Long tongue 

stirrupA

L2270Varus/valgus strap 

padded/liA

L2275Plastic mod low ext 

pad/lineA

L2280Molded inner 

bootA

L2300Abduction bar jointed 

adjustA

L2310Abduction 

bar-straightA

L2320Non-molded 

lacerA

L2330Lacer molded to patient 

modeA

L2335Anterior swing 

bandA
L2340Pre-tibial shell molded to 

pA

L2350Prosthetic type socket 

moldeA

L2360Extended steel 

shankA

L2370Patten 

bottomA

L2375Torsion ank & half solid 

stiA

L2380Torsion straight knee 

jointA

L2385Straight knee joint heavy 

duA

L2387Add LE poly knee custom 

KAFOA

L2390Offset knee joint 

eachA

L2395Offset knee joint heavy 

dutyA

L2397Suspension sleeve lower 

extA

L2405Knee joint drop lock ea 

jntA

L2415Knee joint cam lock each 

joiA

L2425Knee disc/dial lock/adj 

flexA

L2430Knee jnt ratchet lock ea 

jntA

L2492Knee lift loop drop lock 

rinA

L2500Thi/glut/ischia wgt 

bearingA

L2510Th/wght bear quad-lat brim 

mA

L2520Th/wght bear quad-lat brim 

cA

L2525Th/wght bear nar m-l brim 

moA

L2526Th/wght bear nar m-l brim 

cuA

L2530Thigh/wght bear lacer 

non-moA
L2540Thigh/wght bear lacer 

moldedA

L2550Thigh/wght bear high roll 

cuA

L2570Hip clevis type 2 posit 

jntA

L2580Pelvic control pelvic 

slingA

L2600Hip clevis/thrust bearing 

frA

L2610Hip clevis/thrust bearing 

loA

L2620Pelvic control hip heavy 

dutA

L2622Hip joint adjustable 

flexionA

L2624Hip adj flex ext abduct 

contA

L2627Plastic mold recipro hip & 

cA

L2628Metal frame recipro hip & 

caA

L2630Pelvic control band & belt 

uA

L2640Pelvic control band & belt 

bA

L2650Pelv & thor control 

glutealA

L2660Thoracic control thoracic 

baA

L2670Thorac cont paraspinal 

uprigA

L2680Thorac cont lat support 

upriA

L2750Plating chrome/nickel pr 

barA

L2755Carbon graphite 

laminationA

L2760Extension per extension 

perA

L2768Ortho sidebar 

disconnectA

L2780Non-corrosive 

finishA
L2785Drop lock retainer 

eachA

L2795Knee control full 

kneecapA

L2800Knee cap medial or lateral 

pA

L2810Knee control condylar 

padA

L2820Soft interface below knee 

seA

L2830Soft interface above knee 

seA

L2840Tibial length sock fx or 

equA

L2850Femoral lgth sock fx or 

equaA

L2861Torsion mechanism 

knee/ankleE

L2999Lower extremity orthosis 

NOSA

L3000Ft insert ucb berkeley 

shellA

L3001Foot insert remov molded 

speA

L3002Foot insert plastazote or 

eqA

L3003Foot insert silicone gel 

eacA

L3010Foot longitudinal arch 

suppoA

L3020Foot longitud/metatarsal 

supA

L3030Foot arch support remov 

premA

L3031Foot lamin/prepreg 

compositeA

L3040Ft arch suprt premold 

longitA

L3050Foot arch supp premold 

metatA

L3060Foot arch supp 

longitud/metaA

L3070Arch suprt att to sho 

longitA
L3080Arch supp att to shoe 

metataA

L3090Arch supp att to shoe 

long/mA

L3100Hallus-valgus nght dynamic 

sA

L3140Abduction rotation bar 

shoeA

L3150Abduct rotation bar w/o 

shoeA

L3160Shoe styled positioning 

devA

L3170Foot plastic heel 

stabilizerA

L3201Oxford w supinat/pronat 

infA

L3202Oxford w/ supinat/pronator 

cA

L3203Oxford w/ 

supinator/pronatorA

L3204Hightop w/ supp/pronator 

infA

L3206Hightop w/ supp/pronator 

chiA

L3207Hightop w/ supp/pronator 

junA

L3208Surgical boot each 

infantA

L3209Surgical boot each 

childA

L3211Surgical boot each 

juniorA

L3212Benesch boot pair 

infantA

L3213Benesch boot pair 

childA

L3214Benesch boot pair 

juniorA

L3215Orthopedic ftwear ladies oxfE 

L3216Orthoped ladies shoes dpth iE 

L3217Ladies shoes hightop depth iE 
L3219Orthopedic mens shoes oxfordE 

L3221Orthopedic mens shoes dpth iE 

L3222Mens shoes hightop depth inlE 

L3224Woman's shoe oxford 

braceA

L3225Man's shoe oxford 

braceA

L3230Custom shoes depth inlayA 

L3250Custom mold shoe remov prostA 

L3251Shoe molded to pt silicone sA 

L3252Shoe molded plastazote custA 

L3253Shoe molded plastazote custA 

L3254Orth foot non-stndard size/wA 

L3255Orth foot non-standard size/A 

L3257Orth foot add charge split sA 

L3260Ambulatory surgical boot 

eacE

L3265Plastazote sandal eachA 

L3300Sho lift taper to metatarsalA 

L3310Shoe lift elev heel/sole neoA 

L3320Shoe lift elev heel/sole corA 

L3330Lifts elevation metal extensA 

L3332Shoe lifts tapered to one-haA 

L3334Shoe lifts elevation heel /iA 

L3340Shoe wedge sachA 
L3350Shoe heel wedgeA 

L3360Shoe sole wedge outside soleA 

L3370Shoe sole wedge between soleA 

L3380Shoe clubfoot wedgeA 

L3390Shoe outflare wedgeA 

L3400Shoe metatarsal bar wedge roA 

L3410Shoe metatarsal bar betweenA 

L3420Full sole/heel wedge btweenA 

L3430Sho heel count plast reinforA 

L3440Heel leather reinforcedA 

L3450Shoe heel sach cushion typeA 

L3455Shoe heel new leather standaA 

L3460Shoe heel new rubber standarA 

L3465Shoe heel thomas with wedgeA 

L3470Shoe heel thomas extend to bA 

L3480Shoe heel pad & depress forA 

L3485Shoe heel pad removable forA 

L3500Ortho shoe add leather insolA 

L3510Orthopedic shoe add rub inslA 

L3520O shoe add felt w leath inslA 

L3530Ortho shoe add half soleA 

L3540Ortho shoe add full soleA 
L3550O shoe add standard toe tapA 

L3560O shoe add horseshoe toe tapA 

L3570O shoe add instep extensionA 

L3580O shoe add instep velcro cloA 

L3590O shoe convert to sof counteA 

L3595Ortho shoe add march barA 

L3600Trans shoe calip plate existA 

L3610Trans shoe caliper plate newA 

L3620Trans shoe solid stirrup exiA 

L3630Trans shoe solid stirrup newA 

L3640Shoe dennis browne splint boA 

L3649Orthopedic shoe modifica NOSA 

L3650Shlder fig 8 abduct 

restrainA

L3660Abduct restrainer 

canvas&webA

L3670Acromio/clavicular 

canvas&weA

L3671SO cap design w/o jnts 

CFA

L3674SO airplane w/wo joint 

CFA

L3675Canvas vest 

SOA

L3677SO hard plastic 

stabilizerA

L3702EO w/o joints 

CFA

L3710Elbow elastic with metal 

joiA

L3720Forearm/arm cuffs free 

motioA
L3730Forearm/arm cuffs ext/flex 

aA

L3740Cuffs adj lock w/ active 

conA

L3760"EO withjoint, 

Prefabricated"A

L3762Rigid EO wo 

jointsA

L3763EWHO rigid w/o jnts 

CFA

L3764EWHO w/joint(s) 

