fee schedule 2009 new - DE Medical Assistance Program

Fee Schedule <strong>2009</strong><br />

Procedure Code Pricing Action Code Description Max Allowable<br />

00001 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

00002 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

00003 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

00004 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

00005 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

00006 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

00007 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

00008 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

00009 7 AMBULATORY SURGICAL CENTER GROUP LE 0.00<br />

0001F 9 HEART FAILURE COMPOSITE 0.00<br />

0001T O ENDOVAS REPR ABDO AO ANEURYS 0.00<br />

0002F O TOBACCO USE, SMOKING, ASSESS 0.00<br />

0002T 9 ENDOVAS REPR ABDO AO ANEURYS 0.00<br />

0003F O TOBACCO USE, NON-SMOKING 0.00<br />

0003T O CERVICOGRAPHY 0.00<br />

0004F O TOBACCO USE TXMNT COUNSELING 0.00<br />

0005F 9 OSTEOARTHRITIS COMPOSITE 0.00<br />

0005T O PERC CATH STENT/BRAIN CV ART 0.00<br />

0006F O STATIN THERAPY, PRESCRIBED 0.00<br />

0006T O PERC CATH STENT/BRAIN CV ART 0.00<br />

0007F O BETA-BLOCKER THX PRESCRIBED 0.00<br />

0007T O PERC CATH STENT/BRAIN CV ART 0.00<br />

0008F O ACE INHIBITOR THX PRESCRIBED 0.00<br />

0008T O UPPER GI ENDOSCOPY W/SUTURE 0.00<br />

0009F O ASSESS ANGINAL SYMPTOM/LEVEL 0.00<br />

0009T O ENDOMETRIAL CRYOABLATION 0.00<br />

00100 A ANESTH, SALIVARY GLAND 0.00<br />

00102 A ANESTH, REPAIR OF CLEFT LIP 0.00<br />

00103 A ANESTH, BLEPHAROPLASTY 0.00<br />

00104 A ANESTH, ELECTROSHOCK 0.00<br />

0010F O ASSESS ANGINAL SYMPTOM/LEVEL 0.00<br />

0010T O TB TEST, GAMMA INTERFERON 0.00<br />

0011F O ORAL ANTIPLAT THX PRESCRIBED 0.00<br />

00120 A ANESTH, EAR SURGERY 0.00<br />

00124 A ANESTH, EAR EXAM 0.00<br />

00126 A ANESTH, TYMPANOTOMY 0.00<br />

0012F 9 CAP BACTERIAL ASSESS 0.00<br />

0012T O OSTEOCHONDRAL KNEE AUTOGRAFT 0.00<br />

0013T O OSTEOCHONDRAL KNEE ALLOGRAFT 0.00<br />

00140 A ANESTH, PROCEDURES ON EYE 0.00<br />

00142 A ANESTH, LENS SURGERY 0.00<br />

00144 A ANESTH, CORNEAL TRANSPLANT 0.00<br />

00145 A ANESTH, VITREORETINAL SURG 0.00<br />

00147 A ANESTH, IRI<strong>DE</strong>CTOMY 0.00<br />

00148 A ANESTH, EYE EXAM 0.00<br />

0014F 9 COMP PREOP ASSESS CAT SURG 0.00<br />

0014T O MENISCAL TRANSPLANTATION, MEDIAL OR 0.00

---

0015F 9 MELAN FOLLOW-UP COMPLETE 0.00<br />

00160 A ANESTH, NOSE/SINUS SURGERY 0.00<br />

00162 A ANESTH, NOSE/SINUS SURGERY 0.00<br />

00164 A ANESTH, BIOPSY OF NOSE 0.00<br />

0016T 9 THERMOTX CHOROID VASC LESION 0.00<br />

00170 A ANESTH, PROCEDURE ON MOUTH 0.00<br />

00172 A ANESTH, CLEFT PALATE REPAIR 0.00<br />

00174 A ANESTH, PHARYNGEAL SURGERY 0.00<br />

00176 A ANESTH, PHARYNGEAL SURGERY 0.00<br />

0017T 9 PHOTOCOAGULAT MACULAR DRUSEN 0.00<br />

0018T O TRANSCRANIAL MAGNETIC STIMUL 0.00<br />

00190 A ANESTH, FACE/SKULL BONE SURG 0.00<br />

00192 A ANESTH, FACIAL BONE SURGERY 0.00<br />

0019T 9 EXTRACORP SHOCK WAVE, MS, NOS 0.00<br />

0020T O EXTRACORP SHOCK WAVE TX, FT 0.00<br />

00210 A ANESTH, CRANIAL SURG NOS 0.00<br />

00211 A ANESTH, CRAN SURG, HEMOTOMA 0.00<br />

00212 A ANESTH, SKULL DRAINAGE 0.00<br />

00214 A ANESTH, SKULL DRAINAGE 0.00<br />

00215 A ANESTH, SKULL REPAIR/FRACT 0.00<br />

00216 A ANESTH, HEAD VESSEL SURGERY 0.00<br />

00218 A ANESTH, SPECIAL HEAD SURGERY 0.00<br />

0021T O FETAL OXIMETRY, TRNSVAG/CERV 0.00<br />

00220 A ANESTH, INTRCRN NERVE 0.00<br />

00222 A ANESTH, HEAD NERVE SURGERY 0.00<br />

0023T O PHENOTYPE DRUG TEST, HIV 1 0.00<br />

0024T O TRANSCATH CARDIAC REDUCTION 0.00<br />

0025T O ULTRASONIC PACHYMETRY 0.00<br />

0026T O MEASURE REMNANT LIPOPROTEINS 0.00<br />

0027T O ENDOSCOPIC EPIDURAL LYSIS 0.00<br />

0028T O <strong>DE</strong>XA BODY COMPOSITION STUDY 0.00<br />

0029T O MAGNETIC TX FOR INCONTINENCE 0.00<br />

00300 A ANESTH, HEAD/NECK/PTRUNK 0.00<br />

0030T 9 ANTIPROTHROMBIN ANTIBODY 0.00<br />

0031T O SPECULOSCOPY 0.00<br />

00320 A ANESTH, NECK ORGAN, 1 & OVER 0.00<br />

00322 A ANESTH, BIOPSY OF THYROID 0.00<br />

00326 A ANESTH, LARYNX/TRACH, < 1 YR 0.00<br />

0032T O SPECULOSCOPY W/DIRECT SAMPLE 0.00<br />

0033T O ENDOVASC TAA REPR INCL SUBCL 0.00<br />

0034T O ENDOVASC TAA REPR W/O SUBCL 0.00<br />

00350 A ANESTH, NECK VESSEL SURGERY 0.00<br />

00352 A ANESTH, NECK VESSEL SURGERY 0.00<br />

0035T O INSERT ENDOVASC PROSTH, TAA 0.00<br />

0036T O ENDOVASC PROSTH, TAA, ADD-ON 0.00<br />

0037T O ARTERY TRANSPOSE/ENDOVAS TAA 0.00<br />

0038T O RAD ENDOVASC TAA RPR W/COVER 0.00<br />

0039T O RAD S/I, ENDOVASC TAA REPAIR 0.00<br />

00400 A ANESTH, SKIN, EXT/PER/ATRUNK 0.00<br />

00402 A ANESTH, SURGERY OF BREAST 0.00

---

00404 A ANESTH, SURGERY OF BREAST 0.00<br />

00406 A ANESTH, SURGERY OF BREAST 0.00<br />

0040T O RAD S/I, ENDOVASC TAA PROSTH 0.00<br />

00410 A ANESTH, CORRECT HEART RHYTHM 0.00<br />

0041T O <strong>DE</strong>TECT UR INFECT AGNT W/CPAS 0.00<br />

00420 9 ANESTH, SKIN SURGERY, BACK 0.00<br />

0042T 9 CT PERFUSION W/CONTRAST, CBF 0.00<br />

0043T O CO EXPIRED GAS ANALYSIS 0.00<br />

0044T O WHOLE BODY PHOTOGRAPHY 0.00<br />

00450 A ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 0.00<br />

00452 A ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 0.00<br />

00454 A ANESTH, COLLAR BONE BIOPSY 0.00<br />

0045T O WHOLE BODY PHOTOGRAPHY 0.00<br />

0046T O CATH LAVAGE, MAMMARY DUCT(S) 0.00<br />

00470 A ANESTH, REMOVAL OF RIB 0.00<br />

00472 A ANESTH, CHEST WALL REPAIR 0.00<br />

00474 A ANESTH, SURGERY OF RIB(S) 0.00<br />

0047T O CATH LAVAGE, MAMMARY DUCT(S) 0.00<br />

0048T 9 IMPLANT VENTRICULAR <strong>DE</strong>VICE 0.00<br />

0049T O EXTERNAL CIRCULATION ASSIST 0.00<br />

00500 A ANESTH, ESOPHAGEAL SURGERY 0.00<br />

0050T 9 REMOVAL CIRCULATION ASSIST 0.00<br />

0051T 9 IMPLANT TOTAL HEART SYSTEM 0.00<br />

00520 A ANESTH, CHEST PROCEDURE 0.00<br />

00522 A ANESTH, CHEST LINING BIOPSY 0.00<br />

00524 A ANESTH, CHEST DRAINAGE 0.00<br />

00528 A ANESTH, CHEST PARTITION VIEW 0.00<br />

00529 9 ANESTH, CHEST PARTITION VIEW 0.00<br />

0052T 9 REPLACE COMPONENT HEART SYST 0.00<br />

00530 A ANESTH, PACEMAKER INSERTION 0.00<br />

00532 A ANESTH, VASCULAR ACCESS 0.00<br />

00534 A ANESTH, CARDIOVERTER/<strong>DE</strong>FIB 0.00<br />

00537 A ANESTH, CARDIAC ELECTROPHYS 0.00<br />

00539 A ANESTH,TRACHEOBRONCHIAL RECONSTRUC 0.00<br />

0053T 9 REPLACE COMPONENT HEART SYST 0.00<br />

00540 A ANESTH, CHEST SURGERY 0.00<br />

00541 A ANESTH, ONE LUNG VENTILATION 0.00<br />

00542 A ANESTH, RELEASE OF LUNG 0.00<br />

00544 O ANESTH, CHEST LINING REMOVAL 0.00<br />

00546 A ANESTH, LUNG,CHEST WALL SURG 0.00<br />

00548 A ANESTH, TRACHEA,BRONCHI SURG 0.00<br />

0054T O BONE SURGERY USING COMPUTER 0.00<br />

00550 A ANESTH, STERNAL <strong>DE</strong>BRI<strong>DE</strong>MENT 0.00<br />

0055T O BONE SURGERY USING COMPUTER 0.00<br />

00560 A ANESTH, HEART SURG W/O PUMP 0.00<br />

00561 A ANESTH, HEART SURG < AGE 1 0.00<br />

00562 A ANESTH HRT SURG W/PMP AGE 1+ 0.00<br />

00563 A ANESTH, HEART SURG W/ARREST 0.00<br />

00566 A ANESTH, CABG W/O PUMP 0.00<br />

00567 A ANESTH, CABG W/PUMP 0.00

---

0056T O BONE SURGERY USING COMPUTER 0.00<br />

0057T O UPPR GI SCOPE W/ THRML TXMNT 0.00<br />

00580 A ANESTH, HEART/LUNG TRANSPLNT 0.00<br />

0058T O CRYOPRESERVATION, OVARY TISS 0.00<br />

0059T O CRYOPRESERVATION, OOCYTE 0.00<br />

00600 A ANESTH, SPINE, CORD SURGERY 0.00<br />

00604 A ANESTH, SITTING PROCEDURE 0.00<br />

0060T O ELECTRICAL IMPEDANCE SCAN 0.00<br />

0061T O <strong>DE</strong>STRUCTION OF TUMOR, BREAST 0.00<br />

00620 A ANESTH, SPINE, CORD SURGERY 0.00<br />

00622 A ANESTH, REMOVAL OF NERVES 0.00<br />

00625 A ANES SPINE TRANTHOR W/O VENT 0.00<br />

00626 A ANES, SPINE TRANSTHOR W/VENT 0.00<br />

0062T 9 REP INTRADISC ANNULUS;1 LEV 0.00<br />

00630 A ANESTH, SPINE, CORD SURGERY 0.00<br />

00632 A ANESTH, REMOVAL OF NERVES 0.00<br />

00634 5 ANESTH FOR CHEMONUCLEOLYSIS 0.00<br />

00635 A ANESTH, LUMBAR PUNCTURE 0.00<br />

0063T 9 REP INTRADISC ANNULUS;>1LEV 0.00<br />

00640 A ANESTH, SPINE MANIPULATION 0.00<br />

0064T 9 SPECTROSCOP EVAL EXPIRED GAS 0.00<br />

0065T O OCULAR PHOTOSCREEN BILAT 0.00<br />

0066T 9 CT COLONOGRAPHY;SCREEN 0.00<br />

00670 A ANESTH, SPINE, CORD SURGERY 0.00<br />

0067T 9 CT COLONOGRAPHY;DX 0.00<br />

0068T 9 INTERP/REPT HEART SOUND 0.00<br />

0069T 9 ANALYSIS ONLY HEART SOUND 0.00<br />

00700 A ANESTH, ABDOMINAL WALL SURG 0.00<br />

00702 A ANESTH, FOR LIVER BIOPSY 0.00<br />

0070T 9 INTERP ONLY HEART SOUND 0.00<br />

0071T 9 U/S LEIOMYOMATA ABLATE 200 0.00<br />

00730 A ANESTH, ABDOMINAL WALL SURG 0.00<br />

0073T 9 <strong>DE</strong>LIVERY, COMP IMRT 0.00<br />

00740 A ANESTH, UPPER GI VISUALIZE 0.00<br />

0074T O ONLINE PHYSICIAN E/M 0.00<br />

00750 A ANESTH, REPAIR OF HERNIA 0.00<br />

00752 A ANESTH, REPAIR OF HERNIA 0.00<br />

00754 A ANESTH, REPAIR OF HERNIA 0.00<br />

00756 A ANESTH, REPAIR OF HERNIA 0.00<br />

0075T 9 PERQ STENT/CHEST VERT ART 0.00<br />

0076T 9 S&I STENT/CHEST VERT ART 0.00<br />

00770 A ANESTH, BLOOD VESSEL REPAIR 0.00<br />

0077T 9 CEREB THERM PERFUSION PROBE 0.00<br />

0078T 9 ENDOVASC AORT REPR W/<strong>DE</strong>VICE 0.00<br />

00790 A ANESTH, SURG UPPER ABDOMEN 0.00<br />

00792 A ANESTH, HEMORR/EXCISE LIVER 0.00<br />

00794 A ANESTH, PANCREAS REMOVAL 0.00<br />

00796 A ANESTH, FOR LIVER TRANSPLANT 0.00<br />

00797 A ANESTH, SURGERY FOR OBESITY 0.00

---

0079T 9 ENDOVASC VISC EXTNSN REPR 0.00<br />

00800 A ANESTH, ABDOMINAL WALL SURG 0.00<br />

00802 A ANESTH, FAT LAYER REMOVAL 0.00<br />

00806 O ANESTHESIA FOR LAPAROSCOPIC PROCEDU 0.00<br />

0080T 9 ENDOVASC AORT REPR RAD S&I 0.00<br />

00810 A ANESTH, LOW INTESTINE SCOPE 0.00<br />

0081T 9 ENDOVASC VISC EXTNSN S&I 0.00<br />

00820 A ANESTH, ABDOMINAL WALL SURG 0.00<br />

0082T O STEREOTACTIC RAD <strong>DE</strong>LIVERY 0.00<br />

00830 A ANESTH, REPAIR OF HERNIA 0.00<br />

00832 A ANESTH, REPAIR OF HERNIA 0.00<br />

00834 A ANESTH, HERNIA REPAIR< 1 YR 0.00<br />

00836 A ANESTH HERNIA REPAIR PREEMIE 0.00<br />

0083T O STEREOTACTIC RAD TX MNGMT 0.00<br />

00840 A ANESTH, SURG LOWER ABDOMEN 0.00<br />

00842 A ANESTH, AMNIOCENTESIS 0.00<br />

00844 A ANESTH, PELVIS SURGERY 0.00<br />

00846 A ANESTH, HYSTERECTOMY 0.00<br />

00848 A ANESTH, PELVIC ORGAN SURG 0.00<br />

0084T 9 TEMP PROSTATE URETHRAL STENT 0.00<br />

00850 9 ANESTH, CESAREAN SECTION 0.00<br />

00851 A ANESTH, TUBAL LIGATION 0.00<br />

00855 9 ANESTH, HYSTERECTOMY 0.00<br />

00857 9 ANALGESIA, LABOR & C-SECTION 0.00<br />

0085T 9 BREATH TEST HEART REJECT 0.00<br />

00860 A ANESTH, SURGERY OF ABDOMEN 0.00<br />

00862 A ANESTH, KIDNEY/URETER SURG 0.00<br />

00864 A ANESTH, REMOVAL OF BLAD<strong>DE</strong>R 0.00<br />

00865 A ANESTH, REMOVAL OF PROSTATE 0.00<br />

00866 A ANESTH, REMOVAL OF ADRENAL 0.00<br />

00868 A ANESTH, KIDNEY TRANSPLANT 0.00<br />

00869 O ANESTH, VASECTOMY 0.00<br />

0086T 9 L VENTRICLE FILL PRESSURE 0.00<br />

00870 A ANESTH, BLAD<strong>DE</strong>R STONE SURG 0.00<br />

00872 A ANESTH KIDNEY STONE <strong>DE</strong>STRUCT 0.00<br />

00873 A ANESTH KIDNEY STONE <strong>DE</strong>STRUCT 0.00<br />

0087T 9 SPERM EVAL HYALURONAN 0.00<br />

00880 A ANESTH, ABDOMEN VESSEL SURG 0.00<br />

00882 A ANESTH, MAJOR VEIN LIGATION 0.00<br />

00884 9 ANESTH, MAJOR VEIN REVISION 0.00<br />

0088T O RF TONGUE BASE VOL REDUXN 0.00<br />

0089T O ACTIGRAPHY TESTING, 3-DAY 0.00<br />

00900 9 ANESTH, PERINEAL PROCEDURE 0.00<br />

00902 A ANESTH, ANORECTAL SURGERY 0.00<br />

00904 A ANESTH, PERINEAL SURGERY 0.00<br />

00906 A ANESTH, REMOVAL OF VULVA 0.00<br />

00908 A ANESTH, REMOVAL OF PROSTATE 0.00<br />

0090T O CERVICAL ARTIFIC DISC 0.00<br />

00910 A ANESTH, BLAD<strong>DE</strong>R SURGERY 0.00<br />

00912 A ANESTH, BLAD<strong>DE</strong>R TUMOR SURG 0.00

---

00914 A ANESTH, REMOVAL OF PROSTATE 0.00<br />

00916 A ANESTH, BLEEDING CONTROL 0.00<br />

00918 A ANESTH, STONE REMOVAL 0.00<br />

0091T O LUMBAR ARTIFIC DISC 0.00<br />

00920 A ANESTH, GENITALIA SURGERY 0.00<br />

00921 A ANESTH, VASECTOMY 0.00<br />

00922 A ANESTH, SPERM DUCT SURGERY 0.00<br />

00924 A ANESTH, TESTIS EXPLORATION 0.00<br />

00926 A ANESTH, REMOVAL OF TESTIS 0.00<br />

00928 A ANESTH, REMOVAL OF TESTIS 0.00<br />

0092T 9 ARTIFIC DISC ADDL 0.00<br />

00930 A ANESTH, TESTIS SUSPENSION 0.00<br />

00932 A ANESTH, AMPUTATION OF PENIS 0.00<br />

00934 A ANESTH, PENIS, NO<strong>DE</strong>S REMOVAL 0.00<br />

00936 A ANESTH, PENIS, NO<strong>DE</strong>S REMOVAL 0.00<br />

00938 9 ANESTH, INSERT PENIS <strong>DE</strong>VICE 0.00<br />

0093T O CERVICAL ARTIFIC DISKECTOMY 0.00<br />

00940 A ANESTH, VAGINAL PROCEDURES 0.00<br />

00942 A ANESTH, SURG ON VAG/URETHRAL 0.00<br />

00944 A ANESTH, VAGINAL HYSTERECTOMY 0.00<br />

00946 9 ANESTH, VAGINAL <strong>DE</strong>LIVERY 0.00<br />

00948 A ANESTH, REPAIR OF CERVIX 0.00<br />

0094T O LUMBAR ARTIFIC DISKECTOMY 0.00<br />

00950 A ANESTH, VAGINAL ENDOSCOPY 0.00<br />

00952 A ANESTH, HYSTEROSCOPE/GRAPH 0.00<br />

00955 9 ANALGESIA, VAGINAL <strong>DE</strong>LIVERY 0.00<br />

0095T 9 ARTIFIC DISKECTOMY ADDL 0.00<br />

0096T O REV CERVICAL ARTIFIC DISC 0.00<br />

0097T O REV LUMBAR ARTIFIC DISC 0.00<br />

0098T 9 REV ARTIFIC DISC ADDL 0.00<br />

0099T 9 IMPLANT CORNEAL RING 0.00<br />

01000 9 ANESTH, SKIN SURGERY, PELVIS 0.00<br />

0100T 9 PROSTH RETINA RECEIVE&GEN 0.00<br />

0101T 9 EXTRACORP SHOCKWV TX,HI ENRG 0.00<br />

0102T 9 EXTRACORP SHOCKWV TX,ANESTH 0.00<br />

0103T 9 HOLOTRANSCOBALAMIN 0.00<br />

0104T 9 AT REST CARDIO GAS REBREATHE 0.00<br />

0105T 9 EXERC CARDIO GAS REBREATHE 0.00<br />

0106T 9 TOUCH QUANT SENSORY TEST 0.00<br />

0107T 9 VIBRATE QUANT SENSORY TEST 0.00<br />

0108T 9 COOL QUANT SENSORY TEST 0.00<br />

0109T 9 HEAT QUANT SENSORY TEST 0.00<br />

0110T 9 NOS QUANT SENSORY TEST 0.00<br />

01110 9 ANESTH, SKIN SURGERY, PELVIS 0.00<br />

01112 A ANESTH, BONE ASPIRATE/BX 0.00<br />

0111T 9 RBC MEMBRANES FATTY ACIDS 0.00<br />

01120 A ANESTH, PELVIS SURGERY 0.00<br />

01130 A ANESTH, BODY CAST PROCEDURE 0.00<br />

01140 A ANESTH, AMPUTATION AT PELVIS 0.00<br />

01150 A ANESTH, PELVIC TUMOR SURGERY 0.00

---

0115T O MED TX MNGMT 15 MIN 0.00<br />

01160 A ANESTH, PELVIS PROCEDURE 0.00<br />

0116T O MED TX MNGMT SUBSQT 0.00<br />

01170 A ANESTH, PELVIS SURGERY 0.00<br />

01173 A ANESTH, FX REPAIR, PELVIS 0.00<br />

0117T O MED TX MNGMT ADDL 15 MIN 0.00<br />

01180 A ANESTH, PELVIS NERVE REMOVAL 0.00<br />

01190 A ANESTH, PELVIS NERVE REMOVAL 0.00<br />

01200 A ANESTH, HIP JOINT PROCEDURE 0.00<br />

01202 A ANESTH, ARTHROSCOPY OF HIP 0.00<br />

0120T O FIBROA<strong>DE</strong>NOMA CRYOABLATE, EA 0.00<br />

01210 A ANESTH, HIP JOINT SURGERY 0.00<br />

01212 A ANESTH, HIP DISARTICULATION 0.00<br />

01214 A ANESTH, HIP ARTHROPLASTY 0.00<br />

01215 A ANESTH, REVISE HIP REPAIR 0.00<br />

01220 A ANESTH, PROCEDURE ON FEMUR 0.00<br />

01230 A ANESTH, SURGERY OF FEMUR 0.00<br />

01232 A ANESTH, AMPUTATION OF FEMUR 0.00<br />

01234 A ANESTH, RADICAL FEMUR SURG 0.00<br />

0123T 9 SCLERAL FISTULIZATION 0.00<br />

01240 9 ANESTH, UPPER LEG SKIN SURG 0.00<br />

0124T 9 CONJUNCTIVAL DRUG PLACEMENT 0.00<br />

01250 A ANESTH, UPPER LEG SURGERY 0.00<br />

01260 A ANESTH, UPPER LEG VEINS SURG 0.00<br />

0126T 9 CHD RISK IMT STUDY 0.00<br />

01270 A ANESTH, THIGH ARTERIES SURG 0.00<br />

01272 A ANESTH, FEMORAL ARTERY SURG 0.00<br />

01274 A ANESTH, FEMORAL EMBOLECTOMY 0.00<br />

01300 9 ANESTH, SKIN SURGERY, KNEE 0.00<br />

0130T 9 CHRON CARE DRUG INVESTIGATN 0.00<br />

01320 A ANESTH, KNEE AREA SURGERY 0.00<br />

0133T O ESOPHAGEAL IMPLANT INJEXN 0.00<br />

01340 A ANESTH, KNEE AREA PROCEDURE 0.00<br />

0135T O PERQ CRYOABLATE RENAL TUMOR 0.00<br />

01360 A ANESTH, KNEE AREA SURGERY 0.00<br />

0137T O PROSTATE SATURATION SAMPLING 0.00<br />

01380 A ANESTH, KNEE JOINT PROCEDURE 0.00<br />

01382 A ANESTH, DX KNEE ARTHROSCOPY 0.00<br />

01390 A ANESTH, KNEE AREA PROCEDURE 0.00<br />

01392 A ANESTH, KNEE AREA SURGERY 0.00<br />

01400 A ANESTH, KNEE JOINT SURGERY 0.00<br />

01402 A ANESTH, KNEE ARTHROPLASTY 0.00<br />

01404 A ANESTH, AMPUTATION AT KNEE 0.00<br />

0140T 9 EXHALED BREATH CON<strong>DE</strong>NSATE PH 0.00<br />

0141T 9 PERQ ISLET TRANSPLANT 0.00<br />

01420 A ANESTH, KNEE JOINT CASTING 0.00<br />

0142T 9 OPEN ISLET TRANSPLANT 0.00<br />

01430 A ANESTH, KNEE VEINS SURGERY 0.00<br />

01432 A ANESTH, KNEE VESSEL SURG 0.00<br />

0143T 9 LAPAROSCOPIC ISLET TRANSPLNT 0.00

---

01440 A ANESTH, KNEE ARTERIES SURG 0.00<br />

01442 A ANESTH, KNEE ARTERY SURG 0.00<br />

01444 A ANESTH, KNEE ARTERY REPAIR 0.00<br />

0144T 9 CT HEART WO DYE; QUAL CALC 0.00<br />

0145T 9 CT HEART W/WO DYE FUNCT 0.00<br />

01460 9 ANESTH, LOWER LEG SKIN SURG 0.00<br />

01462 A ANESTH, LOWER LEG PROCEDURE 0.00<br />

01464 A ANESTH, ANKLE/FT ARTHROSCOPY 0.00<br />

0146T 9 CCTA W/WO DYE 0.00<br />

01470 A ANESTH, LOWER LEG SURGERY 0.00<br />

01472 A ANESTH, ACHILLES TENDON SURG 0.00<br />

01474 A ANESTH, LOWER LEG SURGERY 0.00<br />

0147T 9 CCTA W/WO, QUAN CALCIUM 0.00<br />

01480 A ANESTH, LOWER LEG BONE SURG 0.00<br />

01482 A ANESTH, RADICAL LEG SURGERY 0.00<br />

01484 A ANESTH, LOWER LEG REVISION 0.00<br />

01486 A ANESTH, ANKLE REPLACEMENT 0.00<br />

0148T 9 CCTA W/WO, STRXR 0.00<br />

01490 A ANESTH, LOWER LEG CASTING 0.00<br />

0149T 9 CCTA W/WO, STRXR QUAN CALC 0.00<br />

01500 A ANESTH, LEG ARTERIES SURG 0.00<br />

01502 A ANESTH, LWR LEG EMBOLECTOMY 0.00<br />

0150T 9 CCTA W/WO, DISEASE STRXR 0.00<br />

0151T 9 CT HEART FUNCT ADD-ON 0.00<br />

01520 A ANESTH, LOWER LEG VEIN SURG 0.00<br />

01522 A ANESTH, LOWER LEG VEIN SURG 0.00<br />

0152T 9 COMPUTER CHEST ADD-ON 0.00<br />

0153T O TCATH SENSOR ANEURYSM SAC 0.00<br />

0154T O STUDY SENSOR ANEURYSM SAC 0.00<br />

0155T 9 LAP IMPL GAST CURVE ELECTRD 0.00<br />

0156T 9 LAP REMV GAST CURVE ELECTRD 0.00<br />

0157T 9 OPEN IMPL GAST CURVE ELECTRD 0.00<br />

0158T 9 OPEN REMV GAST CURVE ELECTRD 0.00<br />

0159T 9 CAD BREAST MRI 0.00<br />

01600 9 ANESTH, SHOUL<strong>DE</strong>R SKIN SURG 0.00<br />

0160T 9 TCRANIAL MAGN STIM TX PLAN 0.00<br />

01610 A ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 0.00<br />

0161T 9 TCRANIAL MAGN STIM TX <strong>DE</strong>LIV 0.00<br />

01620 A ANESTH, SHOUL<strong>DE</strong>R PROCEDURE 0.00<br />

01622 A ANES DX SHOUL<strong>DE</strong>R ARTHROSCOPY 0.00<br />

0162T O ANAL PROGRAM GAST NEUROSTIM 0.00<br />

01630 A ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 0.00<br />

01632 A ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 0.00<br />

01634 A ANESTH, SHOUL<strong>DE</strong>R JOINT AMPUT 0.00<br />

01636 A ANESTH, FOREQUARTER AMPUT 0.00<br />

01638 A ANESTH, SHOUL<strong>DE</strong>R REPLACEMENT 0.00<br />

0163T 9 LUMB ARTIF DISKECTOMY ADDL 0.00<br />

0164T 9 REMOVE LUMB ARTIF DISC ADDL 0.00<br />

01650 A ANESTH, SHOUL<strong>DE</strong>R ARTERY SURG 0.00<br />

01652 A ANESTH, SHOUL<strong>DE</strong>R VESSEL SURG 0.00

---

01654 A ANESTH, SHOUL<strong>DE</strong>R VESSEL SURG 0.00<br />

01656 A ANESTH, ARM-LEG VESSEL SURG 0.00<br />

0165T 9 REVISE LUMB ARTIF DISC ADDL 0.00<br />

0166T 9 TCATH VSD CLOSE W/O BYPASS 0.00<br />

01670 A ANESTH, SHOUL<strong>DE</strong>R VEIN SURG 0.00<br />

0167T 9 TCATH VSD CLOSE W BYPASS 0.00<br />

01680 A ANESTH, SHOUL<strong>DE</strong>R CASTING 0.00<br />

01682 A ANESTH, AIRPLANE CAST 0.00<br />

0168T 9 RHINOPHOTOTX LIGHT APP BILAT 0.00<br />

0169T 9 PLACE STEREO CATH BRAIN 0.00<br />

01700 9 ANESTH, ELBOW AREA SKIN SURG 0.00<br />

0170T 9 ANORECTAL FISTULA PLUG RPR 0.00<br />

01710 A ANESTH, ELBOW AREA SURGERY 0.00<br />

01712 A ANESTH, UPPR ARM TENDON SURG 0.00<br />

01714 A ANESTH, UPPR ARM TENDON SURG 0.00<br />

01716 A ANESTH, BICEPS TENDON REPAIR 0.00<br />

0171T 9 LUMBAR SPINE PROCES DISTRACT 0.00<br />

0172T 9 LUMBAR SPINE PROCES ADDL 0.00<br />

01730 A ANESTH, UPPR ARM PROCEDURE 0.00<br />

01732 A ANESTH, DX ELBOW ARTHROSCOPY 0.00<br />

0173T 9 IOP MONIT IO PRESSURE 0.00<br />

01740 A ANESTH, UPPER ARM SURGERY 0.00<br />

01742 A ANESTH, HUMERUS SURGERY 0.00<br />

01744 A ANESTH, HUMERUS REPAIR 0.00<br />

0174T 9 CAD CXR WITH INTERP 0.00<br />

01756 A ANESTH, RADICAL HUMERUS SURG 0.00<br />

01758 A ANESTH, HUMERAL LESION SURG 0.00<br />

0175T 9 CAD CXR REMOTE 0.00<br />

01760 A ANESTH, ELBOW REPLACEMENT 0.00<br />

0176T 9 AQU CANAL DILAT W/O RETENT 0.00<br />

01770 A ANESTH, UPPR ARM ARTERY SURG 0.00<br />

01772 A ANESTH, UPPR ARM EMBOLECTOMY 0.00<br />

0177T 9 AQU CANAL DILAT W RETENT 0.00<br />

01780 A ANESTH, UPPER ARM VEIN SURG 0.00<br />

01782 A ANESTH, UPPR ARM VEIN REPAIR 0.00<br />

0178T 9 64 LEAD ECG W I&R 0.00<br />

0179T 9 64 LEAD ECG W TRACING 0.00<br />

01800 9 ANESTH, LOWER ARM SKIN SURG 0.00<br />

0180T 9 64 LEAD ECG W I&R ONLY 0.00<br />

01810 A ANESTH, LOWER ARM SURGERY 0.00<br />

0181T 9 CORNEAL HYSTERESIS 0.00<br />

01820 A ANESTH, LOWER ARM PROCEDURE 0.00<br />

01829 A ANESTH, DX WRIST ARTHROSCOPY 0.00<br />

0182T 9 HDR ELECT BRACHYTHERAPY 0.00<br />

01830 A ANESTH, LOWER ARM SURGERY 0.00<br />

01832 A ANESTH, WRIST REPLACEMENT 0.00<br />

0183T 9 WOUND ULTRASOUND 0.00<br />

01840 A ANESTH, LWR ARM ARTERY SURG 0.00<br />

01842 A ANESTH, LWR ARM EMBOLECTOMY 0.00<br />

01844 A ANESTH, VASCULAR SHUNT SURG 0.00

---

0184T 9 EXC RECTAL TUMOR ENDOSCOPIC 0.00<br />

01850 A ANESTH, LOWER ARM VEIN SURG 0.00<br />

01852 A ANESTH, LWR ARM VEIN REPAIR 0.00<br />

0185T 9 COMPTR PROBABILITY ANALYSIS 0.00<br />

01860 A ANESTH, LOWER ARM CASTING 0.00<br />

0186T 9 SUPRACHOROIDAL DRUG <strong>DE</strong>LIVERY 0.00<br />

0187T 9 OPHTHALMIC DX IMAGE ANTERIOR 0.00<br />

0188T 9 VI<strong>DE</strong>OCONF CRIT CARE 74 MIN 0.00<br />

0189T 9 VI<strong>DE</strong>OCONF CRIT CARE ADDL 30 0.00<br />

01900 9 ANESTH, UTERUS/TUBE INJECT 0.00<br />

01902 9 ANESTH, BURR HOLES, SKULL 0.00<br />

01904 9 ANESTH, SKULL X-RAY INJECT 0.00<br />

01905 O ANES, SPINE INJECT, X-RAY/RE 0.00<br />

01906 9 ANESTH, LUMBAR MYELOGRAPHY 0.00<br />

01908 9 ANESTH, CERVICAL MYELOGRAPHY 0.00<br />

0190T 9 PLACE INTRAOC RADIATION SRC 0.00<br />

01910 9 ANESTH, SKULL MYELOGRAPHY 0.00<br />

01912 9 ANESTH, LUMBAR DISKOGRAPHY 0.00<br />

01914 9 ANESTH, CERVICAL DISKOGRAPHY 0.00<br />

01916 A ANESTH, DX ARTERIOGRAPHY 0.00<br />

01918 9 ANESTH, LIMB ARTERIOGRAM 0.00<br />

0191T 9 INSERT ANT SEGMENT DRAIN INT 0.00<br />

01920 A ANESTH, CATHETERIZE HEART 0.00<br />

01921 9 ANESTH, VESSEL SURGERY 0.00<br />

01922 A ANESTH, CAT OR MRI SCAN 0.00<br />

01924 A ANES, THER INTERVEN RAD, ART 0.00<br />

01925 A ANES, THER INTERVEN RAD, CAR 0.00<br />

01926 A ANES, TX INTERV RAD HRT/CRAN 0.00<br />

0192T 9 INSERT ANT SEGMENT DRAIN EXT 0.00<br />

01930 A ANES, THER INTERVEN RAD, VEI 0.00<br />

01931 A ANES, THER INTERVEN RAD, TIP 0.00<br />

01932 A ANES, TX INTERV RAD, TH VEIN 0.00<br />

01933 A ANES, TX INTERV RAD, CRAN V 0.00<br />

01935 A ANESTH, PERC IMG DX SP PROC 0.00<br />

01936 A ANESTH, PERC IMG TX SP PROC 0.00<br />

0193T 9 RF BLAD<strong>DE</strong>R NECK MICROREMO<strong>DE</strong>L 0.00<br />

0194T 9 PROCALCITONIN (PCT) 0.00<br />

01951 A ANESTH, BURN, LESS 4 PERCENT 0.00<br />

01952 A ANESTH, BURN, 4-9 PERCENT 0.00<br />

01953 5 ANESTH, BURN, EACH 9 PERCENT 0.00<br />

01958 A ANESTH, ANTEPARTUM MANIPUL 0.00<br />

0195T 9 ARTHROD PRESAC INTERBODY 0.00<br />

01960 A ANESTH, VAGINAL <strong>DE</strong>LIVERY 0.00<br />

01961 A ANESTH, CS <strong>DE</strong>LIVERY 0.00<br />

01962 A ANESTH, EMER HYSTERECTOMY 0.00<br />

01963 A ANESTH, CS HYSTERECTOMY 0.00<br />

01964 O ANESTH, ABORTION PROCEDURES 0.00<br />

01965 A ANESTH, INC/MISSED AB PROC 0.00<br />

01966 A ANESTH, INDUCED AB PROCEDURE 0.00<br />

01967 A ANESTH/ANALG, VAG <strong>DE</strong>LIVERY 0.00

---

01968 A ANES/ANALG CS <strong>DE</strong>LIVER ADD-ON 0.00<br />

01969 A ANESTH/ANALG CS HYST ADD-ON 0.00<br />

0196T 9 ARTHROD PRESAC INTERBODY EAC 0.00<br />

0197T 9 INTRAFRACTION TRACK MOTION 0.00<br />

0198T 9 OCULAR BLOOD FLOW MEASURE 0.00<br />

01990 A SUPPORT FOR ORGAN DONOR 0.00<br />

01991 A ANESTH, NERVE BLOCK/INJ 0.00<br />

01992 A ANESTH, N BLOCK/INJ, PRONE 0.00<br />

01995 O REGIONAL ANESTHESIA LIMB 0.00<br />

01996 3 HOSP MANAGE CONT DRUG ADMIN 48.15<br />

01999 5 UNLISTED ANESTH PROCEDURE 0.00<br />

0500F 9 INITIAL PRENATAL CARE VISIT 0.00<br />

0501F 9 PRENATAL FLOW SHEET 0.00<br />

0502F 9 SUBSEQUENT PRENATAL CARE 0.00<br />

0503F 9 POSTPARTUM CARE VISIT 0.00<br />

0505F 9 HEMODIALYSIS PLAN DOCÏD 0.00<br />

0507F 9 PERITON DIALYSIS PLAN DOCÏD 0.00<br />

0509F 9 URINE INCON PLAN DOCÏD 0.00<br />

0513F 9 ELEV BP PLAN OF CARE DOCÏD 0.00<br />

0514F 9 CARE PLAN HGB DOCÏD ESA PT 0.00<br />

0516F 9 ANEMIA PLAN OF CARE DOCÏD 0.00<br />

0517F 9 GLAUCOMA PLAN OF CARE DOCÏD 0.00<br />

0518F 9 FALL PLAN OF CARE DOCÏD 0.00<br />

0519F 9 PLANÏD CHEMO DOCÏD B/4 TXMNT 0.00<br />

0520F 9 RAD DOS LIMTS B/4 3D RAD 0.00<br />

0521F 9 PLAN OF CARE 4 PAIN DOCÏD 0.00<br />

0525F 9 INITIAL VISIT FOR EPISO<strong>DE</strong> 0.00<br />

0526F 9 SUBS VISIT FOR EPISO<strong>DE</strong> 0.00<br />

0528F 9 RCMND FLW-UP 10 YRS DOCD 0.00<br />

0529F 9 INTRVL 3+YRS PTS CLNSCP DOCD 0.00<br />

0535F 9 DYSPNEA MNGMNT PLAN DOCD 0.00<br />

0540F 9 GLUCO MNGMNT PLAN DOCD 0.00<br />

0575F 9 HIV RNA PLAN CARE DOCD 0.00<br />

10000 O INCISION AND DRAINAGE OF INFECTED O 0.00<br />

10001 O INCISION AND DRAINAGE OF INFECTED O 0.00<br />

10002 O INCISION AND DRAINAGE OF INFECTED O 0.00<br />

10003 O INCISION AND DRAINAGE OF INFECTED O 0.00<br />

1000F 9 TOBACCO USE ASSESSED 0.00<br />

1000H O PART H-ONLY DME, SUPPLIES AND HEARI 0.00<br />

1001F O TOBACCO USE, NON-SMOKING 0.00<br />

10020 O INCISION AND DRAINAGE OF FURUNCLE 0.00<br />

10021 3 FNA W/O IMAGE 131.46<br />

10022 3 FNA W/IMAGE 137.95<br />

1002F 9 ASSESS ANGINAL SYMPTOM/LEVEL 0.00<br />

1003F 9 LEVEL OF ACTIVITY ASSESS 0.00<br />

10040 3 ACNE SURGERY 87.94<br />

1004F 9 CLIN SYMP VOL OVRLD ASSESS 0.00<br />

1005F 9 ASTHMA SYMPTOMS EVALUATE 0.00<br />

10060 3 DRAINAGE OF SKIN ABSCESS 97.49<br />

10061 3 DRAINAGE OF SKIN ABSCESS 166.43

---

1006F 9 OSTEOARTHRITIS ASSESS 0.00<br />

1007F 9 ANTI-INFLM/ANLGSC OTC ASSESS 0.00<br />

10080 3 DRAINAGE OF PILONIDAL CYST 157.39<br />

10081 3 DRAINAGE OF PILONIDAL CYST 239.77<br />

1008F 9 GI/RENAL RISK ASSESS 0.00<br />

10100 O INCISION AND DRAINAGE OF ONYCHIA OR 0.00<br />

10101 O INCISION AND DRAINAGE OF ONYCHIA OR 0.00<br />

1010H O TRANSPORTATION IN VEHICLE OTHER THA 0.00<br />

1011H O TRANSPORTATION IN VEHICLE OTHER THA 0.00<br />

10120 3 REMOVE FOREIGN BODY 126.19<br />

10121 3 REMOVE FOREIGN BODY 239.89<br />

1012H O TRANSPORTATION IN VEHICLE OTHER THA 0.00<br />

1013H O TRANSPORTATION IN VEHICLE OTHER THA 0.00<br />

10140 3 DRAINAGE OF HEMATOMA/FLUID 137.47<br />

10141 O INCISION AND DRAINAGE OF HEMATOMA C 0.00<br />

1015F 9 COPD SYMPTOMS ASSESS 0.00<br />

1015H O SOCIAL WORK 0.00<br />

10160 3 PUNCTURE DRAINAGE OF LESION 87.84<br />

1016H O PARENT TRAINING 0.00<br />

10180 3 COMPLEX DRAINAGE, WOUND 210.12<br />

1018F 9 ASSESS DYSPNEA NOT PRESENT 0.00<br />

1019F 9 ASSESS DYSPNEA PRESENT 0.00<br />

1020H O INDIVIDUAL <strong>DE</strong>VELOPMENTAL SERVICES 0.00<br />

1021H O GROUP <strong>DE</strong>VELOPMENTAL SERVICES 0.00<br />

1022F 9 PNEUMO IMM STATUS ASSESS 0.00<br />

1022H O CO-TREAT/SIMULTANEOUS <strong>DE</strong>VELOPMENTAL 0.00<br />

1023H O <strong>DE</strong>VELOPMENTAL EVALUATION 0.00<br />

1026F 9 CO-MORBID CONDITION ASSESS 0.00<br />

1030F 9 INFLUENZA IMM STATUS ASSESS 0.00<br />

1034F 9 CURRENT TOBACCO SMOKER 0.00<br />

1035F 9 SMOKELESS TOBACCO USER 0.00<br />

1036F 9 TOBACCO NON-USER 0.00<br />

1038F 9 PERSISTENT ASTHMA 0.00<br />

1039F 9 INTERMITTENT ASTHMA 0.00<br />

1040F 9 SM-IV INFO MDD DOCD 0.00<br />

1050F 9 HISTORY OF MOLE CHANGES 0.00<br />

1055F 9 VISUAL FUNCT STATUS ASSESS 0.00<br />

1060F 9 DOC PERM/CONT/PAROX ATR. FIB 0.00<br />

1061F 9 DOC LACK PERM+CONT+PAROX FIB 0.00<br />

1065F 9 ISCHM STROKE SYMP LT3 HRSB/4 0.00<br />

1066F 9 ISCHM STROKE SYMP GE3 HRSB/4 0.00<br />

1070F 9 ALARM SYMP ASSESSED-ABSENT 0.00<br />

1071F 9 ALARM SYMP ASSESSED-1+ PRSNT 0.00<br />

1090F 9 PRES/ABSN URINE INCON ASSESS 0.00<br />

1091F 9 URINE INCON CHARACTERIZED 0.00<br />

11000 3 <strong>DE</strong>BRI<strong>DE</strong> INFECTED SKIN 48.05<br />

11001 3 <strong>DE</strong>BRI<strong>DE</strong> INFECTED SKIN ADD-ON 20.24<br />

11004 3 <strong>DE</strong>BRI<strong>DE</strong> GENITALIA & PERINEUM 525.69<br />

11005 3 <strong>DE</strong>BRI<strong>DE</strong> ABDOM WALL 695.01<br />

11006 3 <strong>DE</strong>BRI<strong>DE</strong> GENIT/PER/ABDOM WALL 655.35

---

11008 3 REMOVE MESH FROM ABD WALL 252.79<br />

1100F 9 PTFALLS ASSESS-DOCÏD GE2+/YR 0.00<br />

11010 3 <strong>DE</strong>BRI<strong>DE</strong> SKIN, FX 430.73<br />

11011 3 <strong>DE</strong>BRI<strong>DE</strong> SKIN/MUSCLE, FX 488.41<br />

11012 3 <strong>DE</strong>BRI<strong>DE</strong> SKIN/MUSCLE/BONE, FX 682.76<br />

1101F 9 PT FALLS ASSESS-DOCÏD LE1/YR 0.00<br />

11040 3 <strong>DE</strong>BRI<strong>DE</strong> SKIN, PARTIAL 42.32<br />

11041 3 <strong>DE</strong>BRI<strong>DE</strong> SKIN, FULL 50.51<br />

11042 3 <strong>DE</strong>BRI<strong>DE</strong> SKIN/TISSUE 68.57<br />

11043 3 <strong>DE</strong>BRI<strong>DE</strong> TISSUE/MUSCLE 248.01<br />

11044 3 <strong>DE</strong>BRI<strong>DE</strong> TISSUE/MUSCLE/BONE 335.07<br />

11050 O PARING OR CURETTEMENT OF BENIGN HYP 0.00<br />

11051 O PARING OR CURETTEMENT OF BENIGN HYP 0.00<br />

11052 O PARING OR CURETTEMENT OF BENIGN HYP 0.00<br />

11055 3 TRIM SKIN LESION 42.87<br />

11056 3 TRIM SKIN LESIONS, 2 TO 4 52.77<br />

11057 3 TRIM SKIN LESIONS, OVER 4 63.75<br />

11060 O SHAVING OF EPI<strong>DE</strong>RMAL OR SUPERFICIAL 0.00<br />

11061 O SHAVING OF EPI<strong>DE</strong>RMAL OR SUPERFICIAL 0.00<br />

11062 O SHAVING OF EPI<strong>DE</strong>RMAL OR SPUERFICIAL 0.00<br />

11100 3 BIOPSY, SKIN LESION 89.60<br />

11101 3 BIOPSY, SKIN ADD-ON 29.01<br />

1110F 9 PT LFT INPT FAC W/IN 60 DAYS 0.00<br />

1111F 9 DSCHRG MED/CURRENT MED MERGE 0.00<br />

1116F 9 AURIC/PERI PAIN ASSESSED 0.00<br />

1118F 9 GERD SYMPS ASSESSED 12 MONTH 0.00<br />

1119F 9 INIT. EVAL FOR CONDITION 0.00<br />

11200 3 REMOVAL OF SKIN TAGS 72.60<br />

11201 3 REMOVE SKIN TAGS ADD-ON 16.90<br />

1121F 9 SUBS. EVAL FOR CONDITION 0.00<br />

1123F 9 ACP DISCUSS/DSCN MKR DOCÏD 0.00<br />

1124F 9 ACP DISCUSS-NO DSCNMKR DOCÏD 0.00<br />

1125F 9 AMNT PAIN NOTED; PAIN PRSNT 0.00<br />

1126F 9 AMNT PAIN NOTED; NONE PRSNT 0.00<br />

1127F 9 NEW EPISO<strong>DE</strong> FOR CONDITION 0.00<br />

1128F 9 SUBS. EPISO<strong>DE</strong> FOR CONDITION 0.00<br />

11300 3 SHAVE SKIN LESION 61.10<br />

11301 3 SHAVE SKIN LESION 81.60<br />

11302 3 SHAVE SKIN LESION 97.10<br />

11303 3 SHAVE SKIN LESION 115.26<br />

11305 3 SHAVE SKIN LESION 62.56<br />

11306 3 SHAVE SKIN LESION 85.15<br />

11307 3 SHAVE SKIN LESION 99.20<br />

11308 3 SHAVE SKIN LESION 113.76<br />

1130F 9 BK PAIN + FXN ASSESSED 0.00<br />

11310 3 SHAVE SKIN LESION 75.01<br />

11311 3 SHAVE SKIN LESION 93.17<br />

11312 3 SHAVE SKIN LESION 108.30<br />

11313 3 SHAVE SKIN LESION 136.71<br />

1134F 9 EPSD BK PAIN FOR =< 6 WKS 0.00

---

1135F 9 EPSD BK PAIN FOR > 6 WKS 0.00<br />

1136F 9 EPSD BK PAIN FOR 12 WKS 0.00<br />

11400 3 EXC TR-EXT B9+MARG 0.5 < CM 107.75<br />

11401 3 EXC TR-EXT B9+MARG 0.6-1 CM 128.72<br />

11402 3 EXC TR-EXT B9+MARG 1.1-2 CM 142.86<br />

11403 3 EXC TR-EXT B9+MARG 2.1-3 CM 163.83<br />

11404 3 EXC TR-EXT B9+MARG 3.1-4 CM 186.06<br />

11406 3 EXC TR-EXT B9+MARG > 4.0 CM 257.13<br />

11420 3 EXC H-F-NK-SP B9+MARG 0.5 < 107.37<br />

11421 3 EXC H-F-NK-SP B9+MARG 0.6-1 136.95<br />

11422 3 EXC H-F-NK-SP B9+MARG 1.1-2 153.03<br />

11423 3 EXC H-F-NK-SP B9+MARG 2.1-3 178.32<br />

11424 3 EXC H-F-NK-SP B9+MARG 3.1-4 204.28<br />

11426 3 EXC H-F-NK-SP B9+MARG > 4 CM 289.38<br />

11440 3 EXC FACE-MM B9+MARG 0.5 < CM 119.64<br />

11441 3 EXC FACE-MM B9+MARG 0.6-1 CM 147.53<br />

11442 3 EXC FACE-MM B9+MARG 1.1-2 CM 165.55<br />

11443 3 EXC FACE-MM B9+MARG 2.1-3 CM 198.77<br />

11444 3 EXC FACE-MM B9+MARG 3.1-4 CM 249.69<br />

11446 3 EXC FACE-MM B9+MARG > 4 CM 333.81<br />

11450 3 REMOVAL, SWEAT GLAND LESION 316.59<br />

11451 3 REMOVAL, SWEAT GLAND LESION 418.50<br />

11462 3 REMOVAL, SWEAT GLAND LESION 313.81<br />

11463 3 REMOVAL, SWEAT GLAND LESION 426.28<br />

11470 3 REMOVAL, SWEAT GLAND LESION 343.17<br />

11471 3 REMOVAL, SWEAT GLAND LESION 440.49<br />

1150F 9 DOC PT RSK <strong>DE</strong>ATH W/IN 1YR 0.00<br />

1151F 9 DOC NO PT RSK <strong>DE</strong>ATH W/IN 1YR 0.00<br />

1152F 9 DOC ADVNCD DIS COMFORT 1ST 0.00<br />

1153F 9 DOC ADVNCD DIS CMFRT NOT 1ST 0.00<br />

1157F 9 ADVNC CARE PLAN IN RCRD 0.00<br />

1158F 9 ADVNC CARE PLAN TLK DOCD 0.00<br />

1159F 9 MED LIST DOCD IN RCRD 0.00<br />

11600 3 EXC TR-EXT MLG+MARG 0.5 < CM 162.32<br />

11601 3 EXC TR-EXT MLG+MARG 0.6-1 CM 192.88<br />

11602 3 EXC TR-EXT MLG+MARG 1.1-2 CM 210.05<br />

11603 3 EXC TR-EXT MLG+MARG 2.1-3 CM 238.75<br />

11604 3 EXC TR-EXT MLG+MARG 3.1-4 CM 263.68<br />

11606 3 EXC TR-EXT MLG+MARG > 4 CM 367.37<br />

1160F 9 RVW MEDS BY RX/DR IN RCRD 0.00<br />

11620 3 EXC H-F-NK-SP MLG+MARG 0.5 < 163.59<br />

11621 3 EXC H-F-NK-SP MLG+MARG 0.6-1 194.44<br />

11622 3 EXC H-F-NK-SP MLG+MARG 1.1-2 219.18<br />

11623 3 EXC H-F-NK-SP MLG+MARG 2.1-3 256.25<br />

11624 3 EXC H-F-NK-SP MLG+MARG 3.1-4 289.82<br />

11626 3 EXC H-F-NK-SP MLG+MAR > 4 CM 356.96<br />

11640 3 EXC FACE-MM MALIG+MARG 0.5 < 170.84<br />

11641 3 EXC FACE-MM MALIG+MARG 0.6-1 207.76<br />

11642 3 EXC FACE-MM MALIG+MARG 1.1-2 239.01

---

11643 3 EXC FACE-MM MALIG+MARG 2.1-3 281.01<br />

11644 3 EXC FACE-MM MALIG+MARG 3.1-4 348.50<br />

11646 3 EXC FACE-MM MLG+MARG > 4 CM 458.05<br />

11700 O <strong>DE</strong>BRI<strong>DE</strong>MENT OF NAILS, MANUAL; FIVE 0.00<br />

11701 O <strong>DE</strong>BRI<strong>DE</strong>MENT OF NAILS, MANUAL; EACH 0.00<br />

1170F 9 FXNL STATUS ASSESSED 0.00<br />

11710 O <strong>DE</strong>BRI<strong>DE</strong>MENT OF NAILS, ELECTRIC GRIN 0.00<br />

11711 O <strong>DE</strong>BRI<strong>DE</strong>MENT OF NAILS, ELECTRIC GRIN 0.00<br />

11719 3 TRIM NAIL(S) 18.56<br />

11720 3 <strong>DE</strong>BRI<strong>DE</strong> NAIL, 1-5 27.70<br />

11721 3 <strong>DE</strong>BRI<strong>DE</strong> NAIL, 6 OR MORE 39.83<br />

11730 3 REMOVAL OF NAIL PLATE 87.92<br />

11731 O REMOVAL OF SECOND NAIL PLATE 0.00<br />

11732 3 REMOVE NAIL PLATE, ADD-ON 40.60<br />

11740 3 DRAIN BLOOD FROM UN<strong>DE</strong>R NAIL 40.25<br />

11750 3 REMOVAL OF NAIL BED 188.48<br />

11752 3 REMOVE NAIL BED/FINGER TIP 267.07<br />

11755 3 BIOPSY, NAIL UNIT 119.24<br />

11760 3 REPAIR OF NAIL BED 178.93<br />

11762 3 RECONSTRUCTION OF NAIL BED 238.67<br />

11765 3 EXCISION OF NAIL FOLD, TOE 114.36<br />

11770 3 REMOVAL OF PILONIDAL LESION 235.62<br />

11771 3 REMOVAL OF PILONIDAL LESION 466.40<br />

11772 3 REMOVAL OF PILONIDAL LESION 577.32<br />

1180F 9 THROMBOEMB RISK ASSESSED 0.00<br />

11900 3 INJECTION INTO SKIN LESIONS 48.99<br />

11901 3 AD<strong>DE</strong>D SKIN LESIONS INJECTION 60.50<br />

11920 3 CORRECT SKIN COLOR <strong>DE</strong>FECTS 180.60<br />

11921 3 CORRECT SKIN COLOR <strong>DE</strong>FECTS 204.27<br />

11922 3 CORRECT SKIN COLOR <strong>DE</strong>FECTS 59.15<br />

11950 3 THERAPY FOR CONTOUR <strong>DE</strong>FECTS 70.01<br />

11951 3 THERAPY FOR CONTOUR <strong>DE</strong>FECTS 90.90<br />

11952 3 THERAPY FOR CONTOUR <strong>DE</strong>FECTS 130.57<br />

11954 3 THERAPY FOR CONTOUR <strong>DE</strong>FECTS 153.57<br />

11960 3 INSERT TISSUE EXPAN<strong>DE</strong>R(S) 824.99<br />

11970 3 REPLACE TISSUE EXPAN<strong>DE</strong>R 539.50<br />

11971 3 REMOVE TISSUE EXPAN<strong>DE</strong>R(S) 443.42<br />

11975 5 INSERT CONTRACEPTIVE CAP 0.00<br />

11976 3 REMOVAL OF CONTRACEPTIVE CAP 134.34<br />

11977 5 REMOVAL/REINSERT CONTRA CAP 0.00<br />

11980 5 IMPLANT HORMONE PELLET(S) 0.00<br />

11981 5 INSERT DRUG IMPLANT <strong>DE</strong>VICE 0.00<br />

11982 3 REMOVE DRUG IMPLANT <strong>DE</strong>VICE 143.39<br />

11983 5 REMOVE/INSERT DRUG IMPLANT 0.00<br />

12001 3 REPAIR SUPERFICIAL WOUND(S) 135.76<br />

12002 3 REPAIR SUPERFICIAL WOUND(S) 144.49<br />

12004 3 REPAIR SUPERFICIAL WOUND(S) 169.40<br />

12005 3 REPAIR SUPERFICIAL WOUND(S) 210.84<br />

12006 3 REPAIR SUPERFICIAL WOUND(S) 262.20<br />

12007 3 REPAIR SUPERFICIAL WOUND(S) 294.72

---

12011 3 REPAIR SUPERFICIAL WOUND(S) 144.66<br />

12013 3 REPAIR SUPERFICIAL WOUND(S) 158.86<br />

12014 3 REPAIR SUPERFICIAL WOUND(S) 186.36<br />

12015 3 REPAIR SUPERFICIAL WOUND(S) 234.01<br />

12016 3 REPAIR SUPERFICIAL WOUND(S) 276.76<br />

12017 3 REPAIR SUPERFICIAL WOUND(S) 241.37<br />

12018 3 REPAIR SUPERFICIAL WOUND(S) 289.08<br />

12020 3 CLOSURE OF SPLIT WOUND 246.14<br />

12021 3 CLOSURE OF SPLIT WOUND 142.64<br />

12031 3 INTMD WND REPAIR S/TR/EXT 200.15<br />

12032 3 INTMD WND REPAIR S/TR/EXT 267.29<br />

12034 3 INTMD WND REPAIR S/TR/EXT 260.57<br />

12035 3 INTMD WND REPAIR S/TR/EXT 334.77<br />

12036 3 INTMD WND REPAIR S/TR/EXT 369.73<br />

12037 3 INTMD WND REPAIR S/TR/EXT 415.81<br />

12041 3 INTMD WND REPAIR N-HF/GENIT 212.78<br />

12042 3 INTMD WND REPAIR N-HG/GENIT 251.25<br />

12044 3 INTMD WND REPAIR N-HG/GENIT 284.61<br />

12045 3 INTMD WND REPAIR N-HG/GENIT 338.36<br />

12046 3 INTMD WND REPAIR N-HG/GENIT 399.59<br />

12047 3 INTMD WND REPAIR N-HG/GENIT 427.63<br />

12051 3 INTMD WND REPAIR FACE/MM 235.43<br />

12052 3 INTMD WND REPAIR FACE/MM 259.09<br />

12053 3 INTMD WND REPAIR FACE/MM 283.43<br />

12054 3 INTMD WND REPAIR, FACE/MM 303.75<br />

12055 3 INTMD WND REPAIR FACE/MM 370.43<br />

12056 3 INTMD WND REPAIR FACE/MM 457.39<br />

12057 3 INTMD WND REPAIR FACE/MM 492.55<br />

1220F 9 PT SCREENED FOR <strong>DE</strong>PRESSION 0.00<br />

13100 3 REPAIR OF WOUND OR LESION 281.17<br />

13101 3 REPAIR OF WOUND OR LESION 349.45<br />

13102 3 REPAIR WOUND/LESION ADD-ON 95.39<br />

13120 3 REPAIR OF WOUND OR LESION 291.67<br />

13121 3 REPAIR OF WOUND OR LESION 382.67<br />

13122 3 REPAIR WOUND/LESION ADD-ON 110.00<br />

13131 3 REPAIR OF WOUND OR LESION 321.21<br />

13132 3 REPAIR OF WOUND OR LESION 500.81<br />

13133 3 REPAIR WOUND/LESION ADD-ON 149.28<br />

13150 3 REPAIR OF WOUND OR LESION 328.29<br />

13151 3 REPAIR OF WOUND OR LESION 363.52<br />

13152 3 REPAIR OF WOUND OR LESION 493.85<br />

13153 3 REPAIR WOUND/LESION ADD-ON 166.26<br />

13160 3 LATE CLOSURE OF WOUND 726.14<br />

13300 O REPAIR OF WOUND OR LESION 0.00<br />

14000 3 SKIN TISSUE REARRANGEMENT 579.37<br />

14001 3 SKIN TISSUE REARRANGEMENT 751.74<br />

14020 3 SKIN TISSUE REARRANGEMENT 645.54<br />

14021 3 SKIN TISSUE REARRANGEMENT 845.09<br />

14040 3 SKIN TISSUE REARRANGEMENT 678.21<br />

14041 3 SKIN TISSUE REARRANGEMENT 927.00

---

14060 3 SKIN TISSUE REARRANGEMENT 691.32<br />

14061 3 SKIN TISSUE REARRANGEMENT 1,006.23<br />

14300 3 SKIN TISSUE REARRANGEMENT 969.19<br />

14350 3 SKIN TISSUE REARRANGEMENT 682.81<br />

15000 O WOUND PREP, 1ST 100 SQ CM 0.00<br />

15001 O WOUND PREP, ADDL 100 SQ CM 0.00<br />

15002 3 WOUND PREP, TRK/ARM/LEG 304.14<br />

15003 3 WOUND PREP, ADDL 100 CM 65.62<br />

15004 3 WOUND PREP, F/N/HF/G 365.53<br />

15005 3 WND PREP, F/N/HF/G, ADDL CM 109.59<br />

15040 3 HARVEST CULTURED SKIN GRAFT 242.08<br />

15050 3 SKIN PINCH GRAFT 485.03<br />

15100 3 SKIN SPLT GRFT, TRNK/ARM/LEG 808.13<br />

15101 3 SKIN SPLT GRFT T/A/L, ADD-ON 187.21<br />

15110 3 EPIDRM AUTOGRFT TRNK/ARM/LEG 789.68<br />

15111 3 EPIDRM AUTOGRFT T/A/L ADD-ON 112.95<br />

15115 3 EPIDRM A-GRFT FACE/NCK/HF/G 776.46<br />

15116 3 EPIDRM A-GRFT F/N/HF/G ADDL 149.17<br />

15120 3 SKN SPLT A-GRFT FAC/NCK/HF/G 840.27<br />

15121 3 SKN SPLT A-GRFT F/N/HF/G ADD 257.34<br />

15130 3 <strong>DE</strong>RM AUTOGRAFT, TRNK/ARM/LEG 630.70<br />

15131 3 <strong>DE</strong>RM AUTOGRAFT T/A/L ADD-ON 90.88<br />

15135 3 <strong>DE</strong>RM AUTOGRAFT FACE/NCK/HF/G 787.29<br />

15136 3 <strong>DE</strong>RM AUTOGRAFT, F/N/HF/G ADD 87.04<br />

15150 3 CULT EPI<strong>DE</strong>RM GRFT T/ARM/LEG 654.02<br />

15151 3 CULT EPI<strong>DE</strong>RM GRFT T/A/L ADDL 118.94<br />

15152 3 CULT EPI<strong>DE</strong>RM GRAFT T/A/L +% 146.22<br />

15155 3 CULT EPI<strong>DE</strong>RM GRAFT, F/N/HF/G 676.37<br />

15156 3 CULT EPIDRM GRFT F/N/HFG ADD 156.95<br />

15157 3 CULT EPI<strong>DE</strong>RM GRFT F/N/HFG +% 174.57<br />

15170 3 ACELL GRAFT TRUNK/ARMS/LEGS 373.43<br />

15171 3 ACELL GRAFT T/ARM/LEG ADD-ON 83.17<br />

15175 3 ACELLULAR GRAFT, F/N/HF/G 490.10<br />

15176 3 ACELL GRAFT, F/N/HF/G ADD-ON 133.85<br />

15200 3 SKIN FULL GRAFT, TRUNK 713.26<br />

15201 3 SKIN FULL GRAFT TRUNK ADD-ON 140.39<br />

15220 3 SKIN FULL GRAFT SCLP/ARM/LEG 681.15<br />

15221 3 SKIN FULL GRAFT ADD-ON 130.15<br />

15240 3 SKIN FULL GRFT FACE/GENIT/HF 808.97<br />

15241 3 SKIN FULL GRAFT ADD-ON 167.92<br />

15260 3 SKIN FULL GRAFT EEN & LIPS 863.81<br />

15261 3 SKIN FULL GRAFT ADD-ON 193.42<br />

15300 3 APPLY SKINALLOGRFT, T/ARM/LG 302.61<br />

15301 3 APPLY SKNALLOGRFT T/A/L ADDL 56.13<br />

15320 3 APPLY SKIN ALLOGRFT F/N/HF/G 344.48<br />

15321 3 APLY SKNALLOGRFT F/N/HFG ADD 84.19<br />

15330 3 APLY ACELL ALOGRFT T/ARM/LEG 281.07<br />

15331 3 APLY ACELL GRFT T/A/L ADD-ON 56.52<br />

15335 3 APPLY ACELL GRAFT, F/N/HF/G 302.53<br />

15336 3 APLY ACELL GRFT F/N/HF/G ADD 82.37

---

15340 3 APPLY CULT SKIN SUBSTITUTE 290.67<br />

15341 3 APPLY CULT SKIN SUB ADD-ON 43.11<br />

15342 O CULTURED SKIN GRAFT, 25 CM 0.00<br />

15343 O CULTURE SKN GRAFT ADDL 25 CM 0.00<br />

15350 O SKIN HOMOGRAFT 0.00<br />

15351 O SKIN HOMOGRAFT ADD-ON 0.00<br />

15360 3 APPLY CULT <strong>DE</strong>RM SUB, T/A/L 329.30<br />

15361 3 APLY CULT <strong>DE</strong>RM SUB T/A/L ADD 64.28<br />

15365 3 APPLY CULT <strong>DE</strong>RM SUB F/N/HF/G 328.80<br />

15366 3 APPLY CULT <strong>DE</strong>RM F/HF/G ADD 81.07<br />

15400 3 APPLY SKIN XENOGRAFT, T/A/L 339.59<br />

15401 3 APPLY SKN XENOGRFT T/A/L ADD 95.08<br />

15410 O FREE TRANSPLANTATION OF SKIN FLAP B 0.00<br />

15412 O FREE TRANSPLANTATION OF SKIN FLAP B 0.00<br />

15414 O FREE TRANSPLANTATION OF SKIN FLAP B 0.00<br />

15416 O FREE TRANSPLANTATION OF SKIN FLAP B 0.00<br />

15420 3 APPLY SKIN XGRAFT, F/N/HF/G 382.40<br />

15421 3 APPLY SKN XGRFT F/N/HF/G ADD 105.83<br />

15430 3 APPLY ACELLULAR XENOGRAFT 486.50<br />

15431 6 APPLY ACELLULAR XGRAFT ADD 0.00<br />

15500 O FORMATION OF TUBE PEDICLE WITHOUT T 0.00<br />

15505 O FORMATION OF TUBE PEDICLE WITHOUT T 0.00<br />

15510 O FORMATION OF TUBE PEDICLE WITHOUT T 0.00<br />

15515 O FORMATION OF TUBE PEDICLE WITHOUT T 0.00<br />

15540 O PRIMARY ATTACHMENT OF OPEN OR TUBED 0.00<br />

15545 O PRIMARY ATTACHMENT OF OPEN OR TUBED 0.00<br />

15550 O PRIMARY ATTACHMENT OF OPEN OR TUBED 0.00<br />

15555 O PRIMARY ATTACHMENT OF OPEN OR TUBED 0.00<br />

15570 3 FORM SKIN PEDICLE FLAP 799.87<br />

15572 3 FORM SKIN PEDICLE FLAP 751.71<br />

15574 3 FORM SKIN PEDICLE FLAP 809.91<br />

15576 3 FORM SKIN PEDICLE FLAP 721.61<br />

15580 O ATTACH SKIN PEDICLE GRAFT 0.00<br />

15600 3 SKIN GRAFT 328.38<br />

15610 3 SKIN GRAFT 295.75<br />

15620 3 SKIN GRAFT 413.71<br />

15625 O SKIN GRAFT 0.00<br />

15630 3 SKIN GRAFT 421.83<br />

15650 3 TRANSFER SKIN PEDICLE FLAP 453.59<br />

15700 O EXCISION OF LESION AND/OR EXCISIONA 0.00<br />

15710 O EXCISION OF LESION AND/OR EXCISIONA 0.00<br />

15720 O EXCISION OF LESION AND/OR EXCISIONA 0.00<br />

15730 O EXCISION OF LESION AND/OR EXCISIONA 0.00<br />

15731 3 FOREHEAD FLAP W/VASC PEDICLE 984.70<br />

15732 3 MUSCLE-SKIN GRAFT, HEAD/NECK 1,370.93<br />

15734 3 MUSCLE-SKIN GRAFT, TRUNK 1,219.77<br />

15736 3 MUSCLE-SKIN GRAFT, ARM 1,268.96<br />

15738 3 MUSCLE-SKIN GRAFT, LEG 1,345.01<br />

15740 3 ISLAND PEDICLE FLAP GRAFT 877.64<br />

15750 3 NEUROVASCULAR PEDICLE GRAFT 825.80

---

15755 O FREE FLAP (MICROVASCULAR TRANSFER) 0.00<br />

15756 3 FREE MYO/SKIN FLAP MICROVASC 2,152.35<br />

15757 3 FREE SKIN FLAP, MICROVASC 2,145.05<br />

15758 3 FREE FASCIAL FLAP, MICROVASC 2,140.34<br />

15760 3 COMPOSITE SKIN GRAFT 755.71<br />

15770 3 <strong>DE</strong>RMA-FAT-FASCIA GRAFT 589.21<br />

15775 3 HAIR TRANSPLANT PUNCH GRAFTS 289.45<br />

15776 3 HAIR TRANSPLANT PUNCH GRAFTS 409.88<br />

15780 3 ABRASION TREATMENT OF SKIN 755.97<br />

15781 3 ABRASION TREATMENT OF SKIN 483.29<br />

15782 3 ABRASION TREATMENT OF SKIN 523.43<br />

15783 3 ABRASION TREATMENT OF SKIN 446.14<br />

15786 3 ABRASION, LESION, SINGLE 215.77<br />

15787 3 ABRASION, LESIONS, ADD-ON 50.12<br />

15788 9 CHEMICAL PEEL, FACE, EPI<strong>DE</strong>RM 0.00<br />

15789 9 CHEMICAL PEEL, FACE, <strong>DE</strong>RMAL 0.00<br />

15790 O CHEMICAL PEEL (CHEMEXFOLIATION) TOT 0.00<br />

15791 O CHEMICAL PEEL (CHEMEXFOLIATION) REG 0.00<br />

15792 9 CHEMICAL PEEL, NONFACIAL 0.00<br />

15793 9 CHEMICAL PEEL, NONFACIAL 0.00<br />

15810 O SALABRASION 0.00<br />

15811 O SALABRASION 0.00<br />

15819 3 PLASTIC SURGERY, NECK 655.61<br />

15820 3 REVISION OF LOWER EYELID 481.05<br />

15821 3 REVISION OF LOWER EYELID 512.80<br />

15822 3 REVISION OF UPPER EYELID 381.39<br />

15823 3 REVISION OF UPPER EYELID 589.91<br />

15824 9 REMOVAL OF FOREHEAD WRINKLES 0.00<br />

15825 5 REMOVAL OF NECK WRINKLES 0.00<br />

15826 5 REMOVAL OF BROW WRINKLES 0.00<br />

15828 5 REMOVAL OF FACE WRINKLES 0.00<br />

15829 5 REMOVAL OF SKIN WRINKLES 0.00<br />

15830 3 EXC SKIN ABD 1,046.03<br />

15831 O EXCISE EXCESSIVE SKIN TISSUE 0.00<br />

15832 3 EXCISE EXCESSIVE SKIN TISSUE 805.03<br />

15833 3 EXCISE EXCESSIVE SKIN TISSUE 749.95<br />

15834 3 EXCISE EXCESSIVE SKIN TISSUE 765.50<br />

15835 3 EXCISE EXCESSIVE SKIN TISSUE 783.87<br />

15836 3 EXCISE EXCESSIVE SKIN TISSUE 660.69<br />

15837 3 EXCISE EXCESSIVE SKIN TISSUE 691.74<br />

15838 3 EXCISE EXCESSIVE SKIN TISSUE 517.56<br />

15839 3 EXCISE EXCESSIVE SKIN TISSUE 752.02<br />

15840 3 GRAFT FOR FACE NERVE PALSY 911.44<br />

15841 3 GRAFT FOR FACE NERVE PALSY 1,507.91<br />

15842 3 FLAP FOR FACE NERVE PALSY 2,387.50<br />

15845 3 SKIN AND MUSCLE REPAIR, FACE 847.70<br />

15847 6 EXC SKIN ABD ADD-ON 0.00<br />

15850 9 REMOVAL OF SUTURES 0.00<br />

15851 3 REMOVAL OF SUTURES 90.45<br />

15852 3 DRESSING CHANGE NOT FOR BURN 43.34

---

15860 3 TEST FOR BLOOD FLOW IN GRAFT 102.15<br />

15876 5 SUCTION ASSISTED LIPECTOMY 0.00<br />

15877 9 SUCTION ASSISTED LIPECTOMY 0.00<br />

15878 9 SUCTION ASSISTED LIPECTOMY 0.00<br />

15879 9 SUCTION ASSISTED LIPECTOMY 0.00<br />

15920 3 REMOVAL OF TAIL BONE ULCER 521.67<br />

15922 3 REMOVAL OF TAIL BONE ULCER 671.84<br />

15931 3 REMOVE SACRUM PRESSURE SORE 596.20<br />

15933 3 REMOVE SACRUM PRESSURE SORE 736.35<br />

15934 3 REMOVE SACRUM PRESSURE SORE 821.99<br />

15935 3 REMOVE SACRUM PRESSURE SORE 974.05<br />

15936 3 REMOVE SACRUM PRESSURE SORE 802.10<br />

15937 3 REMOVE SACRUM PRESSURE SORE 938.97<br />

15940 3 REMOVE HIP PRESSURE SORE 617.14<br />

15941 3 REMOVE HIP PRESSURE SORE 815.95<br />

15944 3 REMOVE HIP PRESSURE SORE 794.00<br />

15945 3 REMOVE HIP PRESSURE SORE 878.04<br />

15946 3 REMOVE HIP PRESSURE SORE 1,453.28<br />

15950 3 REMOVE THIGH PRESSURE SORE 512.01<br />

15951 3 REMOVE THIGH PRESSURE SORE 730.09<br />

15952 3 REMOVE THIGH PRESSURE SORE 758.39<br />

15953 3 REMOVE THIGH PRESSURE SORE 846.40<br />

15954 O EXCISION, TROCHANTERIC PRESSURE ULC 0.00<br />

15955 O EXCISION, TROCHANTERIC PRESSURE ULC 0.00<br />

15956 3 REMOVE THIGH PRESSURE SORE 1,028.00<br />

15958 3 REMOVE THIGH PRESSURE SORE 1,050.47<br />

15960 O EXCISION, HEEL PRESSURE ULCER, WITH 0.00<br />

15961 O EXCISION, HEEL PRESSURE ULCER, WITH 0.00<br />

15964 O EXCISION, HEEL PRESSURE ULCER, WITH 0.00<br />

15965 O EXCISION, HEEL PRESSURE ULCER, WITH 0.00<br />

15966 O EXCISION, HEEL PRESSURE ULCER, WITH 0.00<br />

15967 O EXCISION, HEEL PRESSURE ULCER, WITH 0.00<br />

15970 O EXCISION, LEG PRESSURE ULCER, WITH 0.00<br />

15971 O EXCISION, LEG PRESSURE ULCER, WITH 0.00<br />

15972 O EXCISION, LEG PRESSURE ULCER, WITH 0.00<br />

15973 O EXCISION, LEG PRESSURE ULCER, WITH 0.00<br />

15974 O EXCISION, LEG PRESSURE ULCER, WITH 0.00<br />

15975 O EXCISION, LEG PRESSURE ULCER, WITH 0.00<br />

15980 O EXCISION, KNEE PRESSURE ULCER, WITH 0.00<br />

15981 O EXCISION, KNEE PRESSURE ULCER, WITH 0.00<br />

15982 O EXCISION, KNEE PRESSURE ULCER, WITH 0.00<br />

15983 O EXCISION, KNEE PRESSURE ULCER, WITH 0.00<br />

15999 5 REMOVAL OF PRESSURE SORE 0.00<br />

16000 3 INITIAL TREATMENT OF BURN(S) 63.48<br />

16010 O TREATMENT OF BURN(S) 0.00<br />

16015 O TREATMENT OF BURN(S) 0.00<br />

16020 3 DRESS/<strong>DE</strong>BRID P-THICK BURN, S 76.53<br />

16025 3 DRESS/<strong>DE</strong>BRID P-THICK BURN, M 134.09<br />

16030 3 DRESS/<strong>DE</strong>BRID P-THICK BURN, L 161.37<br />

16035 3 INCISION OF BURN SCAB, INITI 195.38

---

16036 3 ESCHAROTOMY; ADDÏL INCISION 77.60<br />

16040 O BURN WOUND EXCISION 0.00<br />

16041 O BURN WOUND EXCISION 0.00<br />

16042 O BURN WOUND EXCISION 0.00<br />

17000 3 <strong>DE</strong>STRUCT PREMALG LESION 68.89<br />

17001 O <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

17002 O <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

17003 3 <strong>DE</strong>STRUCT PREMALG LES, 2-14 6.93<br />

17004 3 <strong>DE</strong>STROY PREMLG LESIONS 15+ 158.11<br />

17010 O <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

17100 O <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

17101 O <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

17102 O <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

17104 O <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

17105 O <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

17106 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 350.03<br />

17107 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 609.11<br />

17108 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 821.04<br />

17110 3 <strong>DE</strong>STRUCT B9 LESION, 1-14 91.08<br />

17111 3 <strong>DE</strong>STRUCT LESION, 15 OR MORE 110.55<br />

17200 O ELECTROSURGICAL <strong>DE</strong>STRUCTION OF MULT 0.00<br />

17201 O ELECTROSURGICAL <strong>DE</strong>STRUCTION OF MULT 0.00<br />

17250 3 CHEMICAL CAUTERY, TISSUE 68.68<br />

17260 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 85.48<br />

17261 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 122.57<br />

17262 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 148.92<br />

17263 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 164.02<br />

17264 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 177.18<br />

17266 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 200.79<br />

17270 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 128.36<br />

17271 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 140.33<br />

17272 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 160.88<br />

17273 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 179.07<br />

17274 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 213.10<br />

17276 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 248.65<br />

17280 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 120.21<br />

17281 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 152.26<br />

17282 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 176.32<br />

17283 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 213.36<br />

17284 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 248.94<br />

17286 3 <strong>DE</strong>STRUCTION OF SKIN LESIONS 317.49<br />

17303 O CHEMOSURGERY (MOHS' TECHNIQUE), FIR 0.00<br />

17304 O 1 STAGE MOHS, UP TO 5 SPEC 0.00<br />

17305 O 2 STAGE MOHS, UP TO 5 SPEC 0.00<br />

17306 O 3 STAGE MOHS, UP TO 5 SPEC 0.00<br />

17307 O MOHS ADDL STAGE UP TO 5 SPEC 0.00<br />

17310 O MOHS ANY STAGE > 5 SPEC EACH 0.00<br />

17311 3 MOHS, 1 STAGE, H/N/HF/G 638.72<br />

17312 3 MOHS ADDL STAGE 386.98<br />

17313 3 MOHS, 1 STAGE, T/A/L 583.91

---

17314 3 MOHS, ADDL STAGE, T/A/L 357.75<br />

17315 3 MOHS SURG, ADDL BLOCK 75.39<br />

17340 3 CRYOTHERAPY OF SKIN 41.44<br />

17360 3 SKIN PEEL THERAPY 115.60<br />

17380 9 HAIR REMOVAL BY ELECTROLYSIS 0.00<br />

17999 5 SKIN TISSUE PROCEDURE 0.00<br />

19000 3 DRAINAGE OF BREAST LESION 107.58<br />

19001 3 DRAIN BREAST LESION ADD-ON 25.27<br />

19020 3 INCISION OF BREAST LESION 394.95<br />

19030 3 INJECTION FOR BREAST X-RAY 163.63<br />

19100 3 BX BREAST PERCUT W/O IMAGE 129.70<br />

19101 3 BIOPSY OF BREAST, OPEN 294.82<br />

19102 3 BX BREAST PERCUT W/IMAGE 215.52<br />

19103 3 BX BREAST PERCUT W/<strong>DE</strong>VICE 181.63<br />

19105 3 CRYOSURG ABLATE FA, EACH 1,963.91<br />

19110 3 NIPPLE EXPLORATION 397.66<br />

19112 3 EXCISE BREAST DUCT FISTULA 382.47<br />

19120 3 REMOVAL OF BREAST LESION 408.77<br />

19125 3 EXCISION, BREAST LESION 383.53<br />

19126 3 EXCISION, ADDL BREAST LESION 144.82<br />

19140 O REMOVAL OF BREAST TISSUE 0.00<br />

19160 O PARTIAL MASTECTOMY 0.00<br />

19162 O P-MASTECTOMY W/LN REMOVAL 0.00<br />

19180 O REMOVAL OF BREAST 0.00<br />

19182 O REMOVAL OF BREAST 0.00<br />

19200 O REMOVAL OF BREAST 0.00<br />

19220 O REMOVAL OF BREAST 0.00<br />

19240 O REMOVAL OF BREAST 0.00<br />

19260 3 REMOVAL OF CHEST WALL LESION 1,079.18<br />

19271 3 REVISION OF CHEST WALL 1,483.98<br />

19272 3 EXTENSIVE CHEST WALL SURGERY 1,636.74<br />

19290 3 PLACE NEEDLE WIRE, BREAST 62.12<br />

19291 3 PLACE NEEDLE WIRE, BREAST 68.39<br />

19295 3 PLACE BREAST CLIP, PERCUT 98.26<br />

19296 3 PLACE PO BREAST CATH FOR RAD 4,294.49<br />

19297 3 PLACE BREAST CATH FOR RAD 84.42<br />

19298 3 PLACE BREAST RAD TUBE/CATHS 1,478.97<br />

19300 9 REMOVAL OF BREAST TISSUE 0.00<br />

19301 3 PARTICAL MASTECTOMY 520.78<br />

19302 3 P-MASTECTOMY W/LN REMOVAL 769.32<br />

19303 3 MAST, SIMPLE, COMPLETE 802.76<br />

19304 3 MAST, SUBQ 486.52<br />

19305 3 MAST, RADICAL 957.58<br />

19306 3 MAST, RAD, URBAN TYPE 1,000.50<br />

19307 3 MAST, MOD RAD 1,005.84<br />

19316 3 SUSPENSION OF BREAST 705.34<br />

19318 3 REDUCTION OF LARGE BREAST 1,040.86<br />

19324 9 ENLARGE BREAST 0.00<br />

19325 9 ENLARGE BREAST WITH IMPLANT 0.00<br />

19328 3 REMOVAL OF BREAST IMPLANT 439.29

---

19330 3 REMOVAL OF IMPLANT MATERIAL 557.91<br />

19340 3 IMMEDIATE BREAST PROSTHESIS 362.31<br />

19342 3 <strong>DE</strong>LAYED BREAST PROSTHESIS 826.28<br />

19350 3 BREAST RECONSTRUCTION 813.71<br />

19355 9 CORRECT INVERTED NIPPLE(S) 0.00<br />

19357 3 BREAST RECONSTRUCTION 1,394.57<br />

19360 O BREAST RECONSTRUCTION WITH MUSCLE O 0.00<br />

19361 3 BREAST RECONSTR W/LAT FLAP 1,447.44<br />

19362 O BREAST RECONSTRUCTION WITH TRANSVER 0.00<br />

19364 3 BREAST RECONSTRUCTION 2,522.27<br />

19366 3 BREAST RECONSTRUCTION 1,254.97<br />

19367 3 BREAST RECONSTRUCTION 1,648.90<br />

19368 3 BREAST RECONSTRUCTION 2,030.80<br />

19369 3 BREAST RECONSTRUCTION 1,868.85<br />

19370 3 SURGERY OF BREAST CAPSULE 612.65<br />

19371 3 REMOVAL OF BREAST CAPSULE 706.73<br />

19380 3 REVISE BREAST RECONSTRUCTION 690.16<br />

19396 3 <strong>DE</strong>SIGN CUSTOM BREAST IMPLANT 192.98<br />

19499 5 BREAST SURGERY PROCEDURE 0.00<br />

20000 3 INCISION OF ABSCESS 187.59<br />

20005 3 INCISION OF <strong>DE</strong>EP ABSCESS 274.99<br />

2000F 9 BLOOD PRESSURE MEASURE 0.00<br />

2001F 9 WEIGHT RECORD 0.00<br />

2002F 9 CLIN SIGN VOL OVRLD ASSESS 0.00<br />

2003F O AUSCULTATION HEART PERFORM 0.00<br />

2004F 9 INITIAL EXAM INVOLVED JOINTS 0.00<br />

20100 3 EXPLORE WOUND, NECK 544.37<br />

20101 3 EXPLORE WOUND, CHEST 368.67<br />

20102 3 EXPLORE WOUND, ABDOMEN 432.17<br />

20103 3 EXPLORE WOUND, EXTREMITY 525.02<br />

2010F 9 VITAL SIGNS RECOR<strong>DE</strong>D 0.00<br />

2014F 9 MENTAL STATUS ASSESS 0.00<br />

20150 3 EXCISE EPIPHYSEAL BAR 844.34<br />

2018F 9 HYDRATION STATUS ASSESS 0.00<br />

2019F 9 DILATED MACUL EXAM DONE 0.00<br />

20200 3 MUSCLE BIOPSY 176.87<br />

20205 3 <strong>DE</strong>EP MUSCLE BIOPSY 241.34<br />

20206 3 NEEDLE BIOPSY, MUSCLE 266.13<br />

2020F 9 DILATED FUNDUS EVAL DONE 0.00<br />

2021F 9 DILAT MACUL+ EXAM DONE 0.00<br />

20220 3 BONE BIOPSY, TROCAR/NEEDLE 188.31<br />

20225 3 BONE BIOPSY, TROCAR/NEEDLE 112.54<br />

2022F 9 DIL RETINA EXAM INTERP REV 0.00<br />

20240 3 BONE BIOPSY, EXCISIONAL 213.25<br />

20245 3 BONE BIOPSY, EXCISIONAL 578.39<br />

2024F 9 7 FIELD PHOTO INTERP DOC REV 0.00<br />

20250 3 OPEN BONE BIOPSY 345.46<br />

20251 3 OPEN BONE BIOPSY 384.32<br />

2026F 9 EYE IMAGE VALID TO DX REV 0.00<br />

2027F 9 OPTIC NERVE HEAD EVAL DONE 0.00

---

2028F 9 FOOT EXAM PERFORMED 0.00<br />

2029F 9 COMPLETE PHYS SKIN EXAM DONE 0.00<br />

2030F 9 H2O STAT DOCÏD, NORMAL 0.00<br />

2031F 9 H2O STAT DOCÏD, <strong>DE</strong>HYDRATED 0.00<br />

2035F 9 TYMP MEMB MOTION EXAMÏD 0.00<br />

2040F 9 BK PN XM ON INIT VISIT DATE 0.00<br />

2044F 9 DOC MNTL TST B/4 BK TRXMNT 0.00<br />

20500 3 INJECTION OF SINUS TRACT 116.73<br />

20501 3 INJECT SINUS TRACT FOR X-RAY 37.21<br />

2050F 9 WOUND CHAR SIZE ETC DOCD 0.00<br />

20520 3 REMOVAL OF FOREIGN BODY 178.34<br />

20525 3 REMOVAL OF FOREIGN BODY 453.94<br />

20526 3 THER INJECTION, CARP TUNNEL 70.82<br />

20550 3 INJ TENDON SHEATH/LIGAMENT 54.44<br />

20551 3 INJ TENDON ORIGIN/INSERTION 53.75<br />

20552 3 INJ TRIGGER POINT, 1/2 MUSCL 49.39<br />

20553 3 INJECT TRIGGER POINTS, =/> 3 55.32<br />

20555 3 PLACE NDL MUSC/TIS FOR RT 301.81<br />

20600 3 DRAIN/INJECT, JOINT/BURSA 50.67<br />

20605 3 DRAIN/INJECT, JOINT/BURSA 54.98<br />

20610 3 DRAIN/INJECT, JOINT/BURSA 69.95<br />

20612 3 ASPIRATE/INJ GANGLION CYST 54.37<br />

20615 3 TREATMENT OF BONE CYST 206.45<br />

20650 3 INSERT AND REMOVE BONE PIN 180.23<br />

20660 3 APPLY, REM FIXATION <strong>DE</strong>VICE 242.71<br />

20661 3 APPLICATION OF HEAD BRACE 423.77<br />

20662 3 APPLICATION OF PELVIS BRACE 432.15<br />

20663 3 APPLICATION OF THIGH BRACE 408.85<br />

20664 3 HALO BRACE APPLICATION 678.35<br />

20665 3 REMOVAL OF FIXATION <strong>DE</strong>VICE 119.92<br />

20670 3 REMOVAL OF SUPPORT IMPLANT 142.33<br />

20680 3 REMOVAL OF SUPPORT IMPLANT 369.85<br />

20690 3 APPLY BONE FIXATION <strong>DE</strong>VICE 456.84<br />

20692 3 APPLY BONE FIXATION <strong>DE</strong>VICE 840.77<br />

20693 3 ADJUST BONE FIXATION <strong>DE</strong>VICE 427.08<br />

20694 3 REMOVE BONE FIXATION <strong>DE</strong>VICE 408.60<br />

20696 6 COMP MULTIPLANE EXT FIXATION 0.00<br />

20697 6 COMP EXT FIXATE STRUT CHANGE 0.00<br />

20802 3 REPLANTATION, ARM, COMPLETE 2,220.17<br />

20804 O REPLANTATION, ARM (INCLU<strong>DE</strong>S SURGICA 0.00<br />

20805 3 REPLANT FOREARM, COMPLETE 2,906.69<br />

20806 O REPLANTATION, FOREARM (INCLU<strong>DE</strong>S RAD 0.00<br />

20808 3 REPLANTATION HAND, COMPLETE 3,760.00<br />

20812 O REPLANTATION, HAND (INCLU<strong>DE</strong>S HAND T 0.00<br />

20816 3 REPLANTATION DIGIT, COMPLETE 2,276.13<br />

20820 O REPLANTATION, DIGIT, EXCLUDING THUM 0.00<br />

20822 3 REPLANTATION DIGIT, COMPLETE 1,997.33<br />

20823 O REPLANTATION, DIGIT, EXCLUDING THUM 0.00<br />

20824 3 REPLANTATION THUMB, COMPLETE 2,251.25<br />

20826 O REPLANTATION, THUMB (INCLU<strong>DE</strong>S CARPO 0.00

---

20827 3 REPLANTATION THUMB, COMPLETE 2,040.36<br />

20828 O REPLANTATION, THUMB (INCLU<strong>DE</strong>S DISTA 0.00<br />

20832 O REPLANTATION, LEG; COMPLETE AMPUTAT 0.00<br />

20834 O REPLANTATION, LEG; INCOMPLETE AMPUT 0.00<br />

20838 3 REPLANTATION FOOT, COMPLETE 2,190.83<br />

20840 O REPLANTATION, FOOT; INCOMPLETE AMPU 0.00<br />

20900 3 REMOVAL OF BONE FOR GRAFT 570.83<br />

20902 3 REMOVAL OF BONE FOR GRAFT 562.15<br />

20910 3 REMOVE CARTILAGE FOR GRAFT 396.30<br />

20912 3 REMOVE CARTILAGE FOR GRAFT 449.25<br />

20920 3 REMOVAL OF FASCIA FOR GRAFT 371.60<br />

20922 3 REMOVAL OF FASCIA FOR GRAFT 549.57<br />

20924 3 REMOVAL OF TENDON FOR GRAFT 467.75<br />

20926 3 REMOVAL OF TISSUE FOR GRAFT 400.82<br />

20930 9 SP BONE ALGRFT MORSEL ADD-ON 0.00<br />

20931 3 SP BONE ALGRFT STRUCT ADD-ON 105.42<br />

20936 9 SP BONE AGRFT LOCAL ADD-ON 0.00<br />

20937 3 SP BONE AGRFT MORSEL ADD-ON 160.28<br />

20938 3 SP BONE AGRFT STRUCT ADD-ON 174.48<br />

20950 3 FLUID PRESSURE, MUSCLE 266.63<br />

20955 3 FIBULA BONE GRAFT, MICROVASC 2,344.70<br />

20956 3 ILIAC BONE GRAFT, MICROVASC 2,483.00<br />

20957 3 MT BONE GRAFT, MICROVASC 2,330.10<br />

20960 O BONE GRAFT WITH MICROVASCULAR ANAST 0.00<br />

20962 3 OTHER BONE GRAFT, MICROVASC 2,465.54<br />

20969 3 BONE/SKIN GRAFT, MICROVASC 2,611.04<br />

20970 3 BONE/SKIN GRAFT, ILIAC CREST 2,608.08<br />

20971 O FREE OSTEOCUTANEOUS FLAP WITH MICRO 0.00<br />

20972 3 BONE/SKIN GRAFT, METATARSAL 2,354.45<br />

20973 3 BONE/SKIN GRAFT, GREAT TOE 2,530.27<br />

20974 3 ELECTRICAL BONE STIMULATION 57.09<br />

20975 3 ELECTRICAL BONE STIMULATION 165.43<br />

20976 O ELECTRICAL STIMULATION TO AID BONE 0.00<br />

20979 3 US BONE STIMULATION 51.78<br />

20982 3 ABLATE, BONE TUMOR(S) PERQ 3,998.62<br />

20985 3 CPTR-ASST DIR MS PX 137.87<br />

20986 O CPTR-ASST DIR MS PX IO IMG 0.00<br />

20987 O CPTR-ASST DIR MS PX PRE IMG 0.00<br />

20999 5 MUSCULOSKELETAL SURGERY 0.00<br />

21010 3 INCISION OF JAW JOINT 665.72<br />

21015 3 RESECTION OF FACIAL TUMOR 393.51<br />

21025 3 EXCISION OF BONE, LOWER JAW 902.36<br />

21026 3 EXCISION OF FACIAL BONE(S) 534.19<br />

21029 3 CONTOUR OF FACE BONE LESION 680.34<br />

21030 3 EXCISE MAX/ZYGOMA B9 TUMOR 444.83<br />

21031 3 REMOVE EXOSTOSIS, MANDIBLE 342.68<br />

21032 3 REMOVE EXOSTOSIS, MAXILLA 349.45<br />

21034 3 EXCISE MAX/ZYGOMA MLG TUMOR 1,220.91<br />

21040 3 EXCISE MANDIBLE LESION 446.40<br />

21041 O REMOVAL OF JAW BONE LESION 0.00

---

21044 3 REMOVAL OF JAW BONE LESION 804.43<br />

21045 3 EXTENSIVE JAW SURGERY 1,115.52<br />

21046 3 REMOVE MANDIBLE CYST COMPLEX 988.99<br />

21047 3 EXCISE LWR JAW CYST W/REPAIR 1,200.79<br />

21048 3 REMOVE MAXILLA CYST COMPLEX 1,006.02<br />

21049 3 EXCIS UPPR JAW CYST W/REPAIR 1,152.70<br />

21050 3 REMOVAL OF JAW JOINT 782.13<br />

21060 3 REMOVE JAW JOINT CARTILAGE 721.70<br />

21070 3 REMOVE CORONOID PROCESS 589.20<br />

21073 3 MNPJ OF TMJ W/ANESTH 341.94<br />

21076 3 PREPARE FACE/ORAL PROSTHESIS 914.47<br />

21077 3 PREPARE FACE/ORAL PROSTHESIS 2,257.07<br />

21079 3 PREPARE FACE/ORAL PROSTHESIS 1,548.12<br />

21080 3 PREPARE FACE/ORAL PROSTHESIS 1,760.66<br />

21081 3 PREPARE FACE/ORAL PROSTHESIS 1,604.29<br />

21082 3 PREPARE FACE/ORAL PROSTHESIS 1,472.88<br />

21083 3 PREPARE FACE/ORAL PROSTHESIS 1,402.31<br />

21084 3 PREPARE FACE/ORAL PROSTHESIS 1,600.33<br />

21085 3 PREPARE FACE/ORAL PROSTHESIS 641.96<br />

21086 3 PREPARE FACE/ORAL PROSTHESIS 1,675.32<br />

21087 3 PREPARE FACE/ORAL PROSTHESIS 1,660.64<br />

21088 5 PREPARE FACE/ORAL PROSTHESIS 0.00<br />

21089 5 PREPARE FACE/ORAL PROSTHESIS 0.00<br />

21100 3 MAXILLOFACIAL FIXATION 684.19<br />

21110 3 INTER<strong>DE</strong>NTAL FIXATION 663.05<br />

21116 3 INJECTION, JAW JOINT X-RAY 163.67<br />

21120 3 RECONSTRUCTION OF CHIN 584.96<br />

21121 3 RECONSTRUCTION OF CHIN 688.62<br />

21122 3 RECONSTRUCTION OF CHIN 658.77<br />

21123 3 RECONSTRUCTION OF CHIN 772.82<br />

21125 3 AUGMENTATION, LOWER JAW BONE 2,731.41<br />

21127 3 AUGMENTATION, LOWER JAW BONE 2,975.33<br />

21137 3 REDUCTION OF FOREHEAD 680.77<br />

21138 3 REDUCTION OF FOREHEAD 824.16<br />

21139 3 REDUCTION OF FOREHEAD 895.39<br />

21141 3 RECONSTRUCT MIDFACE, LEFORT 1,225.31<br />

21142 3 RECONSTRUCT MIDFACE, LEFORT 1,198.93<br />

21143 3 RECONSTRUCT MIDFACE, LEFORT 1,266.46<br />

21144 O RECONSTRUCTION MIDFACE, LEFORT I; I 0.00<br />

21145 3 RECONSTRUCT MIDFACE, LEFORT 1,414.82<br />

21146 3 RECONSTRUCT MIDFACE, LEFORT 1,406.21<br />

21147 3 RECONSTRUCT MIDFACE, LEFORT 1,518.72<br />

21150 3 RECONSTRUCT MIDFACE, LEFORT 1,612.79<br />

21151 3 RECONSTRUCT MIDFACE, LEFORT 1,726.67<br />

21154 3 RECONSTRUCT MIDFACE, LEFORT 1,933.78<br />

21155 3 RECONSTRUCT MIDFACE, LEFORT 2,210.87<br />

21159 3 RECONSTRUCT MIDFACE, LEFORT 2,567.71<br />

21160 3 RECONSTRUCT MIDFACE, LEFORT 2,712.51<br />

21172 3 RECONSTRUCT ORBIT/FOREHEAD 1,598.20<br />

21175 3 RECONSTRUCT ORBIT/FOREHEAD 1,893.37

---

21179 3 RECONSTRUCT ENTIRE FOREHEAD 1,346.00<br />

21180 3 RECONSTRUCT ENTIRE FOREHEAD 1,524.87<br />

21181 3 CONTOUR CRANIAL BONE LESION 665.39<br />

21182 3 RECONSTRUCT CRANIAL BONE 1,860.37<br />

21183 3 RECONSTRUCT CRANIAL BONE 2,126.64<br />

21184 3 RECONSTRUCT CRANIAL BONE 2,213.51<br />

21188 3 RECONSTRUCTION OF MIDFACE 1,508.75<br />

21193 3 RECONST LWR JAW W/O GRAFT 1,140.78<br />

21194 3 RECONST LWR JAW W/GRAFT 1,300.04<br />

21195 3 RECONST LWR JAW W/O FIXATION 1,237.73<br />

21196 3 RECONST LWR JAW W/FIXATION 1,341.98<br />

21198 3 RECONSTR LWR JAW SEGMENT 1,051.38<br />

21199 3 RECONSTR LWR JAW W/ADVANCE 933.38<br />

21200 O OSTEOTOMY (EG, FOR PROGNATHISM, MIC 0.00<br />

21202 O OSTEOTOMY (EG, FOR PROGNATHISM, MIC 0.00<br />

21203 O OSTEOTOMY (EG, FOR PROGNATHISM, MIC 0.00<br />

21204 O OSTEOTOMY (EG, FOR PROGNATHISM, MIC 0.00<br />

21206 3 RECONSTRUCT UPPER JAW BONE 1,023.42<br />

21208 3 AUGMENTATION OF FACIAL BONES 1,502.57<br />

21209 3 REDUCTION OF FACIAL BONES 735.92<br />

21210 3 FACE BONE GRAFT 1,770.24<br />

21215 3 LOWER JAW BONE GRAFT 791.09<br />

21230 3 RIB CARTILAGE GRAFT 709.48<br />

21235 3 EAR CARTILAGE GRAFT 658.68<br />

21240 3 RECONSTRUCTION OF JAW JOINT 1,024.38<br />

21242 3 RECONSTRUCTION OF JAW JOINT 942.59<br />

21243 3 RECONSTRUCTION OF JAW JOINT 1,532.89<br />

21244 3 RECONSTRUCTION OF LOWER JAW 954.47<br />

21245 3 RECONSTRUCTION OF JAW 1,034.88<br />

21246 3 RECONSTRUCTION OF JAW 797.34<br />

21247 3 RECONSTRUCT LOWER JAW BONE 1,490.94<br />

21248 3 RECONSTRUCTION OF JAW 958.05<br />

21249 3 RECONSTRUCTION OF JAW 1,342.20<br />

21250 O OSTEOPLASTY OF MAXILLA AND/OR OTHER 0.00<br />

21254 O OSTEOPLASTY OF MAXILLA AND/OR OTHER 0.00<br />

21255 3 RECONSTRUCT LOWER JAW BONE 1,279.76<br />

21256 3 RECONSTRUCTION OF ORBIT 1,056.05<br />

21260 3 REVISE EYE SOCKETS 1,136.52<br />

21261 3 REVISE EYE SOCKETS 2,014.26<br />

21263 3 REVISE EYE SOCKETS 1,771.35<br />

21267 3 REVISE EYE SOCKETS 1,449.14<br />

21268 3 REVISE EYE SOCKETS 1,672.54<br />

21270 3 AUGMENTATION, CHEEK BONE 826.79<br />

21275 3 REVISION, ORBITOFACIAL BONES 734.62<br />

21280 3 REVISION OF EYELID 474.73<br />

21282 3 REVISION OF EYELID 317.05<br />

21295 3 REVISION OF JAW MUSCLE/BONE 159.98<br />

21296 3 REVISION OF JAW MUSCLE/BONE 371.73<br />

21299 5 CRANIO/MAXILLOFACIAL SURGERY 0.00<br />

21300 O TREATMENT OF SKULL FRACTURE 0.00

---

21310 3 TREATMENT OF NOSE FRACTURE 105.31<br />

21315 3 TREATMENT OF NOSE FRACTURE 240.86<br />

21320 3 TREATMENT OF NOSE FRACTURE 230.18<br />

21325 3 TREATMENT OF NOSE FRACTURE 453.91<br />

21330 3 TREATMENT OF NOSE FRACTURE 550.21<br />

21335 3 TREATMENT OF NOSE FRACTURE 680.23<br />

21336 3 TREAT NASAL SEPTAL FRACTURE 598.44<br />

21337 3 TREAT NASAL SEPTAL FRACTURE 360.37<br />

21338 3 TREAT NASOETHMOID FRACTURE 724.72<br />

21339 3 TREAT NASOETHMOID FRACTURE 779.98<br />

21340 3 TREATMENT OF NOSE FRACTURE 726.38<br />

21343 3 TREATMENT OF SINUS FRACTURE 1,078.45<br />

21344 3 TREATMENT OF SINUS FRACTURE 1,378.40<br />

21345 3 TREAT NOSE/JAW FRACTURE 728.08<br />

21346 3 TREAT NOSE/JAW FRACTURE 871.80<br />

21347 3 TREAT NOSE/JAW FRACTURE 1,046.35<br />

21348 3 TREAT NOSE/JAW FRACTURE 1,097.59<br />

21355 3 TREAT CHEEK BONE FRACTURE 395.20<br />

21356 3 TREAT CHEEK BONE FRACTURE 450.40<br />

21360 3 TREAT CHEEK BONE FRACTURE 483.33<br />

21365 3 TREAT CHEEK BONE FRACTURE 1,002.83<br />

21366 3 TREAT CHEEK BONE FRACTURE 1,128.96<br />

21385 3 TREAT EYE SOCKET FRACTURE 652.80<br />

21386 3 TREAT EYE SOCKET FRACTURE 606.77<br />

21387 3 TREAT EYE SOCKET FRACTURE 694.21<br />

21390 3 TREAT EYE SOCKET FRACTURE 693.61<br />

21395 3 TREAT EYE SOCKET FRACTURE 880.08<br />

21400 3 TREAT EYE SOCKET FRACTURE 158.00<br />

21401 3 TREAT EYE SOCKET FRACTURE 428.02<br />

21406 3 TREAT EYE SOCKET FRACTURE 493.45<br />

21407 3 TREAT EYE SOCKET FRACTURE 581.50<br />

21408 3 TREAT EYE SOCKET FRACTURE 793.78<br />

21421 3 TREAT MOUTH ROOF FRACTURE 647.22<br />

21422 3 TREAT MOUTH ROOF FRACTURE 619.00<br />

21423 3 TREAT MOUTH ROOF FRACTURE 730.00<br />

21431 3 TREAT CRANIOFACIAL FRACTURE 684.24<br />

21432 3 TREAT CRANIOFACIAL FRACTURE 613.57<br />

21433 3 TREAT CRANIOFACIAL FRACTURE 1,530.42<br />

21435 3 TREAT CRANIOFACIAL FRACTURE 1,205.94<br />

21436 3 TREAT CRANIOFACIAL FRACTURE 1,726.76<br />

21440 3 TREAT <strong>DE</strong>NTAL RIDGE FRACTURE 460.49<br />

21445 3 TREAT <strong>DE</strong>NTAL RIDGE FRACTURE 661.50<br />

21450 3 TREAT LOWER JAW FRACTURE 482.42<br />

21451 3 TREAT LOWER JAW FRACTURE 643.33<br />

21452 3 TREAT LOWER JAW FRACTURE 579.14<br />

21453 3 TREAT LOWER JAW FRACTURE 741.89<br />

21454 3 TREAT LOWER JAW FRACTURE 503.30<br />

21455 O CLOSED MANIPULATIVE TREATMENT BY IN 0.00<br />

21461 3 TREAT LOWER JAW FRACTURE 837.91<br />

21462 3 TREAT LOWER JAW FRACTURE 1,792.25

---

21465 3 TREAT LOWER JAW FRACTURE 833.96<br />

21470 3 TREAT LOWER JAW FRACTURE 1,079.54<br />

21480 3 RESET DISLOCATED JAW 87.49<br />

21485 3 RESET DISLOCATED JAW 570.01<br />

21490 3 REPAIR DISLOCATED JAW 839.73<br />

21493 O TREAT HYOID BONE FRACTURE 0.00<br />

21494 O TREAT HYOID BONE FRACTURE 0.00<br />

21495 3 TREAT HYOID BONE FRACTURE 607.59<br />

21497 3 INTER<strong>DE</strong>NTAL WIRING 572.56<br />

21499 5 HEAD SURGERY PROCEDURE 0.00<br />

21501 3 DRAIN NECK/CHEST LESION 399.37<br />

21502 3 DRAIN CHEST LESION 481.19<br />

21510 3 DRAINAGE OF BONE LESION 435.46<br />

21550 3 BIOPSY OF NECK/CHEST 231.40<br />

21555 3 REMOVE LESION, NECK/CHEST 387.88<br />

21556 3 REMOVE LESION, NECK/CHEST 372.32<br />

21557 3 REMOVE TUMOR, NECK/CHEST 528.59<br />

21600 3 PARTIAL REMOVAL OF RIB 501.66<br />

21610 3 PARTIAL REMOVAL OF RIB 975.38<br />

21615 3 REMOVAL OF RIB 625.85<br />

21616 3 REMOVAL OF RIB AND NERVES 766.48<br />

21620 3 PARTIAL REMOVAL OF STERNUM 483.25<br />

21627 3 STERNAL <strong>DE</strong>BRI<strong>DE</strong>MENT 506.85<br />

21630 3 EXTENSIVE STERNUM SURGERY 1,157.95<br />

21632 3 EXTENSIVE STERNUM SURGERY 1,144.31<br />

21633 O RADICAL RESECTION OF STERNUM; FOR O 0.00<br />

21685 3 HYOID MYOTOMY & SUSPENSION 904.83<br />

21700 3 REVISION OF NECK MUSCLE 394.77<br />

21705 3 REVISION OF NECK MUSCLE/RIB 571.32<br />

21720 3 REVISION OF NECK MUSCLE 350.44<br />

21725 3 REVISION OF NECK MUSCLE 484.99<br />

21740 3 RECONSTRUCTION OF STERNUM 991.27<br />

21742 5 REPAIR STERN/NUSS W/O SCOPE 0.00<br />

21743 5 REPAIR STERNUM/NUSS W/SCOPE 0.00<br />

21750 3 REPAIR OF STERNUM SEPARATION 657.96<br />

21800 3 TREATMENT OF RIB FRACTURE 88.89<br />

21805 3 TREATMENT OF RIB FRACTURE 233.83<br />

21810 3 TREATMENT OF RIB FRACTURE(S) 465.73<br />

21820 3 TREAT STERNUM FRACTURE 121.02<br />

21825 3 TREAT STERNUM FRACTURE 524.11<br />

21899 5 NECK/CHEST SURGERY PROCEDURE 0.00<br />

21920 3 BIOPSY SOFT TISSUE OF BACK 226.48<br />

21925 3 BIOPSY SOFT TISSUE OF BACK 378.73<br />

21930 3 REMOVE LESION, BACK OR FLANK 422.61<br />

21935 3 REMOVE TUMOR, BACK 1,052.47<br />

22010 3 I&D, P-SPINE, C/T/CERV-THOR 816.90<br />

22015 3 I&D, P-SPINE, L/S/LS 811.28<br />

22100 3 REMOVE PART OF NECK VERTEBRA 739.16<br />

22101 3 REMOVE PART, THORAX VERTEBRA 737.80<br />

22102 3 REMOVE PART, LUMBAR VERTEBRA 740.06

---

22103 3 REMOVE EXTRA SPINE SEGMENT 133.65<br />

22105 O PARTIAL RESECTION OF VERTEBRAL COMP 0.00<br />

22106 O PARTIAL RESECTION OF VERTEBRAL COMP 0.00<br />

22107 O PARTIAL RESECTION OF VERTEBRAL COMP 0.00<br />

22110 3 REMOVE PART OF NECK VERTEBRA 909.82<br />

22112 3 REMOVE PART, THORAX VERTEBRA 905.42<br />

22114 3 REMOVE PART, LUMBAR VERTEBRA 907.89<br />

22116 3 REMOVE EXTRA SPINE SEGMENT 133.87<br />

22140 O RECONSTRUCTION OF SPINE WITH BONE G 0.00<br />

22141 O RECONSTRUCTION OF SPINE WITH BONE G 0.00<br />

22142 O RECONSTRUCTION OF SPINE WITH BONE G 0.00<br />

22145 O RECONSTRUCTION OF SPINE FOLLOWING V 0.00<br />

22148 O HARVESTING OF BONE AUTOGRAFT FOR VE 0.00<br />

22150 O RECONSTRUCTION OF SPINE WITH PREFAB 0.00<br />

22151 O RECONSTRUCTION OF SPINE WITH PREFAB 0.00<br />

22152 O RECONSTRUCTION OF SPINE WITH PREFAB 0.00<br />

22206 3 CUT SPINE 3 COL, THOR 2,136.46<br />

22207 3 CUT SPINE 3 COL, LUMB 2,110.06<br />

22208 3 CUT SPINE 3 COL, ADDL SEG 535.70<br />

22210 3 REVISION OF NECK SPINE 1,603.48<br />

22212 3 REVISION OF THORAX SPINE 1,325.19<br />

22214 3 REVISION OF LUMBAR SPINE 1,338.83<br />

22216 3 REVISE, EXTRA SPINE SEGMENT 350.05<br />

22220 3 REVISION OF NECK SPINE 1,450.83<br />

22222 3 REVISION OF THORAX SPINE 1,321.49<br />

22224 3 REVISION OF LUMBAR SPINE 1,432.25<br />

22226 3 REVISE, EXTRA SPINE SEGMENT 348.48<br />

22230 O OSTEOTOMY OF SPINE, ANY APPROACH, E 0.00<br />

22305 3 TREAT SPINE PROCESS FRACTURE 169.74<br />

22310 3 TREAT SPINE FRACTURE 254.04<br />

22315 3 TREAT SPINE FRACTURE 776.38<br />

22318 3 TREAT ODONTOID FX W/O GRAFT 1,445.64<br />

22319 3 TREAT ODONTOID FX W/GRAFT 1,586.30<br />

22325 3 TREAT SPINE FRACTURE 1,257.05<br />

22326 3 TREAT NECK SPINE FRACTURE 1,317.82<br />

22327 3 TREAT THORAX SPINE FRACTURE 1,300.17<br />

22328 3 TREAT EACH ADD SPINE FX 262.85<br />

22505 3 MANIPULATION OF SPINE 114.32<br />

22520 3 PERCUT VERTEBROPLASTY THOR 2,438.21<br />

22521 3 PERCUT VERTEBROPLASTY LUMB 2,326.10<br />

22522 3 PERCUT VERTEBROPLASTY ADDÏL 232.76<br />

22523 3 PERCUT KYPHOPLASTY, THOR 571.31<br />

22524 3 PERCUT KYPHOPLASTY, LUMBAR 547.20<br />

22525 3 PERCUT KYPHOPLASTY, ADD-ON 253.88<br />

22526 9 I<strong>DE</strong>T, SINGLE LEVEL 0.00<br />

22527 9 I<strong>DE</strong>T, 1 OR MORE LEVELS 0.00<br />

22532 3 LAT THORAX SPINE FUSION 1,566.98<br />

22533 3 LAT LUMBAR SPINE FUSION 1,462.62<br />

22534 3 LAT THOR/LUMB, ADDÏL SEG 344.57<br />

22548 3 NECK SPINE FUSION 1,681.79

---

22554 3 NECK SPINE FUSION 1,179.36<br />

22556 3 THORAX SPINE FUSION 1,504.22<br />

22558 3 LUMBAR SPINE FUSION 1,371.11<br />

22585 3 ADDITIONAL SPINAL FUSION 319.74<br />

22590 3 SPINE & SKULL SPINAL FUSION 1,392.71<br />

22595 3 NECK SPINAL FUSION 1,325.25<br />

22600 3 NECK SPINE FUSION 1,134.40<br />

22610 3 THORAX SPINE FUSION 1,121.10<br />

22612 3 LUMBAR SPINE FUSION 1,450.76<br />

22614 3 SPINE FUSION, EXTRA SEGMENT 372.88<br />

22625 O ARTHRO<strong>DE</strong>SIS, LATERAL TRANSVERSE PRO 0.00<br />

22630 3 LUMBAR SPINE FUSION 1,396.99<br />

22632 3 SPINE FUSION, EXTRA SEGMENT 303.13<br />

22650 O ARTHRO<strong>DE</strong>SIS, POSTERIOR, POSTEROLATE 0.00<br />

22800 3 FUSION OF SPINE 1,236.82<br />

22802 3 FUSION OF SPINE 1,964.93<br />

22804 3 FUSION OF SPINE 2,275.48<br />

22808 3 FUSION OF SPINE 1,669.60<br />

22810 3 FUSION OF SPINE 1,868.31<br />

22812 3 FUSION OF SPINE 2,046.63<br />

22818 3 KYPHECTOMY, 1-2 SEGMENTS 2,048.85<br />

22819 3 KYPHECTOMY, 3 OR MORE 2,321.46<br />

22820 O HARVESTING OF BONE AUTOGRAFT THROUG 0.00<br />

22830 3 EXPLORATION OF SPINAL FUSION 740.90<br />

22840 3 INSERT SPINE FIXATION <strong>DE</strong>VICE 729.19<br />

22841 9 INSERT SPINE FIXATION <strong>DE</strong>VICE 0.00<br />

22842 3 INSERT SPINE FIXATION <strong>DE</strong>VICE 729.55<br />

22843 3 INSERT SPINE FIXATION <strong>DE</strong>VICE 771.89<br />

22844 3 INSERT SPINE FIXATION <strong>DE</strong>VICE 949.43<br />

22845 3 INSERT SPINE FIXATION <strong>DE</strong>VICE 697.07<br />

22846 3 INSERT SPINE FIXATION <strong>DE</strong>VICE 724.47<br />

22847 3 INSERT SPINE FIXATION <strong>DE</strong>VICE 796.25<br />

22848 3 INSERT PELV FIXATION <strong>DE</strong>VICE 345.55<br />

22849 3 REINSERT SPINAL FIXATION 1,193.13<br />

22850 3 REMOVE SPINE FIXATION <strong>DE</strong>VICE 654.65<br />

22851 3 APPLY SPINE PROSTH <strong>DE</strong>VICE 387.34<br />

22852 3 REMOVE SPINE FIXATION <strong>DE</strong>VICE 626.55<br />

22855 3 REMOVE SPINE FIXATION <strong>DE</strong>VICE 1,010.03<br />

22856 6 CERV ARTIFIC DISKECTOMY 0.00<br />

22857 3 LUMBAR ARTIF DISKECTOMY 1,601.41<br />

22861 6 REVISE CERV ARTIFIC DISC 0.00<br />

22862 3 REVISE LUMBAR ARTIF DISC 1,891.39<br />

22864 6 REMOVE CERV ARTIF DISC 0.00<br />

22865 3 REMOVE LUMB ARTIF DISC 1,842.26<br />

22899 5 SPINE SURGERY PROCEDURE 0.00<br />

22900 3 REMOVE ABDOMINAL WALL LESION 363.79<br />

22999 5 ABDOMEN SURGERY PROCEDURE 0.00<br />

23000 3 REMOVAL OF CALCIUM <strong>DE</strong>POSITS 492.15<br />

23020 3 RELEASE SHOUL<strong>DE</strong>R JOINT 635.21<br />

23030 3 DRAIN SHOUL<strong>DE</strong>R LESION 402.65

---

23031 3 DRAIN SHOUL<strong>DE</strong>R BURSA 390.06<br />

23035 3 DRAIN SHOUL<strong>DE</strong>R BONE LESION 639.58<br />

23040 3 EXPLORATORY SHOUL<strong>DE</strong>R SURGERY 661.48<br />

23044 3 EXPLORATORY SHOUL<strong>DE</strong>R SURGERY 525.73<br />

23065 3 BIOPSY SHOUL<strong>DE</strong>R TISSUES 190.33<br />

23066 3 BIOPSY SHOUL<strong>DE</strong>R TISSUES 465.24<br />

23075 3 REMOVAL OF SHOUL<strong>DE</strong>R LESION 236.48<br />

23076 3 REMOVAL OF SHOUL<strong>DE</strong>R LESION 510.85<br />

23077 3 REMOVE TUMOR OF SHOUL<strong>DE</strong>R 1,072.56<br />

23100 3 BIOPSY OF SHOUL<strong>DE</strong>R JOINT 446.87<br />

23101 3 SHOUL<strong>DE</strong>R JOINT SURGERY 413.76<br />

23105 3 REMOVE SHOUL<strong>DE</strong>R JOINT LINING 585.49<br />

23106 3 INCISION OF COLLARBONE JOINT 439.93<br />

23107 3 EXPLORE TREAT SHOUL<strong>DE</strong>R JOINT 609.69<br />

23120 3 PARTIAL REMOVAL, COLLAR BONE 516.57<br />

23125 3 REMOVAL OF COLLAR BONE 645.24<br />

23130 3 REMOVE SHOUL<strong>DE</strong>R BONE, PART 557.29<br />

23140 3 REMOVAL OF BONE LESION 469.02<br />

23145 3 REMOVAL OF BONE LESION 632.91<br />

23146 3 REMOVAL OF BONE LESION 566.40<br />

23150 3 REMOVAL OF HUMERUS LESION 596.38<br />

23155 3 REMOVAL OF HUMERUS LESION 723.55<br />

23156 3 REMOVAL OF HUMERUS LESION 618.47<br />

23170 3 REMOVE COLLAR BONE LESION 490.59<br />

23172 3 REMOVE SHOUL<strong>DE</strong>R BLA<strong>DE</strong> LESION 506.15<br />