CFA

L3765EWHFO rigid w/o jnts 

CFA

L3766EWHFO w/joint(s) 

CFA

L3806WHFO w/joint(s) custom 

fabA

L3807"WHFO,no joint, 

prefabricated"A

L3808"WHFO, rigid w/o 

joints"A

L3891Torsion mechanism 

wrist/elboE

L3900Hinge extension/flex 

wrist/fA

L3901Hinge ext/flex wrist 

fingerA

L3904Whfo electric custom 

fittedA

L3905WHO w/nontorsion jnt(s) 

CFA

L3906WHO w/o joints 

CFA

L3908Wrist cock-up 

non-moldedA

L3912Flex glove w/elastic 

fingerA

L3913HFO w/o joints 

CFA

L3915WHO w nontor jnt(s) 

prefabA

L3917Prefab metacarpl fx 

orthosisA
L3919HO w/o joints 

CFA

L3921HFO w/joint(s) 

CFA

L3923HFO w/o joints 

PFA

L3925FO pip/dip with 

joint/springA

L3927FO pip/dip w/o 

joint/springA

L3929"HFO nontorsion joint, 

prefab"A

L3931WHFO nontorsion joint 

prefabA

L3933FO w/o joints 

CFA

L3935FO nontorsion joint 

CFA

L3956Add joint upper ext 

orthosisA

L3960Sewho airplan desig abdu 

posA

L3961SEWHO cap design w/o jnts 

CFA

L3962Sewho erbs palsey design 

abdA

L3964Seo mobile arm sup att to 

wcY

L3965Arm supp att to wc rancho 

tyY

L3966Mobile arm supports 

reclininY

L3967SEWHO airplane w/o jnts 

CFA

L3968Friction dampening arm 

suppY

L3969Monosuspension arm/hand 

suppY

L3970Elevat proximal arm 

supportY

L3971SEWHO cap design w/jnt(s) 

CFA

L3972Offset/lat rocker arm w/ 

elaY
L3973SEWHO airplane w/jnt(s) 

CFA

L3974Mobile arm support 

supinatorY

L3975SEWHFO cap design w/o jnt 

CFA

L3976SEWHFO airplane w/o jnts 

CFA

L3977SEWHFO cap desgn w/jnt(s) 

CFA

L3978SEWHFO airplane w/jnt(s) 

CFA

L3980Upp ext fx orthosis 

humeralA

L3982Upper ext fx orthosis 

rad/ulA

L3984Upper ext fx orthosis 

wristA

L3995Sock fracture or equal 

eachA

L3999Upper limb orthosis 

NOSA

L4000Repl girdle milwaukee 

orthA

L4002"Replace strap, any 

orthosis"A

L4010Replace trilateral socket 

brA

L4020Replace quadlat socket 

brimA

L4030Replace socket brim cust 

fitA

L4040Replace molded thigh 

lacerA

L4045Replace non-molded thigh 

lacA

L4050Replace molded calf 

lacerA

L4055Replace non-molded calf 

laceA

L4060Replace high roll 

cuffA

L4070Replace prox & dist 

uprightA
L4080Repl met band kafo-afo 

proxA

L4090Repl met band kafo-afo 

calf/A

L4100Repl leath cuff kafo prox 

thA

L4110Repl leath cuff kafo-afo 

calA

L4130Replace pretibial 

shellA

L4205Ortho dvc repair per 15 

minA

L4210Orth dev repair/repl minor 

pA

L4350Ankle control orthosi 

prefabA

L4360Pneumati walking boot 

prefabA

L4370Pneumatic full leg 

splintA

L4380Pneumatic knee 

splintA

L4386Non-pneum walk boot 

prefabA

L4392Replace AFO soft 

interfaceA

L4394Replace foot drop 

spintA

L4396Static 

AFOA

L4398Foot drop splint 

recumbentA

L4631"Afo, walk boot type, cus 

fab"A

L5000Sho insert w arch toe 

fillerA

L5010Mold socket ank hgt w/ toe 

fA

L5020Tibial tubercle hgt w/ toe 

fA

L5050Ank symes mold sckt sach 

ftA

L5060Symes met fr leath socket 

arA
L5100Molded socket shin sach 

footA

L5105Plast socket jts/thgh 

lacerA

L5150Mold sckt ext knee shin 

sachA

L5160Mold socket bent knee shin 

sA

L5200Kne sing axis fric shin 

sachA

L5210No knee/ankle joints w/ ft 

bA

L5220No knee joint with artic 

aliA

L5230Fem focal defic constant 

friA

L5250Hip canad sing axi cons 

fricA

L5270Tilt table locking hip 

singA

L5280Hemipelvect canad sing 

axisA

L5301BK mold socket SACH ft 

endoA

L5311"Knee disart, SACH ft, 

endo"A

L5321AK open end 

SACHA

L5331Hip disart canadian SACH 

ftA

L5341Hemipelvectomy canadian 

SACHA

L5400Postop dress & 1 cast chg 

bkA

L5410Postop dsg bk ea add cast 

chA

L5420Postop dsg & 1 cast chg 

ak/dA

L5430Postop dsg ak ea add cast 

chA

L5450Postop app non-wgt bear 

dsgA

L5460Postop app non-wgt bear 

dsgA
L5500Init bk ptb plaster 

directA

L5505Init ak ischal plstr 

directA

L5510Prep BK ptb plaster 

moldedA

L5520Perp BK ptb thermopls 

directA

L5530Prep BK ptb thermopls 

moldedA

L5535Prep BK ptb open end 

socketA

L5540Prep BK ptb laminated 

socketA

L5560Prep AK ischial plast 

moldedA

L5570Prep AK ischial direct 

formA

L5580Prep AK ischial thermo 

moldA

L5585Prep AK ischial open 

endA

L5590Prep AK ischial 

laminatedA

L5595Hip disartic sach 

thermoplsA

L5600Hip disart sach laminat 

moldA

L5610Above knee 

hydracadenceA

L5611Ak 4 bar link w/fric 

swingA

L5613Ak 4 bar ling w/hydraul 

swigA

L56144-bar link above knee 

w/swngA

L5616Ak univ multiplex sys 

frictA

L5617AK/BK self-aligning unit 

eaA

L5618Test socket 

symesA

L5620Test socket below 

kneeA
L5622Test socket knee 

disarticulaA

L5624Test socket above 

kneeA

L5626Test socket hip 

disarticulatA

L5628Test socket 

hemipelvectomyA

L5629Below knee acrylic 

socketA

L5630Syme typ expandabl wall 

scktA

L5631Ak/knee disartic acrylic 

socA

L5632Symes type ptb brim design 

sA

L5634Symes type poster opening 

soA

L5636Symes type medial opening 

soA

L5637Below knee total 

contactA

L5638Below knee leather 

socketA

L5639Below knee wood 

socketA

L5640Knee disarticulat leather 

soA

L5642Above knee leather 

socketA

L5643Hip flex inner socket ext 

frA

L5644Above knee wood 

socketA

L5645Bk flex inner socket ext 

fraA

L5646Below knee cushion 

socketA

L5647Below knee suction 

socketA

L5648Above knee cushion 

socketA

L5649Isch containmt/narrow m-l 

soA
L5650Tot contact ak/knee disart 

sA

L5651Ak flex inner socket ext 

fraA

L5652Suction susp ak/knee 

disartA

L5653Knee disart expand wall 

sockA

L5654Socket insert 

symesA

L5655Socket insert below 

kneeA

L5656Socket insert knee 

articulatA

L5658Socket insert above 

kneeA

L5661Multi-durometer 

symesA

L5665Multi-durometer below 

kneeA

L5666Below knee cuff 

suspensionA

L5668Socket insert w/o lock 

lowerA

L5670Bk molded supracondylar 

suspA

L5671BK/AK locking 

mechanismA

L5672Bk removable medial brim 

susA

L5673Socket insert w lock 

mechA

L5676Bk knee joints single axis 

pA

L5677Bk knee joints polycentric 

pA

L5678Bk joint covers 

pairA

L5679Socket insert w/o lock 

mechA

L5680Bk thigh lacer 

non-moldedA

L5681Intl custm cong/latyp 

insertA
L5682Bk thigh lacer glut/ischia 

mA

L5683Initial custom socket 

insertA

L5684Bk fork 

strapA

L5685Below knee sus/seal 

sleeveA

L5686Bk back 

checkA

L5688Bk waist belt 

webbingA

L5690Bk waist belt padded and 

linA

L5692Ak pelvic control belt 

lightA

L5694Ak pelvic control belt 

pad/lA

L5695Ak sleeve susp 

neoprene/equaA

L5696Ak/knee disartic pelvic 

joinA

L5697Ak/knee disartic pelvic 

bandA

L5698Ak/knee disartic silesian 

baA

L5699Shoulder 

harnessA

L5700Replace socket below 

kneeA

L5701Replace socket above 

kneeA

L5702Replace socket 

hipA

L5703Symes ankle w/o (SACH) 