23174 3 REMOVE HUMERUS LESION 690.30<br />

23180 3 REMOVE COLLAR BONE LESION 646.81<br />

23182 3 REMOVE SHOUL<strong>DE</strong>R BLA<strong>DE</strong> LESION 622.48<br />

23184 3 REMOVE HUMERUS LESION 698.48<br />

23190 3 PARTIAL REMOVAL OF SCAPULA 509.98<br />

23195 3 REMOVAL OF HEAD OF HUMERUS 686.32<br />

23200 3 REMOVAL OF COLLAR BONE 799.13<br />

23210 3 REMOVAL OF SHOUL<strong>DE</strong>R BLA<strong>DE</strong> 837.24<br />

23220 3 PARTIAL REMOVAL OF HUMERUS 987.72<br />

23221 3 PARTIAL REMOVAL OF HUMERUS 1,154.21<br />

23222 3 PARTIAL REMOVAL OF HUMERUS 1,552.67<br />

23330 3 REMOVE SHOUL<strong>DE</strong>R FOREIGN BODY 209.13<br />

23331 3 REMOVE SHOUL<strong>DE</strong>R FOREIGN BODY 540.76<br />

23332 3 REMOVE SHOUL<strong>DE</strong>R FOREIGN BODY 815.11<br />

23350 3 INJECTION FOR SHOUL<strong>DE</strong>R X-RAY 157.63<br />

23395 3 MUSCLE TRANSFER,SHOUL<strong>DE</strong>R/ARM 1,181.04<br />

23397 3 MUSCLE TRANSFERS 1,056.74<br />

23400 3 FIXATION OF SHOUL<strong>DE</strong>R BLA<strong>DE</strong> 899.89<br />

23405 3 INCISION OF TENDON & MUSCLE 581.21<br />

23406 3 INCISE TENDON(S) & MUSCLE(S) 725.49<br />

23410 3 REPAIR ROTATOR CUFF, ACUTE 830.76<br />

23412 3 REPAIR ROTATOR CUFF, CHRONIC 883.31<br />

23415 3 RELEASE OF SHOUL<strong>DE</strong>R LIGAMENT 680.63<br />

23420 3 REPAIR OF SHOUL<strong>DE</strong>R 973.30<br />

23430 3 REPAIR BICEPS TENDON 684.99

---

23440 3 REMOVE/TRANSPLANT TENDON 706.97<br />

23450 3 REPAIR SHOUL<strong>DE</strong>R CAPSULE 884.37<br />

23455 3 REPAIR SHOUL<strong>DE</strong>R CAPSULE 941.01<br />

23460 3 REPAIR SHOUL<strong>DE</strong>R CAPSULE 1,018.78<br />

23462 3 REPAIR SHOUL<strong>DE</strong>R CAPSULE 996.31<br />

23465 3 REPAIR SHOUL<strong>DE</strong>R CAPSULE 1,036.73<br />

23466 3 REPAIR SHOUL<strong>DE</strong>R CAPSULE 1,020.83<br />

23470 3 RECONSTRUCT SHOUL<strong>DE</strong>R JOINT 1,130.59<br />

23472 3 RECONSTRUCT SHOUL<strong>DE</strong>R JOINT 1,393.13<br />

23480 3 REVISION OF COLLAR BONE 761.40<br />

23485 3 REVISION OF COLLAR BONE 892.77<br />

23490 3 REINFORCE CLAVICLE 755.79<br />

23491 3 REINFORCE SHOUL<strong>DE</strong>R BONES 943.77<br />

23500 3 TREAT CLAVICLE FRACTURE 189.86<br />

23505 3 TREAT CLAVICLE FRACTURE 310.37<br />

23510 O TREATMENT OF OPEN CLAVICULAR FRACTU 0.00<br />

23515 3 TREAT CLAVICLE FRACTURE 627.70<br />

23520 3 TREAT CLAVICLE DISLOCATION 195.70<br />

23525 3 TREAT CLAVICLE DISLOCATION 309.13<br />

23530 3 TREAT CLAVICLE DISLOCATION 506.53<br />

23532 3 TREAT CLAVICLE DISLOCATION 570.74<br />

23540 3 TREAT CLAVICLE DISLOCATION 194.96<br />

23545 3 TREAT CLAVICLE DISLOCATION 278.99<br />

23550 3 TREAT CLAVICLE DISLOCATION 525.24<br />

23552 3 TREAT CLAVICLE DISLOCATION 605.31<br />

23570 3 TREAT SHOUL<strong>DE</strong>R BLA<strong>DE</strong> FX 202.15<br />

23575 3 TREAT SHOUL<strong>DE</strong>R BLA<strong>DE</strong> FX 343.73<br />

23580 O TREATMENT OF OPEN SCAPULAR FRACTURE 0.00<br />

23585 3 TREAT SCAPULA FRACTURE 840.56<br />

23600 3 TREAT HUMERUS FRACTURE 285.43<br />

23605 3 TREAT HUMERUS FRACTURE 419.37<br />

23610 O TREATMENT OF OPEN HUMERAL (SURGICAL 0.00<br />

23615 3 TREAT HUMERUS FRACTURE 791.26<br />

23616 3 TREAT HUMERUS FRACTURE 1,210.29<br />

23620 3 TREAT HUMERUS FRACTURE 233.49<br />

23625 3 TREAT HUMERUS FRACTURE 339.51<br />

23630 3 TREAT HUMERUS FRACTURE 665.32<br />

23650 3 TREAT SHOUL<strong>DE</strong>R DISLOCATION 264.43<br />

23655 3 TREAT SHOUL<strong>DE</strong>R DISLOCATION 341.58<br />

23658 O TREATMENT OF OPEN SHOUL<strong>DE</strong>R DISLOCAT 0.00<br />

23660 3 TREAT SHOUL<strong>DE</strong>R DISLOCATION 531.88<br />

23665 3 TREAT DISLOCATION/FRACTURE 375.30<br />

23670 3 TREAT DISLOCATION/FRACTURE 741.46<br />

23675 3 TREAT DISLOCATION/FRACTURE 492.77<br />

23680 3 TREAT DISLOCATION/FRACTURE 814.03<br />

23700 3 FIXATION OF SHOUL<strong>DE</strong>R 179.54<br />

23800 3 FUSION OF SHOUL<strong>DE</strong>R JOINT 943.92<br />

23802 3 FUSION OF SHOUL<strong>DE</strong>R JOINT 1,117.27<br />

23900 3 AMPUTATION OF ARM & GIRDLE 1,227.28<br />

23920 3 AMPUTATION AT SHOUL<strong>DE</strong>R JOINT 993.71

---

23921 3 AMPUTATION FOLLOW-UP SURGERY 408.84<br />

23929 5 SHOUL<strong>DE</strong>R SURGERY PROCEDURE 0.00<br />

23930 3 DRAINAGE OF ARM LESION 335.52<br />

23931 3 DRAINAGE OF ARM BURSA 271.74<br />

23935 3 DRAIN ARM/ELBOW BONE LESION 460.41<br />

24000 3 EXPLORATORY ELBOW SURGERY 431.50<br />

24006 3 RELEASE ELBOW JOINT 653.02<br />

24065 3 BIOPSY ARM/ELBOW SOFT TISSUE 221.05<br />

24066 3 BIOPSY ARM/ELBOW SOFT TISSUE 540.71<br />

24075 3 REMOVE ARM/ELBOW LESION 436.99<br />

24076 3 REMOVE ARM/ELBOW LESION 429.45<br />

24077 3 REMOVE TUMOR OF ARM/ELBOW 743.49<br />

24100 3 BIOPSY ELBOW JOINT LINING 363.77<br />

24101 3 EXPLORE/TREAT ELBOW JOINT 456.34<br />

24102 3 REMOVE ELBOW JOINT LINING 565.27<br />

24105 3 REMOVAL OF ELBOW BURSA 308.06<br />

24110 3 REMOVE HUMERUS LESION 533.22<br />

24115 3 REMOVE/GRAFT BONE LESION 615.97<br />

24116 3 REMOVE/GRAFT BONE LESION 801.14<br />

24120 3 REMOVE ELBOW LESION 478.48<br />

24125 3 REMOVE/GRAFT BONE LESION 542.43<br />

24126 3 REMOVE/GRAFT BONE LESION 579.26<br />

24130 3 REMOVAL OF HEAD OF RADIUS 464.41<br />

24134 3 REMOVAL OF ARM BONE LESION 700.88<br />

24136 3 REMOVE RADIUS BONE LESION 577.67<br />

24138 3 REMOVE ELBOW BONE LESION 603.20<br />

24140 3 PARTIAL REMOVAL OF ARM BONE 672.74<br />

24145 3 PARTIAL REMOVAL OF RADIUS 567.57<br />

24147 3 PARTIAL REMOVAL OF ELBOW 591.88<br />

24149 3 RADICAL RESECTION OF ELBOW 1,050.05<br />

24150 3 EXTENSIVE HUMERUS SURGERY 897.27<br />

24151 3 EXTENSIVE HUMERUS SURGERY 1,039.63<br />

24152 3 EXTENSIVE RADIUS SURGERY 664.56<br />

24153 3 EXTENSIVE RADIUS SURGERY 625.04<br />

24155 3 REMOVAL OF ELBOW JOINT 774.18<br />

24160 3 REMOVE ELBOW JOINT IMPLANT 556.32<br />

24164 3 REMOVE RADIUS HEAD IMPLANT 455.44<br />

24200 3 REMOVAL OF ARM FOREIGN BODY 187.55<br />

24201 3 REMOVAL OF ARM FOREIGN BODY 524.26<br />

24220 3 INJECTION FOR ELBOW X-RAY 170.58<br />

24300 3 MANIPULATE ELBOW W/ANESTH 364.19<br />

24301 3 MUSCLE/TENDON TRANSFER 692.31<br />

24305 3 ARM TENDON LENGTHENING 532.10<br />

24310 3 REVISION OF ARM TENDON 435.89<br />

24320 3 REPAIR OF ARM TENDON 702.18<br />

24330 3 REVISION OF ARM MUSCLES 661.06<br />

24331 3 REVISION OF ARM MUSCLES 727.69<br />

24332 3 TENOLYSIS, TRICEPS 549.61<br />

24340 3 REPAIR OF BICEPS TENDON 564.73<br />

24341 3 REPAIR ARM TENDON/MUSCLE 657.42

---

24342 3 REPAIR OF RUPTURED TENDON 725.80<br />

24343 3 REPR ELBOW LAT LIGMNT W/TISS 645.12<br />

24344 3 RECONSTRUCT ELBOW LAT LIGMNT 1,000.20<br />

24345 3 REPR ELBW MED LIGMNT W/TISSU 641.87<br />

24346 3 RECONSTRUCT ELBOW MED LIGMNT 997.34<br />

24350 O REPAIR OF TENNIS ELBOW 0.00<br />

24351 O REPAIR OF TENNIS ELBOW 0.00<br />

24352 O REPAIR OF TENNIS ELBOW 0.00<br />

24354 O REPAIR OF TENNIS ELBOW 0.00<br />

24356 O REVISION OF TENNIS ELBOW 0.00<br />

24357 3 REPAIR ELBOW, PERC 408.58<br />

24358 3 REPAIR ELBOW W/<strong>DE</strong>B, OPEN 478.90<br />

24359 3 REPAIR ELBOW <strong>DE</strong>B/ATTCH OPEN 586.01<br />

24360 3 RECONSTRUCT ELBOW JOINT 826.40<br />

24361 3 RECONSTRUCT ELBOW JOINT 929.29<br />

24362 3 RECONSTRUCT ELBOW JOINT 902.49<br />

24363 3 REPLACE ELBOW JOINT 1,360.91<br />

24365 3 RECONSTRUCT HEAD OF RADIUS 589.41<br />

24366 3 RECONSTRUCT HEAD OF RADIUS 631.46<br />

24400 3 REVISION OF HUMERUS 758.23<br />

24410 3 REVISION OF HUMERUS 968.26<br />

24420 3 REVISION OF HUMERUS 899.99<br />

24430 3 REPAIR OF HUMERUS 950.05<br />

24435 3 REPAIR HUMERUS WITH GRAFT 974.49<br />

24470 3 REVISION OF ELBOW JOINT 605.82<br />

24495 3 <strong>DE</strong>COMPRESSION OF FOREARM 614.63<br />

24498 3 REINFORCE HUMERUS 806.90<br />

24500 3 TREAT HUMERUS FRACTURE 309.41<br />

24505 3 TREAT HUMERUS FRACTURE 448.95<br />

24506 O TREATMENT OF CLOSED HUMERAL SHAFT F 0.00<br />

24510 O TREATMENT OF OPEN HUMERAL SHAFT FRA 0.00<br />

24515 3 TREAT HUMERUS FRACTURE 809.01<br />

24516 3 TREAT HUMERUS FRACTURE 799.09<br />

24530 3 TREAT HUMERUS FRACTURE 333.32<br />

24531 O TREATMENT OF CLOSED HUMERAL SUPRACO 0.00<br />

24535 3 TREAT HUMERUS FRACTURE 559.35<br />

24536 O TREATMENT OF CLOSED HUMERAL SUPRACO 0.00<br />

24538 3 TREAT HUMERUS FRACTURE 687.85<br />

24540 O TREATMENT OF OPEN HUMERAL SUPRACOND 0.00<br />

24542 O TREATMENT OF OPEN HUMERAL SUPRACOND 0.00<br />

24545 3 TREAT HUMERUS FRACTURE 823.97<br />

24546 3 TREAT HUMERUS FRACTURE 982.60<br />

24560 3 TREAT HUMERUS FRACTURE 279.62<br />

24565 3 TREAT HUMERUS FRACTURE 465.98<br />

24566 3 TREAT HUMERUS FRACTURE 633.11<br />

24570 O TREATMENT OF OPEN HUMERAL EPICONDYL 0.00<br />

24575 3 TREAT HUMERUS FRACTURE 680.96<br />

24576 3 TREAT HUMERUS FRACTURE 293.93<br />

24577 3 TREAT HUMERUS FRACTURE 482.53<br />

24578 O TREATMENT OF OPEN HUMERAL CONDYLAR 0.00

---

24579 3 TREAT HUMERUS FRACTURE 768.21<br />

24580 O TREATMENT OF CLOSED COMMINUTED ELBO 0.00<br />

24581 O TREATMENT OF CLOSED COMMINUTED ELBO 0.00<br />

24582 3 TREAT HUMERUS FRACTURE 719.51<br />

24583 O TREATMENT OF OPEN COMMINUTED ELBOW 0.00<br />

24585 O OPEN TREATMENT OF CLOSED OR OPEN CO 0.00<br />

24586 3 TREAT ELBOW FRACTURE 1,013.11<br />

24587 3 TREAT ELBOW FRACTURE 1,005.61<br />

24588 O OPEN TREATMENT OF CLOSED OR OPEN CO 0.00<br />

24600 3 TREAT ELBOW DISLOCATION 331.50<br />

24605 3 TREAT ELBOW DISLOCATION 414.93<br />

24610 O TREATMENT OF OPEN ELBOW DISLOCATION 0.00<br />

24615 3 TREAT ELBOW DISLOCATION 659.84<br />

24620 3 TREAT ELBOW FRACTURE 502.51<br />

24625 O TREATMENT OF OPEN MONTEGGIA TYPE OF 0.00<br />

24635 3 TREAT ELBOW FRACTURE 766.43<br />

24640 3 TREAT ELBOW DISLOCATION 111.24<br />

24650 3 TREAT RADIUS FRACTURE 227.08<br />

24655 3 TREAT RADIUS FRACTURE 391.96<br />

24660 O TREATMENT OF OPEN RADIAL HEAD OR NE 0.00<br />

24665 3 TREAT RADIUS FRACTURE 596.31<br />

24666 3 TREAT RADIUS FRACTURE 673.80<br />

24670 3 TREAT ULNAR FRACTURE 254.54<br />

24675 3 TREAT ULNAR FRACTURE 410.33<br />

24680 O TREATMENT OF OPEN ULNAR FRACTURE, P 0.00<br />

24685 3 TREAT ULNAR FRACTURE 599.57<br />

24800 3 FUSION OF ELBOW JOINT 737.89<br />

24802 3 FUSION/GRAFT OF ELBOW JOINT 913.73<br />

24900 3 AMPUTATION OF UPPER ARM 650.85<br />

24920 3 AMPUTATION OF UPPER ARM 642.61<br />

24925 3 AMPUTATION FOLLOW-UP SURGERY 494.66<br />

24930 3 AMPUTATION FOLLOW-UP SURGERY 677.60<br />

24931 3 AMPUTATE UPPER ARM & IMPLANT 720.36<br />

24935 3 REVISION OF AMPUTATION 979.82<br />

24940 5 REVISION OF UPPER ARM 0.00<br />

24999 5 UPPER ARM/ELBOW SURGERY 0.00<br />

25000 3 INCISION OF TENDON SHEATH 346.59<br />

25001 3 INCISE FLEXOR CARPI RADIALIS 301.95<br />

25005 O TENDON SHEATH INCISION; AT WRIST FO 0.00<br />

25020 3 <strong>DE</strong>COMPRESS FOREARM 1 SPACE 555.04<br />

25023 3 <strong>DE</strong>COMPRESS FOREARM 1 SPACE 1,041.73<br />

25024 3 <strong>DE</strong>COMPRESS FOREARM 2 SPACES 686.70<br />

25025 3 <strong>DE</strong>COMPRESS FOREARM 2 SPACES 1,043.92<br />

25028 3 DRAINAGE OF FOREARM LESION 486.28<br />

25031 3 DRAINAGE OF FOREARM BURSA 385.00<br />

25035 3 TREAT FOREARM BONE LESION 670.47<br />

25040 3 EXPLORE/TREAT WRIST JOINT 535.31<br />

25065 3 BIOPSY FOREARM SOFT TISSUES 221.31<br />

25066 3 BIOPSY FOREARM SOFT TISSUES 375.07<br />

25075 3 REMOVAL FOREARM LESION SUBCU 325.48

---

25076 3 REMOVAL FOREARM LESION <strong>DE</strong>EP 459.27<br />

25077 3 REMOVE TUMOR, FOREARM/WRIST 737.40<br />

25085 3 INCISION OF WRIST CAPSULE 444.40<br />

25100 3 BIOPSY OF WRIST JOINT 329.30<br />

25101 3 EXPLORE/TREAT WRIST JOINT 384.21<br />

25105 3 REMOVE WRIST JOINT LINING 469.03<br />

25107 3 REMOVE WRIST JOINT CARTILAGE 570.25<br />

25109 3 EXCISE TENDON FOREARM/WRIST 465.61<br />

25110 3 REMOVE WRIST TENDON LESION 362.83<br />

25111 3 REMOVE WRIST TENDON LESION 296.03<br />

25112 3 REREMOVE WRIST TENDON LESION 359.63<br />

25115 3 REMOVE WRIST/FOREARM LESION 794.74<br />

25116 3 REMOVE WRIST/FOREARM LESION 663.59<br />

25118 3 EXCISE WRIST TENDON SHEATH 364.66<br />

25119 3 PARTIAL REMOVAL OF ULNA 484.23<br />

25120 3 REMOVAL OF FOREARM LESION 576.65<br />

25125 3 REMOVE/GRAFT FOREARM LESION 652.15<br />

25126 3 REMOVE/GRAFT FOREARM LESION 667.36<br />

25130 3 REMOVAL OF WRIST LESION 423.42<br />

25135 3 REMOVE & GRAFT WRIST LESION 524.72<br />

25136 3 REMOVE & GRAFT WRIST LESION 465.11<br />

25145 3 REMOVE FOREARM BONE LESION 587.76<br />

25150 3 PARTIAL REMOVAL OF ULNA 550.47<br />

25151 3 PARTIAL REMOVAL OF RADIUS 653.33<br />

25170 3 EXTENSIVE FOREARM SURGERY 880.36<br />

25210 3 REMOVAL OF WRIST BONE 462.65<br />

25215 3 REMOVAL OF WRIST BONES 598.21<br />

25230 3 PARTIAL REMOVAL OF RADIUS 411.74<br />

25240 3 PARTIAL REMOVAL OF ULNA 425.75<br />

25246 3 INJECTION FOR WRIST X-RAY 173.52<br />

25248 3 REMOVE FOREARM FOREIGN BODY 445.14<br />

25250 3 REMOVAL OF WRIST PROSTHESIS 479.40<br />

25251 3 REMOVAL OF WRIST PROSTHESIS 654.52<br />

25259 3 MANIPULATE WRIST W/ANESTHES 363.30<br />

25260 3 REPAIR FOREARM TENDON/MUSCLE 690.37<br />

25263 3 REPAIR FOREARM TENDON/MUSCLE 683.77<br />

25265 3 REPAIR FOREARM TENDON/MUSCLE 802.57<br />

25270 3 REPAIR FOREARM TENDON/MUSCLE 568.16<br />

25272 3 REPAIR FOREARM TENDON/MUSCLE 633.11<br />

25274 3 REPAIR FOREARM TENDON/MUSCLE 732.88<br />

25275 3 REPAIR FOREARM TENDON SHEATH 614.55<br />

25280 3 REVISE WRIST/FOREARM TENDON 636.81<br />

25290 3 INCISE WRIST/FOREARM TENDON 588.85<br />

25295 3 RELEASE WRIST/FOREARM TENDON 597.17<br />

25300 3 FUSION OF TENDONS AT WRIST 635.84<br />

25301 3 FUSION OF TENDONS AT WRIST 605.95<br />

25310 3 TRANSPLANT FOREARM TENDON 689.12<br />

25312 3 TRANSPLANT FOREARM TENDON 776.99<br />

25315 3 REVISE PALSY HAND TENDON(S) 828.20<br />

25316 3 REVISE PALSY HAND TENDON(S) 957.90

---

25317 O FLEXOR ORIGIN SLI<strong>DE</strong> FOR VOLKMANN CO 0.00<br />

25318 O FLEXOR ORIGIN SLI<strong>DE</strong> FOR VOLKMANN CO 0.00<br />

25320 3 REPAIR/REVISE WRIST JOINT 885.59<br />

25330 O ARTHROPLASTY, WRIST; 0.00<br />

25331 O ARTHROPLASTY, WRIST; WITH IMPLANT 0.00<br />

25332 3 REVISE WRIST JOINT 778.09<br />

25335 3 REALIGNMENT OF HAND 897.95<br />

25337 3 RECONSTRUCT ULNA/RADIOULNAR 823.33<br />

25350 3 REVISION OF RADIUS 747.53<br />

25355 3 REVISION OF RADIUS 824.79<br />

25360 3 REVISION OF ULNA 729.79<br />

25365 3 REVISE RADIUS & ULNA 966.09<br />

25370 3 REVISE RADIUS OR ULNA 1,034.00<br />

25375 3 REVISE RADIUS & ULNA 1,009.80<br />

25390 3 SHORTEN RADIUS OR ULNA 833.80<br />

25391 3 LENGTHEN RADIUS OR ULNA 1,041.62<br />

25392 3 SHORTEN RADIUS & ULNA 1,041.68<br />

25393 3 LENGTHEN RADIUS & ULNA 1,173.06<br />

25394 3 REPAIR CARPAL BONE, SHORTEN 705.64<br />

25400 3 REPAIR RADIUS OR ULNA 874.50<br />

25405 3 REPAIR/GRAFT RADIUS OR ULNA 1,088.79<br />

25415 3 REPAIR RADIUS & ULNA 1,025.83<br />

25420 3 REPAIR/GRAFT RADIUS & ULNA 1,205.26<br />

25425 3 REPAIR/GRAFT RADIUS OR ULNA 1,110.18<br />

25426 3 REPAIR/GRAFT RADIUS & ULNA 1,135.16<br />

25430 3 VASC GRAFT INTO CARPAL BONE 645.07<br />

25431 3 REPAIR NONUNION CARPAL BONE 727.27<br />

25440 3 REPAIR/GRAFT WRIST BONE 727.00<br />

25441 3 RECONSTRUCT WRIST JOINT 863.91<br />

25442 3 RECONSTRUCT WRIST JOINT 740.25<br />

25443 3 RECONSTRUCT WRIST JOINT 711.86<br />

25444 3 RECONSTRUCT WRIST JOINT 757.46<br />

25445 3 RECONSTRUCT WRIST JOINT 665.81<br />

25446 3 WRIST REPLACEMENT 1,086.43<br />

25447 3 REPAIR WRIST JOINT(S) 744.22<br />

25449 3 REMOVE WRIST JOINT IMPLANT 953.79<br />

25450 3 REVISION OF WRIST JOINT 585.60<br />

25455 3 REVISION OF WRIST JOINT 701.60<br />

25490 3 REINFORCE RADIUS 767.81<br />

25491 3 REINFORCE ULNA 805.58<br />

25492 3 REINFORCE RADIUS AND ULNA 953.39<br />

25500 3 TREAT FRACTURE OF RADIUS 230.80<br />

25505 3 TREAT FRACTURE OF RADIUS 450.00<br />

25510 O TREATMENT OF OPEN RADIAL SHAFT FRAC 0.00<br />

25515 3 TREAT FRACTURE OF RADIUS 614.31<br />

25520 3 TREAT FRACTURE OF RADIUS 494.29<br />

25525 3 TREAT FRACTURE OF RADIUS 757.28<br />

25526 3 TREAT FRACTURE OF RADIUS 941.18<br />

25530 3 TREAT FRACTURE OF ULNA 225.26<br />

25535 3 TREAT FRACTURE OF ULNA 431.27

---

25540 O TREATMENT OF OPEN ULNAR SHAFT FRACT 0.00<br />

25545 3 TREAT FRACTURE OF ULNA 582.48<br />

25560 3 TREAT FRACTURE RADIUS & ULNA 233.95<br />

25565 3 TREAT FRACTURE RADIUS & ULNA 469.47<br />

25570 O TREATMENT OF OPEN RADIAL AND ULNAR 0.00<br />

25574 3 TREAT FRACTURE RADIUS & ULNA 599.52<br />

25575 3 TREAT FRACTURE RADIUS/ULNA 816.07<br />

25600 3 TREAT FRACTURE RADIUS/ULNA 256.74<br />

25605 3 TREAT FRACTURE RADIUS/ULNA 544.93<br />

25606 3 TREAT FX DISTAL RADIAL 619.90<br />

25607 3 TREAT FX RAD EXTRA-ARTICUL 640.43<br />

25608 3 TREAT FX RAD INTRA-ARTICUL 729.45<br />

25609 3 TREAT FX RADIAL 3+ FRAG 929.12<br />

25610 O TREATMENT OF CLOSED, COMPLEX, DISTA 0.00<br />

25611 O TREAT FRACTURE RADIUS/ULNA 0.00<br />

25615 O TREATMENT OF OPEN DISTAL RADIAL FRA 0.00<br />

25620 O TREAT FRACTURE RADIUS/ULNA 0.00<br />

25622 3 TREAT WRIST BONE FRACTURE 263.92<br />

25624 3 TREAT WRIST BONE FRACTURE 414.09<br />

25626 O TREATMENT OF OPEN CARPAL SCAPHOID ( 0.00<br />

25628 3 TREAT WRIST BONE FRACTURE 651.62<br />

25630 3 TREAT WRIST BONE FRACTURE 269.24<br />

25635 3 TREAT WRIST BONE FRACTURE 391.18<br />

25640 O TREATMENT OF OPEN CARPAL BONE FRACT 0.00<br />

25645 3 TREAT WRIST BONE FRACTURE 523.49<br />

25650 3 TREAT WRIST BONE FRACTURE 279.73<br />

25651 3 PIN ULNAR STYLOID FRACTURE 427.29<br />

25652 3 TREAT FRACTURE ULNAR STYLOID 563.08<br />

25660 3 TREAT WRIST DISLOCATION 359.03<br />

25665 O TREATMENT OF OPEN RADIOCARPAL OR IN 0.00<br />

25670 3 TREAT WRIST DISLOCATION 560.77<br />

25671 3 PIN RADIOULNAR DISLOCATION 474.23<br />

25675 3 TREAT WRIST DISLOCATION 383.50<br />

25676 3 TREAT WRIST DISLOCATION 580.90<br />

25680 3 TREAT WRIST FRACTURE 408.50<br />

25685 3 TREAT WRIST FRACTURE 669.10<br />

25690 3 TREAT WRIST DISLOCATION 418.91<br />

25695 3 TREAT WRIST DISLOCATION 581.71<br />

25800 3 FUSION OF WRIST JOINT 696.56<br />

25805 3 FUSION/GRAFT OF WRIST JOINT 799.62<br />

25810 3 FUSION/GRAFT OF WRIST JOINT 801.56<br />

25820 3 FUSION OF HAND BONES 571.54<br />

25825 3 FUSE HAND BONES WITH GRAFT 697.63<br />

25830 3 FUSION, RADIOULNAR JNT/ULNA 900.01<br />

25900 3 AMPUTATION OF FOREARM 739.29<br />

25905 3 AMPUTATION OF FOREARM 724.53<br />

25907 3 AMPUTATION FOLLOW-UP SURGERY 648.30<br />

25909 3 AMPUTATION FOLLOW-UP SURGERY 720.80<br />

25915 3 AMPUTATION OF FOREARM 1,165.19<br />

25920 3 AMPUTATE HAND AT WRIST 626.29

---

25922 3 AMPUTATE HAND AT WRIST 551.25<br />

25924 3 AMPUTATION FOLLOW-UP SURGERY 613.75<br />

25927 3 AMPUTATION OF HAND 742.29<br />

25929 3 AMPUTATION FOLLOW-UP SURGERY 522.21<br />

25931 3 AMPUTATION FOLLOW-UP SURGERY 692.31<br />

25999 5 FOREARM OR WRIST SURGERY 0.00<br />

26010 3 DRAINAGE OF FINGER ABSCESS 247.32<br />

26011 3 DRAINAGE OF FINGER ABSCESS 381.51<br />

26020 3 DRAIN HAND TENDON SHEATH 388.95<br />

26025 3 DRAINAGE OF PALM BURSA 379.99<br />

26030 3 DRAINAGE OF PALM BURSA(S) 446.81<br />

26034 3 TREAT HAND BONE LESION 485.03<br />

26035 3 <strong>DE</strong>COMPRESS FINGERS/HAND 736.00<br />

26037 3 <strong>DE</strong>COMPRESS FINGERS/HAND 519.72<br />

26040 3 RELEASE PALM CONTRACTURE 281.12<br />

26045 3 RELEASE PALM CONTRACTURE 425.47<br />

26055 3 INCISE FINGER TENDON SHEATH 574.70<br />

26060 3 INCISION OF FINGER TENDON 239.01<br />

26070 3 EXPLORE/TREAT HAND JOINT 266.80<br />

26075 3 EXPLORE/TREAT FINGER JOINT 286.30<br />

26080 3 EXPLORE/TREAT FINGER JOINT 347.98<br />

26100 3 BIOPSY HAND JOINT LINING 295.34<br />

26105 3 BIOPSY FINGER JOINT LINING 300.33<br />

26110 3 BIOPSY FINGER JOINT LINING 287.28<br />

26115 3 REMOVAL HAND LESION SUBCUT 601.58<br />

26116 3 REMOVAL HAND LESION, <strong>DE</strong>EP 437.76<br />

26117 3 REMOVE TUMOR, HAND/FINGER 590.40<br />

26121 3 RELEASE PALM CONTRACTURE 546.38<br />

26123 3 RELEASE PALM CONTRACTURE 738.73<br />

26125 3 RELEASE PALM CONTRACTURE 261.65<br />

26130 3 REMOVE WRIST JOINT LINING 415.24<br />

26135 3 REVISE FINGER JOINT, EACH 504.51<br />

26140 3 REVISE FINGER JOINT, EACH 459.34<br />

26145 3 TENDON EXCISION, PALM/FINGER 466.22<br />

26160 3 REMOVE TENDON SHEATH LESION 553.32<br />

26170 3 REMOVAL OF PALM TENDON, EACH 367.03<br />

26180 3 REMOVAL OF FINGER TENDON 399.68<br />

26185 3 REMOVE FINGER BONE 470.18<br />

26200 3 REMOVE HAND BONE LESION 409.87<br />

26205 3 REMOVE/GRAFT BONE LESION 551.44<br />

26210 3 REMOVAL OF FINGER LESION 399.99<br />

26215 3 REMOVE/GRAFT FINGER LESION 505.28<br />

26230 3 PARTIAL REMOVAL OF HAND BONE 459.93<br />

26235 3 PARTIAL REMOVAL, FINGER BONE 451.18<br />

26236 3 PARTIAL REMOVAL, FINGER BONE 400.86<br />

26250 3 EXTENSIVE HAND SURGERY 528.87<br />

26255 3 EXTENSIVE HAND SURGERY 831.38<br />

26260 3 EXTENSIVE FINGER SURGERY 499.54<br />

26261 3 EXTENSIVE FINGER SURGERY 602.10<br />

26262 3 PARTIAL REMOVAL OF FINGER 418.41

---

26320 3 REMOVAL OF IMPLANT FROM HAND 313.11<br />

26340 3 MANIPULATE FINGER W/ANESTH 286.98<br />

26350 3 REPAIR FINGER/HAND TENDON 708.80<br />

26352 3 REPAIR/GRAFT HAND TENDON 796.51<br />

26356 3 REPAIR FINGER/HAND TENDON 1,013.83<br />

26357 3 REPAIR FINGER/HAND TENDON 844.25<br />

26358 3 REPAIR/GRAFT HAND TENDON 896.85<br />

26370 3 REPAIR FINGER/HAND TENDON 760.44<br />

26372 3 REPAIR/GRAFT HAND TENDON 875.65<br />

26373 3 REPAIR FINGER/HAND TENDON 833.29<br />

26390 3 REVISE HAND/FINGER TENDON 799.80<br />

26392 3 REPAIR/GRAFT HAND TENDON 947.25<br />

26410 3 REPAIR HAND TENDON 565.42<br />

26412 3 REPAIR/GRAFT HAND TENDON 675.54<br />

26415 3 EXCISION, HAND/FINGER TENDON 692.83<br />

26416 3 GRAFT HAND OR FINGER TENDON 808.80<br />

26418 3 REPAIR FINGER TENDON 569.42<br />

26420 3 REPAIR/GRAFT FINGER TENDON 704.52<br />

26426 3 REPAIR FINGER/HAND TENDON 598.34<br />

26428 3 REPAIR/GRAFT FINGER TENDON 734.29<br />

26432 3 REPAIR FINGER TENDON 492.39<br />

26433 3 REPAIR FINGER TENDON 528.20<br />

26434 3 REPAIR/GRAFT FINGER TENDON 619.43<br />

26437 3 REALIGNMENT OF TENDONS 607.04<br />

26440 3 RELEASE PALM/FINGER TENDON 625.53<br />

26442 3 RELEASE PALM & FINGER TENDON 904.29<br />

26445 3 RELEASE HAND/FINGER TENDON 587.68<br />

26449 3 RELEASE FOREARM/HAND TENDON 767.64<br />

26450 3 INCISION OF PALM TENDON 389.67<br />

26455 3 INCISION OF FINGER TENDON 386.64<br />

26460 3 INCISE HAND/FINGER TENDON 376.05<br />

26471 3 FUSION OF FINGER TENDONS 596.98<br />

26474 3 FUSION OF FINGER TENDONS 578.78<br />

26476 3 TENDON LENGTHENING 560.89<br />

26477 3 TENDON SHORTENING 567.40<br />

26478 3 LENGTHENING OF HAND TENDON 611.29<br />

26479 3 SHORTENING OF HAND TENDON 603.66<br />

26480 3 TRANSPLANT HAND TENDON 745.59<br />

26483 3 TRANSPLANT/GRAFT HAND TENDON 827.05<br />

26485 3 TRANSPLANT PALM TENDON 798.26<br />

26489 3 TRANSPLANT/GRAFT PALM TENDON 818.16<br />

26490 3 REVISE THUMB TENDON 750.72<br />

26492 3 TENDON TRANSFER WITH GRAFT 831.38<br />

26494 3 HAND TENDON/MUSCLE TRANSFER 764.56<br />

26496 3 REVISE THUMB TENDON 819.51<br />

26497 3 FINGER TENDON TRANSFER 823.46<br />

26498 3 FINGER TENDON TRANSFER 1,087.20<br />

26499 3 REVISION OF FINGER 777.66<br />

26500 3 HAND TENDON RECONSTRUCTION 608.42<br />

26502 3 HAND TENDON RECONSTRUCTION 678.09

---

26504 O HAND TENDON RECONSTRUCTION 0.00<br />

26508 3 RELEASE THUMB CONTRACTURE 618.22<br />

26510 3 THUMB TENDON TRANSFER 582.74<br />

26516 3 FUSION OF KNUCKLE JOINT 681.52<br />

26517 3 FUSION OF KNUCKLE JOINTS 788.55<br />

26518 3 FUSION OF KNUCKLE JOINTS 790.17<br />

26520 3 RELEASE KNUCKLE CONTRACTURE 653.55<br />

26525 3 RELEASE FINGER CONTRACTURE 656.97<br />

26527 O ARTHROPLASTY, CARPOMETACARPAL JOINT 0.00<br />

26530 3 REVISE KNUCKLE JOINT 487.30<br />

26531 3 REVISE KNUCKLE WITH IMPLANT 567.34<br />

26535 3 REVISE FINGER JOINT 355.06<br />

26536 3 REVISE/IMPLANT FINGER JOINT 618.54<br />

26540 3 REPAIR HAND JOINT 641.81<br />

26541 3 REPAIR HAND JOINT WITH GRAFT 775.46<br />

26542 3 REPAIR HAND JOINT WITH GRAFT 660.15<br />

26545 3 RECONSTRUCT FINGER JOINT 673.51<br />

26546 3 REPAIR NONUNION HAND 920.48<br />

26548 3 RECONSTRUCT FINGER JOINT 736.15<br />

26550 3 CONSTRUCT THUMB REPLACEMENT 1,435.51<br />

26551 3 GREAT TOE-HAND TRANSFER 2,848.02<br />

26552 O RECONSTRUCTION THUMB WITH TOE 0.00<br />

26553 3 SINGLE TRANSFER, TOE-HAND 2,681.74<br />

26554 3 DOUBLE TRANSFER, TOE-HAND 3,646.65<br />

26555 3 POSITIONAL CHANGE OF FINGER 1,281.63<br />

26556 3 TOE JOINT TRANSFER 2,763.65<br />

26557 O TOE TO FINGER TRANSFER; FIRST STAGE 0.00<br />

26558 O TOE TO FINGER TRANSFER; EACH <strong>DE</strong>LAY 0.00<br />

26559 O TOE TO FINGER TRANSFER; SECOND STAG 0.00<br />

26560 3 REPAIR OF WEB FINGER 533.01<br />

26561 3 REPAIR OF WEB FINGER 845.29<br />

26562 3 REPAIR OF WEB FINGER 1,132.21<br />

26565 3 CORRECT METACARPAL FLAW 656.83<br />

26567 3 CORRECT FINGER <strong>DE</strong>FORMITY 659.14<br />

26568 3 LENGTHEN METACARPAL/FINGER 868.68<br />

26580 3 REPAIR HAND <strong>DE</strong>FORMITY 1,189.24<br />

26585 O REPAIR FINGER <strong>DE</strong>FORMITY 0.00<br />

26587 3 RECONSTRUCT EXTRA FINGER 871.52<br />

26590 3 REPAIR FINGER <strong>DE</strong>FORMITY 1,228.86<br />

26591 3 REPAIR MUSCLES OF HAND 437.86<br />

26593 3 RELEASE MUSCLES OF HAND 578.19<br />

26596 3 EXCISION CONSTRICTING TISSUE 669.10<br />

26597 O RELEASE OF SCAR CONTRACTURE 0.00<br />

26600 3 TREAT METACARPAL FRACTURE 239.57<br />

26605 3 TREAT METACARPAL FRACTURE 283.43<br />

26607 3 TREAT METACARPAL FRACTURE 428.57<br />

26608 3 TREAT METACARPAL FRACTURE 435.93<br />

26610 O TREATMENT OF OPEN METACARPAL FRACTU 0.00<br />

26615 3 TREAT METACARPAL FRACTURE 482.25<br />

26641 3 TREAT THUMB DISLOCATION 316.65

---

26645 3 TREAT THUMB FRACTURE 363.93<br />

26650 3 TREAT THUMB FRACTURE 431.59<br />

26655 O TREATMENT OF OPEN CARPOMETACARPAL F 0.00<br />

26660 O TREATMENT OF OPEN CARPOMETACARPAL F 0.00<br />

26665 3 TREAT THUMB FRACTURE 544.95<br />

26670 3 TREAT HAND DISLOCATION 293.24<br />

26675 3 TREAT HAND DISLOCATION 393.86<br />

26676 3 PIN HAND DISLOCATION 457.94<br />

26680 O TREATMENT OF OPEN CARPOMETACARPAL D 0.00<br />

26685 3 TREAT HAND DISLOCATION 504.80<br />

26686 3 TREAT HAND DISLOCATION 565.43<br />

26700 3 TREAT KNUCKLE DISLOCATION 275.93<br />

26705 3 TREAT KNUCKLE DISLOCATION 362.22<br />

26706 3 PIN KNUCKLE DISLOCATION 392.73<br />

26710 O TREATMENT OF OPEN METACARPOPHALANGE 0.00<br />

26715 3 TREAT KNUCKLE DISLOCATION 486.51<br />

26720 3 TREAT FINGER FRACTURE, EACH 170.30<br />

26725 3 TREAT FINGER FRACTURE, EACH 305.11<br />

26727 3 TREAT FINGER FRACTURE, EACH 429.33<br />

26730 O TREATMENT OF OPEN PHALANGEAL SHAFT 0.00<br />

26735 3 TREAT FINGER FRACTURE, EACH 503.94<br />

26740 3 TREAT FINGER FRACTURE, EACH 197.35<br />

26742 3 TREAT FINGER FRACTURE, EACH 331.40<br />

26744 O TREATMENT OF OPEN ARTICULAR FRACTUR 0.00<br />

26746 3 TREAT FINGER FRACTURE, EACH 602.93<br />

26750 3 TREAT FINGER FRACTURE, EACH 158.67<br />

26755 3 TREAT FINGER FRACTURE, EACH 279.61<br />

26756 3 PIN FINGER FRACTURE, EACH 380.47<br />

26760 O TREATMENT OF OPEN DISTAL PHALANGEAL 0.00<br />

26765 3 TREAT FINGER FRACTURE, EACH 406.80<br />

26770 3 TREAT FINGER DISLOCATION 237.07<br />

26775 3 TREAT FINGER DISLOCATION 337.38<br />

26776 3 PIN FINGER DISLOCATION 404.37<br />

26780 O TREATMENT OF OPEN INTERPHALANGEAL J 0.00<br />

26785 3 TREAT FINGER DISLOCATION 441.07<br />

26820 3 THUMB FUSION WITH GRAFT 758.22<br />

26841 3 FUSION OF THUMB 712.22<br />

26842 3 THUMB FUSION WITH GRAFT 763.50<br />

26843 3 FUSION OF HAND JOINT 705.48<br />

26844 3 FUSION/GRAFT OF HAND JOINT 783.11<br />

26850 3 FUSION OF KNUCKLE 672.60<br />

26852 3 FUSION OF KNUCKLE WITH GRAFT 760.78<br />

26860 3 FUSION OF FINGER JOINT 551.60<br />

26861 3 FUSION OF FINGER JNT, ADD-ON 99.17<br />

26862 3 FUSION/GRAFT OF FINGER JOINT 698.27<br />

26863 3 FUSE/GRAFT AD<strong>DE</strong>D JOINT 221.43<br />

26910 3 AMPUTATE METACARPAL BONE 677.85<br />

26951 3 AMPUTATION OF FINGER/THUMB 584.43<br />

26952 3 AMPUTATION OF FINGER/THUMB 629.31<br />

26989 5 HAND/FINGER SURGERY 0.00

---

26990 3 DRAINAGE OF PELVIS LESION 565.79<br />

26991 3 DRAINAGE OF PELVIS BURSA 658.39<br />

26992 3 DRAINAGE OF BONE LESION 887.27<br />

27000 3 INCISION OF HIP TENDON 413.55<br />

27001 3 INCISION OF HIP TENDON 498.50<br />

27003 3 INCISION OF HIP TENDON 534.61<br />

27005 3 INCISION OF HIP TENDON 670.20<br />

27006 3 INCISION OF HIP TENDONS 679.13<br />

27010 O GLUTEAL-ILIOTIBIAL FASCIOTOMY (OBER 0.00<br />

27015 O ILIAC CREST FASCIOTOMY (SOUTTER OR 0.00<br />

27025 3 INCISION OF HIP/THIGH FASCIA 813.79<br />

27027 6 BUTTOCK FASCIOTOMY 0.00<br />

27030 3 DRAINAGE OF HIP JOINT 873.97<br />

27033 3 EXPLORATION OF HIP JOINT 903.74<br />

27035 3 <strong>DE</strong>NERVATION OF HIP JOINT 1,036.77<br />

27036 3 EXCISION OF HIP JOINT/MUSCLE 920.70<br />

27040 3 BIOPSY OF SOFT TISSUES 311.17<br />

27041 3 BIOPSY OF SOFT TISSUES 625.04<br />

27047 3 REMOVE HIP/PELVIS LESION 563.17<br />

27048 3 REMOVE HIP/PELVIS LESION 430.47<br />

27049 3 REMOVE TUMOR, HIP/PELVIS 903.01<br />

27050 3 BIOPSY OF SACROILIAC JOINT 321.60<br />

27052 3 BIOPSY OF HIP JOINT 505.41<br />

27054 3 REMOVAL OF HIP JOINT LINING 623.81<br />

27057 6 BUTTOCK FASCIOTOMY W/DBRDMT 0.00<br />

27060 3 REMOVAL OF ISCHIAL BURSA 391.60<br />

27062 3 REMOVE FEMUR LESION/BURSA 412.07<br />

27065 3 REMOVAL OF HIP BONE LESION 453.59<br />

27066 3 REMOVAL OF HIP BONE LESION 740.71<br />

27067 3 REMOVE/GRAFT HIP BONE LESION 932.78<br />

27070 3 PARTIAL REMOVAL OF HIP BONE 777.51<br />

27071 3 PARTIAL REMOVAL OF HIP BONE 838.89<br />

27075 3 EXTENSIVE HIP SURGERY 2,109.92<br />

27076 3 EXTENSIVE HIP SURGERY 1,470.12<br />

27077 3 EXTENSIVE HIP SURGERY 2,462.56<br />

27078 3 EXTENSIVE HIP SURGERY 927.92<br />

27079 3 EXTENSIVE HIP SURGERY 908.73<br />

27080 3 REMOVAL OF TAIL BONE 443.48<br />

27086 3 REMOVE HIP FOREIGN BODY 233.02<br />

27087 3 REMOVE HIP FOREIGN BODY 578.04<br />

27090 3 REMOVAL OF HIP PROSTHESIS 768.77<br />

27091 3 REMOVAL OF HIP PROSTHESIS 1,462.53<br />

27093 3 INJECTION FOR HIP X-RAY 197.64<br />

27095 3 INJECTION FOR HIP X-RAY 240.67<br />

27096 3 INJECT SACROILIAC JOINT 185.07<br />

27097 3 REVISION OF HIP TENDON 608.22<br />

27098 3 TRANSFER TENDON TO PELVIS 574.90<br />

27100 3 TRANSFER OF ABDOMINAL MUSCLE 751.42<br />

27105 3 TRANSFER OF SPINAL MUSCLE 779.72<br />

27110 3 TRANSFER OF ILIOPSOAS MUSCLE 869.17

---

27111 3 TRANSFER OF ILIOPSOAS MUSCLE 818.87<br />

27120 3 RECONSTRUCTION OF HIP SOCKET 1,184.88<br />

27122 3 RECONSTRUCTION OF HIP SOCKET 1,021.43<br />

27125 3 PARTIAL HIP REPLACEMENT 1,031.18<br />

27126 O PARTIAL HIP REPLACEMENT (HEMIARTHRO 0.00<br />

27127 O PARTIAL HIP REPLACEMENT (HEMIARTHRO 0.00<br />

27130 3 TOTAL HIP ARTHROPLASTY 1,330.01<br />

27132 3 TOTAL HIP ARTHROPLASTY 1,556.37<br />

27134 3 REVISE HIP JOINT REPLACEMENT 1,807.39<br />

27137 3 REVISE HIP JOINT REPLACEMENT 1,378.81<br />

27138 3 REVISE HIP JOINT REPLACEMENT 1,434.25<br />

27140 3 TRANSPLANT FEMUR RIDGE 832.40<br />

27146 3 INCISION OF HIP BONE 1,171.78<br />

27147 3 REVISION OF HIP BONE 1,344.88<br />

27151 3 INCISION OF HIP BONES 1,336.91<br />

27156 3 REVISION OF HIP BONES 1,593.67<br />

27157 O ACETABULAR AUGMENTATION (WILSON PRO 0.00<br />

27158 3 REVISION OF PELVIS 1,244.94<br />

27161 3 INCISION OF NECK OF FEMUR 1,130.99<br />

27165 3 INCISION/FIXATION OF FEMUR 1,254.01<br />

27170 3 REPAIR/GRAFT FEMUR HEAD/NECK 1,089.97<br />

27175 3 TREAT SLIPPED EPIPHYSIS 591.10<br />

27176 3 TREAT SLIPPED EPIPHYSIS 837.54<br />

27177 3 TREAT SLIPPED EPIPHYSIS 1,022.22<br />

27178 3 TREAT SLIPPED EPIPHYSIS 817.66<br />

27179 3 REVISE HEAD/NECK OF FEMUR 901.39<br />

27181 3 TREAT SLIPPED EPIPHYSIS 980.89<br />

27185 3 REVISION OF FEMUR EPIPHYSIS 677.65<br />

27187 3 REINFORCE HIP BONES 922.45<br />

27190 O TREATMENT OF CLOSED SACRAL FRACTURE 0.00<br />

27192 O OPEN TREATMENT OF CLOSED OR OPEN SA 0.00<br />

27193 3 TREAT PELVIC RING FRACTURE 422.55<br />

27194 3 TREAT PELVIC RING FRACTURE 671.28<br />

27195 O TREATMENT OF SACROILIAC AND/OR SYMP 0.00<br />

27196 O TREATMENT OF SACROILIAC AND/OR SYMP 0.00<br />

27200 3 TREAT TAIL BONE FRACTURE 156.41<br />

27201 O TREATMENT OF OPEN COCCYGEAL FRACTUR 0.00<br />

27202 3 TREAT TAIL BONE FRACTURE 705.49<br />

27210 O TREATMENT OF CLOSED ILIAC, PUBIC OR 0.00<br />

27212 O TREATMENT OF OPEN ILIAC, PUBIC OR I 0.00<br />

27214 O OPEN TREATMENT OF CLOSED OR OPEN IL 0.00<br />

27215 3 TREAT PELVIC FRACTURE(S) 681.18<br />

27216 3 TREAT PELVIC RING FRACTURE 980.09<br />

27217 3 TREAT PELVIC RING FRACTURE 937.78<br />

27218 3 TREAT PELVIC RING FRACTURE 1,260.29<br />

27220 3 TREAT HIP SOCKET FRACTURE 475.62<br />

27222 3 TREAT HIP SOCKET FRACTURE 902.66<br />

27224 O OPEN TREATMENT OF CLOSED OR OPEN AC 0.00<br />

27225 O OPEN TREATMENT OF CLOSED OR OPEN AC 0.00<br />

27226 3 TREAT HIP WALL FRACTURE 927.06

---

27227 3 TREAT HIP FRACTURE(S) 1,541.14<br />

27228 3 TREAT HIP FRACTURE(S) 1,764.82<br />

27230 3 TREAT THIGH FRACTURE 426.80<br />

27232 3 TREAT THIGH FRACTURE 711.74<br />

27234 O TREATMENT OF OPEN FEMORAL FRACTURE, 0.00<br />

27235 3 TREAT THIGH FRACTURE 842.47<br />

27236 3 TREAT THIGH FRACTURE 1,088.61<br />

27238 3 TREAT THIGH FRACTURE 410.50<br />

27240 3 TREAT THIGH FRACTURE 875.24<br />

27242 O TREATMENT OF OPEN INTERTROCHANTERIC 0.00<br />

27244 3 TREAT THIGH FRACTURE 1,072.94<br />

27245 3 TREAT THIGH FRACTURE 1,313.29<br />

27246 3 TREAT THIGH FRACTURE 349.38<br />

27248 3 TREAT THIGH FRACTURE 701.87<br />

27250 3 TREAT HIP DISLOCATION 438.33<br />

27252 3 TREAT HIP DISLOCATION 693.39<br />

27253 3 TREAT HIP DISLOCATION 876.19<br />

27254 3 TREAT HIP DISLOCATION 1,175.57<br />

27255 O OPEN TREATMENT OF CLOSED OR OPEN HI 0.00<br />

27256 3 TREAT HIP DISLOCATION 276.44<br />

27257 3 TREAT HIP DISLOCATION 307.22<br />

27258 3 TREAT HIP DISLOCATION 1,022.65<br />

27259 3 TREAT HIP DISLOCATION 1,421.05<br />

27265 3 TREAT HIP DISLOCATION 364.24<br />

27266 3 TREAT HIP DISLOCATION 531.40<br />

27267 3 CLTX THIGH FX 381.97<br />

27268 3 CLTX THIGH FX W/MNPJ 469.03<br />

27269 3 OPTX THIGH FX 1,111.55<br />

27275 3 MANIPULATION OF HIP JOINT 167.22<br />

27280 3 FUSION OF SACROILIAC JOINT 943.42<br />

27282 3 FUSION OF PUBIC BONES 762.76<br />

27284 3 FUSION OF HIP JOINT 1,487.94<br />

27286 3 FUSION OF HIP JOINT 1,498.45<br />

27290 3 AMPUTATION OF LEG AT HIP 1,443.54<br />

27295 3 AMPUTATION OF LEG AT HIP 1,161.43<br />

27299 5 PELVIS/HIP JOINT SURGERY 0.00<br />

27301 3 DRAIN THIGH/KNEE LESION 616.41<br />

27303 3 DRAINAGE OF BONE LESION 586.46<br />

27305 3 INCISE THIGH TENDON & FASCIA 430.25<br />

27306 3 INCISION OF THIGH TENDON 356.14<br />

27307 3 INCISION OF THIGH TENDONS 432.40<br />

27310 3 EXPLORATION OF KNEE JOINT 665.14<br />

27315 O PARTIAL REMOVAL, THIGH NERVE 0.00<br />

27320 O PARTIAL REMOVAL, THIGH NERVE 0.00<br />

27323 3 BIOPSY, THIGH SOFT TISSUES 237.14<br />

27324 3 BIOPSY, THIGH SOFT TISSUES 347.46<br />

27325 3 NEURECTOMY, HAMSTRING 468.07<br />

27326 3 NEURECTOMY, POPLITEAL 450.80<br />

27327 3 REMOVAL OF THIGH LESION 409.04<br />

27328 3 REMOVAL OF THIGH LESION 381.49

---

27329 3 REMOVE TUMOR, THIGH/KNEE 939.65<br />

27330 3 BIOPSY, KNEE JOINT LINING 369.55<br />

27331 3 EXPLORE/TREAT KNEE JOINT 434.20<br />

27332 3 REMOVAL OF KNEE CARTILAGE 585.41<br />

27333 3 REMOVAL OF KNEE CARTILAGE 532.26<br />

27334 3 REMOVE KNEE JOINT LINING 624.61<br />

27335 3 REMOVE KNEE JOINT LINING 705.07<br />

27340 3 REMOVAL OF KNEECAP BURSA 333.73<br />

27345 3 REMOVAL OF KNEE CYST 439.47<br />

27347 3 REMOVE KNEE CYST 462.05<br />

27350 3 REMOVAL OF KNEECAP 596.86<br />

27355 3 REMOVE FEMUR LESION 554.15<br />

27356 3 REMOVE FEMUR LESION/GRAFT 675.70<br />

27357 3 REMOVE FEMUR LESION/GRAFT 749.80<br />

27358 3 REMOVE FEMUR LESION/FIXATION 270.21<br />

27360 3 PARTIAL REMOVAL, LEG BONE(S) 785.75<br />

27365 3 EXTENSIVE LEG SURGERY 1,125.62<br />

27370 3 INJECTION FOR KNEE X-RAY 167.29<br />

27372 3 REMOVAL OF FOREIGN BODY 559.70<br />

27380 3 REPAIR OF KNEECAP TENDON 547.87<br />

27381 3 REPAIR/GRAFT KNEECAP TENDON 741.80<br />

27385 3 REPAIR OF THIGH MUSCLE 585.56<br />

27386 3 REPAIR/GRAFT OF THIGH MUSCLE 770.86<br />

27390 3 INCISION OF THIGH TENDON 400.13<br />

27391 3 INCISION OF THIGH TENDONS 525.11<br />

27392 3 INCISION OF THIGH TENDONS 649.28<br />

27393 3 LENGTHENING OF THIGH TENDON 465.26<br />

27394 3 LENGTHENING OF THIGH TENDONS 600.90<br />

27395 3 LENGTHENING OF THIGH TENDONS 810.68<br />

27396 3 TRANSPLANT OF THIGH TENDON 564.87<br />

27397 3 TRANSPLANTS OF THIGH TENDONS 818.86<br />

27400 3 REVISE THIGH MUSCLES/TENDONS 621.74<br />

27403 3 REPAIR OF KNEE CARTILAGE 591.09<br />

27405 3 REPAIR OF KNEE LIGAMENT 621.54<br />

27407 3 REPAIR OF KNEE LIGAMENT 714.31<br />

27409 3 REPAIR OF KNEE LIGAMENTS 885.15<br />

27412 3 AUTOCHONDROCYTE IMPLANT KNEE 1,520.62<br />

27415 3 OSTEOCHONDRAL KNEE ALLOGRAFT 1,279.00<br />

27416 3 OSTEOCHONDRAL KNEE AUTOGRAFT 873.53<br />

27418 3 REPAIR <strong>DE</strong>GENERATED KNEECAP 768.65<br />

27420 3 REVISION OF UNSTABLE KNEECAP 690.23<br />

27422 3 REVISION OF UNSTABLE KNEECAP 688.00<br />

27424 3 REVISION/REMOVAL OF KNEECAP 688.77<br />

27425 3 LAT RETINACULAR RELEASE OPEN 407.13<br />

27427 3 RECONSTRUCTION, KNEE 661.55<br />

27428 3 RECONSTRUCTION, KNEE 1,010.76<br />

27429 3 RECONSTRUCTION, KNEE 1,130.55<br />

27430 3 REVISION OF THIGH MUSCLES 682.63<br />

27435 3 INCISION OF KNEE JOINT 728.59<br />

27437 3 REVISE KNEECAP 607.68

---

27438 3 REVISE KNEECAP WITH IMPLANT 772.46<br />

27440 3 REVISION OF KNEE JOINT 681.56<br />

27441 3 REVISION OF KNEE JOINT 720.28<br />

27442 3 REVISION OF KNEE JOINT 803.39<br />

27443 3 REVISION OF KNEE JOINT 755.60<br />

27445 3 REVISION OF KNEE JOINT 1,167.60<br />

27446 3 REVISION OF KNEE JOINT 1,039.02<br />

27447 3 TOTAL KNEE ARTHROPLASTY 1,428.42<br />

27448 3 INCISION OF THIGH 760.18<br />

27450 3 INCISION OF THIGH 944.51<br />

27454 3 REALIGNMENT OF THIGH BONE 1,192.85<br />

27455 3 REALIGNMENT OF KNEE 873.59<br />

27457 3 REALIGNMENT OF KNEE 898.87<br />

27465 3 SHORTENING OF THIGH BONE 1,102.40<br />

27466 3 LENGTHENING OF THIGH BONE 1,093.76<br />

27468 3 SHORTEN/LENGTHEN THIGHS 1,232.96<br />

27470 3 REPAIR OF THIGH 1,090.14<br />

27472 3 REPAIR/GRAFT OF THIGH 1,179.86<br />

27475 3 SURGERY TO STOP LEG GROWTH 603.44<br />

27477 3 SURGERY TO STOP LEG GROWTH 673.60<br />

27479 3 SURGERY TO STOP LEG GROWTH 888.55<br />

27485 3 SURGERY TO STOP LEG GROWTH 618.95<br />

27486 3 REVISE/REPLACE KNEE JOINT 1,303.56<br />

27487 3 REVISE/REPLACE KNEE JOINT 1,643.58<br />

27488 3 REMOVAL OF KNEE PROSTHESIS 1,103.29<br />

27495 3 REINFORCE THIGH 1,050.02<br />

27496 3 <strong>DE</strong>COMPRESSION OF THIGH/KNEE 463.07<br />

27497 3 <strong>DE</strong>COMPRESSION OF THIGH/KNEE 500.08<br />

27498 3 <strong>DE</strong>COMPRESSION OF THIGH/KNEE 545.41<br />

27499 3 <strong>DE</strong>COMPRESSION OF THIGH/KNEE 611.05<br />

27500 3 TREATMENT OF THIGH FRACTURE 467.04<br />

27501 3 TREATMENT OF THIGH FRACTURE 457.80<br />

27502 3 TREATMENT OF THIGH FRACTURE 728.87<br />

27503 3 TREATMENT OF THIGH FRACTURE 737.02<br />

27504 O TREATMENT OF OPEN FEMORAL SHAFT FRA 0.00<br />

27506 3 TREATMENT OF THIGH FRACTURE 1,223.69<br />

27507 3 TREATMENT OF THIGH FRACTURE 913.48<br />

27508 3 TREATMENT OF THIGH FRACTURE 473.92<br />

27509 3 TREATMENT OF THIGH FRACTURE 596.75<br />

27510 3 TREATMENT OF THIGH FRACTURE 640.89<br />

27511 3 TREATMENT OF THIGH FRACTURE 958.00<br />

27512 O TREATMENT OF OPEN FEMORAL FRACTURE, 0.00<br />

27513 3 TREATMENT OF THIGH FRACTURE 1,205.73<br />

27514 3 TREATMENT OF THIGH FRACTURE 997.09<br />

27516 3 TREAT THIGH FX GROWTH PLATE 446.44<br />

27517 3 TREAT THIGH FX GROWTH PLATE 613.73<br />

27518 O TREATMENT OF OPEN DISTAL FEMORAL EP 0.00<br />

27519 3 TREAT THIGH FX GROWTH PLATE 893.49<br />

27520 3 TREAT KNEECAP FRACTURE 283.22<br />

27522 O TREATMENT OF OPEN PATELLAR FRACTURE 0.00

---

27524 3 TREAT KNEECAP FRACTURE 698.12<br />

27530 3 TREAT KNEE FRACTURE 353.48<br />

27532 3 TREAT KNEE FRACTURE 559.80<br />

27534 O TREATMENT OF OPEN TIBIAL FRACTURE, 0.00<br />

27535 3 TREAT KNEE FRACTURE 855.06<br />

27536 3 TREAT KNEE FRACTURE 1,093.31<br />

27537 O OPEN TREATMENT OF CLOSED OR OPEN TI 0.00<br />

27538 3 TREAT KNEE FRACTURE(S) 422.12<br />

27540 3 TREAT KNEE FRACTURE 778.44<br />

27550 3 TREAT KNEE DISLOCATION 441.52<br />

27552 3 TREAT KNEE DISLOCATION 569.39<br />

27554 O TREATMENT OF OPEN KNEE DISLOCATION, 0.00<br />

27556 3 TREAT KNEE DISLOCATION 882.36<br />

27557 3 TREAT KNEE DISLOCATION 1,047.17<br />

27558 3 TREAT KNEE DISLOCATION 1,149.71<br />

27560 3 TREAT KNEECAP DISLOCATION 322.15<br />

27562 3 TREAT KNEECAP DISLOCATION 411.03<br />

27564 O TREATMENT OF OPEN PATELLAR DISLOCAT 0.00<br />

27566 3 TREAT KNEECAP DISLOCATION 828.82<br />

27570 3 FIXATION OF KNEE JOINT 135.45<br />

27580 3 FUSION OF KNEE 1,339.68<br />

27590 3 AMPUTATE LEG AT THIGH 754.45<br />

27591 3 AMPUTATE LEG AT THIGH 843.44<br />

27592 3 AMPUTATE LEG AT THIGH 639.62<br />

27594 3 AMPUTATION FOLLOW-UP SURGERY 467.91<br />

27596 3 AMPUTATION FOLLOW-UP SURGERY 676.39<br />

27598 3 AMPUTATE LOWER LEG AT KNEE 684.71<br />

27599 5 LEG SURGERY PROCEDURE 0.00<br />

27600 3 <strong>DE</strong>COMPRESSION OF LOWER LEG 390.51<br />

27601 3 <strong>DE</strong>COMPRESSION OF LOWER LEG 402.50<br />

27602 3 <strong>DE</strong>COMPRESSION OF LOWER LEG 479.32<br />

27603 3 DRAIN LOWER LEG LESION 481.59<br />

27604 3 DRAIN LOWER LEG BURSA 420.76<br />

27605 3 INCISION OF ACHILLES TENDON 362.53<br />

27606 3 INCISION OF ACHILLES TENDON 278.60<br />

27607 3 TREAT LOWER LEG BONE LESION 560.88<br />

27610 3 EXPLORE/TREAT ANKLE JOINT 604.88<br />

27612 3 EXPLORATION OF ANKLE JOINT 526.81<br />

27613 3 BIOPSY LOWER LEG SOFT TISSUE 220.69<br />

27614 3 BIOPSY LOWER LEG SOFT TISSUE 509.88<br />

27615 3 REMOVE TUMOR, LOWER LEG 821.16<br />

27618 3 REMOVE LOWER LEG LESION 440.85<br />

27619 3 REMOVE LOWER LEG LESION 708.24<br />

27620 3 EXPLORE/TREAT ANKLE JOINT 431.06<br />

27625 3 REMOVE ANKLE JOINT LINING 556.95<br />

27626 3 REMOVE ANKLE JOINT LINING 598.21<br />

27630 3 REMOVAL OF TENDON LESION 492.02<br />

27635 3 REMOVE LOWER LEG BONE LESION 550.69<br />

27637 3 REMOVE/GRAFT LEG BONE LESION 693.15<br />

27638 3 REMOVE/GRAFT LEG BONE LESION 725.02

---

27640 3 PARTIAL REMOVAL OF TIBIA 816.17<br />

27641 3 PARTIAL REMOVAL OF FIBULA 657.27<br />

27645 3 EXTENSIVE LOWER LEG SURGERY 982.14<br />

27646 3 EXTENSIVE LOWER LEG SURGERY 876.26<br />

27647 3 EXTENSIVE ANKLE/HEEL SURGERY 766.53<br />

27648 3 INJECTION FOR ANKLE X-RAY 161.00<br />

27650 3 REPAIR ACHILLES TENDON 653.09<br />

27652 3 REPAIR/GRAFT ACHILLES TENDON 696.55<br />

27654 3 REPAIR OF ACHILLES TENDON 655.27<br />

27656 3 REPAIR LEG FASCIA <strong>DE</strong>FECT 501.73<br />

27658 3 REPAIR OF LEG TENDON, EACH 359.99<br />

27659 3 REPAIR OF LEG TENDON, EACH 472.47<br />

27664 3 REPAIR OF LEG TENDON, EACH 346.01<br />

27665 3 REPAIR OF LEG TENDON, EACH 394.50<br />

27675 3 REPAIR LOWER LEG TENDONS 483.50<br />

27676 3 REPAIR LOWER LEG TENDONS 577.92<br />

27680 3 RELEASE OF LOWER LEG TENDON 406.46<br />

27681 3 RELEASE OF LOWER LEG TENDONS 486.09<br />

27685 3 REVISION OF LOWER LEG TENDON 567.98<br />

27686 3 REVISE LOWER LEG TENDONS 527.58<br />

27687 3 REVISION OF CALF TENDON 436.09<br />

27690 3 REVISE LOWER LEG TENDON 573.73<br />

27691 3 REVISE LOWER LEG TENDON 680.68<br />

27692 3 REVISE ADDITIONAL LEG TENDON 105.27<br />

27695 3 REPAIR OF ANKLE LIGAMENT 465.69<br />

27696 3 REPAIR OF ANKLE LIGAMENTS 554.91<br />

27698 3 REPAIR OF ANKLE LIGAMENT 617.61<br />

27700 3 REVISION OF ANKLE JOINT 576.35<br />

27702 3 RECONSTRUCT ANKLE JOINT 930.58<br />

27703 3 RECONSTRUCTION, ANKLE JOINT 1,064.98<br />

27704 3 REMOVAL OF ANKLE IMPLANT 518.99<br />

27705 3 INCISION OF TIBIA 715.66<br />

27707 3 INCISION OF FIBULA 366.06<br />

27709 3 INCISION OF TIBIA & FIBULA 994.77<br />

27712 3 REALIGNMENT OF LOWER LEG 1,002.15<br />

27715 3 REVISION OF LOWER LEG 984.87<br />

27720 3 REPAIR OF TIBIA 816.10<br />

27722 3 REPAIR/GRAFT OF TIBIA 813.18<br />

27724 3 REPAIR/GRAFT OF TIBIA 1,189.94<br />

27725 3 REPAIR OF LOWER LEG 1,104.55<br />

27726 3 REPAIR FIBULA NONUNION 825.80<br />

27727 3 REPAIR OF LOWER LEG 952.50<br />

27730 3 REPAIR OF TIBIA EPIPHYSIS 539.37<br />

27732 3 REPAIR OF FIBULA EPIPHYSIS 383.93<br />

27734 3 REPAIR LOWER LEG EPIPHYSES 580.79<br />

27740 3 REPAIR OF LEG EPIPHYSES 657.06<br />

27742 3 REPAIR OF LEG EPIPHYSES 608.93<br />

27745 3 REINFORCE TIBIA 701.87<br />

27750 3 TREATMENT OF TIBIA FRACTURE 305.41<br />

27752 3 TREATMENT OF TIBIA FRACTURE 486.46

---

27754 O TREATMENT OF OPEN TIBIAL SHAFT FRAC 0.00<br />

27756 3 TREATMENT OF TIBIA FRACTURE 523.38<br />

27758 3 TREATMENT OF TIBIA FRACTURE 819.61<br />

27759 3 TREATMENT OF TIBIA FRACTURE 929.67<br />

27760 3 CLTX MEDIAL ANKLE FX 295.20<br />

27762 3 CLTX MED ANKLE FX W/MNPJ 438.27<br />

27764 O TREATMENT OF OPEN DISTAL TIBIAL FRA 0.00<br />

27766 3 OPTX MEDIAL ANKLE FX 567.66<br />

27767 3 CLTX POST ANKLE FX 236.02<br />

27768 3 CLTX POST ANKLE FX W/MNPJ 361.98<br />

27769 3 OPTX POST ANKLE FX 621.36<br />

27780 3 TREATMENT OF FIBULA FRACTURE 262.71<br />

27781 3 TREATMENT OF FIBULA FRACTURE 377.51<br />

27782 O TREATMENT OF OPEN PROXIMAL FIBULA O 0.00<br />

27784 3 TREATMENT OF FIBULA FRACTURE 620.73<br />

27786 3 TREATMENT OF ANKLE FRACTURE 279.79<br />

27788 3 TREATMENT OF ANKLE FRACTURE 384.07<br />

27790 O TREATMENT OF OPEN DISTAL FIBULAR FR 0.00<br />

27792 3 TREATMENT OF ANKLE FRACTURE 633.98<br />

27800 O TREATMENT OF CLOSED TIBIA AND FIBUL 0.00<br />

27802 O TREATMENT OF CLOSED TIBIA AND FIBUL 0.00<br />

27804 O TREATMENT OF OPEN TIBIA AND FIBULA 0.00<br />

27806 O OPEN TREATMENT OF CLOSED OR OPEN TI 0.00<br />

27808 3 TREATMENT OF ANKLE FRACTURE 293.17<br />

27810 3 TREATMENT OF ANKLE FRACTURE 430.00<br />

27812 O TREATMENT OF OPEN BIMALLEOLAR ANKLE 0.00<br />

27814 3 TREATMENT OF ANKLE FRACTURE 720.50<br />

27816 3 TREATMENT OF ANKLE FRACTURE 278.08<br />

27818 3 TREATMENT OF ANKLE FRACTURE 444.68<br />

27820 O TREATMENT OF OPEN TRIMALLEOLAR ANKL 0.00<br />

27822 3 TREATMENT OF ANKLE FRACTURE 801.73<br />

27823 3 TREATMENT OF ANKLE FRACTURE 908.71<br />

27824 3 TREAT LOWER LEG FRACTURE 273.77<br />

27825 3 TREAT LOWER LEG FRACTURE 497.44<br />

27826 3 TREAT LOWER LEG FRACTURE 749.14<br />

27827 3 TREAT LOWER LEG FRACTURE 1,017.52<br />

27828 3 TREAT LOWER LEG FRACTURE 1,202.73<br />

27829 3 TREAT LOWER LEG JOINT 591.83<br />

27830 3 TREAT LOWER LEG DISLOCATION 313.33<br />

27831 3 TREAT LOWER LEG DISLOCATION 345.93<br />

27832 3 TREAT LOWER LEG DISLOCATION 625.45<br />

27840 3 TREAT ANKLE DISLOCATION 317.07<br />

27842 3 TREAT ANKLE DISLOCATION 440.39<br />

27844 O TREATMENT OF OPEN ANKLE DISLOCATION 0.00<br />

27846 3 TREAT ANKLE DISLOCATION 684.41<br />

27848 3 TREAT ANKLE DISLOCATION 784.91<br />

27860 3 FIXATION OF ANKLE JOINT 164.03<br />

27870 3 FUSION OF ANKLE JOINT, OPEN 971.69<br />

27871 3 FUSION OF TIBIOFIBULAR JOINT 644.42<br />

27880 3 AMPUTATION OF LOWER LEG 839.91

---

27881 3 AMPUTATION OF LOWER LEG 830.04<br />

27882 3 AMPUTATION OF LOWER LEG 590.51<br />

27884 3 AMPUTATION FOLLOW-UP SURGERY 542.77<br />

27886 3 AMPUTATION FOLLOW-UP SURGERY 615.64<br />

27888 3 AMPUTATION OF FOOT AT ANKLE 657.59<br />

27889 3 AMPUTATION OF FOOT AT ANKLE 641.19<br />

27892 3 <strong>DE</strong>COMPRESSION OF LEG 508.35<br />

27893 3 <strong>DE</strong>COMPRESSION OF LEG 504.84<br />

27894 3 <strong>DE</strong>COMPRESSION OF LEG 767.52<br />

27899 5 LEG/ANKLE SURGERY PROCEDURE 0.00<br />

28001 3 DRAINAGE OF BURSA OF FOOT 240.26<br />

28002 3 TREATMENT OF FOOT INFECTION 443.42<br />

28003 3 TREATMENT OF FOOT INFECTION 612.37<br />

28005 3 TREAT FOOT BONE LESION 577.49<br />

28008 3 INCISION OF FOOT FASCIA 380.24<br />

28010 3 INCISION OF TOE TENDON 211.54<br />

28011 3 INCISION OF TOE TENDONS 299.22<br />

28020 3 EXPLORATION OF FOOT JOINT 456.25<br />

28022 3 EXPLORATION OF FOOT JOINT 416.96<br />

28024 3 EXPLORATION OF TOE JOINT 399.07<br />

28030 O REMOVAL OF FOOT NERVE 0.00<br />

28035 3 <strong>DE</strong>COMPRESSION OF TIBIA NERVE 453.64<br />

28043 3 EXCISION OF FOOT LESION 304.09<br />

28045 3 EXCISION OF FOOT LESION 424.30<br />

28046 3 RESECTION OF TUMOR, FOOT 774.49<br />

28050 3 BIOPSY OF FOOT JOINT LINING 396.61<br />

28052 3 BIOPSY OF FOOT JOINT LINING 371.17<br />

28054 3 BIOPSY OF TOE JOINT LINING 347.82<br />

28055 3 NEURECTOMY, FOOT 371.81<br />

28060 3 PARTIAL REMOVAL, FOOT FASCIA 447.23<br />

28062 3 REMOVAL OF FOOT FASCIA 529.61<br />

28070 3 REMOVAL OF FOOT JOINT LINING 443.89<br />

28072 3 REMOVAL OF FOOT JOINT LINING 434.93<br />

28080 3 REMOVAL OF FOOT LESION 422.81<br />

28086 3 EXCISE FOOT TENDON SHEATH 498.14<br />

28088 3 EXCISE FOOT TENDON SHEATH 401.14<br />

28090 3 REMOVAL OF FOOT LESION 403.28<br />

28092 3 REMOVAL OF TOE LESIONS 369.41<br />

28100 3 REMOVAL OF ANKLE/HEEL LESION 534.27<br />

28102 3 REMOVE/GRAFT FOOT LESION 510.73<br />

28103 3 REMOVE/GRAFT FOOT LESION 419.46<br />

28104 3 REMOVAL OF FOOT LESION 446.14<br />

28106 3 REMOVE/GRAFT FOOT LESION 444.35<br />

28107 3 REMOVE/GRAFT FOOT LESION 492.24<br />

28108 3 REMOVAL OF TOE LESIONS 373.75<br />

28110 3 PART REMOVAL OF METATARSAL 394.96<br />

28111 3 PART REMOVAL OF METATARSAL 454.77<br />

28112 3 PART REMOVAL OF METATARSAL 427.81<br />

28113 3 PART REMOVAL OF METATARSAL 501.77<br />

28114 3 REMOVAL OF METATARSAL HEADS 927.75

---

28116 3 REVISION OF FOOT 653.00<br />

28118 3 REMOVAL OF HEEL BONE 507.89<br />

28119 3 REMOVAL OF HEEL SPUR 454.20<br />

28120 3 PART REMOVAL OF ANKLE/HEEL 516.72<br />

28122 3 PARTIAL REMOVAL OF FOOT BONE 586.43<br />

28124 3 PARTIAL REMOVAL OF TOE 414.67<br />

28126 3 PARTIAL REMOVAL OF TOE 334.10<br />

28130 3 REMOVAL OF ANKLE BONE 606.03<br />

28140 3 REMOVAL OF METATARSAL 561.44<br />

28150 3 REMOVAL OF TOE 376.56<br />

28153 3 PARTIAL REMOVAL OF TOE 346.77<br />

28160 3 PARTIAL REMOVAL OF TOE 357.14<br />

28171 3 EXTENSIVE FOOT SURGERY 583.30<br />

28173 3 EXTENSIVE FOOT SURGERY 661.08<br />

28175 3 EXTENSIVE FOOT SURGERY 483.67<br />

28190 3 REMOVAL OF FOOT FOREIGN BODY 219.08<br />

28192 3 REMOVAL OF FOOT FOREIGN BODY 417.08<br />

28193 3 REMOVAL OF FOOT FOREIGN BODY 472.54<br />

28200 3 REPAIR OF FOOT TENDON 411.21<br />

28202 3 REPAIR/GRAFT OF FOOT TENDON 557.66<br />

28208 3 REPAIR OF FOOT TENDON 393.18<br />

28210 3 REPAIR/GRAFT OF FOOT TENDON 513.40<br />

28220 3 RELEASE OF FOOT TENDON 390.01<br />

28222 3 RELEASE OF FOOT TENDONS 452.17<br />

28225 3 RELEASE OF FOOT TENDON 341.76<br />

28226 3 RELEASE OF FOOT TENDONS 402.11<br />

28230 3 INCISION OF FOOT TENDON(S) 376.65<br />

28232 3 INCISION OF TOE TENDON 335.08<br />

28234 3 INCISION OF FOOT TENDON 344.91<br />

28236 O TRANSFER OF TENDON, ANTERIOR TIBIAL 0.00<br />

28238 3 REVISION OF FOOT TENDON 605.11<br />

28240 3 RELEASE OF BIG TOE 382.18<br />

28250 3 REVISION OF FOOT FASCIA 486.08<br />

28260 3 RELEASE OF MIDFOOT JOINT 598.65<br />

28261 3 REVISION OF FOOT TENDON 863.55<br />

28262 3 REVISION OF FOOT AND ANKLE 1,226.22<br />

28264 3 RELEASE OF MIDFOOT JOINT 757.80<br />

28270 3 RELEASE OF FOOT CONTRACTURE 413.74<br />

28272 3 RELEASE OF TOE JOINT, EACH 340.88<br />

28280 3 FUSION OF TOES 465.47<br />

28285 3 REPAIR OF HAMMERTOE 402.75<br />

28286 3 REPAIR OF HAMMERTOE 395.89<br />

28288 3 PARTIAL REMOVAL OF FOOT BONE 502.42<br />

28289 3 REPAIR HALLUX RIGIDUS 647.80<br />

28290 3 CORRECTION OF BUNION 502.40<br />

28292 3 CORRECTION OF BUNION 673.21<br />

28293 3 CORRECTION OF BUNION 905.77<br />

28294 3 CORRECTION OF BUNION 657.36<br />

28296 3 CORRECTION OF BUNION 699.95<br />

28297 3 CORRECTION OF BUNION 736.84

---

28298 3 CORRECTION OF BUNION 627.52<br />

28299 3 CORRECTION OF BUNION 806.82<br />

28300 3 INCISION OF HEEL BONE 628.64<br />

28302 3 INCISION OF ANKLE BONE 625.87<br />

28304 3 INCISION OF MIDFOOT BONES 696.82<br />

28305 3 INCISE/GRAFT MIDFOOT BONES 644.29<br />

28306 3 INCISION OF METATARSAL 525.28<br />

28307 3 INCISION OF METATARSAL 642.76<br />

28308 3 INCISION OF METATARSAL 471.18<br />

28309 3 INCISION OF METATARSALS 841.57<br />

28310 3 REVISION OF BIG TOE 468.34<br />

28312 3 REVISION OF TOE 426.79<br />

28313 3 REPAIR <strong>DE</strong>FORMITY OF TOE 440.42<br />

28315 3 REMOVAL OF SESAMOID BONE 412.79<br />

28320 3 REPAIR OF FOOT BONES 600.07<br />

28322 3 REPAIR OF METATARSALS 695.11<br />

28340 3 RESECT ENLARGED TOE TISSUE 549.63<br />

28341 3 RESECT ENLARGED TOE 627.08<br />

28344 3 REPAIR EXTRA TOE(S) 400.63<br />

28345 3 REPAIR WEBBED TOE(S) 498.47<br />

28360 3 RECONSTRUCT CLEFT FOOT 896.54<br />

28400 3 TREATMENT OF HEEL FRACTURE 223.15<br />

28405 3 TREATMENT OF HEEL FRACTURE 360.87<br />

28406 3 TREATMENT OF HEEL FRACTURE 494.32<br />

28410 O TREATMENT OF OPEN CALCANEAL FRACTUR 0.00<br />

28415 3 TREAT HEEL FRACTURE 1,083.10<br />

28420 3 TREAT/GRAFT HEEL FRACTURE 1,125.99<br />

28430 3 TREATMENT OF ANKLE FRACTURE 209.83<br />

28435 3 TREATMENT OF ANKLE FRACTURE 287.96<br />

28436 3 TREATMENT OF ANKLE FRACTURE 395.78<br />

28440 O TREATMENT OF OPEN TALUS FRACTURE, W 0.00<br />

28445 3 TREAT ANKLE FRACTURE 1,007.08<br />

28446 3 OSTEOCHONDRAL TALUS AUTOGRFT 1,073.48<br />

28450 3 TREAT MIDFOOT FRACTURE, EACH 193.33<br />

28455 3 TREAT MIDFOOT FRACTURE, EACH 260.53<br />

28456 3 TREAT MIDFOOT FRACTURE 261.22<br />

28460 O TREATMENT OF OPEN TARSAL BONE FRACT 0.00<br />

28465 3 TREAT MIDFOOT FRACTURE, EACH 569.12<br />

28470 3 TREAT METATARSAL FRACTURE 192.72<br />

28475 3 TREAT METATARSAL FRACTURE 240.99<br />

28476 3 TREAT METATARSAL FRACTURE 316.37<br />

28480 O TREATMENT OF OPEN METATARSAL FRACTU 0.00<br />

28485 3 TREAT METATARSAL FRACTURE 488.17<br />

28490 3 TREAT BIG TOE FRACTURE 122.92<br />

28495 3 TREAT BIG TOE FRACTURE 152.26<br />

28496 3 TREAT BIG TOE FRACTURE 399.58<br />

28500 O TREATMENT OF OPEN FRACTURE GREAT TO 0.00<br />

28505 3 TREAT BIG TOE FRACTURE 589.16<br />

28510 3 TREATMENT OF TOE FRACTURE 105.61<br />

28515 3 TREATMENT OF TOE FRACTURE 137.20

---

28520 O TREATMENT OF OPEN FRACTURE, PHALANX 0.00<br />

28525 3 TREAT TOE FRACTURE 507.38<br />

28530 3 TREAT SESAMOID BONE FRACTURE 100.92<br />

28531 3 TREAT SESAMOID BONE FRACTURE 367.03<br />

28540 3 TREAT FOOT DISLOCATION 180.44<br />

28545 3 TREAT FOOT DISLOCATION 209.75<br />

28546 3 TREAT FOOT DISLOCATION 421.36<br />

28550 O TREATMENT OF OPEN TARSAL BONE DISLO 0.00<br />

28555 3 REPAIR FOOT DISLOCATION 760.29<br />

28570 3 TREAT FOOT DISLOCATION 161.35<br />

28575 3 TREAT FOOT DISLOCATION 291.45<br />

28576 3 TREAT FOOT DISLOCATION 334.61<br />

28580 O TREATMENT OF OPEN TALOTARSAL JOINT 0.00<br />

28585 3 REPAIR FOOT DISLOCATION 779.22<br />

28600 3 TREAT FOOT DISLOCATION 188.72<br />

28605 3 TREAT FOOT DISLOCATION 244.27<br />

28606 3 TREAT FOOT DISLOCATION 366.04<br />

28610 O TREATMENT OF OPEN TARSOMETATARSAL J 0.00<br />

28615 3 REPAIR FOOT DISLOCATION 711.40<br />

28630 3 TREAT TOE DISLOCATION 131.34<br />

28635 3 TREAT TOE DISLOCATION 157.74<br />

28636 3 TREAT TOE DISLOCATION 269.17<br />

28640 O TREATMENT OF OPEN METATARSOPHALANGE 0.00<br />

28645 3 REPAIR TOE DISLOCATION 525.33<br />

28660 3 TREAT TOE DISLOCATION 96.56<br />

28665 3 TREAT TOE DISLOCATION 137.67<br />

28666 3 TREAT TOE DISLOCATION 189.78<br />

28670 O TREATMENT OF OPEN INTERPHALANGEAL J 0.00<br />

28675 3 REPAIR OF TOE DISLOCATION 501.09<br />

28705 3 FUSION OF FOOT BONES 1,228.19<br />

28715 3 FUSION OF FOOT BONES 911.29<br />

28725 3 FUSION OF FOOT BONES 757.45<br />

28730 3 FUSION OF FOOT BONES 784.02<br />

28735 3 FUSION OF FOOT BONES 748.94<br />

28737 3 REVISION OF FOOT BONES 664.22<br />

28740 3 FUSION OF FOOT BONES 589.26<br />

28750 3 FUSION OF BIG TOE JOINT 763.39<br />

28755 3 FUSION OF BIG TOE JOINT 444.55<br />

28760 3 FUSION OF BIG TOE JOINT 546.18<br />

28800 3 AMPUTATION OF MIDFOOT 539.90<br />

28805 3 AMPUTATION THRU METATARSAL 687.43<br />

28810 3 AMPUTATION TOE & METATARSAL 414.47<br />

28820 3 AMPUTATION OF TOE 483.03<br />

28825 3 PARTIAL AMPUTATION OF TOE 418.48<br />

28890 3 HIGH ENERGY ESWT, PLANTAR F 328.34<br />

28899 5 FOOT/TOES SURGERY PROCEDURE 0.00<br />

29000 3 APPLICATION OF BODY CAST 225.69<br />

29010 3 APPLICATION OF BODY CAST 233.70<br />

29015 3 APPLICATION OF BODY CAST 219.36<br />

29020 3 APPLICATION OF BODY CAST 217.61

---

29025 3 APPLICATION OF BODY CAST 235.51<br />

29035 3 APPLICATION OF BODY CAST 212.35<br />

29040 3 APPLICATION OF BODY CAST 198.66<br />

29044 3 APPLICATION OF BODY CAST 230.69<br />

29046 3 APPLICATION OF BODY CAST 245.93<br />

29049 3 APPLICATION OF FIGURE EIGHT 81.49<br />

29055 3 APPLICATION OF SHOUL<strong>DE</strong>R CAST 183.43<br />

29058 3 APPLICATION OF SHOUL<strong>DE</strong>R CAST 104.79<br />

29065 3 APPLICATION OF LONG ARM CAST 85.24<br />

29075 3 APPLICATION OF FOREARM CAST 79.21<br />

29085 3 APPLY HAND/WRIST CAST 83.76<br />

29086 3 APPLY FINGER CAST 63.38<br />

29105 3 APPLY LONG ARM SPLINT 78.84<br />

29125 3 APPLY FOREARM SPLINT 61.05<br />

29126 3 APPLY FOREARM SPLINT 71.93<br />

29130 3 APPLICATION OF FINGER SPLINT 36.42<br />

29131 3 APPLICATION OF FINGER SPLINT 45.34<br />

29200 3 STRAPPING OF CHEST 49.10<br />

29220 3 STRAPPING OF LOW BACK 49.89<br />

29240 3 STRAPPING OF SHOUL<strong>DE</strong>R 55.94<br />

29260 3 STRAPPING OF ELBOW OR WRIST 47.90<br />

29280 3 STRAPPING OF HAND OR FINGER 46.94<br />

29305 3 APPLICATION OF HIP CAST 209.51<br />

29325 3 APPLICATION OF HIP CASTS 225.34<br />

29345 3 APPLICATION OF LONG LEG CAST 122.14<br />

29355 3 APPLICATION OF LONG LEG CAST 124.99<br />

29358 3 APPLY LONG LEG CAST BRACE 136.18<br />

29365 3 APPLICATION OF LONG LEG CAST 109.70<br />

29405 3 APPLY SHORT LEG CAST 81.01<br />

29425 3 APPLY SHORT LEG CAST 87.10<br />

29435 3 APPLY SHORT LEG CAST 106.55<br />

29440 3 ADDITION OF WALKER TO CAST 47.98<br />

29445 3 APPLY RIGID LEG CAST 134.54<br />

29450 3 APPLICATION OF LEG CAST 138.65<br />

29505 3 APPLICATION, LONG LEG SPLINT 70.31<br />

29515 3 APPLICATION LOWER LEG SPLINT 63.11<br />

29520 3 STRAPPING OF HIP 48.88<br />

29530 3 STRAPPING OF KNEE 49.06<br />

29540 3 STRAPPING OF ANKLE AND/OR FT 37.99<br />

29550 3 STRAPPING OF TOES 36.84<br />

29580 3 APPLICATION OF PASTE BOOT 47.31<br />

29590 3 APPLICATION OF FOOT SPLINT 50.10<br />

29700 3 REMOVAL/REVISION OF CAST 57.82<br />

29705 3 REMOVAL/REVISION OF CAST 60.73<br />

29710 3 REMOVAL/REVISION OF CAST 107.62<br />

29715 3 REMOVAL/REVISION OF CAST 81.44<br />

29720 3 REPAIR OF BODY CAST 72.29<br />

29730 3 WINDOWING OF CAST 59.26<br />

29740 3 WEDGING OF CAST 86.33<br />

29750 3 WEDGING OF CLUBFOOT CAST 90.66

---

29799 5 CASTING/STRAPPING PROCEDURE 0.00<br />

29800 3 JAW ARTHROSCOPY/SURGERY 485.83<br />

29804 3 JAW ARTHROSCOPY/SURGERY 598.21<br />

29805 3 SHOUL<strong>DE</strong>R ARTHROSCOPY, DX 435.77<br />

29806 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 984.39<br />

29807 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 959.94<br />

29815 O SHOUL<strong>DE</strong>R ARTHROSCOPY 0.00<br />

29819 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 543.69<br />

29820 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 501.80<br />

29821 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 548.24<br />

29822 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 533.59<br />

29823 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 582.52<br />

29824 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 617.80<br />

29825 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 543.30<br />

29826 3 SHOUL<strong>DE</strong>R ARTHROSCOPY/SURGERY 622.66<br />

29827 3 ARTHROSCOP ROTATOR CUFF REPR 1,013.05<br />

29828 3 ARTHROSCOPY BICEPS TENO<strong>DE</strong>SIS 826.94<br />

29830 3 ELBOW ARTHROSCOPY 419.63<br />

29834 3 ELBOW ARTHROSCOPY/SURGERY 456.93<br />

29835 3 ELBOW ARTHROSCOPY/SURGERY 468.49<br />

29836 3 ELBOW ARTHROSCOPY/SURGERY 536.85<br />

29837 3 ELBOW ARTHROSCOPY/SURGERY 490.04<br />

29838 3 ELBOW ARTHROSCOPY/SURGERY 548.93<br />

29840 3 WRIST ARTHROSCOPY 410.24<br />

29843 3 WRIST ARTHROSCOPY/SURGERY 438.22<br />

29844 3 WRIST ARTHROSCOPY/SURGERY 458.83<br />

29845 3 WRIST ARTHROSCOPY/SURGERY 523.77<br />

29846 3 WRIST ARTHROSCOPY/SURGERY 482.25<br />

29847 3 WRIST ARTHROSCOPY/SURGERY 499.61<br />

29848 3 WRIST ENDOSCOPY/SURGERY 450.88<br />

29850 3 KNEE ARTHROSCOPY/SURGERY 506.23<br />

29851 3 KNEE ARTHROSCOPY/SURGERY 867.62<br />

29855 3 TIBIAL ARTHROSCOPY/SURGERY 729.94<br />

29856 3 TIBIAL ARTHROSCOPY/SURGERY 930.90<br />

29860 3 HIP ARTHROSCOPY, DX 599.88<br />

29861 3 HIP ARTHROSCOPY/SURGERY 654.66<br />

29862 3 HIP ARTHROSCOPY/SURGERY 737.41<br />

29863 3 HIP ARTHROSCOPY/SURGERY 728.74<br />

29866 3 AUTGRFT IMPLNT, KNEE W/SCOPE 971.55<br />

29867 3 ALLGRFT IMPLNT, KNEE W/SCOPE 1,176.29<br />

29868 3 MENISCAL TRNSPL, KNEE W/SCPE 1,575.04<br />

29870 3 KNEE ARTHROSCOPY, DX 376.66<br />

29871 3 KNEE ARTHROSCOPY/DRAINAGE 472.67<br />

29873 3 KNEE ARTHROSCOPY/SURGERY 476.77<br />

29874 3 KNEE ARTHROSCOPY/SURGERY 493.05<br />

29875 3 KNEE ARTHROSCOPY/SURGERY 459.17<br />

29876 3 KNEE ARTHROSCOPY/SURGERY 596.33<br />

29877 3 KNEE ARTHROSCOPY/SURGERY 564.58<br />

29879 3 KNEE ARTHROSCOPY/SURGERY 603.53<br />

29880 3 KNEE ARTHROSCOPY/SURGERY 630.34

---

29881 3 KNEE ARTHROSCOPY/SURGERY 587.69<br />

29882 3 KNEE ARTHROSCOPY/SURGERY 634.27<br />

29883 3 KNEE ARTHROSCOPY/SURGERY 778.38<br />

29884 3 KNEE ARTHROSCOPY/SURGERY 562.33<br />

29885 3 KNEE ARTHROSCOPY/SURGERY 681.84<br />

29886 3 KNEE ARTHROSCOPY/SURGERY 574.87<br />

29887 3 KNEE ARTHROSCOPY/SURGERY 678.04<br />

29888 3 KNEE ARTHROSCOPY/SURGERY 914.55<br />

29889 3 KNEE ARTHROSCOPY/SURGERY 1,117.64<br />

29891 3 ANKLE ARTHROSCOPY/SURGERY 640.83<br />

29892 3 ANKLE ARTHROSCOPY/SURGERY 661.44<br />

29893 3 SCOPE, PLANTAR FASCIOTOMY 522.09<br />

29894 3 ANKLE ARTHROSCOPY/SURGERY 480.74<br />

29895 3 ANKLE ARTHROSCOPY/SURGERY 468.31<br />

29897 3 ANKLE ARTHROSCOPY/SURGERY 490.40<br />

29898 3 ANKLE ARTHROSCOPY/SURGERY 547.10<br />

29899 3 ANKLE ARTHROSCOPY/SURGERY 975.63<br />

29900 3 MCP JOINT ARTHROSCOPY, DX 429.62<br />

29901 3 MCP JOINT ARTHROSCOPY, SURG 473.56<br />

29902 3 MCP JOINT ARTHROSCOPY, SURG 492.62<br />

29904 3 SUBTALAR ARTHRO W/FB RMVL 557.14<br />

29905 3 SUBTALAR ARTHRO W/EXC 600.94<br />

29906 3 SUBTALAR ARTHRO W/<strong>DE</strong>B 632.96<br />

29907 3 SUBTALAR ARTHRO W/FUSION 772.87<br />

29909 O ARTHROSCOPY OF JOINT 0.00<br />

29999 5 ARTHROSCOPY OF JOINT 0.00<br />

30000 3 DRAINAGE OF NOSE LESION 211.79<br />

3000F O BLOOD PRESS 140/90 MMHG 0.00<br />

3006F 9 CXR DOC REV 0.00<br />

30100 3 INTRANASAL BIOPSY 123.74<br />

30110 3 REMOVAL OF NOSE POLYP(S) 200.43<br />

30115 3 REMOVAL OF NOSE POLYP(S) 392.11<br />

30117 3 REMOVAL OF INTRANASAL LESION 732.41<br />

30118 3 REMOVAL OF INTRANASAL LESION 705.15<br />

3011F 9 LIPID PANEL DOC REV 0.00<br />

30120 3 REVISION OF NOSE 462.74<br />

30124 3 REMOVAL OF NOSE LESION 257.67<br />

30125 3 REMOVAL OF NOSE LESION 572.79<br />

30130 3 EXCISE INFERIOR TURBINATE 345.80<br />

30140 3 RESECT INFERIOR TURBINATE 389.82<br />

3014F 9 SCREEN MAMMO DOC REV 0.00<br />

30150 3 PARTIAL REMOVAL OF NOSE 742.13<br />

30160 3 REMOVAL OF NOSE 736.78<br />

3016F 9 PT SCRND UNHLTHY OH USE 0.00<br />

3017F 9 COLORECTAL CA SCREEN DOC REV 0.00<br />

3018F 9 PRE-PRXD RSK ET AL DOCD 0.00<br />

30200 3 INJECTION TREATMENT OF NOSE 99.95<br />

3020F 9 LVF ASSESS 0.00

---

30210 3 NASAL SINUS THERAPY 130.90<br />

3021F 9 LVEF MOD/SEVER <strong>DE</strong>PRS SYST 0.00<br />

30220 9 INSERT NASAL SEPTAL BUTTON 0.00<br />

3022F 9 LVEF =40% SYSTOLIC 0.00<br />

3023F 9 SPIROM DOC REV 0.00<br />

3025F 9 SPIROM FEV/FVC 88% /PAO>55 0.00<br />

30400 3 RECONSTRUCTION OF NOSE 968.40<br />

3040F 9 FEV 9.0% 0.00<br />

3047F O HEMOGLOBIN A1C LEVEL = 9.0% 0.00<br />

3048F 9 LDL-C

---

3079F 9 DIAST BP 80-89 MM HG 0.00<br />

30800 O CAUTERIZATION TURBINATES, UNILATERA 0.00<br />

30801 3 ABLATE INF TURBINATE, SUPERF 206.43<br />

30802 3 CAUTERIZATION, INNER NOSE 262.89<br />

30805 O CAUTERIZATION TURBINATES, UNILATERA 0.00<br />

3080F 9 DIAST BP = 90 MM HG 0.00<br />

30820 O CRYOSURGERY OF TURBINATES, UNILATER 0.00<br />

3082F 9 KT/V LT1.2 0.00<br />

3083F 9 KT/V GE 1.2 AND

---

31201 3 REMOVAL OF ETHMOID SINUS 669.93<br />

31205 3 REMOVAL OF ETHMOID SINUS 795.83<br />

3120F 9 12-LEAD ECG PERFORMED 0.00<br />

31225 3 REMOVAL OF UPPER JAW 1,646.55<br />

31230 3 REMOVAL OF UPPER JAW 1,853.72<br />

31231 3 NASAL ENDOSCOPY, DX 177.32<br />

31233 3 NASAL/SINUS ENDOSCOPY, DX 248.24<br />

31235 3 NASAL/SINUS ENDOSCOPY, DX 285.09<br />

31237 3 NASAL/SINUS ENDOSCOPY, SURG 307.86<br />

31238 3 NASAL/SINUS ENDOSCOPY, SURG 316.40<br />

31239 3 NASAL/SINUS ENDOSCOPY, SURG 615.07<br />

31240 3 NASAL/SINUS ENDOSCOPY, SURG 154.68<br />

31245 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31246 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31247 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31248 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31249 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31250 O NASAL ENDOSCOPY, DIAGNOSTIC (INCLUD 0.00<br />

31251 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31252 O NASAL ENDOSCOPY, SURGICAL WITH NASA 0.00<br />

31254 3 REVISION OF ETHMOID SINUS 264.84<br />

31255 3 REMOVAL OF ETHMOID SINUS 391.03<br />

31256 3 EXPLORATION MAXILLARY SINUS 192.25<br />

31258 O NASAL ENDOSCOPY, SURGICAL WITH REMO 0.00<br />

31260 O MAXILLARY SINUS ENDOSCOPY, DIAGNOST 0.00<br />

31261 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31262 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31263 O MAXILLARY SINUS ENDOSCOPY, SURGICAL 0.00<br />

31264 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31265 O MAXILLARY SINUS ENDOSCOPY, SURGICAL 0.00<br />

31266 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31267 3 ENDOSCOPY, MAXILLARY SINUS 309.30<br />

31268 O MAXILLARY SINUS ENDOSCOPY, SURGICAL 0.00<br />

31269 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31270 O SPHENOID ENDOSCOPY, DIAGNOSTIC 0.00<br />

31271 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31275 O SPHENOID ENDOSCOPY, SURGICAL; 0.00<br />

31276 3 SINUS ENDOSCOPY, SURGICAL 492.44<br />

31277 O SPHENOID ENDOSCOPY, SURGICAL WITH R 0.00<br />

31280 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31281 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31282 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31283 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31284 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31285 O SINUS ENDOSCOPY, TWO OR MORE SINUSE 0.00<br />