footA

L5704Custom shape cover 

BKA

L5705Custom shape cover 

AKA

L5706Custom shape cvr knee 

disartA

L5707Custom shape cvr hip 

disartA
L5710Kne-shin exo sng axi mnl 

locA

L5711Knee-shin exo mnl lock 

ultraA

L5712Knee-shin exo frict swg & 

stA

L5714Knee-shin exo variable 

frictA

L5716Knee-shin exo mech stance 

phA

L5718Knee-shin exo frct swg & 

staA

L5722Knee-shin pneum swg frct 

exoA

L5724Knee-shin exo fluid swing 

phA

L5726Knee-shin ext jnts fld swg 

eA

L5728Knee-shin fluid swg & 

stanceA

L5780Knee-shin pneum/hydra 

pneumA

L5781Lower limb pros vacuum 

pumpA

L5782HD low limb pros vacuum 

pumpA

L5785Exoskeletal bk ultralt 

materA

L5790Exoskeletal ak ultra-light 

mA

L5795Exoskel hip ultra-light 

mateA

L5810Endoskel knee-shin mnl 

lockA

L5811Endo knee-shin mnl lck 

ultraA

L5812Endo knee-shin frct swg & 

stA

L5814Endo knee-shin hydral swg 

phA

L5816Endo knee-shin polyc mch 

staA

L5818Endo knee-shin frct swg & 

stA
L5822Endo knee-shin pneum swg 

frcA

L5824Endo knee-shin fluid swing 

pA

L5826Miniature knee 

jointA

L5828Endo knee-shin fluid 

swg/staA

L5830Endo knee-shin pneum/swg 

phaA

L5840Multi-axial knee/shin 

systemA

L5845Knee-shin sys stance 

flexionA

L5848Knee-shin sys hydraul 

stanceA

L5850Endo ak/hip knee extens 

assiA

L5855Mech hip extension 

assistA

L5856Elec knee-shin 

swing/stanceA

L5857Elec knee-shin swing 

onlyA

L5858Stance phase 

onlyA

L5910Endo below knee alignable 

syA

L5920Endo ak/hip alignable 

systemA

L5925Above knee manual 

lockA

L5930High activity knee 

frameA

L5940Endo bk ultra-light 

materialA

L5950Endo ak ultra-light 

materialA

L5960Endo hip ultra-light 

materiaA

L5961"Endo poly hip, 

pneu/hyd/rot"A

L5962Below knee flex cover 

systemA
L5964Above knee flex cover 

systemA

L5966Hip flexible cover 

systemA

L5968Multiaxial ankle w 

dorsiflexA

L5970Foot external keel sach 

footA

L5971"SACH foot, 

replacement"A

L5972Flexible keel 

footA

L5973Ank-foot sys dors-plant 

flexA

L5974Foot single axis 

ankle/footA

L5975Combo ankle/foot 

prosthesisA

L5976Energy storing 

footA

L5978Ft prosth multiaxial 

ankl/ftA

L5979Multi-axial ankle/ft 

prosthA

L5980Flex foot 

systemA

L5981Flex-walk sys low ext 

prosthA

L5982Exoskeletal axial rotation 

uA

L5984Endoskeletal axial 

rotationA

L5985Lwr ext dynamic prosth 

pylonA

L5986Multi-axial rotation 

unitA

L5987Shank ft w vert load 

pylonA

L5988Vertical shock reducing 

pyloA

L5990User adjustable heel 

heightA

L5999Lowr extremity prosthes 

NOSA
L6000Par hand robin-aids thum 

remA

L6010Hand robin-aids 

little/ringA

L6020Part hand robin-aids no 

fingA

L6025Part hand disart 

myoelectricA

L6050Wrst MLd sck flx hng tri 

padA

L6055Wrst mold sock w/exp 

interfaA

L6100Elb mold sock flex hinge 

padA

L6110Elbow mold sock suspension 

tA

L6120Elbow mold doub splt soc 

steA

L6130Elbow stump activated lock 

hA

L6200Elbow mold outsid lock 

hingeA

L6205Elbow molded w/ expand 

interA

L6250Elbow inter loc elbow 

forarmA

L6300Shlder disart int lock 

elbowA

L6310Shoulder passive restor 

compA

L6320Shoulder passive restor 

capA

L6350Thoracic intern lock 

elbowA

L6360Thoracic passive restor 

compA

L6370Thoracic passive restor 

capA

L6380Postop dsg cast chg 

wrst/elbA

L6382Postop dsg cast chg elb 

dis/A

L6384Postop dsg cast chg 

shlder/tA
L6386Postop ea cast chg & 

realignA

L6388Postop applicat rigid dsg 

onA

L6400Below elbow prosth tiss 

shapA

L6450Elb disart prosth tiss 

shapA

L6500Above elbow prosth tiss 

shapA

L6550Shldr disar prosth tiss 

shapA

L6570Scap thorac prosth tiss 

shapA

L6580Wrist/elbow bowden cable 

molA

L6582Wrist/elbow bowden cbl dir 

fA

L6584Elbow fair lead cable 

moldedA

L6586Elbow fair lead cable dir 

foA

L6588Shdr fair lead cable 

moldedA

L6590Shdr fair lead cable 

directA

L6600Polycentric hinge 

pairA

L6605Single pivot hinge 

pairA

L6610Flexible metal hinge 

pairA

L6611"Additional switch, ext 

power"A

L6615Disconnect locking wrist 

uniA

L6616Disconnect insert locking 

wrA

L6620Flexion/extension wrist 

unitA

L6621Flex/ext wrist w/wo 

frictionA

L6623Spring-ass rot wrst w/ 

latchA
L6624Flex/ext/rotation wrist 

unitA

L6625Rotation wrst w/ cable 

lockA

L6628Quick disconn hook adapter 

oA

L6629Lamination collar w/ 

couplinA

L6630Stainless steel any 

wristA

L6632Latex suspension sleeve 

eachA

L6635Lift assist for 

elbowA

L6637Nudge control elbow 

lockA

L6638Elec lock on manual pw 

elbowA

L6640Shoulder abduction joint 

paiA

L6641Excursion amplifier pulley 

tA

L6642Excursion amplifier lever 

tyA

L6645Shoulder flexion-abduction 

jA

L6646Multipo locking shoulder 

jntA

L6647Shoulder lock 

actuatorA

L6648Ext pwrd shlder 

lock/unlockA

L6650Shoulder universal 

jointA

L6655Standard control cable 

extraA

L6660Heavy duty control 

cableA

L6665Teflon or equal cable 

liningA

L6670Hook to hand cable 

adapterA

L6672Harness chest/shlder 

saddleA
L6675Harness figure of 8 sing 

conA

L6676Harness figure of 8 dual 

conA

L6677UE triple control 

harnessA

L6680Test sock wrist disart/bel 

eA

L6682Test sock elbw 

disart/aboveA

L6684Test socket shldr 

disart/thoA

L6686Suction 

socketA

L6687Frame typ socket bel 

elbow/wA

L6688Frame typ sock above 

elb/disA

L6689Frame typ socket shoulder 

diA

L6690Frame typ sock 

interscap-thoA

L6691Removable insert 

eachA

L6692Silicone gel insert or 

equalA

L6693Lockingelbow forearm 

cntrbalA

L6694Elbow socket ins use 

w/lockA

L6695Elbow socket ins use w/o 

lckA

L6696Cus elbo skt in for 

con/atypA

L6697Cus elbo skt in not 

con/atypA

L6698Below/above elbow lock 

mechA

L6703"Term dev, passive hand mitt 

"A

L6704"Term dev, sport/rec/work 

att"A

L6706Term dev mech hook vol openA 
L6707Term dev mech hook vol 

closeA

L6708Term dev mech hand vol 

openA

L6709Term dev mech hand vol 

closeA

L6711"Ped term dev, hook, vol 

open"A

L6712"Ped term dev, hook, vol 

clos"A

L6713"Ped term dev, hand, vol 

open"A

L6714"Ped term dev, hand, vol 

clos"A

L6721"Hook/hand, hvy dty, vol 

open"A

L6722"Hook/hand, hvy dty, vol 

clos"A

L6805Term dev modifier wrist 

unitA

L6810Term dev precision pinch 

devA

L6881Term dev auto grasp 

featureA

L6882Microprocessor control 

uplmbA

L6883Replc sockt below e/w 

disaA

L6884Replc sockt above elbow 

disaA

L6885Replc sockt shldr 

dis/intercA

L6890Prefab glove for term 

deviceA

L6895Custom glove for term 

deviceA

L6900Hand restorat thumb/1 

fingerA

L6905Hand restoration multiple 

fiA

L6910Hand restoration no 

fingersA

L6915Hand restoration replacmnt 

gA
L6920Wrist disarticul switch 

ctrlA

L6925Wrist disart myoelectronic 

cA

L6930Below elbow switch 

controlA

L6935Below elbow myoelectronic 

ctA

L6940Elbow disarticulation 

switchA

L6945Elbow disart myoelectronic 

cA

L6950Above elbow switch 

controlA

L6955Above elbow myoelectronic 

ctA

L6960Shldr disartic switch 

controA

L6965Shldr disartic 

myoelectronicA

L6970Interscapular-thor switch 

ctA

L6975Interscap-thor 

myoelectronicA

L7007Adult electric 

handA

L7008Pediatric electric 

handA

L7009Adult electric 

hookA

L7040Prehensile 

actuatorA

L7045Pediatric electric 

hookA

L7170Electronic elbow hosmer 

switA

L7180Electronic elbow 

sequentialA

L7181Electronic elbo 

simultaneousA

L7185Electron elbow adolescent 

swA

L7186Electron elbow child 

switchA
L7190Elbow adolescent 

myoelectronA

L7191Elbow child myoelectronic 

ctA

L7260Electron wrist rotator 

ottoA

L7261Electron wrist rotator 

utahA

L7266Servo control steeper or 

equA

L7272Analogue control unb or 

equaA

L7274Proportional ctl 12 volt 

utaA

L7360Six volt bat otto bock/eq 

eaA

L7362Battery chrgr six volt 

ottoA

L7364Twelve volt battery 

utah/equA

L7366Battery chrgr 12 volt 

utah/eA

L7367Replacemnt lithium 

ionbatterA

L7368Lithium ion battery 

chargerA

L7400"Add UE prost be/wd, 

ultlite"A

L7401Add UE prost a/e ultlite 

matA

L7402Add UE prost s/d ultlite 

matA

L7403Add UE prost b/e 

acrylicA

L7404Add UE prost a/e 

acrylicA

L7405Add UE prost s/d 

acrylicA

L7499Upper extremity prosthes 

NOSA

L7500Prosthetic dvc repair 

hourlyA

L7510Prosthetic device repair 

repA
L7520Repair prosthesis per 15 

minA

L7600Prosthetic donning sleeveE 

L7900Male vacuum erection 

systemA

L8000Mastectomy 

braA

L8001Breast prosthesis bra & 

formA

L8002Brst prsth bra & bilat 

formA

L8010Mastectomy 

sleeveA

L8015Ext breastprosthesis 

garmentA

L8020Mastectomy 

formA

L8030Breast prosthes w/o 

adhesiveA

L8031Breast prosthesis w 

adhesiveA

L8032Reusable nipple 

prosthesisA

L8035Custom breast 

prosthesisA

L8039Breast prosthesis 

NOSA

L8040Nasal 

prosthesisA

L8041Midfacial 

prosthesisA

L8042Orbital 

prosthesisA

L8043Upper facial 

prosthesisA

L8044Hemi-facial 

prosthesisA

L8045Auricular 

prosthesisA

L8046Partial facial 

prosthesisA

L8047Nasal septal 

prosthesisA
L8048Unspec maxillofacial 

prosthA

L8049Repair maxillofacial 

prosthA

L8300Truss single w/ standard 

padA

L8310Truss double w/ standard 

padA

L8320Truss addition to std pad 

waA

L8330Truss add to std pad 

scrotalA

L8400Sheath below 

kneeA

L8410Sheath above 

kneeA

L8415Sheath upper 

limbA

L8417Pros sheath/sock w gel 

cushnA

L8420Prosthetic sock multi ply 

BKA

L8430Prosthetic sock multi ply 

AKA

L8435Pros sock multi ply upper 

lmA

L8440Shrinker below 

kneeA

L8460Shrinker above 

kneeA

L8465Shrinker upper 

limbA

L8470Pros sock single ply 

BKA

L8480Pros sock single ply 

AKA

L8485Pros sock single ply upper 

lA

L8499Unlisted misc prosthetic 

serA

L8500Artificial 

larynxA

L8501Tracheostomy speaking 

valveA
L8505"Artificial larynx, 

accessory"A

L8507Trach-esoph voice pros pt 

inA

L8509Trach-esoph voice pros md 

inA

L8510Voice 

amplifierA

L8511Indwelling trach 

insertA

L8512Gel cap for trach voice 

prosA

L8513Trach pros cleaning 

deviceA

L8514Repl trach puncture 

dilatorA

L8515Gel cap app device for 

trachA

L8600Implant breast 

silicone/eqN

L8603Collagen imp urinary 2.5 

mlN

L8604Dextranomer/hyaluronic 

acidN

L8606Synthetic implnt urinary 

1mlN

L8609Artificial 

corneaN

L8610Ocular 

implantN

L8612Aqueous shunt 

prosthesisN

L8613Ossicular 

implantN

L8614Cochlear 

deviceN

L8615Coch implant headset 

replaceA

L8616Coch implant microphone 

replA

L8617Coch implant trans coil 

replA

L8618Coch implant tran cable 

replA
L8619Coch imp ext proc/contr 

rplcA

L8621Repl zinc air 

batteryA

L8622Repl alkaline 

batteryA

L8623"Lith ion batt 

CID,non-earlvl"A

L8624"Lith ion batt CID, ear 

level"A

L8627CID ext speech process 

replA

L8628CID ext controller 

replA

L8629CID transmit coil and 

cableA

L8630Metacarpophalangeal 

implantN

L8631MCP joint repl 2 pc or 

moreN

L8641Metatarsal joint 

implantN

L8642Hallux 

implantN

L8658Interphalangeal joint 

spacerN

L8659Interphalangeal joint 

replN

L8670"Vascular graft, 

synthetic"N

L8680Implt neurostim elctr 

eachN

L8681Pt prgrm for implt 

neurostimA

L8682Implt neurostim radiofq 

recN

L8683Radiofq trsmtr for implt 

neuA

L8684Radiof trsmtr implt scrl 

neuA

L8685Implt nrostm pls gen sng recN 

L8686Implt nrostm pls gen sng nonN 
L8687Implt nrostm pls gen dua recN 

L8688Implt nrostm pls gen dua nonN 