31286 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI 0.00<br />

31287 3 NASAL/SINUS ENDOSCOPY, SURG 225.44<br />

31288 3 NASAL/SINUS ENDOSCOPY, SURG 261.26<br />

31290 3 NASAL/SINUS ENDOSCOPY, SURG 1,083.77<br />

31291 3 NASAL/SINUS ENDOSCOPY, SURG 1,142.80

---

31292 3 NASAL/SINUS ENDOSCOPY, SURG 938.51<br />

31293 3 NASAL/SINUS ENDOSCOPY, SURG 1,021.65<br />

31294 3 NASAL/SINUS ENDOSCOPY, SURG 1,174.10<br />

31299 5 SINUS SURGERY PROCEDURE 0.00<br />

31300 3 REMOVAL OF LARYNX LESION 1,149.06<br />

3130F 9 UPPER GI ENDOSCOPY PERFORMED 0.00<br />

31320 3 DIAGNOSTIC INCISION, LARYNX 606.71<br />

3132F 9 DOC REF. UPPER GI ENDOSCOPY 0.00<br />

31360 3 REMOVAL OF LARYNX 1,767.85<br />

31365 3 REMOVAL OF LARYNX 2,216.55<br />

31367 3 PARTIAL REMOVAL OF LARYNX 1,951.83<br />

31368 3 PARTIAL REMOVAL OF LARYNX 2,199.22<br />

31370 3 PARTIAL REMOVAL OF LARYNX 1,849.38<br />

31375 3 PARTIAL REMOVAL OF LARYNX 1,738.35<br />

31380 3 PARTIAL REMOVAL OF LARYNX 1,721.02<br />

31382 3 PARTIAL REMOVAL OF LARYNX 1,879.23<br />

31390 3 REMOVAL OF LARYNX & PHARYNX 2,487.09<br />

31395 3 RECONSTRUCT LARYNX & PHARYNX 2,665.46<br />

31400 3 REVISION OF LARYNX 930.84<br />

3140F 9 UPPER GI ENDO SHOWS BARRTTÏS 0.00<br />

3141F 9 UPPER GI ENDO NOT BARRTTÏS 0.00<br />

31420 3 REMOVAL OF EPIGLOTTIS 765.32<br />

3142F 9 BARIUM SWALLOW TEST OR<strong>DE</strong>RED 0.00<br />

31500 3 INSERT EMERGENCY AIRWAY 102.85<br />

31502 3 CHANGE OF WINDPIPE AIRWAY 33.26<br />

31505 3 DIAGNOSTIC LARYNGOSCOPY 78.93<br />

3150F 9 FORCEPS ESOPH BIOPSY DONE 0.00<br />

31510 3 LARYNGOSCOPY WITH BIOPSY 198.07<br />

31511 3 REMOVE FOREIGN BODY, LARYNX 198.00<br />

31512 3 REMOVAL OF LARYNX LESION 196.98<br />

31513 9 INJECTION INTO VOCAL CORD 0.00<br />

31515 3 LARYNGOSCOPY FOR ASPIRATION 197.96<br />

31520 3 DX LARYNGOSCOPY, NEWBORN 146.85<br />

31525 3 DX LARYNGOSCOPY EXCL NB 235.22<br />

31526 3 DX LARYNGOSCOPY W/OPER SCOPE 151.47<br />

31527 9 LARYNGOSCOPY FOR TREATMENT 0.00<br />

31528 3 LARYNGOSCOPY AND DILATION 136.07<br />

31529 9 LARYNGOSCOPY AND DILATION 0.00<br />

31530 3 LARYNGOSCOPY W/FB REMOVAL 190.21<br />

31531 3 LARYNGOSCOPY W/FB & OP SCOPE 205.81<br />

31535 3 LARYNGOSCOPY W/BIOPSY 182.41<br />

31536 3 LARYNGOSCOPY W/BX & OP SCOPE 204.25<br />

31540 3 LARYNGOSCOPY W/EXC OF TUMOR 234.13<br />

31541 3 LARYNSCOP W/TUMR EXC + SCOPE 256.27<br />

31545 3 REMOVE VC LESION W/SCOPE 342.30<br />

31546 3 REMOVE VC LESION SCOPE/GRAFT 518.32<br />

3155F 9 CYTOGEN TEST MARROW B/4 TX 0.00<br />

31560 3 LARYNGOSCOP W/ARYTENOI<strong>DE</strong>CTOM 301.82<br />

31561 3 LARYNSCOP, REMVE CART + SCOP 329.56<br />

31570 3 LARYNGOSCOPE W/VC INJ 335.63

---

31571 3 LARYNGOSCOP W/VC INJ + SCOPE 241.71<br />

31575 3 DIAGNOSTIC LARYNGOSCOPY 110.83<br />

31576 3 LARYNGOSCOPY WITH BIOPSY 212.00<br />

31577 9 REMOVE FOREIGN BODY, LARYNX 0.00<br />

31578 3 REMOVAL OF LARYNX LESION 265.96<br />

31579 3 DIAGNOSTIC LARYNGOSCOPY 212.58<br />

31580 3 REVISION OF LARYNX 1,105.21<br />

31582 3 REVISION OF LARYNX 1,779.32<br />

31584 3 TREAT LARYNX FRACTURE 1,398.76<br />

31585 O TREAT LARYNX FRACTURE 0.00<br />

31586 O TREAT LARYNX FRACTURE 0.00<br />

31587 3 REVISION OF LARYNX 893.74<br />

31588 3 REVISION OF LARYNX 1,041.17<br />

31590 9 REINNERVATE LARYNX 0.00<br />

31595 9 LARYNX NERVE SURGERY 0.00<br />

31599 5 LARYNX SURGERY PROCEDURE 0.00<br />

31600 3 INCISION OF WINDPIPE 374.45<br />

31601 3 INCISION OF WINDPIPE 243.84<br />

31603 3 INCISION OF WINDPIPE 210.62<br />

31605 3 INCISION OF WINDPIPE 172.09<br />

3160F 9 DOC FE+ STORES B/4 EPO THX 0.00<br />

31610 3 INCISION OF WINDPIPE 653.11<br />

31611 3 SURGERY/SPEECH PROSTHESIS 492.39<br />

31612 3 PUNCTURE/CLEAR WINDPIPE 76.06<br />

31613 3 REPAIR WINDPIPE OPENING 408.35<br />

31614 9 REPAIR WINDPIPE OPENING 0.00<br />

31615 3 VISUALIZATION OF WINDPIPE 173.55<br />

31620 3 ENDOBRONCHIAL US ADD-ON 279.99<br />

31622 3 DX BRONCHOSCOPE/WASH 138.22<br />

31623 3 DX BRONCHOSCOPE/BRUSH 345.58<br />

31624 3 DX BRONCHOSCOPE/LAVAGE 139.82<br />

31625 3 BRONCHOSCOPY W/BIOPSY(S) 341.60<br />

31628 3 BRONCHOSCOPY/LUNG BX, EACH 181.53<br />

31629 3 BRONCHOSCOPY/NEEDLE BX, EACH 193.72<br />

31630 3 BRONCHOSCOPY DILATE/FX REPR 197.47<br />

31631 3 BRONCHOSCOPY, DILATE W/STENT 220.48<br />

31632 3 BRONCHOSCOPY/LUNG BX, ADDÏL 73.02<br />

31633 3 BRONCHOSCOPY/NEEDLE BX ADDÏL 86.78<br />

31635 3 BRONCHOSCOPY W/FB REMOVAL 354.16<br />

31636 3 BRONCHOSCOPY, BRONCH STENTS 216.09<br />

31637 3 BRONCHOSCOPY, STENT ADD-ON 76.26<br />

31638 3 BRONCHOSCOPY, REVISE STENT 241.33<br />

31640 3 BRONCHOSCOPY W/TUMOR EXCISE 251.55<br />

31641 3 BRONCHOSCOPY, TREAT BLOCKAGE 247.05<br />

31643 3 DIAG BRONCHOSCOPE/CATHETER 168.59<br />

31645 3 BRONCHOSCOPY, CLEAR AIRWAYS 152.70<br />

31646 3 BRONCHOSCOPY, RECLEAR AIRWAY 132.75<br />

31656 3 BRONCHOSCOPY, INJ FOR X-RAY 333.33<br />

31659 O BRONCHOSCOPY; WITH OTHER BRONCHOSCO 0.00<br />

31700 O INSERTION OF AIRWAY CATHETER 0.00

---

31708 O INSTILL AIRWAY CONTRAST DYE 0.00<br />

3170F 9 FLOW CYTO DONE B/4 TX 0.00<br />

31710 O INSERTION OF AIRWAY CATHETER 0.00<br />

31715 3 INJECTION FOR BRONCHUS X-RAY 51.61<br />

31717 3 BRONCHIAL BRUSH BIOPSY 353.52<br />

31719 O TRANSTRACHEAL (PERCUTANEOUS) INTROD 0.00<br />

31720 3 CLEARANCE OF AIRWAYS 49.69<br />

31725 3 CLEARANCE OF AIRWAYS 90.04<br />

31730 3 INTRO, WINDPIPE WIRE/TUBE 652.50<br />

31750 3 REPAIR OF WINDPIPE 1,235.19<br />

31755 3 REPAIR OF WINDPIPE 1,576.03<br />

31760 3 REPAIR OF WINDPIPE 1,282.64<br />

31766 3 RECONSTRUCTION OF WINDPIPE 1,703.79<br />

31770 3 REPAIR/GRAFT OF BRONCHUS 1,249.79<br />

31775 3 RECONSTRUCT BRONCHUS 1,339.74<br />

31780 3 RECONSTRUCT WINDPIPE 1,107.59<br />

31781 3 RECONSTRUCT WINDPIPE 1,335.25<br />

31785 3 REMOVE WINDPIPE LESION 1,018.73<br />

31786 3 REMOVE WINDPIPE LESION 1,403.67<br />

31800 3 REPAIR OF WINDPIPE INJURY 650.84<br />

31805 3 REPAIR OF WINDPIPE INJURY 770.99<br />

31820 3 CLOSURE OF WINDPIPE LESION 393.05<br />

31825 3 REPAIR OF WINDPIPE <strong>DE</strong>FECT 549.94<br />

31830 3 REVISE WINDPIPE SCAR 397.21<br />

31899 5 AIRWAYS SURGICAL PROCEDURE 0.00<br />

32000 O DRAINAGE OF CHEST 0.00<br />

32001 O TOTAL LUNG LAVAGE 0.00<br />

32002 O TREATMENT OF COLLAPSED LUNG 0.00<br />

32005 O TREAT LUNG LINING CHEMICALLY 0.00<br />

3200F 9 BARIUM SWALLOW TEST NOT REQ 0.00<br />

32019 O INSERT PLEURAL CATHETER 0.00<br />

32020 O INSERTION OF CHEST TUBE 0.00<br />

32035 3 EXPLORATION OF CHEST 651.84<br />

32036 3 EXPLORATION OF CHEST 706.88<br />

32095 3 BIOPSY THROUGH CHEST WALL 583.43<br />

32100 3 EXPLORATION/BIOPSY OF CHEST 903.47<br />

3210F 9 GRP A STREP TEST PERFORMED 0.00<br />

32110 3 EXPLORE/REPAIR CHEST 1,353.83<br />

32120 3 RE-EXPLORATION OF CHEST 804.91<br />

32124 3 EXPLORE CHEST FREE ADHESIONS 855.01<br />

32140 3 REMOVAL OF LUNG LESION(S) 915.98<br />

32141 3 REMOVE/TREAT LUNG LESIONS 1,327.22<br />

32150 3 REMOVAL OF LUNG LESION(S) 923.35<br />

32151 3 REMOVE LUNG FOREIGN BODY 943.82<br />

3215F 9 PT IMMUNITY TO HEP A DOCÏD 0.00<br />

32160 3 OPEN CHEST HEART MASSAGE 699.18<br />

3216F 9 PT IMMUNITY TO HEP B DOCÏD 0.00<br />

3218F 9 RNA TSTNG HEP C DOCÏD-DONE 0.00<br />

32200 3 DRAIN, OPEN, LUNG LESION 1,031.72<br />

32201 3 DRAIN, PERCUT, LUNG LESION 940.55

---

3220F 9 HEP C QUANT RNA TSTNG DOCÏD 0.00<br />

32215 3 TREAT CHEST LINING 747.09<br />

32220 3 RELEASE OF LUNG 1,490.74<br />

32225 3 PARTIAL RELEASE OF LUNG 922.43<br />

3230F 9 NOTE HRING TST W/IN 6 MON 0.00<br />

32310 3 REMOVAL OF CHEST LINING 854.94<br />

32315 O PLEURECTOMY; PARTIAL 0.00<br />

32320 3 FREE/REMOVE CHEST LINING 1,485.65<br />

32400 3 NEEDLE BIOPSY CHEST LINING 146.84<br />

32402 3 OPEN BIOPSY CHEST LINING 525.95<br />

32405 3 BIOPSY, LUNG OR MEDIASTINUM 95.47<br />

32420 3 PUNCTURE/CLEAR LUNG 105.02<br />

32421 3 THORACENTESIS FOR ASPIRATION 162.14<br />

32422 3 THORACENTESIS W/TUBE INSERT 197.87<br />

32440 3 REMOVAL OF LUNG 1,499.23<br />

32442 3 SLEEVE PNEUMONECTOMY 2,684.38<br />

32445 3 REMOVAL OF LUNG 2,991.91<br />

32450 O PNEUMONECTOMY, EXTRAPLEURAL WITH EM 0.00<br />

32480 3 PARTIAL REMOVAL OF LUNG 1,413.25<br />

32482 3 BILOBECTOMY 1,506.04<br />

32484 3 SEGMENTECTOMY 1,360.20<br />

32485 O REMOVAL OF LUNG, OTHER THAN TOTAL P 0.00<br />

32486 3 SLEEVE LOBECTOMY 2,103.91<br />

32488 3 COMPLETION PNEUMONECTOMY 2,142.76<br />

32490 O LOBECTOMY, TOTAL OR SEGMENTAL WITH 0.00<br />

32491 3 LUNG VOLUME REDUCTION 1,392.72<br />

32500 3 PARTIAL REMOVAL OF LUNG 1,372.04<br />

32501 3 REPAIR BRONCHUS ADD-ON 234.54<br />

32503 3 RESECT APICAL LUNG TUMOR 1,735.92<br />

32504 3 RESECT APICAL LUNG TUM/CHEST 1,978.44<br />

3250F 9 NONPRIM LOC ANAT BX SITE TUM 0.00<br />

32520 O REMOVE LUNG & REVISE CHEST 0.00<br />

32522 O REMOVE LUNG & REVISE CHEST 0.00<br />

32525 O REMOVE LUNG & REVISE CHEST 0.00<br />

32540 3 REMOVAL OF LUNG LESION 1,501.67<br />

32545 O EXTRAPLEURAL ENUCLEATION OF EMPYEMA 0.00<br />

32550 3 INSERT PLEURAL CATH 841.08<br />

32551 3 INSERTION OF CHEST TUBE 170.03<br />

32560 3 TREAT LUNG LINING CHEMICALLY 307.74<br />

32601 3 THORACOSCOPY, DIAGNOSTIC 295.45<br />

32602 3 THORACOSCOPY, DIAGNOSTIC 320.76<br />

32603 3 THORACOSCOPY, DIAGNOSTIC 411.98<br />

32604 3 THORACOSCOPY, DIAGNOSTIC 462.13<br />

32605 3 THORACOSCOPY, DIAGNOSTIC 371.90<br />

32606 3 THORACOSCOPY, DIAGNOSTIC 444.60<br />

3260F 9 PT CAT/PN CAT/HIST GRD DOCÏD 0.00<br />

32650 3 THORACOSCOPY, SURGICAL 647.86<br />

32651 3 THORACOSCOPY, SURGICAL 983.43<br />

32652 3 THORACOSCOPY, SURGICAL 1,482.85<br />

32653 3 THORACOSCOPY, SURGICAL 953.39

---

32654 3 THORACOSCOPY, SURGICAL 1,046.26<br />

32655 3 THORACOSCOPY, SURGICAL 879.62<br />

32656 3 THORACOSCOPY, SURGICAL 776.72<br />

32657 3 THORACOSCOPY, SURGICAL 763.79<br />

32658 3 THORACOSCOPY, SURGICAL 698.36<br />

32659 3 THORACOSCOPY, SURGICAL 710.79<br />

3265F 9 RNA TSTNG HEPC VIR ORD/DOCÏD 0.00<br />

32660 3 THORACOSCOPY, SURGICAL 997.77<br />

32661 3 THORACOSCOPY, SURGICAL 779.51<br />

32662 3 THORACOSCOPY, SURGICAL 874.62<br />

32663 3 THORACOSCOPY, SURGICAL 1,310.26<br />

32664 3 THORACOSCOPY, SURGICAL 811.50<br />

32665 3 THORACOSCOPY, SURGICAL 1,119.82<br />

3266F 9 HEPC GN TSTNG DOCÏD B/4TXMNT 0.00<br />

3268F 9 PSA/T/G1SC DOCÏD B/4 TXMNT 0.00<br />

3269F 9 BONE SCN B/4 TXMNT/AFTR DX 0.00<br />

32700 O THORACOSCOPY, EXPLORATORY (SEPARATE 0.00<br />

32705 O THORACOSCOPY, EXPLORATORY (SEPARATE 0.00<br />

3270F 9 NO BONE SCN B/4 TXMNT/AFTRDX 0.00<br />

3271F 9 LOW RISK, PROSTATE CANCER 0.00<br />

3272F 9 MED. RISK, PROSTATE CANCER 0.00<br />

3273F 9 HIGH RISK, PROSTATE CANCER 0.00<br />

3274F 9 PROST CNCR RSK NOT LW/MD/HGH 0.00<br />

3278F 9 SERUM LVLS CA/IPTH/LPD ORD 0.00<br />

3279F 9 HGB LVL >/=13 G/DL 0.00<br />

32800 3 REPAIR LUNG HERNIA 869.67<br />

3280F 9 HGB LVL 11-12.9 G/DL 0.00<br />

32810 3 CLOSE CHEST AFTER DRAINAGE 845.54<br />

32815 3 CLOSE BRONCHIAL FISTULA 2,367.45<br />

3281F 9 HGB LVL 15% OF PRE-SVC LVL 0.00<br />

32850 9 DONOR PNEUMONECTOMY 0.00<br />

32851 3 LUNG TRANSPLANT, SINGLE 2,495.16<br />

32852 3 LUNG TRANSPLANT WITH BYPASS 2,789.11<br />

32853 3 LUNG TRANSPLANT, DOUBLE 2,982.19<br />

32854 3 LUNG TRANSPLANT WITH BYPASS 3,231.71<br />

32855 9 PREPARE DONOR LUNG, SINGLE 0.00<br />

32856 9 PREPARE DONOR LUNG, DOUBLE 0.00<br />

3285F 9 IOP DOWN

---

32998 3 PERQ RF ABLATE TX, PUL TUMOR 2,967.48<br />

32999 5 CHEST SURGERY PROCEDURE 0.00<br />

3300F 9 AJCC STAGE DOCD B/4 THXPY 0.00<br />

33010 3 DRAINAGE OF HEART SAC 115.80<br />

33011 3 REPEAT DRAINAGE OF HEART SAC 118.46<br />

33015 3 INCISION OF HEART SAC 504.02<br />

3301F 9 CANCER STAGE DOCD METAST 0.00<br />

33020 3 INCISION OF HEART SAC 816.19<br />

33025 3 INCISION OF HEART SAC 756.40<br />

3302F O AJCC STAGE 0 DOCÏD 0.00<br />

33030 3 PARTIAL REMOVAL OF HEART SAC 1,206.23<br />

33031 3 PARTIAL REMOVAL OF HEART SAC 1,336.80<br />

3303F O AJCC STAGE IA DOCÏD 0.00<br />

3304F O AJCC STAGE IB DOCÏD 0.00<br />

33050 3 REMOVAL OF HEART SAC LESION 934.46<br />

3305F O AJCC STAGE IC DOCÏD 0.00<br />

3306F O AJCC STAGE IIA DOCÏD 0.00<br />

3307F O AJCC STAGE IIB DOCÏD 0.00<br />

3308F O AJCC STAGE IIC DOCÏD 0.00<br />

3309F O AJCC STAGE IIIA DOCÏD 0.00<br />

33100 O PERICARDIECTOMY (SEPARATE PROCEDURE 0.00<br />

3310F O AJCC STAGE IIIB DOCÏD 0.00<br />

3311F O AJCC STAGE IIIC DOCÏD 0.00<br />

33120 3 REMOVAL OF HEART LESION 1,472.26<br />

3312F O AJCC STAGE IVA DOCÏD 0.00<br />

33130 3 REMOVAL OF HEART LESION 1,288.24<br />

3313F O AJCC STAGE IVB DOCÏD 0.00<br />

33140 3 HEART REVASCULARIZE (TMR) 1,460.10<br />

33141 3 HEART TMR W/OTHER PROCEDURE 153.10<br />

3314F O AJCC STAGE IVC DOCÏD 0.00<br />

3315F 9 ER +OR PR +BREAST CANCER 0.00<br />

3316F 9 ER- OR PR- BREAST CANCER 0.00<br />

3317F 9 PATH RPT MALIG CANCER DOCÏD 0.00<br />

3318F 9 PATH RPT MALIG CANCER DOCÏD 0.00<br />

3319F 9 X-RAY/CT/ULTRSND ET AL ORDÏD 0.00<br />

33200 O INSERTION OF HEART PACEMAKER 0.00<br />

33201 O INSERTION OF HEART PACEMAKER 0.00<br />

33202 3 INSERT EPICARD ELTRD, OPEN 735.71<br />

33203 3 INSERT EPICARD ELTRD, ENDO 754.40<br />

33206 3 INSERTION OF HEART PACEMAKER 451.82<br />

33207 3 INSERTION OF HEART PACEMAKER 482.90<br />

33208 3 INSERTION OF HEART PACEMAKER 517.28<br />

3320F 9 NO XRAY/CT/ ET AL ORDÏD 0.00<br />

33210 3 INSERTION OF HEART ELECTRO<strong>DE</strong> 174.82<br />

33211 3 INSERTION OF HEART ELECTRO<strong>DE</strong> 178.40<br />

33212 3 INSERTION OF PULSE GENERATOR 338.36<br />

33213 3 INSERTION OF PULSE GENERATOR 385.15<br />

33214 3 UPGRA<strong>DE</strong> OF PACEMAKER SYSTEM 482.76<br />

33215 3 REPOSITION PACING-<strong>DE</strong>FIB LEAD 307.93<br />

33216 3 INSERT LEAD PACE-<strong>DE</strong>FIB, ONE 379.74

---

33217 3 INSERT LEAD PACE-<strong>DE</strong>FIB, DUAL 377.90<br />

33218 3 REPAIR LEAD PACE-<strong>DE</strong>FIB, ONE 392.90<br />

33219 O REPAIR OF PACEMAKER WITH REPLACEMEN 0.00<br />

3321F 9 AJCC CNCR 0/IA MELAN DOCD 0.00<br />

33220 3 REPAIR LEAD PACE-<strong>DE</strong>FIB, DUAL 394.41<br />

33222 3 REVISE POCKET, PACEMAKER 351.42<br />

33223 3 REVISE POCKET, PACING-<strong>DE</strong>FIB 420.06<br />

33224 3 INSERT PACING LEAD & CONNECT 497.57<br />

33225 3 L VENTRIC PACING LEAD ADD-ON 445.46<br />

33226 3 REPOSITION L VENTRIC LEAD 480.04<br />

3322F 9 MELAN >AJCC STAGE 0 OR IA 0.00<br />

33232 O REMOVAL OF PERMANENT PACEMAKER 0.00<br />

33233 3 REMOVAL OF PACEMAKER SYSTEM 247.99<br />

33234 3 REMOVAL OF PACEMAKER SYSTEM 487.24<br />

33235 3 REMOVAL PACEMAKER ELECTRO<strong>DE</strong> 634.73<br />

33236 3 REMOVE ELECTRO<strong>DE</strong>/THORACOTOMY 750.45<br />

33237 3 REMOVE ELECTRO<strong>DE</strong>/THORACOTOMY 824.18<br />

33238 3 REMOVE ELECTRO<strong>DE</strong>/THORACOTOMY 898.23<br />

33240 3 INSERT PULSE GENERATOR 463.70<br />

33241 3 REMOVE PULSE GENERATOR 233.08<br />

33242 O REPAIR PULSE GENERATOR/LEADS 0.00<br />

33243 3 REMOVE ELTRD/THORACOTOMY 1,296.79<br />

33244 3 REMOVE ELTRD, TRANSVEN 859.47<br />

33245 O INSERT EPIC ELTRD PACE-<strong>DE</strong>FIB 0.00<br />

33246 O INSERT EPIC ELTRD/GENERATOR 0.00<br />

33247 O INSERT/REPLACE LEADS 0.00<br />

33248 O REVISION OR REMOVAL OF AUTOMATIC IM 0.00<br />

33249 3 ELTRD/INSERT PACE-<strong>DE</strong>FIB 896.55<br />

33250 3 ABLATE HEART DYSRHYTHM FOCUS 1,399.70<br />

33251 3 ABLATE HEART DYSRHYTHM FOCUS 1,528.42<br />

33253 O RECONSTRUCT ATRIA 0.00<br />

33254 3 ABLATE ATRIA, LMTD 1,282.91<br />

33255 3 ABLATE ATRIA W/O BYPASS, EXT 1,544.30<br />

33256 3 ABLATE ATRIA W/BYPASS, EXTEN 1,841.73<br />

33257 3 ABLATE ATRIA, LMTD, ADD-ON 568.08<br />

33258 3 ABLATE ATRIA, X10SV, ADD-ON 641.05<br />

33259 3 ABLATE ATRIA W/BYPASS ADD-ON 838.96<br />

3325F 9 PREOP ASSES 4 CATARACT SURG 0.00<br />

33260 O OPERATIVE ABLATION OF ARRHYTHMOGENI 0.00<br />

33261 3 ABLATE HEART DYSRHYTHM FOCUS 1,540.41<br />

33265 3 ABLATE ATRIA, LMTD, ENDO 1,282.91<br />

33266 3 ABLATE ATRIA, X10SV, ENDO 1,752.50<br />

33282 3 IMPLANT PAT-ACTIVE HT RECORD 328.71<br />

33284 3 REMOVE PAT-ACTIVE HT RECORD 243.08<br />

33300 3 REPAIR OF HEART WOUND 2,078.89<br />

33305 3 REPAIR OF HEART WOUND 3,401.79<br />

3330F 9 IMAGING STUDY OR<strong>DE</strong>RED (BKP) 0.00<br />

33310 3 EXPLORATORY HEART SURGERY 1,115.35<br />

33315 3 EXPLORATORY HEART SURGERY 1,398.23<br />

3331F 9 BK IMAGING TST NOT OR<strong>DE</strong>RED 0.00

---

33320 3 REPAIR MAJOR BLOOD VESSEL(S) 1,006.74<br />

33321 3 REPAIR MAJOR VESSEL 1,145.71<br />

33322 3 REPAIR MAJOR BLOOD VESSEL(S) 1,300.53<br />

33330 3 INSERT MAJOR VESSEL GRAFT 1,325.86<br />

33332 3 INSERT MAJOR VESSEL GRAFT 1,312.13<br />

33335 3 INSERT MAJOR VESSEL GRAFT 1,780.92<br />

33350 O GREAT VESSEL REPAIR WITH OTHER MAJO 0.00<br />

33400 3 REPAIR OF AORTIC VALVE 2,119.67<br />

33401 3 VALVULOPLASTY, OPEN 1,401.33<br />

33403 3 VALVULOPLASTY, W/CP BYPASS 1,494.05<br />

33404 3 PREPARE HEART-AORTA CONDUIT 1,710.31<br />

33405 3 REPLACEMENT OF AORTIC VALVE 2,211.78<br />

33406 3 REPLACEMENT OF AORTIC VALVE 2,681.43<br />

33407 O VALVOTOMY, AORTIC VALVE (COMMISSURO 0.00<br />

33408 O VALVOTOMY, AORTIC VALVE (COMMISSURO 0.00<br />

3340F 9 MAMMO ASSESS INC XRAY DOCD 0.00<br />

33410 3 REPLACEMENT OF AORTIC VALVE 2,359.45<br />

33411 3 REPLACEMENT OF AORTIC VALVE 3,046.41<br />

33412 3 REPLACEMENT OF AORTIC VALVE 2,393.90<br />

33413 3 REPLACEMENT OF AORTIC VALVE 3,092.09<br />

33414 3 REPAIR OF AORTIC VALVE 2,026.63<br />

33415 3 REVISION, SUBVALVULAR TISSUE 1,878.93<br />

33416 3 REVISE VENTRICLE MUSCLE 1,896.93<br />

33417 3 REPAIR OF AORTIC VALVE 1,608.65<br />

3341F 9 MAMMO ASSESS NEGATIVE DOCD 0.00<br />

33420 3 REVISION OF MITRAL VALVE 1,299.43<br />

33422 3 REVISION OF MITRAL VALVE 1,612.64<br />

33425 3 REPAIR OF MITRAL VALVE 2,413.62<br />

33426 3 REPAIR OF MITRAL VALVE 2,259.29<br />

33427 3 REPAIR OF MITRAL VALVE 2,385.91<br />

3342F 9 MAMMO ASSESS BENGN DOCD 0.00<br />

33430 3 REPLACEMENT OF MITRAL VALVE 2,577.19<br />

3343F 9 MAMMO PROBABLY BENGN DOCD 0.00<br />

3344F 9 MAMMO ASSESS SUSP, DOCD 0.00<br />

33452 O VALVOTOMY, TRICUSPID VALVE, WITH CA 0.00<br />

3345F 9 MAMMO ASSESS HGHLYMALIG DOC 0.00<br />

33460 3 REVISION OF TRICUSPID VALVE 2,126.86<br />

33463 3 VALVULOPLASTY, TRICUSPID 2,688.09<br />

33464 3 VALVULOPLASTY, TRICUSPID 2,209.44<br />

33465 3 REPLACE TRICUSPID VALVE 2,447.71<br />

33468 3 REVISION OF TRICUSPID VALVE 1,801.79<br />

33470 3 REVISION OF PULMONARY VALVE 1,119.53<br />

33471 3 VALVOTOMY, PULMONARY VALVE 1,294.48<br />

33472 3 REVISION OF PULMONARY VALVE 1,288.14<br />

33474 3 REVISION OF PULMONARY VALVE 1,895.81<br />

33475 3 REPLACEMENT, PULMONARY VALVE 2,177.90<br />

33476 3 REVISION OF HEART CHAMBER 1,406.74<br />

33478 3 REVISION OF HEART CHAMBER 1,517.20<br />

33480 O REPLACEMENT AND/OR REPAIR, DOUBLE V 0.00<br />

33481 O SINGLE VALVE REPLACEMENT WITH COMMI 0.00

---

33482 O SINGLE VALVE REPLACEMENT WITH COMMI 0.00<br />

33483 O DOUBLE VALVE REPLACEMENT 0.00<br />

33485 O DOUBLE VALVE REPLACEMENT WITH COMMI 0.00<br />

33490 O REPLACEMENT AND/OR REPAIR, TRIPLE V 0.00<br />

33492 O TRIPLE VALVE REPLACEMENT 0.00<br />

33496 3 REPAIR, PROSTH VALVE CLOT 1,598.91<br />

33500 3 REPAIR HEART VESSEL FISTULA 1,500.54<br />

33501 3 REPAIR HEART VESSEL FISTULA 1,035.62<br />

33502 3 CORONARY ARTERY CORRECTION 1,225.95<br />

33503 3 CORONARY ARTERY GRAFT 1,242.51<br />

33504 3 CORONARY ARTERY GRAFT 1,398.00<br />

33505 3 REPAIR ARTERY W/TUNNEL 1,917.15<br />

33506 3 REPAIR ARTERY, TRANSLOCATION 1,956.42<br />

33507 3 REPAIR ART, INTRAMURAL 1,669.98<br />

33508 3 ENDOSCOPIC VEIN HARVEST 15.51<br />

3350F 9 MAMMO BX PROVEN MALIG DOCD 0.00<br />

33510 3 CABG, VEIN, SINGLE 1,888.63<br />

33511 3 CABG, VEIN, TWO 2,049.46<br />

33512 3 CABG, VEIN, THREE 2,285.88<br />

33513 3 CABG, VEIN, FOUR 2,351.65<br />

33514 3 CABG, VEIN, FIVE 2,464.43<br />

33516 3 CABG, VEIN, SIX OR MORE 2,558.83<br />

33517 3 CABG, ARTERY-VEIN, SINGLE 171.76<br />

33518 3 CABG, ARTERY-VEIN, TWO 367.88<br />

33519 3 CABG, ARTERY-VEIN, THREE 493.98<br />

3351F 9 NEG SCRN <strong>DE</strong>P SYMP BY <strong>DE</strong>PTOOL 0.00<br />

33520 O CORONARY ARTERY BYPASS, NONAUTOGENO 0.00<br />

33521 3 CABG, ARTERY-VEIN, FOUR 602.13<br />

33522 3 CABG, ARTERY-VEIN, FIVE 690.24<br />

33523 3 CABG, ART-VEIN, SIX OR MORE 791.62<br />

33525 O CORONARY ARTERY BYPASS, NONAUTOGENO 0.00<br />

33528 O CORONARY ARTERY BYPASS, NONAUTOGENO 0.00<br />

3352F 9 NO SIG <strong>DE</strong>P SYMP BY <strong>DE</strong>P TOOL 0.00<br />

33530 3 CORONARY ARTERY, BYPASS/REOP 465.12<br />

33533 3 CABG, ARTERIAL, SINGLE 1,846.77<br />

33534 3 CABG, ARTERIAL, TWO 2,126.51<br />

33535 3 CABG, ARTERIAL, THREE 2,340.03<br />

33536 3 CABG, ARTERIAL, FOUR OR MORE 2,500.53<br />

3353F 9 MILD-MOD <strong>DE</strong>P SYMP BY <strong>DE</strong>PTOOL 0.00<br />

33542 3 REMOVAL OF HEART LESION 2,348.15<br />

33545 3 REPAIR OF HEART DAMAGE 2,788.74<br />

33548 3 RESTORE/REMO<strong>DE</strong>L, VENTRICLE 2,753.97<br />

3354F 9 CLIN SIG <strong>DE</strong>P SYM BY <strong>DE</strong>P TOOL 0.00<br />

33570 O CORONARY ANGIOPLASTY (ENDARTERECTOM 0.00<br />

33572 3 OPEN CORONARY ENDARTERECTOMY 224.09<br />

33575 O CORONARY ANGIOPLASTY (ENDARTERECTOM 0.00<br />

33600 3 CLOSURE OF VALVE 1,638.64<br />

33602 3 CLOSURE OF VALVE 1,567.30<br />

33606 3 ANASTOMOSIS/ARTERY-AORTA 1,697.64<br />

33608 3 REPAIR ANOMALY W/CONDUIT 1,746.49

---

33610 3 REPAIR BY ENLARGEMENT 1,728.54<br />

33611 3 REPAIR DOUBLE VENTRICLE 1,854.33<br />

33612 3 REPAIR DOUBLE VENTRICLE 1,973.97<br />

33615 3 REPAIR, MODIFIED FONTAN 1,870.75<br />

33617 3 REPAIR SINGLE VENTRICLE 2,078.01<br />

33619 3 REPAIR SINGLE VENTRICLE 2,602.50<br />

33641 3 REPAIR HEART SEPTUM <strong>DE</strong>FECT 1,498.85<br />

33645 3 REVISION OF HEART VEINS 1,502.78<br />

33647 3 REPAIR HEART SEPTUM <strong>DE</strong>FECTS 1,615.32<br />

33649 O REPAIR OF TRICUSPID ATRESIA (EG, FO 0.00<br />

33660 3 REPAIR OF HEART <strong>DE</strong>FECTS 1,707.60<br />

33665 3 REPAIR OF HEART <strong>DE</strong>FECTS 1,809.29<br />

33670 3 REPAIR OF HEART CHAMBERS 1,944.83<br />

33675 3 CLOSE MULT VSD 1,982.95<br />

33676 3 CLOSE MULT VSD W/RESECTION 2,043.14<br />

33677 3 CL MULT VSD W/REM PUL BAND 2,123.50<br />

33681 3 REPAIR HEART SEPTUM <strong>DE</strong>FECT 1,764.73<br />

33684 3 REPAIR HEART SEPTUM <strong>DE</strong>FECT 1,792.77<br />

33688 3 REPAIR HEART SEPTUM <strong>DE</strong>FECT 1,750.31<br />

33690 3 REINFORCE PULMONARY ARTERY 1,113.15<br />

33692 3 REPAIR OF HEART <strong>DE</strong>FECTS 1,858.86<br />

33694 3 REPAIR OF HEART <strong>DE</strong>FECTS 1,837.20<br />

33696 O COMPLETE REPAIR TETRALOGY OF FALLOT 0.00<br />

33697 3 REPAIR OF HEART <strong>DE</strong>FECTS 2,018.08<br />

33698 O COMPLETE REPAIR TETRALOGY OF FALLOT 0.00<br />

33702 3 REPAIR OF HEART <strong>DE</strong>FECTS 1,482.46<br />

3370F 9 AJCC BRST CNCR STAGE 0 DOCD 0.00<br />

33710 3 REPAIR OF HEART <strong>DE</strong>FECTS 1,654.19<br />

33720 3 REPAIR OF HEART <strong>DE</strong>FECT 1,485.61<br />

33722 3 REPAIR OF HEART <strong>DE</strong>FECT 1,505.02<br />

33724 3 REPAIR VENOUS ANOMALY 1,460.92<br />

33726 3 REPAIR PUL VENOUS STENOSIS 1,925.44<br />

3372F 9 AJCC BRST CNCR STAGE 1 +DOCD 0.00<br />

33730 3 REPAIR HEART-VEIN <strong>DE</strong>FECT(S) 1,901.02<br />

33732 3 REPAIR HEART-VEIN <strong>DE</strong>FECT 1,598.07<br />

33735 3 REVISION OF HEART CHAMBER 1,197.66<br />

33736 3 REVISION OF HEART CHAMBER 1,381.40<br />

33737 3 REVISION OF HEART CHAMBER 1,248.21<br />

33738 O ATRIAL SEPTECTOMY OR SEPTOSTOMY TRA 0.00<br />

33739 O ATRIAL SEPTECTOMY OR SEPTOSTOMY BLA 0.00<br />

3374F 9 AJCC BRST CNCR STAGE 1 +DOCD 0.00<br />

33750 3 MAJOR VESSEL SHUNT 1,168.86<br />

33755 3 MAJOR VESSEL SHUNT 1,183.91<br />

33762 3 MAJOR VESSEL SHUNT 1,224.81<br />

33764 3 MAJOR VESSEL SHUNT & GRAFT 1,227.26<br />

33766 3 MAJOR VESSEL SHUNT 1,299.69<br />

33767 3 MAJOR VESSEL SHUNT 1,363.73<br />

33768 3 CAVOPULMONARY SHUNTING 394.82<br />

3376F 9 AJCC BRSTCNCR STAGE 2 DOCD 0.00<br />

33770 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 2,016.21

---

33771 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 2,045.15<br />

33774 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 1,740.44<br />

33775 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 1,754.64<br />

33776 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 1,834.25<br />

33777 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 1,816.61<br />

33778 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 2,254.96<br />

33779 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 2,097.31<br />

33780 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 2,229.84<br />

33781 3 REPAIR GREAT VESSELS <strong>DE</strong>FECT 2,121.46<br />

33786 3 REPAIR ARTERIAL TRUNK 2,190.75<br />

33788 3 REVISION OF PULMONARY ARTERY 1,441.16<br />

3378F 9 AJCC BRSTCNCR STAGE 3 DOCD 0.00<br />

33800 3 AORTIC SUSPENSION 950.83<br />

33802 3 REPAIR VESSEL <strong>DE</strong>FECT 1,023.55<br />

33803 3 REPAIR VESSEL <strong>DE</strong>FECT 1,096.85<br />

3380F 9 AJCC BRSTCNCR STAGE 4 DOCD 0.00<br />

33813 3 REPAIR SEPTAL <strong>DE</strong>FECT 1,201.01<br />

33814 3 REPAIR SEPTAL <strong>DE</strong>FECT 1,463.22<br />

33820 3 REVISE MAJOR VESSEL 934.26<br />

33822 3 REVISE MAJOR VESSEL 970.04<br />

33824 3 REVISE MAJOR VESSEL 1,129.83<br />

3382F 9 AJCC CLN CNCR STAGE 0 DOCD 0.00<br />

33830 O PATENT DUCTUS ARTERIOSUS LIGATION O 0.00<br />

33840 3 REMOVE AORTA CONSTRICTION 1,169.57<br />

33845 3 REMOVE AORTA CONSTRICTION 1,275.33<br />

3384F 9 AJCC CLN CNCR STAGE 1 DOCD 0.00<br />

33851 3 REMOVE AORTA CONSTRICTION 1,219.75<br />

33852 3 REPAIR SEPTAL <strong>DE</strong>FECT 1,401.40<br />

33853 3 REPAIR SEPTAL <strong>DE</strong>FECT 1,762.33<br />

33855 O EXCISION OF COARCTATION OF AORTA, W 0.00<br />

33860 3 ASCENDING AORTIC GRAFT 2,903.96<br />

33861 3 ASCENDING AORTIC GRAFT 2,335.74<br />

33863 3 ASCENDING AORTIC GRAFT 2,939.21<br />

33864 3 ASCENDING AORTIC GRAFT 3,025.02<br />

33865 O ASCENDING AORTA GRAFT, WITH CARDIOP 0.00<br />

3386F 9 AJCC CLN CNCR STAGE 2 DOCD 0.00<br />

33870 3 TRANSVERSE AORTIC ARCH GRAFT 2,435.70<br />

33875 3 THORACIC AORTIC GRAFT 1,886.11<br />

33877 3 THORACOABDOMINAL GRAFT 3,245.35<br />

33880 3 ENDOVASC TAA REPR INCL SUBCL 1,730.42<br />

33881 3 ENDOVASC TAA REPR W/O SUBCL 1,494.27<br />

33883 3 INSERT ENDOVASC PROSTH, TAA 1,097.05<br />

33884 3 ENDOVASC PROSTH, TAA, ADD-ON 395.13<br />

33886 3 ENDOVASC PROSTH, <strong>DE</strong>LAYED 950.02<br />

33889 3 ARTERY TRANSPOSE/ENDOVAS TAA 784.56<br />

3388F 9 AJCC CLN CNCR STAGE 3 DOCD 0.00<br />

33891 3 CAR-CAR BP GRFT/ENDOVAS TAA 1,010.29<br />

3390F 9 AJCC CLN CNCR STAGE 4 DOCD 0.00<br />

33910 3 REMOVE LUNG ARTERY EMBOLI 1,561.09<br />

33915 3 REMOVE LUNG ARTERY EMBOLI 1,253.79

---

33916 3 SURGERY OF GREAT VESSEL 1,504.50<br />

33917 3 REPAIR PULMONARY ARTERY 1,399.52<br />

33918 O REPAIR PULMONARY ATRESIA 0.00<br />

33919 O REPAIR PULMONARY ATRESIA 0.00<br />

33920 3 REPAIR PULMONARY ATRESIA 1,692.71<br />

33922 3 TRANSECT PULMONARY ARTERY 1,324.71<br />

33924 3 REMOVE PULMONARY SHUNT 277.92<br />

33925 3 RPR PUL ART UNIFOCAL W/O CPB 1,808.30<br />

33926 3 REPR PUL ART, UNIFOCAL W/CPB 2,338.62<br />

33930 9 REMOVAL OF DONOR HEART/LUNG 0.00<br />

33933 9 PREPARE DONOR HEART/LUNG 0.00<br />

33935 3 TRANSPLANTATION, HEART/LUNG 3,377.59<br />

33940 9 REMOVAL OF DONOR HEART 0.00<br />

33944 9 PREPARE DONOR HEART 0.00<br />

33945 3 TRANSPLANTATION OF HEART 4,224.67<br />

33960 3 EXTERNAL CIRCULATION ASSIST 934.25<br />

33961 3 EXTERNAL CIRCULATION ASSIST 525.92<br />

33967 3 INSERT IA PERCUT <strong>DE</strong>VICE 258.20<br />

33968 3 REMOVE AORTIC ASSIST <strong>DE</strong>VICE 33.08<br />

33970 3 AORTIC CIRCULATION ASSIST 347.81<br />

33971 3 AORTIC CIRCULATION ASSIST 677.38<br />

33972 O INTRA-AORTIC BALLOON COUNTERPULSATI 0.00<br />

33973 3 INSERT BALLOON <strong>DE</strong>VICE 510.87<br />

33974 3 REMOVE INTRA-AORTIC BALLOON 865.12<br />

33975 3 IMPLANT VENTRICULAR <strong>DE</strong>VICE 1,049.53<br />

33976 3 IMPLANT VENTRICULAR <strong>DE</strong>VICE 1,174.86<br />

33977 3 REMOVE VENTRICULAR <strong>DE</strong>VICE 1,166.83<br />

33978 3 REMOVE VENTRICULAR <strong>DE</strong>VICE 1,297.47<br />

33979 3 INSERT INTRACORPOREAL <strong>DE</strong>VICE 2,318.98<br />

33980 3 REMOVE INTRACORPOREAL <strong>DE</strong>VICE 3,404.61<br />

33999 5 CARDIAC SURGERY PROCEDURE 0.00<br />

34001 3 REMOVAL OF ARTERY CLOT 915.06<br />

34051 3 REMOVAL OF ARTERY CLOT 938.16<br />

34101 3 REMOVAL OF ARTERY CLOT 599.49<br />

34111 3 REMOVAL OF ARM ARTERY CLOT 598.80<br />

34151 3 REMOVAL OF ARTERY CLOT 1,375.95<br />

34201 3 REMOVAL OF ARTERY CLOT 935.48<br />

34203 3 REMOVAL OF LEG ARTERY CLOT 954.98<br />

34401 3 REMOVAL OF VEIN CLOT 1,379.65<br />

34421 3 REMOVAL OF VEIN CLOT 722.62<br />

34451 3 REMOVAL OF VEIN CLOT 1,487.02<br />

34471 3 REMOVAL OF VEIN CLOT 1,006.17<br />

34490 3 REMOVAL OF VEIN CLOT 601.47<br />

34501 3 REPAIR VALVE, FEMORAL VEIN 930.63<br />

34502 3 RECONSTRUCT VENA CAVA 1,500.10<br />

3450F 9 DYSPNEA SCRND, NO-MILD DYSP 0.00<br />

34510 3 TRANSPOSITION OF VEIN VALVE 1,073.74<br />

3451F 9 DYSPNEA SCRND MOD-HIGH DYSP 0.00<br />

34520 3 CROSS-OVER VEIN GRAFT 1,018.42<br />

3452F 9 DYSPNEA NOT SCREENED 0.00

---

34530 3 LEG VEIN FUSION 956.67<br />

3455F 9 TB SCRNG DONE-INTERPD 6MON 0.00<br />

3470F 9 RA DISEASE ACTIVITY, LOW 0.00<br />

3471F 9 RA DISEASE ACTIVITY, MOD 0.00<br />

3472F 9 RA DISEASE ACTIVITY, HIGH 0.00<br />

3475F 9 DISEASE PROGN RA POOR DOCD 0.00<br />

3476F 9 DISEASE PROGN RA GOOD DOCD 0.00<br />

34800 3 ENDOVAS AAA REPR W/SM TUBE 1,123.58<br />

34802 3 ENDOVAS AAA REPR W/2-P PART 1,226.66<br />

34803 3 ENDOVAS AAA REPR W/3-P PART 1,257.34<br />

34804 3 ENDOVAS AAA REPR W/1-P PART 1,223.80<br />

34805 3 ENDOVAS AAA REPR W/LONG TUBE 1,158.22<br />

34806 3 ANEURYSM PRESS SENSOR ADD-ON 98.64<br />

34808 3 ENDOVAS ILIAC A <strong>DE</strong>VICE ADDON 204.84<br />

34812 3 XPOSE FOR ENDOPROSTH, FEMORL 340.37<br />

34813 3 FEMORAL ENDOVAS GRAFT ADD-ON 235.83<br />

34820 3 XPOSE FOR ENDOPROSTH, ILIAC 486.51<br />

34825 3 ENDOVASC EXTEND PROSTH, INIT 691.44<br />

34826 3 ENDOVASC EXTEN PROSTH, ADDÏL 201.98<br />

34830 3 OPEN AORTIC TUBE PROSTH REPR 1,797.78<br />

34831 3 OPEN AORTOILIAC PROSTH REPR 1,880.96<br />

34832 3 OPEN AORTOFEMOR PROSTH REPR 1,947.06<br />

34833 3 XPOSE FOR ENDOPROSTH, ILIAC 608.41<br />

34834 3 XPOSE, ENDOPROSTH, BRACHIAL 277.44<br />

34900 3 ENDOVASC ILIAC REPR W/GRAFT 896.25<br />

3490F 9 HISTORY - AIDS-<strong>DE</strong>FINING COND 0.00<br />

3491F 9 HIV UNSURE BABY OF HIV+MOMS 0.00<br />

3492F 9 HISTORY CD4+CELL COUNT

---

35103 3 REPAIR ARTERY RUPTURE, GROIN 2,205.89<br />

3510F 9 DOC TB SCRNG-RSLTS INTERPD 0.00<br />

35111 3 REPAIR <strong>DE</strong>FECT OF ARTERY 1,363.63<br />

35112 3 REPAIR ARTERY RUPTURE,SPLEEN 1,654.43<br />

3511F 9 CHLMYD/GONRH TSTS DOCD DONE 0.00<br />

35121 3 REPAIR <strong>DE</strong>FECT OF ARTERY 1,631.80<br />

35122 3 REPAIR ARTERY RUPTURE, BELLY 1,918.99<br />

3512F 9 SYPH SCRNG DOCD AS DONE 0.00<br />

35131 3 REPAIR <strong>DE</strong>FECT OF ARTERY 1,385.11<br />

35132 3 REPAIR ARTERY RUPTURE, GROIN 1,673.53<br />

3513F 9 HEP B SCRNG DOCD AS DONE 0.00<br />

35141 3 REPAIR <strong>DE</strong>FECT OF ARTERY 1,104.02<br />

35142 3 REPAIR ARTERY RUPTURE, THIGH 1,314.40<br />

3514F 9 HEP C SCRNG DOCD AS DONE 0.00<br />

35151 3 REPAIR <strong>DE</strong>FECT OF ARTERY 1,243.44<br />

35152 3 REPAIR ARTERY RUPTURE, KNEE 1,443.49<br />

3515F 9 PT HAS DOCD IMMUN TO HEP C 0.00<br />

35161 O REPAIR <strong>DE</strong>FECT OF ARTERY 0.00<br />

35162 O REPAIR ARTERY RUPTURE 0.00<br />

35180 3 REPAIR BLOOD VESSEL LESION 798.31<br />

35182 3 REPAIR BLOOD VESSEL LESION 1,664.92<br />

35184 3 REPAIR BLOOD VESSEL LESION 1,000.59<br />

35188 3 REPAIR BLOOD VESSEL LESION 847.96<br />

35189 3 REPAIR BLOOD VESSEL LESION 1,576.36<br />

35190 3 REPAIR BLOOD VESSEL LESION 735.88<br />

35201 3 REPAIR BLOOD VESSEL LESION 921.99<br />

35206 3 REPAIR BLOOD VESSEL LESION 755.34<br />

35207 3 REPAIR BLOOD VESSEL LESION 686.94<br />

35211 3 REPAIR BLOOD VESSEL LESION 1,325.40<br />

35216 3 REPAIR BLOOD VESSEL LESION 1,759.03<br />

35221 3 REPAIR BLOOD VESSEL LESION 1,359.22<br />

35226 3 REPAIR BLOOD VESSEL LESION 836.22<br />

35231 3 REPAIR BLOOD VESSEL LESION 1,144.45<br />

35236 3 REPAIR BLOOD VESSEL LESION 959.25<br />

35241 3 REPAIR BLOOD VESSEL LESION 1,385.57<br />

35246 3 REPAIR BLOOD VESSEL LESION 1,492.53<br />

35251 3 REPAIR BLOOD VESSEL LESION 1,619.77<br />

35256 3 REPAIR BLOOD VESSEL LESION 1,010.84<br />

35261 3 REPAIR BLOOD VESSEL LESION 1,012.67<br />

35266 3 REPAIR BLOOD VESSEL LESION 841.73<br />

35271 3 REPAIR BLOOD VESSEL LESION 1,321.46<br />

35276 3 REPAIR BLOOD VESSEL LESION 1,388.55<br />

35281 3 REPAIR BLOOD VESSEL LESION 1,545.61<br />

35286 3 REPAIR BLOOD VESSEL LESION 930.39<br />

35301 3 RECHANNELING OF ARTERY 1,039.05<br />

35302 3 RECHANNELING OF ARTERY 1,081.27<br />

35303 3 RECHANNELING OF ARTERY 1,187.44<br />

35304 3 RECHANNELING OF ARTERY 1,235.60<br />

35305 3 RECHANNELING OF ARTERY 1,187.44<br />

35306 3 RECHANNELING OF ARTERY 443.18

---

35311 3 RECHANNELING OF ARTERY 1,488.68<br />

35321 3 RECHANNELING OF ARTERY 885.34<br />

35331 3 RECHANNELING OF ARTERY 1,444.04<br />

35341 3 RECHANNELING OF ARTERY 1,372.86<br />

35351 3 RECHANNELING OF ARTERY 1,270.01<br />

35355 3 RECHANNELING OF ARTERY 1,033.85<br />

35361 3 RECHANNELING OF ARTERY 1,562.62<br />

35363 3 RECHANNELING OF ARTERY 1,673.80<br />

35371 3 RECHANNELING OF ARTERY 821.27<br />

35372 3 RECHANNELING OF ARTERY 984.04<br />

35381 O RECHANNELING OF ARTERY 0.00<br />

35390 3 REOPERATION, CAROTID ADD-ON 158.80<br />

35400 3 ANGIOSCOPY 150.18<br />

35450 3 REPAIR ARTERIAL BLOCKAGE 506.42<br />

35452 3 REPAIR ARTERIAL BLOCKAGE 353.61<br />

35454 3 REPAIR ARTERIAL BLOCKAGE 310.47<br />

35456 3 REPAIR ARTERIAL BLOCKAGE 375.52<br />

35458 3 REPAIR ARTERIAL BLOCKAGE 482.35<br />

35459 3 REPAIR ARTERIAL BLOCKAGE 442.56<br />

35460 3 REPAIR VENOUS BLOCKAGE 308.11<br />

35470 3 REPAIR ARTERIAL BLOCKAGE 446.45<br />

35471 3 REPAIR ARTERIAL BLOCKAGE 530.57<br />

35472 3 REPAIR ARTERIAL BLOCKAGE 372.61<br />

35473 3 REPAIR ARTERIAL BLOCKAGE 316.35<br />

35474 3 REPAIR ARTERIAL BLOCKAGE 381.67<br />

35475 3 REPAIR ARTERIAL BLOCKAGE 476.40<br />

35476 3 REPAIR VENOUS BLOCKAGE 304.63<br />

35480 3 ATHERECTOMY, OPEN 571.88<br />

35481 3 ATHERECTOMY, OPEN 398.06<br />

35482 3 ATHERECTOMY, OPEN 341.70<br />

35483 3 ATHERECTOMY, OPEN 417.96<br />

35484 3 ATHERECTOMY, OPEN 522.48<br />

35485 3 ATHERECTOMY, OPEN 487.38<br />

35490 3 ATHERECTOMY, PERCUTANEOUS 590.42<br />

35491 3 ATHERECTOMY, PERCUTANEOUS 419.96<br />

35492 3 ATHERECTOMY, PERCUTANEOUS 369.39<br />

35493 3 ATHERECTOMY, PERCUTANEOUS 443.39<br />

35494 3 ATHERECTOMY, PERCUTANEOUS 560.19<br />

35495 3 ATHERECTOMY, PERCUTANEOUS 515.84<br />

35500 3 HARVEST VEIN FOR BYPASS 317.06<br />

35501 3 ARTERY BYPASS GRAFT 1,488.78<br />

35506 3 ARTERY BYPASS GRAFT 1,290.30<br />

35507 O ARTERY BYPASS GRAFT 0.00<br />

35508 3 ARTERY BYPASS GRAFT 1,322.09<br />

35509 3 ARTERY BYPASS GRAFT 1,449.96<br />

3550F 9 LOW RSK THROMBOEMBOLISM 0.00<br />

35510 3 ARTERY BYPASS GRAFT 1,238.12<br />

35511 3 ARTERY BYPASS GRAFT 1,171.03<br />

35512 3 ARTERY BYPASS GRAFT 1,213.30<br />

35515 3 ARTERY BYPASS GRAFT 1,325.24

---

35516 3 ARTERY BYPASS GRAFT 1,167.25<br />

35518 3 ARTERY BYPASS GRAFT 1,175.82<br />

3551F 9 INTRMED RSK THROMBOEMBOLISM 0.00<br />

35521 3 ARTERY BYPASS GRAFT 1,256.03<br />

35522 3 ARTERY BYPASS GRAFT 1,181.98<br />

35523 3 ARTERY BYPASS GRAFT 1,239.71<br />

35525 3 ARTERY BYPASS GRAFT 1,117.75<br />

35526 3 ARTERY BYPASS GRAFT 1,696.91<br />

3552F 9 HGH RISK FOR THROMBOEMBOLISM 0.00<br />

35531 3 ARTERY BYPASS GRAFT 1,985.89<br />

35533 3 ARTERY BYPASS GRAFT 1,541.39<br />

35535 6 ARTERY BYPASS GRAFT 0.00<br />

35536 3 ARTERY BYPASS GRAFT 1,717.95<br />

35537 3 ARTERY BYPASS GRAFT 2,100.54<br />

35538 3 ARTERY BYPASS GRAFT 2,345.22<br />

35539 3 ARTERY BYPASS GRAFT 2,199.45<br />

35540 3 ARTERY BYPASS GRAFT 2,451.59<br />

35541 O ARTERY BYPASS GRAFT 0.00<br />

35546 O ARTERY BYPASS GRAFT 0.00<br />

35548 3 ARTERY BYPASS GRAFT 1,191.26<br />

35549 3 ARTERY BYPASS GRAFT 1,298.97<br />

35551 3 ARTERY BYPASS GRAFT 1,461.66<br />

35556 3 ARTERY BYPASS GRAFT 1,355.50<br />

35558 3 ARTERY BYPASS GRAFT 1,211.21<br />

3555F 9 PT INR MEASUREMENT PERFORMED 0.00<br />

35560 3 ARTERY BYPASS GRAFT 1,760.92<br />

35563 3 ARTERY BYPASS GRAFT 1,367.21<br />

35565 3 ARTERY BYPASS GRAFT 1,305.56<br />

35566 3 ARTERY BYPASS GRAFT 1,623.59<br />

35570 6 ARTERY BYPASS GRAFT 0.00<br />

35571 3 ARTERY BYPASS GRAFT 1,335.09<br />

35572 3 HARVEST FEMOROPOPLITEAL VEIN 342.17<br />

35582 O VEIN BYPASS GRAFT 0.00<br />

35583 3 VEIN BYPASS GRAFT 1,400.11<br />

35585 3 VEIN BYPASS GRAFT 1,650.85<br />

35587 3 VEIN BYPASS GRAFT 1,381.30<br />

35600 3 HARVEST ART FOR CABG ADD-ON 250.87<br />

35601 3 ARTERY BYPASS GRAFT 1,400.32<br />

35606 3 ARTERY BYPASS GRAFT 1,159.13<br />

35612 3 ARTERY BYPASS GRAFT 907.61<br />

35616 3 ARTERY BYPASS GRAFT 1,101.91<br />

35621 3 ARTERY BYPASS GRAFT 1,100.98<br />

35623 3 BYPASS GRAFT, NOT VEIN 1,349.45<br />

35626 3 ARTERY BYPASS GRAFT 1,544.01<br />

35631 3 ARTERY BYPASS GRAFT 1,843.95<br />

35632 6 ARTERY BYPASS GRAFT 0.00<br />

35633 6 ARTERY BYPASS GRAFT 0.00<br />

35634 6 ARTERY BYPASS GRAFT 0.00<br />

35636 3 ARTERY BYPASS GRAFT 1,626.52<br />

35637 3 BYPASS GRAFT, WITH OTHER THAN VEIN 1,666.70

---

35638 3 BYPASS GRAFT, WITH OTHER THAN VEIN 1,693.05<br />

35641 O ARTERY BYPASS GRAFT 0.00<br />

35642 3 ARTERY BYPASS GRAFT 999.78<br />

35645 3 ARTERY BYPASS GRAFT 1,015.72<br />

35646 3 ARTERY BYPASS GRAFT 1,708.46<br />

35647 3 ARTERY BYPASS GRAFT 1,544.08<br />

35650 3 ARTERY BYPASS GRAFT 1,062.26<br />

35651 3 ARTERY BYPASS GRAFT 1,362.49<br />

35654 3 ARTERY BYPASS GRAFT 1,366.19<br />

35656 3 ARTERY BYPASS GRAFT 1,078.16<br />

35661 3 ARTERY BYPASS GRAFT 1,080.64<br />

35663 3 ARTERY BYPASS GRAFT 1,250.86<br />

35665 3 ARTERY BYPASS GRAFT 1,173.52<br />

35666 3 ARTERY BYPASS GRAFT 1,268.27<br />

35671 3 ARTERY BYPASS GRAFT 1,116.73<br />

35681 3 COMPOSITE BYPASS GRAFT 79.59<br />

35682 3 COMPOSITE BYPASS GRAFT 354.49<br />

35683 3 COMPOSITE BYPASS GRAFT 417.57<br />

35685 3 BYPASS GRAFT PATENCY/PATCH 199.49<br />

35686 3 BYPASS GRAFT/AV FIST PATENCY 166.07<br />

35691 3 ARTERIAL TRANSPOSITION 980.24<br />

35693 3 ARTERIAL TRANSPOSITION 868.18<br />

35694 3 ARTERIAL TRANSPOSITION 1,024.16<br />

35695 3 ARTERIAL TRANSPOSITION 1,058.60<br />

35697 3 REIMPLANT ARTERY EACH 148.41<br />

35700 3 REOPERATION, BYPASS GRAFT 152.39<br />

35701 3 EXPLORATION, CAROTID ARTERY 528.06<br />

3570F 9 RPRT BONE SCINT X-REFW/X-RAY 0.00<br />

35721 3 EXPLORATION, FEMORAL ARTERY 452.89<br />

3572F 9 PT CONSID POSS RISK FX 0.00<br />

3573F 9 PT NOT CONSID POSS RISK FX 0.00<br />

35741 3 EXPLORATION POPLITEAL ARTERY 492.62<br />

35761 3 EXPLORATION OF ARTERY/VEIN 366.48<br />

35800 3 EXPLORE NECK VESSELS 468.37<br />

35820 3 EXPLORE CHEST VESSELS 1,701.48<br />

35840 3 EXPLORE ABDOMINAL VESSELS 606.84<br />

35860 3 EXPLORE LIMB VESSELS 397.00<br />

35870 3 REPAIR VESSEL GRAFT <strong>DE</strong>FECT 1,264.38<br />

35875 3 REMOVAL OF CLOT IN GRAFT 589.02<br />

35876 3 REMOVAL OF CLOT IN GRAFT 937.27<br />

35879 3 REVISE GRAFT W/VEIN 922.25<br />

35881 3 REVISE GRAFT W/VEIN 1,025.50<br />

35883 3 REVISE GRAFT W/NONAUTO GRAFT 1,211.27<br />

35884 3 REVISE GRAFT W/VEIN 1,285.92<br />

35900 O EXCISION OF INFECTED GRAFT 0.00<br />

35901 3 EXCISION, GRAFT, NECK 501.64<br />

35903 3 EXCISION, GRAFT, EXTREMITY 570.13<br />

35905 3 EXCISION, GRAFT, THORAX 1,732.45<br />

35907 3 EXCISION, GRAFT, ABDOMEN 1,898.11<br />

35910 O EXCISION OF INFECTED GRAFT WITH REV 0.00

---

36000 3 PLACE NEEDLE IN VEIN 26.52<br />

36002 3 PSEUDOANEURYSM INJECTION TRT 171.97<br />

36005 3 INJECTION EXT VENOGRAPHY 47.60<br />

36010 3 PLACE CATHETER IN VEIN 119.40<br />

36011 3 PLACE CATHETER IN VEIN 155.18<br />

36012 3 PLACE CATHETER IN VEIN 897.32<br />

36013 3 PLACE CATHETER IN ARTERY 882.91<br />

36014 3 PLACE CATHETER IN ARTERY 877.22<br />

36015 3 PLACE CATHETER IN ARTERY 956.14<br />

36100 3 ESTABLISH ACCESS TO ARTERY 568.87<br />

36120 3 ESTABLISH ACCESS TO ARTERY 464.16<br />

36140 3 ESTABLISH ACCESS TO ARTERY 99.25<br />

36145 3 ARTERY TO VEIN SHUNT 97.38<br />

36160 3 ESTABLISH ACCESS TO AORTA 585.76<br />

36200 3 PLACE CATHETER IN AORTA 155.51<br />

36215 3 PLACE CATHETER IN ARTERY 235.10<br />

36216 3 PLACE CATHETER IN ARTERY 264.17<br />

36217 3 PLACE CATHETER IN ARTERY 316.84<br />

36218 3 PLACE CATHETER IN ARTERY 50.51<br />

36230 O SELECTIVE CATHETER PLACEMENT, CORON 0.00<br />

36245 3 PLACE CATHETER IN ARTERY 242.19<br />

36246 3 PLACE CATHETER IN ARTERY 265.06<br />

36247 3 PLACE CATHETER IN ARTERY 315.76<br />

36248 3 PLACE CATHETER IN ARTERY 178.37<br />

36260 3 INSERTION OF INFUSION PUMP 558.53<br />

36261 3 REVISION OF INFUSION PUMP 341.21<br />

36262 3 REMOVAL OF INFUSION PUMP 260.86<br />

36299 5 VESSEL INJECTION PROCEDURE 0.00<br />

36400 3 BL DRAW < 3 YRS FEM/JUGULAR 24.61<br />

36405 3 BL DRAW < 3 YRS SCALP VEIN 21.91<br />

36406 3 BL DRAW < 3 YRS OTHER VEIN 16.69<br />

36410 3 NON-ROUTINE BL DRAW > 3 YRS 18.26<br />

36415 3 ROUTINE VENIPUNCTURE 15.00<br />

36416 9 CAPILLARY BLOOD DRAW 0.00<br />

36420 3 VEIN ACCESS CUTDOWN < 1 YR 45.78<br />

36425 3 VEIN ACCESS CUTDOWN > 1 YR 35.84<br />

36430 3 BLOOD TRANSFUSION SERVICE 39.94<br />

36440 3 BL PUSH TRANSFUSE, 2 YR OR < 48.62<br />

36450 3 BL EXCHANGE/TRANSFUSE, NB 110.80<br />

36455 3 BL EXCHANGE/TRANSFUSE NON-NB 119.89<br />

36460 3 TRANSFUSION SERVICE, FETAL 326.20<br />

36468 5 INJECTION(S), SPI<strong>DE</strong>R VEINS 0.00<br />

36469 9 INJECTION(S), SPI<strong>DE</strong>R VEINS 0.00<br />

36470 3 INJECTION THERAPY OF VEIN 140.84<br />

36471 3 INJECTION THERAPY OF VEINS 170.87<br />

36475 3 ENDOVENOUS RF, 1ST VEIN 325.85<br />

36476 3 ENDOVENOUS RF, VEIN ADD-ON 158.63<br />

36478 3 ENDOVENOUS LASER, 1ST VEIN 329.00<br />

36479 3 ENDOVENOUS LASER VEIN ADDON 160.99<br />

36481 3 INSERTION OF CATHETER, VEIN 350.66

---

36488 O INSERTION OF CATHETER, VEIN 0.00<br />

36489 O INSERTION OF CATHETER, VEIN 0.00<br />

36490 O INSERTION OF CATHETER, VEIN 0.00<br />

36491 O INSERTION OF CATHETER, VEIN 0.00<br />

36493 O REPOSITIONING OF CVC 0.00<br />

36495 O INSERTION OF IMPLANTABLE INTRAVENOU 0.00<br />

36496 O REVISION OF IMPLANTABLE INTRAVENOUS 0.00<br />

36497 O REMOVAL OF IMPLANTABLE INTRAVENOUS 0.00<br />

36500 3 INSERTION OF CATHETER, VEIN 176.44<br />

36510 3 INSERTION OF CATHETER, VEIN 137.50<br />

36511 3 APHERESIS WBC 86.86<br />

36512 3 APHERESIS RBC 87.64<br />

36513 3 APHERESIS PLATELETS 89.13<br />

36514 3 APHERESIS PLASMA 601.87<br />

36515 3 APHERESIS, ADSORP/REINFUSE 2,261.78<br />

36516 3 APHERESIS, SELECTIVE 2,673.71<br />

36520 O PLASMA AND/OR CELL EXCHANGE 0.00<br />

36521 O APHERESIS W/ ADSORP/REINFUSE 0.00<br />

36522 3 PHOTOPHERESIS 97.83<br />

36530 O INSERTION OF INFUSION PUMP 0.00<br />

36531 O REVISION OF INFUSION PUMP 0.00<br />

36532 O REMOVAL OF INFUSION PUMP 0.00<br />

36533 O INSERTION OF ACCESS <strong>DE</strong>VICE 0.00<br />

36534 O REVISION OF ACCESS <strong>DE</strong>VICE 0.00<br />

36535 O REMOVAL OF ACCESS <strong>DE</strong>VICE 0.00<br />

36536 O REMOVE CVA <strong>DE</strong>VICE OBSTRUCT 0.00<br />

36537 O REMOVE CVA LUMEN OBSTRUCT 0.00<br />

36540 O COLLECT BLOOD VENOUS <strong>DE</strong>VICE 0.00<br />

36550 O <strong>DE</strong>CLOT VASCULAR <strong>DE</strong>VICE 0.00<br />

36555 3 INSERT NON-TUNNEL CV CATH 282.19<br />

36556 3 INSERT NON-TUNNEL CV CATH 115.91<br />

36557 3 INSERT TUNNELED CV CATH 287.32<br />

36558 3 INSERT TUNNELED CV CATH 276.92<br />

36560 3 INSERT TUNNELED CV CATH 342.35<br />

36561 3 INSERT TUNNELED CV CATH 330.73<br />

36563 3 INSERT TUNNELED CV CATH 345.26<br />

36565 3 INSERT TUNNELED CV CATH 1,051.51<br />

36566 3 INSERT TUNNELED CV CATH 2,941.61<br />

36568 3 INSERT PICC CATH 91.54<br />

36569 3 INSERT PICC CATH 91.63<br />

36570 3 INSERT PICVAD CATH 1,268.40<br />

36571 3 INSERT PICVAD CATH 298.58<br />

36575 3 REPAIR TUNNELED CV CATH 173.42<br />

36576 3 REPAIR TUNNELED CV CATH 367.58<br />

36578 3 REPLACE TUNNELED CV CATH 524.34<br />

36580 3 REPLACE CVAD CATH 66.43<br />

36581 3 REPLACE TUNNELED CV CATH 194.68<br />

36582 3 REPLACE TUNNELED CV CATH 1,118.36<br />

36583 3 REPLACE TUNNELED CV CATH 1,121.08<br />

36584 3 REPLACE PICC CATH 261.65

---

36585 3 REPLACE PICVAD CATH 1,160.35<br />

36589 3 REMOVAL TUNNELED CV CATH 164.77<br />

36590 3 REMOVAL TUNNELED CV CATH 263.16<br />

36591 3 DRAW BLOOD OFF VENOUS <strong>DE</strong>VICE 21.54<br />

36592 3 COLLECT BLOOD FROM PICC 26.66<br />

36593 3 <strong>DE</strong>CLOT VASCULAR <strong>DE</strong>VICE 34.56<br />

36595 3 MECH REMOV TUNNELED CV CATH 680.67<br />

36596 3 MECH REMOV TUNNELED CV CATH 150.04<br />

36597 3 REPOSITION VENOUS CATHETER 130.62<br />

36598 3 INJ W/FLUOR, EVAL CV <strong>DE</strong>VICE 122.11<br />

36600 3 WITHDRAWAL OF ARTERIAL BLOOD 30.65<br />

36620 3 INSERTION CATHETER, ARTERY 48.44<br />

36625 3 INSERTION CATHETER, ARTERY 99.77<br />

36640 3 INSERTION CATHETER, ARTERY 115.61<br />

36660 3 INSERTION CATHETER, ARTERY 68.03<br />

36680 3 INSERT NEEDLE, BONE CAVITY 59.42<br />

36800 3 INSERTION OF CANNULA 155.51<br />

36810 3 INSERTION OF CANNULA 206.72<br />

36815 3 INSERTION OF CANNULA 142.58<br />

36818 3 AV FUSE, UPPR ARM, CEPHALIC 663.64<br />

36819 3 AV FUSE, UPPR ARM, BASILIC 772.10<br />

36820 3 AV FUSION/FOREARM VEIN 774.56<br />

36821 3 AV FUSION DIRECT ANY SITE 515.94<br />

36822 3 INSERTION OF CANNULA(S) 369.87<br />

36823 3 INSERTION OF CANNULA(S) 1,213.98<br />

36825 3 ARTERY-VEIN AUTOGRAFT 561.74<br />

36830 3 ARTERY-VEIN NONAUTOGRAFT 640.26<br />

36831 3 OPEN THROMBECT AV FISTULA 444.18<br />

36832 3 AV FISTULA REVISION, OPEN 565.22<br />

36833 3 AV FISTULA REVISION 637.25<br />

36834 3 REPAIR A-V ANEURYSM 594.18<br />

36835 3 ARTERY TO VEIN SHUNT 439.39<br />

36838 3 DIST REVAS LIGATION, HEMO 1,144.78<br />

36840 O INSERTION MANDRIL 0.00<br />

36845 O ANASTOMOSIS MANDRIL 0.00<br />

36860 3 EXTERNAL CANNULA <strong>DE</strong>CLOTTING 172.52<br />

36861 3 CANNULA <strong>DE</strong>CLOTTING 146.59<br />

36870 3 PERCUT THROMBECT AV FISTULA 300.24<br />

37140 3 REVISION OF CIRCULATION 1,293.56<br />

37145 3 REVISION OF CIRCULATION 1,401.90<br />

37160 3 REVISION OF CIRCULATION 1,206.18<br />

37180 3 REVISION OF CIRCULATION 1,370.34<br />

37181 3 SPLICE SPLEEN/KIDNEY VEINS 1,449.62<br />

37182 3 INSERT HEPATIC SHUNT (TIPS) 848.80<br />

37183 3 REMOVE HEPATIC SHUNT (TIPS) 404.99<br />

37184 3 PRIM ART MECH THROMBECTOMY 2,704.54<br />

37185 3 PRIM ART M-THROMBECT ADD-ON 890.60<br />

37186 3 SEC ART M-THROMBECT ADD-ON 1,835.73<br />

37187 3 VENOUS MECH THROMBECTOMY 408.12<br />

37188 3 VENOUS M-THROMBECTOMY ADD-ON 2,256.02

---

37190 O PLASTIC REPAIR OF ARTERIOVENOUS ANE 0.00<br />

37195 3 THROMBOLYTIC THERAPY, STROKE 326.02<br />

37200 3 TRANSCATHETER BIOPSY 224.56<br />

37201 3 TRANSCATHETER THERAPY INFUSE 274.81<br />

37202 3 TRANSCATHETER THERAPY INFUSE 330.38<br />

37203 3 TRANSCATHETER RETRIEVAL 259.83<br />

37204 3 TRANSCATHETER OCCLUSION 896.79<br />

37205 3 TRANSCATH IV STENT, PERCUT 435.78<br />

37206 3 TRANSCATH IV STENT/PERC ADDL 207.97<br />

37207 3 TRANSCATH IV STENT, OPEN 423.93<br />

37208 3 TRANSCATH IV STENT/OPEN ADDL 204.06<br />

37209 3 CHANGE IV CATH AT THROMB TX 110.96<br />

37210 3 EMBOLIZATION UTERINE FIBROID 521.80<br />

37215 3 TRANSCATH STENT, CCA W/EPS 1,070.65<br />

37216 3 TRANSCATH STENT, CCA W/O EPS 956.79<br />

37250 3 IV US FIRST VESSEL ADD-ON 107.35<br />

37251 3 IV US EACH ADD VESSEL ADD-ON 80.37<br />

37500 3 ENDOSCOPY LIGATE PERF VEINS 676.79<br />

37501 5 VASCULAR ENDOSCOPY PROCEDURE 0.00<br />

37565 3 LIGATION OF NECK VEIN 656.88<br />

37600 3 LIGATION OF NECK ARTERY 687.69<br />

37605 3 LIGATION OF NECK ARTERY 783.36<br />

37606 3 LIGATION OF NECK ARTERY 517.44<br />

37607 3 LIGATION OF A-V FISTULA 364.45<br />

37609 3 TEMPORAL ARTERY PROCEDURE 284.23<br />

37615 3 LIGATION OF NECK ARTERY 443.27<br />

37616 3 LIGATION OF CHEST ARTERY 1,024.45<br />

37617 3 LIGATION OF ABDOMEN ARTERY 1,227.80<br />

37618 3 LIGATION OF EXTREMITY ARTERY 358.91<br />

37620 3 REVISION OF MAJOR VEIN 636.15<br />

37650 3 REVISION OF MAJOR VEIN 490.69<br />

37660 3 REVISION OF MAJOR VEIN 1,154.21<br />

37700 3 REVISE LEG VEIN 245.04<br />

37718 3 LIGATE/STRIP SHORT LEG VEIN 391.59<br />

37720 O REMOVAL OF LEG VEIN 0.00<br />

37722 3 LIGATE/STRIP LONG LEG VEIN 458.96<br />

37730 O REMOVAL OF LEG VEINS 0.00<br />

37735 3 REMOVAL OF LEG VEINS/LESION 611.03<br />

37760 3 LIGATION, LEG VEINS, OPEN 598.13<br />

37765 3 PHLEB VEINS - EXTREM - TO 20 433.88<br />

37766 3 PHLEB VEINS - EXTREM 20+ 525.29<br />

37780 3 REVISION OF LEG VEIN 250.07<br />

37785 3 LIGATE/DIVI<strong>DE</strong>/EXCISE VEIN 346.37<br />

37788 3 REVASCULARIZATION, PENIS 1,269.81<br />

37790 3 PENILE VENOUS OCCLUSION 488.53<br />

37799 5 VASCULAR SURGERY PROCEDURE 0.00<br />

38100 3 REMOVAL OF SPLEEN, TOTAL 973.33<br />

38101 3 REMOVAL OF SPLEEN, PARTIAL 985.43<br />

38102 3 REMOVAL OF SPLEEN, TOTAL 237.40<br />

38115 3 REPAIR OF RUPTURED SPLEEN 1,078.15

---

38120 3 LAPAROSCOPY, SPLENECTOMY 923.57<br />

38129 5 LAPAROSCOPE PROC, SPLEEN 0.00<br />

38200 3 INJECTION FOR SPLEEN X-RAY 132.43<br />

38204 9 BL DONOR SEARCH MANAGEMENT 0.00<br />

38205 9 HARVEST ALLOGENIC STEM CELLS 0.00<br />

38206 3 HARVEST AUTO STEM CELLS 76.90<br />

38207 9 CRYOPRESERVE STEM CELLS 0.00<br />

38208 9 THAW PRESERVED STEM CELLS 0.00<br />

38209 9 WASH HARVEST STEM CELLS 0.00<br />

38210 9 T-CELL <strong>DE</strong>PLETION OF HARVEST 0.00<br />

38211 9 TUMOR CELL <strong>DE</strong>PLETE OF HARVST 0.00<br />

38212 9 RBC <strong>DE</strong>PLETION OF HARVEST 0.00<br />

38213 9 PLATELET <strong>DE</strong>PLETE OF HARVEST 0.00<br />

38214 9 VOLUME <strong>DE</strong>PLETE OF HARVEST 0.00<br />

38215 9 HARVEST STEM CELL CONCENTRTE 0.00<br />

38220 3 BONE MARROW ASPIRATION 163.96<br />

38221 3 BONE MARROW BIOPSY 180.86<br />

38230 3 BONE MARROW COLLECTION 302.20<br />

38231 O STEM CELL COLLECTION 0.00<br />

38240 3 BONE MARROW/STEM TRANSPLANT 117.67<br />

38241 3 BONE MARROW/STEM TRANSPLANT 118.06<br />

38242 3 LYMPHOCYTE INFUSE TRANSPLANT 89.23<br />

38300 3 DRAINAGE, LYMPH NO<strong>DE</strong> LESION 252.40<br />

38305 3 DRAINAGE, LYMPH NO<strong>DE</strong> LESION 418.19<br />

38308 3 INCISION OF LYMPH CHANNELS 396.71<br />

38380 3 THORACIC DUCT PROCEDURE 515.81<br />

38381 3 THORACIC DUCT PROCEDURE 761.37<br />

38382 3 THORACIC DUCT PROCEDURE 617.43<br />

38500 3 BIOPSY/REMOVAL, LYMPH NO<strong>DE</strong>S 288.31<br />

38505 3 NEEDLE BIOPSY, LYMPH NO<strong>DE</strong>S 123.00<br />

38510 3 BIOPSY/REMOVAL, LYMPH NO<strong>DE</strong>S 463.32<br />

38520 3 BIOPSY/REMOVAL, LYMPH NO<strong>DE</strong>S 413.96<br />

38525 3 BIOPSY/REMOVAL, LYMPH NO<strong>DE</strong>S 371.91<br />

38530 3 BIOPSY/REMOVAL, LYMPH NO<strong>DE</strong>S 480.69<br />

38542 9 EXPLORE <strong>DE</strong>EP NO<strong>DE</strong>(S), NECK 0.00<br />

38550 3 REMOVAL, NECK/ARMPIT LESION 424.55<br />

38555 3 REMOVAL, NECK/ARMPIT LESION 889.35<br />

38562 3 REMOVAL, PELVIC LYMPH NO<strong>DE</strong>S 632.95<br />

38564 3 REMOVAL, ABDOMEN LYMPH NO<strong>DE</strong>S 627.58<br />

38570 3 LAPAROSCOPY, LYMPH NO<strong>DE</strong> BIOP 505.41<br />

38571 3 LAPAROSCOPY, LYMPHA<strong>DE</strong>NECTOMY 777.02<br />

38572 3 LAPAROSCOPY, LYMPHA<strong>DE</strong>NECTOMY 884.47<br />

38589 5 LAPAROSCOPE PROC, LYMPHATIC 0.00<br />

38700 3 REMOVAL OF LYMPH NO<strong>DE</strong>S, NECK 702.43<br />

38720 3 REMOVAL OF LYMPH NO<strong>DE</strong>S, NECK 1,156.52<br />

38724 3 REMOVAL OF LYMPH NO<strong>DE</strong>S, NECK 1,250.66<br />

38740 3 REMOVE ARMPIT LYMPH NO<strong>DE</strong>S 593.09<br />

38745 3 REMOVE ARMPIT LYMPH NO<strong>DE</strong>S 754.68<br />

38746 3 REMOVE THORACIC LYMPH NO<strong>DE</strong>S 246.29<br />

38747 3 REMOVE ABDOMINAL LYMPH NO<strong>DE</strong>S 242.35

---

38760 3 REMOVE GROIN LYMPH NO<strong>DE</strong>S 745.20<br />

38765 3 REMOVE GROIN LYMPH NO<strong>DE</strong>S 1,149.51<br />

38770 3 REMOVE PELVIS LYMPH NO<strong>DE</strong>S 760.55<br />

38780 3 REMOVE ABDOMEN LYMPH NO<strong>DE</strong>S 969.53<br />

38790 3 INJECT FOR LYMPHATIC X-RAY 77.25<br />

38792 3 I<strong>DE</strong>NTIFY SENTINEL NO<strong>DE</strong> 37.59<br />

38794 3 ACCESS THORACIC LYMPH DUCT 292.57<br />

38999 5 BLOOD/LYMPH SYSTEM PROCEDURE 0.00<br />

39000 3 EXPLORATION OF CHEST 455.95<br />

39010 3 EXPLORATION OF CHEST 769.49<br />

39020 O MEDIASTINOTOMY WITH EXPLORATION, DR 0.00<br />

39200 3 REMOVAL CHEST LESION 840.19<br />

39220 3 REMOVAL CHEST LESION 1,074.68<br />

39400 3 VISUALIZATION OF CHEST 472.40<br />

39499 5 CHEST PROCEDURE 0.00<br />

39501 3 REPAIR DIAPHRAGM LACERATION 765.18<br />

39502 3 REPAIR PARAESOPHAGEAL HERNIA 914.03<br />

39503 3 REPAIR OF DIAPHRAGM HERNIA 5,205.63<br />

39520 3 REPAIR OF DIAPHRAGM HERNIA 921.95<br />

39530 3 REPAIR OF DIAPHRAGM HERNIA 875.12<br />

39531 3 REPAIR OF DIAPHRAGM HERNIA 924.45<br />

39540 3 REPAIR OF DIAPHRAGM HERNIA 779.86<br />

39541 3 REPAIR OF DIAPHRAGM HERNIA 837.54<br />

39545 3 REVISION OF DIAPHRAGM 833.72<br />

39547 O IMBRICATION OF DIAPHRAGM FOR EVENTR 0.00<br />

39560 3 RESECT DIAPHRAGM, SIMPLE 718.92<br />

39561 3 RESECT DIAPHRAGM, COMPLEX 1,109.20<br />

39599 5 DIAPHRAGM SURGERY PROCEDURE 0.00<br />

4000F 9 TOBACCO USE TXMNT COUNSELING 0.00<br />

4001F 9 TOBACCO USE TXMNT, PHARMACOL 0.00<br />

4002F 9 STATIN THERAPY, RX 0.00<br />

4003F 9 PT ED WRITE/ORAL, PTS W/ HF 0.00<br />

4005F 9 PHARM THX FOR OP RXÏD 0.00<br />

4006F 9 BETA-BLOCKER THERAPY RX 0.00<br />

4007F O ANTIOX VIT/MIN SUPP RXÏD 0.00<br />

4009F 9 ACE/ARB INHIBITOR THERAPY RX 0.00<br />

4011F 9 ORAL ANTIPLATELET THERAPY RX 0.00<br />

4012F 9 WARFARIN THERAPY RX 0.00<br />

4014F 9 WRITTEN DISCHARGE INSTR PRVD 0.00<br />

4015F 9 PERSIST ASTHMA MEDICINE CTRL 0.00<br />

4016F 9 ANTI-INFLM/ANLGSC AGENT RX 0.00<br />

4017F 9 GI PROPHYLAXIS FOR NSAID RX 0.00<br />

4018F 9 THERAPY EXERCISE JOINT RX 0.00<br />

4019F 9 DOC RECPT COUNSL VIT D/CALC+ 0.00<br />

4025F 9 INHALED BRONCHODILATOR RX 0.00<br />

4030F 9 OXYGEN THERAPY RX 0.00<br />

4033F 9 PULMONARY REHAB REC 0.00<br />

4035F 9 INFLUENZA IMM REC 0.00<br />

4037F 9 INFLUENZA IMM OR<strong>DE</strong>R/ADMIN 0.00<br />

4040F 9 PNEUMOC VAC/ADMIN/RCVD 0.00

---

4041F 9 DOC OR<strong>DE</strong>R CEFAZOLIN/CEFUROX 0.00<br />

4042F 9 DOC ANTIBIO NOT GIVEN 0.00<br />

4043F 9 DOC OR<strong>DE</strong>R GIVEN STOP ANTIBIO 0.00<br />

4044F 9 DOC OR<strong>DE</strong>R GIVEN VTE PROPHYLX 0.00<br />

4045F 9 EMPIRIC ANTIBIOTIC RX 0.00<br />

4046F 9 DOC ANTIBIO GIVEN B/4 SURG 0.00<br />

4047F 9 DOC ANTIBIO GIVEN B/4 SURG 0.00<br />

4048F 9 DOC ANTIBIO GIVEN B/4 SURG 0.00<br />

40490 3 BIOPSY OF LIP 115.47<br />

4049F 9 DOC OR<strong>DE</strong>R GIVEN STOP ANTIBIO 0.00<br />

40500 3 PARTIAL EXCISION OF LIP 449.87<br />

4050F 9 HT CARE PLAN DOC 0.00<br />

40510 3 PARTIAL EXCISION OF LIP 437.89<br />

4051F 9 REFERRED FOR AN AV FISTULA 0.00<br />

40520 3 PARTIAL EXCISION OF LIP 461.22<br />

40525 3 RECONSTRUCT LIP WITH FLAP 512.13<br />

40527 3 RECONSTRUCT LIP WITH FLAP 606.18<br />

4052F 9 HEMODIALYSIS VIA AV FISTULA 0.00<br />

40530 3 PARTIAL REMOVAL OF LIP 504.05<br />

4053F 9 HEMODIALYSIS VIA AV GRAFT 0.00<br />

4054F 9 HEMODIALYSIS VIA CATHETER 0.00<br />

4055F 9 PT. RCVNG PERITON DIALYSIS 0.00<br />

4056F 9 APPROP. ORAL REHYD. RECOMMD 0.00<br />

4058F 9 PED GASTRO ED GIVEN, CAREGVR 0.00<br />

4060F 9 PSYCH SVCS PROVI<strong>DE</strong>D 0.00<br />

4062F 9 PT REFERRAL PSYCH DOCÏD 0.00<br />

4064F 9 ANTI<strong>DE</strong>PRESSANT RX 0.00<br />

40650 3 REPAIR LIP 387.80<br />

40652 3 REPAIR LIP 456.79<br />

40654 3 REPAIR LIP 528.41<br />

4065F 9 ANTIPSYCHOTIC RX 0.00<br />

4066F 9 ECT PROVI<strong>DE</strong>D 0.00<br />

4067F 9 PT REFERRAL FOR ECT DOCÏD 0.00<br />

40700 3 REPAIR CLEFT LIP/NASAL 850.72<br />

40701 3 REPAIR CLEFT LIP/NASAL 1,003.33<br />

40702 3 REPAIR CLEFT LIP/NASAL 790.85<br />

4070F 9 DVT PROPHYLX RECVÏD DAY 2 0.00<br />

40720 3 REPAIR CLEFT LIP/NASAL 928.17<br />

4073F 9 ORAL ANTIPLAT THX RX DISCHRG 0.00<br />

4075F 9 ANTICOAG THX RX AT DISCHRG 0.00<br />

40761 3 REPAIR CLEFT LIP/NASAL 974.74<br />

4077F 9 DOC T-PA ADMIN CONSI<strong>DE</strong>RED 0.00<br />

40799 5 LIP SURGERY PROCEDURE 0.00<br />

4079F 9 DOC REHAB SVCS CONSI<strong>DE</strong>RED 0.00<br />

40800 3 DRAINAGE OF MOUTH LESION 178.05<br />

40801 3 DRAINAGE OF MOUTH LESION 271.28<br />

40804 3 REMOVAL, FOREIGN BODY, MOUTH 187.24<br />

40805 3 REMOVAL, FOREIGN BODY, MOUTH 291.13<br />

40806 3 INCISION OF LIP FOLD 95.38<br />

40808 3 BIOPSY OF MOUTH LESION 159.22

---

40810 3 EXCISION OF MOUTH LESION 178.34<br />

40812 3 EXCISE/REPAIR MOUTH LESION 249.71<br />

40814 3 EXCISE/REPAIR MOUTH LESION 338.50<br />

40816 3 EXCISION OF MOUTH LESION 355.33<br />

40818 3 EXCISE ORAL MUCOSA FOR GRAFT 315.02<br />

40819 3 EXCISE LIP OR CHEEK FOLD 269.20<br />

40820 3 TREATMENT OF MOUTH LESION 228.92<br />

40830 3 REPAIR MOUTH LACERATION 218.73<br />

40831 3 REPAIR MOUTH LACERATION 288.34<br />

40840 3 RECONSTRUCTION OF MOUTH 727.98<br />

40842 3 RECONSTRUCTION OF MOUTH 737.03<br />

40843 3 RECONSTRUCTION OF MOUTH 927.29<br />

40844 3 RECONSTRUCTION OF MOUTH 1,230.82<br />

40845 3 RECONSTRUCTION OF MOUTH 1,359.45<br />

4084F 9 ASPIRIN RECVÏD W/IN 24 HRS 0.00<br />

40899 5 MOUTH SURGERY PROCEDURE 0.00<br />

4090F 9 PT RCVNG EPO THXPY 0.00<br />

4095F 9 PT NOT RCVNG EPO THXPY 0.00<br />

41000 3 DRAINAGE OF MOUTH LESION 144.22<br />

41005 3 DRAINAGE OF MOUTH LESION 197.75<br />

41006 3 DRAINAGE OF MOUTH LESION 322.69<br />

41007 3 DRAINAGE OF MOUTH LESION 322.00<br />

41008 3 DRAINAGE OF MOUTH LESION 328.22<br />

41009 3 DRAINAGE OF MOUTH LESION 349.58<br />

4100F 9 BIPHOS THXPY VEIN ORD/RECÏVD 0.00<br />

41010 3 INCISION OF TONGUE FOLD 182.65<br />

41015 3 DRAINAGE OF MOUTH LESION 379.32<br />

41016 3 DRAINAGE OF MOUTH LESION 387.99<br />

41017 3 DRAINAGE OF MOUTH LESION 391.53<br />

41018 3 DRAINAGE OF MOUTH LESION 448.32<br />

41019 3 PLACE NEEDLES H&N FOR RT 446.08<br />

41100 3 BIOPSY OF TONGUE 151.74<br />

41105 3 BIOPSY OF TONGUE 150.72<br />

41108 3 BIOPSY OF FLOOR OF MOUTH 129.65<br />

4110F 9 INT. MAM ART USED FOR CABG 0.00<br />

41110 3 EXCISION OF TONGUE LESION 186.45<br />

41112 3 EXCISION OF TONGUE LESION 293.85<br />

41113 3 EXCISION OF TONGUE LESION 321.25<br />

41114 3 EXCISION OF TONGUE LESION 585.47<br />

41115 3 EXCISION OF TONGUE FOLD 212.16<br />

41116 3 EXCISION OF MOUTH LESION 285.90<br />

41120 3 PARTIAL REMOVAL OF TONGUE 976.89<br />

41130 3 PARTIAL REMOVAL OF TONGUE 1,184.98<br />

41135 3 TONGUE AND NECK SURGERY 1,954.69<br />

41140 3 REMOVAL OF TONGUE 2,033.18<br />

41145 3 TONGUE REMOVAL, NECK SURGERY 2,518.52<br />

41150 3 TONGUE, MOUTH, JAW SURGERY 1,998.79<br />

41153 3 TONGUE, MOUTH, NECK SURGERY 2,151.62<br />

41155 3 TONGUE, JAW, & NECK SURGERY 2,630.75<br />

4115F 9 BETA BLCKR ADMIN W/IN 24 HRS 0.00

---

4120F 9 ANTIBIOT RXÏD/GIVEN 0.00<br />

4124F 9 ANTIBIOT NOT RXÏD/GIVEN 0.00<br />

41250 3 REPAIR TONGUE LACERATION 200.62<br />

41251 3 REPAIR TONGUE LACERATION 217.27<br />

41252 3 REPAIR TONGUE LACERATION 276.67<br />

4130F 9 TOPICAL PREP RX, AOE 0.00<br />

4131F 9 SYST ANTIMICROBIAL THX RX 0.00<br />

4132F 9 NO SYST ANTIMICROBIAL THX RX 0.00<br />

4133F 9 ANTIHIST/<strong>DE</strong>CONG RX/RECOM 0.00<br />

4134F 9 NO ANTIHIST/<strong>DE</strong>CONG RX/RECOM 0.00<br />

4135F 9 SYSTEMIC CORTICOSTEROIDS RX 0.00<br />

4136F 9 SYST CORTICOSTEROIDS NOT RX 0.00<br />

4148F 9 HEP A VAC INJXN ADMIN/RECVD 0.00<br />

4149F 9 HEP B VAC INJXN ADMIN/RECVD 0.00<br />

41500 3 FIXATION OF TONGUE 430.25<br />

4150F 9 PT RECVNG ANTIVIR TXMNT HEPC 0.00<br />

41510 3 TONGUE TO LIP SURGERY 406.65<br />

41512 6 TONGUE SUSPENSION 0.00<br />

4151F 9 PT NOT RECVNG ANTIV HEP C 0.00<br />

41520 3 RECONSTRUCTION, TONGUE FOLD 307.32<br />

4152F O DOCÏD PEGINTF/RIB THXY CONSD 0.00<br />

41530 6 TONGUE BASE VOL REDUCTION 0.00<br />

4153F 9 COMBO PEGINTF/RIB RX 0.00<br />

4154F O HEP A VAC SERIES RECOMMEN<strong>DE</strong>D 0.00<br />

4155F 9 HEP A VAC SERIES PREV RECVD 0.00<br />

4156F O HEP B VAC SERIES RECOMMEN<strong>DE</strong>D 0.00<br />

4157F 9 HEP B VAC SERIES PREV RECVD 0.00<br />

4158F 9 PT EDU RE: ALCOH DRNKNG DONE 0.00<br />

41599 5 TONGUE AND MOUTH SURGERY 0.00<br />

4159F 9 CONTRCP TALK B/4 ANTIV TXMNT 0.00<br />

4163F 9 PT COUNS 4 TXMNT OPT PROST 0.00<br />

4164F 9 ADJV HRMNL THXPY RXÏD 0.00<br />

4165F 9 3D-CRT/IMRT RECEIVED 0.00<br />

4167F 9 HD BED TILTED, 1ST DAY VENT 0.00<br />

4168F 9 PT CARE, ICU&VENT W/IN 24HRS 0.00<br />

4169F 9 NO PT CARE ICU/VENT IN 24HRS 0.00<br />

4171F 9 PT. RCVNG ESA THXPY 0.00<br />

4172F 9 PT. NOT RCVNG ESA THXPY 0.00<br />

4174F 9 COUNS., POTENT. GLAUC IMPCT 0.00<br />

4175F 9 VIS OF >=20/40 W/IN 90 DAYS 0.00<br />

4176F 9 TALK RE UV LIGHT, PT/CRGVR 0.00<br />

4177F 9 TALK PT/CRGVR RE: AREDS,PREV 0.00<br />

4178F 9 ANTID GLBLN RCVÏD W/IN 26WKS 0.00<br />

4179F 9 TAMOXIFEN/AI PRESCRIBED 0.00<br />

41800 3 DRAINAGE OF GUM LESION 190.32<br />

41805 3 REMOVAL FOREIGN BODY, GUM 191.36<br />

41806 3 REMOVAL FOREIGN BODY,JAWBONE 288.67<br />

4180F 9 ADJV THXPYRXÏD/RCVÏD STG3A-C 0.00<br />

4181F 9 CONFORMAL RADN THXPY RCVD 00 0.00<br />

41820 5 EXCISION, GUM, EACH QUADRANT 0.00

---

41821 5 EXCISION OF GUM FLAP 0.00<br />

41822 3 EXCISION OF GUM LESION 260.03<br />

41823 3 EXCISION OF GUM LESION 373.58<br />

41825 3 EXCISION OF GUM LESION 183.24<br />

41826 3 EXCISION OF GUM LESION 236.52<br />

41827 3 EXCISION OF GUM LESION 375.87<br />

41828 3 EXCISION OF GUM LESION 273.94<br />

4182F 9 NO CONFORMAL RADN THXPY 0.00<br />

41830 3 REMOVAL OF GUM TISSUE 342.98<br />

41850 5 TREATMENT OF GUM LESION 0.00<br />

4185F 9 CONTINUOUS PPI OR H2RA RCVÏD 0.00<br />

4186F 9 NO CONT. PPI OR H2RA RCVÏD 0.00<br />

41870 5 GUM GRAFT 0.00<br />

41872 3 REPAIR GUM 324.64<br />

41874 3 REPAIR TOOTH SOCKET 326.15<br />

4187F 9 ANTI RHEUM DRUGTHXPYRXÏD/GVN 0.00<br />

4188F 9 APPROP ACE/ARB TSTNG DONE 0.00<br />

41899 5 <strong>DE</strong>NTAL SURGERY PROCEDURE 0.00<br />

4189F 9 APPROP DIGOXIN TSTNG DONE 0.00<br />

4190F 9 APPROP DIURETIC TSTNG DONE 0.00<br />

4191F 9 APPROP ANTICONVULS TSTNG 0.00<br />

4192F 9 PT NOT RCVNG GLUCOCO THXPY 0.00<br />

4193F 9 PT RCVNG10MG DAILY PREDNISO 0.00<br />

4195F 9 PT RCVNG ANTI-RHEUM THXPY RA 0.00<br />

4196F 9 PTNOT RCVNG ANTI-RHM THXPYRA 0.00<br />

42000 3 DRAINAGE MOUTH ROOF LESION 145.05<br />

4200F 9 EXTERNAL BEAM TO PROST ONLY 0.00<br />

4201F 9 EXTRNL BEAM OTHER THAN PROST 0.00<br />

42100 3 BIOPSY ROOF OF MOUTH 134.67<br />

42104 3 EXCISION LESION, MOUTH ROOF 181.35<br />

42106 3 EXCISION LESION, MOUTH ROOF 230.49<br />

42107 3 EXCISION LESION, MOUTH ROOF 406.30<br />

4210F 9 ACE/ARB THXPY FOR >= 6 MONS 0.00<br />

42120 3 REMOVE PALATE/LESION 885.31<br />

42140 3 EXCISION OF UVULA 222.96<br />

42145 3 REPAIR PALATE, PHARYNX/UVULA 640.45<br />

42160 3 TREATMENT MOUTH ROOF LESION 224.41<br />

42180 3 REPAIR PALATE 218.39<br />

42182 3 REPAIR PALATE 296.61<br />

42200 3 RECONSTRUCT CLEFT PALATE 829.07<br />

42205 3 RECONSTRUCT CLEFT PALATE 849.98<br />

4220F 9 DIGOXIN THXPY FOR >= 6 MONS 0.00<br />

42210 3 RECONSTRUCT CLEFT PALATE 997.08<br />

42215 3 RECONSTRUCT CLEFT PALATE 664.47<br />

4221F 9 DIURETIC THXPY FOR >= 6 MONS 0.00<br />

42220 3 RECONSTRUCT CLEFT PALATE 536.90<br />

42225 3 RECONSTRUCT CLEFT PALATE 929.92<br />

42226 3 LENGTHENING OF PALATE 900.88<br />

42227 3 LENGTHENING OF PALATE 888.51

---

42235 3 REPAIR PALATE 726.80<br />

42260 3 REPAIR NOSE TO LIP FISTULA 771.86<br />

42280 9 PREPARATION, PALATE MOLD 0.00<br />

42281 3 INSERTION, PALATE PROSTHESIS 182.60<br />

42299 5 PALATE/UVULA SURGERY 0.00<br />

42300 3 DRAINAGE OF SALIVARY GLAND 188.21<br />

42305 3 DRAINAGE OF SALIVARY GLAND 398.03<br />

4230F 9 ANTICONV THXPY FOR >= 6 MONS 0.00<br />

42310 3 DRAINAGE OF SALIVARY GLAND 147.07<br />

42320 3 DRAINAGE OF SALIVARY GLAND 224.79<br />

42325 O CREATE SALIVARY CYST DRAIN 0.00<br />

42326 O CREATE SALIVARY CYST DRAIN 0.00<br />

42330 3 REMOVAL OF SALIVARY STONE 210.14<br />

42335 3 REMOVAL OF SALIVARY STONE 332.27<br />

42340 3 REMOVAL OF SALIVARY STONE 420.93<br />

42400 3 BIOPSY OF SALIVARY GLAND 99.95<br />

42405 3 BIOPSY OF SALIVARY GLAND 276.93<br />

42408 3 EXCISION OF SALIVARY CYST 411.25<br />

42409 3 DRAINAGE OF SALIVARY CYST 298.21<br />

4240F 9 INSTR XRCZ 4BK PN >12 WEEKS 0.00<br />

42410 3 EXCISE PAROTID GLAND/LESION 575.88<br />

42415 3 EXCISE PAROTID GLAND/LESION 1,035.86<br />

42420 3 EXCISE PAROTID GLAND/LESION 1,188.56<br />

42425 3 EXCISE PAROTID GLAND/LESION 786.10<br />

42426 3 EXCISE PAROTID GLAND/LESION 1,271.15<br />

4242F 9 SPRVSD XRCZ BK PN >12 WEEKS 0.00<br />

42440 3 EXCISE SUBMAXILLARY GLAND 426.94<br />

42450 3 EXCISE SUBLINGUAL GLAND 411.88<br />

4245F 9 PT INSTR NRML LIFEST 0.00<br />

4248F 9 PT INSTR-NO BD REST>= 4 DAYS 0.00<br />

42500 3 REPAIR SALIVARY DUCT 391.35<br />

42505 3 REPAIR SALIVARY DUCT 510.95<br />

42507 3 PAROTID DUCT DIVERSION 476.58<br />

42508 3 PAROTID DUCT DIVERSION 666.46<br />

42509 3 PAROTID DUCT DIVERSION 798.72<br />

4250F 9 WRMNG 4 SURG - NORMOTHERMIA 0.00<br />

42510 3 PAROTID DUCT DIVERSION 588.65<br />

42550 3 INJECTION FOR SALIVARY X-RAY 152.62<br />

42600 3 CLOSURE OF SALIVARY FISTULA 436.41<br />

4260F 9 WOUND SRFC CULTURETECH USED 0.00<br />

4261F 9 TECH OTHER THAN SURFC CULTR 0.00<br />

42650 3 DILATION OF SALIVARY DUCT 75.07<br />

4265F 9 WET-DRY DRESSINGS RX-RECMD 0.00<br />

42660 3 DILATION OF SALIVARY DUCT 96.25<br />

42665 3 LIGATION OF SALIVARY DUCT 274.42<br />

4266F 9 NO WET-DRY DRSSINGS RX-RECMD 0.00<br />

4267F 9 COMPRSSION THXPY PRESCRIBED 0.00<br />

4268F 9 PT ED RE COMP THXPY RCVD 0.00<br />

42699 5 SALIVARY SURGERY PROCEDURE 0.00<br />

4269F 9 APPROPOS MTHD OFFLOADING RXD 0.00

---

42700 3 DRAINAGE OF TONSIL ABSCESS 169.85<br />

4270F 9 PT RCVNG ANTI R-VIRAL THXPY 0.00<br />

4271F 9 PT RCVNG ANTI R-VIRAL THXPY 0.00<br />

42720 3 DRAINAGE OF THROAT ABSCESS 414.39<br />

42725 3 DRAINAGE OF THROAT ABSCESS 744.16<br />

4274F 9 FLU IMMUNO ADMIND RCVD 0.00<br />

4275F 9 POTENT ANTIVIR THXPY RXD 0.00<br />

4279F 9 PCP PROPHYLAXIS RXD 0.00<br />

42800 3 BIOPSY OF THROAT 142.67<br />

42802 3 BIOPSY OF THROAT 231.38<br />

42804 3 BIOPSY OF UPPER NOSE/THROAT 189.70<br />

42806 3 BIOPSY OF UPPER NOSE/THROAT 213.55<br />

42808 3 EXCISE PHARYNX LESION 208.50<br />

42809 3 REMOVE PHARYNX FOREIGN BODY 156.43<br />

4280F 9 PCP PROPHYLAX RXD 3MON LOW % 0.00<br />

42810 3 EXCISION OF NECK CYST 355.52<br />

42815 3 EXCISION OF NECK CYST 512.78<br />

42820 3 REMOVE TONSILS AND A<strong>DE</strong>NOIDS 271.28<br />

42821 3 REMOVE TONSILS AND A<strong>DE</strong>NOIDS 284.55<br />

42825 3 REMOVAL OF TONSILS 244.06<br />

42826 3 REMOVAL OF TONSILS 235.65<br />

42830 3 REMOVAL OF A<strong>DE</strong>NOIDS 192.46<br />

42831 3 REMOVAL OF A<strong>DE</strong>NOIDS 207.89<br />

42835 3 REMOVAL OF A<strong>DE</strong>NOIDS 168.56<br />

42836 3 REMOVAL OF A<strong>DE</strong>NOIDS 227.22<br />

42842 3 EXTENSIVE SURGERY OF THROAT 881.65<br />

42844 3 EXTENSIVE SURGERY OF THROAT 1,254.01<br />

42845 3 EXTENSIVE SURGERY OF THROAT 2,028.57<br />

42860 3 EXCISION OF TONSIL TAGS 174.03<br />

42870 3 EXCISION OF LINGUAL TONSIL 537.40<br />

42880 O EXCISION NASOPHARYNGEAL LESION (EG, 0.00<br />

42890 3 PARTIAL REMOVAL OF PHARYNX 1,251.33<br />

42892 3 REVISION OF PHARYNGEAL WALLS 1,627.64<br />

42894 3 REVISION OF PHARYNGEAL WALLS 2,091.76<br />

42900 3 REPAIR THROAT WOUND 323.31<br />

4290F 9 PT SCRNED FOR INJ DRUG USE 0.00<br />

4293F 9 PT SCRND - HGH-RSK SEX BEHAV 0.00<br />

42950 3 RECONSTRUCTION OF THROAT 749.44<br />

42953 3 REPAIR THROAT, ESOPHAGUS 954.75<br />

42955 3 SURGICAL OPENING OF THROAT 700.84<br />

42960 3 CONTROL THROAT BLEEDING 157.72<br />

42961 3 CONTROL THROAT BLEEDING 391.94<br />

42962 3 CONTROL THROAT BLEEDING 483.50<br />

42970 3 CONTROL NOSE/THROAT BLEEDING 359.42<br />

42971 3 CONTROL NOSE/THROAT BLEEDING 426.13<br />

42972 3 CONTROL NOSE/THROAT BLEEDING 484.13<br />

42999 5 THROAT SURGERY PROCEDURE 0.00<br />

43000 O ESOPHAGOTOMY, CERVICAL APPROACH; WI 0.00<br />

4300F 9 PT RCVNG WARF THXPY 0.00<br />

4301F 9 PT NOT RCVNG WARF THXPY 0.00

---

43020 3 INCISION OF ESOPHAGUS 498.55<br />

43030 3 THROAT MUSCLE SURGERY 486.21<br />

43040 O ESOPHAGOTOMY, THORACIC APPROACH; WI 0.00<br />

43045 3 INCISION OF ESOPHAGUS 1,206.33<br />

4305F 9 PT ED RE FT CARE INSPCT RCVD 0.00<br />

4306F 9 PT TLK PSYCH & RX OPD ADDIC 0.00<br />

43100 3 EXCISION OF ESOPHAGUS LESION 576.40<br />

43101 3 EXCISION OF ESOPHAGUS LESION 940.97<br />

43105 O WI<strong>DE</strong> EXCISION OF MALIGNANT LESION O 0.00<br />

43106 O WI<strong>DE</strong> EXCISION OF MALIGNANT LESION O 0.00<br />

43107 3 REMOVAL OF ESOPHAGUS 2,325.49<br />

43108 3 REMOVAL OF ESOPHAGUS 3,684.89<br />

43110 O ESOPHAGECTOMY (AT UPPER TWO-THIRDS 0.00<br />

43111 O ESOPHAGECTOMY (AT UPPER TWO-THIRDS 0.00<br />

43112 3 REMOVAL OF ESOPHAGUS 2,491.00<br />

43113 3 REMOVAL OF ESOPHAGUS 3,635.16<br />

43115 O ESOPHAGECTOMY (AT UPPER TWO-THIRDS 0.00<br />

43116 3 PARTIAL REMOVAL OF ESOPHAGUS 4,161.86<br />

43117 3 PARTIAL REMOVAL OF ESOPHAGUS 2,267.30<br />

43118 3 PARTIAL REMOVAL OF ESOPHAGUS 3,083.67<br />

43119 O TOTAL ESOPHAGECTOMY WITH GASTROPHAR 0.00<br />

43120 O ESOPHAGOGASTRECTOMY (LOWER THIRD) A 0.00<br />

43121 3 PARTIAL REMOVAL OF ESOPHAGUS 2,481.04<br />

43122 3 PARTIAL REMOVAL OF ESOPHAGUS 2,300.92<br />

43123 3 PARTIAL REMOVAL OF ESOPHAGUS 3,719.34<br />

43124 3 REMOVAL OF ESOPHAGUS 3,181.44<br />

43130 3 REMOVAL OF ESOPHAGUS POUCH 729.43<br />

43135 3 REMOVAL OF ESOPHAGUS POUCH 1,308.22<br />

43136 O DIVERTICULOPEXY OF HYPOPHARYNX, WIT 0.00<br />

43200 3 ESOPHAGUS ENDOSCOPY 212.38<br />

43201 3 ESOPH SCOPE W/SUBMUCOUS INJ 277.12<br />

43202 3 ESOPHAGUS ENDOSCOPY, BIOPSY 279.24<br />

43204 3 ESOPH SCOPE W/SCLEROSIS INJ 205.58<br />

43205 3 ESOPHAGUS ENDOSCOPY/LIGATION 206.94<br />

4320F 9 PT TALK PSYCHSOC+RX OH DPND 0.00<br />

43215 3 ESOPHAGUS ENDOSCOPY 143.48<br />

43216 3 ESOPHAGUS ENDOSCOPY/LESION 168.61<br />

43217 3 ESOPHAGUS ENDOSCOPY 372.24<br />

43219 3 ESOPHAGUS ENDOSCOPY 159.26<br />

43220 3 ESOPH ENDOSCOPY, DILATION 117.58<br />

43226 3 ESOPH ENDOSCOPY, DILATION 130.58<br />

43227 3 ESOPH ENDOSCOPY, REPAIR 193.31<br />

43228 3 ESOPH ENDOSCOPY, ABLATION 205.19<br />

43231 3 ESOPH ENDOSCOPY W/US EXAM 175.20<br />

43232 3 ESOPH ENDOSCOPY W/US FN BX 244.40<br />

43234 3 UPPER GI ENDOSCOPY, EXAM 276.20<br />

43235 3 UPPR GI ENDOSCOPY, DIAGNOSIS 292.25<br />

43236 3 UPPR GI SCOPE W/SUBMUC INJ 363.27<br />

43237 3 ENDOSCOPIC US EXAM, ESOPH 221.46<br />

43238 3 UPPR GI ENDOSCOPY W/US FN BX 272.23

---

43239 3 UPPER GI ENDOSCOPY, BIOPSY 335.67<br />

43240 3 ESOPH ENDOSCOPE W/DRAIN CYST 364.83<br />

43241 3 UPPER GI ENDOSCOPY WITH TUBE 143.19<br />

43242 3 UPPR GI ENDOSCOPY W/US FN BX 389.57<br />

43243 3 UPPER GI ENDOSCOPY & INJECT 246.40<br />

43244 3 UPPER GI ENDOSCOPY/LIGATION 272.80<br />

43245 3 UPPR GI SCOPE DILATE STRICTR 172.95<br />

43246 3 PLACE GASTROSTOMY TUBE 231.14<br />

43247 3 OPERATIVE UPPER GI ENDOSCOPY 184.90<br />

43248 3 UPPR GI ENDOSCOPY/GUI<strong>DE</strong> WIRE 174.06<br />

43249 3 ESOPH ENDOSCOPY, DILATION 160.18<br />

43250 3 UPPER GI ENDOSCOPY/TUMOR 173.72<br />

43251 3 OPERATIVE UPPER GI ENDOSCOPY 200.61<br />

43255 3 OPERATIVE UPPER GI ENDOSCOPY 260.57<br />

43256 3 UPPR GI ENDOSCOPY W/STENT 234.46<br />

43257 3 UPPR GI SCOPE W/THRML TXMNT 282.40<br />

43258 3 OPERATIVE UPPER GI ENDOSCOPY 245.62<br />

43259 3 ENDOSCOPIC ULTRASOUND EXAM 278.39<br />

43260 3 ENDO CHOLANGIOPANCREATOGRAPH 319.54<br />

43261 3 ENDO CHOLANGIOPANCREATOGRAPH 335.94<br />

43262 3 ENDO CHOLANGIOPANCREATOGRAPH 394.53<br />

43263 3 ENDO CHOLANGIOPANCREATOGRAPH 388.70<br />

43264 3 ENDO CHOLANGIOPANCREATOGRAPH 473.39<br />

43265 3 ENDO CHOLANGIOPANCREATOGRAPH 531.59<br />

43267 3 ENDO CHOLANGIOPANCREATOGRAPH 387.84<br />

43268 3 ENDO CHOLANGIOPANCREATOGRAPH 399.64<br />

43269 3 ENDO CHOLANGIOPANCREATOGRAPH 437.01<br />

43271 3 ENDO CHOLANGIOPANCREATOGRAPH 394.14<br />

43272 3 ENDO CHOLANGIOPANCREATOGRAPH 395.32<br />

43273 6 ENDOSCOPIC PANCREATOSCOPY 0.00<br />

43279 6 LAP MYOTOMY, HELLER 0.00<br />

43280 3 LAPAROSCOPY, FUNDOPLASTY 951.63<br />

43289 5 LAPAROSCOPE PROC, ESOPH 0.00<br />

43300 3 REPAIR OF ESOPHAGUS 577.56<br />

43305 3 REPAIR ESOPHAGUS AND FISTULA 1,029.68<br />

43310 3 REPAIR OF ESOPHAGUS 1,405.15<br />

43312 3 REPAIR ESOPHAGUS AND FISTULA 1,546.14<br />

43313 3 ESOPHAGOPLASTY CONGENITAL 2,509.39<br />

43314 3 TRACHEO-ESOPHAGOPLASTY CONG 2,673.62<br />

43320 3 FUSE ESOPHAGUS & STOMACH 1,217.55<br />

43321 O ESOPHAGOGASTROSTOMY (CARDIOPLASTY), 0.00<br />

43324 3 REVISE ESOPHAGUS & STOMACH 1,193.59<br />

43325 3 REVISE ESOPHAGUS & STOMACH 1,176.94<br />

43326 3 REVISE ESOPHAGUS & STOMACH 1,199.52<br />

43330 3 REPAIR OF ESOPHAGUS 1,153.34<br />

43331 3 REPAIR OF ESOPHAGUS 1,250.40<br />

43340 3 FUSE ESOPHAGUS & INTESTINE 1,207.13<br />

43341 3 FUSE ESOPHAGUS & INTESTINE 1,290.65<br />

43350 3 SURGICAL OPENING, ESOPHAGUS 1,034.98<br />

43351 3 SURGICAL OPENING, ESOPHAGUS 1,221.14

---

43352 3 SURGICAL OPENING, ESOPHAGUS 981.94<br />

43360 3 GASTROINTESTINAL REPAIR 2,089.94<br />

43361 3 GASTROINTESTINAL REPAIR 2,365.41<br />

43400 3 LIGATE ESOPHAGUS VEINS 1,374.93<br />

43401 3 ESOPHAGUS SURGERY FOR VEINS 1,358.54<br />

43405 3 LIGATE/STAPLE ESOPHAGUS 1,315.10<br />

43410 3 REPAIR ESOPHAGUS WOUND 904.06<br />

43415 3 REPAIR ESOPHAGUS WOUND 1,541.38<br />

43420 3 REPAIR ESOPHAGUS OPENING 899.53<br />

43425 3 REPAIR ESOPHAGUS OPENING 1,336.58<br />

43450 3 DILATE ESOPHAGUS 154.89<br />

43451 O DILATION OF ESOPHAGUS, BY UNGUI<strong>DE</strong>D 0.00<br />

43453 3 DILATE ESOPHAGUS 298.01<br />

43455 O DILATION OF ESOPHAGUS, BY BALLOON O 0.00<br />

43456 3 DILATE ESOPHAGUS 142.91<br />

43458 3 DILATE ESOPHAGUS 377.83<br />

43460 3 PRESSURE TREATMENT ESOPHAGUS 201.52<br />

43496 5 FREE JEJUNUM FLAP, MICROVASC 0.00<br />

43499 5 ESOPHAGUS SURGERY PROCEDURE 0.00<br />

43500 3 SURGICAL OPENING OF STOMACH 675.63<br />

43501 3 SURGICAL REPAIR OF STOMACH 1,163.08<br />

43502 3 SURGICAL REPAIR OF STOMACH 1,321.26<br />

43510 3 SURGICAL OPENING OF STOMACH 862.09<br />

43520 3 INCISION OF PYLORIC MUSCLE 618.59<br />

43600 3 BIOPSY OF STOMACH 96.77<br />

43605 3 BIOPSY OF STOMACH 718.52<br />

43610 3 EXCISION OF STOMACH LESION 848.42<br />

43611 3 EXCISION OF STOMACH LESION 1,052.66<br />

43620 3 REMOVAL OF STOMACH 1,717.47<br />

43621 3 REMOVAL OF STOMACH 1,935.32<br />

43622 3 REMOVAL OF STOMACH 1,974.12<br />

43625 O GASTRECTOMY, TOTAL WITH REPAIR BY I 0.00<br />

43630 O HEMIGASTRECTOMY OR DISTAL SUBTOTAL 0.00<br />

43631 3 REMOVAL OF STOMACH, PARTIAL 1,264.58<br />

43632 3 REMOVAL OF STOMACH, PARTIAL 1,677.72<br />

43633 3 REMOVAL OF STOMACH, PARTIAL 1,604.94<br />

43634 3 REMOVAL OF STOMACH, PARTIAL 1,766.94<br />

43635 3 REMOVAL OF STOMACH, PARTIAL 101.69<br />

43638 O REMOVAL OF STOMACH, PARTIAL 0.00<br />

43639 O REMOVAL OF STOMACH, PARTIAL 0.00<br />

43640 3 VAGOTOMY & PYLORUS REPAIR 1,012.93<br />

43641 3 VAGOTOMY & PYLORUS REPAIR 1,028.97<br />

43644 3 LAP GASTRIC BYPASS/ROUX-EN-Y 1,504.45<br />

43645 3 LAP GASTR BYPASS INCL SMLL I 1,610.91<br />

43647 6 LAP IMPL ELECTRO<strong>DE</strong>, ANTRUM 0.00<br />

43648 6 LAP REVISE/REMV ELTRD ANTRUM 0.00<br />

43651 3 LAPAROSCOPY, VAGUS NERVE 567.36<br />

43652 3 LAPAROSCOPY, VAGUS NERVE 673.11<br />

43653 3 LAPAROSCOPY, GASTROSTOMY 484.03<br />

43659 5 LAPAROSCOPE PROC, STOM 0.00

---

43750 O PLACE GASTROSTOMY TUBE 0.00<br />

43752 3 NASAL/OROGASTRIC W/STENT 38.16<br />

43760 3 CHANGE GASTROSTOMY TUBE 48.43<br />

43761 3 REPOSITION GASTROSTOMY TUBE 115.28<br />

43770 3 LAP PLACE GASTR ADJ <strong>DE</strong>VICE 967.56<br />

43771 3 LAP REVISE GASTR ADJ <strong>DE</strong>VICE 1,104.42<br />

43772 3 LAP RMVL GASTR ADJ <strong>DE</strong>VICE 830.90<br />

43773 3 LAP REPLACE GASTR ADJ <strong>DE</strong>VICE 1,104.32<br />

43774 3 LAP RMVL GASTR ADJ ALL PARTS 836.37<br />

43800 3 RECONSTRUCTION OF PYLORUS 805.02<br />

43810 3 FUSION OF STOMACH AND BOWEL 869.27<br />

43820 3 FUSION OF STOMACH AND BOWEL 1,104.94<br />

43825 3 FUSION OF STOMACH AND BOWEL 1,121.88<br />

43830 3 PLACE GASTROSTOMY TUBE 598.76<br />

43831 3 PLACE GASTROSTOMY TUBE 500.36<br />

43832 3 PLACE GASTROSTOMY TUBE 917.72<br />

43840 3 REPAIR OF STOMACH LESION 1,124.20<br />

43842 3 V-BAND GASTROPLASTY 1,067.04<br />

43843 3 GASTROPLASTY W/O V-BAND 1,094.35<br />

43844 O GASTRIC BYPASS, OTHER THAN WITH ROU 0.00<br />

43845 3 GASTRIC RESTRICTIVE PROCEDURE 1,708.81<br />

43846 3 GASTRIC BYPASS FOR OBESITY 1,411.61<br />

43847 3 GASTRIC BYPASS INCL SMALL I 1,547.52<br />

43848 3 REVISION GASTROPLASTY 1,673.99<br />

43850 3 REVISE STOMACH-BOWEL FUSION 1,407.82<br />

43855 3 REVISE STOMACH-BOWEL FUSION 1,465.34<br />

43860 3 REVISE STOMACH-BOWEL FUSION 1,422.24<br />

43865 3 REVISE STOMACH-BOWEL FUSION 1,482.78<br />

43870 3 REPAIR STOMACH OPENING 608.74<br />

43880 3 REPAIR STOMACH-BOWEL FISTULA 1,391.29<br />

43881 6 IMPL/REDO ELECTRD, ANTRUM 0.00<br />

43882 6 REVISE/REMOVE ELECTRD ANTRUM 0.00<br />

43885 O ANTERIOR GASTROPEXY FOR HIATAL HERN 0.00<br />

43886 3 REVISE GASTRIC PORT, OPEN 290.86<br />

43887 3 REMOVE GASTRIC PORT, OPEN 273.21<br />

43888 3 CHANGE GASTRIC PORT, OPEN 388.63<br />

43999 5 STOMACH SURGERY PROCEDURE 0.00<br />

44005 3 FREEING OF BOWEL ADHESION 948.67<br />

44010 3 INCISION OF SMALL BOWEL 745.47<br />

44015 3 INSERT NEEDLE CATH BOWEL 129.99<br />

44020 3 EXPLORE SMALL INTESTINE 837.10<br />

44021 3 <strong>DE</strong>COMPRESS SMALL BOWEL 844.01<br />

44025 3 INCISION OF LARGE BOWEL 851.05<br />

44040 O EXTERIORIZATION OF INTESTINE (MIKUL 0.00<br />

44050 3 REDUCE BOWEL OBSTRUCTION 810.46<br />

44055 3 CORRECT MALROTATION OF BOWEL 1,290.48<br />

44100 3 BIOPSY OF BOWEL 105.05<br />

44110 3 EXCISE INTESTINE LESION(S) 730.38<br />

44111 3 EXCISION OF BOWEL LESION(S) 852.90<br />

44120 3 REMOVAL OF SMALL INTESTINE 1,049.44

---

44121 3 REMOVAL OF SMALL INTESTINE 219.66<br />

44125 3 REMOVAL OF SMALL INTESTINE 1,023.87<br />

44126 3 ENTERECTOMY W/O TAPER, CONG 2,108.82<br />

44127 3 ENTERECTOMY W/TAPER, CONG 2,452.67<br />

44128 3 ENTERECTOMY CONG, ADD-ON 222.51<br />

44130 3 BOWEL TO BOWEL FUSION 1,080.45<br />

44131 O ENTEROENTEROSTOMY, ANASTOMOSIS OF I 0.00<br />

44132 9 ENTERECTOMY, CADAVER DONOR 0.00<br />

44133 5 ENTERECTOMY, LIVE DONOR 0.00<br />

44135 5 INTESTINE TRANSPLNT, CADAVER 0.00<br />

44136 5 INTESTINE TRANSPLANT, LIVE 0.00<br />

44137 6 REMOVE INTESTINAL ALLOGRAFT 0.00<br />

44139 3 MOBILIZATION OF COLON 109.72<br />

44140 3 PARTIAL REMOVAL OF COLON 1,170.76<br />

44141 3 PARTIAL REMOVAL OF COLON 1,514.54<br />

44143 3 PARTIAL REMOVAL OF COLON 1,439.83<br />

44144 3 PARTIAL REMOVAL OF COLON 1,491.65<br />

44145 3 PARTIAL REMOVAL OF COLON 1,461.28<br />

44146 3 PARTIAL REMOVAL OF COLON 1,808.48<br />

44147 3 PARTIAL REMOVAL OF COLON 1,596.82<br />

44150 3 REMOVAL OF COLON 1,591.62<br />

44151 3 REMOVAL OF COLON/ILEOSTOMY 1,818.62<br />

44152 O REMOVAL OF COLON/ILEOSTOMY 0.00<br />

44153 O REMOVAL OF COLON/ILEOSTOMY 0.00<br />

44155 3 REMOVAL OF COLON/ILEOSTOMY 1,784.06<br />

44156 3 REMOVAL OF COLON/ILEOSTOMY 1,959.84<br />

44157 3 COLECTOMY W/ILEOANAL ANAST 1,992.39<br />

44158 3 COLECTOMY W/NEO-RECTUM POUCH 2,043.50<br />

44160 3 REMOVAL OF COLON 1,074.99<br />

44180 3 LAP, ENTEROLYSIS 807.10<br />

44186 3 LAP, JEJUNOSTOMY 571.36<br />

44187 3 LAP, ILEO/JEJUNO-STOMY 966.30<br />

44188 3 LAP, COLOSTOMY 1,062.08<br />

44200 O LAPAROSCOPY, ENTEROLYSIS 0.00<br />

44201 O LAPAROSCOPY, JEJUNOSTOMY 0.00<br />

44202 3 LAP, ENTERECTOMY 1,212.09<br />

44203 3 LAP RESECT S/INTESTINE, ADDL 218.97<br />

44204 3 LAPARO PARTIAL COLECTOMY 1,354.07<br />

44205 3 LAP COLECTOMY PART W/ILEUM 1,184.24<br />

44206 3 LAP PART COLECTOMY W/STOMA 1,534.68<br />

44207 3 L COLECTOMY/COLOPROCTOSTOMY 1,611.30<br />

44208 3 L COLECTOMY/COLOPROCTOSTOMY 1,758.02<br />

44209 O LAPAROSCOPE PROC, INTESTINE 0.00<br />

44210 3 LAPARO TOTAL PROCTOCOLECTOMY 1,567.94<br />

44211 3 LAP COLECTOMY W/PROCTECTOMY 1,930.02<br />

44212 3 LAPARO TOTAL PROCTOCOLECTOMY 1,803.47<br />

44213 3 LAP, MOBIL SPLENIC FL ADD-ON 172.54<br />

44227 3 LAP, CLOSE ENTEROSTOMY 1,461.94<br />

44238 5 LAPAROSCOPE PROC, INTESTINE 0.00<br />

44239 O LAPAROSCOPE PROC, RECTUM 0.00

---

44300 3 OPEN BOWEL TO SKIN 727.37<br />

44305 O ENTEROSTOMY OR CECOSTOMY, TUBE (EG, 0.00<br />

44310 3 ILEOSTOMY/JEJUNOSTOMY 909.59<br />

44312 3 REVISION OF ILEOSTOMY 513.71<br />

44314 3 REVISION OF ILEOSTOMY 877.55<br />

44316 3 <strong>DE</strong>VISE BOWEL POUCH 1,208.65<br />

44320 3 COLOSTOMY 1,036.69<br />

44322 3 COLOSTOMY WITH BIOPSIES 839.27<br />

44340 3 REVISION OF COLOSTOMY 519.48<br />

44345 3 REVISION OF COLOSTOMY 908.13<br />

44346 3 REVISION OF COLOSTOMY 1,016.92<br />

44360 3 SMALL BOWEL ENDOSCOPY 144.56<br />

44361 3 SMALL BOWEL ENDOSCOPY/BIOPSY 159.11<br />

44363 3 SMALL BOWEL ENDOSCOPY 189.55<br />

44364 3 SMALL BOWEL ENDOSCOPY 202.35<br />

44365 3 SMALL BOWEL ENDOSCOPY 180.14<br />

44366 3 SMALL BOWEL ENDOSCOPY 239.14<br />

44369 3 SMALL BOWEL ENDOSCOPY 243.29<br />

44370 3 SMALL BOWEL ENDOSCOPY/STENT 262.76<br />

44372 3 SMALL BOWEL ENDOSCOPY 235.31<br />

44373 3 SMALL BOWEL ENDOSCOPY 188.76<br />

44376 3 SMALL BOWEL ENDOSCOPY 278.85<br />

44377 3 SMALL BOWEL ENDOSCOPY/BIOPSY 295.37<br />

44378 3 SMALL BOWEL ENDOSCOPY 380.36<br />

44379 3 S BOWEL ENDOSCOPE W/STENT 405.89<br />

44380 3 SMALL BOWEL ENDOSCOPY 63.37<br />

44382 3 SMALL BOWEL ENDOSCOPY 75.40<br />

44383 3 ILEOSCOPY W/STENT 162.60<br />

44385 3 ENDOSCOPY OF BOWEL POUCH 228.54<br />

44386 3 ENDOSCOPY, BOWEL POUCH/BIOP 339.56<br />

44388 3 COLONOSCOPY 323.51<br />

44389 3 COLONOSCOPY WITH BIOPSY 384.56<br />

44390 3 COLONOSCOPY FOR FOREIGN BODY 442.98<br />

44391 3 COLONOSCOPY FOR BLEEDING 504.18<br />

44392 3 COLONOSCOPY & POLYPECTOMY 414.06<br />

44393 3 COLONOSCOPY, LESION REMOVAL 469.98<br />

44394 3 COLONOSCOPY W/SNARE 482.08<br />

44397 3 COLONOSCOPY W/STENT 248.86<br />

44500 9 INTRO, GASTROINTESTINAL TUBE 0.00<br />

44600 O SUTURE OF INTESTINE (ENTERORRHAPHY) 0.00<br />

44602 3 SUTURE, SMALL INTESTINE 1,174.12<br />

44603 3 SUTURE, SMALL INTESTINE 1,341.42<br />

44604 3 SUTURE, LARGE INTESTINE 921.28<br />

44605 3 REPAIR OF BOWEL LESION 1,139.52<br />

44610 O SUTURE OF INTESTINE (ENTERORRHAPHY) 0.00<br />

44615 3 INTESTINAL STRICTUROPLASTY 934.34<br />

44620 3 REPAIR BOWEL OPENING 744.65<br />

44625 3 REPAIR BOWEL OPENING 883.52<br />

44626 3 REPAIR BOWEL OPENING 1,408.03<br />

44640 3 REPAIR BOWEL-SKIN FISTULA 1,226.69

---

44650 3 REPAIR BOWEL FISTULA 1,274.12<br />

44660 3 REPAIR BOWEL-BLAD<strong>DE</strong>R FISTULA 1,227.25<br />

44661 3 REPAIR BOWEL-BLAD<strong>DE</strong>R FISTULA 1,380.67<br />

44680 3 SURGICAL REVISION, INTESTINE 924.15<br />

44700 3 SUSPEND BOWEL W/PROSTHESIS 896.56<br />

44701 3 INTRAOP COLON LAVAGE ADD-ON 151.87<br />

44715 9 PREPARE DONOR INTESTINE 0.00<br />

44720 9 PREP DONOR INTESTINE/VENOUS 0.00<br />

44721 9 PREP DONOR INTESTINE/ARTERY 0.00<br />

44799 5 UNLISTED PROCEDURE INTESTINE 0.00<br />

44800 3 EXCISION OF BOWEL POUCH 662.23<br />

44820 3 EXCISION OF MESENTERY LESION 726.70<br />

44850 3 REPAIR OF MESENTERY 646.03<br />

44899 5 BOWEL SURGERY PROCEDURE 0.00<br />

44900 3 DRAIN APP ABSCESS, OPEN 652.21<br />

44901 3 DRAIN APP ABSCESS, PERCUT 1,059.62<br />

44950 3 APPEN<strong>DE</strong>CTOMY 559.79<br />

44955 3 APPEN<strong>DE</strong>CTOMY ADD-ON 76.39<br />

44960 3 APPEN<strong>DE</strong>CTOMY 747.38<br />

44970 3 LAPAROSCOPY, APPEN<strong>DE</strong>CTOMY 513.52<br />

44979 5 LAPAROSCOPE PROC, APP 0.00<br />

45000 3 DRAINAGE OF PELVIC ABSCESS 354.29<br />

45005 3 DRAINAGE OF RECTAL ABSCESS 233.33<br />

45020 3 DRAINAGE OF RECTAL ABSCESS 455.83<br />

45100 3 BIOPSY OF RECTUM 249.31<br />

45108 3 REMOVAL OF ANORECTAL LESION 304.10<br />

45110 3 REMOVAL OF RECTUM 1,613.26<br />

45111 3 PARTIAL REMOVAL OF RECTUM 946.28<br />

45112 3 REMOVAL OF RECTUM 1,656.39<br />

45113 3 PARTIAL PROCTECTOMY 1,701.01<br />

45114 3 PARTIAL REMOVAL OF RECTUM 1,554.59<br />

45116 3 PARTIAL REMOVAL OF RECTUM 1,406.91<br />

45119 3 REMOVE RECTUM W/RESERVOIR 1,702.48<br />

45120 3 REMOVAL OF RECTUM 1,357.71<br />

45121 3 REMOVAL OF RECTUM AND COLON 1,493.18<br />

45123 3 PARTIAL PROCTECTOMY 960.71<br />

45126 3 PELVIC EXENTERATION 2,515.65<br />

45130 3 EXCISION OF RECTAL PROLAPSE 940.69<br />

45135 3 EXCISION OF RECTAL PROLAPSE 1,155.91<br />

45136 3 EXCISE ILEOANAL RESERVIOR 1,603.53<br />

45150 3 EXCISION OF RECTAL STRICTURE 337.60<br />

45160 3 EXCISION OF RECTAL LESION 855.35<br />

45170 3 EXCISION OF RECTAL LESION 671.65<br />

45180 O EXCISION AND/OR ELECTRO<strong>DE</strong>SICCATION 0.00<br />

45190 3 <strong>DE</strong>STRUCTION, RECTAL TUMOR 581.78<br />

45300 3 PROCTOSIGMOIDOSCOPY DX 96.60<br />

45302 O PROCTOSIGMOIDOSCOPY; WITH COLLECTIO 0.00<br />

45303 3 PROCTOSIGMOIDOSCOPY DILATE 812.04<br />

45305 3 PROCTOSIGMOIDOSCOPY W/BX 160.10<br />

45307 3 PROCTOSIGMOIDOSCOPY FB 184.55

---

45308 3 PROCTOSIGMOIDOSCOPY REMOVAL 156.25<br />

45309 3 PROCTOSIGMOIDOSCOPY REMOVAL 182.06<br />

45310 O PROCTOSIGMOIDOSCOPY; WITH REMOVAL O 0.00<br />

45315 3 PROCTOSIGMOIDOSCOPY REMOVAL 197.07<br />

45317 3 PROCTOSIGMOIDOSCOPY BLEED 186.31<br />

45320 3 PROCTOSIGMOIDOSCOPY ABLATE 189.52<br />

45321 3 PROCTOSIGMOIDOSCOPY VOLVUL 91.08<br />

45327 3 PROCTOSIGMOIDOSCOPY W/STENT 103.98<br />

45330 3 DIAGNOSTIC SIGMOIDOSCOPY 129.52<br />

45331 3 SIGMOIDOSCOPY AND BIOPSY 166.67<br />

45332 3 SIGMOIDOSCOPY W/FB REMOVAL 272.92<br />

45333 3 SIGMOIDOSCOPY & POLYPECTOMY 272.62<br />

45334 3 SIGMOIDOSCOPY FOR BLEEDING 151.05<br />

45335 3 SIGMOIDOSCOPY W/SUBMUC INJ 221.32<br />

45336 O SIGMOIDOSCOPY, FLEXIBLE FIBEROPTIC; 0.00<br />

45337 3 SIGMOIDOSCOPY & <strong>DE</strong>COMPRESS 130.37<br />

45338 3 SIGMOIDOSCOPY W/TUMR REMOVE 304.09<br />

45339 3 SIGMOIDOSCOPY W/ABLATE TUMR 295.34<br />

45340 3 SIG W/BALLOON DILATION 391.77<br />

45341 3 SIGMOIDOSCOPY W/ULTRASOUND 143.77<br />

45342 3 SIGMOIDOSCOPY W/US GUI<strong>DE</strong> BX 219.13<br />

45345 3 SIGMOIDOSCOPY W/STENT 158.09<br />

45355 3 SURGICAL COLONOSCOPY 187.87<br />

45378 3 DIAGNOSTIC COLONOSCOPY 380.71<br />

45379 3 COLONOSCOPY W/FB REMOVAL 479.82<br />

45380 3 COLONOSCOPY AND BIOPSY 454.82<br />

45381 3 COLONOSCOPY, SUBMUCOUS INJ 442.90<br />

45382 3 COLONOSCOPY/CONTROL BLEEDING 604.00<br />

45383 3 LESION REMOVAL COLONOSCOPY 537.09<br />

45384 3 LESION REMOVE COLONOSCOPY 445.68<br />

45385 3 LESION REMOVAL COLONOSCOPY 510.54<br />

45386 3 COLONOSCOPY DILATE STRICTURE 653.81<br />

45387 3 COLONOSCOPY W/STENT 315.55<br />

45391 3 COLONOSCOPY W/ENDOSCOPE US 275.03<br />

45392 3 COLONOSCOPY W/ENDOSCOPIC FNB 346.35<br />

45395 3 LAP, REMOVAL OF RECTUM 1,743.15<br />

45397 3 LAP, REMOVE RECTUM W/POUCH 1,883.38<br />

45400 3 LAPAROSCOPIC PROC 1,008.18<br />

45402 3 LAP PROCTOPEXY W/SIG RESECT 1,346.60<br />

45499 6 LAPAROSCOPE PROC, RECTUM 0.00<br />

45500 3 REPAIR OF RECTUM 438.72<br />

45505 3 REPAIR OF RECTUM 478.54<br />

45520 3 TREATMENT OF RECTAL PROLAPSE 108.49<br />

45540 3 CORRECT RECTAL PROLAPSE 914.49<br />

45541 3 CORRECT RECTAL PROLAPSE 791.59<br />

45550 3 REPAIR RECTUM/REMOVE SIGMOID 1,271.52<br />

45560 3 REPAIR OF RECTOCELE 628.94<br />

45562 3 EXPLORATION/REPAIR OF RECTUM 955.66<br />

45563 3 EXPLORATION/REPAIR OF RECTUM 1,399.76<br />

45800 3 REPAIR RECT/BLAD<strong>DE</strong>R FISTULA 1,065.46

---

45805 3 REPAIR FISTULA W/COLOSTOMY 1,228.79<br />

45820 3 REPAIR RECTOURETHRAL FISTULA 1,061.85<br />

45825 3 REPAIR FISTULA W/COLOSTOMY 1,261.95<br />

45900 3 REDUCTION OF RECTAL PROLAPSE 171.54<br />

45905 3 DILATION OF ANAL SPHINCTER 145.95<br />

45910 3 DILATION OF RECTAL NARROWING 173.22<br />

45915 3 REMOVE RECTAL OBSTRUCTION 283.53<br />

45990 3 SURG DX EXAM, ANORECTAL 96.16<br />

45999 5 RECTUM SURGERY PROCEDURE 0.00<br />

46000 O FISTULOTOMY, SUBCUTANEOUS 0.00<br />

46020 3 PLACEMENT OF SETON 219.07<br />

46030 3 REMOVAL OF RECTAL MARKER 109.85<br />

46040 3 INCISION OF RECTAL ABSCESS 433.48<br />

46045 3 INCISION OF RECTAL ABSCESS 346.92<br />

46050 3 INCISION OF ANAL ABSCESS 158.26<br />

46060 3 INCISION OF RECTAL ABSCESS 381.91<br />

46070 3 INCISION OF ANAL SEPTUM 185.68<br />

46080 3 INCISION OF ANAL SPHINCTER 200.61<br />

46083 3 INCISE EXTERNAL HEMORRHOID 148.57<br />

46200 3 REMOVAL OF ANAL FISSURE 328.84<br />

46210 3 REMOVAL OF ANAL CRYPT 316.80<br />

46211 3 REMOVAL OF ANAL CRYPTS 421.38<br />

46220 3 REMOVAL OF ANAL TAG 163.21<br />

46221 3 LIGATION OF HEMORRHOID(S) 210.48<br />

46230 3 REMOVAL OF ANAL TAGS 226.11<br />

46250 3 HEMORRHOI<strong>DE</strong>CTOMY 377.03<br />

46255 3 HEMORRHOI<strong>DE</strong>CTOMY 422.34<br />

46257 3 REMOVE HEMORRHOIDS & FISSURE 343.67<br />

46258 3 REMOVE HEMORRHOIDS & FISTULA 375.09<br />

46260 3 HEMORRHOI<strong>DE</strong>CTOMY 390.95<br />

46261 3 REMOVE HEMORRHOIDS & FISSURE 437.55<br />

46262 3 REMOVE HEMORRHOIDS & FISTULA 454.34<br />

46270 3 REMOVAL OF ANAL FISTULA 400.74<br />

46275 3 REMOVAL OF ANAL FISTULA 417.10<br />

46280 3 REMOVAL OF ANAL FISTULA 380.40<br />

46281 O CLOSURE OF ANAL FISTULA WITH RECTAL 0.00<br />

46285 3 REMOVAL OF ANAL FISTULA 395.85<br />

46288 3 REPAIR ANAL FISTULA 447.74<br />

46320 3 REMOVAL OF HEMORRHOID CLOT 149.70<br />

46500 3 INJECTION INTO HEMORRHOID(S) 172.71<br />

46505 3 CHEMO<strong>DE</strong>NERVATION ANAL MUSC 234.75<br />

46600 3 DIAGNOSTIC ANOSCOPY 77.80<br />

46602 O ANOSCOPY FOR COLLECTION OF SPECIMEN 0.00<br />

46604 3 ANOSCOPY AND DILATION 464.69<br />

46606 3 ANOSCOPY AND BIOPSY 194.17<br />

46608 3 ANOSCOPY, REMOVE FOR BODY 209.15<br />

46610 3 ANOSCOPY, REMOVE LESION 201.79<br />

46611 3 ANOSCOPY 164.80<br />

46612 3 ANOSCOPY, REMOVE LESIONS 253.47<br />

46614 3 ANOSCOPY, CONTROL BLEEDING 123.61

---

46615 3 ANOSCOPY 143.61<br />

46700 3 REPAIR OF ANAL STRICTURE 540.02<br />

46705 3 REPAIR OF ANAL STRICTURE 427.55<br />

46706 3 REPR OF ANAL FISTULA W/GLUE 143.82<br />

46710 3 REPR PER/VAG POUCH SNGL PROC 918.64<br />

46712 3 REPR PER/VAG POUCH DBL PROC 1,911.70<br />

46715 3 REP PERF ANOPER FISTU 426.90<br />

46716 3 REP PERF ANOPER/VESTIB FISTU 973.65<br />

46730 3 CONSTRUCTION OF ABSENT ANUS 1,578.56<br />

46735 3 CONSTRUCTION OF ABSENT ANUS 1,865.91<br />

46740 3 CONSTRUCTION OF ABSENT ANUS 1,765.89<br />

46742 3 REPAIR OF IMPERFORATED ANUS 2,052.31<br />

46744 3 REPAIR OF CLOACAL ANOMALY 2,944.40<br />

46746 3 REPAIR OF CLOACAL ANOMALY 3,311.73<br />

46748 3 REPAIR OF CLOACAL ANOMALY 3,383.38<br />

46750 3 REPAIR OF ANAL SPHINCTER 652.80<br />

46751 3 REPAIR OF ANAL SPHINCTER 544.71<br />

46753 3 RECONSTRUCTION OF ANUS 492.66<br />

46754 3 REMOVAL OF SUTURE FROM ANUS 245.46<br />

46760 3 REPAIR OF ANAL SPHINCTER 928.64<br />

46761 3 REPAIR OF ANAL SPHINCTER 801.88<br />

46762 3 IMPLANT ARTIFICIAL SPHINCTER 781.67<br />

46900 3 <strong>DE</strong>STRUCTION, ANAL LESION(S) 192.47<br />

46910 3 <strong>DE</strong>STRUCTION, ANAL LESION(S) 202.92<br />

46916 3 CRYOSURGERY, ANAL LESION(S) 203.30<br />

46917 3 LASER SURGERY, ANAL LESIONS 422.66<br />

46922 3 EXCISION OF ANAL LESION(S) 216.40<br />

46924 3 <strong>DE</strong>STRUCTION, ANAL LESION(S) 158.30<br />

46930 6 <strong>DE</strong>STROY INTERNAL HEMORRHOIDS 0.00<br />

46934 O <strong>DE</strong>STRUCTION OF HEMORRHOIDS 0.00<br />

46935 O <strong>DE</strong>STRUCTION OF HEMORRHOIDS 0.00<br />

46936 O <strong>DE</strong>STRUCTION OF HEMORRHOIDS 0.00<br />

46937 3 CRYOTHERAPY OF RECTAL LESION 217.36<br />

46938 3 CRYOTHERAPY OF RECTAL LESION 365.82<br />

46940 3 TREATMENT OF ANAL FISSURE 180.96<br />

46942 3 TREATMENT OF ANAL FISSURE 166.60<br />

46945 3 LIGATION OF HEMORRHOIDS 236.57<br />

46946 3 LIGATION OF HEMORRHOIDS 260.63<br />

46947 3 HEMORRHOIDOPEXY BY STAPLING 322.67<br />

46999 5 ANUS SURGERY PROCEDURE 0.00<br />

47000 3 NEEDLE BIOPSY OF LIVER 279.13<br />

47001 3 NEEDLE BIOPSY, LIVER ADD-ON 94.13<br />

47010 3 OPEN DRAINAGE, LIVER LESION 1,035.93<br />

47011 3 PERCUT DRAIN, LIVER LESION 181.23<br />

47015 3 INJECT/ASPIRATE LIVER CYST 985.54<br />

47100 3 WEDGE BIOPSY OF LIVER 721.62<br />

47120 3 PARTIAL REMOVAL OF LIVER 2,028.85<br />

47122 3 EXTENSIVE REMOVAL OF LIVER 3,016.90<br />

47125 3 PARTIAL REMOVAL OF LIVER 2,707.42<br />

47130 3 PARTIAL REMOVAL OF LIVER 2,910.07

---

47133 9 REMOVAL OF DONOR LIVER 0.00<br />

47134 O PARTIAL REMOVAL, DONOR LIVER 0.00<br />

47135 3 TRANSPLANTATION OF LIVER 4,285.32<br />

47136 3 TRANSPLANTATION OF LIVER 3,651.83<br />

47140 9 PARTIAL REMOVAL, DONOR LIVER 0.00<br />

47141 9 PARTIAL REMOVAL, DONOR LIVER 0.00<br />

47142 9 PARTIAL REMOVAL, DONOR LIVER 0.00<br />

47143 9 PREP DONOR LIVER, WHOLE 0.00<br />

47144 9 PREP DONOR LIVER, 3-SEGMENT 0.00<br />

47145 9 PREP DONOR LIVER, LOBE SPLIT 0.00<br />

47146 9 PREP DONOR LIVER/VENOUS 0.00<br />

47147 9 PREP DONOR LIVER/ARTERIAL 0.00<br />

47300 3 SURGERY FOR LIVER LESION 964.28<br />

47350 3 REPAIR LIVER WOUND 1,181.84<br />

47355 O HEPATORRHAPHY, SUTURE OF LIVER WOUN 0.00<br />

47360 3 REPAIR LIVER WOUND 1,606.31<br />

47361 3 REPAIR LIVER WOUND 2,659.69<br />

47362 3 REPAIR LIVER WOUND 1,222.38<br />

47370 3 LAPARO ABLATE LIVER TUMOR RF 1,087.78<br />

47371 3 LAPARO ABLATE LIVER CRYOSURG 1,093.59<br />

47379 5 LAPAROSCOPE PROCEDURE, LIVER 0.00<br />

47380 3 OPEN ABLATE LIVER TUMOR RF 1,266.50<br />

47381 3 OPEN ABLATE LIVER TUMOR CRYO 1,294.81<br />

47382 3 PERCUT ABLATE LIVER RF 785.19<br />

47399 5 LIVER SURGERY PROCEDURE 0.00<br />

47400 3 INCISION OF LIVER DUCT 1,840.01<br />

47420 3 INCISION OF BILE DUCT 1,161.71<br />

47425 3 INCISION OF BILE DUCT 1,173.80<br />

47440 O DUO<strong>DE</strong>NOCHOLEDOCHOTOMY, TRANSDUO<strong>DE</strong>NA 0.00<br />

47460 3 INCISE BILE DUCT SPHINCTER 1,101.61<br />

47480 3 INCISION OF GALLBLAD<strong>DE</strong>R 733.85<br />

47490 3 INCISION OF GALLBLAD<strong>DE</strong>R 499.37<br />

47500 3 INJECTION FOR LIVER X-RAYS 96.53<br />

47505 3 INJECTION FOR LIVER X-RAYS 37.21<br />

47510 3 INSERT CATHETER, BILE DUCT 472.41<br />

47511 3 INSERT BILE DUCT DRAIN 581.69<br />

47525 3 CHANGE BILE DUCT CATHETER 787.43<br />

47530 3 REVISE/REINSERT BILE TUBE 1,479.98<br />

47550 3 BILE DUCT ENDOSCOPY ADD-ON 149.67<br />

47552 3 BILIARY ENDOSCOPY THRU SKIN 312.50<br />

47553 3 BILIARY ENDOSCOPY THRU SKIN 310.80<br />

47554 3 BILIARY ENDOSCOPY THRU SKIN 465.92<br />

47555 3 BILIARY ENDOSCOPY THRU SKIN 372.07<br />

47556 3 BILIARY ENDOSCOPY THRU SKIN 420.42<br />

47560 3 LAPAROSCOPY W/CHOLANGIO 241.86<br />

47561 3 LAPARO W/CHOLANGIO/BIOPSY 263.59<br />

47562 3 LAPAROSCOPIC CHOLECYSTECTOMY 639.34<br />

47563 3 LAPARO CHOLECYSTECTOMY/GRAPH 658.34<br />

47564 3 LAPARO CHOLECYSTECTOMY/EXPLR 761.11<br />

47570 3 LAPARO CHOLECYSTOENTEROSTOMY 678.11

---

47579 5 LAPAROSCOPE PROC, BILIARY 0.00<br />

47600 3 REMOVAL OF GALLBLAD<strong>DE</strong>R 904.46<br />

47605 3 REMOVAL OF GALLBLAD<strong>DE</strong>R 850.17<br />

47610 3 REMOVAL OF GALLBLAD<strong>DE</strong>R 1,086.76<br />

47612 3 REMOVAL OF GALLBLAD<strong>DE</strong>R 1,096.08<br />

47620 3 REMOVAL OF GALLBLAD<strong>DE</strong>R 1,188.57<br />

47630 3 REMOVE BILE DUCT STONE 533.09<br />

47700 3 EXPLORATION OF BILE DUCTS 906.47<br />

47701 3 BILE DUCT REVISION 1,514.40<br />

47710 O EXCISION OF BILE DUCT TUMOR, WITH R 0.00<br />

47711 3 EXCISION OF BILE DUCT TUMOR 1,348.74<br />

47712 3 EXCISION OF BILE DUCT TUMOR 1,729.01<br />

47715 3 EXCISION OF BILE DUCT CYST 1,135.12<br />

47716 O FUSION OF BILE DUCT CYST 0.00<br />

47719 O FUSION OF BILE DUCT CYST 0.00<br />

47720 3 FUSE GALLBLAD<strong>DE</strong>R & BOWEL 978.70<br />

47721 3 FUSE UPPER GI STRUCTURES 1,152.50<br />

47740 3 FUSE GALLBLAD<strong>DE</strong>R & BOWEL 1,115.58<br />

47741 3 FUSE GALLBLAD<strong>DE</strong>R & BOWEL 1,264.79<br />

47760 3 FUSE BILE DUCTS AND BOWEL 1,864.39<br />

47765 3 FUSE LIVER DUCTS & BOWEL 2,406.93<br />

47780 3 FUSE BILE DUCTS AND BOWEL 2,030.63<br />

47785 3 FUSE BILE DUCTS AND BOWEL 2,625.56<br />

47800 3 RECONSTRUCTION OF BILE DUCTS 1,363.99<br />

47801 3 PLACEMENT, BILE DUCT SUPPORT 952.71<br />

47802 3 FUSE LIVER DUCT & INTESTINE 1,306.46<br />

47900 3 SUTURE BILE DUCT INJURY 1,183.65<br />

47999 5 BILE TRACT SURGERY PROCEDURE 0.00<br />

48000 3 DRAINAGE OF ABDOMEN 1,621.79<br />

48001 3 PLACEMENT OF DRAIN, PANCREAS 2,004.40<br />

48005 O RESECT/<strong>DE</strong>BRI<strong>DE</strong> PANCREAS 0.00<br />

48020 3 REMOVAL OF PANCREATIC STONE 999.20<br />

48100 3 BIOPSY OF PANCREAS, OPEN 762.44<br />

48102 3 NEEDLE BIOPSY, PANCREAS 512.37<br />

48105 3 RESECT/<strong>DE</strong>BRI<strong>DE</strong> PANCREAS 2,463.80<br />

48120 3 REMOVAL OF PANCREAS LESION 953.14<br />

48140 3 PARTIAL REMOVAL OF PANCREAS 1,349.81<br />

48145 3 PARTIAL REMOVAL OF PANCREAS 1,399.88<br />

48146 3 PANCREATECTOMY 1,605.70<br />

48148 3 REMOVAL OF PANCREATIC DUCT 1,065.83<br />

48150 3 PARTIAL REMOVAL OF PANCREAS 2,710.27<br />

48151 O PANCREATECTOMY, NEAR-TOTAL, WITH PR 0.00<br />

48152 3 PANCREATECTOMY 2,504.38<br />

48153 3 PANCREATECTOMY 2,707.63<br />

48154 3 PANCREATECTOMY 2,518.37<br />

48155 3 REMOVAL OF PANCREAS 1,554.11<br />

48160 5 PANCREAS REMOVAL/TRANSPLANT 0.00<br />

48180 O FUSE PANCREAS AND BOWEL 0.00<br />

48400 9 INJECTION, INTRAOP ADD-ON 0.00<br />

48500 3 SURGERY OF PANCREATIC CYST 966.63

---

48510 3 DRAIN PANCREATIC PSEUDOCYST 928.38<br />

48511 3 DRAIN PANCREATIC PSEUDOCYST 950.77<br />

48520 3 FUSE PANCREAS CYST AND BOWEL 939.56<br />

48540 3 FUSE PANCREAS CYST AND BOWEL 1,131.26<br />

48545 3 PANCREATORRHAPHY 1,142.38<br />

48547 3 DUO<strong>DE</strong>NAL EXCLUSION 1,535.40<br />

48548 3 FUSE PANCREAS AND BOWEL 1,439.31<br />

48550 9 DONOR PANCREATECTOMY 0.00<br />

48551 9 PREP DONOR PANCREAS 0.00<br />

48552 9 PREP DONOR PANCREAS/VENOUS 0.00<br />

48554 3 TRANSPL ALLOGRAFT PANCREAS 2,142.95<br />

48556 3 REMOVAL, ALLOGRAFT PANCREAS 1,054.17<br />

48999 5 PANCREAS SURGERY PROCEDURE 0.00<br />

49000 3 EXPLORATION OF ABDOMEN 674.75<br />

49002 3 REOPENING OF ABDOMEN 859.72<br />

49010 3 EXPLORATION BEHIND ABDOMEN 824.50<br />

49020 3 DRAIN ABDOMINAL ABSCESS 1,376.54<br />

49021 3 DRAIN ABDOMINAL ABSCESS 921.32<br />

49040 3 DRAIN, OPEN, ABDOM ABSCESS 861.28<br />

49041 3 DRAIN, PERCUT, ABDOM ABSCESS 918.51<br />

49060 3 DRAIN, OPEN, RETROP ABSCESS 965.14<br />

49061 3 DRAIN, PERCUT, RETROPER ABSC 181.62<br />

49062 3 DRAIN TO PERITONEAL CAVITY 659.34<br />

49080 3 PUNCTURE, PERITONEAL CAVITY 66.68<br />

49081 3 REMOVAL OF ABDOMINAL FLUID 153.99<br />

49085 O REMOVE ABDOMEN FOREIGN BODY 0.00<br />

49180 3 BIOPSY, ABDOMINAL MASS 171.26<br />

49200 O REMOVAL OF ABDOMINAL LESION 0.00<br />

49201 O REMOVE ABDOM LESION, COMPLEX 0.00<br />

49203 3 EXC ABD TUM 5 CM OR LESS 1,046.64<br />

49204 3 EXC ABD TUM OVER 5 CM 1,333.51<br />

49205 3 EXC ABD TUM OVER 10 CM 1,525.15<br />

49215 3 EXCISE SACRAL SPINE TUMOR 1,932.51<br />

49220 3 MULTIPLE SURGERY, ABDOMEN 845.78<br />

49250 3 EXCISION OF UMBILICUS 503.80<br />

49255 3 REMOVAL OF OMENTUM 684.30<br />

49300 O PERITONEOSCOPY WITHOUT BIOPSY 0.00<br />

49301 O PERITONEOSCOPY WITH BIOPSY 0.00<br />

49302 O PERITONEOSCOPY WITH GUI<strong>DE</strong>D TRANSHEP 0.00<br />

49303 O PERITONEOSCOPY WITH GUI<strong>DE</strong>D TRANSHEP 0.00<br />

49310 O LAPAROSCOPY, SURGICAL; CHOLECYSTECT 0.00<br />

49311 O LAPAROSCOPY, SURGICAL; CHOLECYSTECT 0.00<br />

49315 O LAPAROSCOPY, SURGICAL;APPEN<strong>DE</strong>CTOMY 0.00<br />

49320 3 DIAG LAPARO SEPARATE PROC 291.68<br />

49321 3 LAPAROSCOPY, BIOPSY 305.91<br />

49322 3 LAPAROSCOPY, ASPIRATION 333.72<br />

49323 3 LAPARO DRAIN LYMPHOCELE 559.57<br />

49324 3 LAP INSERTION PERM IP CATH 343.93<br />

49325 3 LAP REVISION PERM IP CATH 369.44<br />

49326 3 LAP W/OMENTOPEXY ADD-ON 167.82

---

49329 5 LAPARO PROC, ABDM/PER/OMENT 0.00<br />

49400 3 AIR INJECTION INTO ABDOMEN 177.34<br />

49401 O PNEUMOPERITONEUM (SEPARATE PROCEDUR 0.00<br />

49402 3 REMOVE FOREIGN BODY, ADBOMEN 739.89<br />

49419 3 INSRT ABDOM CATH FOR CHEMOTX 400.03<br />

49420 3 INSERT ABDOM DRAIN, TEMP 125.76<br />

49421 3 INSERT ABDOM DRAIN, PERM 344.51<br />

49422 3 REMOVE PERM CANNULA/CATHETER 344.93<br />

49423 3 EXCHANGE DRAINAGE CATHETER 73.58<br />

49424 3 ASSESS CYST, CONTRAST INJECT 38.79<br />

49425 3 INSERT ABDOMEN-VENOUS DRAIN 670.85<br />

49426 3 REVISE ABDOMEN-VENOUS SHUNT 571.63<br />

49427 3 INJECTION, ABDOMINAL SHUNT 44.30<br />

49428 3 LIGATION OF SHUNT 390.07<br />

49429 3 REMOVAL OF SHUNT 407.92<br />

49435 3 INSERT SUBQ EXTEN TO IP CATH 108.92<br />

49436 3 EMBED<strong>DE</strong>D IP CATH EXIT-SITE 164.86<br />

49440 3 PLACE GASTROSTOMY TUBE PERC 1,142.16<br />

49441 3 PLACE DUOD/JEJ TUBE PERC 1,355.74<br />

49442 3 PLACE CECOSTOMY TUBE PERC 1,104.99<br />

49446 3 CHANGE G-TUBE TO G-J PERC 1,131.66<br />

49450 3 REPLACE G/C TUBE PERC 65.89<br />

49451 3 REPLACE DUOD/JEJ TUBE PERC 90.82<br />

49452 3 REPLACE G-J TUBE PERC 141.71<br />

49460 3 FIX G/COLON TUBE W/<strong>DE</strong>VICE 844.30<br />

49465 3 FLUORO EXAM OF G/COLON TUBE 175.11<br />

49491 3 RPR HERN PREEMIE REDUC 652.72<br />

49492 3 RPR ING HERN PREMIE, BLOCKED 815.76<br />

49495 3 RPR ING HERNIA BABY, REDUC 349.03<br />

49496 3 RPR ING HERNIA BABY, BLOCKED 519.34<br />

49500 3 RPR ING HERNIA, INIT, REDUCE 349.22<br />

49501 3 RPR ING HERNIA, INIT BLOCKED 514.16<br />

49505 3 PRP I/HERN INIT REDUC >5 YR 447.61<br />

49507 3 PRP I/HERN INIT BLOCK >5 YR 550.75<br />

49510 O REPAIR INGUINAL HERNIA, AGE 5 OR OV 0.00<br />

49515 O REPAIR INGUINAL HERNIA, AGE 5 OR OV 0.00<br />

49520 3 REREPAIR ING HERNIA, REDUCE 547.15<br />

49521 3 REREPAIR ING HERNIA, BLOCKED 667.05<br />

49525 3 REPAIR ING HERNIA, SLIDING 494.71<br />

49530 O REPAIR INGUINAL HERNIA, ANY AGE INC 0.00<br />

49535 O REPAIR INGUINAL HERNIA, ANY AGE STR 0.00<br />

49540 3 REPAIR LUMBAR HERNIA 585.46<br />

49550 3 RPR REM HERNIA, INIT, REDUCE 498.11<br />

49552 O REPAIR FEMORAL HERNIA, HENRY APPROA 0.00<br />

49553 3 RPR FEM HERNIA, INIT BLOCKED 544.05<br />

49555 3 REREPAIR FEM HERNIA, REDUCE 517.69<br />

49557 3 REREPAIR FEM HERNIA, BLOCKED 627.90<br />

49560 3 RPR VENTRAL HERN INIT, REDUC 643.71<br />

49561 3 RPR VENTRAL HERN INIT, BLOCK 807.92<br />

49565 3 REREPAIR VENTRL HERN, REDUCE 664.24

---

49566 3 REREPAIR VENTRL HERN, BLOCK 816.26<br />

49568 3 HERNIA REPAIR W/MESH 241.56<br />

49570 3 RPR EPIGASTRIC HERN, REDUCE 353.39<br />

49572 3 RPR EPIGASTRIC HERN, BLOCKED 433.40<br />

49575 O REPAIR EPIGASTRIC HERNIA, PROPERITO 0.00<br />

49580 3 RPR UMBIL HERN, REDUC < 5 YR 273.98<br />

49581 O REPAIR UMBILICAL HERNIA AGE 5 OR OV 0.00<br />

49582 3 RPR UMBIL HERN, BLOCK < 5 YR 406.02<br />

49585 3 RPR UMBIL HERN, REDUC > 5 YR 378.68<br />

49587 3 RPR UMBIL HERN, BLOCK > 5 YR 448.73<br />

49590 3 REPAIR SPIGELIAN HERNIA 493.16<br />

49600 3 REPAIR UMBILICAL LESION 638.46<br />

49605 3 REPAIR UMBILICAL LESION 4,326.42<br />

49606 3 REPAIR UMBILICAL LESION 998.77<br />

49610 3 REPAIR UMBILICAL LESION 605.17<br />

49611 3 REPAIR UMBILICAL LESION 556.84<br />

49650 3 LAP ING HERNIA REPAIR INIT 369.88<br />

49651 3 LAP ING HERNIA REPAIR RECUR 477.32<br />

49652 6 LAP VENT/ABD HERNIA REPAIR 0.00<br />

49653 6 LAP VENT/ABD HERN PROC COMP 0.00<br />

49654 6 LAP INC HERNIA REPAIR 0.00<br />

49655 6 LAP INC HERN REPAIR COMP 0.00<br />

49656 6 LAP INC HERNIA REPAIR RECUR 0.00<br />

49657 6 LAP INC HERN RECUR COMP 0.00<br />

49659 5 LAPARO PROC, HERNIA REPAIR 0.00<br />

49900 3 REPAIR OF ABDOMINAL WALL 710.10<br />

49904 3 OMENTAL FLAP, EXTRA-ABDOM 1,364.26<br />

49905 3 OMENTAL FLAP, INTRA-ABDOM 322.28<br />

49906 5 FREE OMENTAL FLAP, MICROVASC 0.00<br />

49999 5 ABDOMEN SURGERY PROCEDURE 0.00<br />

50010 3 EXPLORATION OF KIDNEY 674.04<br />

50020 3 RENAL ABSCESS, OPEN DRAIN 965.60<br />

50021 3 RENAL ABSCESS, PERCUT DRAIN 165.92<br />

50040 3 DRAINAGE OF KIDNEY 896.87<br />

50045 3 EXPLORATION OF KIDNEY 891.93<br />

5005F 9 PT COUNSLD ON EXAM FOR MOLES 0.00<br />

50060 3 REMOVAL OF KIDNEY STONE 1,112.75<br />

50065 3 INCISION OF KIDNEY 1,144.92<br />

50070 3 INCISION OF KIDNEY 1,162.85<br />

50075 3 REMOVAL OF KIDNEY STONE 1,426.48<br />

50080 3 REMOVAL OF KIDNEY STONE 852.17<br />

50081 3 REMOVAL OF KIDNEY STONE 1,248.42<br />

50100 3 REVISE KIDNEY BLOOD VESSELS 929.01<br />

5010F 9 MACUL+FNDNGS TO DR MNG DM 0.00<br />

50120 3 EXPLORATION OF KIDNEY 926.56<br />

50125 3 EXPLORE AND DRAIN KIDNEY 969.60<br />

50130 3 REMOVAL OF KIDNEY STONE 1,007.89<br />

50135 3 EXPLORATION OF KIDNEY 1,096.00<br />

5015F 9 DOC FX & TEST/TXMNT FOR OP 0.00<br />

50200 3 BIOPSY OF KIDNEY 142.86

---

50205 3 BIOPSY OF KIDNEY 658.59<br />

5020F 9 TXMNTS 2 MAIN DR BY 1 MON 0.00<br />

50220 3 REMOVE KIDNEY, OPEN 998.07<br />

50225 3 REMOVAL KIDNEY OPEN, COMPLEX 1,158.31<br />

50230 3 REMOVAL KIDNEY OPEN, RADICAL 1,246.49<br />

50234 3 REMOVAL OF KIDNEY & URETER 1,268.35<br />

50236 3 REMOVAL OF KIDNEY & URETER 1,434.47<br />

50240 3 PARTIAL REMOVAL OF KIDNEY 1,285.19<br />

50250 3 CRYOABLATE RENAL MASS OPEN 1,195.73<br />

50280 3 REMOVAL OF KIDNEY LESION 919.75<br />

50290 3 REMOVAL OF KIDNEY LESION 863.62<br />

50300 9 REMOVE CADAVER DONOR KIDNEY 0.00<br />

50320 3 REMOVE KIDNEY, LIVING DONOR 1,277.00<br />

50323 9 PREP CADAVER RENAL ALLOGRAFT 0.00<br />

50325 9 PREP DONOR RENAL GRAFT 0.00<br />

50327 9 PREP RENAL GRAFT/VENOUS 0.00<br />

50328 9 PREP RENAL GRAFT/ARTERIAL 0.00<br />

50329 9 PREP RENAL GRAFT/URETERAL 0.00<br />

50340 3 REMOVAL OF KIDNEY 800.30<br />

50360 3 TRANSPLANTATION OF KIDNEY 2,156.62<br />

50365 3 TRANSPLANTATION OF KIDNEY 2,420.25<br />

50370 3 REMOVE TRANSPLANTED KIDNEY 1,004.58<br />

50380 3 REIMPLANTATION OF KIDNEY 1,635.59<br />

50382 3 CHANGE URETER STENT, PERCUT 1,426.32<br />

50384 3 REMOVE URETER STENT, PERCUT 1,278.65<br />

50385 3 CHANGE STENT VIA TRANSURETH 1,364.04<br />

50386 3 REMOVE STENT VIA TRANSURETH 880.46<br />

50387 3 CHANGE EXT/INT URETER STENT 678.00<br />

50389 3 REMOVE RENAL TUBE W/FLUORO 421.84<br />

50390 3 DRAINAGE OF KIDNEY LESION 96.53<br />

50391 3 INSTLL RX AGNT INTO RNAL TUB 128.99<br />

50392 3 INSERT KIDNEY DRAIN 180.08<br />

50393 3 INSERT URETERAL TUBE 218.76<br />

50394 3 INJECTION FOR KIDNEY X-RAY 116.98<br />

50395 3 CREATE PASSAGE TO KIDNEY 180.77<br />

50396 3 MEASURE KIDNEY PRESSURE 117.19<br />

50398 3 CHANGE KIDNEY TUBE 75.51<br />

50400 3 REVISION OF KIDNEY/URETER 1,127.28<br />

50405 3 REVISION OF KIDNEY/URETER 1,355.19<br />

50500 3 REPAIR OF KIDNEY WOUND 1,110.06<br />

5050F 9 PLAN 2 MAIN DR. BY 1 MONTH 0.00<br />

50520 3 CLOSE KIDNEY-SKIN FISTULA 1,007.19<br />

50525 3 REPAIR RENAL-ABDOMEN FISTULA 1,284.58<br />

50526 3 REPAIR RENAL-ABDOMEN FISTULA 1,298.81<br />

50540 3 REVISION OF HORSESHOE KIDNEY 1,123.27<br />

50541 3 LAPARO ABLATE RENAL CYST 900.41<br />

50542 3 LAPARO ABLATE RENAL MASS 1,139.33<br />

50543 3 LAPARO PARTIAL NEPHRECTOMY 1,453.04<br />

50544 3 LAPAROSCOPY, PYELOPLASTY 1,228.40<br />

50545 3 LAPARO RADICAL NEPHRECTOMY 1,315.61

---

50546 3 LAPAROSCOPIC NEPHRECTOMY 1,168.68<br />

50547 3 LAPARO REMOVAL DONOR KIDNEY 1,435.71<br />

50548 3 LAPARO REMOVE W/URETER 1,326.58<br />

50549 5 LAPAROSCOPE PROC, RENAL 0.00<br />

50551 3 KIDNEY ENDOSCOPY 373.22<br />

50553 3 KIDNEY ENDOSCOPY 388.76<br />

50555 3 KIDNEY ENDOSCOPY & BIOPSY 429.09<br />

50557 3 KIDNEY ENDOSCOPY & TREATMENT 431.59<br />

50559 O RENAL ENDOSCOPY/RADIOTRACER 0.00<br />

50561 3 KIDNEY ENDOSCOPY & TREATMENT 487.24<br />

50562 3 RENAL SCOPE W/TUMOR RESECT 581.68<br />

50570 3 KIDNEY ENDOSCOPY 487.97<br />

50572 3 KIDNEY ENDOSCOPY 529.39<br />

50574 3 KIDNEY ENDOSCOPY & BIOPSY 563.91<br />

50575 3 KIDNEY ENDOSCOPY 710.66<br />

50576 3 KIDNEY ENDOSCOPY & TREATMENT 561.08<br />

50578 O RENAL ENDOSCOPY/RADIOTRACER 0.00<br />

50580 3 KIDNEY ENDOSCOPY & TREATMENT 604.41<br />

50590 3 FRAGMENTING OF KIDNEY STONE 926.47<br />

50592 3 PERC RF ABLATE RENAL TUMOR 4,660.93<br />

50593 3 PERC CRYO ABLATE RENAL TUM 4,834.81<br />

50600 3 EXPLORATION OF URETER 910.04<br />

50605 3 INSERT URETERAL SUPPORT 895.40<br />

5060F 9 FNDNGS MAMMO 2PT W/IN 3 DAYS 0.00<br />

50610 3 REMOVAL OF URETER STONE 936.56<br />

50620 3 REMOVAL OF URETER STONE 883.63<br />

5062F 9 DOC F2FMAMMO FNDNG IN 5 DAYS 0.00<br />

50630 3 REMOVAL OF URETER STONE 862.35<br />

50650 3 REMOVAL OF URETER 1,007.40<br />

50660 3 REMOVAL OF URETER 1,116.05<br />

50684 3 INJECTION FOR URETER X-RAY 48.92<br />

50686 3 MEASURE URETER PRESSURE 167.39<br />

50688 3 CHANGE OF URETER TUBE/STENT 81.86<br />

50690 3 INJECTION FOR URETER X-RAY 105.87<br />

50700 3 REVISION OF URETER 911.01<br />

50715 3 RELEASE OF URETER 1,097.91<br />

50722 3 RELEASE OF URETER 956.56<br />

50725 3 RELEASE/REVISE URETER 1,056.67<br />

50727 3 REVISE URETER 491.63<br />

50728 3 REVISE URETER 678.57<br />

50740 3 FUSION OF URETER & KIDNEY 1,062.22<br />

50750 3 FUSION OF URETER & KIDNEY 1,130.07<br />

50760 3 FUSION OF URETERS 1,066.70<br />

50770 3 SPLICING OF URETERS 1,128.21<br />

50780 3 REIMPLANT URETER IN BLAD<strong>DE</strong>R 1,064.42<br />

50782 3 REIMPLANT URETER IN BLAD<strong>DE</strong>R 1,076.26<br />

50783 3 REIMPLANT URETER IN BLAD<strong>DE</strong>R 1,115.48<br />

50785 3 REIMPLANT URETER IN BLAD<strong>DE</strong>R 1,174.68<br />

50800 3 IMPLANT URETER IN BOWEL 893.14<br />

50810 3 FUSION OF URETER & BOWEL 1,214.36

---

50815 3 URINE SHUNT TO INTESTINE 1,185.22<br />

50820 3 CONSTRUCT BOWEL BLAD<strong>DE</strong>R 1,269.67<br />

50825 3 CONSTRUCT BOWEL BLAD<strong>DE</strong>R 1,607.31<br />

50830 3 REVISE URINE FLOW 1,755.55<br />

50840 3 REPLACE URETER BY BOWEL 1,196.43<br />

50845 3 APPENDICO-VESICOSTOMY 1,211.96<br />

50860 3 TRANSPLANT URETER TO SKIN 923.90<br />

50900 3 REPAIR OF URETER 816.32<br />

50920 3 CLOSURE URETER/SKIN FISTULA 857.54<br />

50930 3 CLOSURE URETER/BOWEL FISTULA 1,060.98<br />

50940 3 RELEASE OF URETER 851.47<br />

50945 3 LAPAROSCOPY URETEROLITHOTOMY 967.38<br />

50947 3 LAPARO NEW URETER/BLAD<strong>DE</strong>R 1,365.69<br />

50948 3 LAPARO NEW URETER/BLAD<strong>DE</strong>R 1,244.92<br />

50949 5 LAPAROSCOPE PROC, URETER 0.00<br />

50951 3 ENDOSCOPY OF URETER 389.08<br />

50953 3 ENDOSCOPY OF URETER 407.86<br />

50955 3 URETER ENDOSCOPY & BIOPSY 470.34<br />

50957 3 URETER ENDOSCOPY & TREATMENT 439.62<br />

50959 O URETER ENDOSCOPY & TRACER 0.00<br />

50961 3 URETER ENDOSCOPY & TREATMENT 396.00<br />

50970 3 URETER ENDOSCOPY 369.34<br />

50972 3 URETER ENDOSCOPY & CATHETER 356.44<br />

50974 3 URETER ENDOSCOPY & BIOPSY 465.03<br />

50976 3 URETER ENDOSCOPY & TREATMENT 461.78<br />

50978 O URETER ENDOSCOPY & TRACER 0.00<br />

50980 3 URETER ENDOSCOPY & TREATMENT 354.21<br />

51000 O DRAINAGE OF BLAD<strong>DE</strong>R 0.00<br />

51005 O DRAINAGE OF BLAD<strong>DE</strong>R 0.00<br />

5100F 9 RSK FX REF W/N 24 HRS X-RAY 0.00<br />

51010 O DRAINAGE OF BLAD<strong>DE</strong>R 0.00<br />

51020 3 INCISE & TREAT BLAD<strong>DE</strong>R 452.13<br />

51030 3 INCISE & TREAT BLAD<strong>DE</strong>R 451.76<br />

51040 3 INCISE & DRAIN BLAD<strong>DE</strong>R 286.43<br />

51045 3 INCISE BLAD<strong>DE</strong>R/DRAIN URETER 454.31<br />

51050 3 REMOVAL OF BLAD<strong>DE</strong>R STONE 457.61<br />

51060 3 REMOVAL OF URETER STONE 566.24<br />

51065 3 REMOVE URETER CALCULUS 560.24<br />

51080 3 DRAINAGE OF BLAD<strong>DE</strong>R ABSCESS 396.96<br />

51100 3 DRAIN BLAD<strong>DE</strong>R BY NEEDLE 64.25<br />

51101 3 DRAIN BLAD<strong>DE</strong>R BY TROCAR/CATH 132.43<br />

51102 3 DRAIN BL W/CATH INSERTION 339.95<br />

51500 3 REMOVAL OF BLAD<strong>DE</strong>R CYST 612.58<br />

51520 3 REMOVAL OF BLAD<strong>DE</strong>R LESION 578.35<br />

51525 3 REMOVAL OF BLAD<strong>DE</strong>R LESION 834.80<br />

51530 3 REMOVAL OF BLAD<strong>DE</strong>R LESION 750.09<br />

51535 3 REPAIR OF URETER LESION 768.66<br />

51550 3 PARTIAL REMOVAL OF BLAD<strong>DE</strong>R 922.40<br />

51555 3 PARTIAL REMOVAL OF BLAD<strong>DE</strong>R 1,225.04<br />

51565 3 REVISE BLAD<strong>DE</strong>R & URETER(S) 1,259.61

---

51570 3 REMOVAL OF BLAD<strong>DE</strong>R 1,434.15<br />

51575 3 REMOVAL OF BLAD<strong>DE</strong>R & NO<strong>DE</strong>S 1,777.34<br />

51580 3 REMOVE BLAD<strong>DE</strong>R/REVISE TRACT 1,849.69<br />

51585 3 REMOVAL OF BLAD<strong>DE</strong>R & NO<strong>DE</strong>S 2,058.23<br />

51590 3 REMOVE BLAD<strong>DE</strong>R/REVISE TRACT 1,880.52<br />

51595 3 REMOVE BLAD<strong>DE</strong>R/REVISE TRACT 2,134.19<br />

51596 3 REMOVE BLAD<strong>DE</strong>R/CREATE POUCH 2,291.21<br />

51597 3 REMOVAL OF PELVIC STRUCTURES 2,217.11<br />

51600 3 INJECTION FOR BLAD<strong>DE</strong>R X-RAY 43.62<br />

51605 3 PREPARATION FOR BLAD<strong>DE</strong>R XRAY 38.09<br />

51610 3 INJECTION FOR BLAD<strong>DE</strong>R X-RAY 120.12<br />

51700 3 IRRIGATION OF BLAD<strong>DE</strong>R 92.41<br />

51701 3 INSERT BLAD<strong>DE</strong>R CATHETER 69.67<br />

51702 3 INSERT TEMP BLAD<strong>DE</strong>R CATH 89.34<br />

51703 3 INSERT BLAD<strong>DE</strong>R CATH, COMPLEX 150.99<br />

51705 3 CHANGE OF BLAD<strong>DE</strong>R TUBE 121.70<br />

51710 3 CHANGE OF BLAD<strong>DE</strong>R TUBE 173.30<br />

51715 3 ENDOSCOPIC INJECTION/IMPLANT 298.55<br />

51720 3 TREATMENT OF BLAD<strong>DE</strong>R LESION 121.07<br />

51725 3 SIMPLE CYSTOMETROGRAM 249.13<br />

51726 3 COMPLEX CYSTOMETROGRAM 351.07<br />

51736 3 URINE FLOW MEASUREMENT 52.47<br />

51739 O SOUND RECORDING OF EXTERNAL STREAM 0.00<br />

51741 3 ELECTRO-UROFLOWMETRY, FIRST 82.29<br />

51772 3 URETHRA PRESSURE PROFILE 269.91<br />

51784 3 ANAL/URINARY MUSCLE STUDY 216.06<br />

51785 3 ANAL/URINARY MUSCLE STUDY 233.47<br />

51792 3 URINARY REFLEX STUDY 260.45<br />

51795 3 URINE VOIDING PRESSURE STUDY 333.90<br />

51797 3 INTRAABDOMINAL PRESSURE TEST 193.69<br />

51798 3 US URINE CAPACITY MEASURE 20.86<br />

51800 3 REVISION OF BLAD<strong>DE</strong>R/URETHRA 1,014.34<br />

51820 3 REVISION OF URINARY TRACT 1,064.74<br />

51840 3 ATTACH BLAD<strong>DE</strong>R/URETHRA 636.42<br />

51841 3 ATTACH BLAD<strong>DE</strong>R/URETHRA 758.45<br />

51845 3 REPAIR BLAD<strong>DE</strong>R NECK 573.84<br />

51860 3 REPAIR OF BLAD<strong>DE</strong>R WOUND 703.79<br />

51865 3 REPAIR OF BLAD<strong>DE</strong>R WOUND 863.63<br />

51880 3 REPAIR OF BLAD<strong>DE</strong>R OPENING 456.98<br />

51900 3 REPAIR BLAD<strong>DE</strong>R/VAGINA LESION 802.95<br />

51920 3 CLOSE BLAD<strong>DE</strong>R-UTERUS FISTULA 753.78<br />

51925 3 HYSTERECTOMY/BLAD<strong>DE</strong>R REPAIR 1,062.25<br />

51940 3 CORRECTION OF BLAD<strong>DE</strong>R <strong>DE</strong>FECT 1,565.71<br />