L8689External recharg sys 

internA

L8690"Aud osseo dev, int/ext 

comp"N

L8691Osseointegrated snd proc 

rplA

L8692Non-osseointegrated snd 

procE

L8693"Aud osseo dev, 

abutment"A

L8695External recharg sys 

externA

L8699Prosthetic implant 

NOSN

L9900O&P 

supply/accessory/serviceN

M0064Visit for drug 

monitoringQ306071.9242$133.58.$26.72

M0075Cellular 

therapyE

M0076ProlotherapyE

M0100Intragastric 

hypothermiaE

M0300IV 

chelationtherapyE

M0301Fabric wrapping of 

aneurysmE

P2028Cephalin floculation 

testA

P2029Congo red blood 

testA

P2031Hair 

analysisE

P2033Blood thymol 

turbidityA

P2038Blood 

mucoproteinA

P3000Screen pap by tech w md 
supvA

P3001Screening pap smear by 

physB

P7001Culture bacterial 

urineE

P9010Whole blood for transfusionR 

09502.7926$193.86.$38.78

P9011Blood split unitR 

09672.2455$155.88.$31.18

P9012Cryoprecipitate each unitR 

09521.0975$76.19.$15.24

P9016RBC leukocytes reducedR 

09542.8046$194.70.$38.94

P9017Plasma 1 donor frz w/in 8 hrR 

95081.0927$75.86.$15.18

P9019"Platelets, each unit"R 

09571.2522$86.93.$17.39

P9020Plaelet rich plasma unitR 

09581.9703$136.78.$27.36

P9021Red blood cells unitR 

09592.1382$148.43.$29.69

P9022Washed red blood cells unitR 

09604.0969$284.41.$56.89

P9023"Frozen plasma, pooled, sd"R 

09491.0221$70.95.$14.19

P9031Platelets leukocytes reducedR 

10131.7459$121.20.$24.24

P9032"Platelets, irradiated"R 

95002.1768$151.11.$30.23

P9033Platelets leukoreduced irradR 

09682.0418$141.74.$28.35

P9034"Platelets, pheresis"R 

95076.0636$420.94.$84.19

P9035Platelet pheres leukoreducedR 

95017.5524$524.29.$104.86
P9036Platelet pheresis irradiatedR 

95027.5964$527.34.$105.47

P9037Plate pheres leukoredu irradR 

10199.9046$687.58.$137.52

P9038RBC irradiatedR 

95053.3729$234.15.$46.83

P9039RBC deglycerolizedR 

95043.4728$241.08.$48.22

P9040RBC leukoreduced irradiatedR 

09693.7077$257.39.$51.48

P9041"Albumin (human),5%, 

50ml"K0961$20.37.$4.08

P9043"Plasma protein fract,5%,50ml"R 

09560.2513$17.45.$3.49

P9044CryoprecipitatereducedplasmaR 

10091.1839$82.19.$16.44

P9045"Albumin (human), 5%, 250 

ml"K0963$67.07.$13.42

P9046"Albumin (human), 25%, 20 

ml"K0964$29.16.$5.84

P9047"Albumin (human), 25%, 

50ml"K0965$70.39.$14.08

P9048"Plasmaprotein fract,5%,250ml"R 

09661.2214$84.79.$16.96

P9050"Granulocytes, pheresis unit"R 

950622.1451"$1,537.31".$307.47

P9051"Blood, l/r, cmv-neg"R 

10102.7475$190.73.$38.15

P9052"Platelets, hla-m, l/r, unit"R 

101111.4189$792.70.$158.54

P9053"Plt, pher, l/r cmv-neg, irr"R 

10208.6696$601.84.$120.37

P9054"Blood, l/r, froz/degly/wash"R 

10161.8650$129.47.$25.90
P9055"Plt, aph/pher, l/r, cmv-neg"R 

10175.7123$396.55.$79.31

P9056"Blood, l/r, irradiated"R 

10182.1603$149.97.$30.00

P9057"RBC, frz/deg/wsh, l/r, irrad"R 

10216.2606$434.61.$86.93

P9058"RBC, l/r, cmv-neg, irrad"R 

10224.0635$282.09.$56.42

P9059"Plasma, frz between 8-24hour"R 

09551.0092$70.06.$14.02

P9060Fr frz plasma donor retestedR 

95031.2624$87.64.$17.53

P9603One-way allow prorated 

milesA

P9604One-way allow prorated 

tripA

P9612Catheterize for urine specA 

P9615Urine specimen collect 

multN

Q0035CardiokymographyX01002.5348$175.97$40.87$35.20

Q0081Infusion ther other than cheB 

Q0083Chemo by other than infusionB 

Q0084Chemotherapy by infusionB 

Q0085Chemo by both infusion and 

oB

Q0091Obtaining screen pap 

smearT01910.1274$8.84$0.00$0.00

Q0092Set up port xray 

equipmentN

Q0111Wet mounts/ w 

preparationsA

Q0112Potassium hydroxide 

prepsA
Q0113Pinworm 

examinationsA

Q0114Fern 

testA

Q0115Post-coital mucous 

examA

Q0138"Ferumoxytol, non-esrd"CHK 

1297$0.69.$0.14

Q0139"Ferumoxytol, esrd 

use"A

Q0144"Azithromycin dihydrate, 

oral"E

Q0163Diphenhydramine HCl 

50mgN

Q0164Prochlorperazine maleate 

5mgN

Q0165Prochlorperazine 

maleate10mgN

Q0166Granisetron hcl 1 mg 

oralN

Q0167Dronabinol 2.5mg 

oralN

Q0168Dronabinol 5mg 

oralN

Q0169Promethazine HCl 12.5mg 

oralN

Q0170Promethazine HCl 25 mg 

oralN

Q0171Chlorpromazine HCl 10mg 

oralN

Q0172Chlorpromazine HCl 25mg 

oralN

Q0173Trimethobenzamide HCl 

250mgN

Q0174Thiethylperazine 

maleate10mgE

Q0175Perphenazine 4mg 

oralN

Q0176Perphenazine 8mg 

oralN

Q0177Hydroxyzine pamoate 

25mgN

Q0178Hydroxyzine pamoate 

50mgN
Q0179Ondansetron hcl 8 mg 

oralN

Q0180Dolasetron mesylate 

oralN

Q0181Unspecified oral 

anti-emeticE

Q0478"Power adapter, combo 

vad"A

Q0479"Power module combo vad, 

rep"A

Q0480"Driver pneumatic vad, 

rep"A

Q0481"Microprcsr cu elec vad, 

rep"A

Q0482"Microprcsr cu combo vad, 

rep"A

Q0483"Monitor elec vad, 

rep"A

Q0484Monitor elec or comb vad 

repA

Q0485"Monitor cable elec vad, 

rep"A

Q0486Mon cable elec/pneum vad 

repA

Q0487"Leads any type vad, rep 

only"A

Q0488"Pwr pack base elec vad, 

rep"A

Q0489"Pwr pck base combo vad, 

rep"A

Q0490"Emr pwr source elec vad, 

rep"A

Q0491Emr pwr source combo vad 

repA

Q0492"Emr pwr cbl elec vad, 

rep"A

Q0493"Emr pwr cbl combo vad, 

rep"A

Q0494"Emr hd pmp elec/combo, 

rep"A

Q0495"Charger elec/combo vad, 

rep"A

Q0496"Battery elec/combo vad, 

rep"A
Q0497"Bat clps elec/comb vad, 

rep"A

Q0498"Holster elec/combo vad, 

rep"A

Q0499Belt/vest elec/combo vad 

repA

Q0500"Filters elec/combo vad, 

rep"A

Q0501"Shwr cov elec/combo vad, 

rep"A

Q0502"Mobility cart pneum vad, 

rep"A

Q0503Battery pneum vad 

replacemntA

Q0504"Pwr adpt pneum vad, rep 

veh"A

Q0505Miscl supply/accessory 

vadA

Q0506Lith-ion batt elec/pneum 

VADA

Q0510Dispens fee 

immunosupressiveB

Q0511"Sup fee 

antiem,antica,immuno"B

Q0512Px sup fee anti-can sub 

presB

Q0513Disp fee inhal drugs/30 