51960 3 REVISION OF BLAD<strong>DE</strong>R & BOWEL 1,346.09<br />

51980 3 CONSTRUCT BLAD<strong>DE</strong>R OPENING 691.81<br />

51990 3 LAPARO URETHRAL SUSPENSION 728.52<br />

51992 3 LAPARO SLING OPERATION 792.92<br />

51999 6 LAPAROSCOPE PROC, BLA 0.00<br />

52000 3 CYSTOSCOPY 120.14<br />

52001 3 CYSTOSCOPY, REMOVAL OF CLOTS 395.07

---

52005 3 CYSTOSCOPY & URETER CATHETER 307.80<br />

52007 3 CYSTOSCOPY AND BIOPSY 643.23<br />

52010 3 CYSTOSCOPY & DUCT CATHETER 479.26<br />

52204 3 CYSTOSCOPY W/BIOPSY(S) 137.68<br />

52214 3 CYSTOSCOPY AND TREATMENT 1,274.59<br />

52224 3 CYSTOSCOPY AND TREATMENT 1,205.75<br />

52234 3 CYSTOSCOPY AND TREATMENT 243.60<br />

52235 3 CYSTOSCOPY AND TREATMENT 286.08<br />

52240 3 CYSTOSCOPY AND TREATMENT 499.94<br />

52250 3 CYSTOSCOPY AND RADIOTRACER 239.08<br />

52260 3 CYSTOSCOPY AND TREATMENT 206.45<br />

52265 3 CYSTOSCOPY AND TREATMENT 516.20<br />

52270 3 CYSTOSCOPY & REVISE URETHRA 476.36<br />

52275 3 CYSTOSCOPY & REVISE URETHRA 657.84<br />

52276 3 CYSTOSCOPY AND TREATMENT 262.41<br />

52277 3 CYSTOSCOPY AND TREATMENT 322.44<br />

52281 3 CYSTOSCOPY AND TREATMENT 344.57<br />

52282 3 CYSTOSCOPY, IMPLANT STENT 332.40<br />

52283 3 CYSTOSCOPY AND TREATMENT 291.37<br />

52285 3 CYSTOSCOPY AND TREATMENT 293.82<br />

52290 3 CYSTOSCOPY AND TREATMENT 241.37<br />

52300 3 CYSTOSCOPY AND TREATMENT 278.81<br />

52301 3 CYSTOSCOPY AND TREATMENT 291.65<br />

52305 3 CYSTOSCOPY AND TREATMENT 276.44<br />

52310 3 CYSTOSCOPY AND TREATMENT 272.17<br />

52315 3 CYSTOSCOPY AND TREATMENT 488.29<br />

52317 3 REMOVE BLAD<strong>DE</strong>R STONE 345.49<br />

52318 3 REMOVE BLAD<strong>DE</strong>R STONE 470.82<br />

52320 3 CYSTOSCOPY AND TREATMENT 244.34<br />

52325 3 CYSTOSCOPY, STONE REMOVAL 318.12<br />

52327 3 CYSTOSCOPY, INJECT MATERIAL 853.02<br />

52330 3 CYSTOSCOPY AND TREATMENT 261.89<br />

52332 3 CYSTOSCOPY AND TREATMENT 149.06<br />

52334 3 CREATE PASSAGE TO KIDNEY 253.49<br />

52335 O ENDOSCOPY OF URINARY TRACT 0.00<br />

52336 O CYSTOSCOPY, STONE REMOVAL 0.00<br />

52337 O CYSTOSCOPY, STONE REMOVAL 0.00<br />

52338 O CYSTOSCOPY AND TREATMENT 0.00<br />

52339 O CYSTOSCOPY AND TREATMENT 0.00<br />

52340 O CYSTOSCOPY AND TREATMENT 0.00<br />

52341 3 CYSTO W/URETER STRICTURE TX 323.36<br />

52342 3 CYSTO W/UP STRICTURE TX 347.88<br />

52343 3 CYSTO W/RENAL STRICTURE TX 382.68<br />

52344 3 CYSTO/URETERO, STRICTURE TX 413.00<br />

52345 3 CYSTO/URETERO W/UP STRICTURE 437.91<br />

52346 3 CYSTOURETERO W/RENAL STRICT 489.20<br />

52347 O CYSTOSCOPY, RESECT DUCTS 0.00<br />

52351 3 CYSTOURETERO & OR PYELOSCOPE 310.77<br />

52352 3 CYSTOURETERO W/STONE REMOVE 364.71<br />

52353 3 CYSTOURETERO W/LITHOTRIPSY 419.78

---

52354 3 CYSTOURETERO W/BIOPSY 388.08<br />

52355 3 CYSTOURETERO W/EXCISE TUMOR 462.63<br />

52400 3 CYSTOURETERO W/CONGEN REPR 540.69<br />

52402 3 CYSTOURETHRO CUT EJACUL DUCT 266.05<br />

52450 3 INCISION OF PROSTATE 454.94<br />

52500 3 REVISION OF BLAD<strong>DE</strong>R NECK 534.89<br />

52510 O DILATION PROSTATIC URETHRA 0.00<br />

52601 3 PROSTATECTOMY (TURP) 804.61<br />

52606 O CONTROL POSTOP BLEEDING 0.00<br />

52612 O PROSTATECTOMY, FIRST STAGE 0.00<br />

52614 O PROSTATECTOMY, SECOND STAGE 0.00<br />

52620 O REMOVE RESIDUAL PROSTATE 0.00<br />

52630 3 REMOVE PROSTATE REGROWTH 431.60<br />

52640 3 RELIEVE BLAD<strong>DE</strong>R CONTRACTURE 392.82<br />

52647 3 LASER SURGERY OF PROSTATE 624.39<br />

52648 3 LASER SURGERY OF PROSTATE 2,721.77<br />

52649 3 PROSTATE LASER ENUCLEATION 981.36<br />

52650 O TRANSURETHRAL CRYOSURGICAL REMOVAL 0.00<br />

52700 3 DRAINAGE OF PROSTATE ABSCESS 423.83<br />

53000 3 INCISION OF URETHRA 148.21<br />

53010 3 INCISION OF URETHRA 287.17<br />

53020 3 INCISION OF URETHRA 95.78<br />

53025 3 INCISION OF URETHRA 66.84<br />

53040 3 DRAINAGE OF URETHRA ABSCESS 387.80<br />

53060 3 DRAINAGE OF URETHRA ABSCESS 180.23<br />

53080 3 DRAINAGE OF URINARY LEAKAGE 461.63<br />

53085 3 DRAINAGE OF URINARY LEAKAGE 634.41<br />

53200 3 BIOPSY OF URETHRA 153.12<br />

53210 3 REMOVAL OF URETHRA 754.79<br />

53215 3 REMOVAL OF URETHRA 909.39<br />

53220 3 TREATMENT OF URETHRA LESION 440.94<br />

53230 3 REMOVAL OF URETHRA LESION 589.20<br />

53235 3 REMOVAL OF URETHRA LESION 621.95<br />

53240 3 SURGERY FOR URETHRA POUCH 417.44<br />

53250 3 REMOVAL OF URETHRA GLAND 383.14<br />

53260 3 TREATMENT OF URETHRA LESION 201.51<br />

53265 3 TREATMENT OF URETHRA LESION 224.71<br />

53270 3 REMOVAL OF URETHRA GLAND 206.06<br />

53275 3 REPAIR OF URETHRA <strong>DE</strong>FECT 262.25<br />

53400 3 REVISE URETHRA, STAGE 1 782.35<br />

53405 3 REVISE URETHRA, STAGE 2 853.62<br />

53410 3 RECONSTRUCTION OF URETHRA 957.78<br />

53415 3 RECONSTRUCTION OF URETHRA 1,091.99<br />

53420 3 RECONSTRUCT URETHRA, STAGE 1 801.83<br />

53425 3 RECONSTRUCT URETHRA, STAGE 2 920.34<br />

53430 3 RECONSTRUCTION OF URETHRA 931.29<br />

53431 3 RECONSTRUCT URETHRA/BLAD<strong>DE</strong>R 1,129.41<br />

53440 3 MALE SLING PROCEDURE 846.85<br />

53442 3 REMOVE/REVISE MALE SLING 746.26<br />

53443 O RECONSTRUCTION OF URETHRA 0.00

---

53444 3 INSERT TAN<strong>DE</strong>M CUFF 777.96<br />

53445 3 INSERT URO/VES NCK SPHINCTER 856.50<br />

53446 3 REMOVE URO SPHINCTER 630.97<br />

53447 3 REMOVE/REPLACE UR SPHINCTER 799.04<br />

53448 3 REMOV/REPLC UR SPHINCTR COMP 1,253.58<br />

53449 3 REPAIR URO SPHINCTER 596.29<br />

53450 3 REVISION OF URETHRA 396.92<br />

53460 3 REVISION OF URETHRA 446.26<br />

53500 3 URETHRLYS, TRANSVAG W/ SCOPE 730.84<br />

53502 3 REPAIR OF URETHRA INJURY 473.83<br />

53505 3 REPAIR OF URETHRA INJURY 474.61<br />

53510 3 REPAIR OF URETHRA INJURY 625.31<br />

53515 3 REPAIR OF URETHRA INJURY 782.37<br />

53520 3 REPAIR OF URETHRA <strong>DE</strong>FECT 545.05<br />

53600 3 DILATE URETHRA STRICTURE 88.72<br />

53601 3 DILATE URETHRA STRICTURE 87.12<br />

53605 3 DILATE URETHRA STRICTURE 64.27<br />

53620 3 DILATE URETHRA STRICTURE 131.10<br />

53621 3 DILATE URETHRA STRICTURE 125.11<br />

53640 O PASSAGE OF FILIFORM AND FOLLOWER FO 0.00<br />

53660 3 DILATION OF URETHRA 77.28<br />

53661 3 DILATION OF URETHRA 76.89<br />

53665 3 DILATION OF URETHRA 37.80<br />

53670 O INSERT URINARY CATHETER 0.00<br />

53675 O INSERT URINARY CATHETER 0.00<br />

53800 O TWO OR THREE GLASS TEST INCLUDING E 0.00<br />

53850 3 PROSTATIC MICROWAVE THERMOTX 3,178.46<br />

53852 3 PROSTATIC RF THERMOTX 3,042.32<br />

53853 O PROSTATIC WATER THERMOTHER 0.00<br />

53899 5 UROLOGY SURGERY PROCEDURE 0.00<br />

54000 3 SLITTING OF PREPUCE 166.17<br />

54001 3 SLITTING OF PREPUCE 202.28<br />

54015 3 DRAIN PENIS LESION 305.15<br />

54050 3 <strong>DE</strong>STRUCTION, PENIS LESION(S) 119.08<br />

54055 3 <strong>DE</strong>STRUCTION, PENIS LESION(S) 113.59<br />

54056 3 CRYOSURGERY, PENIS LESION(S) 124.39<br />

54057 3 LASER SURG, PENIS LESION(S) 140.62<br />

54060 3 EXCISION OF PENIS LESION(S) 192.04<br />

54065 3 <strong>DE</strong>STRUCTION, PENIS LESION(S) 203.49<br />

54100 3 BIOPSY OF PENIS 188.44<br />

54105 3 BIOPSY OF PENIS 288.87<br />

54110 3 TREATMENT OF PENIS LESION 612.95<br />

54111 3 TREAT PENIS LESION, GRAFT 784.29<br />

54112 3 TREAT PENIS LESION, GRAFT 920.23<br />

54115 3 TREATMENT OF PENIS LESION 443.62<br />

54120 3 PARTIAL REMOVAL OF PENIS 613.27<br />

54125 3 REMOVAL OF PENIS 790.96<br />

54130 3 REMOVE PENIS & NO<strong>DE</strong>S 1,167.61<br />

54135 3 REMOVE PENIS & NO<strong>DE</strong>S 1,482.44<br />

54150 3 CIRCUMCISION W/REGIONL BLOCK 97.76

---

54152 O CIRCUMCISION 0.00<br />

54160 3 CIRCUMCISION, NEONATE 140.70<br />

54161 3 CIRCUM 28 DAYS OR OL<strong>DE</strong>R 192.44<br />

54162 3 LYSIS PENIL CIRCUMIC LESION 287.47<br />

54163 3 REPAIR OF CIRCUMCISION 212.72<br />

54164 9 FRENULOTOMY OF PENIS 0.00<br />

54200 3 TREATMENT OF PENIS LESION 114.09<br />

54205 3 TREATMENT OF PENIS LESION 527.43<br />

54220 3 TREATMENT OF PENIS LESION 227.90<br />

54230 3 PREPARE PENIS STUDY 96.89<br />

54231 O DYNAMIC CAVERNOSOMETRY 0.00<br />

54235 O PENILE INJECTION 0.00<br />

54240 O PENIS STUDY 0.00<br />

54250 O PENIS STUDY 0.00<br />

54300 3 REVISION OF PENIS 639.50<br />

54304 3 REVISION OF PENIS 749.71<br />

54308 3 RECONSTRUCTION OF URETHRA 659.31<br />

54312 3 RECONSTRUCTION OF URETHRA 835.79<br />

54316 3 RECONSTRUCTION OF URETHRA 994.40<br />

54318 3 RECONSTRUCTION OF URETHRA 666.30<br />

54322 3 RECONSTRUCTION OF URETHRA 780.27<br />

54324 3 RECONSTRUCTION OF URETHRA 971.84<br />

54326 3 RECONSTRUCTION OF URETHRA 938.29<br />

54328 3 REVISE PENIS/URETHRA 925.49<br />

54332 3 REVISE PENIS/URETHRA 1,003.60<br />

54336 3 REVISE PENIS/URETHRA 1,138.62<br />

54340 3 SECONDARY URETHRAL SURGERY 567.89<br />

54344 3 SECONDARY URETHRAL SURGERY 958.86<br />

54348 3 SECONDARY URETHRAL SURGERY 1,015.64<br />

54352 3 RECONSTRUCT URETHRA/PENIS 1,441.79<br />

54360 3 PENIS PLASTIC SURGERY 718.99<br />

54380 3 REPAIR PENIS 791.07<br />

54385 3 REPAIR PENIS 965.49<br />

54390 3 REPAIR PENIS AND BLAD<strong>DE</strong>R 1,142.73<br />

54400 O INSERT SEMI-RIGID PROSTHESIS 0.00<br />

54401 O INSERT SELF-CONTD PROSTHESIS 0.00<br />

54402 O REMOVE PENIS PROSTHESIS 0.00<br />

54405 O INSERT MULTI-COMP PENIS PROS 0.00<br />

54406 9 REMOVE MUTI-COMP PENIS PROS 0.00<br />

54407 O REMOVE MULTI-COMP PROSTHESIS 0.00<br />

54408 9 REPAIR MULTI-COMP PENIS PROS 0.00<br />

54409 O REVISE PENIS PROSTHESIS 0.00<br />

54410 9 REMOVE/REPLACE PENIS PROSTH 0.00<br />

54411 9 REMOV/REPLC PENIS PROS, COMP 0.00<br />

54415 9 REMOVE SELF-CONTD PENIS PROS 0.00<br />

54416 9 REMV/REPL PENIS CONTAIN PROS 0.00<br />

54417 9 REMV/REPLC PENIS PROS, COMPL 0.00<br />

54420 3 REVISION OF PENIS 694.78<br />

54430 3 REVISION OF PENIS 628.98<br />

54435 3 REVISION OF PENIS 409.47

---

54440 5 REPAIR OF PENIS 0.00<br />

54450 3 PREPUTIAL STRETCHING 75.90<br />

54500 3 BIOPSY OF TESTIS 73.21<br />

54505 3 BIOPSY OF TESTIS 211.59<br />

54510 O REMOVAL OF TESTIS LESION 0.00<br />

54512 3 EXCISE LESION TESTIS 525.67<br />

54520 3 REMOVAL OF TESTIS 320.56<br />

54522 3 ORCHIECTOMY, PARTIAL 575.96<br />

54530 3 REMOVAL OF TESTIS 537.90<br />

54535 3 EXTENSIVE TESTIS SURGERY 715.65<br />

54550 3 EXPLORATION FOR TESTIS 476.76<br />

54560 3 EXPLORATION FOR TESTIS 668.94<br />

54600 3 REDUCE TESTIS TORSION 441.13<br />

54620 3 SUSPENSION OF TESTIS 297.11<br />

54640 3 SUSPENSION OF TESTIS 453.80<br />

54645 O ORCHIOPEXY, ANY TYPE, WITH OR WITHO 0.00<br />

54650 3 ORCHIOPEXY (FOWLER-STEPHENS) 666.99<br />

54660 9 REVISION OF TESTIS 0.00<br />

54670 3 REPAIR TESTIS INJURY 400.53<br />

54680 3 RELOCATION OF TESTIS(ES) 778.29<br />

54690 3 LAPAROSCOPY, ORCHIECTOMY 630.28<br />

54692 3 LAPAROSCOPY, ORCHIOPEXY 756.27<br />

54699 5 LAPAROSCOPE PROC, TESTIS 0.00<br />

54700 3 DRAINAGE OF SCROTUM 209.94<br />

54800 3 BIOPSY OF EPIDIDYMIS 127.45<br />

54820 O EXPLORATION OF EPIDIDYMIS 0.00<br />

54830 3 REMOVE EPIDIDYMIS LESION 358.72<br />

54840 3 REMOVE EPIDIDYMIS LESION 317.52<br />

54860 3 REMOVAL OF EPIDIDYMIS 406.42<br />

54861 3 REMOVAL OF EPIDIDYMIS 550.98<br />

54865 3 EXPLORE EPIDIDYMIS 345.62<br />

54900 3 FUSION OF SPERMATIC DUCTS 721.02<br />

54901 3 FUSION OF SPERMATIC DUCTS 1,050.15<br />

55000 3 DRAINAGE OF HYDROCELE 128.89<br />

55040 3 REMOVAL OF HYDROCELE 330.18<br />

55041 3 REMOVAL OF HYDROCELES 492.72<br />

55060 3 REPAIR OF HYDROCELE 366.78<br />

55100 3 DRAINAGE OF SCROTUM ABSCESS 227.13<br />

55110 3 EXPLORE SCROTUM 373.63<br />

55120 3 REMOVAL OF SCROTUM LESION 343.00<br />

55150 3 REMOVAL OF SCROTUM 470.59<br />

55175 3 REVISION OF SCROTUM 350.95<br />

55180 3 REVISION OF SCROTUM 669.59<br />

55200 9 INCISION OF SPERM DUCT 0.00<br />

55250 3 REMOVAL OF SPERM DUCT(S) 223.70<br />

55300 9 PREPARE, SPERM DUCT X-RAY 0.00<br />

55400 9 REPAIR OF SPERM DUCT 0.00<br />

55450 3 LIGATION OF SPERM DUCT 402.33<br />

55500 3 REMOVAL OF HYDROCELE 367.04<br />

55520 3 REMOVAL OF SPERM CORD LESION 383.64

---

55530 3 REVISE SPERMATIC CORD VEINS 345.90<br />

55535 3 REVISE SPERMATIC CORD VEINS 415.89<br />

55540 3 REVISE HERNIA & SPERM VEINS 463.99<br />

55550 3 LAPARO LIGATE SPERMATIC VEIN 411.76<br />

55559 5 LAPARO PROC, SPERMATIC CORD 0.00<br />

55600 3 INCISE SPERM DUCT POUCH 414.17<br />

55605 3 INCISE SPERM DUCT POUCH 486.67<br />

55650 3 REMOVE SPERM DUCT POUCH 700.99<br />

55680 3 REMOVE SPERM POUCH LESION 339.09<br />

55700 3 BIOPSY OF PROSTATE 246.07<br />

55705 3 BIOPSY OF PROSTATE 265.76<br />

55706 6 PROSTATE SATURATION SAMPLING 0.00<br />

55720 3 DRAINAGE OF PROSTATE ABSCESS 459.17<br />

55725 3 DRAINAGE OF PROSTATE ABSCESS 568.16<br />

55740 O PROSTATOLITHOTOMY, REMOVAL OF PROST 0.00<br />

55801 3 REMOVAL OF PROSTATE 1,057.95<br />

55810 3 EXTENSIVE PROSTATE SURGERY 1,284.61<br />

55812 3 EXTENSIVE PROSTATE SURGERY 1,562.94<br />

55815 3 EXTENSIVE PROSTATE SURGERY 1,726.72<br />

55821 3 REMOVAL OF PROSTATE 852.06<br />

55831 3 REMOVAL OF PROSTATE 923.30<br />

55840 3 EXTENSIVE PROSTATE SURGERY 1,308.67<br />

55842 3 EXTENSIVE PROSTATE SURGERY 1,401.74<br />

55845 3 EXTENSIVE PROSTATE SURGERY 1,602.26<br />

55859 O PERCUT/NEEDLE INSERT, PROS 0.00<br />

55860 3 SURGICAL EXPOSURE, PROSTATE 856.62<br />

55862 3 EXTENSIVE PROSTATE SURGERY 1,083.44<br />

55865 3 EXTENSIVE PROSTATE SURGERY 1,301.44<br />

55866 3 LAPARO RADICAL PROSTATECTOMY 1,701.91<br />

55870 O VAG HYST W/ENTEROCELE REPAIR 0.00<br />

55873 3 CRYOABLATE PROSTATE 1,125.17<br />

55875 3 TRANSPERI NEEDLE PLACE, PROS 746.74<br />

55876 3 PLACE RT <strong>DE</strong>VICE/MARKER, PROS 148.26<br />

55899 5 GENITAL SURGERY PROCEDURE 0.00<br />

55920 3 PLACE NEEDLES PELVIC FOR RT 422.57<br />

55970 9 SEX TRANSFORMATION, M TO F 0.00<br />

55980 9 SEX TRANSFORMATION, F TO M 0.00<br />

56000 O INCISION AND DRAINAGE OF PERINEAL A 0.00<br />

56100 O BIOPSY OF PERINEUM (SEPARATE PROCED 0.00<br />

56200 O PERINEOPLASTY, REPAIR OF PERINEUM, 0.00<br />

56300 O LAPAROSCOPY; DIAGNOSTIC 0.00<br />

56301 O LAPAROSCOPY; TUBAL CAUTERY 0.00<br />

56302 O LAPAROSCOPY; TUBAL BLOCK 0.00<br />

56303 O LAPAROSCOPY; EXCISE LESIONS 0.00<br />

56304 O LAPAROSCOPY; LYSIS 0.00<br />

56305 O LAPAROSCOPY; BIOPSY 0.00<br />

56306 O LAPAROSCOPY; ASPIRATION 0.00<br />

56307 O LAPAROSCOPY; REMOVE ADNEXA 0.00<br />

56308 O LAPAROSCOPY; HYSTERECTOMY 0.00<br />

56309 O LAPAROSCOPY; REMOVE MYOMA 0.00

---

56310 O LAPAROSCOPIC ENTEROLYSIS 0.00<br />

56311 O LAPAROSCOPIC LYMPH NO<strong>DE</strong> BIOP 0.00<br />

56312 O LAPAROSCOPIC LYMPHA<strong>DE</strong>NECTOMY 0.00<br />

56313 O LAPAROSCOPIC LYMPHA<strong>DE</strong>NECTOMY 0.00<br />

56314 O LAPAR; DRAIN LYMPHOCELE 0.00<br />

56315 O LAPAROSCOPIC APPEN<strong>DE</strong>CTOMY 0.00<br />

56316 O LAPAROSCOPIC HERNIA REPAIR 0.00<br />

56317 O LAPAROSCOPIC HERNIA REPAIR 0.00<br />

56318 O LAPAROSCOPIC ORCHIECTOMY 0.00<br />

56320 O LAPAROSCOPY, SPERMATIC VEINS 0.00<br />

56321 O LAPAROSCOPY; ADRENALECTOMY 0.00<br />

56322 O LAPAROSCOPY, VAGUS NERVES 0.00<br />

56323 O LAPAROSCOPY, VAGUS NERVES 0.00<br />

56324 O LAPAROSCOPY, CHOLECYSTOENTER 0.00<br />

56340 O LAPAROSCOPIC CHOLECYSTECTOMY 0.00<br />

56341 O LAPAROSCOPIC CHOLECYSTECTOMY 0.00<br />

56342 O LAPAROSCOPIC CHOLECYSTECTOMY 0.00<br />

56343 O LAPAROSCOPIC SALPINGOSTOMY 0.00<br />

56344 O LAPAROSCOPIC FIMBRIOPLASTY 0.00<br />

56345 O LAPAROSCOPIC SPLENECTOMY 0.00<br />

56346 O LAPAROSCOPIC GASTROSTOMY 0.00<br />

56347 O LAPAROSCOPIC JEJUNOSTOMY 0.00<br />

56348 O LAPARO; RESECT INTESTINE 0.00<br />

56349 O LAPAROSCOPY; FUNDOPLASTY 0.00<br />

56350 O HYSTEROSCOPY; DIAGNOSTIC 0.00<br />

56351 O HYSTEROSCOPY; BIOPSY 0.00<br />

56352 O HYSTEROSCOPY; LYSIS 0.00<br />

56353 O HYSTEROSCOPY; RESECT SEPTUM 0.00<br />

56354 O HYSTEROSCOPY; REMOVE MYOMA 0.00<br />

56355 O HYSTEROSCOPY; REMOVE IMPACT 0.00<br />

56356 O HYSTEROSCOPY; ABLATION 0.00<br />

56360 O PERITONEOSCOPY; WITHOUT BIOPSY 0.00<br />

56361 O PERITONEOSCOPY; WITH BIOPSY 0.00<br />

56362 O LAPAROSCOPY W/CHOLANGIO 0.00<br />

56363 O LAPAROSCOPY W/BIOPSY 0.00<br />

56399 O LAPAROSCOPY PROCEDURE 0.00<br />

56400 O INCISION AND DRAINAGE, ABSCESS OF V 0.00<br />

56405 3 I & D OF VULVA/PERINEUM 103.88<br />

56420 3 DRAINAGE OF GLAND ABSCESS 127.24<br />

56440 3 SURGERY FOR VULVA LESION 171.23<br />

56441 3 LYSIS OF LABIAL LESION(S) 142.55<br />

56442 3 HYMENOTOMY 45.54<br />

56501 3 <strong>DE</strong>STROY, VULVA LESIONS, SIM 124.97<br />

56515 3 <strong>DE</strong>STROY VULVA LESION/S COMPL 209.76<br />

56600 O BIOPSY OF VULVA (SEPARATE PROCEDURE 0.00<br />

56605 3 BIOPSY OF VULVA/PERINEUM 80.54<br />

56606 3 BIOPSY OF VULVA/PERINEUM 37.47<br />

56620 3 PARTIAL REMOVAL OF VULVA 493.32<br />

56625 3 COMPLETE REMOVAL OF VULVA 553.10<br />

56630 3 EXTENSIVE VULVA SURGERY 799.69

---

56631 3 EXTENSIVE VULVA SURGERY 1,022.22<br />

56632 3 EXTENSIVE VULVA SURGERY 1,173.72<br />

56633 3 EXTENSIVE VULVA SURGERY 1,041.59<br />

56634 3 EXTENSIVE VULVA SURGERY 1,105.10<br />

56635 O VULVECTOMY, RADICAL WITH INGUINOFEM 0.00<br />

56637 3 EXTENSIVE VULVA SURGERY 1,311.42<br />

56640 3 EXTENSIVE VULVA SURGERY 1,304.31<br />

56680 O CLITORI<strong>DE</strong>CTOMY SIMPLE 0.00<br />

56685 O CLITORI<strong>DE</strong>CTOMY EXTENSIVE 0.00<br />

56700 3 PARTIAL REMOVAL OF HYMEN 174.42<br />

56710 O PLASTIC REVISION OF HYMEN 0.00<br />

56720 O INCISION OF HYMEN 0.00<br />

56740 3 REMOVE VAGINA GLAND LESION 276.62<br />

56800 3 REPAIR OF VAGINA 226.93<br />

56805 3 REPAIR CLITORIS 1,069.63<br />

56810 3 REPAIR OF PERINEUM 244.27<br />

56820 3 EXAM OF VULVA W/SCOPE 105.33<br />

56821 3 EXAM/BIOPSY OF VULVA W/SCOPE 142.01<br />

57000 3 EXPLORATION OF VAGINA 178.51<br />

57010 3 DRAINAGE OF PELVIC ABSCESS 399.24<br />

57020 3 DRAINAGE OF PELVIC FLUID 89.99<br />

57022 3 I & D VAGINAL HEMATOMA, PP 156.78<br />

57023 3 I & D VAG HEMATOMA, NON-OB 288.39<br />

57061 3 <strong>DE</strong>STROY VAG LESIONS, SIMPLE 110.12<br />

57065 3 <strong>DE</strong>STROY VAG LESIONS, COMPLEX 183.49<br />

57100 3 BIOPSY OF VAGINA 85.09<br />

57105 3 BIOPSY OF VAGINA 130.55<br />

57106 3 REMOVE VAGINA WALL, PARTIAL 437.16<br />

57107 3 REMOVE VAGINA TISSUE, PART 1,292.75<br />

57108 O PARTIAL REMOVAL OF VAGINA 0.00<br />

57109 3 VAGINECTOMY PARTIAL W/NO<strong>DE</strong>S 1,476.27<br />

57110 3 REMOVE VAGINA WALL, COMPLETE 837.65<br />

57111 3 REMOVE VAGINA TISSUE, COMPL 1,505.77<br />

57112 3 VAGINECTOMY W/NO<strong>DE</strong>S, COMPL 1,567.74<br />

57120 3 CLOSURE OF VAGINA 476.69<br />

57126 9 COMPLEX CYSTOMETROGRAM (EG, CALIBRA 0.00<br />

57130 3 REMOVE VAGINA LESION 172.42<br />

57135 3 REMOVE VAGINA LESION 184.64<br />

57150 3 TREAT VAGINA INFECTION 53.60<br />

57155 3 INSERT UTERI TAN<strong>DE</strong>MS/OVOIDS 401.55<br />

57160 3 INSERT PESSARY/OTHER <strong>DE</strong>VICE 73.52<br />

57170 3 FITTING OF DIAPHRAGM/CAP 74.19<br />

57180 3 TREAT VAGINAL BLEEDING 139.00<br />

57200 3 REPAIR OF VAGINA 276.38<br />

57210 3 REPAIR VAGINA/PERINEUM 341.14<br />

57220 3 REVISION OF URETHRA 297.21<br />

57230 3 REPAIR OF URETHRAL LESION 365.48<br />

57240 3 REPAIR BLAD<strong>DE</strong>R & VAGINA 588.67<br />

57250 3 REPAIR RECTUM & VAGINA 576.18<br />

57260 3 REPAIR OF VAGINA 725.90

---

57265 3 EXTENSIVE REPAIR OF VAGINA 820.14<br />

57267 3 INSERT MESH/PELVIC FLR ADDON 252.97<br />

57268 3 REPAIR OF BOWEL BULGE 444.35<br />

57270 3 REPAIR OF BOWEL POUCH 739.81<br />

57280 3 SUSPENSION OF VAGINA 895.54<br />

57282 3 COLPOPEXY, EXTRAPERITONEAL 472.92<br />

57283 3 COLPOPEXY, INTRAPERITONEAL 640.12<br />

57284 3 REPAIR PARAVAG <strong>DE</strong>FECT, OPEN 783.47<br />

57285 3 REPAIR PARAVAG <strong>DE</strong>FECT, VAG 612.11<br />

57287 3 REVISE/REMOVE SLING REPAIR 649.23<br />

57288 3 REPAIR BLAD<strong>DE</strong>R <strong>DE</strong>FECT 762.47<br />

57289 3 REPAIR BLAD<strong>DE</strong>R & VAGINA 716.54<br />

57291 3 CONSTRUCTION OF VAGINA 510.27<br />

57292 3 CONSTRUCT VAGINA WITH GRAFT 771.04<br />

57295 3 REVISE VAG GRAFT VIA VAGINA 457.15<br />

57296 3 REVISE VAG GRAFT, OPEN ABD 870.09<br />

57300 3 REPAIR RECTUM-VAGINA FISTULA 488.39<br />

57305 3 REPAIR RECTUM-VAGINA FISTULA 813.06<br />

57307 3 FISTULA REPAIR & COLOSTOMY 910.42<br />

57308 3 FISTULA REPAIR, TRANSPERINE 587.05<br />

57310 3 REPAIR URETHROVAGINAL LESION 446.34<br />

57311 3 REPAIR URETHROVAGINAL LESION 507.29<br />

57320 3 REPAIR BLAD<strong>DE</strong>R-VAGINA LESION 507.71<br />

57330 3 REPAIR BLAD<strong>DE</strong>R-VAGINA LESION 729.89<br />

57335 3 REPAIR VAGINA 1,062.34<br />

57400 3 DILATION OF VAGINA 126.02<br />

57410 3 PELVIC EXAMINATION 100.04<br />

57415 3 REMOVE VAGINAL FOREIGN BODY 147.33<br />

57420 3 EXAM OF VAGINA W/SCOPE 110.67<br />

57421 3 EXAM/BIOPSY OF VAG W/SCOPE 150.36<br />

57423 3 REPAIR PARAVAG <strong>DE</strong>FECT, LAP 847.90<br />

57425 3 LAPAROSCOPY, SURG, COLPOPEXY 892.57<br />

57450 O CULDOSCOPY, DIAGNOSTIC 0.00<br />

57451 O CULDOSCOPY, DIAGNOSTIC WITH BIOPSY 0.00<br />

57452 3 EXAM OF CERVIX W/SCOPE 104.55<br />

57454 3 BX/CURETT OF CERVIX W/SCOPE 147.03<br />

57455 3 BIOPSY OF CERVIX W/SCOPE 137.83<br />

57456 3 ENDOCERV CURETTAGE W/SCOPE 130.26<br />

57460 3 BX OF CERVIX W/SCOPE, LEEP 305.02<br />

57461 3 CONZ OF CERVIX W/SCOPE, LEEP 338.52<br />

57500 3 BIOPSY OF CERVIX 134.07<br />

57505 3 ENDOCERVICAL CURETTAGE 98.11<br />

57510 3 CAUTERIZATION OF CERVIX 127.37<br />

57511 3 CRYOCAUTERY OF CERVIX 139.16<br />

57513 3 LASER SURGERY OF CERVIX 136.41<br />

57520 3 CONIZATION OF CERVIX 296.35<br />

57522 3 CONIZATION OF CERVIX 251.43<br />

57530 3 REMOVAL OF CERVIX 320.61<br />

57531 3 REMOVAL OF CERVIX, RADICAL 1,581.68<br />

57540 3 REMOVAL OF RESIDUAL CERVIX 721.30

---

57545 3 REMOVE CERVIX/REPAIR PELVIS 763.69<br />

57550 3 REMOVAL OF RESIDUAL CERVIX 377.58<br />

57555 3 REMOVE CERVIX/REPAIR VAGINA 559.68<br />

57556 3 REMOVE CERVIX, REPAIR BOWEL 527.15<br />

57558 3 D&C OF CERVICAL STUMP 118.77<br />

57700 3 REVISION OF CERVIX 280.88<br />

57720 3 REVISION OF CERVIX 286.96<br />

57800 3 DILATION OF CERVICAL CANAL 57.96<br />

57820 O D & C OF RESIDUAL CERVIX 0.00<br />

58100 3 BIOPSY OF UTERUS LINING 105.70<br />

58101 O ENDOMETRIAL WASHINGS (EG, FOR CYTOL 0.00<br />

58102 O OFFICE ENDOMETRIAL CURETTAGE 0.00<br />

58110 3 BX DONE W/COLPOSCOPY ADD-ON 47.34<br />

58120 3 DILATION AND CURETTAGE 230.04<br />

58140 3 MYOMECTOMY ABDOM METHOD 847.26<br />

58145 3 MYOMECTOMY VAG METHOD 504.95<br />

58146 3 MYOMECTOMY ABDOM COMPLEX 1,076.96<br />

58150 3 TOTAL HYSTERECTOMY 914.69<br />

58152 3 TOTAL HYSTERECTOMY 1,162.52<br />

58180 3 PARTIAL HYSTERECTOMY 879.10<br />

58200 3 EXTENSIVE HYSTERECTOMY 1,212.06<br />

58210 3 EXTENSIVE HYSTERECTOMY 1,613.71<br />

58240 3 REMOVAL OF PELVIS CONTENTS 2,481.12<br />

58260 3 VAGINAL HYSTERECTOMY 767.52<br />

58262 3 VAG HYST INCLUDING T/O 857.20<br />

58263 3 VAG HYST W/T/O & VAG REPAIR 923.24<br />

58265 O VAGINAL HYSTERECTOMY WITH PLASTIC R 0.00<br />

58267 3 VAG HYST W/URINARY REPAIR 981.05<br />

58270 3 VAG HYST W/ENTEROCELE REPAIR 822.82<br />

58275 3 HYSTERECTOMY/REVISE VAGINA 912.67<br />

58280 3 HYSTERECTOMY/REVISE VAGINA 977.52<br />

58285 3 EXTENSIVE HYSTERECTOMY 1,222.08<br />

58290 3 VAG HYST COMPLEX 1,076.12<br />

58291 3 VAG HYST INCL T/O, COMPLEX 1,167.77<br />

58292 3 VAG HYST T/O & REPAIR, COMPL 1,233.03<br />

58293 3 VAG HYST W/URO REPAIR, COMPL 1,281.59<br />

58294 3 VAG HYST W/ENTEROCELE, COMPL 1,134.01<br />

58300 5 INSERT INTRAUTERINE <strong>DE</strong>VICE 0.00<br />

58301 3 REMOVE INTRAUTERINE <strong>DE</strong>VICE 93.99<br />

58310 9 ARTIFICIAL INSEMINATION 0.00<br />

58311 9 ARTIFICIAL INSEMINATION WITH SPERM 0.00<br />

58320 O INSUFFLATION OF UTERUS AND TUBES WI 0.00<br />

58321 9 ARTIFICIAL INSEMINATION 0.00<br />

58322 9 ARTIFICIAL INSEMINATION 0.00<br />

58323 9 SPERM WASHING 0.00<br />

58340 3 CATHETER FOR HYSTEROGRAPHY 136.97<br />

58345 9 REOPEN FALLOPIAN TUBE 0.00<br />

58346 3 INSERT HEYMAN UTERI CAPSULE 421.01<br />

58350 9 REOPEN FALLOPIAN TUBE 0.00<br />

58353 3 ENDOMETR ABLATE, THERMAL 207.60

---

58356 3 ENDOMETRIAL CRYOABLATION 2,302.70<br />

58400 3 SUSPENSION OF UTERUS 415.14<br />

58410 3 SUSPENSION OF UTERUS 742.96<br />

58520 3 REPAIR OF RUPTURED UTERUS 723.72<br />

58540 3 REVISION OF UTERUS 840.13<br />

58541 3 LSH, UTERUS 250 G OR LESS 784.93<br />

58542 3 LSH W/T/O UT 250 G OR LESS 868.44<br />

58543 3 LSH UTERUS ABOVE 250 G 882.77<br />

58544 3 LSH W/T/O UTERUS ABOVE 250 G 954.07<br />

58545 3 LAPAROSCOPIC MYOMECTOMY 833.26<br />

58546 3 LAPARO-MYOMECTOMY, COMPLEX 1,055.42<br />

58548 3 LAP RADICAL HYST 1,661.02<br />

58550 3 LAPARO-ASST VAG HYSTERECTOMY 822.70<br />

58551 O LAPAROSCOPY, REMOVE MYOMA 0.00<br />

58552 3 LAPARO-VAG HYST INCL T/O 907.13<br />

58553 3 LAPARO-VAG HYST, COMPLEX 1,060.05<br />

58554 3 LAPARO-VAG HYST W/T/O, COMPL 1,213.52<br />

58555 3 HYSTEROSCOPY, DX, SEP PROC 222.23<br />

58558 3 HYSTEROSCOPY, BIOPSY 291.54<br />

58559 3 HYSTEROSCOPY, LYSIS 324.63<br />

58560 3 HYSTEROSCOPY, RESECT SEPTUM 368.28<br />

58561 3 HYSTEROSCOPY, REMOVE MYOMA 520.23<br />

58562 3 HYSTEROSCOPY, REMOVE FB 310.67<br />

58563 3 HYSTEROSCOPY, ABLATION 325.03<br />

58565 3 HYSTEROSCOPY, STERILIZATION 417.94<br />

58570 3 TLH, UTERUS 250 G OR LESS 842.10<br />

58571 3 TLH W/T/O 250 G OR LESS 922.31<br />

58572 3 TLH, UTERUS OVER 250 G 1,044.31<br />

58573 3 TLH W/T/O UTERUS OVER 250 G 1,178.11<br />

58578 5 LAPARO PROC, UTERUS 0.00<br />

58579 5 HYSTEROSCOPE PROCEDURE 0.00<br />

58600 3 DIVISION OF FALLOPIAN TUBE 341.37<br />

58605 3 DIVISION OF FALLOPIAN TUBE 309.85<br />

58611 3 LIGATE OVIDUCT(S) ADD-ON 73.50<br />

58615 3 OCCLU<strong>DE</strong> FALLOPIAN TUBE(S) 239.61<br />

58660 3 LAPAROSCOPY, LYSIS 624.65<br />

58661 3 LAPAROSCOPY, REMOVE ADNEXA 601.80<br />

58662 3 LAPAROSCOPY, EXCISE LESIONS 659.36<br />

58670 3 LAPAROSCOPY, TUBAL CAUTERY 340.88<br />

58671 3 LAPAROSCOPY, TUBAL BLOCK 341.17<br />

58672 3 LAPAROSCOPY, FIMBRIOPLASTY 699.61<br />

58673 3 LAPAROSCOPY, SALPINGOSTOMY 754.86<br />

58679 5 LAPARO PROC, OVIDUCT-OVARY 0.00<br />

58700 3 REMOVAL OF FALLOPIAN TUBE 706.02<br />

58720 3 REMOVAL OF OVARY/TUBE(S) 664.48<br />

58740 3 ADHESIOLYSIS TUBE, OVARY 811.52<br />

58750 9 REPAIR OVIDUCT 0.00<br />

58752 9 REVISE OVARIAN TUBE(S) 0.00<br />

58760 9 FIMBRIOPLASTY 0.00<br />

58770 3 CREATE NEW TUBAL OPENING 798.81

---

58800 3 DRAINAGE OF OVARIAN CYST(S) 301.70<br />

58805 3 DRAINAGE OF OVARIAN CYST(S) 372.99<br />

58820 3 DRAIN OVARY ABSCESS, OPEN 294.07<br />

58822 3 DRAIN OVARY ABSCESS, PERCUT 635.52<br />

58823 3 DRAIN PELVIC ABSCESS, PERCUT 934.70<br />

58825 3 TRANSPOSITION, OVARY(S) 644.98<br />

58900 3 BIOPSY OF OVARY(S) 381.12<br />

58920 3 PARTIAL REMOVAL OF OVARY(S) 653.62<br />

58925 3 REMOVAL OF OVARIAN CYST(S) 675.11<br />

58940 3 REMOVAL OF OVARY(S) 462.38<br />

58943 3 REMOVAL OF OVARY(S) 1,035.66<br />

58950 3 RESECT OVARIAN MALIGNANCY 986.74<br />

58951 3 RESECT OVARIAN MALIGNANCY 1,271.70<br />

58952 3 RESECT OVARIAN MALIGNANCY 1,434.87<br />

58953 3 TAH, RAD DISSECT FOR <strong>DE</strong>BULK 1,780.36<br />

58954 3 TAH RAD <strong>DE</strong>BULK/LYMPH REMOVE 1,932.99<br />

58956 3 BSO, OMENTECTOMY W/TAH 1,258.66<br />

58957 3 RESECT RECURRENT GYN MAL 1,347.53<br />

58958 3 RESECT RECUR GYN MAL W/LYM 1,490.33<br />

58960 3 EXPLORATION OF ABDOMEN 852.57<br />

58970 9 RETRIEVAL OF OOCYTE 0.00<br />

58972 O CULTURE AND FERTILIZATION OF OOCYTE 0.00<br />

58974 9 TRANSFER OF EMBRYO 0.00<br />

58976 9 TRANSFER OF EMBRYO 0.00<br />

58980 O LAPAROSCOPY, SURGICAL 0.00<br />

58982 O LAPAROSCOPY, SURGICAL WITH FULGURAT 0.00<br />

58983 O LAPAROSCOPY, SURGICAL WITH OCCLUSIO 0.00<br />

58984 O LAPAROSCOPY, SURGICAL WITH FULGURAT 0.00<br />

58985 O LAPAROSCOPY, SURGICAL WITH LYSIS OF 0.00<br />

58986 O LAPAROSCOPY, SURGICAL WITH BIOPSY ( 0.00<br />

58987 O LAPAROSCOPY, SURGICAL WITH ASPIRATI 0.00<br />

58988 O LAPAROSCOPY, SURGICAL WITH REMOVAL 0.00<br />

58990 O HYSTEROSCOPY DIAGNOSTIC 0.00<br />

58992 O HYSTEROSCOPY WITH LYSIS OF INTRAUTE 0.00<br />

58994 O HYSTEROSCOPY WITH REMOVAL OF SUBMUC 0.00<br />

58996 O HYSTEROSCOPY; WITH ENDOMETRIAL ABLA 0.00<br />

58999 5 GENITAL SURGERY PROCEDURE 0.00<br />

59000 3 AMNIOCENTESIS, DIAGNOSTIC 128.22<br />

59001 3 AMNIOCENTESIS, THERAPEUTIC 171.45<br />

59012 3 FETAL CORD PUNCTURE,PRENATAL 193.66<br />

59015 3 CHORION BIOPSY 148.32<br />

59020 3 FETAL CONTRACT STRESS TEST 66.22<br />

59025 3 FETAL NON-STRESS TEST 43.78<br />

59030 3 FETAL SCALP BLOOD SAMPLE 105.29<br />

59050 3 FETAL MONITOR W/REPORT 48.45<br />

59051 3 FETAL MONITOR/INTERPRET ONLY 39.90<br />

59070 3 TRANSABDOM AMNIOINFUS W/US 373.47<br />

59072 3 UMBILICAL CORD OCCLUD W/US 418.29<br />

59074 3 FETAL FLUID DRAINAGE W/US 346.72<br />

59076 3 FETAL SHUNT PLACEMENT, W/US 418.29

---

59100 3 REMOVE UTERUS LESION 773.11<br />

59120 3 TREAT ECTOPIC PREGNANCY 735.65<br />

59121 3 TREAT ECTOPIC PREGNANCY 740.91<br />

59130 3 TREAT ECTOPIC PREGNANCY 834.84<br />

59135 3 TREAT ECTOPIC PREGNANCY 842.82<br />

59136 3 TREAT ECTOPIC PREGNANCY 799.72<br />

59140 3 TREAT ECTOPIC PREGNANCY 345.46<br />

59150 3 TREAT ECTOPIC PREGNANCY 716.45<br />

59151 3 TREAT ECTOPIC PREGNANCY 703.30<br />

59160 3 D & C AFTER <strong>DE</strong>LIVERY 215.22<br />

59200 3 INSERT CERVICAL DILATOR 74.28<br />

59300 3 EPISIOTOMY OR VAGINAL REPAIR 184.27<br />

59320 3 REVISION OF CERVIX 145.47<br />

59325 3 REVISION OF CERVIX 229.60<br />

59350 3 REPAIR OF UTERUS 262.71<br />

59400 7 OBSTETRICAL CARE 0.00<br />

59409 3 OBSTETRICAL CARE 729.80<br />

59410 3 OBSTETRICAL CARE 843.18<br />

59412 9 ANTEPARTUM MANIPULATION 0.00<br />

59414 3 <strong>DE</strong>LIVER PLACENTA 87.17<br />

59420 O ANTEPARTUM CARE ONLY (SEPARATE PROC 0.00<br />

59425 9 ANTEPARTUM CARE ONLY 0.00<br />

59426 9 ANTEPARTUM CARE ONLY 0.00<br />

59430 3 CARE AFTER <strong>DE</strong>LIVERY 132.43<br />

59510 7 CESAREAN <strong>DE</strong>LIVERY 0.00<br />

59514 3 CESAREAN <strong>DE</strong>LIVERY ONLY 729.80<br />

59515 3 CESAREAN <strong>DE</strong>LIVERY 843.18<br />

59525 3 REMOVE UTERUS AFTER CESAREAN 456.26<br />

59610 9 VBAC <strong>DE</strong>LIVERY 0.00<br />

59612 3 VBAC <strong>DE</strong>LIVERY ONLY 729.80<br />

59614 3 VBAC CARE AFTER <strong>DE</strong>LIVERY 843.18<br />

59618 9 ATTEMPTED VBAC <strong>DE</strong>LIVERY 0.00<br />

59620 3 ATTEMPTED VBAC <strong>DE</strong>LIVERY ONLY 729.80<br />

59622 3 ATTEMPTED VBAC AFTER CARE 843.18<br />

59812 3 TREATMENT OF MISCARRIAGE 288.08<br />

59820 3 CARE OF MISCARRIAGE 353.97<br />

59821 3 TREATMENT OF MISCARRIAGE 360.94<br />

59830 3 TREAT UTERUS INFECTION 409.22<br />

59840 3 ABORTION 204.10<br />

59841 3 ABORTION 355.21<br />

59850 3 ABORTION 350.63<br />

59851 3 ABORTION 376.59<br />

59852 3 ABORTION 507.03<br />

59855 3 ABORTION 389.54<br />

59856 3 ABORTION 460.76<br />

59857 3 ABORTION 539.60<br />

59866 9 ABORTION (MPR) 0.00<br />

59870 3 EVACUATE MOLE OF UTERUS 433.49<br />

59871 3 REMOVE CERCLAGE SUTURE 127.32<br />

59897 6 FETAL INVAS PX W/US 0.00

---

59898 5 LAPARO PROC, OB CARE/<strong>DE</strong>LIVER 0.00<br />

59899 5 MATERNITY CARE PROCEDURE 0.00<br />

60000 3 DRAIN THYROID/TONGUE CYST 143.97<br />

60001 O ASPIRATE/INJECT THYRIOD CYST 0.00<br />

6005F 9 CARE LEVEL RATIONALE DOC 0.00<br />

60100 3 BIOPSY OF THYROID 109.22<br />

6010F 9 DYSPHAG TEST DONE B/4 EATING 0.00<br />

6015F 9 DYSPHAG TEST DONE B/4 EATING 0.00<br />

60200 3 REMOVE THYROID LESION 591.88<br />

6020F 9 NPO (NOTHING-MOUTH) OR<strong>DE</strong>RED 0.00<br />

60210 3 PARTIAL THYROID EXCISION 628.17<br />

60212 3 PARTIAL THYROID EXCISION 898.64<br />

60220 3 PARTIAL REMOVAL OF THYROID 688.22<br />

60225 3 PARTIAL REMOVAL OF THYROID 827.73<br />

60240 3 REMOVAL OF THYROID 878.77<br />

60245 O THYROI<strong>DE</strong>CTOMY, SUBTOTAL OR PARTIAL; 0.00<br />

60246 O THYROI<strong>DE</strong>CTOMY, SUBTOTAL OR PARTIAL; 0.00<br />

60252 3 REMOVAL OF THYROID 1,182.27<br />

60254 3 EXTENSIVE THYROID SURGERY 1,535.70<br />

60260 3 REPEAT THYROID SURGERY 989.82<br />

60270 3 REMOVAL OF THYROID 1,240.51<br />

60271 3 REMOVAL OF THYROID 956.34<br />

60280 3 REMOVE THYROID DUCT LESION 401.02<br />

60281 3 REMOVE THYROID DUCT LESION 536.48<br />

60300 3 ASPIR/INJ THYROID CYST 100.51<br />

6030F 9 MAX STERILE BARRIERS FOLLWD 0.00<br />

6040F 9 APPRO RAD DS DVCS TECHS DOCD 0.00<br />

6045F 9 RADXPS IN END RPRT4FLURO PXD 0.00<br />

60500 3 EXPLORE PARATHYROID GLANDS 906.04<br />

60502 3 RE-EXPLORE PARATHYROIDS 1,141.23<br />

60505 3 EXPLORE PARATHYROID GLANDS 1,254.82<br />

60512 3 AUTOTRANSPLANT PARATHYROID 221.72<br />

60520 3 REMOVAL OF THYMUS GLAND 944.83<br />

60521 3 REMOVAL OF THYMUS GLAND 1,079.31<br />

60522 3 REMOVAL OF THYMUS GLAND 1,299.97<br />

60540 3 EXPLORE ADRENAL GLAND 970.63<br />

60545 3 EXPLORE ADRENAL GLAND 1,111.23<br />

60600 3 REMOVE CAROTID BODY LESION 1,302.13<br />

60605 3 REMOVE CAROTID BODY LESION 1,634.46<br />

60650 3 LAPAROSCOPY ADRENALECTOMY 1,083.75<br />

60659 5 LAPARO PROC, ENDOCRINE 0.00<br />

60699 5 ENDOCRINE SURGERY PROCEDURE 0.00<br />

61000 3 REMOVE CRANIAL CAVITY FLUID 100.26<br />

61001 3 REMOVE CRANIAL CAVITY FLUID 97.28<br />

61020 3 REMOVE BRAIN CAVITY FLUID 119.50<br />

61026 3 INJECTION INTO BRAIN CANAL 119.86<br />

61050 3 REMOVE BRAIN CANAL FLUID 102.07<br />

61055 3 INJECTION INTO BRAIN CANAL 130.17<br />

61070 3 BRAIN CANAL SHUNT PROCEDURE 77.56<br />

61105 3 TWIST DRILL HOLE 396.25

---

61106 O DRILL SKULL FOR EXAM/SURGERY 0.00<br />

61107 3 DRILL SKULL FOR IMPLANTATION 292.99<br />

61108 3 DRILL SKULL FOR DRAINAGE 773.49<br />

61120 3 BURR HOLE FOR PUNCTURE 636.23<br />

61130 O PIERCE SKULL, EXAM/SURGERY 0.00<br />

61140 3 PIERCE SKULL FOR BIOPSY 1,101.17<br />

61150 3 PIERCE SKULL FOR DRAINAGE 1,179.79<br />

61151 3 PIERCE SKULL FOR DRAINAGE 863.70<br />

61154 3 PIERCE SKULL & REMOVE CLOT 1,098.06<br />

61156 3 PIERCE SKULL FOR DRAINAGE 1,099.11<br />

61210 3 PIERCE SKULL, IMPLANT <strong>DE</strong>VICE 341.47<br />

61215 3 INSERT BRAIN-FLUID <strong>DE</strong>VICE 418.60<br />

61250 3 PIERCE SKULL & EXPLORE 749.09<br />

61253 3 PIERCE SKULL & EXPLORE 831.70<br />

61304 3 OPEN SKULL FOR EXPLORATION 1,456.41<br />

61305 3 OPEN SKULL FOR EXPLORATION 1,742.78<br />

61312 3 OPEN SKULL FOR DRAINAGE 1,803.52<br />

61313 3 OPEN SKULL FOR DRAINAGE 1,731.82<br />

61314 3 OPEN SKULL FOR DRAINAGE 1,594.62<br />

61315 3 OPEN SKULL FOR DRAINAGE 1,833.50<br />

61316 3 IMPLT CRAN BONE FLAP TO ABDO 79.37<br />

61320 3 OPEN SKULL FOR DRAINAGE 1,692.85<br />

61321 3 OPEN SKULL FOR DRAINAGE 1,875.54<br />

61322 3 <strong>DE</strong>COMPRESSIVE CRANIOTOMY 2,033.68<br />

61323 3 <strong>DE</strong>COMPRESSIVE LOBECTOMY 2,079.12<br />

61330 3 <strong>DE</strong>COMPRESS EYE SOCKET 1,418.86<br />

61332 3 EXPLORE/BIOPSY EYE SOCKET 1,671.27<br />

61333 3 EXPLORE ORBIT/REMOVE LESION 1,665.48<br />

61334 3 EXPLORE ORBIT/REMOVE OBJECT 1,099.69<br />

61340 3 SUBTEMPORAL <strong>DE</strong>COMPRESSION 1,270.23<br />

61343 3 INCISE SKULL (PRESS RELIEF) 1,946.01<br />

61345 3 RELIEVE CRANIAL PRESSURE 1,790.52<br />

61440 3 INCISE SKULL FOR SURGERY 1,750.61<br />

61450 3 INCISE SKULL FOR SURGERY 1,664.94<br />

61458 3 INCISE SKULL FOR BRAIN WOUND 1,779.50<br />

61460 3 INCISE SKULL FOR SURGERY 1,809.37<br />

61470 3 INCISE SKULL FOR SURGERY 1,656.84<br />

61480 3 INCISE SKULL FOR SURGERY 1,607.51<br />

61490 3 INCISE SKULL FOR SURGERY 1,686.14<br />

61500 3 REMOVAL OF SKULL LESION 1,190.71<br />

61501 3 REMOVE INFECTED SKULL BONE 1,012.23<br />

61510 3 REMOVAL OF BRAIN LESION 1,918.18<br />

61512 3 REMOVE BRAIN LINING LESION 2,273.53<br />

61514 3 REMOVAL OF BRAIN ABSCESS 1,680.03<br />

61516 3 REMOVAL OF BRAIN LESION 1,641.83<br />

61517 3 IMPLT BRAIN CHEMOTX ADD-ON 80.15<br />

61518 3 REMOVAL OF BRAIN LESION 2,446.17<br />

61519 3 REMOVE BRAIN LINING LESION 2,634.23<br />

61520 3 REMOVAL OF BRAIN LESION 3,368.42<br />

61521 3 REMOVAL OF BRAIN LESION 2,837.83

---

61522 3 REMOVAL OF BRAIN ABSCESS 1,924.01<br />

61524 3 REMOVAL OF BRAIN LESION 1,838.44<br />

61526 3 REMOVAL OF BRAIN LESION 3,060.45<br />

61530 3 REMOVAL OF BRAIN LESION 2,599.21<br />

61531 3 IMPLANT BRAIN ELECTRO<strong>DE</strong>S 1,049.91<br />

61533 3 IMPLANT BRAIN ELECTRO<strong>DE</strong>S 1,334.57<br />

61534 3 REMOVAL OF BRAIN LESION 1,433.01<br />

61535 3 REMOVE BRAIN ELECTRO<strong>DE</strong>S 851.67<br />

61536 3 REMOVAL OF BRAIN LESION 2,301.33<br />

61537 3 REMOVAL OF BRAIN TISSUE 2,063.13<br />

61538 3 REMOVAL OF BRAIN TISSUE 2,202.16<br />

61539 3 REMOVAL OF BRAIN TISSUE 2,084.74<br />

61540 3 REMOVAL OF BRAIN TISSUE 1,967.63<br />

61541 3 INCISION OF BRAIN TISSUE 1,875.39<br />

61542 3 REMOVAL OF BRAIN TISSUE 2,038.82<br />

61543 3 REMOVAL OF BRAIN TISSUE 1,876.37<br />

61544 3 REMOVE & TREAT BRAIN LESION 1,654.38<br />

61545 3 EXCISION OF BRAIN TUMOR 2,807.92<br />

61546 3 REMOVAL OF PITUITARY GLAND 2,029.93<br />

61548 3 REMOVAL OF PITUITARY GLAND 1,370.49<br />

61550 3 RELEASE OF SKULL SEAMS 800.16<br />

61552 3 RELEASE OF SKULL SEAMS 1,137.32<br />

61553 O CRANIECTOMY FOR CRANIOSTENOSIS EACH 0.00<br />

61555 O RECONSTRUCTION OF SKULL BY MULTIPLE 0.00<br />

61556 3 INCISE SKULL/SUTURES 1,436.35<br />

61557 3 INCISE SKULL/SUTURES 1,493.04<br />

61558 3 EXCISION OF SKULL/SUTURES 1,502.10<br />

61559 3 EXCISION OF SKULL/SUTURES 2,140.18<br />

61561 O RECONSTRUCTION OF SKULL BY ORBITAL 0.00<br />

61563 3 EXCISION OF SKULL TUMOR 1,672.00<br />

61564 3 EXCISION OF SKULL TUMOR 2,144.85<br />

61566 3 REMOVAL OF BRAIN TISSUE 1,978.37<br />

61567 3 INCISION OF BRAIN TISSUE 2,224.83<br />

61570 3 REMOVE FOREIGN BODY, BRAIN 1,618.14<br />

61571 3 INCISE SKULL FOR BRAIN WOUND 1,745.95<br />

61575 3 SKULL BASE/BRAINSTEM SURGERY 2,096.38<br />

61576 3 SKULL BASE/BRAINSTEM SURGERY 3,270.01<br />

61580 3 CRANIOFACIAL APPROACH, SKULL 2,217.06<br />

61581 3 CRANIOFACIAL APPROACH, SKULL 2,443.62<br />

61582 3 CRANIOFACIAL APPROACH, SKULL 2,534.85<br />

61583 3 CRANIOFACIAL APPROACH, SKULL 2,578.49<br />

61584 3 ORBITOCRANIAL APPROACH/SKULL 2,512.40<br />

61585 3 ORBITOCRANIAL APPROACH/SKULL 2,663.64<br />

61586 3 RESECT NASOPHARYNX, SKULL 1,944.20<br />

61590 3 INFRATEMPORAL APPROACH/SKULL 2,797.94<br />

61591 3 INFRATEMPORAL APPROACH/SKULL 2,821.68<br />

61592 3 ORBITOCRANIAL APPROACH/SKULL 2,804.37<br />

61595 3 TRANSTEMPORAL APPROACH/SKULL 2,111.75<br />

61596 3 TRANSCOCHLEAR APPROACH/SKULL 2,326.80<br />

61597 3 TRANSCONDYLAR APPROACH/SKULL 2,553.23

---

61598 3 TRANSPETROSAL APPROACH/SKULL 2,296.29<br />

61600 3 RESECT/EXCISE CRANIAL LESION 1,901.92<br />

61601 3 RESECT/EXCISE CRANIAL LESION 2,092.11<br />

61605 3 RESECT/EXCISE CRANIAL LESION 1,998.42<br />

61606 3 RESECT/EXCISE CRANIAL LESION 2,650.22<br />

61607 3 RESECT/EXCISE CRANIAL LESION 2,469.79<br />

61608 3 RESECT/EXCISE CRANIAL LESION 2,900.18<br />

61609 3 TRANSECT ARTERY, SINUS 570.10<br />

61610 3 TRANSECT ARTERY, SINUS 1,708.35<br />

61611 3 TRANSECT ARTERY, SINUS 415.96<br />

61612 3 TRANSECT ARTERY, SINUS 1,459.65<br />

61613 3 REMOVE ANEURYSM, SINUS 2,828.95<br />

61615 3 RESECT/EXCISE LESION, SKULL 2,214.65<br />

61616 3 RESECT/EXCISE LESION, SKULL 2,924.78<br />

61618 3 REPAIR DURA 1,150.80<br />

61619 3 REPAIR DURA 1,333.69<br />

61623 3 ENDOVASC TEMPORY VESSEL OCCL 521.83<br />

61624 3 TRANSCATH OCCLUSION, CNS 1,019.28<br />

61626 3 TRANSCATH OCCLUSION, NON-CNS 825.88<br />

61630 3 INTRACRANIAL ANGIOPLASTY 1,180.54<br />

61635 3 INTRACRAN ANGIOPLSTY W/STENT 1,291.93<br />

61640 3 DILATE IC VASOSPASM, INIT 550.14<br />

61641 3 DILATE IC VASOSPASM ADD-ON 193.45<br />

61642 3 DILATE IC VASOSPASM ADD-ON 386.89<br />

61680 3 INTRACRANIAL VESSEL SURGERY 2,006.23<br />

61682 3 INTRACRANIAL VESSEL SURGERY 3,793.23<br />

61684 3 INTRACRANIAL VESSEL SURGERY 2,545.81<br />

61686 3 INTRACRANIAL VESSEL SURGERY 4,060.15<br />

61690 3 INTRACRANIAL VESSEL SURGERY 1,917.04<br />

61692 3 INTRACRANIAL VESSEL SURGERY 3,262.83<br />

61697 3 BRAIN ANEURYSM REPR, COMPLX 3,638.52<br />

61698 3 BRAIN ANEURYSM REPR, COMPLX 3,853.33<br />

61700 3 BRAIN ANEURYSM REPR, SIMPLE 3,115.54<br />

61702 3 INNER SKULL VESSEL SURGERY 3,402.59<br />

61703 3 CLAMP NECK ARTERY 1,158.40<br />

61705 3 REVISE CIRCULATION TO HEAD 2,289.41<br />

61708 3 REVISE CIRCULATION TO HEAD 1,922.06<br />

61710 3 REVISE CIRCULATION TO HEAD 1,731.32<br />

61711 3 FUSION OF SKULL ARTERIES 2,326.44<br />

61712 O SKULL OR SPINE MICROSURGERY 0.00<br />

61720 3 INCISE SKULL/BRAIN SURGERY 1,028.05<br />

61735 3 INCISE SKULL/BRAIN SURGERY 1,254.15<br />

61750 3 INCISE SKULL/BRAIN BIOPSY 1,233.05<br />

61751 3 BRAIN BIOPSY W/CT/MR GUI<strong>DE</strong> 1,203.55<br />

61760 3 IMPLANT BRAIN ELECTRO<strong>DE</strong>S 1,323.13<br />

61770 3 INCISE SKULL FOR TREATMENT 1,323.81<br />

61780 O STEREOTACTIC LOCALIZATION, ANY METH 0.00<br />

61790 3 TREAT TRIGEMINAL NERVE 741.45<br />

61791 3 TREAT TRIGEMINAL TRACT 956.86<br />

61793 O FOCUS RADIATION BEAM 0.00

---

61795 3 BRAIN SURGERY USING COMPUTER 228.14<br />

61796 6 SRS, CRANIAL LESION SIMPLE 0.00<br />

61797 6 SRS, CRAN LES SIMPLE, ADDL 0.00<br />

61798 6 SRS, CRANIAL LESION COMPLEX 0.00<br />

61799 6 SRS, CRAN LES COMPLEX, ADDL 0.00<br />

61800 6 APPLY SRS HEADFRAME ADD-ON 0.00<br />

61850 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 851.14<br />

61855 O IMPLANT NEUROELECTRO<strong>DE</strong>S 0.00<br />

61860 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 1,363.18<br />

61862 O IMPLANT NEUROSTIMUL, SUBCORT 0.00<br />

61863 3 IMPLANT NEUROELECTRO<strong>DE</strong> 1,334.10<br />

61864 3 IMPLANT NEUROELECTR<strong>DE</strong>, ADDL 390.69<br />

61865 O IMPLANT NEUROELECTRO<strong>DE</strong>S 0.00<br />

61867 3 IMPLANT NEUROELECTRO<strong>DE</strong> 1,952.16<br />

61868 3 IMPLANT NEUROELECTR<strong>DE</strong>, ADDÏL 566.00<br />

61870 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 1,046.80<br />

61875 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 915.61<br />

61880 3 REVISE/REMOVE NEUROELECTRO<strong>DE</strong> 473.69<br />

61885 3 INSRT/REDO NEUROSTIM 1 ARRAY 540.50<br />

61886 3 IMPLANT NEUROSTIM ARRAYS 681.01<br />

61888 3 REVISE/REMOVE NEURORECEIVER 356.17<br />

62000 3 TREAT SKULL FRACTURE 758.86<br />

62005 3 TREAT SKULL FRACTURE 1,071.02<br />

62010 3 TREATMENT OF HEAD INJURY 1,337.17<br />

62100 3 REPAIR BRAIN FLUID LEAKAGE 1,426.28<br />

62115 3 REDUCTION OF SKULL <strong>DE</strong>FECT 1,435.60<br />

62116 3 REDUCTION OF SKULL <strong>DE</strong>FECT 1,550.89<br />

62117 3 REDUCTION OF SKULL <strong>DE</strong>FECT 1,645.65<br />

62120 3 REPAIR SKULL CAVITY LESION 1,620.54<br />

62121 3 INCISE SKULL REPAIR 1,485.10<br />

62140 3 REPAIR OF SKULL <strong>DE</strong>FECT 926.12<br />

62141 3 REPAIR OF SKULL <strong>DE</strong>FECT 1,014.24<br />

62142 3 REMOVE SKULL PLATE/FLAP 769.31<br />

62143 3 REPLACE SKULL PLATE/FLAP 906.14<br />

62145 3 REPAIR OF SKULL & BRAIN 1,227.13<br />

62146 3 REPAIR OF SKULL WITH GRAFT 1,066.64<br />

62147 3 REPAIR OF SKULL WITH GRAFT 1,263.87<br />

62148 3 RETR BONE FLAP TO FIX SKULL 113.45<br />

62160 3 NEUROENDOSCOPY ADD-ON 176.38<br />

62161 3 DISSECT BRAIN W/SCOPE 1,346.27<br />

62162 3 REMOVE COLLOID CYST W/SCOPE 1,659.73<br />

62163 3 NEUROENDOSCOPY W/FB REMOVAL 1,052.00<br />

62164 3 REMOVE BRAIN TUMOR W/SCOPE 1,759.37<br />

62165 3 REMOVE PITUIT TUMOR W/SCOPE 1,367.23<br />

62180 3 ESTABLISH BRAIN CAVITY SHUNT 1,393.75<br />

62190 3 ESTABLISH BRAIN CAVITY SHUNT 776.64<br />

62192 3 ESTABLISH BRAIN CAVITY SHUNT 846.41<br />

62194 3 REPLACE/IRRIGATE CATHETER 329.53<br />

62200 3 ESTABLISH BRAIN CAVITY SHUNT 1,212.09<br />

62201 3 BRAIN CAVITY SHUNT W/SCOPE 1,037.11

---

62220 3 ESTABLISH BRAIN CAVITY SHUNT 900.47<br />

62223 3 ESTABLISH BRAIN CAVITY SHUNT 910.46<br />

62225 3 REPLACE/IRRIGATE CATHETER 436.75<br />

62230 3 REPLACE/REVISE BRAIN SHUNT 734.38<br />

62252 3 CSF SHUNT REPROGRAM 94.98<br />

62256 3 REMOVE BRAIN CAVITY SHUNT 507.02<br />

62258 3 REPLACE BRAIN CAVITY SHUNT 991.93<br />

62263 3 EPIDURAL LYSIS MULT SESSIONS 665.24<br />

62264 3 EPIDURAL LYSIS ON SINGLE DAY 420.60<br />

62267 6 INTERDISCAL PERQ ASPIR, DX 0.00<br />

62268 3 DRAIN SPINAL CORD CYST 532.11<br />

62269 3 NEEDLE BIOPSY, SPINAL CORD 592.69<br />

62270 3 SPINAL FLUID TAP, DIAGNOSTIC 154.79<br />

62272 3 DRAIN CEREBRO SPINAL FLUID 183.74<br />

62273 3 INJECT EPIDURAL PATCH 162.79<br />

62274 O INJECT SPINAL ANESTHETIC 0.00<br />

62275 O INJECT SPINAL ANESTHETIC 0.00<br />

62276 O INJECT SPINAL ANESTHETIC 0.00<br />

62277 O INJECT SPINAL ANESTHETIC 0.00<br />

62278 O INJECT SPINAL ANESTHETIC 0.00<br />

62279 O INJECT SPINAL ANESTHETIC 0.00<br />

62280 3 TREAT SPINAL CORD LESION 325.62<br />

62281 3 TREAT SPINAL CORD LESION 287.33<br />

62282 3 TREAT SPINAL CANAL LESION 328.69<br />

62284 3 INJECTION FOR MYELOGRAM 228.54<br />

62287 3 PERCUTANEOUS DISKECTOMY 512.25<br />

62288 O INJECTION INTO SPINAL CANAL 0.00<br />

62289 O INJECTION INTO SPINAL CANAL 0.00<br />

62290 3 INJECT FOR SPINE DISK X-RAY 337.44<br />

62291 3 INJECT FOR SPINE DISK X-RAY 306.53<br />

62292 3 INJECTION INTO DISK LESION 478.63<br />

62294 3 INJECTION INTO SPINAL ARTERY 707.53<br />

62298 O INJECTION INTO SPINAL CANAL 0.00<br />

62310 3 INJECT SPINE C/T 221.68<br />

62311 3 INJECT SPINE L/S (CD) 204.14<br />

62318 3 INJECT SPINE W/CATH, C/T 246.37<br />

62319 3 INJECT SPINE W/CATH L/S (CD) 219.84<br />

62350 3 IMPLANT SPINAL CANAL CATH 458.61<br />

62351 3 IMPLANT SPINAL CANAL CATH 748.56<br />

62355 3 REMOVE SPINAL CANAL CATHETER 376.14<br />

62360 3 INSERT SPINE INFUSION <strong>DE</strong>VICE 250.10<br />

62361 3 IMPLANT SPINE INFUSION PUMP 403.99<br />

62362 3 IMPLANT SPINE INFUSION PUMP 503.47<br />

62365 3 REMOVE SPINE INFUSION <strong>DE</strong>VICE 392.01<br />

62367 3 ANALYZE SPINE INFUSION PUMP 37.52<br />

62368 3 ANALYZE SPINE INFUSION PUMP 51.98<br />

63001 3 REMOVAL OF SPINAL LAMINA 1,084.60<br />

63003 3 REMOVAL OF SPINAL LAMINA 1,093.95<br />

63005 3 REMOVAL OF SPINAL LAMINA 1,039.24<br />

63010 O LAMINECTOMY FOR EXPLORATION/<strong>DE</strong>COMPR 0.00

---

63011 3 REMOVAL OF SPINAL LAMINA 975.19<br />

63012 3 REMOVAL OF SPINAL LAMINA 1,061.56<br />

63015 3 REMOVAL OF SPINAL LAMINA 1,309.45<br />

63016 3 REMOVAL OF SPINAL LAMINA 1,339.72<br />

63017 3 REMOVAL OF SPINAL LAMINA 1,098.31<br />

63020 3 NECK SPINE DISK SURGERY 1,038.96<br />

63030 3 LOW BACK DISK SURGERY 865.56<br />

63035 3 SPINAL DISK SURGERY ADD-ON 184.73<br />

63040 3 LAMINOTOMY, SINGLE CERVICAL 1,266.15<br />

63042 3 LAMINOTOMY, SINGLE LUMBAR 1,188.78<br />

63043 5 LAMINOTOMY, ADDÏL CERVICAL 0.00<br />

63044 5 LAMINOTOMY, ADDÏL LUMBAR 0.00<br />

63045 3 REMOVAL OF SPINAL LAMINA 1,129.45<br />

63046 3 REMOVAL OF SPINAL LAMINA 1,079.07<br />

63047 3 REMOVAL OF SPINAL LAMINA 990.35<br />

63048 3 REMOVE SPINAL LAMINA ADD-ON 197.76<br />

63050 3 CERVICAL LAMINOPLASTY 1,345.65<br />

63051 3 C-LAMINOPLASTY W/GRAFT/PLATE 1,521.30<br />

63055 3 <strong>DE</strong>COMPRESS SPINAL CORD 1,454.14<br />

63056 3 <strong>DE</strong>COMPRESS SPINAL CORD 1,349.21<br />

63057 3 <strong>DE</strong>COMPRESS SPINE CORD ADD-ON 304.89<br />

63064 3 <strong>DE</strong>COMPRESS SPINAL CORD 1,597.19<br />

63066 3 <strong>DE</strong>COMPRESS SPINE CORD ADD-ON 187.19<br />

63075 3 NECK SPINE DISK SURGERY 1,251.82<br />

63076 3 NECK SPINE DISK SURGERY 235.92<br />

63077 3 SPINE DISK SURGERY, THORAX 1,359.12<br />

63078 3 SPINE DISK SURGERY, THORAX 187.08<br />

63081 3 REMOVAL OF VERTEBRAL BODY 1,592.44<br />

63082 3 REMOVE VERTEBRAL BODY ADD-ON 254.38<br />

63085 3 REMOVAL OF VERTEBRAL BODY 1,698.75<br />

63086 3 REMOVE VERTEBRAL BODY ADD-ON 179.96<br />

63087 3 REMOVAL OF VERTEBRAL BODY 2,162.24<br />

63088 3 REMOVE VERTEBRAL BODY ADD-ON 244.56<br />

63090 3 REMOVAL OF VERTEBRAL BODY 1,767.21<br />

63091 3 REMOVE VERTEBRAL BODY ADD-ON 168.16<br />

63101 3 REMOVAL OF VERTEBRAL BODY 2,033.64<br />

63102 3 REMOVAL OF VERTEBRAL BODY 2,029.70<br />

63103 3 REMOVE VERTEBRAL BODY ADD-ON 267.09<br />

63170 3 INCISE SPINAL CORD TRACT(S) 1,331.36<br />

63172 3 DRAINAGE OF SPINAL CYST 1,226.69<br />

63173 3 DRAINAGE OF SPINAL CYST 1,507.42<br />

63180 3 REVISE SPINAL CORD LIGAMENTS 1,240.36<br />

63182 3 REVISE SPINAL CORD LIGAMENTS 1,283.64<br />

63185 3 INCISE SPINAL COLUMN/NERVES 989.86<br />

63190 3 INCISE SPINAL COLUMN/NERVES 1,120.62<br />

63191 3 INCISE SPINAL COLUMN/NERVES 1,112.31<br />

63194 3 INCISE SPINAL COLUMN & CORD 1,292.74<br />

63195 3 INCISE SPINAL COLUMN & CORD 1,330.08<br />

63196 3 INCISE SPINAL COLUMN & CORD 1,558.26<br />

63197 3 INCISE SPINAL COLUMN & CORD 1,358.45

---

63198 3 INCISE SPINAL COLUMN & CORD 1,541.24<br />

63199 3 INCISE SPINAL COLUMN & CORD 1,581.85<br />

63200 3 RELEASE OF SPINAL CORD 1,330.16<br />

63250 3 REVISE SPINAL CORD VESSELS 2,553.79<br />

63251 3 REVISE SPINAL CORD VESSELS 2,685.94<br />

63252 3 REVISE SPINAL CORD VESSELS 2,672.30<br />

63265 3 EXCISE INTRASPINAL LESION 1,471.27<br />

63266 3 EXCISE INTRASPINAL LESION 1,515.59<br />

63267 3 EXCISE INTRASPINAL LESION 1,221.32<br />

63268 3 EXCISE INTRASPINAL LESION 1,209.43<br />

63270 3 EXCISE INTRASPINAL LESION 1,814.87<br />

63271 3 EXCISE INTRASPINAL LESION 1,822.66<br />

63272 3 EXCISE INTRASPINAL LESION 1,681.57<br />

63273 3 EXCISE INTRASPINAL LESION 1,622.87<br />

63275 3 BIOPSY/EXCISE SPINAL TUMOR 1,586.15<br />

63276 3 BIOPSY/EXCISE SPINAL TUMOR 1,574.97<br />

63277 3 BIOPSY/EXCISE SPINAL TUMOR 1,388.29<br />

63278 3 BIOPSY/EXCISE SPINAL TUMOR 1,358.84<br />

63280 3 BIOPSY/EXCISE SPINAL TUMOR 1,871.12<br />

63281 3 BIOPSY/EXCISE SPINAL TUMOR 1,855.00<br />

63282 3 BIOPSY/EXCISE SPINAL TUMOR 1,747.05<br />

63283 3 BIOPSY/EXCISE SPINAL TUMOR 1,665.22<br />

63285 3 BIOPSY/EXCISE SPINAL TUMOR 2,305.82<br />

63286 3 BIOPSY/EXCISE SPINAL TUMOR 2,303.87<br />

63287 3 BIOPSY/EXCISE SPINAL TUMOR 2,420.31<br />

63290 3 BIOPSY/EXCISE SPINAL TUMOR 2,431.24<br />

63295 3 REPAIR OF LAMINECTOMY <strong>DE</strong>FECT 289.03<br />

63300 3 REMOVAL OF VERTEBRAL BODY 1,634.55<br />

63301 3 REMOVAL OF VERTEBRAL BODY 1,811.00<br />

63302 3 REMOVAL OF VERTEBRAL BODY 1,798.53<br />

63303 3 REMOVAL OF VERTEBRAL BODY 1,899.95<br />

63304 3 REMOVAL OF VERTEBRAL BODY 2,018.91<br />

63305 3 REMOVAL OF VERTEBRAL BODY 2,082.60<br />

63306 3 REMOVAL OF VERTEBRAL BODY 2,124.84<br />

63307 3 REMOVAL OF VERTEBRAL BODY 1,934.91<br />

63308 3 REMOVE VERTEBRAL BODY ADD-ON 305.39<br />

63600 3 REMOVE SPINAL CORD LESION 740.12<br />

63610 3 STIMULATION OF SPINAL CORD 1,770.21<br />

63615 3 REMOVE LESION OF SPINAL CORD 1,018.25<br />

63620 6 SRS, SPINAL LESION 0.00<br />

63621 6 SRS, SPINAL LESION, ADDL 0.00<br />

63650 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 392.52<br />

63652 O PERCUTANEOUS IMPLANTATION OF NEUROS 0.00<br />

63655 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 745.60<br />

63656 O LAMINECTOMY FOR IMPLANTATION OF NEU 0.00<br />

63657 O LAMINECTOMY FOR IMPLANTATION OF NEU 0.00<br />

63658 O LAMINECTOMY FOR IMPLANTATION OF NEU 0.00<br />

63660 3 REVISE/REMOVE NEUROELECTRO<strong>DE</strong> 394.53<br />

63685 3 INSRT/REDO SPINE N GENERATOR 451.36<br />

63688 3 REVISE/REMOVE NEURORECEIVER 372.39

---

63690 O ANALYSIS OF NEURORECEIVER 0.00<br />

63691 O ANALYSIS OF NEURORECEIVER 0.00<br />

63700 3 REPAIR OF SPINAL HERNIATION 1,090.23<br />

63702 3 REPAIR OF SPINAL HERNIATION 1,188.79<br />

63704 3 REPAIR OF SPINAL HERNIATION 1,373.02<br />

63706 3 REPAIR OF SPINAL HERNIATION 1,586.32<br />

63707 3 REPAIR SPINAL FLUID LEAKAGE 805.00<br />

63709 3 REPAIR SPINAL FLUID LEAKAGE 979.69<br />

63710 3 GRAFT REPAIR OF SPINE <strong>DE</strong>FECT 977.64<br />

63740 3 INSTALL SPINAL SHUNT 818.23<br />

63741 3 INSTALL SPINAL SHUNT 545.29<br />

63744 3 REVISION OF SPINAL SHUNT 573.36<br />

63746 3 REMOVAL OF SPINAL SHUNT 477.04<br />

63750 O INSERTION, SUBARACHNOID CATHETER WI 0.00<br />

63780 O INSERTION OR REPLACEMENT, SUBARACHN 0.00<br />

64400 3 N BLOCK INJ, TRIGEMINAL 105.12<br />

64402 3 N BLOCK INJ, FACIAL 104.43<br />

64405 3 N BLOCK INJ, OCCIPITAL 98.57<br />

64408 3 N BLOCK INJ, VAGUS 110.12<br />

64410 3 N BLOCK INJ, PHRENIC 138.13<br />

64412 3 N BLOCK INJ, SPINAL ACCESSOR 136.45<br />

64413 3 N BLOCK INJ, CERVICAL PLEXUS 111.89<br />

64415 3 N BLOCK INJ, BRACHIAL PLEXUS 135.74<br />

64416 3 N BLOCK CONT INFUSE, B PLEX 164.50<br />

64417 3 N BLOCK INJ, AXILLARY 139.89<br />

64418 3 N BLOCK INJ, SUPRASCAPULAR 135.66<br />

64420 3 N BLOCK INJ, INTERCOST, SNG 165.95<br />

64421 3 N BLOCK INJ, INTERCOST, MLT 249.88<br />

64425 3 N BLOCK INJ, ILIO-ING/HYPOGI 120.98<br />

64430 3 N BLOCK INJ, PU<strong>DE</strong>NDAL 149.02<br />

64435 3 N BLOCK INJ, PARACERVICAL 142.94<br />

64440 O INJECTION FOR NERVE BLOCK 0.00<br />

64441 O INJECTION FOR NERVE BLOCK 0.00<br />

64442 O INJECTION FOR NERVE BLOCK 0.00<br />

64443 O INJECT, NERVE BLOCK ADD-ON 0.00<br />

64445 3 N BLOCK INJ, SCIATIC, SNG 137.61<br />

64446 3 N BLK INJ, SCIATIC, CONT INF 157.48<br />

64447 3 N BLOCK INJ FEM, SINGLE 65.29<br />

64448 3 N BLOCK INJ FEM, CONT INF 142.91<br />

64449 3 N BLOCK INJ, LUMBAR PLEXUS 141.33<br />

64450 3 N BLOCK, OTHER PERIPHERAL 96.55<br />

64455 6 N BLOCK INJ, PLANTAR DIGIT 0.00<br />

64470 3 INJ PARAVERTEBRAL C/T 283.59<br />

64472 3 INJ PARAVERTEBRAL C/T ADD-ON 116.30<br />

64475 3 INJ PARAVERTEBRAL L/S 257.66<br />

64476 3 INJ PARAVERTEBRAL L/S ADD-ON 98.53<br />

64479 3 INJ FORAMEN EPIDURAL C/T 299.37<br />

64480 3 INJ FORAMEN EPIDURAL ADD-ON 141.88<br />

64483 3 INJ FORAMEN EPIDURAL L/S 298.12<br />

64484 3 INJ FORAMEN EPIDURAL ADD-ON 143.81

---

64505 3 N BLOCK, SPENOPALATINE GANGL 95.59<br />

64508 3 N BLOCK, CAROTID SINUS S/P 145.63<br />

64510 3 N BLOCK, STELLATE GANGLION 148.71<br />

64517 3 N BLOCK INJ, HYPOGAS PLXS 165.30<br />

64520 3 N BLOCK, LUMBAR/THORACIC 200.06<br />

64530 3 N BLOCK INJ, CELIAC PELUS 198.91<br />

64550 3 APPLY NEUROSTIMULATOR 15.90<br />

64553 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 192.07<br />

64555 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 199.08<br />

64560 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 186.52<br />

64561 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 383.64<br />

64565 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 177.61<br />

64573 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 528.80<br />

64575 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 259.55<br />

64577 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 346.82<br />

64580 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 274.35<br />

64581 3 IMPLANT NEUROELECTRO<strong>DE</strong>S 746.53<br />

64585 3 REVISE/REMOVE NEUROELECTRO<strong>DE</strong> 414.74<br />

64590 3 INSRT/REDO PN/GASTR STIMUL 354.00<br />

64595 3 REVISE/RMV PN/GASTR STIMUL 396.20<br />

64600 3 INJECTION TREATMENT OF NERVE 418.26<br />

64605 3 INJECTION TREATMENT OF NERVE 544.08<br />

64610 3 INJECTION TREATMENT OF NERVE 644.61<br />

64612 3 <strong>DE</strong>STROY NERVE, FACE MUSCLE 150.12<br />

64613 3 <strong>DE</strong>STROY NERVE, NECK MUSCLE 154.84<br />

64614 3 <strong>DE</strong>STROY NERVE, EXTREM MUSC 172.87<br />

64620 3 INJECTION TREATMENT OF NERVE 267.41<br />

64622 3 <strong>DE</strong>STR PARAVERTEBRL NERVE L/S 340.27<br />

64623 3 <strong>DE</strong>STR PARAVERTEBRAL N ADD-ON 126.55<br />

64626 3 <strong>DE</strong>STR PARAVERTEBRL NERVE C/T 381.59<br />

64627 3 <strong>DE</strong>STR PARAVERTEBRAL N ADD-ON 177.08<br />

64630 3 INJECTION TREATMENT OF NERVE 217.13<br />

64632 6 N BLOCK INJ, COMMON DIGIT 0.00<br />

64640 3 INJECTION TREATMENT OF NERVE 232.76<br />

64650 3 CHEMO<strong>DE</strong>NERV ECCRINE GLANDS 56.73<br />

64653 3 CHEMO<strong>DE</strong>NERV ECCRINE GLANDS 64.67<br />

64680 3 INJECTION TREATMENT OF NERVE 310.27<br />

64681 3 INJECTION TREATMENT OF NERVE 414.28<br />

64702 3 REVISE FINGER/TOE NERVE 403.06<br />

64704 3 REVISE HAND/FOOT NERVE 304.22<br />

64708 3 REVISE ARM/LEG NERVE 417.65<br />

64712 3 REVISION OF SCIATIC NERVE 482.55<br />

64713 3 REVISION OF ARM NERVE(S) 671.39<br />

64714 3 REVISE LOW BACK NERVE(S) 557.87<br />

64716 3 REVISION OF CRANIAL NERVE 476.27<br />

64718 3 REVISE ULNAR NERVE AT ELBOW 510.58<br />

64719 3 REVISE ULNAR NERVE AT WRIST 359.11<br />

64721 3 CARPAL TUNNEL SURGERY 383.93<br />

64722 3 RELIEVE PRESSURE ON NERVE(S) 293.59<br />

64726 3 RELEASE FOOT/TOE NERVE 269.00

---

64727 3 INTERNAL NERVE REVISION 172.05<br />

64732 3 INCISION OF BROW NERVE 333.12<br />

64734 3 INCISION OF CHEEK NERVE 377.98<br />

64736 3 INCISION OF CHIN NERVE 341.70<br />

64738 3 INCISION OF JAW NERVE 426.29<br />

64740 3 INCISION OF TONGUE NERVE 426.65<br />

64742 3 INCISION OF FACIAL NERVE 426.98<br />

64744 3 INCISE NERVE, BACK OF HEAD 379.54<br />

64746 3 INCISE DIAPHRAGM NERVE 407.82<br />

64752 3 INCISION OF VAGUS NERVE 443.69<br />

64755 9 INCISION OF STOMACH NERVES 0.00<br />

64760 3 INCISION OF VAGUS NERVE 420.53<br />

64761 3 INCISION OF PELVIS NERVE 405.18<br />

64763 3 INCISE HIP/THIGH NERVE 459.82<br />

64766 3 INCISE HIP/THIGH NERVE 544.21<br />

64771 3 SEVER CRANIAL NERVE 528.58<br />

64772 3 INCISION OF SPINAL NERVE 501.55<br />

64774 3 REMOVE SKIN NERVE LESION 369.82<br />

64776 3 REMOVE DIGIT NERVE LESION 355.20<br />

64778 3 DIGIT NERVE SURGERY ADD-ON 172.23<br />

64782 3 REMOVE LIMB NERVE LESION 411.94<br />

64783 3 LIMB NERVE SURGERY ADD-ON 203.96<br />

64784 3 REMOVE NERVE LESION 652.37<br />

64786 3 REMOVE SCIATIC NERVE LESION 983.63<br />

64787 3 IMPLANT NERVE END 236.68<br />

64788 3 REMOVE SKIN NERVE LESION 343.97<br />

64790 3 REMOVAL OF NERVE LESION 747.24<br />

64792 3 REMOVAL OF NERVE LESION 943.40<br />

64795 3 BIOPSY OF NERVE 176.05<br />

64802 3 REMOVE SYMPATHETIC NERVES 555.46<br />

64804 3 REMOVE SYMPATHETIC NERVES 857.35<br />

64809 3 REMOVE SYMPATHETIC NERVES 791.76<br />

64818 3 REMOVE SYMPATHETIC NERVES 609.42<br />

64820 3 REMOVE SYMPATHETIC NERVES 681.48<br />

64821 3 REMOVE SYMPATHETIC NERVES 621.26<br />

64822 3 REMOVE SYMPATHETIC NERVES 618.70<br />

64823 3 REMOVE SYMPATHETIC NERVES 699.86<br />

64830 O MICROREPAIR OF NERVE 0.00<br />

64831 3 REPAIR OF DIGIT NERVE 658.17<br />

64832 3 REPAIR NERVE ADD-ON 320.00<br />

64834 3 REPAIR OF HAND OR FOOT NERVE 675.04<br />

64835 3 REPAIR OF HAND OR FOOT NERVE 731.85<br />

64836 3 REPAIR OF HAND OR FOOT NERVE 732.83<br />

64837 3 REPAIR NERVE ADD-ON 354.59<br />

64840 3 REPAIR OF LEG NERVE 821.12<br />

64856 3 REPAIR/TRANSPOSE NERVE 917.57<br />

64857 3 REPAIR ARM/LEG NERVE 959.81<br />

64858 3 REPAIR SCIATIC NERVE 1,098.89<br />

64859 3 NERVE SURGERY 241.35<br />

64861 3 REPAIR OF ARM NERVES 1,252.61

---

64862 3 REPAIR OF LOW BACK NERVES 1,271.86<br />

64864 3 REPAIR OF FACIAL NERVE 808.05<br />

64865 3 REPAIR OF FACIAL NERVE 1,078.38<br />

64866 3 FUSION OF FACIAL/OTHER NERVE 1,104.72<br />

64868 3 FUSION OF FACIAL/OTHER NERVE 961.49<br />

64870 3 FUSION OF FACIAL/OTHER NERVE 943.85<br />

64872 3 SUBSEQUENT REPAIR OF NERVE 112.56<br />

64874 3 REPAIR & REVISE NERVE ADD-ON 168.00<br />

64876 3 REPAIR NERVE/SHORTEN BONE 190.83<br />

64885 3 NERVE GRAFT, HEAD OR NECK 1,046.07<br />

64886 3 NERVE GRAFT, HEAD OR NECK 1,235.14<br />

64890 3 NERVE GRAFT, HAND OR FOOT 987.84<br />

64891 3 NERVE GRAFT, HAND OR FOOT 971.13<br />

64892 3 NERVE GRAFT, ARM OR LEG 956.94<br />

64893 3 NERVE GRAFT, ARM OR LEG 1,028.72<br />

64895 3 NERVE GRAFT, HAND OR FOOT 1,170.51<br />

64896 3 NERVE GRAFT, HAND OR FOOT 1,279.28<br />

64897 3 NERVE GRAFT, ARM OR LEG 1,145.18<br />

64898 3 NERVE GRAFT, ARM OR LEG 1,245.65<br />

64901 3 NERVE GRAFT ADD-ON 561.41<br />

64902 3 NERVE GRAFT ADD-ON 655.25<br />

64905 3 NERVE PEDICLE TRANSFER 872.29<br />

64907 3 NERVE PEDICLE TRANSFER 1,139.84<br />

64910 3 NERVE REPAIR W/ALLOGRAFT 614.89<br />

64911 3 NEURORRAPHY W/VEIN AUTOGRAFT 747.54<br />

64999 5 NERVOUS SYSTEM SURGERY 0.00<br />

65091 3 REVISE EYE 547.94<br />

65093 3 REVISE EYE WITH IMPLANT 550.26<br />

65101 3 REMOVAL OF EYE 629.16<br />

65103 3 REMOVE EYE/INSERT IMPLANT 655.32<br />

65105 3 REMOVE EYE/ATTACH IMPLANT 719.76<br />

65110 3 REMOVAL OF EYE 1,040.65<br />

65112 3 REMOVE EYE/REVISE SOCKET 1,234.09<br />

65114 3 REMOVE EYE/REVISE SOCKET 1,273.76<br />

65125 3 REVISE OCULAR IMPLANT 418.75<br />

65130 3 INSERT OCULAR IMPLANT 620.42<br />

65135 3 INSERT OCULAR IMPLANT 631.20<br />

65140 3 ATTACH OCULAR IMPLANT 684.10<br />

65150 3 REVISE OCULAR IMPLANT 504.17<br />

65155 3 REINSERT OCULAR IMPLANT 728.30<br />

65175 3 REMOVAL OF OCULAR IMPLANT 559.38<br />

65205 3 REMOVE FOREIGN BODY FROM EYE 48.75<br />

65210 3 REMOVE FOREIGN BODY FROM EYE 59.58<br />

65220 3 REMOVE FOREIGN BODY FROM EYE 50.13<br />

65222 3 REMOVE FOREIGN BODY FROM EYE 65.41<br />

65230 O REMOVAL OF FOREIGN BODY, INTRAOCULA 0.00<br />

65235 3 REMOVE FOREIGN BODY FROM EYE 574.57<br />

65240 O REMOVAL OF FOREIGN BODY, INTRAOCULA 0.00<br />

65245 O REMOVAL OF FOREIGN BODY, INTRAOCULA 0.00<br />

65260 3 REMOVE FOREIGN BODY FROM EYE 795.47

---

65265 3 REMOVE FOREIGN BODY FROM EYE 892.82<br />

65270 3 REPAIR OF EYE WOUND 245.57<br />

65272 3 REPAIR OF EYE WOUND 284.41<br />

65273 3 REPAIR OF EYE WOUND 313.62<br />

65275 3 REPAIR OF EYE WOUND 464.27<br />

65280 3 REPAIR OF EYE WOUND 549.22<br />

65285 3 REPAIR OF EYE WOUND 854.58<br />

65286 3 REPAIR OF EYE WOUND 617.00<br />

65290 3 REPAIR OF EYE SOCKET WOUND 405.01<br />

65300 O <strong>DE</strong>LIMITING KERATOTOMY 0.00<br />

65400 3 REMOVAL OF EYE LESION 565.35<br />

65410 3 BIOPSY OF CORNEA 126.10<br />

65420 3 REMOVAL OF EYE LESION 459.08<br />

65426 3 REMOVAL OF EYE LESION 567.61<br />

65430 3 CORNEAL SMEAR 98.56<br />

65435 3 CURETTE/TREAT CORNEA 68.96<br />

65436 3 CURETTE/TREAT CORNEA 320.63<br />

65450 3 TREATMENT OF CORNEAL LESION 270.59<br />

65600 3 REVISION OF CORNEA 328.59<br />

65710 3 CORNEAL TRANSPLANT 915.71<br />

65730 3 CORNEAL TRANSPLANT 1,014.94<br />

65750 3 CORNEAL TRANSPLANT 1,029.05<br />

65755 3 CORNEAL TRANSPLANT 1,022.93<br />

65756 6 CORNEAL TRNSPL, ENDOTHELIAL 0.00<br />

65757 6 PREP CORNEAL ENDO ALLOGRAFT 0.00<br />

65760 5 REVISION OF CORNEA 0.00<br />

65765 5 REVISION OF CORNEA 0.00<br />

65767 5 CORNEAL TISSUE TRANSPLANT 0.00<br />

65770 3 REVISE CORNEA WITH IMPLANT 1,172.86<br />

65771 5 RADIAL KERATOTOMY 0.00<br />

65772 3 CORRECTION OF ASTIGMATISM 378.68<br />

65775 3 CORRECTION OF ASTIGMATISM 458.13<br />

65780 3 OCULAR RECONST, TRANSPLANT 744.60<br />

65781 3 OCULAR RECONST, TRANSPLANT 1,114.86<br />

65782 3 OCULAR RECONST, TRANSPLANT 963.40<br />

65800 3 DRAINAGE OF EYE 130.30<br />

65805 3 DRAINAGE OF EYE 143.68<br />

65810 3 DRAINAGE OF EYE 383.38<br />

65815 3 DRAINAGE OF EYE 558.23<br />

65820 3 RELIEVE INNER EYE PRESSURE 633.33<br />

65825 O GONIOTOMY WITH GONIOPUNCTURE 0.00<br />

65830 O GONIOPUNCTURE, WITHOUT GONIOTOMY 0.00<br />

65850 3 INCISION OF EYE 706.63<br />

65855 3 LASER SURGERY OF EYE 291.14<br />

65860 3 INCISE INNER EYE ADHESIONS 269.46<br />

65865 3 INCISE INNER EYE ADHESIONS 403.06<br />

65870 3 INCISE INNER EYE ADHESIONS 492.11<br />

65875 3 INCISE INNER EYE ADHESIONS 521.62<br />

65880 3 INCISE INNER EYE ADHESIONS 549.64<br />

65900 3 REMOVE EYE LESION 808.76

---

65920 3 REMOVE IMPLANT OF EYE 650.18<br />

65930 3 REMOVE BLOOD CLOT FROM EYE 538.37<br />

66020 3 INJECTION TREATMENT OF EYE 166.03<br />

66030 3 INJECTION TREATMENT OF EYE 148.38<br />

66130 3 REMOVE EYE LESION 611.03<br />

66150 3 GLAUCOMA SURGERY 717.05<br />

66155 3 GLAUCOMA SURGERY 714.39<br />

66160 3 GLAUCOMA SURGERY 809.71<br />

66165 3 GLAUCOMA SURGERY 701.71<br />

66170 3 GLAUCOMA SURGERY 979.59<br />

66172 3 INCISION OF EYE 1,228.09<br />

66180 3 IMPLANT EYE SHUNT 966.82<br />

66185 3 REVISE EYE SHUNT 612.41<br />

66220 3 REPAIR EYE LESION 596.94<br />

66225 3 REPAIR/GRAFT EYE LESION 767.66<br />

66250 3 FOLLOW-UP SURGERY OF EYE 655.31<br />

66500 3 INCISION OF IRIS 301.18<br />

66505 3 INCISION OF IRIS 329.03<br />

66600 3 REMOVE IRIS AND LESION 672.31<br />

66605 3 REMOVAL OF IRIS 880.39<br />

66625 3 REMOVAL OF IRIS 359.53<br />

66630 3 REMOVAL OF IRIS 467.41<br />

66635 3 REMOVAL OF IRIS 471.67<br />

66680 3 REPAIR IRIS & CILIARY BODY 422.80<br />

66682 9 REPAIR IRIS & CILIARY BODY 0.00<br />

66700 3 <strong>DE</strong>STRUCTION, CILIARY BODY 375.95<br />

66701 O CYCLODIATHERMY SUBSEQUENT 0.00<br />

66702 O CILIARY BODY <strong>DE</strong>STRUCTION, ANY METHO 0.00<br />

66710 3 CILIARY TRANSSLERAL THERAPY 370.54<br />

66711 3 CILIARY ENDOSCOPIC ABLATION 520.96<br />

66720 3 <strong>DE</strong>STRUCTION, CILIARY BODY 392.04<br />

66721 O CYCLOCRYOTHERAPY SUBSEQUENT 0.00<br />

66740 3 <strong>DE</strong>STRUCTION, CILIARY BODY 367.79<br />

66741 O CYCLODIALYSIS SUBSEQUENT 0.00<br />

66761 3 REVISION OF IRIS 380.03<br />

66762 3 REVISION OF IRIS 396.37<br />

66770 3 REMOVAL OF INNER EYE LESION 439.21<br />

66800 O DISCISSION OF LENS CAPSULE INCISION 0.00<br />

66801 O DISCISSION OF LENS CAPSULE INCISION 0.00<br />

66802 O DISCISSION OF LENS CAPSULE LASER SU 0.00<br />

66820 3 INCISION, SECONDARY CATARACT 344.23<br />

66821 3 AFTER CATARACT LASER SURGERY 271.49<br />

66825 3 REPOSITION INTRAOCULAR LENS 642.30<br />

66830 3 REMOVAL OF LENS LESION 586.89<br />

66840 3 REMOVAL OF LENS MATERIAL 575.01<br />

66850 3 REMOVAL OF LENS MATERIAL 652.51<br />

66852 3 REMOVAL OF LENS MATERIAL 698.31<br />

66915 O EXPRESSION OF LENS, LINEAR, ONE OR 0.00<br />

66920 3 EXTRACTION OF LENS 623.79<br />

66930 3 EXTRACTION OF LENS 707.21

---

66940 3 EXTRACTION OF LENS 643.79<br />

66982 3 CATARACT SURGERY, COMPLEX 891.76<br />

66983 3 CATARACT SURG W/IOL, 1 STAGE 598.19<br />

66984 3 CATARACT SURG W/IOL, 1 STAGE 635.37<br />

66985 3 INSERT LENS PROSTHESIS 627.47<br />

66986 3 EXCHANGE LENS PROSTHESIS 772.76<br />

66990 3 OPHTHALMIC ENDOSCOPE ADD-ON 77.28<br />

66999 5 EYE SURGERY PROCEDURE 0.00<br />

67005 3 PARTIAL REMOVAL OF EYE FLUID 389.60<br />

67010 3 PARTIAL REMOVAL OF EYE FLUID 450.31<br />

67015 3 RELEASE OF EYE FLUID 486.47<br />

67025 3 REPLACE EYE FLUID 614.45<br />

67027 3 IMPLANT EYE DRUG SYSTEM 705.90<br />

67028 3 INJECTION EYE DRUG 184.64<br />

67030 3 INCISE INNER EYE STRANDS 432.77<br />

67031 3 LASER SURGERY, EYE STRANDS 323.57<br />

67036 3 REMOVAL OF INNER EYE FLUID 799.10<br />

67038 O STRIP RETINAL MEMBRANE 0.00<br />

67039 3 LASER TREATMENT OF RETINA 1,026.75<br />

67040 3 LASER TREATMENT OF RETINA 1,182.24<br />

67041 3 VIT FOR MACULAR PUCKER 1,077.65<br />

67042 3 VIT FOR MACULAR HOLE 1,232.14<br />

67043 3 VIT FOR MEMBRANE DISSECT 1,294.49<br />

67101 3 REPAIR <strong>DE</strong>TACHED RETINA 649.06<br />

67105 3 REPAIR <strong>DE</strong>TACHED RETINA 598.88<br />

67107 3 REPAIR <strong>DE</strong>TACHED RETINA 1,002.18<br />

67108 3 REPAIR <strong>DE</strong>TACHED RETINA 1,330.83<br />

67109 O REPAIR OF RETINAL <strong>DE</strong>TACHMENT, ONE O 0.00<br />

67110 3 REPAIR <strong>DE</strong>TACHED RETINA 729.56<br />

67112 3 REREPAIR <strong>DE</strong>TACHED RETINA 1,096.05<br />

67113 3 REPAIR RETINAL <strong>DE</strong>TACH, CPLX 1,422.32<br />

67115 3 RELEASE ENCIRCLING MATERIAL 405.12<br />

67120 3 REMOVE EYE IMPLANT MATERIAL 556.65<br />

67121 3 REMOVE EYE IMPLANT MATERIAL 746.89<br />

67141 3 TREATMENT OF RETINA 432.51<br />

67145 3 TREATMENT OF RETINA 434.65<br />

67208 3 TREATMENT OF RETINAL LESION 495.64<br />

67210 3 TREATMENT OF RETINAL LESION 575.43<br />

67218 3 TREATMENT OF RETINAL LESION 1,161.14<br />

67220 3 TREATMENT OF CHOROID LESION 886.92<br />

67221 3 OCULAR PHOTODYNAMIC THER 265.40<br />

67225 3 EYE PHOTODYNAMIC THER ADD-ON 25.82<br />

67227 3 TREATMENT OF RETINAL LESION 507.53<br />

67228 3 TREATMENT OF RETINAL LESION 975.63<br />

67229 3 TR RETINAL LES PRETERM INF 938.11<br />

67250 3 REINFORCE EYE WALL 665.94<br />

67255 3 REINFORCE/GRAFT EYE WALL 711.49<br />

67299 5 EYE SURGERY PROCEDURE 0.00<br />

67311 3 REVISE EYE MUSCLE 494.79<br />

67312 3 REVISE TWO EYE MUSCLES 588.80

---

67313 O STRABISMUS SURGERY ON PATIENT NOT P 0.00<br />

67314 3 REVISE EYE MUSCLE 552.48<br />

67316 3 REVISE TWO EYE MUSCLES 662.05<br />

67318 3 REVISE EYE MUSCLE(S) 578.80<br />

67320 3 REVISE EYE MUSCLE(S) ADD-ON 266.13<br />

67331 3 EYE SURGERY FOLLOW-UP ADD-ON 251.87<br />

67332 3 REREVISE EYE MUSCLES ADD-ON 274.17<br />

67334 3 REVISE EYE MUSCLE W/SUTURE 248.09<br />

67335 3 EYE SUTURE DURING SURGERY 127.52<br />

67340 3 REVISE EYE MUSCLE ADD-ON 296.09<br />

67343 3 RELEASE EYE TISSUE 539.52<br />

67345 3 <strong>DE</strong>STROY NERVE OF EYE MUSCLE 199.55<br />

67346 3 BIOPSY, EYE MUSCLE 170.71<br />

67350 O BIOPSY EYE MUSCLE 0.00<br />

67399 5 EYE MUSCLE SURGERY PROCEDURE 0.00<br />

67400 3 EXPLORE/BIOPSY EYE SOCKET 795.36<br />

67405 3 EXPLORE/DRAIN EYE SOCKET 674.83<br />

67412 3 EXPLORE/TREAT EYE SOCKET 742.03<br />

67413 3 EXPLORE/TREAT EYE SOCKET 740.32<br />

67414 3 EXPLR/<strong>DE</strong>COMPRESS EYE SOCKET 1,088.07<br />

67415 3 ASPIRATION, ORBITAL CONTENTS 89.49<br />

67420 3 EXPLORE/TREAT EYE SOCKET 1,389.61<br />

67430 3 EXPLORE/TREAT EYE SOCKET 1,060.15<br />

67440 3 EXPLORE/DRAIN EYE SOCKET 1,028.59<br />

67445 3 EXPLR/<strong>DE</strong>COMPRESS EYE SOCKET 1,182.33<br />

67450 3 EXPLORE/BIOPSY EYE SOCKET 1,063.78<br />

67500 3 INJECT/TREAT EYE SOCKET 74.78<br />

67505 3 INJECT/TREAT EYE SOCKET 70.97<br />

67515 3 INJECT/TREAT EYE SOCKET 75.00<br />

67550 3 INSERT EYE SOCKET IMPLANT 827.62<br />

67560 3 REVISE EYE SOCKET IMPLANT 838.71<br />

67570 3 <strong>DE</strong>COMPRESS OPTIC NERVE 985.76<br />

67599 5 ORBIT SURGERY PROCEDURE 0.00<br />

67700 3 DRAINAGE OF EYELID ABSCESS 252.07<br />

67710 3 INCISION OF EYELID 215.53<br />

67715 3 INCISION OF EYELID FOLD 225.12<br />

67800 3 REMOVE EYELID LESION 108.06<br />

67801 3 REMOVE EYELID LESIONS 138.19<br />

67805 3 REMOVE EYELID LESIONS 171.57<br />

67808 3 REMOVE EYELID LESION(S) 302.52<br />

67810 3 BIOPSY OF EYELID 195.05<br />

67820 3 REVISE EYELASHES 45.90<br />

67825 3 REVISE EYELASHES 111.20<br />

67830 3 REVISE EYELASHES 247.79<br />

67835 3 REVISE EYELASHES 370.44<br />

67840 3 REMOVE EYELID LESION 257.18<br />

67850 3 TREAT EYELID LESION 191.23<br />

67875 3 CLOSURE OF EYELID BY SUTURE 159.63<br />

67880 3 REVISION OF EYELID 394.58<br />

67882 3 REVISION OF EYELID 481.49

---

67900 3 REPAIR BROW <strong>DE</strong>FECT 561.45<br />

67901 3 REPAIR EYELID <strong>DE</strong>FECT 552.63<br />

67902 3 REPAIR EYELID <strong>DE</strong>FECT 577.96<br />

67903 3 REPAIR EYELID <strong>DE</strong>FECT 550.15<br />

67904 3 REPAIR EYELID <strong>DE</strong>FECT 627.98<br />

67906 3 REPAIR EYELID <strong>DE</strong>FECT 432.30<br />

67907 O REPAIR OF BLEPHAROPTOSIS SUPERIOR R 0.00<br />

67908 3 REPAIR EYELID <strong>DE</strong>FECT 423.86<br />

67909 3 REVISE EYELID <strong>DE</strong>FECT 474.12<br />

67911 3 REVISE EYELID <strong>DE</strong>FECT 452.64<br />

67912 3 CORRECTION EYELID W/IMPLANT 850.76<br />

67914 3 REPAIR EYELID <strong>DE</strong>FECT 349.51<br />

67915 3 REPAIR EYELID <strong>DE</strong>FECT 316.33<br />

67916 3 REPAIR EYELID <strong>DE</strong>FECT 474.09<br />

67917 3 REPAIR EYELID <strong>DE</strong>FECT 515.28<br />

67921 3 REPAIR EYELID <strong>DE</strong>FECT 333.78<br />

67922 3 REPAIR EYELID <strong>DE</strong>FECT 307.47<br />

67923 3 REPAIR EYELID <strong>DE</strong>FECT 496.69<br />

67924 3 REPAIR EYELID <strong>DE</strong>FECT 518.40<br />

67930 3 REPAIR EYELID WOUND 326.75<br />

67935 3 REPAIR EYELID WOUND 524.68<br />

67938 3 REMOVE EYELID FOREIGN BODY 228.97<br />

67950 3 REVISION OF EYELID 511.10<br />

67961 3 REVISION OF EYELID 509.52<br />

67966 3 REVISION OF EYELID 648.49<br />

67971 3 RECONSTRUCTION OF EYELID 615.09<br />

67973 3 RECONSTRUCTION OF EYELID 796.76<br />

67974 3 RECONSTRUCTION OF EYELID 793.63<br />

67975 3 RECONSTRUCTION OF EYELID 580.85<br />

67999 5 REVISION OF EYELID 0.00<br />

68020 3 INCISE/DRAIN EYELID LINING 100.69<br />

68040 3 TREATMENT OF EYELID LESIONS 56.03<br />

68100 3 BIOPSY OF EYELID LINING 158.45<br />

68110 3 REMOVE EYELID LINING LESION 204.75<br />

68115 3 REMOVE EYELID LINING LESION 287.03<br />

68130 3 REMOVE EYELID LINING LESION 478.30<br />

68135 3 REMOVE EYELID LINING LESION 132.70<br />

68200 3 TREAT EYELID BY INJECTION 36.43<br />

68320 3 REVISE/GRAFT EYELID LINING 628.41<br />

68325 3 REVISE/GRAFT EYELID LINING 547.39<br />

68326 3 REVISE/GRAFT EYELID LINING 531.89<br />

68328 3 REVISE/GRAFT EYELID LINING 598.92<br />

68330 3 REVISE EYELID LINING 529.37<br />

68335 3 REVISE/GRAFT EYELID LINING 532.56<br />

68340 3 SEPARATE EYELID ADHESIONS 480.28<br />

68360 3 REVISE EYELID LINING 462.33<br />

68362 3 REVISE EYELID LINING 539.52<br />

68371 3 HARVEST EYE TISSUE, ALOGRAFT 354.40<br />

68399 5 EYELID LINING SURGERY 0.00<br />

68400 3 INCISE/DRAIN TEAR GLAND 263.53

---

68420 3 INCISE/DRAIN TEAR SAC 293.87<br />

68440 3 INCISE TEAR DUCT OPENING 99.91<br />

68500 3 REMOVAL OF TEAR GLAND 818.72<br />

68505 3 PARTIAL REMOVAL, TEAR GLAND 822.32<br />

68510 3 BIOPSY OF TEAR GLAND 409.44<br />

68520 3 REMOVAL OF TEAR SAC 575.89<br />

68525 3 BIOPSY OF TEAR SAC 227.12<br />

68530 3 CLEARANCE OF TEAR DUCT 400.78<br />

68540 3 REMOVE TEAR GLAND LESION 771.82<br />

68550 3 REMOVE TEAR GLAND LESION 941.62<br />

68700 3 REPAIR TEAR DUCTS 496.40<br />

68705 3 REVISE TEAR DUCT OPENING 215.06<br />

68720 3 CREATE TEAR SAC DRAIN 634.52<br />

68745 3 CREATE TEAR DUCT DRAIN 636.16<br />

68750 3 CREATE TEAR DUCT DRAIN 656.19<br />

68760 3 CLOSE TEAR DUCT OPENING 182.35<br />

68761 3 CLOSE TEAR DUCT OPENING 129.41<br />

68770 3 CLOSE TEAR SYSTEM FISTULA 460.39<br />

68800 O DILATION OF LACRIMAL PUNCTUM, WITH 0.00<br />

68801 3 DILATE TEAR DUCT OPENING 107.39<br />

68810 3 PROBE NASOLACRIMAL DUCT 231.18<br />

68811 3 PROBE NASOLACRIMAL DUCT 174.02<br />

68815 3 PROBE NASOLACRIMAL DUCT 403.16<br />

68816 3 PROBE NL DUCT W/BALLOON 608.03<br />

68820 O PROBING OF NASOLACRIMAL DUCT, WITH 0.00<br />

68825 O PROBING OF NASOLACRIMAL DUCT, WITH 0.00<br />

68830 O PROBING OF NASOLACRIMAL DUCT, WITH 0.00<br />

68840 3 EXPLORE/IRRIGATE TEAR DUCTS 105.89<br />

68850 3 INJECTION FOR TEAR SAC X-RAY 59.61<br />

68899 5 TEAR DUCT SYSTEM SURGERY 0.00<br />

69000 3 DRAIN EXTERNAL EAR LESION 166.53<br />

69005 3 DRAIN EXTERNAL EAR LESION 193.88<br />

69020 3 DRAIN OUTER EAR CANAL LESION 213.33<br />

69090 9 PIERCE EARLOBES 0.00<br />

69100 3 BIOPSY OF EXTERNAL EAR 98.26<br />

69105 3 BIOPSY OF EXTERNAL EAR CANAL 128.92<br />

69110 3 REMOVE EXTERNAL EAR, PARTIAL 413.52<br />

69120 3 REMOVAL OF EXTERNAL EAR 376.50<br />

69140 3 REMOVE EAR CANAL LESION(S) 813.17<br />

69145 3 REMOVE EAR CANAL LESION(S) 348.13<br />

69150 3 EXTENSIVE EAR CANAL SURGERY 982.99<br />

69155 3 EXTENSIVE EAR/NECK SURGERY 1,558.38<br />

69200 3 CLEAR OUTER EAR CANAL 117.27<br />

69205 3 CLEAR OUTER EAR CANAL 94.92<br />

69210 O REMOVE IMPACTED EAR WAX 0.00<br />

69220 3 CLEAN OUT MASTOID CAVITY 126.97<br />

69222 3 CLEAN OUT MASTOID CAVITY 205.52<br />

69300 3 REVISE EXTERNAL EAR 542.01<br />

69310 3 REBUILD OUTER EAR CANAL 1,018.45<br />

69320 3 REBUILD OUTER EAR CANAL 1,442.78

---

69399 5 OUTER EAR SURGERY PROCEDURE 0.00<br />

69400 3 INFLATE MIDDLE EAR CANAL 128.15<br />

69401 3 INFLATE MIDDLE EAR CANAL 76.95<br />

69405 3 CATHETERIZE MIDDLE EAR CANAL 236.78<br />

69410 O INSET MIDDLE EAR (BAFFLE) 0.00<br />

69420 3 INCISION OF EARDRUM 176.55<br />

69421 3 INCISION OF EARDRUM 142.82<br />

69424 3 REMOVE VENTILATING TUBE 119.87<br />

69433 3 CREATE EARDRUM OPENING 182.51<br />

69436 3 CREATE EARDRUM OPENING 155.25<br />

69440 3 EXPLORATION OF MIDDLE EAR 628.55<br />

69450 9 EARDRUM REVISION 0.00<br />

69501 3 MASTOI<strong>DE</strong>CTOMY 678.61<br />

69502 3 MASTOI<strong>DE</strong>CTOMY 896.61<br />

69505 3 REMOVE MASTOID STRUCTURES 1,129.76<br />

69511 3 EXTENSIVE MASTOID SURGERY 1,158.09<br />

69530 3 EXTENSIVE MASTOID SURGERY 1,544.59<br />

69535 3 REMOVE PART OF TEMPORAL BONE 2,506.40<br />

69540 3 REMOVE EAR LESION 194.45<br />

69550 3 REMOVE EAR LESION 974.25<br />

69552 3 REMOVE EAR LESION 1,479.59<br />

69554 3 REMOVE EAR LESION 2,366.79<br />

69601 3 MASTOID SURGERY REVISION 967.28<br />

69602 3 MASTOID SURGERY REVISION 1,007.66<br />

69603 3 MASTOID SURGERY REVISION 1,196.19<br />

69604 3 MASTOID SURGERY REVISION 1,032.12<br />

69605 3 MASTOID SURGERY REVISION 1,465.57<br />

69610 3 REPAIR OF EARDRUM 367.37<br />

69620 3 REPAIR OF EARDRUM 649.16<br />

69631 3 REPAIR EARDRUM STRUCTURES 807.56<br />

69632 3 REBUILD EARDRUM STRUCTURES 992.42<br />

69633 3 REBUILD EARDRUM STRUCTURES 956.40<br />

69635 3 REPAIR EARDRUM STRUCTURES 1,136.30<br />

69636 3 REBUILD EARDRUM STRUCTURES 1,292.78<br />

69637 3 REBUILD EARDRUM STRUCTURES 1,285.87<br />

69641 3 REVISE MIDDLE EAR & MASTOID 960.98<br />

69642 3 REVISE MIDDLE EAR & MASTOID 1,239.96<br />

69643 3 REVISE MIDDLE EAR & MASTOID 1,131.25<br />

69644 3 REVISE MIDDLE EAR & MASTOID 1,390.41<br />

69645 3 REVISE MIDDLE EAR & MASTOID 1,361.28<br />

69646 3 REVISE MIDDLE EAR & MASTOID 1,446.14<br />

69650 3 RELEASE MIDDLE EAR BONE 735.12<br />

69660 3 REVISE MIDDLE EAR BONE 859.99<br />

69661 9 REVISE MIDDLE EAR BONE 0.00<br />

69662 3 REVISE MIDDLE EAR BONE 1,078.80<br />

69666 3 REPAIR MIDDLE EAR STRUCTURES 744.80<br />

69667 3 REPAIR MIDDLE EAR STRUCTURES 746.36<br />

69670 3 REMOVE MASTOID AIR CELLS 873.11<br />

69676 3 REMOVE MIDDLE EAR NERVE 769.55<br />

69700 3 CLOSE MASTOID FISTULA 653.45

---

69710 5 IMPLANT/REPLACE HEARING AID 0.00<br />

69711 3 REMOVE/REPAIR HEARING AID 798.18<br />

69714 3 IMPLANT TEMPLE BONE W/STIMUL 999.79<br />

69715 3 TEMPLE BNE IMPLNT W/STIMULAT 1,239.75<br />

69717 3 TEMPLE BONE IMPLANT REVISION 1,065.05<br />

69718 3 REVISE TEMPLE BONE IMPLANT 1,306.40<br />

69720 3 RELEASE FACIAL NERVE 1,090.19<br />

69725 3 RELEASE FACIAL NERVE 1,753.88<br />

69740 3 REPAIR FACIAL NERVE 1,078.49<br />

69745 3 REPAIR FACIAL NERVE 1,097.32<br />

69799 5 MIDDLE EAR SURGERY PROCEDURE 0.00<br />

69801 3 INCISE INNER EAR 688.03<br />

69802 3 INCISE INNER EAR 961.42<br />

69805 3 EXPLORE INNER EAR 974.53<br />

69806 3 EXPLORE INNER EAR 876.08<br />

69820 3 ESTABLISH INNER EAR WINDOW 801.90<br />

69840 3 REVISE INNER EAR WINDOW 856.54<br />

69905 3 REMOVE INNER EAR 845.41<br />

69910 3 REMOVE INNER EAR & MASTOID 948.43<br />

69915 3 INCISE INNER EAR NERVE 1,434.23<br />

69930 3 IMPLANT COCHLEAR <strong>DE</strong>VICE 1,185.54<br />

69949 5 INNER EAR SURGERY PROCEDURE 0.00<br />

69950 3 INCISE INNER EAR NERVE 1,701.94<br />

69955 3 RELEASE FACIAL NERVE 1,867.06<br />

69960 3 RELEASE INNER EAR CANAL 1,802.41<br />

69970 3 REMOVE INNER EAR LESION 2,006.00<br />

69979 5 TEMPORAL BONE SURGERY 0.00<br />

69990 3 MICROSURGERY ADD-ON 203.98<br />

70010 3 CONTRAST X-RAY OF BRAIN 196.75<br />

70011 O MYELOGRAPHY, POSTERIOR FOSSA COMPLE 0.00<br />

70015 3 CONTRAST X-RAY OF BRAIN 136.84<br />

70016 O CISTERNOGRAPHY, POSITIVE CONTRAST C 0.00<br />

70030 3 X-RAY EYE FOR FOREIGN BODY 27.91<br />

70100 3 X-RAY EXAM OF JAW 31.05<br />

7010F 9 PT INFO INTO RECALL SYSTEM 0.00<br />

70110 3 X-RAY EXAM OF JAW 39.46<br />

70120 3 X-RAY EXAM OF MASTOIDS 34.79<br />

70130 3 X-RAY EXAM OF MASTOIDS 53.75<br />

70134 3 X-RAY EXAM OF MIDDLE EAR 47.85<br />

70140 3 X-RAY EXAM OF FACIAL BONES 32.42<br />

70150 3 X-RAY EXAM OF FACIAL BONES 44.07<br />

70160 3 X-RAY EXAM OF NASAL BONES 31.84<br />

70170 3 X-RAY EXAM OF TEAR DUCT 55.62<br />

70171 O DACRYOCYSTOGRAPHY, NASOLACRIMAL DUC 0.00<br />

70190 3 X-RAY EXAM OF EYE SOCKETS 36.34<br />

70200 3 X-RAY EXAM OF EYE SOCKETS 45.63<br />

7020F 9 MAMMO ASSESS CAT IN DBASE 0.00<br />

70210 3 X-RAY EXAM OF SINUSES 31.65<br />

70220 3 X-RAY EXAM OF SINUSES 41.72<br />

70240 3 X-RAY EXAM, PITUITARY SADDLE 28.68

---

70250 3 X-RAY EXAM OF SKULL 36.71<br />

7025F 9 PT INFOSYS ALARM 4 NXT MAMMO 0.00<br />

70260 3 X-RAY EXAM OF SKULL 50.90<br />

70300 3 X-RAY EXAM OF TEETH 14.98<br />

70310 3 X-RAY EXAM OF TEETH 31.85<br />

70320 3 FULL MOUTH X-RAY OF TEETH 47.26<br />

70328 3 X-RAY EXAM OF JAW JOINT 30.26<br />

70330 3 X-RAY EXAM OF JAW JOINTS 47.63<br />

70332 3 X-RAY EXAM OF JAW JOINT 96.59<br />

70333 O TEMPOROMANDIBULAR JOINT ARTHROGRAPH 0.00<br />

70336 3 MAGNETIC IMAGE, JAW JOINT 389.34<br />

70350 3 X-RAY HEAD FOR ORTHODONTIA 22.01<br />

70355 3 PANORAMIC X-RAY OF JAWS 26.90<br />

70360 3 X-RAY EXAM OF NECK 27.12<br />

70370 3 THROAT X-RAY & FLUOROSCOPY 73.35<br />

70371 3 SPEECH EVALUATION, COMPLEX 109.16<br />

70373 3 CONTRAST X-RAY OF LARYNX 88.11<br />

70374 O LARYNGOGRAPHY, CONTRAST COMPLETE PR 0.00<br />

70380 3 X-RAY EXAM OF SALIVARY GLAND 37.94<br />

70390 3 X-RAY EXAM OF SALIVARY DUCT 100.36<br />

70391 O SIALOGRAPHY COMPLETE PROCEDURE 0.00<br />

70450 3 CT HEAD/BRAIN W/O DYE 232.61<br />

70460 3 CT HEAD/BRAIN W/DYE 295.94<br />

70470 3 CT HEAD/BRAIN W/O & W/DYE 359.19<br />

70480 3 CT ORBIT/EAR/FOSSA W/O DYE 258.65<br />

70481 3 CT ORBIT/EAR/FOSSA W/DYE 351.33<br />

70482 3 CT ORBIT/EAR/FOSSA W/O&W/DYE 403.42<br />

70486 3 CT MAXILLOFACIAL W/O DYE 251.08<br />

70487 3 CT MAXILLOFACIAL W/DYE 339.01<br />

70488 3 CT MAXILLOFACIAL W/O & W/DYE 401.67<br />

70490 3 CT SOFT TISSUE NECK W/O DYE 258.35<br />

70491 3 CT SOFT TISSUE NECK W/DYE 336.19<br />

70492 3 CT SFT TSUE NCK W/O & W/DYE 403.22<br />

70496 3 CT ANGIOGRAPHY, HEAD 421.40<br />

70498 3 CT ANGIOGRAPHY, NECK 421.79<br />

70540 3 MRI ORBIT/FACE/NECK W/O DYE 417.55<br />

70541 O MAGNETIC IMAGE, HEAD (MRA) 0.00<br />

70542 3 MRI ORBIT/FACE/NECK W/DYE 485.82<br />

70543 3 MRI ORBT/FAC/NCK W/O & W/DYE 641.55<br />

70544 3 MR ANGIOGRAPHY HEAD W/O DYE 409.60<br />

70545 3 MR ANGIOGRAPHY HEAD W/DYE 464.10<br />

70546 3 MR ANGIOGRAPH HEAD W/O&W/DYE 626.73<br />

70547 3 MR ANGIOGRAPHY NECK W/O DYE 409.21<br />

70548 3 MR ANGIOGRAPHY NECK W/DYE 464.59<br />

70549 3 MR ANGIOGRAPH NECK W/O&W/DYE 626.73<br />

70551 3 MRI BRAIN W/O DYE 422.39<br />

70552 3 MRI BRAIN W/DYE 492.40<br />

70553 3 MRI BRAIN W/O & W/DYE 649.18<br />

70554 3 FMRI BRAIN BY TECH 705.53<br />

70555 3 FMRI BRAIN BY PHYS/PSYCH 0.00

---

70557 3 MRI BRAIN W/O DYE 361.13<br />

70558 3 MRI BRAIN W/DYE 401.45<br />

70559 3 MRI BRAIN W/O & W/DYE 401.18<br />

71010 3 CHEST X-RAY 25.93<br />

71015 3 CHEST X-RAY 30.64<br />

71020 3 CHEST X-RAY 33.58<br />

71021 3 CHEST X-RAY 41.31<br />

71022 3 CHEST X-RAY 46.01<br />

71023 3 CHEST X-RAY AND FLUOROSCOPY 62.88<br />

71030 3 CHEST X-RAY 47.58<br />

71034 3 CHEST X-RAY AND FLUOROSCOPY 91.53<br />

71035 3 CHEST X-RAY 33.80<br />

71036 O X-RAY GUIDANCE FOR BIOPSY 0.00<br />

71037 O NEEDLE BIOPSY OF INTRATHORACIC LESI 0.00<br />

71038 O X-RAY GUIDANCE FOR BIOPSY 0.00<br />

71040 3 CONTRAST X-RAY OF BRONCHI 95.68<br />

71041 O BRONCHOGRAPHY, UNILATERAL COMPLETE 0.00<br />

71060 3 CONTRAST X-RAY OF BRONCHI 139.14<br />

71061 O BRONCHOGRAPHY, BILATERAL COMPLETE P 0.00<br />

71090 3 X-RAY & PACEMAKER INSERTION 100.31<br />

71100 3 X-RAY EXAM OF RIBS 33.58<br />

71101 3 X-RAY EXAM OF RIBS/CHEST 40.62<br />

71110 3 X-RAY EXAM OF RIBS 43.28<br />

71111 3 X-RAY EXAM OF RIBS/CHEST 53.38<br />

71120 3 X-RAY EXAM OF BREASTBONE 35.16<br />

71130 3 X-RAY EXAM OF BREASTBONE 38.70<br />

71250 3 CT THORAX W/O DYE 251.96<br />

71260 3 CT THORAX W/DYE 342.99<br />

71270 3 CT THORAX W/O & W/DYE 399.64<br />

71275 3 CT ANGIOGRAPHY, CHEST 430.91<br />

71550 3 MRI CHEST W/O DYE 422.78<br />

71551 3 MRI CHEST W/DYE 490.76<br />

71552 3 MRI CHEST W/O & W/DYE 648.63<br />

71555 3 MRI ANGIO CHEST W OR W/O DYE 494.25<br />

72010 3 X-RAY EXAM OF SPINE 66.95<br />

72020 3 X-RAY EXAM OF SPINE 24.39<br />

72040 3 X-RAY EXAM OF NECK SPINE 37.12<br />

72050 3 X-RAY EXAM OF NECK SPINE 52.99<br />

72052 3 X-RAY EXAM OF NECK SPINE 66.62<br />

72069 3 X-RAY EXAM OF TRUNK SPINE 34.17<br />

72070 3 X-RAY EXAM OF THORACIC SPINE 35.55<br />

72072 3 X-RAY EXAM OF THORACIC SPINE 39.78<br />

72074 3 X-RAY EXAM OF THORACIC SPINE 47.16<br />

72080 3 X-RAY EXAM OF TRUNK SPINE 36.73<br />

72090 3 X-RAY EXAM OF TRUNK SPINE 46.12<br />

72100 3 X-RAY EXAM OF LOWER SPINE 39.09<br />

72110 3 X-RAY EXAM OF LOWER SPINE 54.57<br />

72114 3 X-RAY EXAM OF LOWER SPINE 70.95<br />

72120 3 X-RAY EXAM OF LOWER SPINE 49.12<br />

72125 3 CT NECK SPINE W/O DYE 251.96

---

72126 3 CT NECK SPINE W/DYE 341.82<br />

72127 3 CT NECK SPINE W/O & W/DYE 394.21<br />

72128 3 CT CHEST SPINE W/O DYE 251.96<br />

72129 3 CT CHEST SPINE W/DYE 342.22<br />

72130 3 CT CHEST SPINE W/O & W/DYE 394.21<br />

72131 3 CT LUMBAR SPINE W/O DYE 251.96<br />

72132 3 CT LUMBAR SPINE W/DYE 341.82<br />

72133 3 CT LUMBAR SPINE W/O & W/DYE 394.21<br />

72141 3 MRI NECK SPINE W/O DYE 428.20<br />

72142 3 MRI NECK SPINE W/DYE 498.89<br />

72146 3 MRI CHEST SPINE W/O DYE 428.10<br />

72147 3 MRI CHEST SPINE W/DYE 498.50<br />

72148 3 MRI LUMBAR SPINE W/O DYE 422.30<br />

72149 3 MRI LUMBAR SPINE W/DYE 492.40<br />

72156 3 MRI NECK SPINE W/O & W/DYE 659.16<br />

72157 3 MRI CHEST SPINE W/O & W/DYE 658.87<br />

72158 3 MRI LUMBAR SPINE W/O & W/DYE 649.18<br />

72159 3 MR ANGIO SPINE W/O&W/DYE 626.07<br />

72170 3 X-RAY EXAM OF PELVIS 27.91<br />

72190 3 X-RAY EXAM OF PELVIS 39.49<br />

72191 3 CT ANGIOGRAPH PELV W/O&W/DYE 425.48<br />

72192 3 CT PELVIS W/O DYE 248.76<br />

72193 3 CT PELVIS W/DYE 339.80<br />

72194 3 CT PELVIS W/O & W/DYE 391.40<br />

72195 3 MRI PELVIS W/O DYE 422.59<br />

72196 3 MRI PELVIS W/DYE 490.86<br />

72197 3 MRI PELVIS W/O & W/DYE 646.58<br />

72198 3 MR ANGIO PELVIS W/O & W/DYE 493.46<br />

72200 3 X-RAY EXAM SACROILIAC JOINTS 29.88<br />

72202 3 X-RAY EXAM SACROILIAC JOINTS 35.96<br />

72220 3 X-RAY EXAM OF TAILBONE 31.26<br />

72240 3 CONTRAST X-RAY OF NECK SPINE 188.89<br />

72241 O MYELOGRAPHY, CERVICAL COMPLETE PROC 0.00<br />

72255 3 CONTRAST X-RAY, THORAX SPINE 173.45<br />

72256 O MYELOGRAPHY, THORACIC COMPLETE PROC 0.00<br />

72265 3 CONTRAST X-RAY, LOWER SPINE 170.75<br />

72266 O MYELOGRAPHY, LUMBOSACRAL COMPLETE P 0.00<br />

72270 3 CONTRAST X-RAY, SPINE 263.94<br />

72271 O MYELOGRAPHY, ENTIRE SPINAL CANAL CO 0.00<br />

72275 3 EPIDUROGRAPHY 112.97<br />

72285 3 X-RAY C/T SPINE DISK 254.33<br />

72286 O DISKOGRAPHY, CERVICAL COMPLETE PROC 0.00<br />

72291 3 PERQ VERTEBROPLASTY, FLUOR 0.00<br />

72292 3 PERQ VERTEBROPLASTY, CT 0.00<br />

72295 3 X-RAY OF LOWER SPINE DISK 230.57<br />

72296 O DISKOGRAPHY, LUMBAR COMPLETE PROCED 0.00<br />

73000 3 X-RAY EXAM OF COLLAR BONE 28.31<br />

73010 3 X-RAY EXAM OF SHOUL<strong>DE</strong>R BLA<strong>DE</strong> 29.48<br />

73020 3 X-RAY EXAM OF SHOUL<strong>DE</strong>R 24.78<br />

73030 3 X-RAY EXAM OF SHOUL<strong>DE</strong>R 31.25

---

73040 3 CONTRAST X-RAY OF SHOUL<strong>DE</strong>R 111.94<br />

73041 O RADIOLOGIC EXAMINATION, SHOUL<strong>DE</strong>R, A 0.00<br />

73050 3 X-RAY EXAM OF SHOUL<strong>DE</strong>RS 37.13<br />

73060 3 X-RAY EXAM OF HUMERUS 30.86<br />

73070 3 X-RAY EXAM OF ELBOW 27.93<br />

73080 3 X-RAY EXAM OF ELBOW 34.40<br />

73085 3 CONTRAST X-RAY OF ELBOW 104.07<br />

73086 O RADIOLOGIC EXAMINATION, ELBOW, ARTH 0.00<br />

73090 3 X-RAY EXAM OF FOREARM 28.31<br />

73092 3 X-RAY EXAM OF ARM, INFANT 28.31<br />

73100 3 X-RAY EXAM OF WRIST 28.70<br />

73110 3 X-RAY EXAM OF WRIST 33.42<br />

73115 3 CONTRAST X-RAY OF WRIST 102.30<br />

73116 O RADIOLOGIC EXAMINATION, WRIST, ARTH 0.00<br />

73120 3 X-RAY EXAM OF HAND 27.92<br />

73130 3 X-RAY EXAM OF HAND 31.45<br />

73140 3 X-RAY EXAM OF FINGER(S) 27.55<br />

73200 3 CT UPPER EXTREMITY W/O DYE 249.15<br />

73201 3 CT UPPER EXTREMITY W/DYE 329.27<br />

73202 3 CT UPPR EXTREMITY W/O&W/DYE 391.69<br />

73206 3 CT ANGIO UPR EXTRM W/O&W/DYE 425.29<br />

73218 3 MRI UPPER EXTREMITY W/O DYE 417.55<br />

73219 3 MRI UPPER EXTREMITY W/DYE 485.82<br />

73220 3 MRI UPPR EXTREMITY W/O&W/DYE 641.94<br />

73221 3 MRI JOINT UPR EXTREM W/O DYE 417.45<br />

73222 3 MRI JOINT UPR EXTREM W/DYE 485.72<br />

73223 3 MRI JOINT UPR EXTR W/O&W/DYE 641.45<br />

73225 3 MR ANGIO UPR EXTR W/O&W/DYE 596.71<br />

73500 3 X-RAY EXAM OF HIP 26.73<br />

73510 3 X-RAY EXAM OF HIP 36.34<br />

73520 3 X-RAY EXAM OF HIPS 40.63<br />

73525 3 CONTRAST X-RAY OF HIP 103.97<br />

73526 O RADIOLOGIC EXAMINATION, HIP, ARTHRO 0.00<br />

73530 3 X-RAY EXAM OF HIP 36.65<br />

73540 3 X-RAY EXAM OF PELVIS & HIPS 36.74<br />

73542 3 X-RAY EXAM, SACROILIAC JOINT 91.35<br />

73550 3 X-RAY EXAM OF THIGH 30.47<br />

73560 3 X-RAY EXAM OF KNEE, 1 OR 2 29.48<br />

73562 3 X-RAY EXAM OF KNEE, 3 34.39<br />

73564 3 X-RAY EXAM, KNEE, 4 OR MORE 39.09<br />

73565 3 X-RAY EXAM OF KNEES 30.27<br />

73580 3 CONTRAST X-RAY OF KNEE JOINT 128.96<br />

73581 O RADIOLOGIC EXAMINATION, KNEE, ARTHR 0.00<br />

73590 3 X-RAY EXAM OF LOWER LEG 28.70<br />

73592 3 X-RAY EXAM OF LEG, INFANT 28.31<br />

73600 3 X-RAY EXAM OF ANKLE 27.92<br />

73610 3 X-RAY EXAM OF ANKLE 31.45<br />

73615 3 CONTRAST X-RAY OF ANKLE 107.12<br />

73616 O RADIOLOGIC EXAMINATION, ANKLE, ARTH 0.00<br />

73620 3 X-RAY EXAM OF FOOT 27.52

---

73630 3 X-RAY EXAM OF FOOT 31.45<br />

73650 3 X-RAY EXAM OF HEEL 27.13<br />

73660 3 X-RAY EXAM OF TOE(S) 26.76<br />

73700 3 CT LOWER EXTREMITY W/O DYE 249.15<br />

73701 3 CT LOWER EXTREMITY W/DYE 330.85<br />

73702 3 CT LWR EXTREMITY W/O&W/DYE 392.09<br />

73706 3 CT ANGIO LWR EXTR W/O&W/DYE 430.14<br />

73718 3 MRI LOWER EXTREMITY W/O DYE 417.55<br />

73719 3 MRI LOWER EXTREMITY W/DYE 485.82<br />

73720 3 MRI LWR EXTREMITY W/O&W/DYE 641.55<br />

73721 3 MRI JNT OF LWR EXTRE W/O DYE 417.45<br />

73722 3 MRI JOINT OF LWR EXTR W/DYE 485.72<br />

73723 3 MRI JOINT LWR EXTR W/O&W/DYE 641.84<br />

73725 3 MR ANG LWR EXT W OR W/O DYE 494.24<br />

74000 3 X-RAY EXAM OF ABDOMEN 27.51<br />

74010 3 X-RAY EXAM OF ABDOMEN 37.51<br />

74020 3 X-RAY EXAM OF ABDOMEN 40.62<br />

74022 3 X-RAY EXAM SERIES, ABDOMEN 48.36<br />

74150 3 CT ABDOMEN W/O DYE 253.50<br />

74160 3 CT ABDOMEN W/DYE 345.81<br />

74170 3 CT ABDOMEN W/O & W/DYE 401.00<br />

74175 3 CT ANGIO ABDOM W/O & W/DYE 429.45<br />

74181 3 MRI ABDOMEN W/O DYE 422.69<br />

74182 3 MRI ABDOMEN W/DYE 491.05<br />

74183 3 MRI ABDOMEN W/O & W/DYE 646.58<br />

74185 3 MRI ANGIO, ABDOM W ORW/O DYE 493.46<br />

74190 3 X-RAY EXAM OF PERITONEUM 79.79<br />

74210 3 CONTRST X-RAY EXAM OF THROAT 75.28<br />

74220 3 CONTRAST X-RAY, ESOPHAGUS 84.25<br />

74230 3 CINE/VID X-RAY, THROAT/ESOPH 88.43<br />

74235 3 REMOVE ESOPHAGUS OBSTRUCTION 145.15<br />

74240 3 X-RAY EXAM, UPPER GI TRACT 105.43<br />

74241 3 X-RAY EXAM, UPPER GI TRACT 110.94<br />

74245 3 X-RAY EXAM, UPPER GI TRACT 166.46<br />

74246 3 CONTRST X-RAY UPPR GI TRACT 119.40<br />

74247 3 CONTRST X-RAY UPPR GI TRACT 123.73<br />

74249 3 CONTRST X-RAY UPPR GI TRACT 178.16<br />

74250 3 X-RAY EXAM OF SMALL BOWEL 95.96<br />

74251 3 X-RAY EXAM OF SMALL BOWEL 179.69<br />

74260 3 X-RAY EXAM OF SMALL BOWEL 115.11<br />

74270 3 CONTRAST X-RAY EXAM OF COLON 124.12<br />

74280 3 CONTRAST X-RAY EXAM OF COLON 186.07<br />

74283 3 CONTRAST X-RAY EXAM OF COLON 187.38<br />

74290 3 CONTRAST X-RAY, GALLBLAD<strong>DE</strong>R 60.16<br />

74291 3 CONTRAST X-RAYS, GALLBLAD<strong>DE</strong>R 47.95<br />

74300 O X-RAY BILE DUCTS/PANCREAS 0.00<br />

74301 3 X-RAYS AT SURGERY ADD-ON 25.96<br />

74305 3 X-RAY BILE DUCTS/PANCREAS 55.24<br />

74320 3 CONTRAST X-RAY OF BILE DUCTS 131.51<br />

74321 O CHOLANGIOGRAPHY, PERCUTANEOUS, TRAN 0.00

---

74327 3 X-RAY BILE STONE REMOVAL 125.59<br />

74328 3 X-RAY BILE DUCT ENDOSCOPY 167.89<br />

74329 3 X-RAY FOR PANCREAS ENDOSCOPY 0.00<br />

74330 3 X-RAY BILE/PANC ENDOSCOPY 178.44<br />

74340 3 X-RAY GUI<strong>DE</strong> FOR GI TUBE 137.32<br />

74350 O X-RAY GUI<strong>DE</strong>, STOMACH TUBE 0.00<br />

74351 O PERCUTANEOUS PLACEMENT OF GASTROSTO 0.00<br />

74355 3 X-RAY GUI<strong>DE</strong>, INTESTINAL TUBE 149.03<br />

74356 O PERCUTANEOUS PLACEMENT OF ENTEROCLY 0.00<br />

74360 3 X-RAY GUI<strong>DE</strong>, GI DILATION 159.66<br />

74361 O INTRALUMINAL DILATION OF STRICTURES 0.00<br />

74363 3 X-RAY, BILE DUCT DILATION 106.66<br />

74400 3 CONTRST X-RAY, URINARY TRACT 107.75<br />

74405 O CONTRAST X-RAY URINARY TRACT 0.00<br />

74410 3 CONTRST X-RAY, URINARY TRACT 114.83<br />

74415 3 CONTRST X-RAY, URINARY TRACT 130.08<br />

74420 3 CONTRST X-RAY, URINARY TRACT 128.04<br />

74425 3 CONTRST X-RAY, URINARY TRACT 73.61<br />

74426 O UROGRAPHY, ANTEGRA<strong>DE</strong>, (PYELOSTOGRAM 0.00<br />

74430 3 CONTRAST X-RAY, BLAD<strong>DE</strong>R 74.53<br />

74431 O CYSTOGRAPHY, MINIMUM OF THREE VIEWS 0.00<br />

74440 3 X-RAY, MALE GENITAL TRACT 81.17<br />

74441 O VASOGRAPHY, VESICULOGRAPHY, OR EPID 0.00<br />

74445 3 X-RAY EXAM OF PENIS 108.47<br />

74446 O CORPORA CAVERNOSOGRAPHY COMPLETE PR 0.00<br />

74450 3 X-RAY, URETHRA/BLAD<strong>DE</strong>R 78.34<br />

74451 O URETHROCYSTOGRAPHY, RETROGRA<strong>DE</strong> COMP 0.00<br />

74455 3 X-RAY, URETHRA/BLAD<strong>DE</strong>R 91.05<br />

74456 O URETHROCYSTOGRAPHY, VOIDING COMPLET 0.00<br />

74470 3 X-RAY EXAM OF KIDNEY LESION 80.57<br />

74471 O RADIOLOGIC EXAMINATION, RENAL CYST 0.00<br />

74475 3 X-RAY CONTROL, CATH INSERT 151.09<br />

74476 O INTRODUCTION OF INTRACATHETER OR CA 0.00<br />

74480 3 X-RAY CONTROL, CATH INSERT 151.09<br />

74481 O INTRODUCTION OF URETERAL CATHETER O 0.00<br />

74485 3 X-RAY GUI<strong>DE</strong>, GU DILATION 134.56<br />

74486 O DILATION OF NEPHROSTOMY OR URETERS 0.00<br />

74710 3 X-RAY MEASUREMENT OF PELVIS 49.33<br />

74740 3 X-RAY, FEMALE GENITAL TRACT 78.32<br />

74741 O HYSTEROSALPINGOGRAPHY COMPLETE PROC 0.00<br />

74742 9 X-RAY, FALLOPIAN TUBE 0.00<br />

74775 3 X-RAY EXAM OF PERINEUM 93.92<br />

75120 O RADIOLOGIC EXAMINATION, HAND; TWO V 0.00<br />

75500 O ANGIOCARDIOGRAPHY BY CINERADIOGRAPH 0.00<br />

75501 O ANGIOCARDIOGRAPHY BY CINERADIOGRAPH 0.00<br />

75505 O ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, 0.00<br />

75506 O ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, 0.00<br />

75507 O ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, 0.00<br />

75509 O ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, 0.00<br />

75519 O CARDIAC RADIOGRAPHY, SELECTIVE CARD 0.00

---

75520 O CARDIAC RADIOGRAPHY, SELECTIVE CARD 0.00<br />

75523 O CARDIAC RADIOGRAPHY, SELECTIVE CARD 0.00<br />

75524 O CARDIAC RADIOGRAPHY, SELECTIVE CARD 0.00<br />

75527 O CARDIAC RADIOGRAPHY, SELECTIVE CARD 0.00<br />

75528 O CARDIAC RADIOGRAPHY, SELECTIVE CARD 0.00<br />

75552 O HEART MRI FOR MORPH W/O DYE 0.00<br />

75553 O HEART MRI FOR MORPH W/DYE 0.00<br />

75554 O CARDIAC MRI/FUNCTION 0.00<br />

75555 O CARDIAC MRI/LIMITED STUDY 0.00<br />

75556 O CARDIAC MRI/FLOW MAPPING 0.00<br />

75557 3 CARDIAC MRI FOR MORPH 467.71<br />

75558 3 CARDIAC MRI FLOW/VELOCITY 607.31<br />

75559 3 CARDIAC MRI W/STRESS IMG 503.34<br />

75560 3 CARDIAC MRI FLOW/VEL/STRESS 793.80<br />

75561 3 CARDIAC MRI FOR MORPH W/DYE 666.81<br />

75562 3 CARD MRI FLOW/VEL W/DYE 787.31<br />

75563 3 CARD MRI W/STRESS IMG & DYE 695.52<br />

75564 3 HT MRI W/FLO/VEL/STRS & DYE 925.66<br />

75600 3 CONTRAST X-RAY EXAM OF AORTA 414.87<br />

75601 O AORTOGRAPHY, THORACIC, WITHOUT SERI 0.00<br />

75605 3 CONTRAST X-RAY EXAM OF AORTA 384.99<br />

75606 O AORTOGRAPHY, THORACIC, BY SERIALOGR 0.00<br />

75625 3 CONTRAST X-RAY EXAM OF AORTA 380.96<br />

75626 O AORTOGRAPHY, ABDOMINAL, TRANSLUMBAR 0.00<br />

75627 O AORTOGRAPHY, ABDOMINAL, CATHETER, B 0.00<br />

75628 O AORTOGRAPHY, ABDOMINAL, CATHETER, B 0.00<br />

75630 3 X-RAY AORTA, LEG ARTERIES 429.17<br />

75631 O AORTOGRAPHY, ABDOMINAL PLUS BILATER 0.00<br />

75635 3 CT ANGIO ABDOMINAL ARTERIES 455.24<br />

75650 3 ARTERY X-RAYS, HEAD & NECK 398.70<br />

75651 O ANGIOGRAPHY, CERVICOCEREBRAL, CATHE 0.00<br />

75652 O ANGIOGRAPHY, CERVICOCEREBRAL, SELEC 0.00<br />

75653 O ANGIOGRAPHY, CERVICOCEREBRAL, SELEC 0.00<br />

75654 O ANGIOGRAPHY, CERVICOCEREBRAL, SELEC 0.00<br />

75655 O ANGIOGRAPHY, CERVICOCEREBRAL, SELEC 0.00<br />

75656 O ANGIOGRAPHY, CERVICOCEREBRAL, SELEC 0.00<br />

75657 O ANGIOGRAPHY, CERVICOCEREBRAL, SELEC 0.00<br />

75658 3 ARTERY X-RAYS, ARM 396.47<br />

75659 O ANGIOGRAPHY, BRACHIAL, RETROGRA<strong>DE</strong> C 0.00<br />

75660 3 ARTERY X-RAYS, HEAD & NECK 398.54<br />

75661 O ANGIOGRAPHY, EXTERNAL CAROTID, CERE 0.00<br />

75662 3 ARTERY X-RAYS, HEAD & NECK 435.65<br />

75663 O ANGIOGRAPHY, EXTERNAL CAROTID, CERE 0.00<br />

75665 3 ARTERY X-RAYS, HEAD & NECK 403.75<br />

75667 O ANGIOGRAPHY, CAROTID, CEREBRAL, UNI 0.00<br />

75669 O ANGIOGRAPHY, CAROTID, CEREBRAL, UNI 0.00<br />

75671 3 ARTERY X-RAYS, HEAD & NECK 436.74<br />

75672 O ANGIOGRAPHY, CAROTID, CEREBRAL, BIL 0.00<br />

75673 O ANGIOGRAPHY, CAROTID, CEREBRAL, BIL 0.00<br />

75676 3 ARTERY X-RAYS, NECK 398.44

---

75677 O ANGIOGRAPHY, CAROTID, CERVICAL, UNI 0.00<br />

75678 O ANGIOGRAPHY, CAROTID, CERVICAL, UNI 0.00<br />

75680 3 ARTERY X-RAYS, NECK 426.90<br />

75681 O ANGIOGRAPHY, CAROTID, CERVICAL, BIL 0.00<br />

75682 O ANGIOGRAPHY, CAROTID, CERVICAL, BIL 0.00<br />

75685 3 ARTERY X-RAYS, SPINE 398.54<br />

75686 O ANGIOGRAPHY, VERTEBRAL DIRECT PUNCT 0.00<br />

75687 O ANGIOGRAPHY, VERTEBRAL CATHETER, CO 0.00<br />

75690 O ANGIOGRAPHY, VERTEBRAL, CERVICAL, U 0.00<br />

75692 O ANGIOGRAPHY, VERTEBRAL, CERVICAL, U 0.00<br />

75695 O ANGIOGRAPHY, VERTEBRAL, CERVICAL, B 0.00<br />

75697 O ANGIOGRAPHY, VERTEBRAL, CERVICAL, B 0.00<br />

75705 3 ARTERY X-RAYS, SPINE 441.27<br />

75706 O ANGIOGRAPHY, SPINAL, SELECTIVE COMP 0.00<br />

75710 3 ARTERY X-RAYS, ARM/LEG 393.45<br />

75711 O ANGIOGRAPHY, EXTREMITY, UNILATERAL 0.00<br />

75712 O ANGIOGRAPHY, EXTREMITY, UNILATERAL 0.00<br />

75716 3 ARTERY X-RAYS, ARMS/LEGS 418.90<br />

75717 O ANGIOGRAPHY, EXTREMITY, BILATERAL W 0.00<br />

75718 O ANGIOGRAPHY, EXTREMITY, BILATERAL B 0.00<br />

75722 3 ARTERY X-RAYS, KIDNEY 390.89<br />

75723 O ANGIOGRAPHY, RENAL, UNILATERAL, SEL 0.00<br />

75724 3 ARTERY X-RAYS, KIDNEYS 431.15<br />

75725 O ANGIOGRAPHY, RENAL, BILATERAL, SELE 0.00<br />

75726 3 ARTERY X-RAYS, ABDOMEN 388.53<br />

75727 O ANGIOGRAPHY, VISCERAL SELECTIVE (WI 0.00<br />

75728 O ANGIOGRAPHY, VISCERAL SUPRASELECTIV 0.00<br />

75731 3 ARTERY X-RAYS, ADRENAL GLAND 395.51<br />

75732 O ANGIOGRAPHY, ADRENAL, UNILATERAL, S 0.00<br />

75733 3 ARTERY X-RAYS, ADRENALS 429.62<br />

75734 O ANGIOGRAPHY, ADRENAL, BILATERAL, SE 0.00<br />

75736 3 ARTERY X-RAYS, PELVIS 391.58<br />

75737 O ANGIOGRAPHY, PELVIC SELECTIVE, COMP 0.00<br />

75738 O ANGIOGRAPHY, PELVIC SUPRASELECTIVE, 0.00<br />

75741 3 ARTERY X-RAYS, LUNG 384.37<br />

75742 O ANGIOGRAPHY, PULMONARY, UNILATERAL, 0.00<br />

75743 3 ARTERY X-RAYS, LUNGS 406.44<br />

75744 O ANGIOGRAPHY, PULMONARY, BILATERAL, 0.00<br />

75746 3 ARTERY X-RAYS, LUNG 384.20<br />

75747 O ANGIOGRAPHY, PULMONARY CATHETER, NO 0.00<br />

75748 O ANGIOGRAPHY, PULMONARY VENOUS INJEC 0.00<br />

75750 O ANGIOGRAPHY, CORONARY, ROOT INJECTI 0.00<br />

75751 O ANGIOGRAPHY, CORONARY, ROOT INJECTI 0.00<br />

75752 O ANGIOGRAPHY, CORONARY, UNILATERAL S 0.00<br />

75753 O ANGIOGRAPHY, CORONARY, UNILATERAL S 0.00<br />

75754 O ANGIOGRAPHY, CORONARY, BILATERAL SE 0.00<br />

75755 O ANGIOGRAPHY, CORONARY, BILATERAL SE 0.00<br />

75756 3 ARTERY X-RAYS, CHEST 401.22<br />

75757 O ANGIOGRAPHY, INTERNAL MAMMARY COMPL 0.00<br />

75762 O ANGIOGRAPHY, CORONARY BYPASS, UNILA 0.00

---

75764 O ANGIOGRAPHY, CORONARY BYPASS, UNILA 0.00<br />

75766 O ANGIOGRAPHY, CORONARY BYPASS, MULTI 0.00<br />

75767 O ANGIOGRAPHY, CORONARY BYPASS, MULTI 0.00<br />

75774 3 ARTERY X-RAY, EACH VESSEL 331.95<br />

75775 O ANGIOGRAPHY, SELECTIVE, EACH ADDITI 0.00<br />

75790 3 VISUALIZE A-V SHUNT 167.34<br />

75801 3 LYMPH VESSEL X-RAY, ARM/LEG 269.75<br />

75802 O LYMPHANGIOGRAPHY, EXTREMITY ONLY, U 0.00<br />

75803 3 LYMPH VESSEL X-RAY,ARMS/LEGS 286.46<br />

75804 O LYMPHANGIOGRAPHY, EXTREMITY ONLY, B 0.00<br />

75805 3 LYMPH VESSEL X-RAY, TRUNK 296.90<br />

75806 O LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, 0.00<br />

75807 3 LYMPH VESSEL X-RAY, TRUNK 141.28<br />

75808 O LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, 0.00<br />

75809 3 NONVASCULAR SHUNT, X-RAY 78.45<br />

75810 3 VEIN X-RAY, SPLEEN/LIVER 581.14<br />

75811 O SPLENOPORTOGRAPHY COMPLETE PROCEDUR 0.00<br />

75820 3 VEIN X-RAY, ARM/LEG 108.77<br />

75821 O VENOGRAPHY, EXTREMITY, UNILATERAL C 0.00<br />

75822 3 VEIN X-RAY, ARMS/LEGS 138.02<br />

75823 O VENOGRAPHY, EXTREMITY, BILATERAL CO 0.00<br />

75825 3 VEIN X-RAY, TRUNK 372.99<br />

75826 O VENOGRAPHY, CAVAL, INFERIOR, WITH S 0.00<br />

75827 3 VEIN X-RAY, CHEST 372.79<br />

75828 O VENOGRAPHY, CAVAL, SUPERIOR, WITH S 0.00<br />

75831 3 VEIN X-RAY, KIDNEY 374.66<br />

75832 O VENOGRAPHY, RENAL, UNILATERAL, SELE 0.00<br />

75833 3 VEIN X-RAY, KIDNEYS 402.44<br />

75834 O VENOGRAPHY, RENAL, BILATERAL, SELEC 0.00<br />

75840 3 VEIN X-RAY, ADRENAL GLAND 373.78<br />

75841 O VENOGRAPHY, ADRENAL, UNILATERAL, SE 0.00<br />

75842 3 VEIN X-RAY, ADRENAL GLANDS 403.03<br />

75843 O VENOGRAPHY, ADRENAL, BILATERAL, SEL 0.00<br />

75860 3 VEIN X-RAY, NECK 381.55<br />

75861 O VENOGRAPHY, SINUS OR JUGULAR, CATHE 0.00<br />

75870 3 VEIN X-RAY, SKULL 379.87<br />

75871 O VENOGRAPHY, SUPERIOR SAGITTAL SINUS 0.00<br />

75872 3 VEIN X-RAY, SKULL 397.09<br />

75873 O VENOGRAPHY, EPIDURAL COMPLETE PROCE 0.00<br />

75880 3 VEIN X-RAY, EYE SOCKET 113.09<br />

75881 O VENOGRAPHY, ORBITAL COMPLETE PROCED 0.00<br />

75885 3 VEIN X-RAY, LIVER 389.78<br />

75886 O PERCUTANEOUS TRANSHEPATIC PORTOGRAP 0.00<br />

75887 3 VEIN X-RAY, LIVER 394.50<br />

75888 O PERCUTANEOUS TRANSHEPATIC PORTOGRAP 0.00<br />

75889 3 VEIN X-RAY, LIVER 375.15<br />

75890 O HEPATIC VENOGRAPHY WEDGED OR FREE, 0.00<br />

75891 3 VEIN X-RAY, LIVER 374.76<br />

75892 O HEPATIC VENOGRAPHY, WEDGED OR FREE, 0.00<br />

75893 3 VENOUS SAMPLING BY CATHETER 346.37

---

75894 3 X-RAYS, TRANSCATH THERAPY 1,068.60<br />

75895 O TRANSCATHETER THERAPY, EMBOLIZATION 0.00<br />

75896 3 X-RAYS, TRANSCATH THERAPY 937.84<br />

75897 O TRANSCATHETER THERAPY, INFUSION (EG 0.00<br />

75898 3 FOLLOW-UP ANGIOGRAPHY 132.07<br />

75900 3 INTRAVASCULAR CATH EXCHANGE 0.00<br />

75901 3 REMOVE CVA <strong>DE</strong>VICE OBSTRUCT 152.27<br />

75902 3 REMOVE CVA LUMEN OBSTRUCT 98.44<br />

75940 3 X-RAY PLACEMENT, VEIN FILTER 550.10<br />

75941 O PERCUTANEOUS PLACEMENT OF IVC FILTE 0.00<br />

75945 3 INTRAVASCULAR US 211.21<br />

75946 3 INTRAVASCULAR US ADD-ON 0.00<br />

75950 O TRANSCATHETER INTRAVASCULAR OCCLUSI 0.00<br />

75951 O TRANSCATHETER INTRAVASCULAR OCCLUSI 0.00<br />

75952 3 ENDOVASC REPAIR ABDOM AORTA 0.00<br />

75953 3 ABDOM ANEURYSM ENDOVAS RPR 0.00<br />

75954 3 ILIAC ANEURYSM ENDOVAS RPR 0.00<br />

75955 O TRANSCATHETER INTRAVASCULAR OCCLUSI 0.00<br />

75956 3 ENDOVASCULAR REPAIR OF <strong>DE</strong>SCENDING 0.00<br />

75957 3 XRAY, ENDOVASC THOR AO REPR 0.00<br />

75958 3 XRAY, PLACE PROX EXT THOR AO 0.00<br />

75959 3 XRAY, PLACE DIST EXT THOR AO 0.00<br />

75960 3 TRANSCATH IV STENT RS&I 404.12<br />

75961 3 RETRIEVAL, BROKEN CATHETER 491.39<br />

75962 3 REPAIR ARTERIAL BLOCKAGE 426.36<br />

75963 O PERCUTANEOUS TRANSLUMINAL ANGIOPLAS 0.00<br />

75964 3 REPAIR ARTERY BLOCKAGE, EACH 239.57<br />

75965 O PERCUTANEOUS TRANSLUMINAL ANGIOPLAS 0.00<br />

75966 3 REPAIR ARTERIAL BLOCKAGE 471.53<br />

75967 O PERCUTANEOUS TRANSLUMINAL ANGIOPLAS 0.00<br />

75968 3 REPAIR ARTERY BLOCKAGE, EACH 240.46<br />

75969 O PERCUTANEOUS TRANSLUMINAL ANGIOPLAS 0.00<br />

75970 3 VASCULAR BIOPSY 521.38<br />

75971 O TRANSCATHETER BIOPSY COMPLETE PROCE 0.00<br />

75978 3 REPAIR VENOUS BLOCKAGE 421.34<br />

75979 O PERCUTANEOUS TRANSLUMINAL ANGIOPLAS 0.00<br />

75980 3 CONTRAST XRAY EXAM BILE DUCT 300.87<br />

75981 O PERCUTANEOUS TRANSHEPATIC BILIARY D 0.00<br />

75982 9 CONTRAST XRAY EXAM BILE DUCT 0.00<br />

75983 O PERCUTANEOUS PLACEMENT OF DRAINAGE 0.00<br />

75984 3 XRAY CONTROL CATHETER CHANGE 116.53<br />

75985 O CHANGE OF PERCUTANEOUS DRAINAGE CAT 0.00<br />

75989 3 ABSCESS DRAINAGE UN<strong>DE</strong>R X-RAY 161.04<br />

75990 O RADIOLOGICAL GUIDANCE FOR PERCUTANE 0.00<br />

75992 3 ATHERECTOMY, X-RAY EXAM 680.53<br />

75993 3 ATHERECTOMY, X-RAY EXAM 0.00<br />

75994 3 ATHERECTOMY, X-RAY EXAM 0.00<br />

75995 3 ATHERECTOMY, X-RAY EXAM 0.00<br />

75996 3 ATHERECTOMY, X-RAY EXAM 0.00<br />

75998 O FLUOROGUI<strong>DE</strong> FOR VEIN <strong>DE</strong>VICE 0.00

---

76000 3 FLUOROSCOPE EXAMINATION 89.19<br />

76001 3 FLUOROSCOPE EXAM, EXTENSIVE 145.38<br />

76003 O NEEDLE LOCALIZATION BY X-RAY 0.00<br />

76005 O FLUOROGUI<strong>DE</strong> FOR SPINE INJECT 0.00<br />

76006 O X-RAY STRESS VIEW 0.00<br />

76010 3 X-RAY, NOSE TO RECTUM 29.08<br />

76012 O PERCUT VERTEBROPLASTY FLUOR 0.00<br />

76013 O PERCUT VERTEBROPLASTY, CT 0.00<br />

76020 O X-RAYS FOR BONE AGE 0.00<br />

76040 O X-RAYS, BONE EVALUATION 0.00<br />

76061 O X-RAYS, BONE SURVEY 0.00<br />

76062 O X-RAYS, BONE SURVEY 0.00<br />

76065 O X-RAYS, BONE EVALUATION 0.00<br />

76066 O JOINT SURVEY, SINGLE VIEW 0.00<br />

76070 O CT BONE <strong>DE</strong>NSITY, AXIAL 0.00<br />

76071 O CT BONE <strong>DE</strong>NSITY, PERIPHERAL 0.00<br />

76075 O DXA BONE <strong>DE</strong>NSITY, AXIAL 0.00<br />

76076 O DXA BONE <strong>DE</strong>NSITY/PERIPHERAL 0.00<br />

76077 O DXA BONE <strong>DE</strong>NSITY/V-FRACTURE 0.00<br />

76078 O RADIOGRAPHIC ABSORPTIOMETRY 0.00<br />

76080 3 X-RAY EXAM OF FISTULA 66.49<br />

76081 O RADIOLOGIC EXAMINATION, FISTULA OR 0.00<br />

76082 O COMPUTER MAMMOGRAM ADD-ON 0.00<br />

76083 O COMPUTER MAMMOGRAM ADD-ON 0.00<br />

76085 O COMPUTER MAMMOGRAM ADD-ON 0.00<br />

76086 O X-RAY OF MAMMARY DUCT 0.00<br />

76087 O MAMMARY DUCTOGRAM OR GALACTOGRAM, S 0.00<br />

76088 O X-RAY OF MAMMARY DUCTS 0.00<br />

76089 O MAMMARY DUCTOGRAM OR GALACTOGRAM, M 0.00<br />

76090 O MAMMOGRAM, ONE BREAST 0.00<br />

76091 O MAMMOGRAM, BOTH BREASTS 0.00<br />

76092 O MAMM0GRAM, SCREENING 0.00<br />

76093 O MAGNETIC IMAGE, BREAST 0.00<br />

76094 O MAGNETIC IMAGE, BOTH BREASTS 0.00<br />

76095 O STEREOTACTIC BREAST BIOPSY 0.00<br />

76096 O X-RAY OF NEEDLE WIRE, BREAST 0.00<br />

76097 O LOCALIZATION OF BREAST NODULE OR CA 0.00<br />

76098 3 X-RAY EXAM, BREAST SPECIMEN 21.62<br />

76100 3 X-RAY EXAM OF BODY SECTION 104.14<br />

76101 3 COMPLEX BODY SECTION X-RAY 162.17<br />

76102 3 COMPLEX BODY SECTION X-RAYS 202.89<br />

76120 3 CINE/VI<strong>DE</strong>O X-RAYS 75.27<br />

76125 3 CINE/VI<strong>DE</strong>O X-RAYS ADD-ON 47.01<br />

76140 3 X-RAY CONSULTATION 38.59<br />

76150 3 X-RAY EXAM, DRY PROCESS 22.23<br />

76350 5 SPECIAL X-RAY CONTRAST STUDY 0.00<br />

76355 O CT SCAN FOR LOCALIZATION 0.00<br />

76360 O CT SCAN FOR NEEDLE BIOPSY 0.00<br />

76361 O COMPUTERIZED TOMOGRAPHY GUIDANCE FO 0.00<br />

76362 O CT GUI<strong>DE</strong> FOR TISSUE ABLATION 0.00

---

76365 O CAT SCAN FOR CYST ASPIRATION 0.00<br />

76366 O COMPUTERIZED TOMOGRAPHY GUIDANCE FO 0.00<br />

76370 O CT SCAN FOR THERAPY GUI<strong>DE</strong> 0.00<br />

76375 O 3D/HOLOGRAPH RECONSTR ADD-ON 0.00<br />

76376 3 3D REN<strong>DE</strong>R W/O POSTPROCESS 106.28<br />

76377 3 3D REN<strong>DE</strong>RING W/POSTPROCESS 138.43<br />

76380 3 CAT SCAN FOLLOW-UP STUDY 150.37<br />

76390 3 MR SPECTROSCOPY 478.43<br />

76393 O MR GUIDANCE FOR NEEDLE PLACE 0.00<br />

76394 O MRI FOR TISSUE ABLATION 0.00<br />

76400 O MAGNETIC IMAGE, BONE MARROW 0.00<br />

76490 O US FOR TISSUE ABLATION 0.00<br />

76496 5 FLUOROSCOPIC PROCEDURE 0.00<br />

76497 5 CT PROCEDURE 0.00<br />

76498 5 MRI PROCEDURE 0.00<br />

76499 5 RADIOGRAPHIC PROCEDURE 0.00<br />

76506 3 ECHO EXAM OF HEAD 93.97<br />

76510 3 OPHTH US, B & QUANT A 155.65<br />

76511 3 OPHTH US, QUANT A ONLY 109.28<br />

76512 3 OPHTH US, B W/NON-QUANT A 102.00<br />

76513 3 ECHO EXAM OF EYE, WATER BATH 91.59<br />

76514 3 ECHO EXAM OF EYE, THICKNESS 12.27<br />

76516 3 ECHO EXAM OF EYE 72.39<br />

76519 3 ECHO EXAM OF EYE 76.72<br />

76529 3 ECHO EXAM OF EYE 71.79<br />

76536 3 US EXAM OF HEAD AND NECK 106.02<br />

76604 3 US EXAM, CHEST 86.46<br />

76645 3 US EXAM, BREAST(S) 86.55<br />

76700 3 US EXAM, ABDOM, COMPLETE 135.25<br />

76705 3 ECHO EXAM OF ABDOMEN 101.18<br />

76770 3 US EXAM ABDO BACK WALL, COMP 130.29<br />

76775 3 US EXAM ABDO BACK WALL, LIM 101.97<br />

76776 3 US EXAM K TRANSPL W/DOPPLER 141.29<br />

76778 O US EXAM KIDNEY TRANSPLANT 0.00<br />

76800 3 US EXAM, SPINAL CANAL 122.22<br />

76801 3 OB US < 14 WKS, SINGLE FETUS 134.63<br />

76802 3 OB US < 14 WKS, ADDÏL FETUS 78.48<br />

76805 3 OB US >/= 14 WKS, SNGL FETUS 145.25<br />

76810 3 OB US >/= 14 WKS, ADDL FETUS 100.61<br />

76811 3 OB US, <strong>DE</strong>TAILED, SNGL FETUS 222.91<br />

76812 3 OB US, <strong>DE</strong>TAILED, ADDL FETUS 146.15<br />

76813 3 OB US NUCHAL MEAS, 1 GEST 132.62<br />

76814 3 OB US NUCHAL MEAS, ADD-ON 84.37<br />

76815 3 OB US, LIMITED, FETUS(S) 92.88<br />

76816 3 OB US, FOLLOW-UP, PER FETUS 103.44<br />

76817 3 TRANSVAGINAL US, OBSTETRIC 98.11<br />

76818 3 FETAL BIOPHYS PROFILE W/NST 122.88<br />

76819 3 FETAL BIOPHYS PROFIL W/O NST 99.28<br />

76820 3 UMBILICAL ARTERY ECHO 67.81<br />

76821 3 MIDDLE CEREBRAL ARTERY ECHO 102.28

---

76825 3 ECHO EXAM OF FETAL HEART 178.58<br />

76826 3 ECHO EXAM OF FETAL HEART 102.08<br />

76827 3 ECHO EXAM OF FETAL HEART 82.80<br />

76828 3 ECHO EXAM OF FETAL HEART 60.68<br />

76830 3 TRANSVAGINAL US, NON-OB 116.25<br />

76831 3 ECHO EXAM, UTERUS 116.63<br />

76855 O ECHOGRAPHY, PELVIC AREA (DOPPLER) 0.00<br />

76856 3 US EXAM, PELVIC, COMPLETE 116.65<br />

76857 3 US EXAM, PELVIC, LIMITED 80.88<br />

76870 3 US EXAM, SCROTUM 115.11<br />

76872 3 US, TRANSRECTAL 132.38<br />

76873 3 ECHOGRAP TRANS R, PROS STUDY 173.17<br />

76880 3 US EXAM, EXTREMITY 117.70<br />

76885 3 US EXAM INFANT HIPS, DYNAMIC 97.63<br />

76886 3 US EXAM INFANT HIPS, STATIC 92.60<br />

76925 O ECHOGRAPHY, PERIPHERAL VASCULAR SYS 0.00<br />

76926 O ECHOGRAPHY, HEAD AND TRUNK, VASCULA 0.00<br />

76930 3 ECHO GUI<strong>DE</strong>, CARDIOCENTESIS 101.81<br />

76931 O ULTRASONIC GUIDANCE FOR PERICARDIOC 0.00<br />

76932 3 ECHO GUI<strong>DE</strong> FOR HEART BIOPSY 100.21<br />

76933 O ULTRASONIC GUIDANCE FOR ENDOMYOCARD 0.00<br />

76934 O ECHO GUI<strong>DE</strong> FOR CHEST TAP 0.00<br />

76935 O ULTRASONIC GUIDANCE FOR THORACENTES 0.00<br />

76936 3 ECHO GUI<strong>DE</strong> FOR ARTERY REPAIR 339.00<br />

76937 3 US GUI<strong>DE</strong>, VASCULAR ACCESS 35.50<br />

76938 O ECHO EXAM FOR DRAINAGE 0.00<br />

76939 O ULTRASONIC GUIDANCE FOR CYST (ANY L 0.00<br />

76940 3 US GUI<strong>DE</strong>, TISSUE ABLATION 190.84<br />

76941 3 ECHO GUI<strong>DE</strong> FOR TRANSFUSION 136.50<br />

76942 3 ECHO GUI<strong>DE</strong> FOR BIOPSY 180.40<br />

76943 O ULTRASONIC GUIDANCE FOR NEEDLE BIOP 0.00<br />

76945 3 ECHO GUI<strong>DE</strong>, VILLUS SAMPLING 98.94<br />

76946 3 ECHO GUI<strong>DE</strong> FOR AMNIOCENTESIS 57.57<br />

76947 O ULTRASONIC GUIDANCE FOR AMNIOCENTES 0.00<br />

76948 9 ECHO GUI<strong>DE</strong>, OVA ASPIRATION 0.00<br />

76949 O ULTRASONIC GUIDANCE FOR ASPIRATION 0.00<br />

76950 3 ECHO GUIDANCE RADIOTHERAPY 75.71<br />

76960 O ECHO GUIDANCE RADIOTHERAPY 0.00<br />

76965 3 ECHO GUIDANCE RADIOTHERAPY 198.02<br />

76970 3 ULTRASOUND EXAM FOLLOW-UP 78.01<br />

76975 3 GI ENDOSCOPIC ULTRASOUND 107.78<br />

76977 3 US BONE <strong>DE</strong>NSITY MEASURE 22.20<br />

76986 O ULTRASOUND GUI<strong>DE</strong> INTRAOPER 0.00<br />

76998 3 US GUI<strong>DE</strong>, INTRAOP 176.79<br />

76999 5 ECHO EXAMINATION PROCEDURE 0.00<br />

77001 3 FLUOROGUI<strong>DE</strong> FOR VEIN <strong>DE</strong>VICE 97.80<br />

77002 3 NEEDLE LOCALIZATION BY XRAY 74.26<br />

77003 3 FLUOROGUI<strong>DE</strong> FOR SPINE INJECT 67.04<br />

77011 3 CT SCAN FOR LOCALIZATION 624.42<br />

77012 3 CT SCAN FOR NEEDLE BIOPSY 269.18

---

77013 3 CT GUI<strong>DE</strong> FOR TISSUE ABLATION 605.39<br />

77014 3 CT SCAN FOR THERAPY GUI<strong>DE</strong> 186.67<br />

77021 3 MR GUIDANCE FOR NEEDLE PLACE 491.14<br />

77022 3 MRI FOR TISSUE ABLATION 740.48<br />

77031 3 STEREOTACT GUI<strong>DE</strong> FOR BRST BX 255.59<br />

77032 3 GUIDANCE FOR NEEDLE, BREAST 67.56<br />

77051 3 COMPUTER DX MAMMOGRAM ADD-ON 15.11<br />

77052 3 COMP SCREEN MAMMOGRAM ADD-ON 15.11<br />

77053 3 X-RAY OF MAMMARY DUCT 95.35<br />

77054 3 X-RAY OF MAMMARY DUCTS 129.42<br />

77055 3 MAMMOGRAM, ONE BREAST 83.98<br />

77056 3 MAMMOGRAM, BOTH BREASTS 106.08<br />

77057 3 MAMMOGRAM, SCREENING 84.28<br />

77058 3 MRI, ONE BREAST 868.08<br />

77059 3 MRI, BOTH BREASTS 999.91<br />

77071 3 X-RAY STRESS VIEW 34.52<br />

77072 3 X-RAYS FOR BONE AGE 23.96<br />

77073 3 X-RAYS, BONE LENGTH STUDIES 41.71<br />

77074 3 X-RAYS, BONE SURVEY, LIMITED 68.92<br />

77075 3 X-RAYS, BONE SURVEY COMPLETE 98.56<br />

77076 3 X-RAYS, BONE SURVEY, INFANT 79.06<br />

77077 3 JOINT SURVEY, SINGLE VIEW 49.35<br />

77078 3 CT BONE <strong>DE</strong>NSITY, AXIAL 86.28<br />

77079 3 CT BONE <strong>DE</strong>NSITY, PERIPHERAL 84.63<br />

77080 3 DXA BONE <strong>DE</strong>NSITY, AXIAL 83.76<br />

77081 3 DXA BONE <strong>DE</strong>NSITY/PERIPHERAL 34.67<br />

77082 3 DXA BONE <strong>DE</strong>NSITY, VERT FX 33.52<br />

77083 3 RADIOGRAPHIC ABSORPTIOMETRY 31.92<br />

77084 3 MAGNETIC IMAGE, BONE MARROW 394.56<br />

77261 3 RADIATION THERAPY PLANNING 68.33<br />

77262 3 RADIATION THERAPY PLANNING 103.20<br />

77263 3 RADIATION THERAPY PLANNING 153.49<br />

77280 3 SET RADIATION THERAPY FIELD 190.51<br />

77285 3 SET RADIATION THERAPY FIELD 320.01<br />

77290 3 SET RADIATION THERAPY FIELD 467.57<br />

77295 3 SET RADIATION THERAPY FIELD 930.51<br />

77299 5 RADIATION THERAPY PLANNING 0.00<br />

77300 3 RADIATION THERAPY DOSE PLAN 77.65<br />

77301 3 RADIOTHERAPY DOSE PLAN, IMRT 2,057.45<br />

77305 3 TELETX ISODOSE PLAN SIMPLE 87.33<br />

77310 3 TELETX ISODOSE PLAN INTERMED 117.87<br />

77315 3 TELETX ISODOSE PLAN COMPLEX 162.34<br />

77321 3 SPECIAL TELETX PORT PLAN 155.32<br />

77326 3 BRACHYTX ISODOSE CALC SIMP 147.85<br />

77327 3 BRACHYTX ISODOSE CALC INTERM 212.14<br />

77328 3 BRACHYTX ISODOSE PLAN COMPL 295.54<br />

77331 3 SPECIAL RADIATION DOSIMETRY 62.51<br />

77332 3 RADIATION TREATMENT AID(S) 81.64<br />

77333 3 RADIATION TREATMENT AID(S) 85.65<br />

77334 3 RADIATION TREATMENT AID(S) 173.89

---

77336 3 RADIATION PHYSICS CONSULT 85.78<br />

77370 3 RADIATION PHYSICS CONSULT 133.98<br />

77371 3 SRS, MULTISOURCE 1,188.49<br />

77372 3 SRS, LINEAR BASED 902.07<br />

77373 3 SBRT <strong>DE</strong>LIVERY 1,682.65<br />

77380 O PROTON BEAM <strong>DE</strong>LIVERY 0.00<br />

77381 O PROTON BEAM TREATMENT 0.00<br />

77399 5 EXTERNAL RADIATION DOSIMETRY 0.00<br />

77400 O DAILY MEGAVOLTAGE TREATMENT MANAGEM 0.00<br />

77401 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 47.32<br />

77402 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 123.65<br />

77403 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 112.24<br />

77404 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 120.89<br />

77405 O DAILY MEGAVOLTAGE TREATMENT MANAGEM 0.00<br />

77406 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 121.68<br />

77407 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 158.57<br />

77408 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 146.76<br />

77409 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 158.17<br />

77410 O DAILY MEGAVOLTAGE TREATMENT MANAGEM 0.00<br />

77411 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 157.78<br />

77412 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 183.26<br />

77413 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 184.83<br />

77414 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 201.75<br />

77415 O THERAPEUTIC RADIOLOGY TREATMENT POR 0.00<br />

77416 3 RADIATION TREATMENT <strong>DE</strong>LIVERY 201.75<br />

77417 3 RADIOLOGY PORT FILM(S) 20.07<br />

77418 3 RADIATION TX <strong>DE</strong>LIVERY, IMRT 617.61<br />

77419 O WEEKLY RADIATION THERAPY 0.00<br />

77420 O WEEKLY RADIATION THERAPY 0.00<br />

77421 3 STEREOSCOPIC X-RAY GUIDANCE 131.92<br />

77422 3 NEUTRON BEAM TX, SIMPLE 142.73<br />

77423 3 NEUTRON BEAM TX, COMPLEX 195.06<br />

77425 O WEEKLY RADIATION THERAPY 0.00<br />

77427 3 RADIATION TX MANAGEMENT, X5 178.56<br />

77430 O WEEKLY RADIATION THERAPY 0.00<br />

77431 3 RADIATION THERAPY MANAGEMENT 92.61<br />

77432 3 STEREOTACTIC RADIATION TRMT 388.72<br />

77435 3 SBRT MANAGEMENT 648.00<br />

77465 O DAILY KILOVOLTAGE TREATMENT MANAGEM 0.00<br />

77470 3 SPECIAL RADIATION TREATMENT 362.25<br />

77499 5 RADIATION THERAPY MANAGEMENT 0.00<br />

77520 5 PROTON TRMT, SIMPLE W/O COMP 0.00<br />

77522 5 PROTON TRMT, SIMPLE W/COMP 0.00<br />

77523 5 PROTON TRMT, INTERMEDIATE 0.00<br />

77525 5 PROTON TREATMENT, COMPLEX 0.00<br />

77600 9 HYPERTHERMIA TREATMENT 0.00<br />

77605 9 HYPERTHERMIA TREATMENT 0.00<br />

77610 9 HYPERTHERMIA TREATMENT 0.00<br />

77615 9 HYPERTHERMIA TREATMENT 0.00<br />

77620 3 HYPERTHERMIA TREATMENT 340.39

---

77750 3 INFUSE RADIOACTIVE MATERIALS 323.72<br />

77761 3 APPLY INTRCAV RADIAT SIMPLE 334.68<br />

77762 3 APPLY INTRCAV RADIAT INTERM 465.97<br />

77763 3 APPLY INTRCAV RADIAT COMPL 656.85<br />

77776 3 APPLY INTERSTIT RADIAT SIMPL 383.65<br />

77777 3 APPLY INTERSTIT RADIAT INTER 557.83<br />

77778 3 APPLY INTERSTIT RADIAT COMPL 799.51<br />

77781 O REMOTE AFTERLOADING HIGH INTENSITY 0.00<br />

77782 O REMOTE AFTERLOADING HIGH INTENSITY 0.00<br />

77783 O REMOTE AFTERLOADING HIGH INTENSITY 0.00<br />

77784 O REMOTE AFTERLOADING HIGH INTENSITY 0.00<br />

77785 6 HDR BRACHYTX, 1 CHANNEL 0.00<br />

77786 6 HDR BRACHYTX, 2-12 CHANNEL 0.00<br />

77787 6 HDR BRACHYTX OVER 12 CHAN 0.00<br />

77789 3 APPLY SURFACE RADIATION 96.74<br />

77790 3 RADIATION HANDLING 82.74<br />

77799 5 RADIUM/RADIOISOTOPE THERAPY 0.00<br />

78000 3 THYROID, SINGLE UPTAKE 65.27<br />

78001 3 THYROID, MULTIPLE UPTAKES 84.01<br />

78003 3 THYROID SUPPRESS/STIMUL 72.25<br />

78006 3 THYROID IMAGING WITH UPTAKE 193.32<br />

78007 3 THYROID IMAGE, MULT UPTAKES 135.77<br />

78010 3 THYROID IMAGING 137.72<br />

78011 3 THYROID IMAGING WITH FLOW 155.58<br />

78015 3 THYROID MET IMAGING 188.27<br />

78016 3 THYROID MET IMAGING/STUDIES 275.90<br />

78017 O THYROID MET IMAGING, MULT 0.00<br />

78018 3 THYROID MET IMAGING, BODY 307.75<br />

78020 3 THYROID MET UPTAKE 90.45<br />

78070 3 PARATHYROID NUCLEAR IMAGING 190.33<br />

78075 3 ADRENAL NUCLEAR IMAGING 374.82<br />

78099 5 ENDOCRINE NUCLEAR PROCEDURE 0.00<br />

78102 3 BONE MARROW IMAGING, LTD 148.92<br />

78103 3 BONE MARROW IMAGING, MULT 206.02<br />

78104 3 BONE MARROW IMAGING, BODY 242.48<br />

78110 3 PLASMA VOLUME, SINGLE 70.78<br />

78111 3 PLASMA VOLUME, MULTIPLE 106.18<br />

78120 3 RED CELL MASS, SINGLE 88.37<br />

78121 3 RED CELL MASS, MULTIPLE 118.30<br />

78122 9 BLOOD VOLUME 0.00<br />

78130 3 RED CELL SURVIVAL STUDY 154.87<br />

78135 3 RED CELL SURVIVAL KINETICS 300.93<br />

78140 3 RED CELL SEQUESTRATION 167.17<br />

78160 O PLASMA IRON TURNOVER 0.00<br />

78162 O RADIOIRON ABSORPTION EXAM 0.00<br />

78170 O RED CELL IRON UTILIZATION 0.00<br />

78172 O TOTAL BODY IRON ESTIMATION 0.00<br />

78185 3 SPLEEN IMAGING 169.39<br />

78186 O SPLEEN IMAGING ONLY WITH VASCULAR F 0.00<br />

78190 3 KINETICS, STUDY OF PLATELET SURVIV 240.79

---

78191 3 PLATELET SURVIVAL 250.20<br />

78192 O WHITE BLOOD CELL LOCALIZATION LIMIT 0.00<br />

78193 O WHITE BLOOD CELL LOCALIZATION WHOLE 0.00<br />

78195 3 LYMPH SYSTEM IMAGING 307.99<br />

78199 5 BLOOD/LYMPH NUCLEAR EXAM 0.00<br />

78201 3 LIVER IMAGING 159.52<br />

78202 3 LIVER IMAGING WITH FLOW 187.31<br />

78205 3 LIVER IMAGING (3D) 258.97<br />

78206 3 LIVER IMAGE (3D) WITH FLOW 329.10<br />

78215 3 LIVER AND SPLEEN IMAGING 177.49<br />

78216 3 LIVER & SPLEEN IMAGE/FLOW 153.43<br />

78220 3 LIVER FUNCTION STUDY 159.69<br />

78223 3 HEPATOBILIARY IMAGING 280.41<br />

78225 O LIVER-LUNG IMAGING (EG, SUBPHRENIC 0.00<br />

78230 3 SALIVARY GLAND IMAGING 147.71<br />

78231 3 SERIAL SALIVARY IMAGING 144.12<br />

78232 3 SALIVARY GLAND FUNCTION EXAM 149.18<br />

78258 3 ESOPHAGEAL MOTILITY STUDY 200.42<br />

78261 3 GASTRIC MUCOSA IMAGING 234.29<br />

78262 3 GASTROESOPHAGEAL REFLUX EXAM 235.88<br />

78264 3 GASTRIC EMPTYING STUDY 261.38<br />

78267 5 BREATH TST ATTAIN/ANAL C-14 0.00<br />

78268 5 BREATH TEST ANALYSIS, C-14 0.00<br />

78270 3 VIT B-12 ABSORPTION EXAM 80.22<br />

78271 3 VIT B-12 ABSRP EXAM, INT FAC 81.01<br />

78272 3 VIT B-12 ABSORP, COMBINED 101.51<br />

78276 O GASTROINTESTINAL ASPIRATE BLOOD LOS 0.00<br />

78278 3 ACUTE GI BLOOD LOSS IMAGING 295.26<br />

78280 O GASTROINTESTINAL BLOOD LOSS STUDY ( 0.00<br />

78282 3 GI PROTEIN LOSS EXAM 0.00<br />

78290 3 MECKELÏS DIVERT EXAM 261.25<br />

78291 3 LEVEEN/SHUNT PATENCY EXAM 222.85<br />

78299 5 GI NUCLEAR PROCEDURE 0.00<br />

78300 3 BONE IMAGING, LIMITED AREA 162.34<br />

78305 3 BONE IMAGING, MULTIPLE AREAS 220.23<br />

78306 3 BONE IMAGING, WHOLE BODY 246.27<br />

78310 O BONE IMAGING VASCULAR FLOW ONLY 0.00<br />

78315 3 BONE IMAGING, 3 PHASE 297.89<br />

78320 3 BONE IMAGING (3D) 274.76<br />

78350 3 BONE MINERAL, SINGLE PHOTON 35.45<br />

78351 3 BONE MINERAL, DUAL PHOTON 13.85<br />

78380 O JOINT IMAGING LIMITED AREA 0.00<br />

78381 O JOINT IMAGING MULTIPLE AREAS 0.00<br />

78399 5 MUSCULOSKELETAL NUCLEAR EXAM 0.00<br />

78414 3 NON-IMAGING HEART FUNCTION 0.00<br />

78415 O CARDIAC BLOOD POOL IMAGING, FUNCTIO 0.00<br />

78425 O CARDIAC REGURGITANT IN<strong>DE</strong>X 0.00<br />

78428 3 CARDIAC SHUNT IMAGING 184.75<br />

78435 O CARDIAC FLOW IMAGING (IE, ANGIOCARD 0.00<br />

78445 3 VASCULAR FLOW IMAGING 148.67

---

78455 O VENOUS THROMBOSIS STUDY 0.00<br />

78456 3 ACUTE VENOUS THROMBUS IMAGE 253.55<br />

78457 3 VENOUS THROMBOSIS IMAGING 180.33<br />

78458 3 VEN THROMBOSIS IMAGES, BILAT 212.11<br />

78459 3 HEART MUSCLE IMAGING (PET) 311.13<br />

78460 3 HEART MUSCLE BLOOD, SINGLE 177.90<br />

78461 3 HEART MUSCLE BLOOD, MULTIPLE 231.84<br />

78464 3 HEART IMAGE (3D), SINGLE 311.13<br />

78465 3 HEART IMAGE (3D), MULTIPLE 536.91<br />

78466 3 HEART INFARCT IMAGE 174.88<br />

78467 O MYOCARDIAL IMAGING, INFARCT AVID, A 0.00<br />

78468 3 HEART INFARCT IMAGE (EF) 226.25<br />

78469 3 HEART INFARCT IMAGE (3D) 273.28<br />

78470 O CARDIAC OUTPUT 0.00<br />

78471 O CARDIAC BLOOD POOL IMAGING, GATED E 0.00<br />

78472 3 GATED HEART, PLANAR, SINGLE 276.88<br />

78473 3 GATED HEART, MULTIPLE 389.25<br />

78474 O CARDIAC BLOOD POOL IMAGING, GATED E 0.00<br />

78475 O CARDIAC BLOOD POOL IMAGING, GATED E 0.00<br />

78476 O CARDIAC BLOOD POOL IMAGING, GATED E 0.00<br />

78477 O CARDIAC BLOOD POOL IMAGING, GATED E 0.00<br />

78478 3 HEART WALL MOTION ADD-ON 71.64<br />

78479 O CARDIAC BLOOD POOL IMAGING, GATED E 0.00<br />

78480 3 HEART FUNCTION ADD-ON 62.35<br />

78481 3 HEART FIRST PASS, SINGLE 251.99<br />

78483 3 HEART FIRST PASS, MULTIPLE 363.87<br />

78484 O CARDIAC BLOOD POOL IMAGING, FIRST P 0.00<br />

78485 O CARDIAC BLOOD POOL IMAGING, FIRST P 0.00<br />

78486 O CARDIAC BLOOD POOL IMAGING, FIRST P 0.00<br />

78487 O CARDIAC BLOOD POOL IMAGING, FIRST P 0.00<br />

78489 O CARDIAC BLOOD POOL IMAGING, FIRST P 0.00<br />

78491 3 HEART IMAGE (PET), SINGLE 323.62<br />

78492 3 HEART IMAGE (PET), MULTIPLE 323.62<br />

78494 3 HEART IMAGE, SPECT 320.69<br />

78496 3 HEART FIRST PASS ADD-ON 186.15<br />

78499 5 CARDIOVASCULAR NUCLEAR EXAM 0.00<br />

78580 3 LUNG PERFUSION IMAGING 204.75<br />

78581 O PULMONARY PERFUSION IMAGING GASEOUS 0.00<br />

78582 O PULMONARY PERFUSION IMAGING GASEOUS 0.00<br />

78584 3 LUNG V/Q IMAGE SINGLE BREATH 168.76<br />

78585 3 LUNG V/Q IMAGING 335.32<br />

78586 3 AEROSOL LUNG IMAGE, SINGLE 153.55<br />

78587 3 AEROSOL LUNG IMAGE, MULTIPLE 186.93<br />

78588 3 PERFUSION LUNG IMAGE 284.16<br />

78591 3 VENT IMAGE, 1 BREATH, 1 PROJ 159.06<br />

78593 3 VENT IMAGE, 1 PROJ, GAS 188.11<br />

78594 3 VENT IMAGE, MULT PROJ, GAS 231.86<br />

78596 3 LUNG DIFFERENTIAL FUNCTION 373.85<br />

78599 5 RESPIRATORY NUCLEAR EXAM 0.00<br />

78600 3 BRAIN IMAGE < 4 VIEWS 165.72

---

78601 3 BRAIN IMAGE W/FLOW < 4 VIEWS 199.11<br />

78605 3 BRAIN IMAGE 4+ VIEWS 190.05<br />

78606 3 BRAIN IMAGE W/FLOW 4 + VIEWS 276.93<br />

78607 3 BRAIN IMAGING (3D) 360.70<br />

78608 3 BRAIN IMAGING (PET) 323.62<br />

78609 3 BRAIN IMAGING (PET) 323.62<br />

78610 3 BRAIN FLOW IMAGING ONLY 180.08<br />

78615 O CEREBRAL VASCULAR FLOW IMAGE 0.00<br />

78630 3 CEREBROSPINAL FLUID SCAN 305.81<br />

78635 3 CSF VENTRICULOGRAPHY 253.33<br />

78645 3 CSF SHUNT EVALUATION 238.22<br />

78647 3 CEREBROSPINAL FLUID SCAN 331.14<br />

78650 3 CSF LEAKAGE IMAGING 292.78<br />

78652 O CSF LEAKAGE <strong>DE</strong>TECTION AND LOCALIZAT 0.00<br />

78655 O RADIOPHARMACEUTICAL I<strong>DE</strong>NTIFICATION 0.00<br />

78660 3 NUCLEAR EXAM OF TEAR FLOW 151.29<br />

78699 5 NERVOUS SYSTEM NUCLEAR EXAM 0.00<br />

78700 3 KIDNEY IMAGING, MORPHOL 170.24<br />

78701 3 KIDNEY IMAGING WITH FLOW 201.88<br />

78704 O IMAGING RENOGRAM 0.00<br />

78707 3 K FLOW/FUNCT IMAGE W/O DRUG 242.95<br />

78708 3 K FLOW/FUNCT IMAGE W/DRUG 213.94<br />

78709 3 K FLOW/FUNCT IMAGE, MULTIPLE 328.20<br />

78710 3 KIDNEY IMAGING (3D) 257.05<br />

78715 O RENAL VASCULAR FLOW EXAM 0.00<br />

78725 3 KIDNEY FUNCTION STUDY 100.75<br />

78726 O KIDNEY FUNCTION STUDY INCLUDING PHA 0.00<br />

78727 O KIDNEY TRANSPLANT EVALUATION 0.00<br />

78730 3 URINARY BLAD<strong>DE</strong>R RETENTION 78.00<br />

78740 3 URETERAL REFLUX STUDY 180.28<br />

78760 O TESTICULAR IMAGING 0.00<br />

78761 3 TESTICULAR IMAGING W/FLOW 197.00<br />

78799 5 GENITOURINARY NUCLEAR EXAM 0.00<br />

78800 3 TUMOR IMAGING, LIMITED AREA 185.83<br />

78801 3 TUMOR IMAGING, MULT AREAS 242.29<br />

78802 3 TUMOR IMAGING, WHOLE BODY 313.95<br />

78803 3 TUMOR IMAGING (3D) 353.32<br />

78804 3 TUMOR IMAGING, WHOLE BODY 563.24<br />

78805 3 ABSCESS IMAGING, LTD AREA 185.87<br />

78806 3 ABSCESS IMAGING, WHOLE BODY 337.46<br />

78807 3 NUCLEAR LOCALIZATION/ABSCESS 352.64<br />

78808 6 IV INJ RA DRUG DX STUDY 0.00<br />

78810 O TUMOR IMAGING (PET) 0.00<br />

78811 3 PET IMAGE, LTD AREA 1,460.39<br />

78812 3 PET IMAGE, SKULL-THIGH 1,907.10<br />

78813 3 PET IMAGE, FULL BODY 1,994.19<br />

78814 3 PET IMAGE W/CT, LMTD 2,226.60<br />

78815 3 PET IMAGE W/CT, SKULL-THIGH 2,501.95<br />

78816 3 PET IMAGE W/CT, FULL BODY 2,570.73<br />

78890 O NUCLEAR MEDICINE DATA PROC 0.00

---

78891 O NUCLEAR MED DATA PROC 0.00<br />

78990 O PROVI<strong>DE</strong> DIAG RADIONUCLI<strong>DE</strong>(S) 0.00<br />

78999 5 NUCLEAR DIAGNOSTIC EXAM 0.00<br />

79000 O INIT HYPERTHYROID THERAPY 0.00<br />

79001 O REPEAT HYPERTHYROID THERAPY 0.00<br />

79005 3 NUCLEAR RX, ORAL ADMIN 167.67<br />

79020 O THYROID ABLATION 0.00<br />

79030 O THYROID ABLATION, CARCINOMA 0.00<br />

79035 O THYROID METASTATIC THERAPY 0.00<br />

79100 O HEMATOPOETIC NUCLEAR THERAPY 0.00<br />

79101 3 NUCLEAR RX, IV ADMIN 180.53<br />

79200 3 NUCLEAR RX, INTRACAV ADMIN 183.17<br />

79300 3 NUCLR RX, INTERSTIT COLLOID 0.00<br />

79400 O NONHEMATO NUCLEAR THERAPY 0.00<br />

79403 3 HEMATOPOIETIC NUCLEAR TX 242.29<br />

79420 O INTRAVASCULAR NUCLEAR THER 0.00<br />

79440 3 NUCLEAR RX, INTRA-ARTICULAR 175.80<br />

79445 3 NUCLEAR RX, INTRA-ARTERIAL 0.00<br />

79900 O PROVI<strong>DE</strong> THER RADIOPHARM(S) 0.00<br />

79999 5 NUCLEAR MEDICINE THERAPY 0.00<br />

80002 O AUTOMATED MULTICHANNEL TEST 1 OR 2 0.00<br />

80003 O AUTOMATED MULTICHANNEL TEST 3 CLINI 0.00<br />

80004 O AUTOMATED MULTICHANNEL TEST 4 CLINI 0.00<br />

80005 O AUTOMATED MULTICHANNEL TEST 5 CLINI 0.00<br />

80006 O AUTOMATED MULTICHANNEL TEST 6 CLINI 0.00<br />

80007 O AUTOMATED MULTICHANNEL TEST 7 CLINI 0.00<br />

80008 O AUTOMATED MULTICHANNEL TEST 8 CLINI 0.00<br />

80009 O AUTOMATED MULTICHANNEL TEST 9 CLINI 0.00<br />

80010 O AUTOMATED MULTICHANNEL TEST 10 CLIN 0.00<br />

80011 O AUTOMATED MULTICHANNEL TEST 11 CLIN 0.00<br />

80012 O AUTOMATED MULTICHANNEL TEST 12 CLIN 0.00<br />

80016 O AUTOMATED MULTICHANNEL TEST 13-16 C 0.00<br />

80018 O AUTOMATED MULTICHANNEL TEST 17-18 C 0.00<br />

80019 O AUTOMATED MULTICHANNEL TEST; 19 CLI 0.00<br />

80031 O THERAPEUTIC QUANTITATIVE DRUG MONIT 0.00<br />

80032 O THERAPEUTIC QUANTITATIVE DRUG MONIT 0.00<br />

80033 O THERAPEUTIC QUANTITATIVE DRUG MONIT 0.00<br />

80034 O THERAPEUTIC QUANTITATIVE DRUG MONIT 0.00<br />

80040 O SERUM RADIOIMMUNOASSAY FOR CIRCULAT 0.00<br />

80042 O SERUM ANTIMICROBIAL LEVEL, BIOASSAY 0.00<br />

80047 3 METABOLIC PANEL IONIZED CA 20.27<br />

80048 3 METABOLIC PANEL TOTAL CA 11.83<br />

80049 9 METABOLIC PANEL, BASIC 0.00<br />

80050 3 GENERAL HEALTH PANEL 16.32<br />

80051 3 ELECTROLYTE PANEL 9.80<br />

80052 9 PRE-MARITAL PROFILE 0.00<br />

80053 3 COMPREHEN METABOLIC PANEL 14.77<br />

80054 9 COMPREHEN METABOLIC PANEL 0.00<br />

80055 3 OBSTETRIC PANEL 23.08<br />

80056 9 AMENORRHEA PROFILE 0.00

---

80057 9 MALE INFERTILITY AND/OR GYNECOMASTI 0.00<br />

80058 O HEPATIC FUNCTION PANEL 0.00<br />

80059 O HEPATITIS PANEL 0.00<br />

80060 O HYPERTENSION PANEL 0.00<br />

80061 3 LIPID PANEL 18.72<br />

80062 O CARDIAC EVALUATION (INCLUDING CORON 0.00<br />

80063 O CARDIAC INJURY PANEL 0.00<br />

80064 O CARDIAC INJURY PANEL WITH CREATINE 0.00<br />

80065 O METABOLIC PANEL 0.00<br />

80066 O MALABSORPTION PANEL 0.00<br />

80067 O PULMONARY (LUNG FUNCTION) PANEL 0.00<br />

80068 O LUNG MATURITY PROFILE 0.00<br />

80069 3 RENAL FUNCTION PANEL 12.13<br />

80070 O THYROID PANEL 0.00<br />

80071 O THYROID PANEL WITH THYROTROPIN RELE 0.00<br />

80072 O ARTHRITIS PANEL 0.00<br />

80073 O RENAL PANEL 0.00<br />

80074 3 ACUTE HEPATITIS PANEL 66.28<br />

80075 O PARATHYROID PANEL 0.00<br />

80076 3 HEPATIC FUNCTION PANEL 11.42<br />

80080 O PROSTATIC PANEL 0.00<br />

80082 O PANCREATIC PANEL 0.00<br />

80084 O PITUITARY PANEL 0.00<br />

80085 O MICROCYTIC ANEMIA PANEL 0.00<br />

80086 O MACROCYTIC ANEMIA PANEL 0.00<br />

80088 O TRANSITION PANEL (FOR MANAGEMENT OF 0.00<br />

80089 O MUSCLE PANEL 0.00<br />

80090 O TORCH ANTIBODY PANEL 0.00<br />

80091 O THYROID PANEL 0.00<br />

80092 O THYROID PANEL W/TSH 0.00<br />

80099 O UNLISTED PANEL 0.00<br />

80100 3 DRUG SCREEN, QUALITATE/MULTI 20.32<br />

80101 3 DRUG SCREEN, SINGLE 19.24<br />

80102 3 DRUG CONFIRMATION 18.51<br />

80103 5 DRUG ANALYSIS, TISSUE PREP 0.00<br />

80150 3 ASSAY OF AMIKACIN 21.06<br />

80152 3 ASSAY OF AMITRIPTYLINE 25.01<br />

80154 3 ASSAY OF BENZODIAZEPINES 22.43<br />

80156 3 ASSAY, CARBAMAZEPINE, TOTAL 20.34<br />

80157 3 ASSAY, CARBAMAZEPINE, FREE 18.52<br />

80158 3 ASSAY OF CYCLOSPORINE 25.23<br />

80160 3 ASSAY OF <strong>DE</strong>SIPRAMINE 24.05<br />

80162 3 ASSAY OF DIGOXIN 18.55<br />

80164 3 ASSAY, DIPROPYLACETIC ACID 18.93<br />

80166 3 ASSAY OF DOXEPIN 21.66<br />

80168 3 ASSAY OF ETHOSUXIMI<strong>DE</strong> 21.05<br />

80170 3 ASSAY OF GENTAMICIN 22.90<br />

80172 3 ASSAY OF GOLD 22.76<br />

80173 3 ASSAY OF HALOPERIDOL 20.34<br />

80174 3 ASSAY OF IMIPRAMINE 24.05

---

80176 3 ASSAY OF LIDOCAINE 20.52<br />

80178 3 ASSAY OF LITHIUM 9.24<br />

80182 3 ASSAY OF NORTRIPTYLINE 18.93<br />

80184 3 ASSAY OF PHENOBARBITAL 16.01<br />

80185 3 ASSAY OF PHENYTOIN, TOTAL 18.52<br />

80186 3 ASSAY OF PHENYTOIN, FREE 19.23<br />

80188 3 ASSAY OF PRIMIDONE 23.18<br />

80190 3 ASSAY OF PROCAINAMI<strong>DE</strong> 23.41<br />

80192 3 ASSAY OF PROCAINAMI<strong>DE</strong> 23.41<br />

80194 3 ASSAY OF QUINIDINE 20.39<br />

80195 3 ASSAY OF SIROLIMUS 19.17<br />

80196 3 ASSAY OF SALICYLATE 9.92<br />

80197 3 ASSAY OF TACROLIMUS 19.17<br />

80198 3 ASSAY OF THEOPHYLLINE 19.77<br />

80200 3 ASSAY OF TOBRAMYCIN 22.52<br />

80201 3 ASSAY OF TOPIRAMATE 16.66<br />

80202 3 ASSAY OF VANCOMYCIN 18.93<br />

80299 3 QUANTITATIVE ASSAY, DRUG 19.13<br />

80400 3 ACTH STIMULATION PANEL 45.56<br />

80402 3 ACTH STIMULATION PANEL 121.46<br />

80406 3 ACTH STIMULATION PANEL 109.34<br />

80408 3 ALDOSTERONE SUPPRESSION EVAL 175.34<br />

80410 3 CALCITONIN STIMUL PANEL 62.79<br />

80412 3 CRH STIMULATION PANEL 460.50<br />

80414 3 TESTOSTERONE RESPONSE 72.16<br />

80415 3 ESTRADIOL RESPONSE PANEL 78.08<br />

80416 3 RENIN STIMULATION PANEL 184.38<br />

80417 3 RENIN STIMULATION PANEL 61.46<br />

80418 3 PITUITARY EVALUATION PANEL 809.76<br />

80420 3 <strong>DE</strong>XAMETHASONE PANEL 100.30<br />

80422 3 GLUCAGON TOLERANCE PANEL 64.38<br />

80424 3 GLUCAGON TOLERANCE PANEL 70.56<br />

80426 3 GONADOTROPIN HORMONE PANEL 207.40<br />

80428 3 GROWTH HORMONE PANEL 93.16<br />

80430 3 GROWTH HORMONE PANEL 109.60<br />

80432 3 INSULIN SUPPRESSION PANEL 188.73<br />

80434 3 INSULIN TOLERANCE PANEL 141.30<br />

80435 3 INSULIN TOLERANCE PANEL 143.85<br />

80436 3 METYRAPONE PANEL 127.36<br />

80438 3 TRH STIMULATION PANEL 70.41<br />

80439 3 TRH STIMULATION PANEL 93.88<br />

80440 3 TRH STIMULATION PANEL 81.24<br />

80500 3 LAB PATHOLOGY CONSULTATION 22.88<br />

80502 3 LAB PATHOLOGY CONSULTATION 76.36<br />

81000 3 URINALYSIS, NONAUTO W/SCOPE 4.41<br />

81001 3 URINALYSIS, AUTO W/SCOPE 4.41<br />

81002 3 URINALYSIS NONAUTO W/O SCOPE 3.57<br />

81003 3 URINALYSIS, AUTO, W/O SCOPE 3.14<br />

81004 O URINALYSIS COMPONENTS, SINGLE, NOT 0.00<br />

81005 3 URINALYSIS 3.03

---

81007 3 URINE SCREEN FOR BACTERIA 3.59<br />

81010 O URINALYSIS CONCENTRATION AND DILUTI 0.00<br />

81011 O URINALYSIS WATER <strong>DE</strong>PRIVATION TEST 0.00<br />

81012 O URINALYSIS WATER <strong>DE</strong>PRIVATION TEST W 0.00<br />

81015 3 MICROSCOPIC EXAM OF URINE 4.24<br />

81020 3 URINALYSIS, GLASS TEST 4.30<br />

81025 3 URINE PREGNANCY TEST 8.84<br />

81030 O QUANTITATIVE SEDIMENT ANALYSIS AND 0.00<br />

81050 3 URINALYSIS, VOLUME MEASURE 4.02<br />

81099 5 URINALYSIS TEST PROCEDURE 0.00<br />

82000 3 ASSAY OF BLOOD ACETAL<strong>DE</strong>HY<strong>DE</strong> 17.31<br />