daysB

Q0514Disp fee inhal drugs/90 

daysB

Q0515Sermorelin acetate injectionK 

3050$1.76.$0.36

Q1004Ntiol category 4E 

Q1005Ntiol category 5E 

Q2004Bladder calculi irrig 

solN

Q2009Fosphenytoin inj 

PEN

Q2017"Teniposide, 50 

mg"K7035$316.52.$63.31

Q2026Radiesse 
injectionB

Q2027Sculptra 

injectionB

Q2035"Afluria vacc, 3 yrs & >, 

im"L

Q2036"Flulaval vacc, 3 yrs & >, 

im"L

Q2037"Fluvirin vacc, 3 yrs & >, 

im"L

Q2038"Fluzone vacc, 3 yrs & >, 

im"L

Q2039"NOS flu vacc, 3 yrs & >, 

im"L

Q2040Incobotulinumtoxin 

AG9278$5.57.$1.10

Q3001Brachytherapy 

RadioelementsB

Q3014Telehealth facility 

feeA

Q3025IM inj interferon beta 

1-aK9022$220.75.$44.15

Q3026Subc inj interferon 

beta-1aE

Q3031Collagen skin 

testN

Q4001Cast sup body cast 

plasterB

Q4002Cast sup body cast 

fiberglasB

Q4003Cast sup shoulder cast 

plstrB

Q4004Cast sup shoulder cast 

fbrglB

Q4005Cast sup long arm adult 

plstB

Q4006Cast sup long arm adult 

fbrgB

Q4007Cast sup long arm ped 

plsterB

Q4008Cast sup long arm ped 

fbrglsB

Q4009Cast sup sht arm adult 

plstrB
Q4010Cast sup sht arm adult 

fbrglB

Q4011Cast sup sht arm ped 

plasterB

Q4012Cast sup sht arm ped 

fbrglasB

Q4013Cast sup gauntlet 

plasterB

Q4014Cast sup gauntlet 

fiberglassB

Q4015Cast sup gauntlet ped 

plsterB

Q4016Cast sup gauntlet ped 

fbrglsB

Q4017Cast sup lng arm splint 

plstB

Q4018Cast sup lng arm splint 

fbrgB

Q4019Cast sup lng arm splnt ped 

pB

Q4020Cast sup lng arm splnt ped 

fB

Q4021Cast sup sht arm splint 

plstB

Q4022Cast sup sht arm splint 

fbrgB

Q4023Cast sup sht arm splnt ped 

pB

Q4024Cast sup sht arm splnt ped 

fB

Q4025Cast sup hip spica 

plasterB

Q4026Cast sup hip spica 

fiberglasB

Q4027Cast sup hip spica ped 

plstrB

Q4028Cast sup hip spica ped 

fbrglB

Q4029Cast sup long leg 

plasterB

Q4030Cast sup long leg 

fiberglassB

Q4031Cast sup lng leg ped 

plasterB
Q4032Cast sup lng leg ped 

fbrglsB

Q4033Cast sup lng leg cylinder 

plB

Q4034Cast sup lng leg cylinder 

fbB

Q4035Cast sup lngleg cylndr ped 

pB

Q4036Cast sup lngleg cylndr ped 

fB

Q4037Cast sup shrt leg 

plasterB

Q4038Cast sup shrt leg 

fiberglassB

Q4039Cast sup shrt leg ped 

plsterB

Q4040Cast sup shrt leg ped 

fbrglsB

Q4041Cast sup lng leg splnt 

plstrB

Q4042Cast sup lng leg splnt 

fbrglB

Q4043Cast sup lng leg splnt ped 

pB

Q4044Cast sup lng leg splnt ped 

fB

Q4045Cast sup sht leg splnt 

plstrB

Q4046Cast sup sht leg splnt 

fbrglB

Q4047Cast sup sht leg splnt ped 

pB

Q4048Cast sup sht leg splnt ped 

fB

Q4049"Finger splint, 

static"B

Q4050Cast supplies 

unlistedB

Q4051Splint supplies 

miscB

Q4074Iloprost non-comp unit 

doseY

Q4081"Epoetin alfa, 100 units ESRD "A 
Q4082Drug/bio NOC part B drug CAPB 

Q4100"Skin substitute, 

NOS"N

Q4101ApligrafK1240$34.06.$6.82

Q4102Oasis wound 

matrixK1241$4.68.$0.94

Q4103Oasis burn 

matrixCHN

Q4104Integra 

BMWDK1243$15.45.$3.09

Q4105Integra 

DRTK1244$10.95.$2.19

Q4106DermagraftK1245$39.39.$7.88

Q4107GraftjacketK1246$92.79.$18.56

Q4108Integra 

matrixK1247$20.95.$4.19

Q4110PrimatrixK1248$31.67.$6.34

Q4111GammagraftK1252$7.17.$1.44

Q4112Cymetra 

injectableK1249$334.07.$66.82

Q4113Graftjacket 

xpressK1250$334.07.$66.82

Q4114Integra flowable wound 

matriK1251$972.75.$194.55

Q4115AlloskinK1287$6.07.$1.22

Q4116AllodermK1270$31.11.$6.23

Q4117HyalomatrixE

Q4118Matristem 

micromatrixK1342$3.13.$0.63

Q4119Matristem wound 

matrixK1351$6.04.$1.21
Q4120Matristem burn 

matrixE

Q4121TheraskinK1345$20.32.$4.07

Q5001Hospice in patient homeB 

Q5002Hospice in assisted livingB 

Q5003Hospice in LT/non-skilled NFB 

Q5004Hospice in SNFB 

Q5005"Hospice, inpatient hospital"B 

Q5006Hospice in hospice facilityB 

Q5007Hospice in LTCHB 

Q5008Hospice in inpatient psychB 

Q5009"Hospice care, NOS"B 

Q5010Hospice home care in hospiceB 

Q9951"LOCM >= 400 mg/ml iodine,1ml"N 

Q9953"Inj Fe-based MR contrast,1ml"N 

Q9954"Oral MR contrast, 100 ml"N 

Q9955"Inj perflexane lip micros,ml "N 

Q9956"Inj octafluoropropane mic,ml"N 

Q9957"Inj perflutren lip micros,ml"N 

Q9958"HOCM <=149 mg/ml iodine, 

1ml"N

Q9959"HOCM 150-199mg/ml iodine,1ml"N 

Q9960"HOCM 200-249mg/ml iodine,1ml"N 

Q9961"HOCM 250-299mg/ml iodine,1ml"N 
Q9962"HOCM 300-349mg/ml iodine,1ml"N 

Q9963"HOCM 350-399mg/ml iodine,1ml"N 

Q9964"HOCM>= 400mg/ml iodine, 1ml"N 

Q9965"LOCM 100-199mg/ml 

iodine,1ml"N

Q9966"LOCM 200-299mg/ml 

iodine,1ml"N

Q9967"LOCM 300-399mg/ml 

iodine,1ml"N

Q9968Visualization 

adjunctCHN

R0070Transport portable x-rayB 

R0075Transport port x-ray multiplB 

R0076Transport portable EKGB 

V2020Vision svcs frames 

purchasesA

V2025Eyeglasses delux 

framesE

V2100Lens spher single plano 

4.00A

V2101Single visn sphere 

4.12-7.00A

V2102Singl visn sphere 

7.12-20.00A

V2103Spherocylindr 

4.00d/12-2.00dA

V2104Spherocylindr 

4.00d/2.12-4dA

V2105Spherocylinder 

4.00d/4.25-6dA

V2106Spherocylinder 

4.00d/>6.00dA

V2107Spherocylinder 

4.25d/12-2dA

V2108Spherocylinder 

4.25d/2.12-4dA

V2109Spherocylinder 

4.25d/4.25-6dA
V2110Spherocylinder 4.25d/over 

6dA

V2111Spherocylindr 

7.25d/.25-2.25A

V2112Spherocylindr 

7.25d/2.25-4dA

V2113Spherocylindr 

7.25d/4.25-6dA

V2114Spherocylinder over 

12.00dA

V2115Lens lenticular 

bifocalA

V2118Lens aniseikonic 

singleA

V2121"Lenticular lens, 

single"A

V2199Lens single vision not oth 

cA

V2200Lens spher bifoc plano 

4.00dA

V2201Lens sphere bifocal 

4.12-7.0A

V2202Lens sphere bifocal 

7.12-20.A

V2203Lens sphcyl bifocal 

4.00d/.1A

V2204Lens sphcy bifocal 

4.00d/2.1A

V2205Lens sphcy bifocal 

4.00d/4.2A

V2206Lens sphcy bifocal 

4.00d/oveA

V2207Lens sphcy bifocal 

4.25-7d/.A

V2208Lens sphcy bifocal 

4.25-7/2.A

V2209Lens sphcy bifocal 

4.25-7/4.A

V2210Lens sphcy bifocal 4.25-7/ovA 

V2211Lens sphcy bifo 

7.25-12/.25-A

V2212Lens sphcyl bifo 

7.25-12/2.2A
V2213Lens sphcyl bifo 

7.25-12/4.2A

V2214Lens sphcyl bifocal over 

12.A

V2215Lens lenticular 

bifocalA

V2218Lens aniseikonic 

bifocalA

V2219Lens bifocal seg width 

overA

V2220Lens bifocal add over 

3.25dA

V2221"Lenticular lens, 

bifocal"A

V2299Lens bifocal 

specialityA

V2300Lens sphere trifocal 

4.00dA

V2301Lens sphere trifocal 

4.12-7.A

V2302Lens sphere trifocal 

7.12-20A

V2303Lens sphcy trifocal 

4.0/.12-A

V2304Lens sphcy trifocal 

4.0/2.25A

V2305Lens sphcy trifocal 

4.0/4.25A

V2306Lens sphcyl trifocal 

4.00/>6A

V2307Lens sphcy trifocal 

4.25-7/.A

V2308Lens sphc trifocal 

4.25-7/2.A

V2309Lens sphc trifocal 

4.25-7/4.A

V2310Lens sphc trifocal 

4.25-7/>6A

V2311Lens sphc trifo 

7.25-12/.25-A

V2312Lens sphc trifo 

7.25-12/2.25A

V2313Lens sphc trifo 

7.25-12/4.25A
V2314Lens sphcyl trifocal over 

12A

V2315Lens lenticular 

trifocalA

V2318Lens aniseikonic 

trifocalA

V2319Lens trifocal seg width > 

28A

V2320Lens trifocal add over 

3.25dA

V2321"Lenticular lens, 

trifocal"A

V2399Lens trifocal 

specialityA

V2410Lens variab asphericity 

singA

V2430Lens variable asphericity 

biA

V2499Variable asphericity 

lensA

V2500Contact lens pmma 

sphericalA

V2501Cntct lens 

pmma-toric/prismA

V2502Contact lens pmma 

bifocalA

V2503Cntct lens pmma color 

visionA

V2510Cntct gas permeable 

sphericlA

V2511Cntct toric prism 

ballastA

V2512Cntct lens gas permbl 

bifoclA

V2513Contact lens extended 

wearA

V2520Contact lens 

hydrophilicA

V2521Cntct lens hydrophilic 

toricA

V2522Cntct lens hydrophil 

bifoclA

V2523Cntct lens hydrophil 

extendA
V2530Contact lens gas 

impermeableA

V2531Contact lens gas 

permeableA

V2599Contact lens/es other 

typeA

V2600Hand held low vision 

aidsA

V2610Single lens spectacle 

mountA

V2615Telescop/othr compound 

lensA

V2623Plastic eye prosth 

customA

V2624Polishing artifical 

eyeA

V2625Enlargemnt of eye 

prosthesisA

V2626Reduction of eye 

prosthesisA

V2627Scleral cover 

shellA

V2628Fabrication & 

fittingA

V2629Prosthetic eye other 

typeA

V2630Anter chamber intraocul 

lensN

V2631Iris support intraoclr 

lensN

V2632Post chmbr intraocular 

lensN

V2700Balance 

lensA

V2702Deluxe lens 

featureE

V2710Glass/plastic slab off 

prismA

V2715Prism 

lens/esA

V2718Fresnell prism press-on 

lensA

V2730Special base 

curveA
V2744Tint photochromatic 

lens/esA

V2745"Tint, any 

color/solid/grad"A

V2750Anti-reflective 

coatingA

V2755UV 

lens/esA

V2756Eye glass 

caseE

V2760Scratch resistant 

coatingA

V2761Mirror 

coatingB

V2762"Polarization, any 

lens"A

V2770Occluder 

lens/esA

V2780Oversize 

lens/esA

V2781Progressive lens per 

lensB

V2782"Lens, 1.54-1.65 

p/1.60-1.79g"A

V2783"Lens, >= 1.66 p/>=1.80 

g"A

V2784Lens polycarb or 

equalA

V2785Corneal tissue 

processingF

V2786Occupational multifocal 

lensA

V2787Astigmatism-correct 

functionE

V2788Presbyopia-correct 

functionE

V2790Amniotic 

membraneN

V2797Vis item/svc in other 

codeA

V2799Miscellaneous vision 

serviceA

V5008Hearing 

screeningE
V5010Assessment for hearing 

aidE

V5011Hearing aid 

fitting/checkingE

V5014Hearing aid 

repair/modifyingE

V5020Conformity 

evaluationE

V5030Body-worn hearing aid 

airE

V5040Body-worn hearing aid 

boneE

V5050Hearing aid monaural in 

earE

V5060Behind ear hearing 

aidE

V5070Glasses air 

conductionE

V5080Glasses bone 

conductionE

V5090Hearing aid dispensing 

feeE

V5095Implant mid ear hearing 

prosE

V5100Body-worn bilat hearing 

aidE

V5110Hearing aid dispensing 

feeE

V5120Body-worn binaur hearing 

aidE

V5130In ear binaural hearing 

aidE

V5140Behind ear binaur hearing 

aiE

V5150Glasses binaural hearing 

aidE

V5160Dispensing fee 

binauralE

V5170Within ear cros hearing 

aidE

V5180Behind ear cros hearing 

aidE

V5190Glasses cros hearing 

aidE
V5200Cros hearing aid dispens 

feeE

V5210In ear bicros hearing 

aidE

V5220Behind ear bicros hearing 

aiE

V5230Glasses bicros hearing 

aidE

V5240Dispensing fee 

bicrosE

V5241"Dispensing fee, 

monaural"E

V5242"Hearing aid, monaural, 

cic"E

V5243"Hearing aid, monaural, 

itc"E

V5244"Hearing aid, prog, mon, 

cic"E

V5245"Hearing aid, prog, mon, 

itc"E

V5246"Hearing aid, prog, mon, 

ite"E

V5247"Hearing aid, prog, mon, 

bte"E

V5248"Hearing aid, binaural, 

cic"E

V5249"Hearing aid, binaural, 

itc"E

V5250"Hearing aid, prog, bin, 

cic"E

V5251"Hearing aid, prog, bin, 

itc"E

V5252"Hearing aid, prog, bin, 

ite"E

V5253"Hearing aid, prog, bin, 

bte"E

V5254"Hearing id, digit, mon, 

cic"E

V5255"Hearing aid, digit, mon, 

itc"E

V5256"Hearing aid, digit, mon, 

ite"E

V5257"Hearing aid, digit, mon, 

bte"E
V5258"Hearing aid, digit, bin, 

cic"E

V5259"Hearing aid, digit, bin, 

itc"E

V5260"Hearing aid, digit, bin, 

ite"E

V5261"Hearing aid, digit, bin, 

bte"E

V5262"Hearing aid, disp, 

monaural"E

V5263"Hearing aid, disp, 

binaural"E

V5264Ear 

mold/insertE

V5265"Ear mold/insert, 

disp"E

V5266Battery for hearing 

deviceE

V5267Hearing aid 

supply/accessoryE

V5268ALD Telephone 

AmplifierE

V5269"Alerting device, any 

type"E

V5270"ALD, TV amplifier, any 

type"E

V5271"ALD, TV caption 

decoder"E

V5272TddE

V5273ALD for cochlear 

implantE

V5274ALD 

unspecifiedE

V5275Ear 

impressionE

V5298Hearing aid 

nocE

V5299Hearing 

serviceB

V5336Repair communication 

deviceE

V5362Speech 

screeningE
V5363Language 

screeningE

V5364Dysphagia 

screeningE