82003 3 ASSAY OF ACETAMINOPHEN 28.28<br />

82005 O ACETOACETIC ACID 0.00<br />

8<strong>2009</strong> 3 TEST FOR ACETONE/KETONES 6.31<br />

82010 3 ACETONE ASSAY 11.42<br />

82011 O ACETYLSALICYLIC ACID QUANTITATIVE 0.00<br />

82012 O ACETYLSALICYLIC ACID QUALITATIVE 0.00<br />

82013 3 ACETYLCHOLINESTERASE ASSAY 12.08<br />

82015 O ACIDITY, TITRATABLE, URINE 0.00<br />

82016 3 ACYLCARNITINES, QUAL 19.37<br />

82017 3 ACYLCARNITINES, QUANT 23.57<br />

82024 3 ASSAY OF ACTH 53.97<br />

82030 3 ASSAY OF ADP & AMP 36.05<br />

82035 O A<strong>DE</strong>NOSINE 5'-TRIPHOSPHATE, BLOOD 0.00<br />

82040 3 ASSAY OF SERUM ALBUMIN 6.92<br />

82042 3 ASSAY OF URINE ALBUMIN 2.46<br />

82043 3 MICROALBUMIN, QUANTITATIVE 8.09<br />

82044 3 MICROALBUMIN, SEMIQUANT 3.55<br />

82045 3 ALBUMIN, ISCHEMIA MODIFIED 47.43<br />

82055 3 ASSAY OF ETHANOL 15.10<br />

82060 O ALCOHOL (ETHANOL), BLOOD BY GAS-LIQ 0.00<br />

82065 O ALCOHOL (ETHANOL), URINE CHEMICAL 0.00<br />

82070 O ALCOHOL (ETHANOL), URINE BY GAS-LIQ 0.00<br />

82072 O ALCOHOL (ETHANOL) GELATION 0.00<br />

82075 3 ASSAY OF BREATH ETHANOL 16.84<br />

82076 O ALCOHOL ISOPROPYL 0.00<br />

82078 O ALCOHOL METHYL 0.00<br />

82085 3 ASSAY OF ALDOLASE 13.56<br />

82086 O ALDOLASE, BLOOD COLORIMETRIC 0.00<br />

82087 O ALDOSTERONE DOUBLE ISOTOPE TECHNIQU 0.00<br />

82088 3 ASSAY OF ALDOSTERONE 56.94<br />

82089 O ALDOSTERONE RIA, URINE 0.00<br />

82091 O ALDOSTERONE SALINE INFUSION TEST 0.00<br />

82095 O ALKALOIDS, TISSUE SCREENING 0.00<br />

82096 O ALKALOIDS, TISSUE QUANTITATIVE 0.00<br />

82100 O ALKALOIDS, URINE SCREENING 0.00<br />

82101 3 ASSAY OF URINE ALKALOIDS 41.94<br />

82103 3 ALPHA-1-ANTITRYPSIN, TOTAL 18.77<br />

82104 3 ALPHA-1-ANTITRYPSIN, PHENO 20.20<br />

82105 3 ALPHA-FETOPROTEIN, SERUM 23.44

---

82106 3 ALPHA-FETOPROTEIN, AMNIOTIC 23.44<br />

82107 3 ALPHA-FETOPROTEIN L3 88.52<br />

82108 3 ASSAY OF ALUMINUM 35.60<br />

82112 O AMIKACIN 0.00<br />

82120 3 AMINES, VAGINAL FLUID QUAL 5.25<br />

82126 O AMINO ACID NITROGEN, ALPHA 0.00<br />

82127 3 AMINO ACID, SINGLE QUAL 19.37<br />

82128 3 AMINO ACIDS, MULT QUAL 19.37<br />

82130 O AMINO ACIDS ANALYSIS 0.00<br />

82131 3 AMINO ACIDS, SINGLE QUANT 23.57<br />

82134 O AMINOHIPPURATE, PARA (PAH) 0.00<br />

82135 3 ASSAY, AMINOLEVULINIC ACID 23.00<br />

82136 3 AMINO ACIDS, QUANT, 2-5 23.57<br />

82137 O AMINOPHYLLINE 0.00<br />

82138 O AMITRIPTYLINE 0.00<br />

82139 3 AMINO ACIDS, QUAN, 6 OR MORE 23.57<br />

82140 3 ASSAY OF AMMONIA 20.36<br />

82141 O AMMONIA URINE 0.00<br />

82142 O AMMONIUM CHLORI<strong>DE</strong> LOADING TEST 0.00<br />

82143 3 AMNIOTIC FLUID SCAN 9.61<br />

82145 3 ASSAY OF AMPHETAMINES 21.72<br />

82150 3 ASSAY OF AMYLASE 9.06<br />

82154 3 ANDROSTANEDIOL GLUCURONI<strong>DE</strong> 40.29<br />

82156 O AMYLASE, URINE (DIASTASE) 0.00<br />

82157 3 ASSAY OF ANDROSTENEDIONE 40.90<br />

82159 O ANDROSTERONE 0.00<br />

82160 3 ASSAY OF ANDROSTERONE 34.94<br />

82163 3 ASSAY OF ANGIOTENSIN II 28.68<br />

82164 3 ANGIOTENSIN I ENZYME TEST 20.39<br />

82165 O ANILINE 0.00<br />

82168 O ANTIHISTAMINES 0.00<br />

82170 O ANTIMONY, URINE 0.00<br />

82172 3 ASSAY OF APOLIPOPROTEIN 21.65<br />

82173 O ARGININE TOLERANCE TEST 0.00<br />

82175 3 ASSAY OF ARSENIC 26.51<br />

82180 3 ASSAY OF ASCORBIC ACID 13.81<br />

82190 3 ATOMIC ABSORPTION 20.83<br />

82205 3 ASSAY OF BARBITURATES 16.01<br />

82210 O BARBITURATES QUANTITATIVE AND I<strong>DE</strong>NT 0.00<br />

82225 O BARIUM 0.00<br />

82230 O BERYLLIUM, URINE 0.00<br />

82231 O BETA-2 MICROGLOBULIN, RIA URINE 0.00<br />

82232 3 ASSAY OF BETA-2 PROTEIN 22.61<br />

82235 O BICARBONATE EXCRETION, URINE 0.00<br />

82236 O BICARBONATE LOADING TEST 0.00<br />

82239 3 BILE ACIDS, TOTAL 23.94<br />

82240 3 BILE ACIDS, CHOLYLGLYCINE 37.13<br />

82245 O BILE PIGMENTS, URINE 0.00<br />

82247 3 BILIRUBIN, TOTAL 7.02<br />

82248 3 BILIRUBIN, DIRECT 7.02

---

82250 O ASSAY BILIRUBIN 0.00<br />

82251 O ASSAY OF BILIRUBIN 0.00<br />

82252 3 FECAL BILIRUBIN TEST 6.35<br />

82260 O BILIRUBIN URINE, QUANTITATIVE 0.00<br />

82261 3 ASSAY OF BIOTINIDASE 23.57<br />

82265 O BILIRUBIN AMNIOTIC FLUID, QUANTITAT 0.00<br />

82268 O BISMUTH 0.00<br />

82270 3 OCCULT BLOOD, FECES 4.54<br />

82271 3 OCCULT BLOOD, OTHER SOURCES 4.54<br />

82272 3 OCCULT BLD FECES, 1-3 TESTS 4.54<br />

82273 O TEST FOR BLOOD, OTHER SOURCE 0.00<br />

82274 3 ASSAY TEST FOR BLOOD, FECAL 22.22<br />

82280 O BORIC ACID BLOOD 0.00<br />

82285 O BORIC ACID URINE 0.00<br />

82286 3 ASSAY OF BRADYKININ 9.62<br />

82290 O BROMI<strong>DE</strong>S BLOOD 0.00<br />

82291 O BROMI<strong>DE</strong>S URINE 0.00<br />

82300 3 ASSAY OF CADMIUM 32.33<br />

82305 O CAFFEINE 0.00<br />

82306 3 ASSAY OF VITAMIN D 41.36<br />

82307 3 ASSAY OF VITAMIN D 45.02<br />

82308 3 ASSAY OF CALCITONIN 20.93<br />

82310 3 ASSAY OF CALCIUM 7.20<br />

82315 O CALCIUM, BLOOD FLUOROMETRIC 0.00<br />

82320 O CALCIUM, BLOOD EMISSION FLAME PHOTO 0.00<br />

82325 O CALCIUM, BLOOD ATOMIC ABSORPTION FL 0.00<br />

82330 3 ASSAY OF CALCIUM 8.85<br />

82331 3 CALCIUM INFUSION TEST 7.23<br />

82335 O CALCIUM, URINE QUALITATIVE (SULKOWI 0.00<br />

82340 3 ASSAY OF CALCIUM IN URINE 8.43<br />

82355 3 CALCULUS ANALYSIS, QUAL 16.17<br />

82360 3 CALCULUS ASSAY, QUANT 17.99<br />

82365 3 CALCULUS SPECTROSCOPY 18.01<br />

82370 3 X-RAY ASSAY, CALCULUS 17.51<br />

82372 O CARBAMAZEPINE, SERUM 0.00<br />

82373 3 ASSAY, C-D TRANSFER MEASURE 25.23<br />

82374 3 ASSAY, BLOOD CARBON DIOXI<strong>DE</strong> 6.83<br />

82375 3 ASSAY, BLOOD CARBON MONOXI<strong>DE</strong> 17.22<br />

82376 3 ASSAY, CARBOXYHB, QUAL 7.67<br />

82378 3 CARCINOEMBRYONIC ANTIGEN 26.51<br />

82379 3 ASSAY OF CARNITINE 23.57<br />

82380 3 ASSAY OF CAROTENE 12.89<br />

82382 3 ASSAY, URINE CATECHOLAMINES 24.02<br />

82383 3 ASSAY, BLOOD CATECHOLAMINES 35.01<br />

82384 3 ASSAY, THREE CATECHOLAMINES 35.28<br />

82387 3 ASSAY OF CATHEPSIN-D 29.07<br />

82390 3 ASSAY OF CERULOPLASMIN 15.01<br />

82397 3 CHEMILUMINESCENT ASSAY 19.74<br />

82400 O CHLORAL HYDRATE BLOOD 0.00<br />

82405 O CHLORAL HYDRATE URINE 0.00

---

82415 3 ASSAY OF CHLORAMPHENICOL 17.70<br />

82418 O CHLORAZEPATE DIPOTASSIUM 0.00<br />

82420 O CHLORDIAZEPOXI<strong>DE</strong> BLOOD 0.00<br />

82425 O CHLORDIAZEPOXI<strong>DE</strong> URINE 0.00<br />

82435 3 ASSAY OF BLOOD CHLORI<strong>DE</strong> 6.42<br />

82436 3 ASSAY OF URINE CHLORI<strong>DE</strong> 7.02<br />

82437 O CHLORI<strong>DE</strong>S SWEAT (WITHOUT IONTOPHORE 0.00<br />

82438 3 ASSAY, OTHER FLUID CHLORI<strong>DE</strong>S 6.83<br />

82441 3 TEST FOR CHLOROHYDROCARBONS 8.38<br />

82443 O CHLOROTHIAZI<strong>DE</strong>-HYDROCHLOROTHIAZI<strong>DE</strong> 0.00<br />

82465 3 ASSAY, BLD/SERUM CHOLESTEROL 6.08<br />

82470 O CHOLESTEROL, SERUM TOTAL AND ESTERS 0.00<br />

82480 3 ASSAY, SERUM CHOLINESTERASE 11.01<br />

82482 3 ASSAY, RBC CHOLINESTERASE 10.74<br />

82484 O CHOLINESTERASE SERUM AND RBC 0.00<br />

82485 3 ASSAY, CHONDROITIN SULFATE 28.85<br />

82486 3 GAS/LIQUID CHROMATOGRAPHY 25.23<br />

82487 3 PAPER CHROMATOGRAPHY 22.30<br />

82488 3 PAPER CHROMATOGRAPHY 29.85<br />

82489 3 THIN LAYER CHROMATOGRAPHY 25.84<br />

82491 3 CHROMOTOGRAPHY, QUANT, SING 25.23<br />

82492 3 CHROMOTOGRAPHY, QUANT, MULT 25.23<br />

82495 3 ASSAY OF CHROMIUM 28.34<br />

82507 3 ASSAY OF CITRATE 38.85<br />

82512 O CLONAZEPAM 0.00<br />

82520 3 ASSAY OF COCAINE 19.49<br />

82523 3 COLLAGEN CROSSLINKS 15.17<br />

82525 3 ASSAY OF COPPER 17.34<br />

82526 O COPPER URINE 0.00<br />

82528 3 ASSAY OF CORTICOSTERONE 31.45<br />

82529 O CORTISOL FLUOROMETRIC, PLASMA 0.00<br />

82530 3 CORTISOL, FREE 23.35<br />

82531 O CORTISOL CPB, PLASMA 0.00<br />

82532 O CORTISOL CPB, URINE 0.00<br />

82533 3 TOTAL CORTISOL 22.78<br />

82534 O CORTISOL RIA, URINE 0.00<br />

82536 O CORTISOL AFTER ADRENOCORTICOTROPIC 0.00<br />

82537 O CORTISOL 48 HOURS AFTER CONTINUOUS 0.00<br />

82538 O CORTISOL AFTER METYRAPONE TARTRATE 0.00<br />

82539 O CORTISOL <strong>DE</strong>XAMETHASONE SUPPRESSION 0.00<br />

82540 3 ASSAY OF CREATINE 6.48<br />

82541 3 COLUMN CHROMOTOGRAPHY, QUAL 25.23<br />

82542 3 COLUMN CHROMOTOGRAPHY, QUANT 25.23<br />

82543 3 COLUMN CHROMOTOGRAPH/ISOTOPE 25.23<br />

82544 3 COLUMN CHROMOTOGRAPH/ISOTOPE 25.23<br />

82545 O CREATINE URINE 0.00<br />

82546 O CREATINE AND CREATININE 0.00<br />

82550 3 ASSAY OF CK (CPK) 9.10<br />

82552 3 ASSAY OF CPK IN BLOOD 18.71<br />

82553 3 CREATINE, MB FRACTION 10.60

---

82554 3 CREATINE, ISOFORMS 16.58<br />

82555 O CREATINE PHOSPHOKINASE (CPK), BLOOD 0.00<br />

82565 3 ASSAY OF CREATININE 6.41<br />

82570 3 ASSAY OF URINE CREATININE 7.23<br />

82575 3 CREATININE CLEARANCE TEST 13.20<br />

82585 3 ASSAY OF CRYOFIBRINOGEN 11.98<br />

82595 3 ASSAY OF CRYOGLOBULIN 9.04<br />

82600 3 ASSAY OF CYANI<strong>DE</strong> 27.11<br />

82601 O CYANI<strong>DE</strong> TISSUE 0.00<br />

82606 O CYANOCOBALAMIN (VITAMIN B-12) BIOAS 0.00<br />

82607 3 VITAMIN B-12 21.06<br />

82608 3 B-12 BINDING CAPACITY 20.01<br />

82610 3 CYSTATIN C 19.00<br />

82614 O CYSTINE, BLOOD, QUALITATIVE 0.00<br />

82615 3 TEST FOR URINE CYSTINES 11.41<br />

82620 O CYSTINE AND HOMOCYSTINE, URINE QUAN 0.00<br />

82624 O CYSTINE AMINOPEPTIDASE 0.00<br />

82626 3 <strong>DE</strong>HYDROEPIANDROSTERONE 35.31<br />

82627 3 <strong>DE</strong>HYDROEPIANDROSTERONE 31.07<br />

82628 O <strong>DE</strong>SIPRAMINE 0.00<br />

82633 3 <strong>DE</strong>SOXYCORTICOSTERONE 43.28<br />

82634 3 <strong>DE</strong>OXYCORTISOL 40.90<br />

82635 O DIACETIC ACID 0.00<br />

82636 O DIAZEPAM 0.00<br />

82638 3 ASSAY OF DIBUCAINE NUMBER 16.26<br />

82639 O DICUMAROL 0.00<br />

82640 O DIGITOXIN (DIGITALIS) BLOOD, RIA 0.00<br />

82641 O DIGITOXIN (DIGITALIS) URINE 0.00<br />

82643 O DIGOXIN, RIA 0.00<br />

82646 3 ASSAY OF DIHYDROCO<strong>DE</strong>INONE 28.85<br />

82649 3 ASSAY OF DIHYDROMORPHINONE 35.91<br />

82651 3 ASSAY OF DIHYDROTESTOSTERONE 36.07<br />

82652 3 ASSAY OF DIHYDROXYVITAMIN D 53.78<br />

82654 3 ASSAY OF DIMETHADIONE 19.34<br />

82656 3 ELASTASE, PANCREATIC (EL-1), FECAL 15.39<br />

82657 3 ENZYME CELL ACTIVITY 25.23<br />

82658 3 ENZYME CELL ACTIVITY, RA 25.23<br />

82660 O DRUG SCREEN (AMPHETAMINES, BARBITUR 0.00<br />

82664 3 ELECTROPHORETIC TEST 48.00<br />

82666 3 ASSAY OF EPIANDROSTERONE 30.01<br />

82668 3 ASSAY OF ERYTHROPOIETIN 24.31<br />

82670 3 ASSAY OF ESTRADIOL 39.04<br />

82671 3 ASSAY OF ESTROGENS 45.13<br />

82672 3 ASSAY OF ESTROGEN 13.92<br />

82673 O ESTRIOL FLUOROMETRIC 0.00<br />

82674 O ESTRIOL GLC 0.00<br />

82676 O ESTRIOL CHEMICAL 0.00<br />

82677 3 ASSAY OF ESTRIOL 33.79<br />

82678 O ESTRONE CHEMICAL 0.00<br />

82679 3 ASSAY OF ESTRONE 32.79

---

82690 3 ASSAY OF ETHCHLORVYNOL 24.15<br />

82691 O ETHCHLORVYNOL URINE 0.00<br />

82692 O ETHOSUXIMI<strong>DE</strong> 0.00<br />

82693 3 ASSAY OF ETHYLENE GLYCOL 18.01<br />

82694 O ETIOCHOLANOLONE 0.00<br />

82696 3 ASSAY OF ETIOCHOLANOLONE 32.95<br />

82705 3 FATS/LIPIDS, FECES, QUAL 7.11<br />

82710 3 FATS/LIPIDS, FECES, QUANT 4.02<br />

82715 3 ASSAY OF FECAL FAT 12.22<br />

82720 O FATTY ACIDS, BLOOD ESTERIFIED 0.00<br />

82725 3 ASSAY OF BLOOD FATTY ACIDS 18.60<br />

82726 3 LONG CHAIN FATTY ACIDS 25.23<br />

82727 O FERRIC CHLORI<strong>DE</strong>, URINE 0.00<br />

82728 3 ASSAY OF FERRITIN 19.03<br />

82730 O FIBRINOGEN, QUANTITATIVE 0.00<br />

82731 3 ASSAY OF FETAL FIBRONECTIN 88.52<br />

82735 3 ASSAY OF FLUORI<strong>DE</strong> 25.91<br />

82740 O FLUORI<strong>DE</strong> URINE 0.00<br />

82741 O FLUCYTOSINE (5-FLUOROCYTOSINE) 0.00<br />

82742 3 ASSAY OF FLURAZEPAM 21.97<br />

82745 O FOLIC ACID (FOLATE), BLOOD BIOASSAY 0.00<br />

82746 3 BLOOD FOLIC ACID SERUM 20.54<br />

82747 3 ASSAY OF FOLIC ACID, RBC 24.07<br />

82750 O FORMIMINOGLUTAMIC ACID (FIGLU), URI 0.00<br />

82755 O FREE RADICAL ASSAY TECHNIQUE FOR DR 0.00<br />

82756 O FREE THYROXINE IN<strong>DE</strong>X (T-7) 0.00<br />

82757 3 ASSAY OF SEMEN FRUCTOSE 24.24<br />

82759 3 ASSAY OF RBC GALACTOKINASE 30.01<br />

82760 3 ASSAY OF GALACTOSE 15.64<br />

82763 O GALACTOSE TOLERANCE TEST 0.00<br />

82765 O GALACTOSE URINE 0.00<br />

82775 3 ASSAY GALACTOSE TRANSFERASE 29.43<br />

82776 3 GALACTOSE TRANSFERASE TEST 11.71<br />

82780 O GALLIUM 0.00<br />

82784 3 ASSAY OF GAMMAGLOBULIN IGM 12.99<br />

82785 3 ASSAY OF GAMMAGLOBULIN IGE 23.01<br />

82786 O GAMMAGLOBULIN, SALT PRECIPITATION M 0.00<br />

82787 3 IGG 1, 2, 3 OR 4, EACH 11.20<br />

82790 O GASES, BLOOD, OXYGEN SATURATION BY 0.00<br />

82791 O GASES, BLOOD, OXYGEN SATURATION BY 0.00<br />

82792 O GASES, BLOOD, OXYGEN SATURATION QUA 0.00<br />

82793 O GASES, BLOOD, OXYGEN SATURATION BY 0.00<br />

82795 O GASES, BLOOD, OXYGEN SATURATION BY 0.00<br />

82800 3 BLOOD PH 11.83<br />

82801 O GASES, BLOOD PCO2 0.00<br />

82802 O GASES, BLOOD PH, PCO2 BY ELECTRO<strong>DE</strong> 0.00<br />

82803 3 BLOOD GASES: PH, PO2 & PCO2 27.04<br />

82804 O GASES, BLOOD PO2 BY ELECTRO<strong>DE</strong> 0.00<br />

82805 3 BLOOD GASES W/02 SATURATION 39.65<br />

82810 3 BLOOD GASES, O2 SAT ONLY 12.20

---

82812 O GASES, BLOOD PO2 BY MANOMETRY 0.00<br />

82817 O GASES, BLOOD PH, PCO2 BY TONOMETRY 0.00<br />

82820 3 HEMOGLOBIN-OXYGEN AFFINITY 13.96<br />

82926 3 ASSAY OF GASTRIC ACID 7.61<br />

82927 O GASTRIC ACID, FREE AND TOTAL EACH A 0.00<br />

82928 3 ASSAY OF GASTRIC ACID 9.15<br />

82929 O GASTRIC ACID, FREE OR TOTAL EACH AD 0.00<br />

82931 O GASTRIC ACID, PH TITRATION SINGLE S 0.00<br />

82932 O GASTRIC ACID, PH TITRATION EACH ADD 0.00<br />

82938 3 GASTRIN TEST 24.72<br />

82941 3 ASSAY OF GASTRIN 24.64<br />

82942 O GLOBULIN, SERUM 0.00<br />

82943 3 ASSAY OF GLUCAGON 19.97<br />

82944 O GLUCOSAMINE 0.00<br />

82945 3 GLUCOSE OTHER FLUID 5.48<br />

82946 3 GLUCAGON TOLERANCE TEST 21.06<br />

82947 3 ASSAY, GLUCOSE, BLOOD QUANT 5.48<br />

82948 3 REAGENT STRIP/BLOOD GLUCOSE 4.43<br />

82949 O GLUCOSE FERMENTATION 0.00<br />

82950 3 GLUCOSE TEST 6.64<br />

82951 3 GLUCOSE TOLERANCE TEST (GTT) 17.99<br />

82952 3 GTT-AD<strong>DE</strong>D SAMPLES 4.02<br />

82953 3 GLUCOSE-TOLBUTAMI<strong>DE</strong> TEST 21.16<br />

82954 O GLUCOSE, URINE 0.00<br />

82955 3 ASSAY OF G6PD ENZYME 13.55<br />

82960 3 TEST FOR G6PD ENZYME 8.47<br />

82961 O GLUCOSE TOLERANCE TEST, INTRAVENOUS 0.00<br />

82962 3 GLUCOSE BLOOD TEST 3.27<br />

82963 3 ASSAY OF GLUCOSIDASE 30.01<br />

82965 3 ASSAY OF GDH ENZYME 10.80<br />

82975 3 ASSAY OF GLUTAMINE 22.13<br />

82977 3 ASSAY OF GGT 9.36<br />

82978 3 ASSAY OF GLUTATHIONE 8.33<br />

82979 3 ASSAY, RBC GLUTATHIONE 9.62<br />

82980 3 ASSAY OF GLUTETHIMI<strong>DE</strong> 25.60<br />

82985 3 GLYCATED PROTEIN 21.06<br />

82995 O GOLD, BLOOD 0.00<br />

83000 O GONADOTROPIN, PITUITARY, FOLLICLE S 0.00<br />

83001 3 GONADOTROPIN (FSH) 25.97<br />

83002 3 GONADOTROPIN (LH) 25.88<br />

83003 3 ASSAY, GROWTH HORMONE (HGH) 23.29<br />

83004 O GROWTH HORMONE, HUMAN (HGH) (SOMATO 0.00<br />

83008 3 ASSAY OF GUANOSINE 23.45<br />

83009 3 H PYLORI (C-13), BLOOD 94.11<br />

83010 3 ASSAY OF HAPTOGLOBIN, QUANT 17.58<br />

83011 O HAPTOGLOBIN QUANTITATIVE, ELECTROPH 0.00<br />

83012 3 ASSAY OF HAPTOGLOBINS 24.02<br />

83013 3 H PYLORI (C-13), BREATH 94.11<br />

83014 3 H PYLORI DRUG ADMIN 10.98<br />

83015 3 HEAVY METAL SCREEN 26.31

---

83018 3 QUANTITATIVE SCREEN, METALS 30.68<br />

83019 O BREATH ISOTOPE TEST 0.00<br />

83020 3 HEMOGLOBIN ELECTROPHORESIS 17.99<br />

83021 3 HEMOGLOBIN CHROMOTOGRAPHY 25.23<br />

83026 3 HEMOGLOBIN, COPPER SULFATE 3.30<br />

83030 3 FETAL HEMOGLOBIN, CHEMICAL 11.56<br />

83033 3 FETAL HEMOGLOBIN ASSAY, QUAL 8.06<br />

83036 3 GLYCOSYLATED HEMOGLOBIN TEST 13.56<br />

83037 3 GLYCOSYLATED HB, HOME <strong>DE</strong>VICE 21.06<br />

83040 O HEMOGLOBIN METHEMOGLOBIN, ELECTROPH 0.00<br />

83045 3 BLOOD METHEMOGLOBIN TEST 6.93<br />

83050 3 BLOOD METHEMOGLOBIN ASSAY 10.23<br />

83051 3 ASSAY OF PLASMA HEMOGLOBIN 4.02<br />

83052 O HEMOGLOBIN SICKLE, TURBIDIMETRIC 0.00<br />

83053 O HEMOGLOBIN SOLUBILITY, S-D, ETC 0.00<br />

83055 3 BLOOD SULFHEMOGLOBIN TEST 4.02<br />

83060 3 BLOOD SULFHEMOGLOBIN ASSAY 11.56<br />

83065 3 ASSAY OF HEMOGLOBIN HEAT 9.62<br />

83068 3 HEMOGLOBIN STABILITY SCREEN 3.28<br />

83069 3 ASSAY OF URINE HEMOGLOBIN 5.51<br />

83070 3 ASSAY OF HEMOSI<strong>DE</strong>RIN, QUAL 6.64<br />

83071 3 ASSAY OF HEMOSI<strong>DE</strong>RIN, QUANT 8.97<br />

83080 3 ASSAY OF B HEXOSAMINIDASE 23.57<br />

83086 O HISTIDINE BLOOD, QUALITATIVE 0.00<br />

83087 O HISTIDINE URINE, QUALITATIVE 0.00<br />

83088 3 ASSAY OF HISTAMINE 41.26<br />

83090 3 ASSAY OF HOMOCYSTINE 23.57<br />

83093 O HOMOGENTISIC ACID BLOOD, QUALITATIV 0.00<br />

83094 O HOMOGENTISIC ACID URINE, QUALITATIV 0.00<br />

83095 O HOMOGENTISIC ACID URINE, QUANTITATI 0.00<br />

83150 3 ASSAY OF FOR HVA 27.04<br />

83485 O HYDROXYBUTYRIC <strong>DE</strong>HYDROGENASE, ALPHA 0.00<br />

83486 O HYDROXYBUTYRIC <strong>DE</strong>HYDROGENASE, ALPHA 0.00<br />

83491 3 ASSAY OF CORTICOSTEROIDS 24.47<br />

83492 O HYDROXYCORTICOSTEROIDS, 17- (17-OHC 0.00<br />

83493 O HYDROXYCORTICOSTEROIDS, 17- (17-OHC 0.00<br />

83494 O HYDROXYCORTICOSTEROIDS, 17- (17-OHC 0.00<br />

83495 O HYDROXYCORTICOSTEROIDS, 17- (17-OHC 0.00<br />

83496 O HYDROXYCORTICOSTEROIDS, 17- (17-OHC 0.00<br />

83497 3 ASSAY OF 5-HIAA 18.01<br />

83498 3 ASSAY OF PROGESTERONE 37.95<br />

83499 3 ASSAY OF PROGESTERONE 20.28<br />

83500 3 ASSAY, FREE HYDROXYPROLINE 31.65<br />

83505 3 ASSAY, TOTAL HYDROXYPROLINE 33.96<br />

83510 O HYDROXYPROLINE, URINE FREE AND TOTA 0.00<br />

83516 3 IMMUNOASSAY, NONANTIBODY 15.39<br />

83518 3 IMMUNOASSAY, DIPSTICK 11.85<br />

83519 3 IMMUNOASSAY, NONANTIBODY 18.88<br />

83520 3 IMMUNOASSAY, RIA 18.09<br />

83523 O IMIPRAMINE 0.00

---

83524 O INDICAN, URINE 0.00<br />

83525 3 ASSAY OF INSULIN 15.98<br />

83526 O INSULIN TOLERANCE TEST 0.00<br />

83527 3 ASSAY OF INSULIN 18.09<br />

83528 3 ASSAY OF INTRINSIC FACTOR 22.22<br />

83530 O INULIN CLEARANCE 0.00<br />

83540 3 ASSAY OF IRON 9.05<br />

83545 O IRON, SERUM AUTOMATED 0.00<br />

83546 O IRON, SERUM RADIOACTIVE UPTAKE METH 0.00<br />

83550 3 IRON BINDING TEST 12.21<br />

83555 O IRON BINDING CAPACITY, SERUM AUTOMA 0.00<br />

83565 O IRON BINDING CAPACITY, SERUM RADIOA 0.00<br />

83570 3 ASSAY OF IDH ENZYME 10.51<br />

83571 O ISOCITRIC <strong>DE</strong>HYDROGENASE (IDH), BLOO 0.00<br />

83576 O ISONICOTINIC ACID HYDRAZI<strong>DE</strong> (INH) 0.00<br />

83578 O KANAMYCIN 0.00<br />

83582 3 ASSAY OF KETOGENIC STEROIDS 19.80<br />

83583 O KETOGENIC STEROIDS, URINE 11-<strong>DE</strong>SOXY 0.00<br />

83584 O KETOGLUTARATE, ALPHA 0.00<br />

83586 3 ASSAY 17- KETOSTEROIDS 17.89<br />

83587 O KETOSTEROIDS, 17- (17-KS), BLOOD FR 0.00<br />

83588 O KETOSTEROIDS, 17- (17-KS), BLOOD RI 0.00<br />

83589 O KETOSTEROIDS, 17- (17-KS), URINE TO 0.00<br />

83590 O KETOSTEROIDS, 17- (17-KS), URINE FR 0.00<br />

83593 3 FRACTIONATION, KETOSTEROIDS 36.75<br />

83597 O KETOSTEROIDS, 17- (17-KS), URINE 11 0.00<br />

83599 O KETOSTEROIDS, 17-OH, RIA 0.00<br />

83600 O KYNURENIC ACID 0.00<br />

83605 3 ASSAY OF LACTIC ACID 14.92<br />

83610 O LACTIC <strong>DE</strong>HYDROGENASE (LDH), RIA 0.00<br />

83615 3 LACTATE (LD) (LDH) ENZYME 7.83<br />

83620 O LACTIC <strong>DE</strong>HYDROGENASE (LDH), BLOOD C 0.00<br />

83624 O LACTIC <strong>DE</strong>HYDROGENASE (LDH), BLOOD H 0.00<br />

83625 3 ASSAY OF LDH ENZYMES 17.88<br />

83626 O LACTIC <strong>DE</strong>HYDROGENASE (LDH), BLOOD I 0.00<br />

83628 O LACTIC <strong>DE</strong>HYDROGENASE, LIVER (LLDH) 0.00<br />

83629 O LACTIC <strong>DE</strong>HYDROGENASE (LDH), URINE 0.00<br />

83630 3 LACTOFERRIN, FECAL (QUAL) 27.42<br />

83631 3 LACTOFERRIN, FECAL; QUANTITATIVE 27.42<br />

83632 3 PLACENTAL LACTOGEN 28.24<br />

83633 3 TEST URINE FOR LACTOSE 7.69<br />

83634 3 ASSAY OF URINE FOR LACTOSE 16.10<br />

83645 O LEAD, SCREENING BLOOD 0.00<br />

83650 O LEAD, SCREENING URINE 0.00<br />

83655 3 ASSAY OF LEAD 16.91<br />

83660 O LEAD, QUANTITATIVE URINE 0.00<br />

83661 3 L/S RATIO, FETAL LUNG 30.71<br />

83662 3 FOAM STABILITY, FETAL LUNG 26.43<br />

83663 3 FLUORO POLARIZE, FETAL LUNG 26.43<br />

83664 3 LAMELLAR BDY, FETAL LUNG 26.43

---

83670 3 ASSAY OF LAP ENZYME 12.80<br />

83675 O LEUCINE AMINOPEPTIDASE (LAP), BLOOD 0.00<br />

83680 O LEUCINE AMINOPEPTIDASE (LAP), URINE 0.00<br />

83681 O LEUCINE TOLERANCE TEST 0.00<br />

83685 O LIDOCAINE 0.00<br />

83690 3 ASSAY OF LIPASE 9.62<br />

83695 3 ASSAY OF LIPOPROTEIN(A) 18.09<br />

83698 3 ASSAY LIPOPROTEIN PLA2 47.43<br />

83700 3 LIPOPROTEIN, BLOOD; ELECTROPHORETI 15.73<br />

83701 3 LIPOPROTEIN BLD, HR FRACTION 34.68<br />

83704 3 LIPOPROTEIN, BLD, BY NMR 44.08<br />

83705 O LIPIDS, BLOOD FRACTIONATED (CHOLEST 0.00<br />

83715 O ASSAY OF BLOOD LIPOPROTEINS 0.00<br />

83716 O ASSAY OF BLOOD LIPOPROTEINS 0.00<br />

83717 O ASSAY BLOOD LIPOPROTEINS 0.00<br />

83718 3 ASSAY OF LIPOPROTEIN 11.44<br />

83719 3 ASSAY OF BLOOD LIPOPROTEIN 16.26<br />

83720 O LIPOPROTEIN CHOLESTEROL FRACTIONATI 0.00<br />

83721 3 ASSAY OF BLOOD LIPOPROTEIN 13.33<br />

83725 O LITHIUM, BLOOD, QUANTITATIVE 0.00<br />

83727 3 ASSAY OF LRH HORMONE 24.02<br />

83728 O LYSERGIC ACID DIETHYLAMI<strong>DE</strong> (LSD), R 0.00<br />

83730 O MACROGLOBULINS (SIA TEST) 0.00<br />

83735 3 ASSAY OF MAGNESIUM 9.36<br />

83740 O MAGNESIUM, BLOOD FLUOROMETRIC 0.00<br />

83750 O MAGNESIUM, BLOOD ATOMIC ABSORPTION 0.00<br />

83755 O MAGNESIUM, URINE CHEMICAL 0.00<br />

83760 O MAGNESIUM, URINE FLUOROMETRIC 0.00<br />

83765 O MAGNESIUM, URINE ATOMIC ABSORPTION 0.00<br />

83775 3 ASSAY OF MD ENZYME 10.30<br />

83785 3 ASSAY OF MANGANESE 15.21<br />

83788 3 MASS SPECTROMETRY QUAL 25.23<br />

83789 3 MASS SPECTROMETRY QUANT 25.23<br />

83790 O MANNITOL CLEARANCE 0.00<br />

83795 O MELANIN, URINE, QUALITATIVE 0.00<br />

83799 O MEPERIDINE, QUANTITATIVE 0.00<br />

83805 3 ASSAY OF MEPROBAMATE 24.63<br />

83825 3 ASSAY OF MERCURY 22.72<br />

83830 O MERCURY, QUANTITATIVE URINE 0.00<br />

83835 3 ASSAY OF METANEPHRINES 23.67<br />

83840 3 ASSAY OF METHADONE 22.76<br />

83842 O METHAPYRILENE 0.00<br />

83845 O METHAQUALONE 0.00<br />

83857 3 ASSAY OF METHEMALBUMIN 15.01<br />

83858 3 ASSAY OF METHSUXIMI<strong>DE</strong> 20.71<br />

83859 O METHYPRYLON 0.00<br />

83860 O MORPHINE SCREENING 0.00<br />

83861 O MORPHINE QUANTITATIVE 0.00<br />

83862 O MORPHINE RIA 0.00<br />

83864 3 MUCOPOLYSACCHARI<strong>DE</strong>S 27.82

---

83865 O MUCOPOLYSACCHARI<strong>DE</strong>S, ACID, URINE QU 0.00<br />

83866 3 MUCOPOLYSACCHARI<strong>DE</strong>S SCREEN 13.76<br />

83872 3 ASSAY SYNOVIAL FLUID MUCIN 8.19<br />

83873 3 ASSAY OF CSF PROTEIN 24.04<br />

83874 3 ASSAY OF MYOGLOBIN 18.04<br />

83875 O MYOGLOBIN, URINE 0.00<br />

83876 6 ASSAY, MYELOPEROXIDASE 0.00<br />

83880 3 NATRIURETIC PEPTI<strong>DE</strong> 47.43<br />

83883 3 ASSAY, NEPHELOMETRY NOT SPEC 19.00<br />

83885 3 ASSAY OF NICKEL 34.23<br />

83887 3 ASSAY OF NICOTINE 33.09<br />

83890 3 MOLECULE ISOLATE 5.60<br />

83891 3 MOLECULE ISOLATE NUCLEIC 5.60<br />

83892 3 MOLECULAR DIAGNOSTICS 5.60<br />

83893 3 MOLECULE DOT/SLOT/BLOT 5.60<br />

83894 3 MOLECULE GEL ELECTROPHOR 5.60<br />

83895 O NITROGEN, TOTAL URINE, 24-HOUR SPEC 0.00<br />

83896 3 MOLECULAR DIAGNOSTICS 5.60<br />

83897 3 MOLECULE NUCLEIC TRANSFER 5.60<br />

83898 3 MOLECULE NUCLEIC AMPLI, EACH 23.42<br />

83900 3 MOLECULE NUCLEIC AMPLI 2 SEQ 46.84<br />

83901 3 MOLECULE NUCLEIC AMPLI ADDON 23.42<br />

83902 3 MOLECULAR DIAGNOSTICS 19.83<br />

83903 3 MOLECULE MUTATION SCAN 23.42<br />

83904 3 MOLECULE MUTATION I<strong>DE</strong>NTIFY 23.42<br />

83905 3 MOLECULE MUTATION I<strong>DE</strong>NTIFY 23.42<br />

83906 3 MOLECULE MUTATION I<strong>DE</strong>NTIFY 23.42<br />

83907 3 LYSE CELLS FOR NUCLEIC EXT 18.66<br />

83908 3 NUCLEIC ACID, SIGNAL AMPLI 23.42<br />

83909 3 NUCLEIC ACID, HIGH RESOLUTE 23.42<br />

83910 O NONPROTEIN NITROGEN (NPN), BLOOD 0.00<br />

83912 3 GENETIC EXAMINATION 5.60<br />

83913 3 NUCLEIC ACID PROBE, WITH ELECTROPHO 18.66<br />

83914 3 MUTATION I<strong>DE</strong>NT OLA/SBCE/ASPE 23.42<br />

83915 3 ASSAY OF NUCLEOTIDASE 15.58<br />

83916 3 OLIGOCLONAL BANDS 28.09<br />

83917 O ORGANIC ACIDS SCREEN, QUALITATIVE 0.00<br />

83918 3 ORGANIC ACIDS, TOTAL, QUANT 23.00<br />

83919 3 ORGANIC ACIDS, QUAL, EACH 23.00<br />

83920 O ORNITHINE CARBAMYL TRANSFERASE (OCT 0.00<br />

83921 3 ORGANIC ACID, SINGLE, QUANT 23.00<br />

83925 3 ASSAY OF OPIATES 27.19<br />

83930 3 ASSAY OF BLOOD OSMOLALITY 9.24<br />

83935 3 ASSAY OF URINE OSMOLALITY 9.52<br />

83937 3 ASSAY OF OSTEOCALCIN 41.71<br />

83938 O OUABAIN 0.00<br />

83945 3 ASSAY OF OXALATE 17.99<br />

83946 O OXAZEPAM 0.00<br />

83947 O OXYBUTYRIC ACID, BETA 0.00<br />

83948 O OXYCODINONE 0.00

---

83949 O OXYTOCINASE, RIA 0.00<br />

83950 3 ONCOPROTEIN, HER-2/NEU 88.52<br />

83951 6 ONCOPROTEIN, DCP 0.00<br />

83965 O PARAL<strong>DE</strong>HY<strong>DE</strong>, BLOOD, QUANTITATIVE 0.00<br />

83970 3 ASSAY OF PARATHORMONE 57.67<br />

83971 O PENICILLIN, URINE 0.00<br />

83972 O PENTAZOCINE 0.00<br />

83973 O PENTOSE, URINE, QUALITATIVE 0.00<br />

83975 O PEPSINOGEN, BLOOD 0.00<br />

83985 O PESTICI<strong>DE</strong> OTHER THAN CHLORINATED HY 0.00<br />

83986 3 ASSAY OF BODY FLUID ACIDITY 3.28<br />

83992 3 ASSAY FOR PHENCYCLIDINE 20.54<br />

83993 3 ASSAY FOR CALPROTECTIN FECAL 27.42<br />

83995 O PHENOL, BLOOD OR URINE 0.00<br />

84005 O PHENOLSULFONPHTHALEIN (PSP) TEST, U 0.00<br />

84021 O PHENOTHIAZINE, URINE QUALITATIVE, C 0.00<br />

84022 3 ASSAY OF PHENOTHIAZINE 21.76<br />

84030 3 ASSAY OF BLOOD PKU 7.69<br />

84031 O PHENYLALANINE (PKU), BLOOD FLUOROME 0.00<br />

84033 O PHENYLBUTAZONE 0.00<br />

84035 3 ASSAY OF PHENYLKETONES 5.11<br />

84037 O PHENYLKETONES URINE, QUALITATIVE 0.00<br />

84038 O PHENYLPROPANOLAMINE 0.00<br />

84039 O PHENYLPYRUVIC ACID BLOOD 0.00<br />

84040 O PHENYLPYRUVIC ACID URINE 0.00<br />

84045 O PHENYTOIN 0.00<br />

84060 3 ASSAY ACID PHOSPHATASE 8.06<br />

84061 3 PHOSPHATASE, FORENSIC EXAM 8.06<br />

84065 O PHOSPHATASE, ACID PROSTATIC FRACTIO 0.00<br />

84066 3 ASSAY PROSTATE PHOSPHATASE 13.10<br />

84075 3 ASSAY ALKALINE PHOSPHATASE 6.37<br />

84078 3 ASSAY ALKALINE PHOSPHATASE 10.20<br />

84080 3 ASSAY ALKALINE PHOSPHATASES 20.66<br />

84081 3 AMNIOTIC FLUID ENZYME TEST 23.09<br />

84082 O PHOSPHATES, TUBULAR REABSORPTION OF 0.00<br />

84083 O PHOSPHOGLUCOMUTASE, ISOENZYMES 0.00<br />

84085 3 ASSAY OF RBC PG6D ENZYME 9.42<br />

84087 3 ASSAY PHOSPHOHEXOSE ENZYMES 14.42<br />

84090 O PHOSPHOLIPIDS, BLOOD 0.00<br />

84100 3 ASSAY OF PHOSPHORUS 6.63<br />

84105 3 ASSAY OF URINE PHOSPHORUS 7.23<br />

84106 3 TEST FOR PORPHOBILINOGEN 5.99<br />

84110 3 ASSAY OF PORPHOBILINOGEN 10.79<br />

84118 O PORPHYRINS, COPRO-, URINE QUANTITAT 0.00<br />

84119 3 TEST URINE FOR PORPHYRINS 12.03<br />

84120 3 ASSAY OF URINE PORPHYRINS 20.40<br />

84121 O PORPHYRINS URO-, COPRO- AND PORPHOB 0.00<br />

84126 3 ASSAY OF FECES PORPHYRINS 35.59<br />

84127 3 ASSAY OF FECES PORPHYRINS 16.28<br />

84128 O PORPHYRINS, PLASMA 0.00

---

84132 3 ASSAY OF SERUM POTASSIUM 6.42<br />

84133 3 ASSAY OF URINE POTASSIUM 6.01<br />

84134 3 ASSAY OF PREALBUMIN 20.38<br />

84135 3 ASSAY OF PREGNANEDIOL 26.73<br />

84136 O PREGNANEDIOL OTHER METHOD (SPECIFY) 0.00<br />

84138 3 ASSAY OF PREGNANETRIOL 26.46<br />

84139 O PREGNANETRIOL OTHER METHOD (SPECIFY 0.00<br />

84140 3 ASSAY OF PREGNENOLONE 28.89<br />

84141 O PRIMIDONE 0.00<br />

84142 O PROCAINAMI<strong>DE</strong> 0.00<br />

84143 3 ASSAY OF 17-HYDROXYPREGNENO 31.89<br />

84144 3 ASSAY OF PROGESTERONE 29.15<br />

84146 3 ASSAY OF PROLACTIN 27.08<br />

84147 O PROPOXYPHENE 0.00<br />

84149 O PROPRANOLOL 0.00<br />

84150 3 ASSAY OF PROSTAGLANDIN 34.88<br />

84152 3 ASSAY OF PSA, COMPLEXED 25.70<br />

84153 3 ASSAY OF PSA, TOTAL 25.70<br />

84154 3 ASSAY OF PSA, FREE 25.70<br />

84155 3 ASSAY OF PROTEIN, SERUM 4.67<br />

84156 3 ASSAY OF PROTEIN, URINE 4.67<br />

84157 3 ASSAY OF PROTEIN, OTHER 4.67<br />

84160 3 ASSAY OF PROTEIN, ANY SOURCE 7.23<br />

84163 3 PAPPA, SERUM 20.27<br />

84165 3 PROTEIN E-PHORESIS, SERUM 15.01<br />

84166 3 PROTEIN E-PHORESIS/URINE/CSF 24.92<br />

84170 O PROTEIN, TOTAL, AND ALBUMIN/GLOBULI 0.00<br />

84175 O PROTEIN;ELECTROPHORESIS,OTHER SOURC 0.00<br />

84176 O PROTEIN, SPECIAL STUDIES (EG, MONOC 0.00<br />

84180 O PROTEIN, URINE QUANTITATIVE, 24-HOU 0.00<br />

84181 3 WESTERN BLOT TEST 23.80<br />

84182 3 PROTEIN, WESTERN BLOT TEST 25.15<br />

84185 O PROTEIN, URINE BENCE-JONES 0.00<br />

84190 O PROTEIN, URINE ELECTROPHORETIC FRAC 0.00<br />

84195 O PROTEIN, SPINAL FLUID SEMI-QUANTITA 0.00<br />

84200 O PROTEIN, SPINAL FLUID ELECTROPHORET 0.00<br />

84201 O PROTIRELIN, THYROTROPIN RELEASING H 0.00<br />

84202 3 ASSAY RBC PROTOPORPHYRIN 20.05<br />

84203 3 TEST RBC PROTOPORPHYRIN 12.03<br />

84205 O PROTRIPTYLENE 0.00<br />

84206 3 ASSAY OF PROINSULIN 10.91<br />

84207 3 ASSAY OF VITAMIN B-6 39.25<br />

84208 O PYROPHOSPHATE VS URATE, CRYSTALS (P 0.00<br />

84210 3 ASSAY OF PYRUVATE 15.17<br />

84220 3 ASSAY OF PYRUVATE KINASE 13.18<br />

84228 3 ASSAY OF QUININE 16.26<br />

84230 O QUINIDINE, BLOOD 0.00<br />

84231 O RADIOIMMUNOASSAY (RIA) NOT ELSEWHER 0.00<br />

84232 O RELEASING FACTOR 0.00<br />

84233 3 ASSAY OF ESTROGEN 88.52

---

84234 3 ASSAY OF PROGESTERONE 90.64<br />

84235 3 ASSAY OF ENDOCRINE HORMONE 73.12<br />

84236 O RECEPTOR ASSAY PROGESTERONE AND EST 0.00<br />

84238 3 ASSAY, NONENDOCRINE RECEPTOR 51.09<br />

84244 3 ASSAY OF RENIN 30.73<br />

84246 O RENIN (ANGIOTENSIN I) FUROSEMI<strong>DE</strong> TE 0.00<br />

84252 3 ASSAY OF VITAMIN B-2 27.56<br />

84255 3 ASSAY OF SELENIUM 35.67<br />

84260 3 ASSAY OF SEROTONIN 43.28<br />

84270 3 ASSAY OF SEX HORMONE GLOBUL 27.56<br />

84275 3 ASSAY OF SIALIC ACID 18.77<br />

84285 3 ASSAY OF SILICA 32.90<br />

84295 3 ASSAY OF SERUM SODIUM 6.50<br />

84300 3 ASSAY OF URINE SODIUM 6.79<br />

84302 3 ASSAY OF SWEAT SODIUM 6.79<br />

84305 3 ASSAY OF SOMATOMEDIN 27.44<br />

84307 3 ASSAY OF SOMATOSTATIN 25.54<br />

84310 O SORBITOL <strong>DE</strong>HYDROGENASE, SERUM 0.00<br />

84311 3 SPECTROPHOTOMETRY 9.77<br />

84315 3 BODY FLUID SPECIFIC GRAVITY 3.50<br />

84318 O STERCOBILIN, QUALITATIVE, FECES 0.00<br />

84324 O STRYCHNINE 0.00<br />

84375 3 CHROMATOGRAM ASSAY, SUGARS 27.39<br />

84376 3 SUGARS, SINGLE, QUAL 7.69<br />

84377 3 SUGARS, MULTIPLE, QUAL 7.69<br />

84378 3 SUGARS, SINGLE, QUANT 16.10<br />

84379 3 SUGARS MULTIPLE QUANT 16.10<br />

84392 3 ASSAY OF URINE SULFATE 6.64<br />

84395 O SULFONAMI<strong>DE</strong>, BLOOD, CHEMICAL 0.00<br />

84402 3 ASSAY OF TESTOSTERONE 35.57<br />

84403 3 ASSAY OF TOTAL TESTOSTERONE 36.08<br />

84405 O TESTOSTERONE, URINE, RIA 0.00<br />

84406 O TESTOSTERONE, BINDING PROTEIN 0.00<br />

84407 O TETRACAINE 0.00<br />

84408 O TETRAHYDROCANNABINOL THC (MARIJUANA 0.00<br />

84409 O TETRAHYDROCORTISONE OR TETRAHYDROCO 0.00<br />

84410 O THALLIUM, BLOOD OR URINE 0.00<br />

84420 O THEOPHYLLINE, BLOOD OR SALIVA 0.00<br />

84425 3 ASSAY OF VITAMIN B-1 29.67<br />

84430 3 ASSAY OF THIOCYANATE 6.37<br />

84432 3 ASSAY OF THYROGLOBULIN 22.44<br />

84434 O THIORIDAZINE 0.00<br />

84435 O THYROXINE, (T-4), CPB OR RESIN UPTA 0.00<br />

84436 3 ASSAY OF TOTAL THYROXINE 9.61<br />

84437 3 ASSAY OF NEONATAL THYROXINE 9.04<br />

84439 3 ASSAY OF FREE THYROXINE 12.60<br />

84442 3 ASSAY OF THYROID ACTIVITY 20.66<br />

84443 3 ASSAY THYROID STIM HORMONE 23.47<br />

84444 O THYROTROPIN RELEASING FACTOR (TRF) 0.00<br />

84445 3 ASSAY OF TSI 71.05

---

84446 3 ASSAY OF VITAMIN E 19.81<br />

84447 O TOXICOLOGY, SCREEN GENERAL 0.00<br />

84448 O TOXICOLOGY, SCREEN SEDATIVE (ACID A 0.00<br />

84449 3 ASSAY OF TRANSCORTIN 25.15<br />

84450 3 TRANSFERASE (AST) (SGOT) 7.22<br />

84455 O TRANSAMINASE, GLUTAMIC OXALOACETIC 0.00<br />

84460 3 ALANINE AMINO (ALT) (SGPT) 7.40<br />

84465 O TRANSAMINASE, GLUTAMIC PYRUVIC (SGP 0.00<br />

84466 3 ASSAY OF TRANSFERRIN 17.84<br />

84472 O TRICHLOROETHANOL 0.00<br />

84474 O TRICHLOROACETIC ACID 0.00<br />

84476 O TRIFLUOPERAZINE 0.00<br />

84478 3 ASSAY OF TRIGLYCERI<strong>DE</strong>S 8.04<br />

84479 3 ASSAY OF THYROID (T3 OR T4) 9.04<br />

84480 3 ASSAY, TRIIODOTHYRONINE (T3) 19.81<br />

84481 3 FREE ASSAY (FT-3) 23.67<br />

84482 3 T3 REVERSE 22.02<br />

84483 O TRIMETHADIONE 0.00<br />

84484 3 ASSAY OF TROPONIN, QUANT 12.17<br />

84485 3 ASSAY DUO<strong>DE</strong>NAL FLUID TRYPSIN 10.49<br />

84488 3 TEST FECES FOR TRYPSIN 10.20<br />

84490 3 ASSAY OF FECES FOR TRYPSIN 10.63<br />

84510 3 ASSAY OF TYROSINE 14.53<br />

84512 3 ASSAY OF TROPONIN, QUAL 10.31<br />

84520 3 ASSAY OF UREA NITROGEN 5.51<br />

84525 3 UREA NITROGEN SEMI-QUANT 5.25<br />

84540 3 ASSAY OF URINE/UREA-N 6.64<br />

84545 3 UREA-N CLEARANCE TEST 9.23<br />

84550 3 ASSAY OF BLOOD/URIC ACID 6.31<br />

84555 O URIC ACID URICASE, ULTRAVIOLET METH 0.00<br />

84560 3 ASSAY OF URINE/URIC ACID 4.83<br />

84565 O UROBILIN, URINE QUALITATIVE 0.00<br />

84570 O UROBILIN, URINE QUANTITATIVE, TIMED 0.00<br />

84575 O UROBILIN, FECES, QUANTITATIVE 0.00<br />

84577 3 ASSAY OF FECES/UROBILINOGEN 17.43<br />

84578 3 TEST URINE UROBILINOGEN 4.02<br />

84580 3 ASSAY OF URINE UROBILINOGEN 9.92<br />

84583 3 ASSAY OF URINE UROBILINOGEN 7.02<br />

84584 O UROPEPSIN, URINE 0.00<br />

84585 3 ASSAY OF URINE VMA 21.66<br />

84586 3 ASSAY OF VIP 49.37<br />

84588 3 ASSAY OF VASOPRESSIN 47.43<br />

84589 O VISCOSITY 0.00<br />

84590 3 ASSAY OF VITAMIN A 16.20<br />

84591 3 ASSAY OF NOS VITAMIN 16.20<br />

84595 O VITAMIN A, BLOOD INCLUDING CAROTENE 0.00<br />

84597 3 ASSAY OF VITAMIN K 19.15<br />

84600 3 ASSAY OF VOLATILES 22.45<br />

84605 O VOLUME, BLOOD, DYE METHOD (EVANS BL 0.00<br />

84610 O VOLUME, BLOOD, DYE METHOD (EVANS BL 0.00

---

84613 O WARFARIN 0.00<br />

84615 O XANTHURENIC ACID 0.00<br />

84620 3 XYLOSE TOLERANCE TEST 6.50<br />

84630 3 ASSAY OF ZINC 15.91<br />

84635 O ZINC, QUANTITATIVE URINE 0.00<br />

84681 3 ASSAY OF C-PEPTI<strong>DE</strong> 29.07<br />

84695 O GENTAMICIN 0.00<br />

84702 3 CHORIONIC GONADOTROPIN TEST 20.27<br />

84703 3 CHORIONIC GONADOTROPIN ASSAY 10.49<br />

84704 3 HCG, FREE BETACHAIN TEST 20.27<br />

84800 O THYROID STIMULATING HORMONE (TSH), 0.00<br />

84810 O TOBRAMYCIN 0.00<br />

84830 9 OVULATION TESTS 0.00<br />

84999 5 CLINICAL CHEMISTRY TEST 0.00<br />

85000 O BLEEDING TIME DUKE 0.00<br />

85002 3 BLEEDING TIME TEST 6.29<br />

85004 3 AUTOMATED DIFF WBC COUNT 9.04<br />

85005 O BLOOD COUNT BASOPHIL COUNT, DIRECT 0.00<br />

85007 3 BL SMEAR W/DIFF WBC COUNT 4.81<br />

85008 3 BL SMEAR W/O DIFF WBC COUNT 4.81<br />

85009 3 MANUAL DIFF WBC COUNT B-COAT 5.19<br />

85012 O BLOOD COUNT EOSINOPHIL COUNT, DIREC 0.00<br />

85013 3 SPUN MICROHEMATOCRIT 3.31<br />

85014 3 HEMATOCRIT 3.31<br />

85018 3 HEMOGLOBIN 3.31<br />

85021 O AUTOMATED HEMOGRAM 0.00<br />

85022 O AUTOMATED HEMOGRAM 0.00<br />

85023 O AUTOMATED HEMOGRAM 0.00<br />

85024 O AUTOMATED HEMOGRAM 0.00<br />

85025 3 COMPLETE CBC W/AUTO DIFF WBC 10.86<br />

85027 3 COMPLETE CBC, AUTOMATED 9.04<br />

85029 O AUTOMATED HEMOGRAM 0.00<br />

85030 O AUTOMATED HEMOGRAM 0.00<br />

85031 O MANUAL HEMOGRAM, CBC 0.00<br />

85032 3 MANUAL CELL COUNT, EACH 6.01<br />

85041 3 AUTOMATED RBC COUNT 4.02<br />

85044 3 MANUAL RETICULOCYTE COUNT 6.01<br />

85045 3 AUTOMATED RETICULOCYTE COUNT 5.59<br />

85046 3 RETICYTE/HGB CONCENTRATE 7.80<br />

85048 3 AUTOMATED LEUKOCYTE COUNT 3.55<br />

85049 3 AUTOMATED PLATELET COUNT 6.25<br />

85055 3 RETICULATED PLATELET ASSAY 37.41<br />

85060 3 BLOOD SMEAR INTERPRETATION 25.45<br />

85095 O BONE MARROW ASPIRATION 0.00<br />

85097 3 BONE MARROW INTERPRETATION 104.59<br />

85100 O BONE MARROW SMEAR AND/OR CELL BLOCK 0.00<br />

85101 O BONE MARROW SMEAR AND/OR CELL BLOCK 0.00<br />

85102 O BONE MARROW BIOPSY 0.00<br />

85103 O BONE MARROW BIOPSY, NEEDLE OR TROCA 0.00<br />

85105 O BONE MARROW BIOPSY, NEEDLE OR TROCA 0.00

---

85109 O BONE MARROW BIOPSY, NEEDLE OR TROCA 0.00<br />

85130 3 CHROMOGENIC SUBSTRATE ASSAY 16.62<br />

85170 3 BLOOD CLOT RETRACTION 5.05<br />

85171 O CLOT RETRACTION QUANTITATIVE 0.00<br />

85172 O CLOT RETRACTION INHIBITION BY DRUGS 0.00<br />

85175 3 BLOOD CLOT LYSIS TIME 6.35<br />

85210 3 BLOOD CLOT FACTOR II TEST 8.06<br />

85220 3 BLOOD CLOT FACTOR V TEST 24.66<br />

85230 3 BLOOD CLOT FACTOR VII TEST 25.02<br />

85240 3 BLOOD CLOT FACTOR VIII TEST 25.02<br />

85242 O CLOTTING FACTOR VIII (AHG), TWO STA 0.00<br />

85244 3 BLOOD CLOT FACTOR VIII TEST 28.53<br />

85245 3 BLOOD CLOT FACTOR VIII TEST 32.06<br />

85246 3 BLOOD CLOT FACTOR VIII TEST 32.06<br />

85247 3 BLOOD CLOT FACTOR VIII TEST 32.06<br />

85250 3 BLOOD CLOT FACTOR IX TEST 26.60<br />

85260 3 BLOOD CLOT FACTOR X TEST 25.02<br />

85270 3 BLOOD CLOT FACTOR XI TEST 25.02<br />

85280 3 BLOOD CLOT FACTOR XII TEST 27.04<br />

85290 3 BLOOD CLOT FACTOR XIII TEST 11.31<br />

85291 3 BLOOD CLOT FACTOR XIII TEST 11.31<br />

85292 3 BLOOD CLOT FACTOR ASSAY 26.46<br />

85293 3 BLOOD CLOT FACTOR ASSAY 26.46<br />

85300 3 ANTITHROMBIN III TEST 13.52<br />

85301 3 ANTITHROMBIN III TEST 15.11<br />

85302 3 BLOOD CLOT INHIBITOR ANTIGEN 16.80<br />

85303 3 BLOOD CLOT INHIBITOR TEST 19.32<br />

85305 3 BLOOD CLOT INHIBITOR ASSAY 16.20<br />

85306 3 BLOOD CLOT INHIBITOR TEST 21.41<br />

85307 3 ASSAY ACTIVATED PROTEIN C 21.41<br />

85310 O CLOTTING INHIBITORS OR ANTICOAGULAN 0.00<br />

85311 O CLOTTING INHIBITORS OR ANTICOAGULAN 0.00<br />

85320 O CLOTTING INHIBITORS OR ANTICOAGULAN 0.00<br />

85330 O CLOTTING INHIBITORS OR ANTICOAGULAN 0.00<br />

85335 3 FACTOR INHIBITOR TEST 17.99<br />

85337 3 THROMBOMODULIN 14.56<br />

85340 O CLOTTING INHIBITORS OR ANTICOAGULAN 0.00<br />

85341 O CLOTTING INHIBITORS OR ANTICOAGULAN 0.00<br />

85345 3 COAGULATION TIME 4.67<br />

85347 3 COAGULATION TIME 5.95<br />

85348 3 COAGULATION TIME 5.20<br />

85360 3 EUGLOBULIN LYSIS 11.71<br />

85362 3 FIBRIN <strong>DE</strong>GRADATION PRODUCTS 9.62<br />

85363 O FIBRIN <strong>DE</strong>GRADATION (SPLIT) PRODUCTS 0.00<br />

85364 O FIBRIN <strong>DE</strong>GRADATION (SPLIT) PRODUCTS 0.00<br />

85365 O FIBRIN <strong>DE</strong>GRADATION (SPLIT) PRODUCTS 0.00<br />

85366 3 FIBRINOGEN TEST 12.03<br />

85367 O FIBRIN <strong>DE</strong>GRADATION (SPLIT) PRODUCTS 0.00<br />

85368 O FIBRIN <strong>DE</strong>GRADATION (SPLIT) PRODUCTS 0.00<br />

85369 O FIBRIN <strong>DE</strong>GRADATION (SPLIT) PRODUCTS 0.00

---

85370 3 FIBRINOGEN TEST 11.31<br />

85371 O FIBRINOGEN, SEMIQUANTITATIVE LATEX 0.00<br />

85372 O FIBRINOGEN, SEMIQUANTITATIVE TURBID 0.00<br />

85376 O FIBRINOGEN THROMBIN WITH PLASMA DIL 0.00<br />

85377 O FIBRINOGEN THROMBIN TIME DILUTION 0.00<br />

85378 3 FIBRIN <strong>DE</strong>GRA<strong>DE</strong>, SEMIQUANT 9.97<br />

85379 3 FIBRIN <strong>DE</strong>GRADATION, QUANT 11.31<br />

85380 3 FIBRIN <strong>DE</strong>GRADATION, VTE 11.31<br />

85384 3 FIBRINOGEN 11.87<br />

85385 3 FIBRINOGEN 11.87<br />

85390 3 FIBRINOLYSINS SCREEN 7.22<br />

85392 O FIBRINOLYSINS WITH EACA CONTROL 0.00<br />

85395 O FIBRINOLYSINS SEMIQUANTITATIVE 0.00<br />

85396 3 CLOTTING ASSAY, WHOLE BLOOD 21.84<br />

85397 6 CLOTTING FUNCT ACTIVITY 0.00<br />

85398 O FIBRINOLYSIS, QUANTITATIVE 0.00<br />

85400 3 FIBRINOLYTIC PLASMIN 12.36<br />

85410 3 FIBRINOLYTIC ANTIPLASMIN 10.77<br />

85415 3 FIBRINOLYTIC PLASMINOGEN 20.30<br />

85420 3 FIBRINOLYTIC PLASMINOGEN 9.13<br />

85421 3 FIBRINOLYTIC PLASMINOGEN 14.23<br />

85426 O FIBRINOLYTIC MECHANISMS VON WILLEBR 0.00<br />

85441 3 HEINZ BODIES, DIRECT 5.88<br />

85445 3 HEINZ BODIES, INDUCED 8.06<br />

85460 3 HEMOGLOBIN, FETAL 10.81<br />

85461 3 HEMOGLOBIN, FETAL 9.26<br />

85475 3 HEMOLYSIN 10.91<br />

85520 3 HEPARIN ASSAY 18.29<br />

85525 3 HEPARIN NEUTRALIZATION 16.55<br />

85530 3 HEPARIN-PROTAMINE TOLERANCE 19.81<br />

85535 O IRON STAIN, BLOOD CELLS 0.00<br />

85536 3 IRON STAIN PERIPHERAL BLOOD 9.04<br />

85538 O LE<strong>DE</strong>R STAIN (ESTERASE) BLOOD OR BON 0.00<br />

85540 3 WBC ALKALINE PHOSPHATASE 12.02<br />

85544 O LUPUS ERYTHEMATOSUS (LE) CELL PREP 0.00<br />

85547 3 RBC MECHANICAL FRAGILITY 12.02<br />

85548 O MORPHOLOGY OF RED BLOOD CELLS, ONLY 0.00<br />

85549 3 MURAMIDASE 20.28<br />

85555 3 RBC OSMOTIC FRAGILITY 9.34<br />

85556 O OSMOTIC FRAGILITY, RBC INCUBATED, Q 0.00<br />

85557 3 RBC OSMOTIC FRAGILITY 18.66<br />

85560 O PEROXIDASE STAIN, WBC 0.00<br />

85575 O PLATELET; IN VITRO AGGREGATION,EACH 0.00<br />

85576 3 BLOOD PLATELET AGGREGATION 30.01<br />

85577 O PLATELET RETENTION (IN VITRO), GLAS 0.00<br />

85580 O PLATELET COUNT (REES-ECKER) 0.00<br />

85585 O BLOOD PLATELET ESTIMATION 0.00<br />

85590 O PLATELET COUNT, MANUAL 0.00<br />

85595 O PLATELET COUNT, AUTOMATED 0.00<br />

85597 3 PLATELET NEUTRALIZATION 25.12

---

85610 3 PROTHROMBIN TIME 5.49<br />

85611 3 PROTHROMBIN TEST 5.51<br />

85612 3 VIPER VENOM PROTHROMBIN TIME 13.37<br />

85613 3 RUSSELL VIPER VENOM, DILUTED 13.37<br />

85615 O PROTHROMBIN UTILIZATION (CONSUMPTIO 0.00<br />

85618 O PROTHROMBIN-PROCONVERTIN, P&P (OWRE 0.00<br />

85630 O RED BLOOD CELL SIZE (PRICE-JONES) 0.00<br />

85632 O RED BLOOD CELL PEROXI<strong>DE</strong> HEMOLYSIS 0.00<br />

85635 3 REPTILASE TEST 9.77<br />

85650 O SEDIMENTATION RATE (ESR) WINTROBE T 0.00<br />

85651 3 RBC SED RATE, NONAUTOMATED 4.96<br />

85652 3 RBC SED RATE, AUTOMATED 3.77<br />

85660 3 RBC SICKLE CELL TEST 6.31<br />

85665 O STREPTOKINASE TITER (PLASMINOGEN AC 0.00<br />

85667 O T-CELL <strong>DE</strong>PLETION (ANY METHOD) OF BO 0.00<br />

85670 3 THROMBIN TIME, PLASMA 8.07<br />

85675 3 THROMBIN TIME, TITER 9.58<br />

85700 O THROMBOPLASTIN GENERATION TEST SCRE 0.00<br />

85705 3 THROMBOPLASTIN INHIBITION 11.89<br />

85710 O THROMBOPLASTIN GENERATION TEST <strong>DE</strong>FI 0.00<br />

85711 O THROMBOPLASTIN GENERATION TEST WITH 0.00<br />

85720 O THROMBOPLASTIN GENERATION TEST ALL 0.00<br />

85730 3 THROMBOPLASTIN TIME, PARTIAL 8.38<br />

85732 3 THROMBOPLASTIN TIME, PARTIAL 9.04<br />

85810 3 BLOOD VISCOSITY EXAMINATION 16.32<br />

85820 O VISCOSITY SERUM OR PLASMA 0.00<br />

85999 5 HEMATOLOGY PROCEDURE 0.00<br />

86000 3 AGGLUTININS, FEBRILE 9.75<br />

86001 3 ALLERGEN SPECIFIC IGG 7.30<br />

86002 O AGGLUTININS FEBRILE PANEL (TYPHOID 0.00<br />

86003 3 ALLERGEN SPECIFIC IGE 7.30<br />

86004 O AGGLUTININS WARM 0.00<br />

86005 3 ALLERGEN SPECIFIC IGE 4.05<br />

86006 O ANTIBODY, NON-RBC QUALITATIVE FIRST 0.00<br />

86007 O ANTIBODY, NON-RBC QUALITATIVE EACH 0.00<br />

86008 O ANTIBODY, NON-RBC, QUANTITATIVE FIR 0.00<br />

86009 O ANTIBODY, NON-RBC, QUANTITATIVE EAC 0.00<br />

86011 O ANTIBODY, <strong>DE</strong>TECTION, LEUKOCYTE ANTI 0.00<br />

86012 O ANTIBODY ABSORPTION, COLD AUTO ABSO 0.00<br />

86013 O ANTIBODY ABSORPTION, COLD AUTO ABSO 0.00<br />

86014 O ANTIBODY, PLATELET ANTIBODIES (AGGL 0.00<br />

86016 O ANTIBODY SCREEN, RBC, EACH SERUM 0.00<br />

86019 O ANTIBODY (RBC) ELUTION, ANY METHOD, 0.00<br />

86021 3 WBC ANTIBODY I<strong>DE</strong>NTIFICATION 18.58<br />

86022 3 PLATELET ANTIBODIES 18.58<br />

86023 3 IMMUNOGLOBULIN ASSAY 17.40<br />

86024 O ANTIBODY I<strong>DE</strong>NTIFICATION RBC ANTIBOD 0.00<br />

86031 O ANTIHUMAN GLOBULIN TEST DIRECT (COO 0.00<br />

86032 O ANTIHUMAN GLOBULIN TEST INDIRECT, Q 0.00<br />

86033 O ANTIHUMAN GLOBULIN TEST INDIRECT, T 0.00

---

86034 O ANTIHUMAN GLOBULIN TEST ENZYME TECH 0.00<br />

86038 3 ANTINUCLEAR ANTIBODIES 16.89<br />

86039 3 ANTINUCLEAR ANTIBODIES (ANA) 15.60<br />

86060 3 ANTISTREPTOLYSIN O, TITER 10.20<br />

86063 3 ANTISTREPTOLYSIN O, SCREEN 8.07<br />

86064 O B CELLS, TOTAL COUNT 0.00<br />

86066 O ANTITRYPSIN, ALPHA-1 PI (PROTEASE I 0.00<br />

86067 O ANTITRYPSIN, ALPHA-1 OTHER METHOD ( 0.00<br />

86068 O BLOOD COMPATIBILITY TEST CROSSMATCH 0.00<br />

86070 O BLOOD COMPATIBILITY TEST CROSSMATCH 0.00<br />

86077 9 PHYSICIAN BLOOD BANK SERVICE 0.00<br />

86078 9 PHYSICIAN BLOOD BANK SERVICE 0.00<br />

86079 9 PHYSICIAN BLOOD BANK SERVICE 0.00<br />

86080 O BLOOD TYPING ABO ONLY 0.00<br />

86082 O BLOOD TYPING ABO AND RHO(D) 0.00<br />

86083 O BLOOD TYPING ABO, RH(D) AND RBC ANT 0.00<br />

86084 O BLOOD TYPING ANTIGEN SCREENING FOR 0.00<br />

86085 O BLOOD TYPING ANTIGEN SCREENING FOR 0.00<br />

86095 O BLOOD TYPING RBC ANTIGENS, OTHER TH 0.00<br />

86100 O BLOOD TYPING RHO(D) ONLY 0.00<br />

86105 O BLOOD TYPING RH GENOTYPING, COMPLET 0.00<br />

86115 O BLOOD TYPING ANTI-RH IMMUNOGLOBULIN 0.00<br />

86128 O COLLECTION, PROCESSING AND STORAGE 0.00<br />

86130 O COLLECTION AND PROCESSING FOR TRANS 0.00<br />

86140 3 C-REACTIVE PROTEIN 7.23<br />

86141 3 C-REACTIVE PROTEIN, HS 18.09<br />

86146 3 GLYCOPROTEIN ANTIBODY 35.54<br />

86147 3 CARDIOLIPIN ANTIBODY 35.54<br />

86148 3 PHOSPHOLIPID ANTIBODY 13.87<br />

86149 O CARCINOEMBRYONIC ANTIGEN (CEA) GEL 0.00<br />

86151 O CARCINOEMBRYONIC ANTIGEN (CEA) RIA 0.00<br />

86155 3 CHEMOTAXIS ASSAY 22.33<br />

86156 3 COLD AGGLUTININ, SCREEN 8.92<br />

86157 3 COLD AGGLUTININ, TITER 11.27<br />

86158 O COMPLEMENT C'1 ESTERASE 0.00<br />

86159 O COMPLEMENT C'2 ESTERASE 0.00<br />

86160 3 COMPLEMENT, ANTIGEN 16.78<br />

86161 3 COMPLEMENT/FUNCTION ACTIVITY 16.78<br />

86162 3 COMPLEMENT, TOTAL (CH50) 28.39<br />

86163 O COMPLEMENT C'3 ESTERASE 0.00<br />

86164 O COMPLEMENT C'4 ESTERASE 0.00<br />

86171 3 COMPLEMENT FIXATION, EACH 9.88<br />

86185 3 COUNTERIMMUNOELECTROPHORESIS 12.50<br />

86200 3 CCP ANTIBODY 18.09<br />

86215 3 <strong>DE</strong>OXYRIBONUCLEASE, ANTIBODY 18.51<br />

86225 3 DNA ANTIBODY 19.20<br />

86226 3 DNA ANTIBODY, SINGLE STRAND 16.92<br />

86235 3 NUCLEAR ANTIGEN ANTIBODY 25.06<br />

86243 3 FC RECEPTOR 28.68<br />

86244 O FETO-PROTEIN, ALPHA-1, RIA OR EIA 0.00

---

86255 3 FLUORESCENT ANTIBODY, SCREEN 16.84<br />

86256 3 FLUORESCENT ANTIBODY, TITER 12.22<br />

86265 O FROZEN BLOOD, PREPARATION FOR FREEZ 0.00<br />

86266 O FROZEN BLOOD, PREPARATION FOR FREEZ 0.00<br />

86267 O FROZEN BLOOD, PREPARATION FOR FREEZ 0.00<br />

86277 3 GROWTH HORMONE ANTIBODY 21.99<br />

86280 3 HEMAGGLUTINATION INHIBITION 11.44<br />

86281 O HEMOLYSINS, ACID (FOR PAROXYSMAL HE 0.00<br />

86282 O HEMOLYSINS AND AGGLUTININS, AUTO, S 0.00<br />

86283 O HEMOLYSINS AND AGGLUTININS, AUTO, S 0.00<br />

86287 O HEPATITIS B SURFACE ANTIGEN (HBSAG) 0.00<br />

86288 O HEPATITIS B CORE ANTIGEN (HBCAG), R 0.00<br />

86289 O HEPATITIS B CORE ANTIBODY (HBCAB); 0.00<br />

86290 O HEPATITIS B CORE ANTIBODY (HBCAB); 0.00<br />

86291 O HEPATITIS B SURFACE ANTIBODY (HBSAB 0.00<br />

86293 O HEPATITIS BE ANTIGEN (HBEAG) 0.00<br />

86294 3 IMMUNOASSAY, TUMOR, QUAL 24.45<br />

86295 O HEPATITIS BE ANTIBODY (HBEAB) 0.00<br />

86296 O HEPATITIS A ANTIBODY (HAAB); IGG AN 0.00<br />

86298 O HEPATITIS A ANTIBODY (HAAB) (EG, RI 0.00<br />

86299 O HEPATITIS A ANTIBODY (HAAB); IGM AN 0.00<br />

86300 3 IMMUNOASSAY, TUMOR, CA 15-3 29.07<br />

86301 3 IMMUNOASSAY, TUMOR, CA 19-9 29.07<br />

86302 O HEPATITIS C ANTIBODY; 0.00<br />

86303 O HEPATITIS C ANTIBODY; CONFIRMATORY 0.00<br />

86304 3 IMMUNOASSAY, TUMOR, CA 125 29.07<br />

86305 O HETEROPHILE ANTIBODIES QUANTITATIVE 0.00<br />

86306 O HEPATITIS, <strong>DE</strong>LTA AGENT 0.00<br />

86308 3 HETEROPHILE ANTIBODIES 7.23<br />

86309 3 HETEROPHILE ANTIBODIES 8.58<br />

86310 3 HETEROPHILE ANTIBODIES 10.30<br />

86311 O HIV, ANTIGEN 0.00<br />

86312 O HIV (HTLV-III) ANTIBODY <strong>DE</strong>TECTION I 0.00<br />

86313 O IMMUNOASSAY FOR INFECTIOUS AGENT AN 0.00<br />

86314 O HIV (HTLV-III) ANTIBODY <strong>DE</strong>TECTION C 0.00<br />

86315 O IMMUNOASSAY FOR INFECTIOUS AGENT AN 0.00<br />

86316 3 IMMUNOASSAY, TUMOR OTHER 29.07<br />

86317 3 IMMUNOASSAY,INFECTIOUS AGENT 20.95<br />

86318 3 IMMUNOASSAY,INFECTIOUS AGENT 18.09<br />

86319 O IMMUNOASSAY TECHNIQUE FOR DRUGS 0.00<br />

86320 3 SERUM IMMUNOELECTROPHORESIS 31.32<br />

86325 3 OTHER IMMUNOELECTROPHORESIS 29.78<br />

86327 3 IMMUNOELECTROPHORESIS ASSAY 31.70<br />

86329 3 IMMUNODIFFUSION 19.62<br />

86331 3 IMMUNODIFFUSION OUCHTERLONY 16.75<br />

86332 3 IMMUNE COMPLEX ASSAY 34.05<br />

86333 O IMMUNE COMPLEX ASSAY RAJI CELL 0.00<br />

86334 3 IMMUNOFIX E-PHORESIS, SERUM 31.21<br />

86335 3 IMMUNOFIXATION ELECTROPHORESIS; OT 41.00<br />

86336 3 INHIBIN A 21.77

---

86337 3 INSULIN ANTIBODIES 20.42<br />

86338 O INSULIN FACTOR ANTIBODIES, RIA 0.00<br />

86340 3 INTRINSIC FACTOR ANTIBODY 21.06<br />

86341 3 ISLET CELL ANTIBODY 27.65<br />

86342 O IRRADIATION OF BLOOD PRODUCTS, EACH 0.00<br />

86343 3 LEUKOCYTE HISTAMINE RELEASE 17.41<br />

86344 3 LEUKOCYTE PHAGOCYTOSIS 11.16<br />

86349 O LEUKOCYTE TRANSFUSION (LEUKAPHERESI 0.00<br />

86353 3 LYMPHOCYTE TRANSFORMATION 68.49<br />

86355 3 B CELLS, TOTAL COUNT 52.70<br />

86356 3 MONONUCLEAR CELL ANTIGEN 37.41<br />

86357 3 NATURAL KILLER (NK) CELLS, TOTAL C 52.70<br />

86358 O LYMPHOCYTES B-CELL EVALUATION 0.00<br />

86359 3 T CELLS, TOTAL COUNT 52.70<br />

86360 3 T CELL, ABSOLUTE COUNT/RATIO 65.65<br />

86361 3 T CELL, ABSOLUTE COUNT 37.41<br />

86367 3 STEM CELLS, TOTAL COUNT 52.70<br />

86376 3 MICROSOMAL ANTIBODY 20.33<br />

86377 O MICROSOMAL ANTIBODY (THYROID) OTHER 0.00<br />

86378 3 MIGRATION INHIBITORY FACTOR 27.51<br />

86379 O NK CELLS, TOTAL COUNT 0.00<br />

86382 3 NEUTRALIZATION TEST, VIRAL 23.62<br />

86384 3 NITROBLUE TETRAZOLIUM DYE 15.91<br />

86385 O PATERNITY TESTING, ABO+RH FACTORS+M 0.00<br />

86386 O PATERNITY TESTING, ABO+RH FACTORS+M 0.00<br />

86403 3 PARTICLE AGGLUTINATION TEST 14.24<br />

86404 O POOLING OF PLATELETS OR OTHER BLOOD 0.00<br />

86405 O PRECIPITIN TEST FOR BLOOD (SPECIES 0.00<br />

86406 3 PARTICLE AGGLUTINATION TEST 14.87<br />

86410 O PRETREATMENT OF RBC'S FOR USE IN RB 0.00<br />

86411 O PRETREATMENT OF RBC'S FOR USE IN RB 0.00<br />

86412 O PRETREATMENT OF RBC'S FOR USE IN RB 0.00<br />

86417 O PRETREATMENT OF SERUM FOR USE IN RB 0.00<br />

86418 O PRETREATMENT OF SERUM FOR USE IN RB 0.00<br />

86419 O PRETREATMENT OF SERUM FOR USE IN RB 0.00<br />

86420 O PRETREATMENT OF SERUM FOR USE IN RB 0.00<br />

86421 O RADIOALLERGOSORBENT TEST, IN VITRO 0.00<br />

86422 9 RADIOALLERGOSORBENT TEST, IN VITRO 0.00<br />

86423 O RADIOIMMUNOSORBENT TEST (RIST) IGE, 0.00<br />

86430 3 RHEUMATOID FACTOR TEST 7.93<br />

86431 3 RHEUMATOID FACTOR, QUANT 7.93<br />

86455 O SKIN TEST ANERGY TESTING, ONE OR MO 0.00<br />

86480 3 TB TEST, CELL IMMUN MEASURE 86.59<br />

86485 5 SKIN TEST, CANDIDA 0.00<br />

86486 6 SKIN TEST, NOS ANTIGEN 0.00<br />

86490 3 COCCIDIOIDOMYCOSIS SKIN TEST 11.81<br />

86510 3 HISTOPLASMOSIS SKIN TEST 12.97<br />

86540 O SKIN TEST MUMPS 0.00<br />

86580 3 TB INTRA<strong>DE</strong>RMAL TEST 5.00<br />

86585 O TB TINE TEST 0.00

---

86586 O SKIN TEST, UNLISTED 0.00<br />

86587 O STEM CELLS (IE, CD34), TOTAL COUNT 0.00<br />

86588 O STREPTOCOLLUS, DIRECT SCREEN 0.00<br />

86590 3 STREPTOKINASE, ANTIBODY 15.41<br />

86592 3 BLOOD SEROLOGY, QUALITATIVE 5.73<br />

86593 3 BLOOD SEROLOGY, QUANTITATIVE 6.11<br />

86594 O THYROID AUTOANTIBODIES 0.00<br />

86595 O TISSUE CULTURE 0.00<br />

86600 O TOXOPLASMOSIS, DYE TEST 0.00<br />

86602 3 ANTINOMYCES ANTIBODY 14.22<br />

86603 3 A<strong>DE</strong>NOVIRUS ANTIBODY 17.98<br />

86606 3 ASPERGILLUS ANTIBODY 21.03<br />

86609 3 BACTERIUM ANTIBODY 18.00<br />

86611 3 BARTONELLA ANTIBODY 14.22<br />

86612 3 BLASTOMYCES ANTIBODY 18.03<br />

86615 3 BOR<strong>DE</strong>TELLA ANTIBODY 18.43<br />

86617 3 LYME DISEASE ANTIBODY 21.64<br />

86618 3 LYME DISEASE ANTIBODY 23.80<br />

86619 3 BORRELIA ANTIBODY 18.69<br />

86622 3 BRUCELLA ANTIBODY 11.43<br />

86625 3 CAMPYLOBACTER ANTIBODY 18.33<br />

86628 3 CANDIDA ANTIBODY 16.78<br />

86630 O TRANSFER FACTOR TEST (TFT) 0.00<br />

86631 3 CHLAMYDIA ANTIBODY 9.88<br />

86632 3 CHLAMYDIA IGM ANTIBODY 17.74<br />

86635 3 COCCIDIOI<strong>DE</strong>S ANTIBODY 16.03<br />

86638 3 Q FEVER ANTIBODY 16.94<br />

86641 3 CRYPTOCOCCUS ANTIBODY 20.14<br />

86644 3 CMV ANTIBODY 20.11<br />

86645 3 CMV ANTIBODY, IGM 23.54<br />

86648 3 DIPHTHERIA ANTIBODY 21.25<br />

86650 O TREPONEMA ANTIBODIES, FLUORESCENT, 0.00<br />

86651 3 ENCEPHALITIS ANTIBODY 18.43<br />

86652 3 ENCEPHALITIS ANTIBODY 18.43<br />

86653 3 ENCEPHALITIS ANTIBODY 18.43<br />

86654 3 ENCEPHALITIS ANTIBODY 18.43<br />

86658 3 ENTEROVIRUS ANTIBODY 18.20<br />

86662 O TREPONEMA PALLIDUM TEST, OTHER, SPE 0.00<br />

86663 3 EPSTEIN-BARR ANTIBODY 18.33<br />

86664 3 EPSTEIN-BARR ANTIBODY 21.38<br />

86665 3 EPSTEIN-BARR ANTIBODY 25.35<br />

86666 3 EHRLICHIA ANTIBODY 14.22<br />

86668 3 FRANCISELLA TULARENSIS 14.53<br />

86671 3 FUNGUS ANTIBODY 17.13<br />

86674 3 GIARDIA LAMBLIA ANTIBODY 20.56<br />

86677 3 HELICOBACTER PYLORI 20.28<br />

86681 O ADRENAL CORTEX ANTIBODIES, RIA 0.00<br />

86682 3 HELMINTH ANTIBODY 18.17<br />

86683 O HEMOGLOBIN, FECAL ANTIBODY 0.00<br />

86684 3 HEMOPHILUS INFLUENZA 22.14

---

86685 O ANTI-ACHR (ACETYLCHOLINE RECEPTOR) 0.00<br />

86687 3 HTLV-I ANTIBODY 11.72<br />

86688 3 HTLV-II ANTIBODY 14.76<br />

86689 3 HTLV/HIV CONFIRMATORY TEST 27.05<br />

86692 3 HEPATITIS, <strong>DE</strong>LTA AGENT 23.98<br />

86694 3 HERPES SIMPLEX TEST 20.11<br />

86695 3 HERPES SIMPLEX TEST 18.43<br />

86696 3 HERPES SIMPLEX TYPE 2 27.05<br />

86698 3 HISTOPLASMA 17.46<br />

86701 3 HIV-1 12.41<br />

86702 3 HIV-2 14.76<br />

86703 3 HIV-1/HIV-2, SINGLE ASSAY 19.17<br />

86704 3 HEP B CORE ANTIBODY, TOTAL 16.84<br />

86705 3 HEP B CORE ANTIBODY, IGM 16.44<br />

86706 3 HEP B SURFACE ANTIBODY 15.01<br />

86707 3 HEP BE ANTIBODY 16.16<br />

86708 3 HEP A ANTIBODY, TOTAL 17.31<br />

86709 3 HEP A ANTIBODY, IGM 15.73<br />

86710 3 INFLUENZA VIRUS ANTIBODY 18.94<br />

86713 3 LEGIONELLA ANTIBODY 21.39<br />

86717 3 LEISHMANIA ANTIBODY 17.12<br />

86720 3 LEPTOSPIRA ANTIBODY 18.43<br />

86723 3 LISTERIA MONOCYTOGENES AB 18.43<br />

86727 3 LYMPH CHORIOMENINGITIS AB 17.98<br />

86729 3 LYMPHO VENEREUM ANTIBODY 9.88<br />

86732 3 MUCORMYCOSIS ANTIBODY 18.43<br />

86735 3 MUMPS ANTIBODY 18.23<br />

86738 3 MYCOPLASMA ANTIBODY 18.51<br />

86741 3 NEISSERIA MENINGITIDIS 18.43<br />

86744 3 NOCARDIA ANTIBODY 18.43<br />

86747 3 PARVOVIRUS ANTIBODY 21.00<br />

86750 3 MALARIA ANTIBODY 18.43<br />

86753 3 PROTOZOA ANTIBODY NOS 17.32<br />

86756 3 RESPIRATORY VIRUS ANTIBODY 18.01<br />

86757 3 RICKETTSIA ANTIBODY 27.05<br />

86759 3 ROTAVIRUS ANTIBODY 18.43<br />

86762 3 RUBELLA ANTIBODY 20.11<br />

86765 3 RUBEOLA ANTIBODY 13.68<br />

86768 3 SALMONELLA ANTIBODY 18.43<br />

86771 3 SHIGELLA ANTIBODY 18.43<br />

86774 3 TETANUS ANTIBODY 20.68<br />

86777 3 TOXOPLASMA ANTIBODY 20.11<br />

86778 3 TOXOPLASMA ANTIBODY, IGM 20.12<br />

86781 3 TREPONEMA PALLIDUM, CONFIRM 18.50<br />

86784 3 TRICHINELLA ANTIBODY 17.55<br />

86787 3 VARICELLA-ZOSTER ANTIBODY 18.00<br />

86788 3 WEST NILE VIRUS AB, IGM 23.54<br />

86789 3 WEST NILE VIRUS ANTIBODY 20.11<br />

86790 3 VIRUS ANTIBODY NOS 18.00<br />

86793 3 YERSINIA ANTIBODY 12.12

---

86800 3 THYROGLOBULIN ANTIBODY 22.22<br />

86803 3 HEPATITIS C AB TEST 19.94<br />

86804 3 HEP C AB TEST, CONFIRM 21.64<br />

86805 3 LYMPHOCYTOTOXICITY ASSAY 47.03<br />

86806 3 LYMPHOCYTOTOXICITY ASSAY 47.03<br />

86807 3 CYTOTOXIC ANTIBODY SCREENING 55.29<br />

86808 3 CYTOTOXIC ANTIBODY SCREENING 41.47<br />

86812 3 HLA TYPING, A, B, OR C 36.06<br />

86813 3 HLA TYPING, A, B, OR C 81.02<br />

86816 3 HLA TYPING, DR/DQ 38.92<br />

86817 3 HLA TYPING, DR/DQ 89.95<br />

86821 3 LYMPHOCYTE CULTURE, MIXED 78.88<br />

86822 3 LYMPHOCYTE CULTURE, PRIMED 51.07<br />

86849 5 IMMUNOLOGY PROCEDURE 0.00<br />

86850 3 RBC ANTIBODY SCREEN 15.00<br />

86860 5 RBC ANTIBODY ELUTION 0.00<br />

86870 3 RBC ANTIBODY I<strong>DE</strong>NTIFICATION 15.00<br />

86880 3 COOMBS TEST, DIRECT 7.50<br />

86885 3 COOMBS TEST, INDIRECT, QUAL 7.99<br />

86886 3 COOMBS TEST, INDIRECT, TITER 7.23<br />

86890 5 AUTOLOGOUS BLOOD PROCESS 0.00<br />

86891 5 AUTOLOGOUS BLOOD, OP SALVAGE 0.00<br />

86900 3 BLOOD TYPING, ABO 4.17<br />

86901 3 BLOOD TYPING, RH (D) 4.17<br />

86903 3 BLOOD TYPING, ANTIGEN SCREEN 13.19<br />

86904 3 BLOOD TYPING, PATIENT SERUM 13.28<br />

86905 3 BLOOD TYPING, RBC ANTIGENS 5.34<br />

86906 3 BLOOD TYPING, RH PHENOTYPE 10.83<br />

86910 9 BLOOD TYPING, PATERNITY TEST 0.00<br />

86911 9 BLOOD TYPING, ANTIGEN SYSTEM 0.00<br />

86915 O BONE MARROW/STEM CELL PREP 0.00<br />

86920 3 COMPATIBILITY TEST, SPIN 36.00<br />

86921 3 COMPATIBILITY TEST, INCUBATE 36.00<br />

86922 3 COMPATIBILITY TEST, ANTIGLOB 36.00<br />

86923 6 COMPATIBILITY TEST, ELECTRIC 0.00<br />

86927 5 PLASMA, FRESH FROZEN 0.00<br />

86930 5 FROZEN BLOOD PREP 0.00<br />

86931 5 FROZEN BLOOD THAW 0.00<br />

86932 5 FROZEN BLOOD FREEZE/THAW 0.00<br />

86940 3 HEMOLYSINS/AGGLUTININS, AUTO 8.53<br />

86941 3 HEMOLYSINS/AGGLUTININS 16.62<br />

86945 3 BLOOD PRODUCT/IRRADIATION 42.00<br />

86950 5 LEUKACYTE TRANSFUSION 0.00<br />

86960 6 VOL REDUCTION OF BLOOD/PROD 0.00<br />

86965 5 POOLING BLOOD PLATELETS 0.00<br />

86970 5 RBC PRETREATMENT 0.00<br />

86971 5 RBC PRETREATMENT 0.00<br />

86972 5 RBC PRETREATMENT 0.00<br />

86975 5 RBC PRETREATMENT, SERUM 0.00<br />

86976 5 RBC PRETREATMENT, SERUM 0.00

---

86977 5 RBC PRETREATMENT, SERUM 0.00<br />

86978 5 RBC PRETREATMENT, SERUM 0.00<br />

86985 5 SPLIT BLOOD OR PRODUCTS 0.00<br />

86999 5 TRANSFUSION PROCEDURE 0.00<br />

87001 3 SMALL ANIMAL INOCULATION 18.47<br />

87003 3 SMALL ANIMAL INOCULATION 23.52<br />

87015 3 SPECIMEN CONCENTRATION 9.33<br />

87040 3 BLOOD CULTURE FOR BACTERIA 14.42<br />

87045 3 FECES CULTURE, BACTERIA 13.18<br />

87046 3 STOOL CULTR, BACTERIA, EACH 13.18<br />

87060 O NOSE/THROAT CULTURE, BACT 0.00<br />

87070 3 CULTURE, BACTERIA, OTHER 12.03<br />

87071 3 CULTURE BACTERI AEROBIC OTHR 13.18<br />

87072 O CULTURE OF SPECIMEN BY KIT 0.00<br />

87073 3 CULTURE BACTERIA ANAEROBIC 13.18<br />

87075 3 CULTR BACTERIA, EXCEPT BLOOD 13.22<br />

87076 3 CULTURE ANAEROBE I<strong>DE</strong>NT, EACH 11.29<br />

87077 3 CULTURE AEROBIC I<strong>DE</strong>NTIFY 11.29<br />

87081 3 CULTURE SCREEN ONLY 9.26<br />

87082 O CULTURE OF SPECIMEN BY KIT 0.00<br />

87083 O CULTURE OF SPECIMEN BY KIT 0.00<br />

87084 3 CULTURE OF SPECIMEN BY KIT 12.03<br />

87085 O CULTURE OF SPECIMEN BY KIT 0.00<br />

87086 3 URINE CULTURE/COLONY COUNT 11.28<br />

87087 O URINE BACTERIA CULTURE 0.00<br />

87088 3 URINE BACTERIA CULTURE 11.31<br />

87101 3 SKIN FUNGI CULTURE 10.77<br />

87102 3 FUNGUS ISOLATION CULTURE 11.74<br />

87103 3 BLOOD FUNGUS CULTURE 12.60<br />

87106 3 FUNGI I<strong>DE</strong>NTIFICATION, YEAST 14.42<br />

87107 3 FUNGI I<strong>DE</strong>NTIFICATION, MOLD 14.42<br />

87109 3 MYCOPLASMA 21.50<br />

87110 3 CHLAMYDIA CULTURE 27.37<br />

87116 3 MYCOBACTERIA CULTURE 15.10<br />

87117 O MYCOBACTERIA CULTURE 0.00<br />

87118 3 MYCOBACTERIC I<strong>DE</strong>NTIFICATION 15.29<br />

87140 3 CULTURE TYPE IMMUNOFLUORESC 6.76<br />

87143 3 CULTURE TYPING, GLC/HPLC 17.51<br />

87145 O CULTURE TYPING, PHAGE METHOD 0.00<br />

87147 3 CULTURE TYPE, IMMUNOLOGIC 7.23<br />

87149 3 CULTURE TYPE, NUCLEIC ACID 28.02<br />

87151 O CULTURE TYPING, SEROLOGIC 0.00<br />

87152 3 CULTURE TYPE PULSE FIELD GEL 7.31<br />

87155 O CULTURE TYPING, PRECIPITIN 0.00<br />

87158 3 CULTURE TYPING, AD<strong>DE</strong>D METHOD 7.31<br />

87163 O SPECIAL MICROBIOLOGY CULTURE 0.00<br />

87164 3 DARK FIELD EXAMINATION 15.01<br />

87166 3 DARK FIELD EXAMINATION 15.78<br />

87168 3 MACROSCOPIC EXAM ARTHROPOD 5.96<br />

87169 3 MACROSCOPIC EXAM PARASITE 5.96

---

87172 3 PINWORM EXAM 5.96<br />

87174 O ENDOTOXIN, BACTERIAL 0.00<br />

87175 O ASSAY, ENDOTOXIN, BACTERIAL 0.00<br />

87176 3 TISSUE HOMOGENIZATION, CULTR 8.22<br />

87177 3 OVA AND PARASITES SMEARS 12.43<br />

87178 O MICROBIAL I<strong>DE</strong>NTIFICATION, NUCLEIC A 0.00<br />

87179 O MICROBIAL I<strong>DE</strong>NTIFICATION, NUCLEIC A 0.00<br />

87181 3 MICROBE SUSCEPTIBLE, DIFFUSE 6.64<br />

87184 3 MICROBE SUSCEPTIBLE, DISK 9.63<br />

87185 3 MICROBE SUSCEPTIBLE, ENZYME 6.64<br />

87186 3 MICROBE SUSCEPTIBLE, MIC 12.08<br />

87187 3 MICROBE SUSCEPTIBLE, MLC 14.48<br />

87188 3 MICROBE SUSCEPT, MACROBROTH 8.97<br />

87190 3 MICROBE SUSCEPT, MYCOBACTERI 7.90<br />

87192 O ANTIBIOTIC SENSITIVITY, EACH 0.00<br />

87197 3 BACTERICIDAL LEVEL, SERUM 16.24<br />

87198 O CYTOMEGALOVIRUS ANTIBODY DFA 0.00<br />

87199 O ENTEROVIRUS ANTIBODY, DFA 0.00<br />

87205 3 SMEAR, GRAM STAIN 5.96<br />

87206 3 SMEAR, FLUORESCENT/ACID STAI 6.76<br />

87207 3 SMEAR, SPECIAL STAIN 8.06<br />

87208 O SMEAR, STAIN & INTERPRET 0.00<br />

87209 3 SMEAR, COMPLEX STAIN 24.18<br />

87210 3 SMEAR, WET MOUNT, SALINE/INK 5.96<br />

87211 O SMEAR, STAIN & INTERPRET 0.00<br />

87220 3 TISSUE EXAM FOR FUNGI 4.83<br />

87230 3 ASSAY, TOXIN OR ANTITOXIN 24.37<br />

87250 3 VIRUS INOCULATE, EGGS/ANIMAL 27.32<br />

87252 3 VIRUS INOCULATION, TISSUE 36.42<br />

87253 3 VIRUS INOCULATE TISSUE, ADDL 28.22<br />

87254 3 VIRUS INOCULATION, SHELL VIA 27.32<br />

87255 3 GENET VIRUS ISOLATE, HSV 47.31<br />

87260 3 A<strong>DE</strong>NOVIRUS AG, IF 15.39<br />

87265 3 PERTUSSIS AG, IF 15.39<br />

87267 3 ENTEROVIRUS ANTIBODY, DFA 15.39<br />

87269 3 GIARDIA AG, IF 15.39<br />

87270 3 CHLAMYDIA TRACHOMATIS AG, IF 15.39<br />

87271 3 CYTOMEGALOVIRUS DFA 15.39<br />

87272 3 CRYPTOSPORIDIUM AG, IF 15.39<br />

87273 3 HERPES SIMPLEX 2, AG, IF 15.39<br />

87274 3 HERPES SIMPLEX 1, AG, IF 15.39<br />

87275 3 INFLUENZA B, AG, IF 15.39<br />

87276 3 INFLUENZA A, AG, IF 15.39<br />

87277 3 LEGIONELLA MICDA<strong>DE</strong>I, AG, IF 15.39<br />

87278 3 LEGION PNEUMOPHILIA AG, IF 15.39<br />

87279 3 PARAINFLUENZA, AG, IF 15.39<br />

87280 3 RESPIRATORY SYNCYTIAL AG, IF 15.39<br />

87281 3 PNEUMOCYSTIS CARINII, AG, IF 15.39<br />

87283 3 RUBEOLA, AG, IF 15.39<br />

87285 3 TREPONEMA PALLIDUM, AG, IF 15.39

---

87290 3 VARICELLA ZOSTER, AG, IF 15.39<br />

87299 3 ANTIBODY <strong>DE</strong>TECTION, NOS, IF 15.39<br />

87300 3 AG <strong>DE</strong>TECTION, POLYVAL, IF 15.39<br />

87301 3 A<strong>DE</strong>NOVIRUS AG, EIA 15.39<br />

87305 3 ASPERGILLUS AG, EIA 15.39<br />

87320 3 CHYLMD TRACH AG, EIA 15.39<br />

87324 3 CLOSTRIDIUM AG, EIA 15.39<br />

87327 3 CRYPTOCOCCUS NEOFORM AG, EIA 15.39<br />

87328 3 CRYPTOSPORIDIUM AG, EIA 15.39<br />

87329 3 GIARDIA AG, EIA 15.39<br />

87332 3 CYTOMEGALOVIRUS AG, EIA 15.39<br />

87335 3 E COLI 0157 AG, EIA 15.39<br />

87336 3 ENTAMOEB HIST DISPR, AG, EIA 15.39<br />

87337 3 ENTAMOEB HIST GROUP, AG, EIA 15.39<br />

87338 3 HPYLORI, STOOL, EIA 15.39<br />

87339 3 H PYLORI AG, EIA 15.39<br />

87340 3 HEPATITIS B SURFACE AG, EIA 14.17<br />

87341 3 HEPATITIS B SURFACE, AG, EIA 14.17<br />

87350 3 HEPATITIS BE AG, EIA 16.10<br />

87380 3 HEPATITIS <strong>DE</strong>LTA AG, EIA 22.94<br />

87385 3 HISTOPLASMA CAPSUL AG, EIA 15.39<br />

87390 3 HIV-1 AG, EIA 24.65<br />

87391 3 HIV-2 AG, EIA 24.65<br />

87400 3 INFLUENZA A/B, AG, EIA 15.39<br />

87420 3 RESP SYNCYTIAL AG, EIA 15.39<br />

87425 3 ROTAVIRUS AG, EIA 15.39<br />

87427 3 SHIGA-LIKE TOXIN AG, EIA 15.39<br />

87430 3 STREP A AG, EIA 15.39<br />

87449 3 AG <strong>DE</strong>TECT NOS, EIA, MULT 15.39<br />

87450 3 AG <strong>DE</strong>TECT NOS, EIA, SINGLE 13.39<br />

87451 3 AG <strong>DE</strong>TECT POLYVAL, EIA, MULT 13.39<br />

87470 3 BARTONELLA, DNA, DIR PROBE 28.02<br />

87471 3 BARTONELLA, DNA, AMP PROBE 49.04<br />

87472 3 BARTONELLA, DNA, QUANT 39.65<br />

87475 3 LYME DIS, DNA, DIR PROBE 28.02<br />

87476 3 LYME DIS, DNA, AMP PROBE 49.04<br />

87477 3 LYME DIS, DNA, QUANT 39.65<br />

87480 3 CANDIDA, DNA, DIR PROBE 28.02<br />

87481 3 CANDIDA, DNA, AMP PROBE 49.04<br />

87482 3 CANDIDA, DNA, QUANT 39.65<br />

87485 3 CHYLMD PNEUM, DNA, DIR PROBE 28.02<br />

87486 3 CHYLMD PNEUM, DNA, AMP PROBE 49.04<br />

87487 3 CHYLMD PNEUM, DNA, QUANT 39.65<br />

87490 3 CHYLMD TRACH, DNA, DIR PROBE 28.02<br />

87491 3 CHYLMD TRACH, DNA, AMP PROBE 49.04<br />

87492 3 CHYLMD TRACH, DNA, QUANT 39.65<br />

87495 3 CYTOMEG, DNA, DIR PROBE 28.02<br />

87496 3 CYTOMEG, DNA, AMP PROBE 49.04<br />

87497 3 CYTOMEG, DNA, QUANT 39.65<br />

87498 3 ENTEROVIRUS, DNA, AMP PROBE 49.04

---

87500 3 VANOMYCIN, DNA, AMP PROBE 49.04<br />

87510 3 GARDNER VAG, DNA, DIR PROBE 28.02<br />

87511 3 GARDNER VAG, DNA, AMP PROBE 49.04<br />

87512 3 GARDNER VAG, DNA, QUANT 39.65<br />

87515 3 HEPATITIS B, DNA, DIR PROBE 28.02<br />

87516 3 HEPATITIS B, DNA, AMP PROBE 49.04<br />

87517 3 HEPATITIS B, DNA, QUANT 39.65<br />

87520 3 HEPATITIS C, RNA, DIR PROBE 28.02<br />

87521 3 HEPATITIS C, RNA, AMP PROBE 49.04<br />

87522 3 HEPATITIS C, RNA, QUANT 39.65<br />

87525 3 HEPATITIS G, DNA, DIR PROBE 28.02<br />

87526 3 HEPATITIS G, DNA, AMP PROBE 49.04<br />

87527 3 HEPATITIS G, DNA, QUANT 39.65<br />

87528 3 HSV, DNA, DIR PROBE 28.02<br />

87529 3 HSV, DNA, AMP PROBE 49.04<br />

87530 3 HSV, DNA, QUANT 39.65<br />

87531 3 HHV-6, DNA, DIR PROBE 28.02<br />

87532 3 HHV-6, DNA, AMP PROBE 49.04<br />

87533 3 HHV-6, DNA, QUANT 39.65<br />

87534 3 HIV-1, DNA, DIR PROBE 28.02<br />

87535 3 HIV-1, DNA, AMP PROBE 49.04<br />

87536 3 HIV-1, DNA, QUANT 118.89<br />

87537 3 HIV-2, DNA, DIR PROBE 28.02<br />

87538 3 HIV-2, DNA, AMP PROBE 49.04<br />

87539 3 HIV-2, DNA, QUANT 39.65<br />

87540 3 LEGION PNEUMO, DNA, DIR PROB 28.02<br />

87541 3 LEGION PNEUMO, DNA, AMP PROB 49.04<br />

87542 3 LEGION PNEUMO, DNA, QUANT 39.65<br />

87550 3 MYCOBACTERIA, DNA, DIR PROBE 28.02<br />

87551 3 MYCOBACTERIA, DNA, AMP PROBE 49.04<br />

87552 3 MYCOBACTERIA, DNA, QUANT 39.65<br />

87555 3 M.TUBERCULO, DNA, DIR PROBE 28.02<br />

87556 3 M.TUBERCULO, DNA, AMP PROBE 49.04<br />

87557 3 M.TUBERCULO, DNA, QUANT 39.65<br />

87560 3 M.AVIUM-INTRA, DNA, DIR PROB 28.02<br />

87561 3 M.AVIUM-INTRA, DNA, AMP PROB 49.04<br />

87562 3 M.AVIUM-INTRA, DNA, QUANT 39.65<br />

87580 3 M.PNEUMON, DNA, DIR PROBE 28.02<br />

87581 3 M.PNEUMON, DNA, AMP PROBE 49.04<br />

87582 3 M.PNEUMON, DNA, QUANT 39.65<br />

87590 3 N.GONORRHOEAE, DNA, DIR PROB 28.02<br />

87591 3 N.GONORRHOEAE, DNA, AMP PROB 49.04<br />

87592 3 N.GONORRHOEAE, DNA, QUANT 39.65<br />

87620 3 HPV, DNA, DIR PROBE 28.02<br />

87621 3 HPV, DNA, AMP PROBE 49.04<br />

87622 3 HPV, DNA, QUANT 39.65<br />

87640 3 STAPH A, DNA, AMP PROBE 49.04<br />

87641 3 MR-STAPH, DNA, AMP PROBE 49.04<br />

87650 3 STREP A, DNA, DIR PROBE 28.02<br />

87651 3 STREP A, DNA, AMP PROBE 49.04

---

87652 3 STREP A, DNA, QUANT 39.65<br />

87653 3 STREP B, DNA, AMP PROBE 49.04<br />

87660 3 TRICHOMONAS VAGIN, DIR PROBE 28.02<br />

87797 3 <strong>DE</strong>TECT AGENT NOS, DNA, DIR 28.02<br />

87798 3 <strong>DE</strong>TECT AGENT NOS, DNA, AMP 49.04<br />

87799 3 <strong>DE</strong>TECT AGENT NOS, DNA, QUANT 59.85<br />

87800 3 <strong>DE</strong>TECT AGNT MULT, DNA, DIREC 56.03<br />

87801 3 <strong>DE</strong>TECT AGNT MULT, DNA, AMPLI 98.07<br />

87802 3 STREP B ASSAY W/OPTIC 15.39<br />

87803 3 CLOSTRIDIUM TOXIN A W/OPTIC 15.39<br />

87804 3 INFLUENZA ASSAY W/OPTIC 15.39<br />

87807 3 INFECTIOUS AGENT ANTIGEN <strong>DE</strong>TECTION 15.39<br />

87808 3 TRICHOMONAS ASSAY W/OPTIC 15.39<br />

87809 3 A<strong>DE</strong>NOVIRUS ASSAY W/OPTIC 15.39<br />

87810 3 CHYLMD TRACH ASSAY W/OPTIC 15.39<br />

87850 3 N. GONORRHOEAE ASSAY W/OPTIC 15.39<br />

87880 3 STREP A ASSAY W/OPTIC 15.39<br />

87899 3 AGENT NOS ASSAY W/OPTIC 15.39<br />

87900 3 PHENOTYPE, INFECT AGENT DRUG 182.11<br />

87901 3 GENOTYPE, DNA, HIV REVERSE T 359.69<br />

87902 3 GENOTYPE, DNA, HEPATITIS C 359.69<br />

87903 3 PHENOTYPE, DNA HIV W/CULTURE 682.72<br />

87904 3 PHENOTYPE, DNA HIV W/CLT ADD 36.42<br />

87905 6 SIALIDASE ENZYME ASSAY 0.00<br />

87999 5 MICROBIOLOGY PROCEDURE 0.00<br />

88000 9 AUTOPSY (NECROPSY), GROSS 0.00<br />

88005 9 AUTOPSY (NECROPSY), GROSS 0.00<br />

88007 9 AUTOPSY (NECROPSY), GROSS 0.00<br />

88012 9 AUTOPSY (NECROPSY), GROSS 0.00<br />

88014 9 AUTOPSY (NECROPSY), GROSS 0.00<br />

88016 9 AUTOPSY (NECROPSY), GROSS 0.00<br />

88020 9 AUTOPSY (NECROPSY), COMPLETE 0.00<br />

88025 9 AUTOPSY (NECROPSY), COMPLETE 0.00<br />

88027 9 AUTOPSY (NECROPSY), COMPLETE 0.00<br />

88028 9 AUTOPSY (NECROPSY), COMPLETE 0.00<br />

88029 9 AUTOPSY (NECROPSY), COMPLETE 0.00<br />

88036 9 LIMITED AUTOPSY 0.00<br />

88037 9 LIMITED AUTOPSY 0.00<br />

88040 9 FORENSIC AUTOPSY (NECROPSY) 0.00<br />

88045 9 CORONERÏS AUTOPSY (NECROPSY) 0.00<br />

88099 9 NECROPSY (AUTOPSY) PROCEDURE 0.00<br />

88104 3 CYTOPATH FL NONGYN, SMEARS 51.49<br />

88106 3 CYTOPATH FL NONGYN, FILTER 46.46<br />

88107 3 CYTOPATH FL NONGYN, SM/FLTR 68.58<br />

88108 3 CYTOPATH, CONCENTRATE TECH 53.81<br />

88112 3 CYTOPATH, CELL ENHANCE TECH 123.81<br />

88125 3 FORENSIC CYTOPATHOLOGY 20.54<br />

88130 3 SEX CHROMATIN I<strong>DE</strong>NTIFICATION 21.02<br />

88140 3 SEX CHROMATIN I<strong>DE</strong>NTIFICATION 11.17<br />

88141 3 CYTOPATH, C/V, INTERPRET 23.24

---

88142 3 CYTOPATH, C/V, THIN LAYER 28.31<br />

88143 3 CYTOPATH C/V THIN LAYER REDO 28.31<br />

88144 O CYTOPATH, C/V, THIN LYR REDO 0.00<br />

88145 O CYTOPATH, C/V, THIN LYR SEL 0.00<br />

88147 3 CYTOPATH, C/V, AUTOMATED 15.90<br />

88148 3 CYTOPATH, C/V, AUTO RESCREEN 21.23<br />

88150 3 CYTOPATH, C/V, MANUAL 14.76<br />

88151 O CYTOPATHOLOGY, SMEARS, CERVICAL OR 0.00<br />

88152 3 CYTOPATH, C/V, AUTO REDO 14.76<br />

88153 3 CYTOPATH, C/V, REDO 14.76<br />

88154 3 CYTOPATH, C/V, SELECT 14.76<br />

88155 3 CYTOPATH, C/V, IN<strong>DE</strong>X ADD-ON 8.37<br />

88156 O CYTOPATH CERV/VAG TBS 0.00<br />

88157 O CYTOPATHOLOGY, SMEARS, CERVICAL OR 0.00<br />

88158 O CYTOPATH CERV/VAG TBS AUTO 0.00<br />

88160 3 CYTOPATH SMEAR, OTHER SOURCE 55.77<br />

88161 3 CYTOPATH SMEAR, OTHER SOURCE 54.23<br />

88162 3 CYTOPATH SMEAR, OTHER SOURCE 56.99<br />

88164 3 CYTOPATH TBS, C/V, MANUAL 14.76<br />

88165 3 CYTOPATH TBS, C/V, REDO 14.76<br />

88166 3 CYTOPATH TBS, C/V, AUTO REDO 14.76<br />

88167 3 CYTOPATH TBS, C/V, SELECT 14.76<br />

88170 O FINE NEEDLE ASPIRATION 0.00<br />

88171 O FINE NEEDLE ASPIRATION 0.00<br />

88172 3 CYTOPATHOLOGY EVAL OF FNA 49.53<br />

88173 3 CYTOPATH EVAL, FNA, REPORT 122.91<br />

88174 3 CYTOPATH, C/V AUTO, IN FLUID 29.85<br />

88175 3 CYTOPATH C/V AUTO FLUID REDO 37.01<br />

88180 O CELL MARKER STUDY 0.00<br />

88182 3 CELL MARKER STUDY 93.14<br />

88184 3 FLOWCYTOMETRY/ TC, 1 MARKER 49.26<br />

88185 3 FLOWCYTOMETRY/TC, ADD-ON 24.22<br />

88187 3 FLOWCYTOMETRY/READ, 2-8 63.03<br />

88188 3 FLOWCYTOMETRY/READ, 9-15 83.19<br />

88189 3 FLOWCYTOMETRY/READ, 16 & > 109.59<br />

88199 5 CYTOPATHOLOGY PROCEDURE 0.00<br />

88230 3 TISSUE CULTURE, LYMPHOCYTE 162.77<br />

88233 3 TISSUE CULTURE, SKIN/BIOPSY 196.63<br />

88235 3 TISSUE CULTURE, PLACENTA 205.74<br />

88237 3 TISSUE CULTURE, BONE MARROW 176.47<br />

88239 3 TISSUE CULTURE, TUMOR 206.12<br />

88240 3 CELL CRYOPRESERVE/STORAGE 14.11<br />

88241 3 FROZEN CELL PREPARATION 14.11<br />

88245 3 CHROMOSOME ANALYSIS, 20-25 207.98<br />

88248 3 CHROMOSOME ANALYSIS, 50-100 241.96<br />

88249 3 CHROMOSOME ANALYSIS, 100 241.96<br />

88250 O CHROMOSOME ANALYSIS 0.00<br />

88260 O CHROMOSOME ANALYSIS: 5 CELLS 0.00<br />

88261 3 CHROMOSOME ANALYSIS, 5 246.93<br />

88262 3 CHROMOSOME ANALYSIS, 15-20 174.14

---

88263 3 CHROMOSOME ANALYSIS, 45 209.97<br />

88264 3 CHROMOSOME ANALYSIS, 20-25 174.14<br />

88267 3 CHROMOSOME ANALYS, PLACENTA 251.17<br />

88269 3 CHROMOSOME ANALYS, AMNIOTIC 232.38<br />

88271 3 CYTOGENETICS, DNA PROBE 29.93<br />

88272 3 CYTOGENETICS, 3-5 37.41<br />

88273 3 CYTOGENETICS, 10-30 44.89<br />

88274 3 CYTOGENETICS, 25-99 48.63<br />

88275 3 CYTOGENETICS, 100-300 56.11<br />

88280 3 CHROMOSOME KARYOTYPE STUDY 35.07<br />

88283 3 CHROMOSOME BANDING STUDY 95.84<br />

88285 3 CHROMOSOME COUNT, ADDITIONAL 26.54<br />

88289 3 CHROMOSOME STUDY, ADDITIONAL 48.11<br />

88291 3 CYTO/MOLECULAR REPORT 31.20<br />

88299 5 CYTOGENETIC STUDY 0.00<br />

88300 3 SURGICAL PATH, GROSS 14.46<br />

88302 3 TISSUE EXAM BY PATHOLOGIST 32.51<br />

88304 3 TISSUE EXAM BY PATHOLOGIST 42.89<br />

88305 3 TISSUE EXAM BY PATHOLOGIST 97.57<br />

88307 3 TISSUE EXAM BY PATHOLOGIST 166.79<br />

88309 3 TISSUE EXAM BY PATHOLOGIST 217.13<br />

88311 3 <strong>DE</strong>CALCIFY TISSUE 17.46<br />

88312 3 SPECIAL STAINS 73.61<br />

88313 3 SPECIAL STAINS 51.85<br />

88314 3 HISTOCHEMICAL STAIN 52.71<br />

88317 O INTERPRETATION AND REPORT BY TREATI 0.00<br />

88318 3 CHEMICAL HISTOCHEMISTRY 47.79<br />

88319 3 ENZYME HISTOCHEMISTRY 94.40<br />

88321 3 MICROSLI<strong>DE</strong> CONSULTATION 82.65<br />

88323 9 MICROSLI<strong>DE</strong> CONSULTATION 0.00<br />

88325 3 COMPREHENSIVE REVIEW OF DATA 199.53<br />

88329 3 PATH CONSULT INTROP 50.44<br />

88331 3 PATH CONSULT INTRAOP, 1 BLOC 85.84<br />

88332 3 PATH CONSULT INTRAOP, ADDÏL 42.97<br />

88333 3 INTRAOP CYTO PATH CONSULT, 1 90.40<br />

88334 3 INTRAOP CYTO PATH CONSULT, 2 52.97<br />

88342 3 IMMUNOHISTOCHEMISTRY 86.31<br />

88346 3 IMMUNOFLUORESCENT STUDY 90.16<br />

88347 3 IMMUNOFLUORESCENT STUDY 102.53<br />

88348 3 ELECTRON MICROSCOPY 388.66<br />

88349 3 SCANNING ELECTRON MICROSCOPY 417.97<br />

88355 3 ANALYSIS, SKELETAL MUSCLE 175.05<br />

88356 3 ANALYSIS, NERVE 231.50<br />

88358 3 ANALYSIS, TUMOR 63.47<br />

88360 3 TUMOR IMMUNOHISTOCHEM/MANUAL 106.57<br />

88361 3 TUMOR IMMUNOHISTOCHEM/COMPUT 141.54<br />

88362 3 NERVE TEASING PREPARATIONS 256.79<br />

88365 3 INSITU HYBRIDIZATION (FISH) 122.58<br />

88367 3 INSITU HYBRIDIZATION, AUTO 200.25<br />

88368 3 INSITU HYBRIDIZATION, MANUAL 143.52

---

88371 3 PROTEIN, WESTERN BLOT TISSUE 31.05<br />

88372 3 PROTEIN ANALYSIS W/PROBE 31.79<br />

88380 5 MICRODISSECTION, LASER 0.00<br />

88381 6 MICRODISSECTION, MANUAL 0.00<br />

88384 3 EVAL MOLECULAR PROBES, 11-50 326.65<br />

88385 3 EVAL MOLECUL PROBES, 51-250 335.50<br />

88386 3 EVAL MOLECUL PROBES, 251-500 349.50<br />

88399 5 SURGICAL PATHOLOGY PROCEDURE 0.00<br />

88400 O BILIRUBIN TOTAL TRANSCUT 0.00<br />

88720 6 BILIRUBIN TOTAL TRANSCUT 0.00<br />

88740 6 TRANSCUTANEOUS CARBOXYHB 0.00<br />

88741 6 TRANSCUTANEOUS METHB 0.00<br />

89049 6 CHCT FOR MAL HYPERTHERMIA 0.00<br />

89050 3 BODY FLUID CELL COUNT 6.61<br />

89051 3 BODY FLUID CELL COUNT 7.70<br />

89055 3 LEUKOCYTE ASSESSMENT, FECAL 5.96<br />

89060 3 EXAM,SYNOVIAL FLUID CRYSTALS 9.99<br />

89100 3 SAMPLE INTESTINAL CONTENTS 85.26<br />

89105 3 SAMPLE INTESTINAL CONTENTS 106.19<br />

89125 3 SPECIMEN FAT STAIN 6.03<br />

89130 3 SAMPLE STOMACH CONTENTS 84.96<br />

89132 3 SAMPLE STOMACH CONTENTS 64.72<br />

89135 3 SAMPLE STOMACH CONTENTS 92.70<br />

89136 3 SAMPLE STOMACH CONTENTS 70.12<br />

89140 3 SAMPLE STOMACH CONTENTS 116.57<br />

89141 3 SAMPLE STOMACH CONTENTS 138.65<br />

89160 3 EXAM FECES FOR MEAT FIBERS 5.15<br />

89190 3 NASAL SMEAR FOR EOSINOPHILS 6.64<br />

89205 O OCCULT BLOOD, ANY SOURCE EXCEPT FEC 0.00<br />

89220 3 SPUTUM SPECIMEN COLLECTION 16.06<br />

89225 3 STARCH GRANULES, FECES 4.67<br />

89230 3 COLLECT SWEAT FOR TEST 17.60<br />

89235 3 WATER LOAD TEST 7.69<br />

89240 6 PATHOLOGY LAB PROCEDURE 0.00<br />

89250 9 CULTR OOCYTE/EMBRYO

---

89281 9 ASSIST OOCYTE FERTILIZATION 0.00<br />

89290 9 BIOPSY, OOCYTE POLAR BODY 0.00<br />

89291 9 BIOPSY, OOCYTE POLAR BODY 0.00<br />

89300 9 SEMEN ANALYSIS W/HUHNER 0.00<br />

89310 3 SEMEN ANALYSIS W/COUNT 12.03<br />

89320 3 SEMEN ANAL VOL/COUNT/MOT 16.84<br />

89321 3 SEMEN ANAL, SPERM <strong>DE</strong>TECTION 16.84<br />

89322 3 SEMEN ANAL, STRICT CRITERIA 21.65<br />

89325 3 SPERM ANTIBODY TEST 14.91<br />

89329 9 SPERM EVALUATION TEST 0.00<br />

89330 9 EVALUATION, CERVICAL MUCUS 0.00<br />

89331 3 RETROGRA<strong>DE</strong> EJACULATION ANAL 27.37<br />

89335 9 CRYOPRESERVE TESTICULAR TISS 0.00<br />

89342 9 STORAGE/YEAR; EMBRYO(S) 0.00<br />

89343 9 STORAGE/YEAR; SPERM/SEMEN 0.00<br />

89344 9 STORAGE/YEAR; REPROD TISSUE 0.00<br />

89346 9 STORAGE/YEAR; OOCYTE(S) 0.00<br />

89350 O SPUTUM SPECIMEN COLLECTION 0.00<br />

89352 9 THAWING CRYOPRESRVED; EMBRYO 0.00<br />

89353 9 THAWING CRYOPRESRVED; SPERM 0.00<br />

89354 9 THAW CRYOPRSVRD; REPROD TISS 0.00<br />

89355 O EXAM FECES FOR STARCH 0.00<br />

89356 9 THAWING CRYOPRESRVED; OOCYTE 0.00<br />

89360 O COLLECT SWEAT FOR TEST 0.00<br />

89365 O WATER LOAD TEST 0.00<br />

89399 O PATHOLOGY LAB PROCEDURE 0.00<br />

90000 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90010 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90015 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90017 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90020 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90030 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90040 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90050 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90060 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90070 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90080 O OFFICE AND OTHER OUTPATIENT MEDICAL 0.00<br />

90100 O HOME MEDICAL SERVICE, NEW PATIENT B 0.00<br />

90110 O HOME MEDICAL SERVICE, NEW PATIENT L 0.00<br />

90115 O HOME MEDICAL SERVICE, NEW PATIENT I 0.00<br />

90117 O HOME MEDICAL SERVICE, NEW PATIENT E 0.00<br />

90130 O HOME MEDICAL SERVICE, ESTABLISHED P 0.00<br />

90140 O HOME MEDICAL SERVICE, ESTABLISHED P 0.00<br />

90150 O HOME MEDICAL SERVICE, ESTABLISHED P 0.00<br />

90160 O HOME MEDICAL SERVICE, ESTABLISHED P 0.00<br />

90170 O HOME MEDICAL SERVICE, ESTABLISHED P 0.00<br />

90200 O INITIAL HOSPITAL CARE BRIEF HISTORY 0.00<br />

90215 O INITIAL HOSPITAL CARE INTERMEDIATE 0.00<br />

90220 O INITIAL HOSPITAL CARE COMPREHENSIVE 0.00<br />

90225 O HISTORY AND EXAMINATION OF THE NORM 0.00

---

90240 O SUBSEQUENT HOSPITAL CARE, EACH DAY 0.00<br />

90250 O SUBSEQUENT HOSPITAL CARE, EACH DAY 0.00<br />

90260 O SUBSEQUENT HOSPITAL CARE, EACH DAY 0.00<br />

90270 O SUBSEQUENT HOSPITAL CARE, EACH DAY 0.00<br />

90280 O SUBSEQUENT HOSPITAL CARE, EACH DAY 0.00<br />

90281 5 HUMAN IG, IM 0.00<br />

90282 O SUBSEQUENT HOSPITAL CARE, EACH DAY 0.00<br />

90283 5 HUMAN IG, IV 0.00<br />

90284 6 HUMAN IG, SC 0.00<br />

90287 5 BOTULINUM ANTITOXIN 0.00<br />

90288 5 BOTULISM IG, IV 0.00<br />

90291 5 CMV IG, IV 0.00<br />

90292 O HOSPITAL DISCHARGE DAY MANAGEMENT 0.00<br />

90296 5 DIPHTHERIA ANTITOXIN 0.00<br />

90300 O INITIAL CARE, SKILLED NURSING FACIL 0.00<br />

90315 O INITIAL CARE, SKILLED NURSING FACIL 0.00<br />

90320 O INITIAL CARE, SKILLED NURSING FACIL 0.00<br />

90340 O SUBSEQUENT CARE, SKILLED NURSING FA 0.00<br />

90350 O SUBSEQUENT CARE, SKILLED NURSING FA 0.00<br />

90360 O SUBSEQUENT CARE, SKILLED NURSING FA 0.00<br />

90370 O SUBSEQUENT CARE, SKILLED NURSING FA 0.00<br />

90371 5 HEP B IG, IM 0.00<br />

90375 5 RABIES IG, IM/SC 0.00<br />

90376 5 RABIES IG, HEAT TREATED 0.00<br />

90378 5 RSV IG, IM, 50MG 0.00<br />

90379 5 RSV IG, IV 0.00<br />

90384 5 RH IG, FULL-DOSE, IM 0.00<br />

90385 5 RH IG, MINIDOSE, IM 0.00<br />

90386 5 RH IG, IV 0.00<br />

90389 5 TETANUS IG, IM 0.00<br />

90393 5 VACCINA IG, IM 0.00<br />

90396 5 VARICELLA-ZOSTER IG, IM 0.00<br />

90399 5 IMMUNE GLOBULIN 0.00<br />

90400 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90410 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90415 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90420 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90430 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90440 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90450 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90460 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90465 9 IMMUNE ADMIN 1 INJ, < 8 YRS 0.00<br />

90466 9 IMMUNE ADMIN ADDL INJ, < 8 Y 0.00<br />

90467 9 IMMUNE ADMIN O OR N, < 8 YRS 0.00<br />

90468 9 IMMUNE ADMIN O/N, ADDL < 8 Y 0.00<br />

90470 O REST HOME (EG, BOARDING HOME), DOMI 0.00<br />

90471 9 IMMUNIZATION ADMIN 0.00<br />

90472 9 IMMUNIZATION ADMIN, EACH ADD 0.00<br />

90473 9 IMMUNE ADMIN ORAL/NASAL 0.00<br />

90474 9 IMMUNE ADMIN ORAL/NASAL ADDL 0.00

---

90476 5 A<strong>DE</strong>NOVIRUS VACCINE, TYPE 4 0.00<br />

90477 5 A<strong>DE</strong>NOVIRUS VACCINE, TYPE 7 0.00<br />

90500 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, NEW P 0.00<br />

90505 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, NEW P 0.00<br />

90510 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, NEW P 0.00<br />

90515 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, NEW P 0.00<br />

90517 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, NEW P 0.00<br />

90520 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, NEW P 0.00<br />

90530 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, ESTAB 0.00<br />

90540 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, ESTAB 0.00<br />

90550 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, ESTAB 0.00<br />

90560 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, ESTAB 0.00<br />

90570 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, ESTAB 0.00<br />

90580 O EMERGENCY <strong>DE</strong>PARTMENT SERVICE, ESTAB 0.00<br />

90581 5 ANTHRAX VACCINE, SC 0.00<br />

90585 5 BCG VACCINE, PERCUT 0.00<br />

90586 5 BCG VACCINE, INTRAVESICAL 0.00<br />

90590 9 PHYSICIAN DIRECTION OF EMERGENCY ME 0.00<br />

90592 9 CHOLERA VACCINE, ORAL 0.00<br />

90600 O INITIAL CONSULTATION LIMITED 0.00<br />

90605 O INITIAL CONSULTATION INTERMEDIATE 0.00<br />

90610 O INITIAL CONSULTATION EXTEN<strong>DE</strong>D 0.00<br />

90620 O INITIAL CONSULTATION COMPREHENSIVE 0.00<br />

90630 O INITIAL CONSULTATION COMPLEX 0.00<br />

90632 6 HEP A VACCINE, ADULT IM 0.00<br />

90633 5 HEP A VACC, PED/ADOL, 2 DOSE 0.00<br />

90634 5 HEP A VACC, PED/ADOL, 3 DOSE 0.00<br />

90636 6 HEP A/HEP B VACC, ADULT IM 0.00<br />

90640 9 FOLLOW-UP CONSULTATION BRIEF 0.00<br />

90641 9 FOLLOW-UP CONSULTATION LIMITED 0.00<br />

90642 9 FOLLOW-UP CONSULTATION INTERMEDIATE 0.00<br />

90643 9 FOLLOW-UP CONSULTATION COMPLEX 0.00<br />

90645 5 HIB VACCINE, HBOC, IM 0.00<br />

90646 5 HIB VACCINE, PRP-D, IM 0.00<br />

90647 5 HIB VACCINE, PRP-OMP, IM 0.00<br />

90648 5 HIB VACCINE, PRP-T, IM 0.00<br />

90650 9 HPV VACCINE TYPES 16, 18, BIVALENT 0.00<br />

90651 9 CONFIRMATORY CONSULTATION INTERMEDI 0.00<br />

90652 9 CONFIRMATORY CONSULTATION EXTEN<strong>DE</strong>D 0.00<br />

90653 9 CONFIRMATORY CONSULTATION COMPREHEN 0.00<br />

90654 9 CONFIRMATORY CONSULTATION COMPLEX 0.00<br />

90655 5 FLU VACCINE NO PRESERV 6-35M 0.00<br />

90656 5 FLU VACCINE NO PRESERV 3 & > 0.00<br />

90657 5 FLU VACCINE, 3 YRS, IM 0.00<br />

90658 6 FLU VACCINE, 3 YRS & >, IM 0.00<br />

90659 O FLU VACCINE, WHOLE, IM 0.00<br />

90660 5 FLU VACCINE, NASAL 0.00<br />

90661 9 FLU VACC CELL CULT PRSV FREE 0.00<br />

90662 9 FLU VACC PRSV FREE INC ANTIG 0.00<br />

90663 9 FLU VACC PAN<strong>DE</strong>MIC 0.00

---

90665 3 LYME DISEASE VACCINE, IM 53.35<br />

90669 5 PNEUMOCOCCAL VACC, PED /= 7 IM 0.00<br />

90715 6 TDAP VACCINE >7 IM 0.00<br />

90716 6 CHICKEN POX VACCINE, SC 0.00<br />

90717 9 YELLOW FEVER VACCINE, SC 0.00<br />

90718 6 TD VACCINE > 7, IM 0.00<br />

90719 5 DIPHTHERIA VACCINE, IM 0.00<br />

90720 5 DTP/HIB VACCINE, IM 0.00<br />

90721 6 DTAP/HIB VACCINE, IM 0.00<br />

90723 5 DTAP-HEP B-IPV VACCINE, IM 0.00<br />

90724 O INFLUENZA IMMUNIZATION 0.00<br />

90725 9 CHOLERA VACCINE, INJECTABLE 0.00<br />

90726 O RABIES IMMUNIZATION 0.00<br />

90727 9 PLAGUE VACCINE, IM 0.00<br />

90728 O BCG IMMUNIZATION 0.00<br />

90730 O HEPATITIS A VACCINE 0.00<br />

90731 O IMMUNIZATION, ACTIVE; HEPATITIS B V 0.00<br />

90732 3 PNEUMOCOCCAL VACCINE 12.85<br />

90733 3 MENINGOCOCCAL VACCINE, SC 12.85<br />

90734 3 MENINGOCOCCAL VACCINE, IM 41.00<br />

90735 9 ENCEPHALITIS VACCINE, SC 0.00<br />

90736 6 ZOSTER VACC, SC 0.00<br />

90737 O INFLUENZA B IMMUNIZATION 0.00<br />

90738 9 JAPANESE ENCEPHALITIS VIRUS VACCIN 0.00

---

90740 5 HEPB VACC, ILL PAT 3 DOSE IM 0.00<br />

90741 O PASSIVE IMMUNIZATION, ISG 0.00<br />

90742 O SPECIAL PASSIVE IMMUNIZATION 0.00<br />

90743 5 HEP B VACC, ADOL, 2 DOSE, IM 0.00<br />

90744 5 HEPB VACC PED/ADOL 3 DOSE IM 0.00<br />

90745 O HEPB VACCINE, ADOL/RISK, IM 0.00<br />

90746 6 HEP B VACCINE, ADULT, IM 0.00<br />

90747 5 HEPB VACC, ILL PAT 4 DOSE IM 0.00<br />

90748 6 HEP B/HIB VACCINE, IM 0.00<br />

90749 5 VACCINE TOXOID 0.00<br />

90750 9 INITIAL HISTORY AND EXAMINATION REL 0.00<br />

90751 9 INITIAL HISTORY AND EXAMINATION REL 0.00<br />

90752 O INITIAL HISTORY AND EXAMINATION REL 0.00<br />

90753 O INITIAL HISTORY AND EXAMINATION REL 0.00<br />

90754 O INITIAL HISTORY AND EXAMINATION REL 0.00<br />

90755 9 INFANT CARE TO ONE YEAR OF AGE, WIT 0.00<br />

90757 O NEWBORN CARE, IN OTHER THAN HOSPITA 0.00<br />

90760 O HYDRATION IV INFUSION, INIT 0.00<br />

90761 O HYDRATE IV INFUSION, ADD-ON 0.00<br />

90762 O INTERVAL HISTORY AND EXAMINATION RE 0.00<br />

90763 O INTERVAL HISTORY AND EXAMINATION RE 0.00<br />

90764 O INTERVAL HISTORY AND EXAMINATION RE 0.00<br />

90765 O THER/PROPH/DIAG IV INF, INIT 0.00<br />

90766 O THER/PROPH/DG IV INF, ADD-ON 0.00<br />

90767 O TX/PROPH/DG ADDL SEQ IV INF 0.00<br />

90768 O THER/DIAG CONCURRENT INF 0.00<br />

90769 O SC THER INFUSION, UP TO 1 HR 0.00<br />

90770 O SC THER INFUSION, ADDL HR 0.00<br />

90771 O SC THER INFUSION, RESET PUMP 0.00<br />

90772 O THER/PROPH/DIAG INJ, SC/IM 0.00<br />

90773 O THER/PROPH/DIAG INJ, IA 0.00<br />

90774 O THERAPEUTIC, PROPHYLACTIC OR DIAG 0.00<br />

90775 O TX/PRO/DX INJ NEW DRUG ADDON 0.00<br />

90776 O TX/PRO/DX INJ SAME DRUG ADON 0.00<br />

90778 O CIRCADIAN RESPIRATORY PATTERN RECOR 0.00<br />

90779 O THER/PROP/DIAG INJ/INF PROC 0.00<br />

90780 O IV INFUSION THERAPY, 1 HOUR 0.00<br />

90781 O IV INFUSION, ADDITIONAL HOUR 0.00<br />

90782 O INJECTION, SC/IM 0.00<br />

90783 O INJECTION, IA 0.00<br />

90784 O INJECTION, IV 0.00<br />

90788 O INJECTION OF ANTIBIOTIC 0.00<br />

90798 O INTRAVENOUS THERAPY FOR SEVERE OR I 0.00<br />

90799 O THER/PROPHYLACTIC/DX INJECT 0.00<br />

90801 3 PSY DX INTERVIEW 149.21<br />

90802 3 INTAC PSY DX INTERVIEW 158.01<br />

90804 3 PSYTX, OFFICE, 20-30 MIN 65.68<br />

90805 3 PSYTX, OFF, 20-30 MIN W/E&M 72.58<br />

90806 3 PSYTX, OFF, 45-50 MIN 92.75<br />

90807 3 PSYTX, OFF, 45-50 MIN W/E&M 102.44

---

90808 3 PSYTX, OFFICE, 75-80 MIN 136.85<br />

90809 3 PSYTX, OFF, 75-80, W/E&M 145.72<br />

90810 3 INTAC PSYTX, OFF, 20-30 MIN 69.62<br />

90811 3 INTAC PSYTX, 20-30, W/E&M 80.24<br />

90812 3 INTAC PSYTX, OFF, 45-50 MIN 100.93<br />

90813 3 INTAC PSYTX, 45-50 MIN W/E&M 110.61<br />

90814 3 INTAC PSYTX, OFF, 75-80 MIN 144.21<br />

90815 3 INTAC PSYTX, 75-80 W/E&M 153.07<br />

90816 3 PSYTX, HOSP, 20-30 MIN 61.52<br />

90817 3 PSYTX, HOSP, 20-30 MIN W/E&M 67.59<br />

90818 3 PSYTX, HOSP, 45-50 MIN 91.49<br />

90819 3 PSYTX, HOSP, 45-50 MIN W/E&M 97.87<br />

90820 9 INTERACTIVE MEDICAL PSYCHIATRIC DIA 0.00<br />

90821 3 PSYTX, HOSP, 75-80 MIN 135.59<br />

90822 3 PSYTX, HOSP, 75-80 MIN W/E&M 141.46<br />

90823 3 INTAC PSYTX, HOSP, 20-30 MIN 66.39<br />

90824 3 INTAC PSYTX, HSP 20-30 W/E&M 73.18<br />

90825 9 PSYCHIATRIC EVALUATION OF HOSPITAL 0.00<br />

90826 3 INTAC PSYTX, HOSP, 45-50 MIN 97.49<br />

90827 3 INTAC PSYTX, HSP 45-50 W/E&M 102.33<br />

90828 3 INTAC PSYTX, HOSP, 75-80 MIN 141.28<br />

90829 3 INTAC PSYTX, HSP 75-80 W/E&M 146.01<br />

90830 O PSYCHOLOGICAL TESTING (INCLU<strong>DE</strong>S PSY 0.00<br />

90835 9 NARCOSYNTHESIS FOR PSYCHIATRIC DIAG 0.00<br />

90841 9 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY 0.00<br />

90842 9 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY 0.00<br />

90843 9 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY 0.00<br />

90844 9 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY 0.00<br />

90845 3 PSYCHOANALYSIS 80.91<br />

90846 3 FAMILY PSYTX W/O PATIENT 86.00<br />

90847 3 FAMILY PSYTX W/PATIENT 107.25<br />

90849 3 MULTIPLE FAMILY GROUP PSYTX 32.42<br />

90853 3 GROUP PSYCHOTHERAPY 30.55<br />

90855 9 INTERACTIVE INDIVIDUAL MEDICAL PSYC 0.00<br />

90857 3 INTAC GROUP PSYTX 34.46<br />

90862 3 MEDICATION MANAGEMENT 53.00<br />

90865 9 NARCOSYNTHESIS 0.00<br />

90870 3 ELECTROCONVULSIVE THERAPY 141.04<br />

90871 O ELECTROCONVULSIVE THERAPY 0.00<br />

90875 9 PSYCHOPHYSIOLOGICAL THERAPY 0.00<br />

90876 9 PSYCHOPHYSIOLOGICAL THERAPY 0.00<br />

90880 9 HYPNOTHERAPY 0.00<br />

90882 9 ENVIRONMENTAL MANIPULATION 0.00<br />

90885 3 PSY EVALUATION OF RECORDS 45.13<br />

90887 9 CONSULTATION WITH FAMILY 0.00<br />

90889 9 PREPARATION OF REPORT 0.00<br />

90899 O PSYCHIATRIC SERVICE/THERAPY 0.00<br />

90900 O BIOFEEDBACK TRAINING; BY ELECTROMYO 0.00<br />

90901 9 BIOFEEDBACK TRAIN, ANY METH 0.00<br />

90902 O BIOFEEDBACK TRAINING; IN CONDUCTION 0.00

---

90904 O BIOFEEDBACK TRAINING; REGULATION OF 0.00<br />

90906 9 BIOFEEDBACK TRAINING REGULATION OF 0.00<br />

90908 O BIOFEEDBACK TRAINING; BY ELECTROENC 0.00<br />

90910 O BIOFEEDBACK TRAINING; BY ELECTRO-OC 0.00<br />

90911 3 BIOFEEDBACK PERI/URO/RECTAL 89.65<br />

90915 O BIOFEEDBACK TRAINING; OTHER 0.00<br />

90918 O ESRD RELATED SERVICES, MONTH 0.00<br />

90919 O ESRD RELATED SERVICES, MONTH 0.00<br />

90920 O ESRD RELATED SERVICES, MONTH 0.00<br />

90921 O ESRD RELATED SERVICES, MONTH 0.00<br />

90922 O ESRD RELATED SERVICES, DAY 0.00<br />

90923 O ESRD RELATED SERVICES, DAY 0.00<br />

90924 O ESRD RELATED SERVICES, DAY 0.00<br />

90925 O ESRD RELATED SERVICES, DAY 0.00<br />

90935 3 HEMODIALYSIS, ONE EVALUATION 65.99<br />

90937 3 HEMODIALYSIS, REPEATED EVAL 107.92<br />

90939 O HEMODIALYSIS STUDY, TRANSCUT 0.00<br />

90940 5 HEMODIALYSIS ACCESS STUDY 0.00<br />

90945 3 DIALYSIS, ONE EVALUATION 69.09<br />

90947 3 DIALYSIS, REPEATED EVAL 110.25<br />

90951 6 ESRD SERV, 4 VISITS P MO,

---

90999 5 DIALYSIS PROCEDURE 0.00<br />

91000 3 ESOPHAGEAL INTUBATION 74.22<br />

91010 3 ESOPHAGUS MOTILITY STUDY 204.86<br />

91011 3 ESOPHAGUS MOTILITY STUDY 263.20<br />

91012 3 ESOPHAGUS MOTILITY STUDY 273.85<br />

91020 3 GASTRIC MOTILITY STUDIES 236.49<br />

91022 3 DUO<strong>DE</strong>NAL MOTILITY STUDY 200.68<br />

91030 3 ACID PERFUSION OF ESOPHAGUS 137.63<br />

91032 O ESOPHAGUS, ACID REFLUX TEST 0.00<br />

91033 O PROLONGED ACID REFLUX TEST 0.00<br />

91034 3 GASTROESOPHAGEAL REFLUX TEST 220.80<br />

91035 3 G-ESOPH REFLX TST W/ELECTROD 494.18<br />

91037 3 ESOPH IMPED FUNCTION TEST 162.18<br />

91038 3 ESOPH IMPED FUNCT TEST > 1H 140.05<br />

91040 3 ESOPH BALLOON DISTENSION TST 407.29<br />

91052 3 GASTRIC ANALYSIS TEST 133.88<br />

91055 3 GASTRIC INTUBATION FOR SMEAR 142.62<br />

91060 O GASTRIC SALINE LOAD TEST 0.00<br />

91065 3 BREATH HYDROGEN TEST 62.90<br />

91100 O PASS INTESTINE BLEEDING TUBE 0.00<br />

91105 3 GASTRIC INTUBATION TREATMENT 87.95<br />

91110 3 GI TRACT CAPSULE ENDOSCOPY 971.08<br />

91111 3 ESOPHAGEAL CAPSULE ENDOSCOPY 776.60<br />

91120 3 RECTAL SENSATION TEST 427.06<br />

91122 3 ANAL PRESSURE RECORD 251.20<br />

91123 3 IRRIGATE FECAL IMPACTION 92.29<br />

91132 3 ELECTROGASTROGRAPHY 0.00<br />

91133 3 ELECTROGASTROGRAPHY W/TEST 0.00<br />

91299 5 GASTROENTEROLOGY PROCEDURE 0.00<br />

92002 3 EYE EXAM, NEW PATIENT 67.62<br />

92004 3 EYE EXAM, NEW PATIENT 126.92<br />

92012 3 EYE EXAM ESTABLISHED PAT 71.52<br />

92014 3 EYE EXAM & TREATMENT 103.71<br />

92015 3 REFRACTION 44.08<br />

92018 3 NEW EYE EXAM & TREATMENT 124.55<br />

92019 3 EYE EXAM & TREATMENT 63.27<br />

92020 3 SPECIAL EYE EVALUATION 24.41<br />

92025 3 CORNEAL TOPOGRAPHY 31.81<br />

92060 3 SPECIAL EYE EVALUATION 53.88<br />

92065 3 ORTHOPTIC/PLEOPTIC TRAINING 40.45<br />

92070 9 FITTING OF CONTACT LENS 0.00<br />

92081 3 VISUAL FIELD EXAMINATION(S) 50.29<br />

92082 3 VISUAL FIELD EXAMINATION(S) 65.58<br />

92083 3 VISUAL FIELD EXAMINATION(S) 75.37<br />

92100 3 SERIAL TONOMETRY EXAM(S) 82.54<br />

92120 3 TONOGRAPHY & EYE EVALUATION 68.06<br />

92130 3 WATER PROVOCATION TONOGRAPHY 76.32<br />

92135 3 OPHTH DX IMAGING POST SEG 43.61<br />

92136 3 OPHTHALMIC BIOMETRY 81.44<br />

92140 3 GLAUCOMA PROVOCATIVE TESTS 54.22

---

92225 3 SPECIAL EYE EXAM, INITIAL 22.05<br />

92226 3 SPECIAL EYE EXAM, SUBSEQUENT 20.12<br />

92230 3 EYE EXAM WITH PHOTOS 64.28<br />

92235 3 EYE EXAM WITH PHOTOS 125.71<br />

92240 3 ICG ANGIOGRAPHY 198.77<br />

92250 3 EYE EXAM WITH PHOTOS 71.08<br />

92260 3 OPHTHALMOSCOPY/DYNAMOMETRY 16.67<br />

92265 3 EYE MUSCLE EVALUATION 77.90<br />

92270 3 ELECTRO-OCULOGRAPHY 84.69<br />

92275 3 ELECTRORETINOGRAPHY 121.52<br />

92280 O VISUALLY EVOKED POTENTIAL (RESPONSE 0.00<br />

92283 3 COLOR VISION EXAMINATION 42.17<br />

92284 3 DARK ADAPTATION EYE EXAM 67.69<br />

92285 3 EYE PHOTOGRAPHY 42.54<br />

92286 3 INTERNAL EYE PHOTOGRAPHY 124.24<br />

92287 3 INTERNAL EYE PHOTOGRAPHY 112.13<br />

92310 9 CONTACT LENS FITTING 0.00<br />

92311 O CONTACT LENS FITTING 0.00<br />

92312 O CONTACT LENS FITTING 0.00<br />

92313 9 CONTACT LENS FITTING 0.00<br />

92314 9 PRESCRIPTION OF CONTACT LENS 0.00<br />

92315 O PRESCRIPTION OF CONTACT LENS 0.00<br />

92316 O PRESCRIPTION OF CONTACT LENS 0.00<br />

92317 9 PRESCRIPTION OF CONTACT LENS 0.00<br />

92325 9 MODIFICATION OF CONTACT LENS 0.00<br />

92326 9 REPLACEMENT OF CONTACT LENS 0.00<br />

92330 O FITTING OF ARTIFICIAL EYE 0.00<br />

92335 O FITTING OF ARTIFICIAL EYE 0.00<br />

92340 9 FITTING OF SPECTACLES 0.00<br />

92341 9 FITTING OF SPECTACLES 0.00<br />

92342 9 FITTING OF SPECTACLES 0.00<br />

92352 9 SPECIAL SPECTACLES FITTING 0.00<br />

92353 9 SPECIAL SPECTACLES FITTING 0.00<br />

92354 9 SPECIAL SPECTACLES FITTING 0.00<br />

92355 9 SPECIAL SPECTACLES FITTING 0.00<br />

92358 9 EYE PROSTHESIS SERVICE 0.00<br />

92370 9 REPAIR & ADJUST SPECTACLES 0.00<br />

92371 9 REPAIR & ADJUST SPECTACLES 0.00<br />

92390 O SUPPLY OF SPECTACLES 0.00<br />

92391 O SUPPLY OF CONTACT LENSES 0.00<br />

92392 O SUPPLY OF LOW VISION AIDS 0.00<br />

92393 O SUPPLY OF ARTIFICIAL EYE 0.00<br />

92395 O SUPPLY OF SPECTACLES 0.00<br />

92396 O SUPPLY OF CONTACT LENSES 0.00<br />

92499 5 EYE SERVICE OR PROCEDURE 0.00<br />

92502 3 EAR AND THROAT EXAMINATION 92.43<br />

92504 3 EAR MICROSCOPY EXAMINATION 28.10<br />

92506 3 SPEECH/HEARING EVALUATION 150.15<br />

92507 3 SPEECH/HEARING THERAPY 64.34<br />

92508 3 SPEECH/HEARING THERAPY 30.00

---

92510 O REHAB FOR EAR IMPLANT 0.00<br />

92511 3 NASOPHARYNGOSCOPY 156.07<br />

92512 3 NASAL FUNCTION STUDIES 61.17<br />

92516 3 FACIAL NERVE FUNCTION TEST 62.53<br />

92520 3 LARYNGEAL FUNCTION STUDIES 54.63<br />

92525 O ORAL FUNCTION EVALUATION 0.00<br />

92526 3 ORAL FUNCTION THERAPY 84.78<br />

92531 5 SPONTANEOUS NYSTAGMUS STUDY 0.00<br />

92532 5 POSITIONAL NYSTAGMUS TEST 0.00<br />

92533 5 CALORIC VESTIBULAR TEST 0.00<br />

92534 5 OPTOKINETIC NYSTAGMUS TEST 0.00<br />

92541 3 SPONTANEOUS NYSTAGMUS TEST 57.55<br />

92542 3 POSITIONAL NYSTAGMUS TEST 60.05<br />

92543 3 CALORIC VESTIBULAR TEST 28.06<br />

92544 3 OPTOKINETIC NYSTAGMUS TEST 47.91<br />

92545 3 OSCILLATING TRACKING TEST 44.00<br />

92546 3 SINUSOIDAL ROTATIONAL TEST 85.65<br />

92547 3 SUPPLEMENTAL ELECTRICAL TEST 5.32<br />

92548 3 POSTUROGRAPHY 99.28<br />

92551 3 PURE TONE HEARING TEST, AIR 10.13<br />

92552 3 PURE TONE AUDIOMETRY, AIR 21.64<br />

92553 3 AUDIOMETRY, AIR & BONE 29.71<br />

92555 3 SPEECH THRESHOLD AUDIOMETRY 16.92<br />

92556 3 SPEECH AUDIOMETRY, COMPLETE 23.02<br />

92557 3 COMPREHENSIVE HEARING TEST 53.07<br />

92559 9 GROUP AUDIOMETRIC TESTING 0.00<br />

92560 5 BEKESY AUDIOMETRY, SCREEN 0.00<br />

92561 3 BEKESY AUDIOMETRY, DIAGNOSIS 29.71<br />

92562 3 LOUDNESS BALANCE TEST 21.25<br />

92563 3 TONE <strong>DE</strong>CAY HEARING TEST 19.28<br />

92564 3 SISI HEARING TEST 19.97<br />

92565 3 STENGER TEST, PURE TONE 14.17<br />

92566 O IMPEDANCE TESTING 0.00<br />

92567 3 TYMPANOMETRY 21.69<br />

92568 3 ACOUSTIC REFL THRESHOLD TST 20.64<br />

92569 3 ACOUSTIC REFLEX <strong>DE</strong>CAY TEST 17.56<br />

92571 3 FILTERED SPEECH HEARING TEST 17.31<br />

92572 3 STAGGERED SPONDAIC WORD TEST 13.67<br />

92573 O LOMBARD TEST 0.00<br />

92574 O SWINGING STORY TEST 0.00<br />

92575 3 SENSORINEURAL ACUITY TEST 29.31<br />

92576 3 SYNTHETIC SENTENCE TEST 21.55<br />

92577 3 STENGER TEST, SPEECH 21.35<br />

92578 O <strong>DE</strong>LAYED AUDITORY FEEDBACK TEST 0.00<br />

92579 3 VISUAL AUDIOMETRY (VRA) 46.89<br />

92580 O ELECTRO<strong>DE</strong>RMAL AUDIOMETRY 0.00<br />

92581 O EVOKED RESPONSE (EEG) AUDIOMETRY 0.00<br />

92582 3 CONDITIONING PLAY AUDIOMETRY 39.15<br />

92583 3 SELECT PICTURE AUDIOMETRY 34.24<br />

92584 3 ELECTROCOCHLEOGRAPHY 81.75

---

92585 3 AUDITOR EVOKE POTENT, COMPRE 103.81<br />

92586 3 AUDITOR EVOKE POTENT, LIMIT 68.67<br />

92587 3 EVOKED AUDITORY TEST 47.52<br />

92588 3 EVOKED AUDITORY TEST 70.76<br />

92589 O AUDITORY FUNCTION TEST(S) 0.00<br />

92590 9 HEARING AID EXAM, ONE EAR 0.00<br />

92591 9 HEARING AID EXAM, BOTH EARS 0.00<br />

92592 9 HEARING AID CHECK, ONE EAR 0.00<br />

92593 9 HEARING AID CHECK, BOTH EARS 0.00<br />

92594 9 ELECTRO HEARNG AID TEST, ONE 0.00<br />

92595 9 ELECTRO HEARNG AID TST, BOTH 0.00<br />

92596 9 EAR PROTECTOR EVALUATION 0.00<br />

92597 9 ORAL SPEECH <strong>DE</strong>VICE EVAL 0.00<br />

92598 9 MODIFY ORAL SPEECH <strong>DE</strong>VICE 0.00<br />

92599 O ENT PROCEDURE/SERVICE 0.00<br />

92601 3 COCHLEAR IMPLT F/UP EXAM < 7 170.34<br />

92602 3 REPROGRAM COCHLEAR IMPLT < 7 109.31<br />

92603 3 COCHLEAR IMPLT F/UP EXAM 7 > 144.02<br />

92604 3 REPROGRAM COCHLEAR IMPLT 7 > 86.13<br />

92605 5 EVAL FOR NONSPEECH <strong>DE</strong>VICE RX 0.00<br />

92606 5 NON-SPEECH <strong>DE</strong>VICE SERVICE 0.00<br />

92607 3 EX FOR SPEECH <strong>DE</strong>VICE RX, 1HR 153.35<br />

92608 3 EX FOR SPEECH <strong>DE</strong>VICE RX ADDL 29.81<br />

92609 3 USE OF SPEECH <strong>DE</strong>VICE SERVICE 80.66<br />

92610 3 EVALUATE SWALLOWING FUNCTION 103.48<br />

92611 3 MOTION FLUOROSCOPY/SWALLOW 108.20<br />

92612 3 ENDOSCOPY SWALLOW TST (FEES) 156.83<br />

92613 3 ENDOSCOPY SWALLOW TST (FEES) 38.33<br />

92614 3 LARYNGOSCOPIC SENSORY TEST 141.10<br />

92615 3 EVAL LARYNGOSCOPY SENSE TST 33.67<br />

92616 3 FEES W/LARYNGEAL SENSE TEST 194.74<br />

92617 3 INTERPRT FEES/LARYNGEAL TEST 42.20<br />

92620 9 AUDITORY FUNCTION, 60 MIN 0.00<br />

92621 9 AUDITORY FUNCTION, + 15 MIN 0.00<br />

92625 9 TINNITUS ASSESSMENT 0.00<br />

92626 9 EVAL AUD REHAB STATUS 0.00<br />

92627 9 EVAL AUD STATUS REHAB ADD-ON 0.00<br />

92630 9 AUD REHAB PRE-LING HEAR LOSS 0.00<br />

92633 9 AUD REHAB POSTLING HEAR LOSS 0.00<br />

92640 3 AUD BRAINSTEM IMPLT PROGRAMG 53.02<br />

92700 5 ENT PROCEDURE/SERVICE 0.00<br />

92950 3 HEART/LUNG RESUSCITATION CPR 283.26<br />

92953 9 TEMPORARY EXTERNAL PACING 0.00<br />

92960 3 CARDIOVERSION ELECTRIC, EXT 288.41<br />

92961 9 CARDIOVERSION, ELECTRIC, INT 0.00<br />

92970 3 CARDIOASSIST, INTERNAL 173.29<br />

92971 3 CARDIOASSIST, EXTERNAL 100.01<br />

92973 3 PERCUT CORONARY THROMBECTOMY 177.89<br />

92974 3 CATH PLACE, CARDIO BRACHYTX 162.95<br />

92975 3 DISSOLVE CLOT, HEART VESSEL 391.48

---

92977 3 DISSOLVE CLOT, HEART VESSEL 206.00<br />

92978 3 INTRAVASC US, HEART ADD-ON 291.66<br />

92979 3 INTRAVASC US, HEART ADD-ON 0.00<br />

92980 3 INSERT INTRACORONARY STENT 811.93<br />

92981 3 INSERT INTRACORONARY STENT 225.45<br />

92982 3 CORONARY ARTERY DILATION 602.20<br />

92984 3 CORONARY ARTERY DILATION 161.00<br />

92986 3 REVISION OF AORTIC VALVE 1,349.10<br />

92987 3 REVISION OF MITRAL VALVE 1,397.71<br />

92990 3 REVISION OF PULMONARY VALVE 1,065.93<br />

92992 5 REVISION OF HEART CHAMBER 0.00<br />

92993 5 REVISION OF HEART CHAMBER 0.00<br />

92995 3 CORONARY ATHERECTOMY 662.37<br />

92996 3 CORONARY ATHERECTOMY ADD-ON 172.88<br />

92997 3 PUL ART BALLOON REPR, PERCUT 623.45<br />

92998 3 PUL ART BALLOON REPR, PERCUT 313.51<br />

93000 3 ELECTROCARDIOGRAM, COMPLETE 23.19<br />

93005 3 ELECTROCARDIOGRAM, TRACING 14.76<br />

93010 3 ELECTROCARDIOGRAM REPORT 8.43<br />

93012 9 TRANSMISSION OF ECG 0.00<br />

93014 9 REPORT ON TRANSMITTED ECG 0.00<br />

93015 3 CARDIOVASCULAR STRESS TEST 105.88<br />

93016 9 CARDIOVASCULAR STRESS TEST 0.00<br />

93017 3 CARDIOVASCULAR STRESS TEST 66.60<br />

93018 3 CARDIOVASCULAR STRESS TEST 15.42<br />

93024 3 CARDIAC DRUG STRESS TEST 121.11<br />

93025 3 MICROVOLT T-WAVE ASSESS 256.57<br />

93040 3 RHYTHM ECG WITH REPORT 13.85<br />

93041 3 RHYTHM ECG, TRACING 6.20<br />

93042 3 RHYTHM ECG, REPORT 7.65<br />

93201 O PHONOCARDIOGRAM WITH OR WITHOUT ECG 0.00<br />

93202 O PHONOCARDIOGRAM WITH OR WITHOUT ECG 0.00<br />

93204 O PHONOCARDIOGRAM WITH OR WITHOUT ECG 0.00<br />

93205 O PHONOCARDIOGRAM WITH ECG LEAD, WITH 0.00<br />

93208 O PHONOCARDIOGRAM WITH ECG LEAD, WITH 0.00<br />

93209 O PHONOCARDIOGRAM WITH ECG LEAD, WITH 0.00<br />

93210 O PHONOCARDIOGRAM, INTRACARDIAC 0.00<br />

93220 O VECTORCARDIOGRAM (VCG), WITH OR WIT 0.00<br />

93221 O VECTORCARDIOGRAM (VCG), WITH OR WIT 0.00<br />

93222 O VECTORCARDIOGRAM (VCG), WITH OR WIT 0.00<br />

93224 3 ECG MONITOR/REPORT, 24 HRS 141.67<br />

93225 3 ECG MONITOR/RECORD, 24 HRS 43.68<br />

93226 3 ECG MONITOR/REPORT, 24 HRS 70.63<br />

93227 3 ECG MONITOR/REVIEW, 24 HRS 27.35<br />

93228 6 REMOTE 30 DAY ECG REV/REPORT 0.00<br />

93229 6 REMOTE 30 DAY ECG TECH SUPP 0.00<br />

93230 3 ECG MONITOR/REPORT, 24 HRS 147.37<br />

93231 3 ECG MONITOR/RECORD, 24 HRS 47.32<br />

93232 3 ECG MONITOR/REPORT, 24 HRS 73.49<br />

93233 3 ECG MONITOR/REVIEW, 24 HRS 26.57

---

93235 3 ECG MONITOR/REPORT, 24 HRS 124.39<br />

93236 3 ECG MONITOR/REPORT, 24 HRS 101.38<br />

93237 3 ECG MONITOR/REVIEW, 24 HRS 23.47<br />

93255 O APEXCARDIOGRAPHY 0.00<br />

93268 3 ECG RECORD/REVIEW 286.06<br />

93270 3 ECG RECORDING 32.27<br />

93271 3 ECG/MONITORING AND ANALYSIS 227.62<br />

93272 3 ECG/REVIEW, INTERPRET ONLY 26.17<br />

93278 3 ECG/SIGNAL-AVERAGED 48.61<br />

93279 6 PM <strong>DE</strong>VICE PROGR EVAL, SNGL 0.00<br />

93280 O CARDIAC FLUOROSCOPY 0.00<br />

93281 6 PM <strong>DE</strong>VICE PROGR EVAL, MULTI 0.00<br />

93282 6 ICD <strong>DE</strong>VICE PROG EVAL, 1 SNGL 0.00<br />

93283 6 ICD <strong>DE</strong>VICE PROGR EVAL, DUAL 0.00<br />

93284 6 ICD <strong>DE</strong>VICE PROGR EVAL, MULT 0.00<br />

93285 6 ILR <strong>DE</strong>VICE EVAL PROGR 0.00<br />

93286 6 PRE-OP PM <strong>DE</strong>VICE EVAL 0.00<br />

93287 6 PRE-OP ICD <strong>DE</strong>VICE EVAL 0.00<br />

93288 6 PM <strong>DE</strong>VICE EVAL IN PERSON 0.00<br />

93289 6 ICD <strong>DE</strong>VICE INTERROGATE 0.00<br />

93290 6 ICM <strong>DE</strong>VICE EVAL 0.00<br />

93291 6 ILR <strong>DE</strong>VICE INTERROGATE 0.00<br />

93292 6 WCD <strong>DE</strong>VICE INTERROGATE 0.00<br />

93293 6 PM PHONE R-STRIP <strong>DE</strong>VICE EVAL 0.00<br />

93294 6 PM <strong>DE</strong>VICE INTERROGATE REMOTE 0.00<br />

93295 6 ICD <strong>DE</strong>VICE INTERROGAT REMOTE 0.00<br />

93296 6 PM/ICD REMOTE TECH SERV 0.00<br />

93297 6 ICM <strong>DE</strong>VICE INTERROGAT REMOTE 0.00<br />

93298 6 ILR <strong>DE</strong>VICE INTERROGAT REMOTE 0.00<br />

93299 6 ICM/ILR REMOTE TECH SERV 0.00<br />

93303 3 ECHO TRANSTHORACIC 225.39<br />

93304 3 ECHO TRANSTHORACIC 134.90<br />

93306 6 TTE W/DOPPLER, COMPLETE 0.00<br />

93307 3 TTE W/O DOPPLER, COMPLETE 195.08<br />

93308 3 TTE, F-UP OR LMTD 116.18<br />

93312 3 ECHO TRANSESOPHAGEAL 320.93<br />

93313 3 ECHO TRANSESOPHAGEAL 40.81<br />

93314 3 ECHO TRANSESOPHAGEAL 277.56<br />

93315 3 ECHO TRANSESOPHAGEAL 0.00<br />

93316 3 ECHO TRANSESOPHAGEAL 43.66<br />

93317 3 ECHO TRANSESOPHAGEAL 0.00<br />

93318 3 ECHO TRANSESOPHAGEAL INTRAOP 0.00<br />

93320 3 DOPPLER ECHO EXAM, HEART 86.19<br />

93321 3 DOPPLER ECHO EXAM, HEART 42.69<br />

93325 3 DOPPLER COLOR FLOW ADD-ON 79.64<br />

93350 3 STRESS TTE ONLY 201.35<br />

93351 6 STRESS TTE COMPLETE 0.00<br />

93352 6 ADMIN ECG CONTRAST AGENT 0.00<br />

93501 3 RIGHT HEART CATHETERIZATION 866.30<br />

93503 3 INSERT/PLACE HEART CATHETER 104.49

---

93505 3 BIOPSY OF HEART LINING 645.40<br />

93508 3 CATH PLACEMENT, ANGIOGRAPHY 1,025.81<br />

93510 3 LEFT HEART CATHETERIZATION 1,550.63<br />

93511 3 LEFT HEART CATHETERIZATION 0.00<br />

93514 3 LEFT HEART CATHETERIZATION 0.00<br />

93524 3 LEFT HEART CATHETERIZATION 0.00<br />

93526 3 RT & LT HEART CATHETERS 2,001.43<br />

93527 3 RT & LT HEART CATHETERS 0.00<br />

93528 3 RT & LT HEART CATHETERS 0.00<br />

93529 3 RT, LT HEART CATHETERIZATION 0.00<br />

93530 3 RT HEART CATH, CONGENITAL 0.00<br />

93531 3 R & L HEART CATH, CONGENITAL 0.00<br />

93532 3 R & L HEART CATH, CONGENITAL 0.00<br />

93533 3 R & L HEART CATH, CONGENITAL 0.00<br />

93536 O INSERT CIRCULATION ASSI 0.00<br />

93539 3 INJECTION, CARDIAC CATH 65.31<br />

93540 3 INJECTION, CARDIAC CATH 187.65<br />

93541 3 INJECTION FOR LUNG ANGIOGRAM 15.42<br />

93542 3 INJECTION FOR HEART X-RAYS 114.57<br />

93543 3 INJECTION FOR HEART X-RAYS 64.21<br />

93544 3 INJECTION FOR AORTOGRAPHY 46.93<br />

93545 3 INJECT FOR CORONARY X-RAYS 21.25<br />

93546 O COMBINED LEFT HEART CATHETERIZATION 0.00<br />

93547 O COMBINED LEFT HEART CATHETERIZATION 0.00<br />

93548 O COMBINED LEFT HEART CATHETERIZATION 0.00<br />

93549 O COMBINED RIGHT AND LEFT HEART CATHE 0.00<br />

93550 O COMBINED RIGHT AND LEFT HEART CATHE 0.00<br />

93551 O SELECTIVE OPACIFICATION OF AORTOCOR 0.00<br />

93552 O COMBINED LEFT HEART CATHETERIZATION 0.00<br />

93553 O COMBINED LEFT HEART CATHETERIZATION 0.00<br />

93555 3 IMAGING, CARDIAC CATH 179.53<br />

93556 3 IMAGING, CARDIAC CATH 262.45<br />

93561 3 CARDIAC OUTPUT MEASUREMENT 0.00<br />

93562 3 CARDIAC OUTPUT MEASUREMENT 0.00<br />

93571 3 HEART FLOW RESERVE MEASURE 0.00<br />

93572 3 HEART FLOW RESERVE MEASURE 0.00<br />

93580 3 TRANSCATH CLOSURE OF ASD 976.64<br />

93581 3 TRANSCATH CLOSURE OF VSD 1,290.33<br />

93600 3 BUNDLE OF HIS RECORDING 0.00<br />

93602 3 INTRA-ATRIAL RECORDING 0.00<br />

93603 3 RIGHT VENTRICULAR RECORDING 0.00<br />

93607 O LEFT VENTRICULAR RECORDING 0.00<br />

93609 3 MAP TACHYCARDIA, ADD-ON 0.00<br />

93610 3 INTRA-ATRIAL PACING 0.00<br />

93612 3 INTRAVENTRICULAR PACING 0.00<br />

93613 3 ELECTROPHYS MAP 3D, ADD-ON 378.78<br />

93615 3 ESOPHAGEAL RECORDING 0.00<br />

93616 3 ESOPHAGEAL RECORDING 0.00<br />

93618 3 HEART RHYTHM PACING 0.00<br />

93619 3 ELECTROPHYSIOLOGY EVALUATION 0.00

---

93620 3 ELECTROPHYSIOLOGY EVALUATION 0.00<br />

93621 3 ELECTROPHYSIOLOGY EVALUATION 0.00<br />

93622 3 ELECTROPHYSIOLOGY EVALUATION 0.00<br />

93623 3 STIMULATION, PACING HEART 0.00<br />

93624 3 ELECTROPHYSIOLOGIC STUDY 0.00<br />

93631 3 HEART PACING, MAPPING 0.00<br />

93640 3 EVALUATION HEART <strong>DE</strong>VICE 0.00<br />

93641 3 ELECTROPHYSIOLOGY EVALUATION 0.00<br />

93642 3 ELECTROPHYSIOLOGY EVALUATION 512.15<br />

93650 3 ABLATE HEART DYSRHYTHM FOCUS 578.84<br />

93651 3 ABLATE HEART DYSRHYTHM FOCUS 876.02<br />

93652 3 ABLATE HEART DYSRHYTHM FOCUS 954.25<br />

93660 3 TILT TABLE EVALUATION 172.91<br />

93662 3 INTRACARDIAC ECG (ICE) 0.00<br />

93668 9 PERIPHERAL VASCULAR REHAB 0.00<br />

93701 3 BIOIMPEDANCE, THORACIC 39.42<br />

93720 3 TOTAL BODY PLETHYSMOGRAPHY 46.01<br />

93721 3 PLETHYSMOGRAPHY TRACING 37.97<br />

93722 3 PLETHYSMOGRAPHY REPORT 8.04<br />

93724 3 ANALYZE PACEMAKER SYSTEM 356.13<br />

93727 O ANALYZE ILR SYSTEM 0.00<br />

93731 O ANALYZE PACEMAKER SYSTEM 0.00<br />

93732 O ANALYZE PACEMAKER SYSTEM 0.00<br />

93733 O TELEPHONE ANALY, PACEMAKER 0.00<br />

93734 O ANALYZE PACEMAKER SYSTEM 0.00<br />

93735 O ANALYZE PACEMAKER SYSTEM 0.00<br />

93736 O TELEPHONIC ANALY, PACEMAKER 0.00<br />

93737 O ANALYZE CARDIO/<strong>DE</strong>FIBRILLATOR 0.00<br />

93738 O ANALYZE CARDIO/<strong>DE</strong>FIBRILLATOR 0.00<br />

93740 O TEMPERATURE GRADIENT STUDIES 0.00<br />

93741 O ANALYZE HT PACE <strong>DE</strong>VICE SNGL 0.00<br />

93742 O ANALYZE HT PACE <strong>DE</strong>VICE SNGL 0.00<br />

93743 O ANALYZE HT PACE <strong>DE</strong>VICE DUAL 0.00<br />

93744 O ANALYZE HT PACE <strong>DE</strong>VICE DUAL 0.00<br />

93745 3 SET-UP CARDIOVERT-<strong>DE</strong>FIBRILL 215.95<br />

93760 O CEPHALIC THERMOGRAM 0.00<br />

93762 O PERIPHERAL THERMOGRAM 0.00<br />

93770 3 MEASURE VENOUS PRESSURE 7.95<br />

93784 3 AMBULATORY BP MONITORING 71.43<br />

93786 3 AMBULATORY BP RECORDING 34.13<br />

93788 3 AMBULATORY BP ANALYSIS 19.18<br />

93790 3 REVIEW/REPORT BP RECORDING 18.12<br />

93797 3 CARDIAC REHAB 18.65<br />

93798 3 CARDIAC REHAB/MONITOR 27.63<br />

93799 5 CARDIOVASCULAR PROCEDURE 0.00<br />

93850 O NON-INVASIVE STUDIES OF CEREBRAL AR 0.00<br />

93860 O NON-INVASIVE STUDIES OF CAROTID ART 0.00<br />

93870 O NON-INVASIVE STUDIES OF CAROTID ART 0.00<br />

93875 3 EXTRACRANIAL STUDY 106.87<br />

93880 3 EXTRACRANIAL STUDY 183.81

---

93882 3 EXTRACRANIAL STUDY 171.47<br />

93886 3 INTRACRANIAL STUDY 200.77<br />

93888 3 INTRACRANIAL STUDY 92.99<br />

93890 3 TRANSCRANIAL DOPPLER STUDY OF THE 147.31<br />

93892 3 TCD, EMBOLI <strong>DE</strong>TECT W/O INJ 153.60<br />

93893 3 TCD, EMBOLI <strong>DE</strong>TECT W/INJ 153.60<br />

93910 O NON-INVASIVE STUDIES OF LOWER EXTRE 0.00<br />

93920 O NON-INVASIVE PHYSIOLOGIC STUDIES OF 0.00<br />

93921 O NON-INVASIVE PHYSIOLOGIC STUDIES OF 0.00<br />

93922 3 EXTREMITY STUDY 127.01<br />

93923 3 EXTREMITY STUDY 194.24<br />

93924 3 EXTREMITY STUDY 236.70<br />

93925 3 LOWER EXTREMITY STUDY 182.74<br />

93926 3 LOWER EXTREMITY STUDY 116.97<br />

93930 3 UPPER EXTREMITY STUDY 176.73<br />

93931 3 UPPER EXTREMITY STUDY 112.90<br />

93950 O NON-INVASIVE STUDIES OF EXTREMITY V 0.00<br />

93960 O QUANTITATIVE VENOUS FLOW STUDIES (E 0.00<br />

93965 3 EXTREMITY STUDY 130.18<br />

93970 3 EXTREMITY STUDY 187.49<br />

93971 3 EXTREMITY STUDY 119.68<br />

93975 3 VASCULAR STUDY 243.51<br />

93976 3 VASCULAR STUDY 212.67<br />

93978 3 VASCULAR STUDY 186.34<br />

93979 3 VASCULAR STUDY 119.39<br />

93980 3 PENILE VASCULAR STUDY 179.11<br />

93981 3 PENILE VASCULAR STUDY 137.31<br />

93982 3 ANEURYSM PRESSURE SENS STUDY 41.78<br />

93990 3 DOPPLER FLOW TESTING 110.48<br />

94002 9 VENT MGMT INPAT, INIT DAY 0.00<br />

94003 9 VENT MGMT INPAT, SUBQ DAY 0.00<br />

94004 9 VENT MGMT NF PER DAY 0.00<br />

94005 9 HOME VENT MGMT SUPERVISION 0.00<br />

94010 3 BREATHING CAPACITY TEST 34.60<br />

94014 3 PATIENT RECOR<strong>DE</strong>D SPIROMETRY 49.29<br />

94015 3 PATIENT RECOR<strong>DE</strong>D SPIROMETRY 25.08<br />

94016 3 REVIEW PATIENT SPIROMETRY 24.21<br />

94060 3 EVALUATION OF WHEEZING 59.29<br />

94070 3 EVALUATION OF WHEEZING 59.66<br />

94150 3 VITAL CAPACITY TEST 21.39<br />

94160 O VITAL CAPACITY SCREENING TESTS: TOT 0.00<br />

94200 3 LUNG FUNCTION TEST (MBC/MVV) 23.23<br />

94240 3 RESIDUAL LUNG CAPACITY 39.75<br />

94250 3 EXPIRED GAS COLLECTION 27.26<br />

94260 3 THORACIC GAS VOLUME 31.68<br />

94350 3 LUNG NITROGEN WASHOUT CURVE 37.48<br />

94360 3 MEASURE AIRFLOW RESISTANCE 43.19<br />

94370 3 BREATH AIRWAY CLOSING VOLUME 35.71<br />

94375 3 RESPIRATORY FLOW VOLUME LOOP 37.25<br />

94400 3 CO2 BREATHING RESPONSE CURVE 53.12

---

94450 3 HYPOXIA RESPONSE CURVE 50.86<br />

94452 3 HAST W/REPORT 56.43<br />

94453 3 HAST W/OXYGEN TITRATE 77.61<br />

94610 3 SURFACTANT ADMIN THRU TUBE 60.35<br />

94620 3 PULMONARY STRESS TEST/SIMPLE 89.93<br />

94621 3 PULM STRESS TEST/COMPLEX 158.70<br />

94640 3 AIRWAY INHALATION TREATMENT 13.97<br />

94642 3 AEROSOL INHALATION TREATMENT 34.88<br />

94644 3 CBT, 1ST HOUR 38.36<br />

94645 3 CBT, EACH ADDL HOUR 14.36<br />

94650 O PRESSURE BREATHING (IPPB) 0.00<br />

94651 O PRESSURE BREATHING (IPPB) 0.00<br />

94652 O PRESSURE BREATHING (IPPB) 0.00<br />

94656 O INITIAL VENTILATOR MGMT 0.00<br />

94657 O CONTINUED VENTILATOR MGMT 0.00<br />

94660 9 POS AIRWAY PRESSURE, CPAP 0.00<br />

94662 9 NEG PRESS VENTILATION, CNP 0.00<br />

94664 3 EVALUATE PT USE OF INHALER 15.35<br />

94665 O AEROSOL OR VAPOR INHALATIONS 0.00<br />

94667 9 CHEST WALL MANIPULATION 0.00<br />

94668 9 CHEST WALL MANIPULATION 0.00<br />

94680 3 EXHALED AIR ANALYSIS, O2 68.37<br />

94681 3 EXHALED AIR ANALYSIS, O2/CO2 81.20<br />

94690 3 EXHALED AIR ANALYSIS 63.59<br />

94700 O ANALYSIS OF ARTERIAL BLOOD GAS (OXY 0.00<br />

94705 O ANALYSIS OF ARTERIAL BLOOD GAS (OXY 0.00<br />

94710 O ANALYSIS OF ARTERIAL BLOOD GAS (OXY 0.00<br />

94715 O HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 0.00<br />

94720 3 MONOXI<strong>DE</strong> DIFFUSING CAPACITY 53.42<br />

94725 3 MEMBRANE DIFFUSION CAPACITY 89.03<br />

94750 3 PULMONARY COMPLIANCE STUDY 70.16<br />

94760 3 MEASURE BLOOD OXYGEN LEVEL 2.56<br />

94761 3 MEASURE BLOOD OXYGEN LEVEL 5.32<br />

94762 3 MEASURE BLOOD OXYGEN LEVEL 28.93<br />

94770 3 EXHALED CARBON DIOXI<strong>DE</strong> TEST 38.06<br />

94772 3 BREATH RECORDING, INFANT 167.00<br />

94774 9 PED HOME APNEA REC, COMPL 0.00<br />

94775 9 PED HOME APNEA REC, HK-UP 0.00<br />

94776 9 PED HOME APNEA REC, DOWNLD 0.00<br />

94777 9 PED HOME APNEA REC, REPORT 0.00<br />

94799 O PULMONARY SERVICE/PROCEDURE 0.00<br />

95000 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU 0.00<br />

95001 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU 0.00<br />

95002 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU 0.00<br />

95003 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU 0.00<br />

95004 3 PERCUT ALLERGY SKIN TESTS 5.80<br />

95005 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU 0.00<br />

95006 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU 0.00<br />

95007 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU 0.00<br />

95010 3 PERCUT ALLERGY TITRATE TEST 17.89

---

95011 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU 0.00<br />

95012 3 EXHALED NITRIC OXI<strong>DE</strong> MEAS 19.57<br />

95014 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS, 0.00<br />

95015 3 ID ALLERGY TITRATE-DRUG/BUG 12.38<br />

95016 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS, 0.00<br />

95017 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS, 0.00<br />

95018 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS, 0.00<br />

95020 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95021 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95022 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95023 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95024 3 ID ALLERGY TEST, DRUG/BUG 6.98<br />

95027 3 ID ALLERGY TITRATE-AIRBORNE 5.40<br />

95028 3 ID ALLERGY TEST-<strong>DE</strong>LAYED TYPE 10.92<br />

95030 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95031 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95032 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95033 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95034 O INTRACUTANEOUS (INTRA<strong>DE</strong>RMAL) TESTS 0.00<br />

95040 O PATCH OR APPLICATION TESTS UP TO 10 0.00<br />

95041 O PATCH OR APPLICATION TESTS 11-20 TE 0.00<br />

95042 O PATCH OR APPLICATION TESTS 21-30 TE 0.00<br />

95043 O PATCH OR APPLICATION TESTS MORE THA 0.00<br />

95044 3 ALLERGY PATCH TESTS 7.38<br />

95050 9 PHOTO PATCH TESTS UP TO 10 TESTS 0.00<br />

95051 9 PHOTO PATCH TESTS MORE THAN 10 TEST 0.00<br />

95052 3 PHOTO PATCH TEST 8.16<br />

95056 3 PHOTOSENSITIVITY TESTS 28.23<br />

95060 3 EYE ALLERGY TESTS 21.84<br />

95065 3 NOSE ALLERGY TEST 18.00<br />

95070 3 BRONCHIAL ALLERGY TESTS 61.57<br />

95071 3 BRONCHIAL ALLERGY TESTS 77.31<br />

95075 3 INGESTION CHALLENGE TEST 62.74<br />

95078 O PROVOCATIVE TESTING 0.00<br />

95080 9 PASSIVE TRANSFER TESTS UP TO 10 TES 0.00<br />

95081 9 PASSIVE TRANSFER TESTS 11-20 TESTS 0.00<br />

95082 9 PASSIVE TRANSFER TESTS MORE THAN 20 0.00<br />

95105 O MEDICAL CONFERENCE SERVICES (EG, US 0.00<br />

95115 3 IMMUNOTHERAPY, ONE INJECTION 14.19<br />

95117 3 IMMUNOTHERAPY INJECTIONS 17.67<br />

95120 9 IMMUNOTHERAPY, ONE INJECTION 0.00<br />

95125 9 IMMUNOTHERAPY, MANY ANTIGENS 0.00<br />

95130 9 IMMUNOTHERAPY, INSECT VENOM 0.00<br />

95131 9 IMMUNOTHERAPY, INSECT VENOMS 0.00<br />

95132 9 IMMUNOTHERAPY, INSECT VENOMS 0.00<br />

95133 9 IMMUNOTHERAPY, INSECT VENOMS 0.00<br />

95134 9 IMMUNOTHERAPY, INSECT VENOMS 0.00<br />

95135 9 PROFESSIONAL SERVICES FOR THE SUPER 0.00<br />

95140 9 PROFESSIONAL SERVICES FOR THE SUPER 0.00<br />

95144 3 ANTIGEN THERAPY SERVICES 11.27

---

95145 3 ANTIGEN THERAPY SERVICES 15.60<br />

95146 3 ANTIGEN THERAPY SERVICES 24.25<br />

95147 3 ANTIGEN THERAPY SERVICES 23.47<br />

95148 3 ANTIGEN THERAPY SERVICES 32.91<br />

95149 3 ANTIGEN THERAPY SERVICES 43.53<br />

95150 9 PROFESSIONAL SERVICE FOR THE SUPERV 0.00<br />

95155 O PROFESSIONAL SERVICE FOR THE SUPERV 0.00<br />

95165 3 ANTIGEN THERAPY SERVICES 11.27<br />

95170 3 ANTIGEN THERAPY SERVICES 8.91<br />

95180 3 RAPID <strong>DE</strong>SENSITIZATION 142.13<br />

95199 5 ALLERGY IMMUNOLOGY SERVICES 0.00<br />

95250 3 GLUCOSE MONITORING, CONT 149.80<br />

95251 3 GLUC MONITOR, CONT, PHYS I&R 38.13<br />

95803 9 ACTIGRAPHY TESTING 0.00<br />

95805 3 MULTIPLE SLEEP LATENCY TEST 554.28<br />

95806 9 SLEEP STUDY, UNATTEN<strong>DE</strong>D 0.00<br />

95807 3 SLEEP STUDY, ATTEN<strong>DE</strong>D 546.29<br />

95808 3 POLYSOMNOGRAPHY, 1-3 675.69<br />

95810 3 POLYSOMNOGRAPHY, 4 OR MORE 829.28<br />

95811 3 POLYSOMNOGRAPHY W/CPAP 911.90<br />

95812 3 EEG, 41-60 MINUTES 237.15<br />

95813 3 EEG, OVER 1 HOUR 291.46<br />

95816 3 EEG, AWAKE AND DROWSY 217.97<br />

95817 O ELECTROENCEPHALOGRAM (EEG) INCLUDIN 0.00<br />

95819 3 EEG, AWAKE AND ASLEEP 220.72<br />

95821 O ELECTROENCEPHALOGRAM (EEG) INCLUDIN 0.00<br />

95822 3 EEG, COMA OR SLEEP ONLY 241.28<br />

95823 O ELECTROENCEPHALOGRAM (EEG); PHYSICA 0.00<br />

95824 3 EEG, CEREBRAL <strong>DE</strong>ATH ONLY 0.00<br />

95826 O ELECTROENCEPHALOGRAM (EEG); INTRACE 0.00<br />

95827 3 EEG, ALL NIGHT RECORDING 322.33<br />

95828 O POLYSOMNOGRAPHY (RECORDING, ANALYSI 0.00<br />

95829 3 SURGERY ELECTROCORTICOGRAM 1,322.73<br />

95830 9 INSERT ELECTRO<strong>DE</strong>S FOR EEG 0.00<br />

95831 3 LIMB MUSCLE TESTING, MANUAL 26.84<br />

95832 3 HAND MUSCLE TESTING, MANUAL 24.37<br />

95833 3 BODY MUSCLE TESTING, MANUAL 37.63<br />

95834 3 BODY MUSCLE TESTING, MANUAL 44.12<br />

95842 O MUSCLE TESTING, ELECTRICAL: REACTIO 0.00<br />

95851 9 RANGE OF MOTION MEASUREMENTS 0.00<br />

95852 3 RANGE OF MOTION MEASUREMENTS 13.98<br />

95857 3 TENSILON TEST 41.90<br />

95858 O TENSILON TEST & MYOGRAM 0.00<br />

95860 3 MUSCLE TEST, ONE LIMB 85.56<br />

95861 3 MUSCLE TEST, 2 LIMBS 116.41<br />

95863 3 MUSCLE TEST, 3 LIMBS 139.58<br />

95864 3 MUSCLE TEST, 4 LIMBS 168.03<br />

95865 3 MUSCLE TEST, LARYNX 112.26<br />

95866 3 MUSCLE TEST, HEMIDIAPHRAGM 85.84<br />

95867 3 MUSCLE TEST CRAN NERV UNILAT 69.94

---

95868 3 MUSCLE TEST CRAN NERVE BILAT 96.12<br />

95869 3 MUSCLE TEST, THOR PARASPINAL 41.43<br />

95870 3 MUSCLE TEST, NONPARASPINAL 40.64<br />

95872 9 MUSCLE TEST, ONE FIBER 0.00<br />

95873 3 GUI<strong>DE</strong> NERV <strong>DE</strong>STR, ELEC STIM 41.04<br />

95874 3 GUI<strong>DE</strong> NERV <strong>DE</strong>STR, NEEDLE EMG 40.25<br />

95875 3 LIMB EXERCISE TEST 98.05<br />

95880 O ASSESSMENT OF APHASIA (INCLU<strong>DE</strong>S ASS 0.00<br />

95881 O <strong>DE</strong>VELOPMENTAL TESTING (INCLU<strong>DE</strong>S ASS 0.00<br />

95882 O NEUROBEHAVIORAL STATUS EXAM (CLINIC 0.00<br />

95883 O NEUROPSYCHOLOGICAL TESTING BATTERY 0.00<br />

95900 3 MOTOR NERVE CONDUCTION TEST 58.32<br />

95903 3 MOTOR NERVE CONDUCTION TEST 65.17<br />

95904 3 SENSE NERVE CONDUCTION TEST 50.90<br />

95920 3 INTRAOP NERVE TEST ADD-ON 156.72<br />

95921 3 AUTONOMIC NERV FUNCTION TEST 69.18<br />

95922 3 AUTONOMIC NERV FUNCTION TEST 81.62<br />

95923 3 AUTONOMIC NERV FUNCTION TEST 116.69<br />

95925 3 SOMATOSENSORY TESTING 104.06<br />

95926 3 SOMATOSENSORY TESTING 102.59<br />

95927 3 SOMATOSENSORY TESTING 106.03<br />

95928 3 C MOTOR EVOKED, UPPR LIMBS 190.41<br />

95929 3 C MOTOR EVOKED, LWR LIMBS 200.64<br />

95930 3 VISUAL EVOKED POTENTIAL TEST 109.22<br />

95933 3 BLINK REFLEX TEST 65.08<br />

95934 3 H-REFLEX TEST 43.69<br />

95935 O ''H'' OR ''F'' REFLEX STUDY, BY ELE 0.00<br />

95936 3 H-REFLEX TEST 40.42<br />

95937 3 NEUROMUSCULAR JUNCTION TEST 54.81<br />

95950 3 AMBULATORY EEG MONITORING 240.60<br />

95951 3 EEG MONITORING/VI<strong>DE</strong>ORECORD 1,700.37<br />

95952 9 MONITORING FOR LOCALIZATION OF CERE 0.00<br />

95953 3 EEG MONITORING/COMPUTER 422.13<br />

95954 9 EEG MONITORING/GIVING DRUGS 0.00<br />

95955 9 EEG DURING SURGERY 0.00<br />

95956 3 EEG MONITORING, CABLE/RADIO 745.81<br />

95957 3 EEG DIGITAL ANALYSIS 239.05<br />

95958 9 EEG MONITORING/FUNCTION TEST 0.00<br />

95961 3 ELECTRO<strong>DE</strong> STIMULATION, BRAIN 228.90<br />

95962 3 ELECTRO<strong>DE</strong> STIM, BRAIN ADD-ON 216.91<br />

95965 3 MEG, SPONTANEOUS 0.00<br />

95966 3 MEG, EVOKED, SINGLE 0.00<br />

95967 3 MEG, EVOKED, EACH ADDÏL 0.00<br />

95970 3 ANALYZE NEUROSTIM, NO PROG 50.52<br />

95971 3 ANALYZE NEUROSTIM, SIMPLE 53.43<br />

95972 3 ANALYZE NEUROSTIM, COMPLEX 101.40<br />

95973 3 ANALYZE NEUROSTIM, COMPLEX 54.90<br />

95974 3 CRANIAL NEUROSTIM, COMPLEX 168.16<br />

95975 3 CRANIAL NEUROSTIM, COMPLEX 93.18<br />

95978 3 ANALYZE NEUROSTIM BRAIN/1H 198.68

---

95979 3 ANALYZ NEUROSTIM BRAIN ADDON 89.29<br />

95980 3 IO ANAL GAST N-STIM INIT 38.86<br />

95981 3 IO ANAL GAST N-STIM SUBSQ 27.91<br />

95982 3 IO GA N-STIM SUBSQ W/REPROG 41.92<br />

95990 3 SPIN/BRAIN PUMP REFIL & MAIN 63.15<br />

95991 3 SPIN/BRAIN PUMP REFIL & MAIN 88.94<br />

95992 6 CANALITH REPOSITIONING PROC 0.00<br />

95999 5 NEUROLOGICAL PROCEDURE 0.00<br />

96000 9 MOTION ANALYSIS, VI<strong>DE</strong>O/3D 0.00<br />

96001 9 MOTION TEST W/FT PRESS MEAS 0.00<br />

96002 9 DYNAMIC SURFACE EMG 0.00<br />

96003 9 DYNAMIC FINE WIRE EMG 0.00<br />

96004 9 PHYS REVIEW OF MOTION TESTS 0.00<br />

96020 3 FUNCTIONAL BRAIN MAPPING 0.00<br />

96040 9 GENETIC COUNSELING, 30 MIN 0.00<br />

96100 O PSYCHOLOGICAL TESTING 0.00<br />

96101 3 PSYCHO TESTING BY PSYCH/PHYS 84.30<br />

96102 9 PSYCHO TESTING BY TECHNICIAN 0.00<br />

96103 9 PSYCHO TESTING ADMIN BY COMP 0.00<br />

96105 9 ASSESSMENT OF APHASIA 0.00<br />

96110 3 <strong>DE</strong>VELOPMENTAL TEST, LIM 12.41<br />

96111 7 <strong>DE</strong>VELOPMENTAL TEST, EXTEND 0.00<br />

96115 O NEUROBEHAVIOR STATUS EXAM 0.00<br />

96116 9 NEUROBEHAVIORAL STATUS EXAM 0.00<br />

96117 O NEUROPSYCH TEST BATTERY 0.00<br />

96118 3 NEUROPSYCH TST BY PSYCH/PHYS 112.15<br />

96119 9 NEUROPSYCH TESTING BY TEC 0.00<br />

96120 9 NEUROPSYCH TST ADMIN W/COMP 0.00<br />

96125 9 COGNITIVE TEST BY HC PRO 0.00<br />

96150 9 ASSESS HLTH/BEHAVE, INIT 0.00<br />

96151 9 ASSESS HLTH/BEHAVE, SUBSEQ 0.00<br />

96152 9 INTERVENE HLTH/BEHAVE, INDIV 0.00<br />

96153 9 INTERVENE HLTH/BEHAVE, GROUP 0.00<br />

96154 7 INTERV HLTH/BEHAV, FAM W/PT 0.00<br />

96155 7 INTERV HLTH/BEHAV FAM NO PT 0.00<br />

96360 6 HYDRATION IV INFUSION, INIT 0.00<br />

96361 6 HYDRATE IV INFUSION, ADD-ON 0.00<br />

96365 6 THER/PROPH/DIAG IV INF, INIT 0.00<br />

96366 6 THER/PROPH/DIAG IV INF ADDON 0.00<br />

96367 6 TX/PROPH/DG ADDL SEQ IV INF 0.00<br />

96368 6 THER/DIAG CONCURRENT INF 0.00<br />

96369 6 SC THER INFUSION, UP TO 1 HR 0.00<br />

96370 6 SC THER INFUSION, ADDL HR 0.00<br />

96371 6 SC THER INFUSION, RESET PUMP 0.00<br />

96372 9 THER/PROPH/DIAG INJ, SC/IM 0.00<br />

96373 9 THER/PROPH/DIAG INJ, IA 0.00<br />

96374 9 THER/PROPH/DIAG INJ, IV PUSH 0.00<br />

96375 9 TX/PRO/DX INJ NEW DRUG ADDON 0.00<br />

96376 6 TX/PRO/DX INJ NEW DRUG ADON 0.00<br />

96379 9 THER/PROP/DIAG INJ/INF PROC 0.00

---

96400 O CHEMOTHERAPY, SC/IM 0.00<br />

96401 3 CHEMO, ANTI-NEOPL, SQ/IM 66.64<br />

96402 3 CHEMO HORMON ANTINEOPL SQ/IM 41.86<br />

96405 3 CHEMO INTRALESIONAL, UP TO 7 138.99<br />

96406 3 CHEMO INTRALESIONAL OVER 7 158.07<br />

96408 O CHEMOTHERAPY, PUSH TECHNIQUE 0.00<br />

96409 3 CHEMO, IV PUSH, SNGL DRUG 122.39<br />

96410 O CHEMOTHERAPY,INFUSION METHOD 0.00<br />

96411 3 CHEMO, IV PUSH, ADDL DRUG 69.69<br />

96412 O CHEMO, INFUSE METHOD ADD-ON 0.00<br />

96413 3 CHEMO, IV INFUSION, 1 HR 165.83<br />

96414 O CHEMO, INFUSE METHOD ADD-ON 0.00<br />

96415 3 CHEMO, IV INFUSION, ADDL HR 36.55<br />

96416 3 CHEMO PROLONG INFUSE W/PUMP 180.05<br />

96417 3 CHEMO IV INFUS EACH ADDL SEQ 81.40<br />

96420 3 CHEMO, IA, PUSH TECNIQUE 115.16<br />

96422 3 CHEMO IA INFUSION UP TO 1 HR 191.49<br />

96423 3 CHEMO IA INFUSE EACH ADDL HR 82.69<br />

96425 3 CHEMOTHERAPY,INFUSION METHOD 187.94<br />

96440 3 CHEMOTHERAPY, INTRACAVITARY 354.62<br />

96445 3 CHEMOTHERAPY, INTRACAVITARY 343.63<br />

96450 3 CHEMOTHERAPY, INTO CNS 289.53<br />

96520 O PORT PUMP REFILL & MAIN 0.00<br />

96521 3 REFILL/MAINT, PORTABLE PUMP 144.84<br />

96522 3 REFILL/MAINT PUMP/RESVR SYST 115.33<br />

96523 3 IRRIG DRUG <strong>DE</strong>LIVERY <strong>DE</strong>VICE 28.20<br />

96530 O SYST PUMP REFILL & MAIN 0.00<br />

96542 3 CHEMOTHERAPY INJECTION 180.93<br />

96545 O PROVI<strong>DE</strong> CHEMOTHERAPY AGENT 0.00<br />

96549 5 CHEMOTHERAPY, UNSPECIFIED 0.00<br />

96567 3 PHOTODYNAMIC TX, SKIN 113.31<br />

96570 3 PHOTODYNAMIC TX, 30 MIN 55.56<br />

96571 3 PHOTODYNAMIC TX, ADDL 15 MIN 26.85<br />

96900 3 ULTRAVIOLET LIGHT THERAPY 20.26<br />

96902 3 TRICHOGRAM 20.06<br />

96904 9 WHOLE BODY PHOTOGRAPHY 0.00<br />

96910 3 PHOTOCHEMOTHERAPY WITH UV-B 60.20<br />

96912 3 PHOTOCHEMOTHERAPY WITH UV-A 77.02<br />

96913 3 PHOTOCHEMOTHERAPY, UV-A OR B 104.07<br />

96920 3 LASER TX, SKIN < 250 SQ CM 159.88<br />

96921 3 LASER TX, SKIN 250-500 SQ CM 157.40<br />

96922 3 LASER TX, SKIN > 500 SQ CM 232.16<br />

96999 5 <strong>DE</strong>RMATOLOGICAL PROCEDURE 0.00<br />

97001 3 PT EVALUATION 69.84<br />

97002 3 PT RE-EVALUATION 37.52<br />

97003 3 OT EVALUATION 74.85<br />

97004 3 OT RE-EVALUATION 45.00<br />

97005 9 ATHLETIC TRAIN EVAL 0.00<br />

97006 9 ATHLETIC TRAIN REEVAL 0.00<br />

97010 3 HOT OR COLD PACKS THERAPY 4.58

---

97012 3 MECHANICAL TRACTION THERAPY 14.28<br />

97014 3 ELECTRIC STIMULATION THERAPY 13.54<br />

97016 3 VASOPNEUMATIC <strong>DE</strong>VICE THERAPY 14.72<br />

97018 3 PARAFFIN BATH THERAPY 7.34<br />

97020 O MICROWAVE THERAPY 0.00<br />

97022 3 WHIRLPOOL THERAPY 16.69<br />

97024 3 DIATHERMY EG, MICROWAVE 4.98<br />

97026 3 INFRARED THERAPY 4.58<br />

97028 3 ULTRAVIOLET THERAPY 6.14<br />

97032 3 ELECTRICAL STIMULATION 15.85<br />

97033 3 ELECTRIC CURRENT THERAPY 23.32<br />

97034 3 CONTRAST BATH THERAPY 13.92<br />

97035 3 ULTRASOUND THERAPY 11.16<br />

97036 3 HYDROTHERAPY 24.87<br />

97039 3 PHYSICAL THERAPY TREATMENT 11.27<br />

97110 3 THERAPEUTIC EXERCISES 27.40<br />

97112 3 NEUROMUSCULAR REEDUCATION 28.68<br />

97113 3 AQUATIC THERAPY/EXERCISES 33.41<br />

97114 O PHYSICAL MEDICINE TREATMENT TO ONE 0.00<br />

97116 3 GAIT TRAINING THERAPY 24.00<br />

97118 O PHYSICAL MEDICINE TREATMENT TO ONE 0.00<br />

97120 O PHYSICAL MEDICINE TREATMENT TO ONE 0.00<br />

97122 O MANUAL TRACTION THERAPY 0.00<br />

97124 3 MASSAGE THERAPY 22.07<br />

97126 O PHYSICAL MEDICINE TREATMENT TO ONE 0.00<br />

97128 O PHYSICAL MEDICINE TREATMENT TO ONE 0.00<br />

97139 3 PHYSICAL MEDICINE PROCEDURE 15.30<br />

97140 3 MANUAL THERAPY 25.55<br />

97145 O PHYSICAL MEDICINE TREATMENT TO ONE 0.00<br />

97150 3 GROUP THERAPEUTIC PROCEDURES 17.41<br />

97220 O HUBBARD TANK; INITIAL 30 MINUTES, E 0.00<br />

97221 O HUBBARD TANK; EACH ADDITIONAL 15 MI 0.00<br />

97240 O POOL THERAPY OR HUBBARD TANK WITH T 0.00<br />

97241 O POOL THERAPY OR HUBBARD TANK WITH T 0.00<br />

97250 O MYOFASCIAL RELEASE 0.00<br />

97260 O REGIONAL MANIPULATION 0.00<br />

97261 O SUPPLEMENTAL MANIPULATIONS 0.00<br />

97265 O JOINT MOBILIZATION 0.00<br />

97500 O ORTHOTICS TRAINING (DYNAMIC BRACING 0.00<br />

97501 O ORTHOTICS TRAINING (DYNAMIC BRACING 0.00<br />

97504 O ORTHOTIC TRAINING 0.00<br />

97520 O PROSTHETIC TRAINING 0.00<br />

97521 O PROSTHETIC TRAINING; EACH ADDITIONA 0.00<br />

97530 3 THERAPEUTIC ACTIVITIES 29.08<br />

97531 O KINETIC ACTIVITIES TO INCREASE COOR 0.00<br />

97532 3 COGNITIVE SKILLS <strong>DE</strong>VELOPMENT 23.58<br />

97533 3 SENSORY INTEGRATION 25.15<br />

97535 3 SELF CARE MNGMENT TRAINING 29.47<br />

97537 3 COMMUNITY/WORK REINTEGRATION 26.32<br />

97540 O TRAINING IN ACTIVITIES OF DAILY LIV 0.00

---

97541 O TRAINING IN ACTIVITIES OF DAILY LIV 0.00<br />

97542 3 WHEELCHAIR MNGMENT TRAINING 26.71<br />

97545 O WORK HAR<strong>DE</strong>NING 0.00<br />

97546 O WORK HAR<strong>DE</strong>NING ADD-ON 0.00<br />

97597 3 ACTIVE WOUND CARE/20 CM OR < 55.74<br />

97598 3 ACTIVE WOUND CARE > 20 CM 68.96<br />

97601 O WOUND(S) CARE, SELECTIVE 0.00<br />

97602 9 WOUND(S) CARE NON-SELECTIVE 0.00<br />

97605 3 NEG PRESS WOUND TX, < 50 CM 33.63<br />

97606 3 NEG PRESS WOUND TX, > 50 CM 36.25<br />

97700 O OFFICE VISIT, INCLUDING ONE OF THE 0.00<br />

97701 O OFFICE VISIT, INCLUDING ONE OF THE 0.00<br />

97703 O PROSTHETIC CHECKOUT 0.00<br />

97720 O EXTREMITY TESTING FOR STRENGTH, <strong>DE</strong>X 0.00<br />

97721 O EXTREMITY TESTING FOR STRENGTH, <strong>DE</strong>X 0.00<br />

97750 3 PHYSICAL PERFORMANCE TEST 28.58<br />

97752 O MUSCLE TESTING WITH TORQUE CURVES D 0.00<br />

97755 3 ASSISTIVE TECHNOLOGY ASSESS 32.79<br />

97760 3 ORTHOTIC MGMT AND TRAINING 31.24<br />

97761 3 PROSTHETIC TRAINING 27.80<br />

97762 3 C/O FOR ORTHOTIC/PROSTH USE 31.88<br />

97770 O COGNITIVE SKILLS <strong>DE</strong>VELOPMENT 0.00<br />

97780 O ACUPUNCTURE W/O STIMUL 0.00<br />

97781 O ACUPUNCTURE W/STIMUL 0.00<br />

97799 5 PHYSICAL MEDICINE PROCEDURE 0.00<br />

97802 7 MEDICAL NUTRITION, INDIV, IN 0.00<br />

97803 7 MED NUTRITION, INDIV, SUBSEQ 0.00<br />

97804 9 MEDICAL NUTRITION, GROUP 0.00<br />

97810 9 ACUPUNCT W/O STIMUL 15 MIN 0.00<br />

97811 9 ACUPUNCT W/O STIMUL ADDL 15M 0.00<br />

97813 9 ACUPUNCT W/STIMUL 15 MIN 0.00<br />

97814 9 ACUPUNCT W/STIMUL ADDL 15M 0.00<br />

98900 O MEDICAL CONFERENCE BY PHYSICIAN REG 0.00<br />

98902 O MEDICAL CONFERENCE BY PHYSICIAN REG 0.00<br />

98910 O MEDICAL CONFERENCE BY PHYSICIAN WIT 0.00<br />

98912 O MEDICAL CONFERENCE BY PHYSICIAN WIT 0.00<br />

98920 9 TELEPHONE CALL BY A PHYSICIAN TO PA 0.00<br />

98921 9 TELEPHONE CALL BY A PHYSICIAN TO PA 0.00<br />

98922 9 TELEPHONE CALL BY A PHYSICIAN TO PA 0.00<br />

98925 3 OSTEOPATHIC MANIPULATION 27.80<br />

98926 3 OSTEOPATHIC MANIPULATION 38.18<br />

98927 3 OSTEOPATHIC MANIPULATION 49.42<br />

98928 3 OSTEOPATHIC MANIPULATION 57.86<br />

98929 3 OSTEOPATHIC MANIPULATION 66.30<br />

98940 9 CHIROPRACTIC MANIPULATION 0.00<br />

98941 9 CHIROPRACTIC MANIPULATION 0.00<br />

98942 9 CHIROPRACTIC MANIPULATION 0.00<br />

98943 9 CHIROPRACTIC MANIPULATION 0.00<br />

98960 9 SELF-MGMT EDUC & TRAIN, 1 PT 0.00<br />

98961 9 SELF-MGMT EDUC/TRAIN, 2-4 PT 0.00

---

98962 9 SELF-MGMT EDUC/TRAIN, 5-8 PT 0.00<br />

98966 9 HC PRO PHONE CALL 5-10 MIN 0.00<br />

98967 9 HC PRO PHONE CALL 11-20 MIN 0.00<br />

98968 9 HC PRO PHONE CALL 21-30 MIN 0.00<br />

98969 9 ONLINE SERVICE BY HC PRO 0.00<br />

99000 9 SPECIMEN HANDLING 0.00<br />

99001 3 SPECIMEN HANDLING 3.10<br />

99002 9 <strong>DE</strong>VICE HANDLING 0.00<br />

99024 9 POSTOP FOLLOW-UP VISIT 0.00<br />

99025 O INITIAL SURGICAL EVALUATION 0.00<br />

99026 9 IN-HOSPITAL ON CALL SERVICE 0.00<br />

99027 9 OUT-OF-HOSP ON CALL SERVICE 0.00<br />

99050 3 MEDICAL SERVICES AFTER HRS 20.00<br />

99051 9 MED SERV, EVE/WKEND/HOLIDAY 0.00<br />

99052 O MEDICAL SERVICES AT NIGHT 0.00<br />

99053 9 MED SERV 10PM-8AM, 24 HR FAC 0.00<br />

99054 O MEDICAL SERVCS, UNUSUAL HRS 0.00<br />

99056 O MED SERVICE OUT OF OFFICE 0.00<br />

99058 9 OFFICE EMERGENCY CARE 0.00<br />

99060 9 OUT OF OFFICE EMERG MED SERV 0.00<br />

99062 O EMERGENCY CARE FACILITY SERVICES: W 0.00<br />

99064 O EMERGENCY CARE FACILITY SERVICES: W 0.00<br />

99065 O EMERGENCY CARE FACILITY SERVICES: W 0.00<br />

99070 O SPECIAL SUPPLIES 0.00<br />

99071 9 PATIENT EDUCATION MATERIALS 0.00<br />

99075 9 MEDICAL TESTIMONY 0.00<br />

99078 9 GROUP HEALTH EDUCATION 0.00<br />

99080 9 SPECIAL REPORTS OR FORMS 0.00<br />

99082 9 UNUSUAL PHYSICIAN TRAVEL 0.00<br />

99090 9 COMPUTER DATA ANALYSIS 0.00<br />

99091 9 COLLECT/REVIEW DATA FROM PT 0.00<br />

99100 9 SPECIAL ANESTHESIA SERVICE 0.00<br />

99116 9 ANESTHESIA WITH HYPOTHERMIA 0.00<br />

99135 9 SPECIAL ANESTHESIA PROCEDURE 0.00<br />

99140 9 EMERGENCY ANESTHESIA 0.00<br />

99141 O SEDATION, IV/IM OR INHALANT 0.00<br />

99142 O SEDATION, ORAL/RECTAL/NASAL 0.00<br />

99143 9 MOD CS BY SAME PHYS, < 5 YRS 0.00<br />

99144 9 MOD CS BY SAME PHYS, 5 YRS + 0.00<br />

99145 9 MOD CS BY SAME PHYS ADD-ON 0.00<br />

99148 3 MOD CS DIFF PHYS < 5 YRS 112.36<br />

99149 3 MOD CS DIFF PHYS 5 YRS + 112.36<br />

99150 3 MO<strong>DE</strong>RATE SEDATION SERVICES (OTHER 56.18<br />

99151 O PROLONGED PHYSICIAN ATTENDANCE REQU 0.00<br />

99152 O NEWBORN RESUSCITATION: CARE OF THE 0.00<br />

99160 O CRITICAL CARE, INITIAL, INCLUDING T 0.00<br />

99162 O CRITICAL CARE, INITIAL, INCLUDING T 0.00<br />

99170 3 ANOGENITAL EXAM, CHILD 132.49<br />

99171 O CRITICAL CARE, SUBSEQUENT FOLLOW-UP 0.00<br />

99172 O OCULAR FUNCTION SCREEN 0.00

---

99173 3 VISUAL ACUITY SCREEN 2.66<br />

99174 6 OCULAR PHOTOSCREENING WITH INTERPR 0.00<br />

99175 3 INDUCTION OF VOMITING 37.19<br />

99178 O ADMINISTRATION AND MEDICAL INTERPRE 0.00<br />

99180 O HYPERBARIC OXYGEN PRESSURIZATION IN 0.00<br />

99182 O HYPERBARIC OXYGEN PRESSURIZATION SU 0.00<br />

99183 3 HYPERBARIC OXYGEN THERAPY 198.94<br />

99185 3 REGIONAL HYPOTHERMIA 46.43<br />

99186 3 TOTAL BODY HYPOTHERMIA 80.60<br />

99190 9 SPECIAL PUMP SERVICES 0.00<br />

99191 9 SPECIAL PUMP SERVICES 0.00<br />

99192 9 SPECIAL PUMP SERVICES 0.00<br />

99195 3 PHLEBOTOMY 59.61<br />

99199 5 SPECIAL SERVICE/PROC/REPORT 0.00<br />

99201 3 OFFICE/OUTPATIENT VISIT, NEW 36.75<br />

99202 3 OFFICE/OUTPATIENT VISIT, NEW 63.00<br />

99203 3 OFFICE/OUTPATIENT VISIT, NEW 92.17<br />

99204 3 OFFICE/OUTPATIENT VISIT, NEW 140.34<br />

99205 3 OFFICE/OUTPATIENT VISIT, NEW 176.13<br />

99211 3 OFFICE/OUTPATIENT VISIT, EST 20.24<br />

99212 3 OFFICE/OUTPATIENT VISIT, EST 37.93<br />

99213 3 OFFICE/OUTPATIENT VISIT, EST 60.80<br />

99214 3 OFFICE/OUTPATIENT VISIT, EST 91.32<br />

99215 3 OFFICE/OUTPATIENT VISIT, EST 123.25<br />

99217 9 OBSERVATION CARE DISCHARGE 0.00<br />

99218 O OBSERVATION CARE 0.00<br />

99219 O OBSERVATION CARE 0.00<br />

99220 O OBSERVATION CARE 0.00<br />

99221 3 INITIAL HOSPITAL CARE 85.66<br />

99222 3 INITIAL HOSPITAL CARE 117.93<br />

99223 3 INITIAL HOSPITAL CARE 173.38<br />

99231 3 SUBSEQUENT HOSPITAL CARE 35.74<br />

99232 3 SUBSEQUENT HOSPITAL CARE 63.90<br />

99233 3 SUBSEQUENT HOSPITAL CARE 91.58<br />

99234 3 OBSERV/HOSP SAME DATE 123.14<br />

99235 3 OBSERV/HOSP SAME DATE 162.35<br />

99236 3 OBSERV/HOSP SAME DATE 201.95<br />

99238 3 HOSPITAL DISCHARGE DAY 65.45<br />

99239 3 HOSPITAL DISCHARGE DAY 93.92<br />

99241 3 OFFICE CONSULTATION 48.62<br />

99242 3 OFFICE CONSULTATION 90.10<br />

99243 3 OFFICE CONSULTATION 123.64<br />

99244 3 OFFICE CONSULTATION 181.13<br />

99245 3 OFFICE CONSULTATION 223.37<br />

99251 3 INPATIENT CONSULTATION 45.99<br />

99252 3 INPATIENT CONSULTATION 73.16<br />

99253 3 INPATIENT CONSULTATION 109.38<br />

99254 3 INPATIENT CONSULTATION 158.01<br />

99255 3 INPATIENT CONSULTATION 194.77<br />

99261 O FOLLOW-UP INPATIENT CONSULT 0.00

---

99262 O FOLLOW-UP INPATIENT CONSULT 0.00<br />

99263 O FOLLOW-UP INPATIENT CONSULT 0.00<br />

99271 O CONFIRMATORY CONSULTATION 0.00<br />

99272 O CONFIRMATORY CONSULTATION 0.00<br />

99273 O CONFIRMATORY CONSULTATION 0.00<br />

99274 O CONFIRMATORY CONSULTATION 0.00<br />

99275 O CONFIRMATORY CONSULTATION 0.00<br />

99281 3 EMERGENCY <strong>DE</strong>PT VISIT 19.54<br />

99282 3 EMERGENCY <strong>DE</strong>PT VISIT 36.73<br />

99283 3 EMERGENCY <strong>DE</strong>PT VISIT 59.12<br />

99284 3 EMERGENCY <strong>DE</strong>PT VISIT 109.27<br />

99285 3 EMERGENCY <strong>DE</strong>PT VISIT 162.95<br />

99288 9 DIRECT ADVANCED LIFE SUPPORT 0.00<br />

99289 O PED CRIT CARE TRANSPORT 0.00<br />

99290 O PED CRIT CARE TRANSPORT ADDL 0.00<br />

99291 3 CRITICAL CARE, FIRST HOUR 253.91<br />

99292 3 CRITICAL CARE, ADDÏL 30 MIN 112.94<br />

99293 O PED CRITICAL CARE, INITIAL 0.00<br />

99294 O PED CRITICAL CARE, SUBSEQ 0.00<br />

99295 O NEONATE CRIT CARE, INITIAL 0.00<br />

99296 O NEONATE CRITICAL CARE SUBSEQ 0.00<br />

99297 O NEONATAL CRITICAL CARE 0.00<br />

99298 O IC FOR LBW INFANT < 1500 GM 0.00<br />

99299 O IC, LBW INFANT 1500-2500 GM 0.00<br />

99300 O IC, INFANT PBW 2501-5000 GM 0.00<br />

99301 O NURSING FACILITY CARE 0.00<br />

99302 O NURSING FACILITY CARE 0.00<br />

99303 O NURSING FACILITY CARE 0.00<br />

99304 3 NURSING FACILITY CARE, INIT 77.01<br />

99305 3 NURSING FACILITY CARE, INIT 106.99<br />

99306 3 NURSING FACILITY CARE, INIT 136.97<br />

99307 3 NURSING FAC CARE, SUBSEQ 38.10<br />

99308 3 NURSING FAC CARE, SUBSEQ 58.56<br />

99309 3 NURSING FAC CARE, SUBSEQ 78.14<br />

99310 3 NURSING FAC CARE, SUBSEQ 114.34<br />

99311 O NURSING FAC CARE, SUBSEQ 0.00<br />

99312 O NURSING FAC CARE, SUBSEQ 0.00<br />

99313 O NURSING FAC CARE, SUBSEQ 0.00<br />

99315 9 NURSING FAC DISCHARGE DAY 0.00<br />

99316 9 NURSING FAC DISCHARGE DAY 0.00<br />

99318 3 ANNUAL NURSING FAC ASSESSMNT 80.48<br />

99321 O REST HOME VISIT, NEW PATIENT 0.00<br />

99322 O REST HOME VISIT, NEW PATIENT 0.00<br />

99323 O REST HOME VISIT, NEW PATIENT 0.00<br />

99324 9 DOMICIL/R-HOME VISIT NEW PAT 0.00<br />

99325 9 DOMICIL/R-HOME VISIT NEW PAT 0.00<br />

99326 9 DOMICIL/R-HOME VISIT NEW PAT 0.00<br />

99327 9 DOMICIL/R-HOME VISIT NEW PAT 0.00<br />

99328 9 DOMICIL/R-HOME VISIT NEW PAT 0.00<br />

99331 O REST HOME VISIT, EST PAT 0.00

---

99332 O REST HOME VISIT, EST PAT 0.00<br />

99333 O REST HOME VISIT, EST PAT 0.00<br />

99334 9 DOMICIL/R-HOME VISIT EST PAT 0.00<br />

99335 9 DOMICIL/R-HOME VISIT EST PAT 0.00<br />

99336 9 DOMICIL/R-HOME VISIT EST PAT 0.00<br />

99337 9 DOMICIL/R-HOME VISIT EST PAT 0.00<br />

99339 9 DOMICIL/R-HOME CARE SUPERVIS 0.00<br />

99340 9 DOMICIL/R-HOME CARE SUPERVIS 0.00<br />

99341 3 HOME VISIT, NEW PATIENT 53.45<br />

99342 3 HOME VISIT, NEW PATIENT 78.06<br />

99343 3 HOME VISIT, NEW PATIENT 123.45<br />

99344 3 HOME VISIT, NEW PATIENT 161.48<br />

99345 3 HOME VISIT, NEW PATIENT 194.11<br />

99347 3 HOME VISIT, EST PATIENT 51.20<br />

99348 3 HOME VISIT, EST PATIENT 76.95<br />

99349 3 HOME VISIT, EST PATIENT 112.29<br />

99350 3 HOME VISIT, EST PATIENT 157.23<br />

99351 O HOME VISIT FOR THE EVALUATION AND M 0.00<br />

99352 O HOME VISIT FOR THE EVALUATION AND M 0.00<br />

99353 O HOME VISIT FOR THE EVALUATION AND M 0.00<br />

99354 3 PROLONGED SERVICE, OFFICE 90.37<br />

99355 3 PROLONGED SERVICE, OFFICE 88.89<br />

99356 3 PROLONGED SERVICE, INPATIENT 82.25<br />

99357 3 PROLONGED SERVICE, INPATIENT 82.54<br />

99358 9 PROLONGED SERV, W/O CONTACT 0.00<br />

99359 9 PROLONGED SERV, W/O CONTACT 0.00<br />

99360 3 PHYSICIAN STANDBY SERVICES 53.31<br />

99361 O PHYSICIAN/TEAM CONFERENCE 0.00<br />

99362 O PHYSICIAN/TEAM CONFERENCE 0.00<br />

99363 9 ANTICOAG MGMT, INIT 0.00<br />

99364 9 ANTICOAG MGMT, SUBSEQ 0.00<br />

99366 9 TEAM CONF W/PAT BY HC PRO 0.00<br />

99367 9 TEAM CONF W/O PAT BY PHYS 0.00<br />

99368 9 TEAM CONF W/O PAT BY HC PRO 0.00<br />

99371 O PHYSICIAN PHONE CONSULTATION 0.00<br />

99372 O PHYSICIAN PHONE CONSULTATION 0.00<br />

99373 O PHYSICIAN PHONE CONSULTATION 0.00<br />

99374 9 HOME HEALTH CARE SUPERVISION 0.00<br />

99375 9 HOME HEALTH CARE SUPERVISION 0.00<br />

99376 9 PHYSICIAN SUPERVISION OF PATIENTS U 0.00<br />

99377 9 HOSPICE CARE SUPERVISION 0.00<br />

99378 9 HOSPICE CARE SUPERVISION 0.00<br />

99379 9 NURSING FAC CARE SUPERVISION 0.00<br />

99380 9 NURSING FAC CARE SUPERVISION 0.00<br />

99381 3 INIT PM E/M, NEW PAT, INF 91.09<br />

99382 3 INIT PM E/M, NEW PAT 1-4 YRS 98.44<br />

99383 3 PREV VISIT, NEW, AGE 5-11 96.87<br />

99384 3 PREV VISIT, NEW, AGE 12-17 105.30<br />

99385 3 PREV VISIT, NEW, AGE 18-39 105.30<br />

99386 3 PREV VISIT, NEW, AGE 40-64 123.04

---

99387 3 INIT PM E/M, NEW PAT 65+ YRS 133.93<br />

99391 3 PER PM REEVAL, EST PAT, INF 72.82<br />

99392 3 PREV VISIT, EST, AGE 1-4 81.25<br />

99393 3 PREV VISIT, EST, AGE 5-11 80.47<br />

99394 3 PREV VISIT, EST, AGE 12-17 88.21<br />

99395 3 PREV VISIT, EST, AGE 18-39 89.00<br />

99396 3 PREV VISIT, EST, AGE 40-64 97.43<br />

99397 3 PER PM REEVAL EST PAT 65+ YR 108.71<br />

99401 7 PREVENTIVE COUNSELING, INDIV 0.00<br />

99402 7 PREVENTIVE COUNSELING, INDIV 0.00<br />

99403 7 PREVENTIVE COUNSELING, INDIV 0.00<br />

99404 7 PREVENTIVE COUNSELING, INDIV 0.00<br />

99406 9 BEHAV CHNG SMOKING 3-10 MIN 0.00<br />

99407 9 BEHAV CHNG SMOKING > 10 MIN 0.00<br />

99408 9 AUDIT/DAST, 15-30 MIN 0.00<br />

99409 9 AUDIT/DAST, OVER 30 MIN 0.00<br />

99411 9 PREVENTIVE COUNSELING, GROUP 0.00<br />

99412 9 PREVENTIVE COUNSELING, GROUP 0.00<br />

99420 9 HEALTH RISK ASSESSMENT TEST 0.00<br />

99429 9 UNLISTED PREVENTIVE SERVICE 0.00<br />

99431 O INITIAL CARE, NORMAL NEWBORN 0.00<br />

99432 O NEWBORN CARE, NOT IN HOSP 0.00<br />

99433 O NORMAL NEWBORN CARE/HOSPITAL 0.00<br />

99435 O NEWBORN DISCHARGE DAY HOSP 0.00<br />

99436 O ATTENDANCE, BIRTH 0.00<br />

99438 9 INFANT CARE TO ONE YEAR OF AGE, WIT 0.00<br />

99440 O NEWBORN RESUSCITATION 0.00<br />

99441 9 PHONE E/M BY PHYS 5-10 MIN 0.00<br />

99442 9 PHONE E/M BY PHYS 11-20 MIN 0.00<br />

99443 9 PHONE E/M BY PHYS 21-30 MIN 0.00<br />

99444 9 ONLINE E/M BY PHYS 0.00<br />

99450 9 BASIC LIFE DISABILITY EXAM 0.00<br />

99455 9 WORK RELATED DISABILITY EXAM 0.00<br />

99456 9 DISABILITY EXAMINATION 0.00<br />

99460 6 INIT NB EM PER DAY, HOSP 0.00<br />

99461 6 INIT NB EM PER DAY, NON-FAC 0.00<br />

99462 6 SBSQ NB EM PER DAY, HOSP 0.00<br />

99463 6 SAME DAY NB DISCHARGE 0.00<br />

99464 6 ATTENDANCE AT <strong>DE</strong>LIVERY 0.00<br />

99465 6 NB RESUSCITATION 0.00<br />

99466 6 PED CRIT CARE TRANSPORT 0.00<br />

99467 6 PED CRIT CARE TRANSPORT ADDL 0.00<br />

99468 6 NEONATE CRIT CARE, INITIAL 0.00<br />

99469 6 NEONATE CRIT CARE, SUBSQ 0.00<br />

99471 6 PED CRITICAL CARE, INITIAL 0.00<br />

99472 6 PED CRITICAL CARE, SUBSQ 0.00<br />

99475 6 PED CRIT CARE AGE 2-5, INIT 0.00<br />

99476 6 PED CRIT CARE AGE 2-5, SUBSQ 0.00<br />

99477 3 INIT DAY HOSP NEONATE CARE 324.57<br />

99478 6 IC, LBW INF < 1500 GM SUBSQ 0.00

---

99479 6 IC LBW INF 1500-2500 G SUBSQ 0.00<br />

99480 6 IC INF PBW 2501-5000 G SUBSQ 0.00<br />

99499 5 UNLISTED E&M SERVICE 0.00<br />

99500 9 HOME VISIT, PRENATAL 0.00<br />

99501 9 HOME VISIT, POSTNATAL 0.00<br />

99502 9 HOME VISIT, NB CARE 0.00<br />

99503 9 HOME VISIT, RESP THERAPY 0.00<br />

99504 9 HOME VISIT MECH VENTILATOR 0.00<br />

99505 9 HOME VISIT, STOMA CARE 0.00<br />

99506 9 HOME VISIT, IM INJECTION 0.00<br />

99507 9 HOME VISIT, CATH MAINTAIN 0.00<br />

99508 9 HOME VISIT, SLEEP STUDIES 0.00<br />

99509 9 HOME VISIT DAY LIFE ACTIVITY 0.00<br />

99510 7 HOME VISIT, SING/M/FAM COUNS 0.00<br />

99511 9 HOME VISIT, FECAL/ENEMA MGMT 0.00<br />

99512 9 HOME VISIT FOR HEMODIALYSIS 0.00<br />

99539 9 HOME VISIT, NOS 0.00<br />

99551 O HOME INFUS, PAIN MGMT, IV/SC 0.00<br />

99552 O HM INFUS PAIN MGMT, EPID/ITH 0.00<br />

99553 O HOME INFUSE, TOCOLYTIC TX 0.00<br />

99554 O HOME INFUS, HORMONE/PLATELET 0.00<br />

99555 O HOME INFUSE, CHEMOTHERAPHY 0.00<br />

99556 O HOME INFUS, ANTIBIO/FUNG/VIR 0.00<br />

99557 O HOME INFUSE, ANTICOAGULANT 0.00<br />

99558 O HOME INFUSE, IMMUNOTHERAPY 0.00<br />

99559 O HOME INFUS, PERITON DIALYSIS 0.00<br />

99560 O HOME INFUS, ENTERO NUTRITION 0.00<br />

99561 O HOME INFUSE, HYDRATION TX 0.00<br />

99562 O HOME INFUS, PARENT NUTRITION 0.00<br />

99563 O HOME ADMIN, PENTAMIDINE 0.00<br />

99564 O HME INFUS, ANTIHEMOPHIL AGNT 0.00<br />

99565 O HOME INFUS, PROTEINASE INHIB 0.00<br />

99566 O HOME INFUSE, IV THERAPY 0.00<br />

99567 O HOME INFUSE, SYMPATH AGENT 0.00<br />

99568 O HOME INFUS, MISC DRUG, DAILY 0.00<br />

99569 O HOME INFUSE, EACH ADDL TX 0.00<br />

99600 9 HOME VISIT NOS 0.00<br />

99601 9 HOME INFUSION/VISIT, 2 HRS 0.00<br />

99602 9 HOME INFUSION, EACH ADDTL HR 0.00<br />

99605 9 MTMS BY PHARM, NP, 15 MIN 0.00<br />

99606 9 MTMS BY PHARM, EST, 15 MIN 0.00<br />

99607 9 MTMS BY PHARM, ADDL 15 MIN 0.00<br />

A0010 9 AMBULANCE SERVICE, BASIC LIFE SUPPO 0.00<br />

A0020 9 AMBULANCE SERVICE, (BLS) PER MILE, 0.00<br />

A0021 9 OUTSI<strong>DE</strong> STATE AMBULANCE SERV 0.00<br />

A0030 9 AIR AMBULANCE SERVICE 0.00<br />

A0040 O HELICOPTER AMBULANCE SERVICE 0.00<br />

A0050 9 WATER AMB SERVICE EMERGENCY 0.00<br />

A0060 9 AMBULANCE SERVICE, WAITING TIME, ON 0.00<br />

A0070 O AMBULANCE SERVICE, OXYGEN, ADMINIST 0.00

---

A0080 9 NONINTEREST ESCORT IN NON ER 0.00<br />

A0090 3 INTEREST ESCORT IN NON ER 0.20<br />

A0100 7 NONEMERGENCY TRANSPORT TAXI 0.00<br />

A0110 7 NONEMERGENCY TRANSPORT BUS 0.00<br />

A0120 7 NONER TRANSPORT MINI-BUS 0.00<br />

A0130 3 NONER TRANSPORT WHEELCH VAN 11.01<br />

A0140 5 NONEMERGENCY TRANSPORT AIR 0.00<br />

A0150 O NON-EMERGENCY TRANSPORTATION, AMBUL 0.00<br />

A0160 9 NONER TRANSPORT CASE WORKER 0.00<br />

A0170 5 TRANSPORT PARKING FEES/TOLLS 0.00<br />

A0180 5 NONER TRANSPORT LODGNG RECIP 0.00<br />

A0190 5 NONER TRANSPORT MEALS RECIP 0.00<br />

A0200 5 NONER TRANSPORT LODGNG ESCRT 0.00<br />

A0210 5 NONER TRANSPORT MEALS ESCORT 0.00<br />

A0215 9 AMBULANCE SERVICE, MISCELLANEOUS DI 0.00<br />

A0220 9 AMBULANCE SERVICE, ADVANCED LIFE SU 0.00<br />

A0221 9 AMBULANCE SERVICE, (ALS) PER MILE, 0.00<br />

A0222 9 AMBULANCE SERVICE, RETURN TRIP, TRA 0.00<br />

A0223 9 AMBULANCE SERVICE, ADVANCED LIFE SU 0.00<br />

A0225 3 NEONATAL EMERGENCY TRANSPORT 95.00<br />

A0300 9 AMBULANCE BASIC NON-EMER ALL 0.00<br />

A0302 9 AMBULANCE BASIC EMERGENY ALL 0.00<br />

A0304 9 AMB ADV NON-ER NO SERV ALL 0.00<br />

A0306 9 AMB ADV NON-ER SPEC SERV ALL 0.00<br />

A0308 9 AMB ADV ER NO SPEC SERV ALL 0.00<br />

A0310 9 AMB ADV ER SPEC SERV ALL 0.00<br />

A0320 9 AMB BASIC NON-ER + SUPPLIES 0.00<br />

A0322 9 AMB BASIC EMERG + SUPPLIES 0.00<br />

A0324 9 ADV NON-ER SERV SEP MILEAGE 0.00<br />

A0326 9 ADV NON-ER NO SERV SEP MILE 0.00<br />

A0328 9 ADV ER NO SERV SEP MILEAGE 0.00<br />

A0330 9 ADV ER SPEC SERV SEP MILE 0.00<br />

A0340 9 AMB BASIC NON-ER + MILEAGE 0.00<br />

A0342 9 AMBUL BASIC EMER + MILEAGE 0.00<br />

A0344 9 AMB ADV NON-ER NO SERV +MILE 0.00<br />

A0346 9 AMB ADV NON-ER SERV + MILE 0.00<br />

A0348 9 ADV EMER NO SPEC SERV + MILE 0.00<br />

A0350 9 ADV EMER SPEC SERV + MILEAGE 0.00<br />

A0360 9 BASIC NON-ER SEP MILE & SUPP 0.00<br />

A0362 9 BASIC EMER SEP MILE & SUPPLY 0.00<br />

A0364 9 ADV NON-ER NO SERV SEP MI&SU 0.00<br />

A0366 9 ADV NON-ER SERV SEP MIL&SUPP 0.00<br />

A0368 9 ADV ER NO SERV SEP MILE&SUPP 0.00<br />

A0370 9 ADV ER SPEC SERV SEP MI&SUPP 0.00<br />

A0380 3 BASIC LIFE SUPPORT MILEAGE 1.50<br />

A0382 9 BASIC SUPPORT ROUTINE SUPPLS 0.00<br />

A0384 9 BLS <strong>DE</strong>FIBRILLATION SUPPLIES 0.00<br />

A0390 3 ADVANCED LIFE SUPPORT MILEAG 1.50<br />

A0392 9 ALS <strong>DE</strong>FIBRILLATION SUPPLIES 0.00<br />

A0394 9 ALS IV DRUG THERAPY SUPPLIES 0.00

---

A0396 9 ALS ESOPHAGEAL INTUB SUPPLS 0.00<br />

A0398 9 ALS ROUTINE DISPOSBLE SUPPLS 0.00<br />

A0420 9 AMBULANCE WAITING 1/2 HR 0.00<br />

A0422 3 AMBULANCE 02 LIFE SUSTAINING 12.00<br />

A0424 5 EXTRA AMBULANCE ATTENDANT 0.00<br />

A0425 9 GROUND MILEAGE 0.00<br />

A0426 3 ALS 1 35.00<br />

A0427 3 ALS1-EMERGENCY 55.00<br />

A0428 3 BLS 35.00<br />

A0429 3 BLS-EMERGENCY 55.00<br />

A0430 9 FIXED WING AIR TRANSPORT 0.00<br />

A0431 3 ROTARY WING AIR TRANSPORT 2,124.00<br />

A0432 9 PI VOLUNTEER AMBULANCE CO 0.00<br />

A0433 9 ALS 2 0.00<br />

A0434 9 SPECIALTY CARE TRANSPORT 0.00<br />

A0435 9 FIXED WING AIR MILEAGE 0.00<br />

A0436 3 ROTARY WING AIR MILEAGE 12.80<br />

A0800 O AMB TRANS 7PM-7AM 0.00<br />

A0888 9 NONCOVERED AMBULANCE MILEAGE 0.00<br />

A0998 9 AMBULANCE RESPONSE/TREATMENT 0.00<br />

A0999 9 UNLISTED AMBULANCE SERVICE 0.00<br />

A2000 9 MANIPULATION OF SPINE BY CHIROPRACT 0.00<br />

A4190 O TRANSPARENT FILM, EACH 0.00<br />

A4200 O GAUZE PADS, MEDICATED OR NON-MEDICA 0.00<br />

A4202 O GAUZE, ELASTIC, ALL TYPES, PER ROLL 0.00<br />

A4203 O GAUZE, NON-ELASTIC, PER ROLL 0.00<br />

A4204 O ABSORPTIVE DRESSING (E.G. HYDROCOLL 0.00<br />

A4205 O NON-ABSORPTIVE DRESSING (E.G. HYDRO 0.00<br />

A4206 3 1 CC STERILE SYRINGE&NEEDLE 0.22<br />

A4207 3 2 CC STERILE SYRINGE&NEEDLE 0.20<br />

A4208 3 3 CC STERILE SYRINGE&NEEDLE 0.18<br />

A4209 3 5+ CC STERILE SYRINGE&NEEDLE 0.36<br />

A4210 3 NONNEEDLE INJECTION <strong>DE</strong>VICE 1.50<br />

A4211 O SUPP FOR SELF-ADM INJECTIONS 0.00<br />

A4212 5 NON CORING NEEDLE OR STYLET 0.00<br />

A4213 3 20+ CC SYRINGE ONLY 0.68<br />

A4214 O 30 CC STERILE WATER/SALINE 0.00<br />

A4215 5 STERILE NEEDLE 0.00<br />

A4216 3 STERILE WATER/SALINE, 10 ML 0.54<br />

A4217 3 STERILE WATER/SALINE, 500 ML 3.13<br />

A4218 6 STERILE SALINE OR WATER 0.00<br />

A4220 9 INFUSION PUMP REFILL KIT 0.00<br />

A4221 3 MAINT DRUG INFUS CATH PER WK 22.52<br />

A4222 3 INFUSION SUPPLIES WITH PUMP 46.50<br />

A4223 6 INFUSION SUPPLIES W/O PUMP 0.00<br />

A4230 3 INFUS INSULIN PUMP NON NEEDL 10.07<br />

A4231 5 INFUSION INSULIN PUMP NEEDLE 0.00<br />

A4232 3 SYRINGE W/NEEDLE INSULIN 3CC 2.54<br />

A4233 6 ALKALIN BATT FOR GLUCOSE MON 0.00<br />

A4234 6 J-CELL BATT FOR GLUCOSE MON 0.00

---

A4235 3 LITHIUM BATT FOR GLUCOSE MON 2.34<br />

A4236 6 SILVR OXI<strong>DE</strong> BATT GLUCOSE MON 0.00<br />

A4244 3 ALCOHOL OR PEROXI<strong>DE</strong> PER PINT 1.00<br />

A4245 3 ALCOHOL WIPES PER BOX 10.00<br />

A4246 3 BETADINE/PHISOHEX SOLUTION 10.00<br />

A4247 3 BETADINE/IODINE SWABS/WIPES 8.00<br />

A4248 6 CHLORHEXIDINE ANTISEPT 0.00<br />

A4250 3 URINE REAGENT STRIPS/TABLETS 17.25<br />

A4252 6 BLOOD KETONE TEST OR STRIP 0.00<br />

A4253 9 BLOOD GLUCOSE/REAGENT STRIPS 0.00<br />

A4254 O BATTERY FOR GLUCOSE MONITOR 0.00<br />

A4255 9 GLUCOSE MONITOR PLATFORMS 0.00<br />

A4256 9 CALIBRATOR SOLUTION/CHIPS 0.00<br />

A4257 9 REPLACE LENSSHIELD CARTRIDGE 0.00<br />

A4258 9 LANCET <strong>DE</strong>VICE EACH 0.00<br />

A4259 9 LANCETS PER BOX 0.00<br />

A4260 O LEVONORGESTREL (CONTRACEPTIVE) IMP 0.00<br />

A4261 9 CERVICAL CAP CONTRACEPTIVE 0.00<br />

A4262 9 TEMPORARY TEAR DUCT PLUG 0.00<br />

A4263 9 PERMANENT TEAR DUCT PLUG 0.00<br />

A4265 9 PARAFFIN 0.00<br />

A4266 9 DIAPHRAGM 0.00<br />

A4267 9 MALE CONDOM 0.00<br />

A4268 9 FEMALE CONDOM 0.00<br />

A4269 9 SPERMICI<strong>DE</strong> 0.00<br />

A4270 9 DISPOSABLE ENDOSCOPE SHEATH 0.00<br />

A4280 3 BRST PRSTHS ADHSV ATTCHMNT 4.62<br />

A4281 5 REPLACEMENT BREASTPUMP TUBE 0.00<br />

A4282 5 REPLACEMENT BREASTPUMP ADPT 0.00<br />

A4283 5 REPLACEMENT BREASTPUMP CAP 0.00<br />

A4284 5 REPLCMNT BREAST PUMP SHIELD 0.00<br />

A4285 5 REPLCMNT BREAST PUMP BOTTLE 0.00<br />

A4286 5 REPLCMNT BREASTPUMP LOK RING 0.00<br />

A4290 5 SACRAL NERVE STIM TEST LEAD 0.00<br />

A4300 9 CATH IMPL VASC ACCESS PORTAL 0.00<br />

A4301 9 IMPLANTABLE ACCESS SYST PERC 0.00<br />

A4305 3 DRUG <strong>DE</strong>LIVERY SYSTEM >=50 ML 17.04<br />

A4306 3 DRUG <strong>DE</strong>LIVERY SYSTEM

---

A4324 O MALE EXT CATH W/ADH COATING 0.00<br />

A4325 O MALE EXT CATH W/ADH STRIP 0.00<br />

A4326 3 MALE EXTERNAL CATHETER 10.29<br />

A4327 3 FEM URINARY COLLECT <strong>DE</strong>V CUP 40.32<br />

A4328 3 FEM URINARY COLLECT POUCH 9.97<br />

A4329 O EXTERNAL CATHETER START SET 0.00<br />

A4330 3 STOOL COLLECTION POUCH 6.82<br />

A4331 3 EXTENSION DRAINAGE TUBING 3.04<br />

A4332 3 LUBE STERILE PACKET 0.12<br />

A4333 3 URINARY CATH ANCHOR <strong>DE</strong>VICE 2.10<br />

A4334 3 URINARY CATH LEG STRAP 4.71<br />

A4335 5 INCONTINENCE SUPPLY 0.00<br />

A4338 3 INDWELLING CATHETER LATEX 10.08<br />

A4340 3 INDWELLING CATHETER SPECIAL 30.28<br />

A4344 3 CATH INDW FOLEY 2 WAY SILICN 12.99<br />

A4346 3 CATH INDW FOLEY 3 WAY 16.26<br />

A4347 O MALE EXTERNAL CATHETER 0.00<br />

A4348 O MALE EXT CATH EXTEN<strong>DE</strong>D WEAR 0.00<br />

A4349 3 DISPOSABLE MALE EXTERNAL CAT 2.02<br />

A4350 9 CATHETER CARE KIT 0.00<br />

A4351 3 STRAIGHT TIP URINE CATHETER 1.66<br />

A4352 3 COU<strong>DE</strong> TIP URINARY CATHETER 6.12<br />

A4353 3 INTERMITTENT URINARY CATH 6.66<br />

A4354 3 CATH INSERTION TRAY W/BAG 11.16<br />

A4355 3 BLAD<strong>DE</strong>R IRRIGATION TUBING 8.50<br />

A4356 3 EXT URETH CLMP OR COMPR DVC 43.52<br />

A4357 3 BEDSI<strong>DE</strong> DRAINAGE BAG 8.77<br />

A4358 3 URINARY LEG OR ABDOMEN BAG 6.33<br />

A4359 O URINARY SUSPENSORY W/O LEG B 0.00<br />

A4360 9 ADULT INCONTINENCE GARMENT 0.00<br />

A4361 3 OSTOMY FACE PLATE 17.42<br />

A4362 3 SOLID SKIN BARRIER 3.30<br />

A4363 6 OSTOMY CLAMP 0.00<br />

A4364 3 ADHESIVE, LIQUID OR EQUAL 2.80<br />

A4365 3 ADHESIVE REMOVER WIPES 10.80<br />

A4366 6 OSTOMY VENT 0.00<br />

A4367 3 OSTOMY BELT 7.01<br />

A4368 9 OSTOMY FILTER 0.00<br />

A4369 3 SKIN BARRIER LIQUID PER OZ 2.30<br />

A4370 O SKIN BARRIER PASTE PER OZ 0.00<br />

A4371 3 SKIN BARRIER POW<strong>DE</strong>R PER OZ 3.48<br />

A4372 3 SKIN BARRIER SOLID 4X4 EQUIV 3.98<br />

A4373 3 SKIN BARRIER WITH FLANGE 5.99<br />

A4374 O SKIN BARRIER EXTEN<strong>DE</strong>D WEAR 0.00<br />

A4375 3 DRAINABLE PLASTIC PCH W FCPL 16.38<br />

A4376 3 DRAINABLE RUBBER PCH W FCPLT 45.38<br />

A4377 3 DRAINABLE PLSTIC PCH W/O FP 4.09<br />

A4378 3 DRAINABLE RUBBER PCH W/O FP 29.33<br />

A4379 3 URINARY PLASTIC POUCH W FCPL 14.33<br />

A4380 3 URINARY RUBBER POUCH W FCPLT 35.60

---

A4381 3 URINARY PLASTIC POUCH W/O FP 4.40<br />

A4382 3 URINARY HVY PLSTC PCH W/O FP 23.48<br />

A4383 3 URINARY RUBBER POUCH W/O FP 26.89<br />

A4384 3 OSTOMY FACEPLT/SILICONE RING 9.18<br />

A4385 3 OST SKN BARRIER SLD EXT WEAR 4.86<br />

A4386 O OST SKN BARRIER W FLNG EX WR 0.00<br />

A4387 3 OST CLSD POUCH W ATT ST BARR 3.83<br />

A4388 3 DRAINABLE PCH W EX WEAR BARR 4.16<br />

A4389 3 DRAINABLE PCH W ST WEAR BARR 5.93<br />

A4390 3 DRAINABLE PCH EX WEAR CONVEX 9.17<br />

A4391 3 URINARY POUCH W EX WEAR BARR 6.74<br />

A4392 3 URINARY POUCH W ST WEAR BARR 6.34<br />

A4393 3 URINE PCH W EX WEAR BAR CONV 8.75<br />

A4394 3 OSTOMY POUCH LIQ <strong>DE</strong>ODORANT 2.46<br />

A4395 3 OSTOMY POUCH SOLID <strong>DE</strong>ODORANT 0.05<br />

A4396 3 PERISTOMAL HERNIA SUPPRT BLT 38.61<br />

A4397 3 IRRIGATION SUPPLY SLEEVE 4.57<br />

A4398 3 OSTOMY IRRIGATION BAG 13.17<br />

A4399 3 OSTOMY IRRIG CONE/CATH W BRS 11.70<br />

A4400 3 OSTOMY IRRIGATION SET 46.62<br />

A4402 3 LUBRICANT PER OUNCE 1.32<br />

A4404 3 OSTOMY RING EACH 1.52<br />

A4405 3 NONPECTIN BASED OSTOMY PASTE 3.40<br />

A4406 3 PECTIN BASED OSTOMY PASTE 5.74<br />

A4407 3 EXT WEAR OST SKN BARR 4SQÊ 9.87<br />

A4409 3 OST SKN BARR CONVEX 4 SQ 9.04<br />

A4411 6 OST SKN BARR EXTND =4SQ 0.00<br />

A4412 6 OST POUCH DRAIN HIGH OUTPUT 0.00<br />

A4413 3 2 PC DRAINABLE OST POUCH 5.50<br />

A4414 3 OST SKNBAR W/O CONV4 SQI 6.00<br />

A4416 3 OST PCH CLSD W BARRIER/FILTR 2.75<br />

A4417 6 OST PCH W BAR/BLTINCONV/FLTR 0.00<br />

A4418 6 OST PCH CLSD W/O BAR W FILTR 0.00<br />

A4419 3 OST PCH FOR BAR W FLANGE/FLT 1.74<br />

A4420 6 OST PCH CLSD FOR BAR W LK FL 0.00<br />

A4421 3 OSTOMY SUPPLY MISC 200.00<br />

A4422 3 OST POUCH ABSORBENT MATERIAL 0.12<br />

A4423 3 OST PCH FOR BAR W LK FL/FLTR 1.86<br />

A4424 3 OST PCH DRAIN W BAR & FILTER 4.75<br />

A4425 3 OST PCH DRAIN FOR BARRIER FL 3.58<br />

A4426 3 OST PCH DRAIN 2 PIECE SYSTEM 2.73<br />

A4427 3 OST PCH DRAIN/BARR LK FLNG/F 2.78<br />

A4428 3 URINE OST POUCH W FAUCET/TAP 6.51<br />

A4429 3 URINE OST POUCH W BLTINCONV 8.25<br />

A4430 3 OST URINE PCH W B/BLTIN CONV 8.52<br />

A4431 3 OST PCH URINE W BARRIER/TAPV 6.22<br />

A4432 3 OS PCH URINE W BAR/FANGE/TAP 3.59

---

A4433 3 URINE OST PCH BAR W LOCK FLN 3.34<br />

A4434 3 OST PCH URINE W LOCK FLNG/FT 3.76<br />

A4450 3 NON-WATERPROOF TAPE 0.09<br />

A4452 3 WATERPROOF TAPE 0.36<br />

A4454 O TAPE ALL TYPES ALL SIZES 0.00<br />

A4455 3 ADHESIVE REMOVER PER OUNCE 1.33<br />

A4458 5 REUSABLE ENEMA BAG 0.00<br />

A4460 O ELASTIC COMPRESSION BANDAGE 0.00<br />

A4461 6 SURGICL DRESS HOLD NON-REUSE 0.00<br />

A4462 O ABDMNL DRSSNG HOL<strong>DE</strong>R/BIN<strong>DE</strong>R 0.00<br />

A4463 6 SURGICAL DRESS HOL<strong>DE</strong>R REUSE 0.00<br />

A4464 O JOINT SUPPORT <strong>DE</strong>VICE/GARMENT 0.00<br />

A4465 9 NON-ELASTIC EXTREMITY BIN<strong>DE</strong>R 0.00<br />

A4470 5 GRAVLEE JET WASHER 0.00<br />

A4480 3 VABRA ASPIRATOR 20.00<br />

A4481 9 TRACHEOSTOMA FILTER 0.00<br />

A4483 3 MOISTURE EXCHANGER 2.86<br />

A4490 3 ABOVE KNEE SURGICAL STOCKING 60.00<br />

A4495 3 THIGH LENGTH SURG STOCKING 60.00<br />

A4500 3 BELOW KNEE SURGICAL STOCKING 30.00<br />

A4510 3 FULL LENGTH SURG STOCKING 60.00<br />

A4520 9 INCONTINENCE GARMENT ANYTYPE 0.00<br />

A4521 O ADULT SIZE DIAPER SM EACH 0.00<br />

A4522 O ADULT SIZE DIAPER MED EACH 0.00<br />

A4523 O ADULT SIZE DIAPER LG EACH 0.00<br />

A4524 O ADULT SIZE DIAPER XL EACH 0.00<br />

A4525 O ADULT SIZE BRIEF SM EACH 0.00<br />

A4526 O ADULT SIZE BRIEF MED EACH 0.00<br />

A4527 O ADULT SIZE BRIEF LG EACH 0.00<br />

A4528 O ADULT SIZE BRIEF XL EACH 0.00<br />

A4529 O CHILD SIZE DIAPER SM/MED EA 0.00<br />

A4530 O CHILD SIZE DIAPER LG EACH 0.00<br />

A4531 O CHILD SIZE BRIEF SM/MED EACH 0.00<br />

A4532 O CHILD SIZE BRIEF LG EACH 0.00<br />

A4533 O YOUTH SIZE DIAPER EACH 0.00<br />

A4534 9 YOUTH SIZE BRIEF EACH 0.00<br />

A4535 O DISP INCONT LINER/SHIELD EA 0.00<br />

A4536 O PROT UN<strong>DE</strong>RWR WSHBL ANY SZ EA 0.00<br />

A4537 O UN<strong>DE</strong>R PAD REUSABLE ANY SZ EA 0.00<br />

A4538 O REUSABLE DIAPER FROM DPR SVC 0.00<br />

A4550 9 SURGICAL TRAYS 0.00<br />

A4554 3 DISPOSABLE UN<strong>DE</strong>RPADS 0.20<br />

A4555 9 PRIMARY SURGICAL DRESSING KIT, (E.G 0.00<br />

A4556 5 ELECTRO<strong>DE</strong>S, PAIR 0.00<br />

A4557 3 LEAD WIRES, PAIR 17.16<br />

A4558 3 CONDUCTIVE GEL OR PASTE 4.44<br />

A4559 9 COUPLING GEL OR PASTE 0.00<br />

A4560 O PESSARY 0.00<br />

A4561 3 PESSARY RUBBER, ANY TYPE 17.78<br />

A4562 3 PESSARY, NON RUBBER,ANY TYPE 44.25

---

A4565 3 SLINGS 60.00<br />

A4570 3 SPLINT 50.00<br />

A4572 O RIB BELT 0.00<br />

A4575 9 HYPERBARIC O2 CHAMBER DISPS 0.00<br />

A4580 O CAST SUPPLIES (PLASTER) 0.00<br />

A4581 9 SUPPLIES RISSER JACKET 0.00<br />

A4590 O SPECIAL CASTING MATERIAL 0.00<br />

A4595 3 TENS SUPPL 2 LEAD PER MONTH 27.56<br />

A4600 6 SLEEVE, INTER LIMB COMP <strong>DE</strong>V 0.00<br />

A4601 6 LITH ION BATT, NON-PROS USE 0.00<br />

A4604 3 TUBING WITH HEATING ELEMENT 66.81<br />

A4605 6 TRACH SUCTION CATH CLOSE SYS 0.00<br />

A4606 5 OXYGEN PROBE USED W OXIMETER 0.00<br />

A4608 3 TRANSTRACHEAL OXYGEN CATH 58.32<br />

A4609 O TRACH SUCTION CATH CLSED SYS 0.00<br />

A4610 O TRACH SUCTION CATH CLSED SYS 0.00<br />

A4611 3 HEAVY DUTY BATTERY 187.94<br />

A4612 3 BATTERY CABLES 65.00<br />

A4613 3 BATTERY CHARGER 137.96<br />

A4614 3 HAND-HELD PEFR METER 22.75<br />

A4615 3 CANNULA NASAL 20.00<br />

A4616 3 TUBING (OXYGEN) PER FOOT 1.00<br />

A4617 3 MOUTH PIECE 5.00<br />

A4618 3 BREATHING CIRCUITS 8.51<br />

A4619 3 FACE TENT 1.21<br />

A4620 3 VARIABLE CONCENTRATION MASK 20.00<br />

A4621 O TRACHEOTOMY MASK OR COLLAR 0.00<br />

A4622 O TRACHEOSTOMY OR LARNGECTOMY 0.00<br />

A4623 3 TRACHEOSTOMY INNER CANNULA 6.25<br />

A4624 3 TRACHEAL SUCTION TUBE 2.25<br />

A4625 3 TRACH CARE KIT FOR NEW TRACH 6.61<br />

A4626 3 TRACHEOSTOMY CLEANING BRUSH 3.05<br />

A4627 9 SPACER BAG/RESERVOIR 0.00<br />

A4628 3 OROPHARYNGEAL SUCTION CATH 3.51<br />

A4629 3 TRACHEOSTOMY CARE KIT 4.42<br />

A4630 3 REPL BAT T.E.N.S. OWN BY PT 5.45<br />

A4631 O WHEELCHAIR BATTERY 0.00<br />

A4632 O INFUS PUMP RPLCEMNT BATTERY 0.00<br />

A4633 3 UVL REPLACEMENT BULB 41.04<br />

A4634 5 REPLACEMENT BULB TH LIGHTBOX 0.00<br />

A4635 3 UN<strong>DE</strong>RARM CRUTCH PAD 4.16<br />

A4636 3 HANDGRIP FOR CANE ETC 3.42<br />

A4637 3 REPL TIP CANE/CRUTCH/WALKER 1.90<br />

A4638 6 REPL BATT PULSE GEN SYS 0.00<br />

A4639 3 INFRARED HT SYS REPLCMNT PAD 287.21<br />

A4640 3 ALTERNATING PRESSURE PAD 51.49<br />

A4641 9 RADIOPHARM DX AGENT NOC 0.00<br />

A4642 9 IN111 SATUMOMAB 0.00<br />

A4643 O HIGH DOSE CONTRAST MRI 0.00<br />

A4644 O CONTRAST 100-199 MGS IODINE 0.00

---

A4645 O CONTRAST 200-299 MGS IODINE 0.00<br />

A4646 O CONTRAST 300-399 MGS IODINE 0.00<br />

A4647 O SUPP- PARAMAGNETIC CONTR MAT 0.00<br />

A4648 9 TISSUE MARKER, IMPLANTABLE, ANY TY 0.00<br />

A4649 9 SURGICAL SUPPLIES 0.00<br />

A4650 9 IMPLANTABLE RADIATION DOSIMETER, E 0.00<br />

A4651 9 CALIBRATED MICROCAP TUBE 0.00<br />

A4652 9 MICROCAPILLARY TUBE SEALANT 0.00<br />

A4653 5 PD CATHETER ANCHOR BELT 0.00<br />

A4655 9 ESRD SYRINGE/NEEDLE 0.00<br />

A4656 O NEEDLE ANY SIZE 0.00<br />

A4657 9 SYRINGE W/WO NEEDLE 0.00<br />

A4660 3 SPHYG/BP APP W CUFF AND STET 20.00<br />

A4663 3 DIALYSIS BLOOD PRESSURE CUFF 6.27<br />

A4670 5 AUTOMATIC BP MONITOR, DIAL 0.00<br />

A4671 6 DISPOSABLE CYCLER SET 0.00<br />

A4672 6 DRAINAGE EXT LINE, DIALYSIS 0.00<br />

A4673 6 EXT LINE W EASY LOCK CONNECT 0.00<br />

A4674 6 CHEM/ANTISEPT SOLUTION, 8OZ 0.00<br />

A4680 9 ACTIFICIAL CARBON FILTER, EA 0.00<br />

A4690 9 DIALYZER, EACH 0.00<br />

A4700 9 STANDARD DIALYSATE SOLUTION 0.00<br />

A4705 9 BICARB DIALYSATE SOLUTION 0.00<br />

A4706 9 BICARBONATE CONC SOL PER GAL 0.00<br />

A4707 9 BICARBONATE CONC POW PER PAC 0.00<br />

A4708 9 ACETATE CONC SOL PER GALLON 0.00<br />

A4709 9 ACID CONC SOL PER GALLON 0.00<br />

A4712 O STERILE WATER INJ PER 10 ML 0.00<br />

A4714 9 TREATED WATER PER GALLON 0.00<br />

A4719 9 ¾Y SET¾ TUBING 0.00<br />

A4720 9 DIALYSAT SOL FLD VOL > 249CC 0.00<br />

A4721 9 DIALYSAT SOL FLD VOL > 999CC 0.00<br />

A4722 9 DIALYS SOL FLD VOL > 1999CC 0.00<br />

A4723 9 DIALYS SOL FLD VOL > 2999CC 0.00<br />

A4724 9 DIALYS SOL FLD VOL > 3999CC 0.00<br />

A4725 9 DIALYS SOL FLD VOL > 4999CC 0.00<br />

A4726 9 DIALYS SOL FLD VOL > 5999CC 0.00<br />

A4728 6 DIALYSATE SOLUTION, NON-<strong>DE</strong>X 0.00<br />

A4730 9 FISTULA CANNULATION SET, EA 0.00<br />

A4735 9 LOCAL/TOPICAL ANESTHETICS 0.00<br />

A4736 9 TOPICAL ANESTHETIC, PER GRAM 0.00<br />

A4737 9 INJ ANESTHETIC PER 10 ML 0.00<br />

A4740 9 SHUNT ACCESSORY 0.00<br />

A4750 9 ART OR VENOUS BLOOD TUBING 0.00<br />

A4755 9 COMB ART/VENOUS BLOOD TUBING 0.00<br />

A4760 9 DIALYSATE SOL TEST KIT, EACH 0.00<br />

A4765 9 DIALYSATE CONC POW PER PACK 0.00<br />

A4766 9 DIALYSATE CONC SOL ADD 10 ML 0.00<br />

A4770 9 BLOOD COLLECTION TUBE/VACUUM 0.00<br />

A4771 9 SERUM CLOTTING TIME TUBE 0.00

---

A4772 9 BLOOD GLUCOSE TEST STRIPS 0.00<br />

A4773 9 OCCULT BLOOD TEST STRIPS 0.00<br />

A4774 9 AMMONIA TEST STRIPS 0.00<br />

A4780 9 ESRD STERILIZING AGENT 0.00<br />

A4790 9 ESRD CLEANSING AGENTS 0.00<br />

A4800 9 HEPARIN/ANTIDOTE DIALYSIS 0.00<br />

A4801 9 HEPARIN PER 1000 UNITS 0.00<br />

A4802 9 PROTAMINE SULFATE PER 50 MG 0.00<br />

A4820 9 SUPPLIES HEMODIALYSIS KIT 0.00<br />

A4850 9 RUBBER TIPPED HEMOSTATS 0.00<br />

A4860 9 DISPOSABLE CATHETER TIPS 0.00<br />

A4870 9 PLUMB/ELEC WK HM HEMO EQUIP 0.00<br />

A4880 9 WATER STORAGE TANKS 0.00<br />

A4890 9 REPAIR/MAINT CONT HEMO EQUIP 0.00<br />

A4900 9 CAPD SUPPLY KIT 0.00<br />

A4901 9 CCPD SUPPLY KIT 0.00<br />

A4905 9 IPD SUPPLY KIT 0.00<br />

A4910 9 ESRD NONMEDICAL SUPPLIES 0.00<br />

A4911 9 DRAIN BAG/BOTTLE 0.00<br />

A4912 9 GOMCO DRAIN BOTTLE 0.00<br />

A4913 9 MISC DIALYSIS SUPPLIES NOC 0.00<br />

A4914 9 PREPARATION KIT 0.00<br />

A4918 9 VENOUS PRESSURE CLAMP 0.00<br />

A4919 9 SUPP DIALYSIS DIALYZER HOL<strong>DE</strong> 0.00<br />

A4920 9 HARVARD PRESSURE CLAMP 0.00<br />

A4921 9 MEASURING CYLIN<strong>DE</strong>R 0.00<br />

A4927 3 NON-STERILE GLOVES 6.19<br />

A4928 9 SURGICAL MASK 0.00<br />

A4929 9 TOURNIQUET FOR DIALYSIS, EA 0.00<br />

A4930 3 STERILE, GLOVES PER PAIR 0.44<br />

A4931 9 REUSABLE ORAL THERMOMETER 0.00<br />

A4932 9 REUSABLE RECTAL THERMOMETER 0.00<br />

A5051 3 POUCH CLSD W BARR ATTACHED 2.21<br />

A5052 3 CLSD OSTOMY POUCH W/O BARR 1.59<br />

A5053 3 CLSD OSTOMY POUCH FACEPLATE 1.66<br />

A5054 3 CLSD OSTOMY POUCH W/FLANGE 1.37<br />

A5055 3 STOMA CAP 1.35<br />

A5061 3 POUCH DRAINABLE W BARRIER AT 2.58<br />

A5062 3 DRNBLE OSTOMY POUCH W/O BARR 2.12<br />

A5063 3 DRAIN OSTOMY POUCH W/FLANGE 2.09<br />

A5064 O DRAIN OSTOMY POUCH W/FCEPLTE 0.00<br />

A5065 O DRAIN OSTOMY POUCH ON FCPLTE 0.00<br />

A5071 3 URINARY POUCH W/BARRIER 4.15<br />

A5072 3 URINARY POUCH W/O BARRIER 3.36<br />

A5073 3 URINARY POUCH ON BARR W/FLNG 3.04<br />

A5074 O URINARY POUCH W/FACEPLATE 0.00<br />

A5075 O URINARY POUCH ON FACEPLATE 0.00<br />

A5081 3 CONTINENT STOMA PLUG 3.14<br />

A5082 3 CONTINENT STOMA CATHETER 11.34<br />

A5083 6 STOMA ABSORPTIVE COVER 0.00

---

A5093 3 OSTOMY ACCESSORY CONVEX INSE 1.85<br />

A5102 3 BEDSI<strong>DE</strong> DRAIN BTL W/WO TUBE 21.39<br />

A5105 3 URINARY SUSPENSORY 38.88<br />

A5112 3 URINARY LEG BAG 28.07<br />

A5113 3 LATEX LEG STRAP 4.48<br />

A5114 3 FOAM/FABRIC LEG STRAP 8.52<br />

A5119 O SKIN BARRIER WIPES BOX PR 50 0.00<br />

A5120 3 SKIN BARRIER, WIPE OR SWAB 0.23<br />

A5121 3 SOLID SKIN BARRIER 6X6 6.24<br />

A5122 3 SOLID SKIN BARRIER 8X8 10.42<br />

A5123 O SKIN BARRIER WITH FLANGE 0.00<br />

A5126 3 DISK/FOAM PAD +OR- ADHESIVE 1.26<br />

A5131 3 APPLIANCE CLEANER 15.13<br />

A5149 O INCONTINENCE/OSTOMY SUPPLY 0.00<br />

A5200 3 PERCUTANEOUS CATHETER ANCHOR 10.78<br />

A5500 5 DIAB SHOE FOR <strong>DE</strong>NSITY INSERT 0.00<br />

A5501 5 DIABETIC CUSTOM MOL<strong>DE</strong>D SHOE 0.00<br />

A5502 9 DIABETIC SHOE <strong>DE</strong>NSITY INSERT 0.00<br />

A5503 5 DIABETIC SHOE W/ROLLER/ROCKR 0.00<br />

A5504 5 DIABETIC SHOE WITH WEDGE 0.00<br />

A5505 5 DIAB SHOE W/METATARSAL BAR 0.00<br />

A5506 5 DIABETIC SHOE W/OFF SET HEEL 0.00<br />

A5507 5 MODIFICATION DIABETIC SHOE 0.00<br />

A5508 5 DIABETIC <strong>DE</strong>LUXE SHOE 0.00<br />

A5509 O DIRECT HEAT FORM SHOE INSERT 0.00<br />

A5510 5 COMPRESSION FORM SHOE INSERT 0.00<br />

A5511 O CUSTOM FAB MOL<strong>DE</strong>D SHOE INSER 0.00<br />

A5512 6 MULTI <strong>DE</strong>N INSERT DIRECT FORM 0.00<br />

A5513 6 MULTI <strong>DE</strong>N INSERT CUSTOM MOLD 0.00<br />

A6000 5 WOUND WARMING WOUND COVER 0.00<br />

A6010 3 COLLAGEN BASED WOUND FILLER 30.62<br />

A6011 3 COLLAGEN GEL/PASTE WOUND FIL 2.28<br />

A6020 O COLLAGEN WOUND DRESSING 0.00<br />

A6021 3 COLLAGEN DRESSING 648 SQ IN 181.51<br />

A6024 3 COLLAGEN DSG WOUND FILLER 5.90<br />

A6025 9 SILICONE GEL SHEET, EACH 0.00<br />

A6154 9 WOUND POUCH EACH 0.00<br />

A6196 3 ALGINATE DRESSING 16 48 SQ IN 15.68<br />

A6199 3 ALGINATE DRSG WOUND FILLER 5.04<br />

A6200 3 COMPOS DRSG 1648 NO BOR<strong>DE</strong>R 33.27<br />

A6203 3 COMPOSITE DRSG 16 48 SQ IN 5.94<br />

A6206 3 CONTACT LAYER

---

A6207 3 CONTACT LAYER >16 48 SQ IN 7.00<br />

A6209 3 FOAM DRSG 16 48 SQ IN W/O BRDR 28.01<br />

A6212 3 FOAM DRG 16 48 SQ IN W/BOR<strong>DE</strong>R 9.82<br />

A6215 5 FOAM DRESSING WOUND FILLER 0.00<br />

A6216 3 NON-STERILE GAUZE16 48 SQ IN 0.41<br />

A6219 3 GAUZE 16 48 SQ IN W/BOR<strong>DE</strong>R 2.46<br />

A6222 3 GAUZE 16 48 IN NO W/SAL W/O B 3.44<br />

A6228 3 GAUZE 16 48 SQ IN WATER/SALNE 3.44<br />

A6231 3 HYDROGEL DSG1648 SQ IN 18.30<br />

A6234 3 HYDROCOLLD DRG 16 48 IN W/O B 25.99<br />

A6237 3 HYDROCOLLD DRG 16 48 IN W/BDR 21.74<br />

A6240 3 HYDROCOLLD DRG FILLER PASTE 11.68<br />

A6241 3 HYDROCOLLOID DRG FILLER DRY 2.45<br />

A6242 3 HYDROGEL DRG 1648 IN W/O BDR 37.46<br />

A6245 3 HYDROGEL DRG 16 48 SQ IN W/B 22.68<br />

A6248 3 HYDROGEL DRSG GEL FILLER 15.49<br />

A6250 9 SKIN SEAL PROTECT MOISTURIZR 0.00<br />

A6251 3 ABSORPT DRG 16 48 SQ IN W/O B 6.05<br />

A6254 3 ABSORPT DRG 16 48 SQ IN W/BDR 2.89<br />

A6257 3 TRANSPARENT FILM 16 48 SQ IN 10.43<br />

A6260 9 WOUND CLEANSER ANY TYPE/SIZE 0.00

---

A6261 5 WOUND FILLER GEL/PASTE /OZ 0.00<br />

A6262 5 WOUND FILLER DRY FORM / GRAM 0.00<br />

A6263 O NON-STERILE ELASTIC GAUZE/YD 0.00<br />

A6264 O NON-STERILE NO ELASTIC GAUZE 0.00<br />

A6265 O TAPE PER 18 SQ INCHES 0.00<br />

A6266 3 IMPREG GAUZE NO H20/SAL/YARD 1.83<br />

A6402 3 STERILE GAUZE 16 48 SQ IN 0.41<br />

A6405 O STERILE ELASTIC GAUZE /YD 0.00<br />

A6406 O STERILE NON-ELASTIC GAUZE/YD 0.00<br />

A6407 3 PACKING STRIPS, NON-IMPREG 1.88<br />

A6410 5 STERILE EYE PAD 0.00<br />

A6411 5 NON-STERILE EYE PAD 0.00<br />

A6412 5 OCCLUSIVE EYE PATCH 0.00<br />

A6413 9 ADHESIVE BANDAGE, FIRST-AID 0.00<br />

A6421 O PAD BANDAGE >=3 =3=5ÊW /ROLL 0.00<br />

A6426 O CONF BANDAGE S >=3=5Ê W /ROLL 0.00<br />

A6430 O LT COMPRES BDG >=3=5ÊW /ROLL 0.00<br />

A6434 O MO COMPRES BDG >=3=3=3=3=3" =3"=3"=5"/YD 1.39<br />

A6456 3 ZINC PASTE BAND W >=3"

---

A6507 5 CMPRS BURNGARMENT FOOT-KNEE 0.00<br />

A6508 5 CMPRS BURNGARMENT FOOT-THIGH 0.00<br />

A6509 5 COMPRES BURN GARMENT JACKET 0.00<br />

A6510 5 COMPRES BURN GARMENT LEOTARD 0.00<br />

A6511 5 COMPRES BURN GARMENT PANTY 0.00<br />

A6512 5 COMPRES BURN GARMENT, NOC 0.00<br />

A6513 6 COMPRESS BURN MASK FACE/NECK 0.00<br />

A6530 6 COMPRESSION STOCKING BK18-30 0.00<br />

A6531 6 COMPRESSION STOCKING BK30-40 0.00<br />

A6532 6 COMPRESSION STOCKING BK40-50 0.00<br />

A6533 6 GC STOCKING THIGHLNGTH 18-30 0.00<br />

A6534 6 GC STOCKING THIGHLNGTH 30-40 0.00<br />

A6535 6 GC STOCKING THIGHLNGTH 40-50 0.00<br />

A6536 6 GC STOCKING FULL LNGTH 18-30 0.00<br />

A6537 6 GC STOCKING FULL LNGTH 30-40 0.00<br />

A6538 6 GC STOCKING FULL LNGTH 40-50 0.00<br />

A6539 6 GC STOCKING WAISTLNGTH 18-30 0.00<br />

A6540 6 GC STOCKING WAISTLNGTH 30-40 0.00<br />

A6541 6 GC STOCKING WAISTLNGTH 40-50 0.00<br />

A6542 6 GC STOCKING CUSTOM MA<strong>DE</strong> 0.00<br />

A6543 6 GC STOCKING LYMPHE<strong>DE</strong>MA 0.00<br />

A6544 6 GC STOCKING GARTER BELT 0.00<br />

A6545 6 GRAD COMP NON-ELASTIC BK 0.00<br />

A6549 6 G COMPRESSION STOCKING 0.00<br />

A6550 6 NEG PRES WOUND THER DRSG SET 0.00<br />

A6551 O NEG PRESS WOUND THER CANISTR 0.00<br />

A7000 3 DISPOSABLE CANISTER FOR PUMP 7.97<br />

A7001 3 NONDISPOSABLE PUMP CANISTER 28.55<br />

A7002 3 TUBING USED W SUCTION PUMP 3.31<br />

A7003 3 NEBULIZER ADMINISTRATION SET 2.61<br />

A7004 3 DISPOSABLE NEBULIZER SML VOL 1.47<br />

A7005 3 NONDISPOSABLE NEBULIZER SET 26.59<br />

A7006 3 FILTERED NEBULIZER ADMIN SET 7.78<br />

A7007 3 LG VOL NEBULIZER DISPOSABLE 3.80<br />

A7008 3 DISPOSABLE NEBULIZER PREFILL 10.52<br />

A7009 3 NEBULIZER RESERVOIR BOTTLE 36.26<br />

A7010 3 DISPOSABLE CORRUGATED TUBING 22.31<br />

A7011 5 NONDISPOS CORRUGATED TUBING 0.00<br />

A7012 3 NEBULIZER WATER COLLEC <strong>DE</strong>VIC 3.42<br />

A7013 3 DISPOSABLE COMPRESSOR FILTER 0.71<br />

A7014 3 COMPRESSOR NONDISPOS FILTER 3.87<br />

A7015 3 AEROSOL MASK USED W NEBULIZE 1.57<br />

A7016 3 NEBULIZER DOME & MOUTHPIECE 6.24<br />

A7017 3 NEBULIZER NOT USED W OXYGEN 128.23<br />

A7018 3 WATER DISTILLED W/NEBULIZER 0.37<br />

A7019 O SALINE SOLUTION DISPENSER 0.00<br />

A7020 O STERILE H2O OR NSS W LGV NEB 0.00<br />

A7025 3 REPLACE CHEST COMPRESS VEST 434.94<br />

A7026 3 REPLACE CHST CMPRSS SYS HOSE 28.75<br />

A7027 6 COMBINATION ORAL/NASAL MASK 0.00

---

A7028 6 REPL ORAL CUSHION COMBO MASK 0.00<br />

A7029 6 REPL NASAL PILLOW COMB MASK 0.00<br />

A7030 3 CPAP FULL FACE MASK 188.64<br />

A7031 3 REPLACEMENT FACEMASK INTERFA 69.77<br />

A7032 3 REPLACEMENT NASAL CUSHION 40.53<br />

A7033 3 REPLACEMENT NASAL PILLOWS 28.41<br />

A7034 3 NASAL APPLICATION <strong>DE</strong>VICE 117.64<br />

A7035 3 POS AIRWAY PRESS HEADGEAR 35.42<br />

A7036 3 POS AIRWAY PRESS CHINSTRAP 18.20<br />

A7037 3 POS AIRWAY PRESSURE TUBING 39.21<br />

A7038 3 POS AIRWAY PRESSURE FILTER 4.58<br />

A7039 3 FILTER, NON DISPOSABLE W PAP 15.33<br />

A7040 6 ONE WAY CHEST DRAIN VALVE 0.00<br />

A7041 6 WATER SEAL DRAIN CONTAINER 0.00<br />

A7042 9 IMPLANTED PLEURAL CATHETER 0.00<br />

A7043 5 VACUUM DRAINAGEBOTTLE/TUBING 0.00<br />

A7044 3 PAP ORAL INTERFACE 120.91<br />

A7045 3 REPL EXHALATION PORT FOR PAP 19.47<br />

A7046 6 REPL WATER CHAMBER, PAP <strong>DE</strong>V 0.00<br />

A7501 3 TRACHEOSTOMA VALVE W DIAPHRA 100.18<br />

A7502 3 REPLACEMENT DIAPHRAGM/FPLATE 47.61<br />

A7503 3 HMES FILTER HOL<strong>DE</strong>R OR CAP 10.81<br />

A7504 3 TRACHEOSTOMA HMES FILTER 0.64<br />

A7505 3 HMES OR TRACH VALVE HOUSING 4.46<br />

A7506 3 HMES/TRACHVALVE ADHESIVEDISK 0.32<br />

A7507 3 INTEGRATED FILTER & HOL<strong>DE</strong>R 2.37<br />

A7508 3 HOUSING & INTEGRATED ADHESIV 2.74<br />

A7509 3 HEAT & MOISTURE EXCHANGE SYS 1.34<br />

A7520 6 TRACH/LARYN TUBE NON-CUFFED 0.00<br />

A7521 6 TRACH/LARYN TUBE CUFFED 0.00<br />

A7522 6 TRACH/LARYN TUBE STAINLESS 0.00<br />

A7523 6 TRACHEOSTOMY SHOWER PROTECT 0.00<br />

A7524 6 TRACHEOSTOMA STENT/STUD/BTTN 0.00<br />

A7525 3 TRACHEOSTOMY MASK 2.07<br />

A7526 3 TRACHEOSTOMY TUBE COLLAR 3.37<br />

A7527 6 TRACH/LARYN TUBE PLUG/STOP 0.00<br />

A8000 6 SOFT PROTECT HELMET PREFAB 0.00<br />

A8001 6 HARD PROTECT HELMET PREFAB 0.00<br />

A8002 6 SOFT PROTECT HELMET CUSTOM 0.00<br />

A8003 6 HARD PROTECT HELMET CUSTOM 0.00<br />

A8004 6 REPL SOFT INTERFACE, HELMET 0.00<br />

A9150 9 MISC/EXPER NON-PRESCRIPT DRU 0.00<br />

A9152 9 SINGLE VITAMIN NOS 0.00<br />

A9153 9 MULTI-VITAMIN NOS 0.00<br />

A9155 6 ARTIFICIAL SALIVA 0.00<br />

A9160 9 PODIATRIST NON-COVERED SERVI 0.00<br />

A9170 9 CHIROPRACTOR NON-COVERED SER 0.00<br />

A9180 9 PEDICULOSIS (LICE INFESTATION) TRE 0.00<br />

A9190 9 MISC/EXPE PERSONAL COMFORT I 0.00<br />

A9250 9 NURSING HOME RENTALS 0.00

---

A9260 9 NON-CERTIFIED PHYSICAL THERAPISTS 0.00<br />

A9270 9 NON-COVERED ITEM OR SERVICE 0.00<br />

A9274 6 EXT AMB INSULIN <strong>DE</strong>LIVERY SYS 0.00<br />

A9275 9 DISP HOME GLUCOSE MONITOR 0.00<br />

A9276 9 DISPOSABLE SENSOR, CGM SYS 0.00<br />

A9277 9 EXTERNAL TRANSMITTER, CGM 0.00<br />

A9278 9 EXTERNAL RECEIVER, CGM SYS 0.00<br />

A9279 9 MONITORING FEATURE/<strong>DE</strong>VICENOC 0.00<br />

A9280 6 ALERT OR ALARM <strong>DE</strong>VICE, NOC 0.00<br />

A9281 9 REACHING/GRABBING <strong>DE</strong>VICE 0.00<br />

A9282 9 WIG ANY TYPE 0.00<br />

A9283 6 FOOT PRESS OFF LOAD SUPP <strong>DE</strong>V 0.00<br />

A9284 9 NON-ELECTRONIC SPIROMETER 0.00<br />

A9290 9 <strong>DE</strong>SCRIPTION OF SERVICE DOES NOT IND 0.00<br />

A9300 O EXERCISE EQUIPMENT 0.00<br />

A9500 9 TC99M SESTAMIBI 0.00<br />

A9501 9 TECHNETIUM TC-99M TEBOROXIME 0.00<br />

A9502 9 TC99M TETROFOSMIN 0.00<br />

A9503 9 TC99M MEDRONATE 0.00<br />

A9504 9 TC99M APCITI<strong>DE</strong> 0.00<br />

A9505 9 TL201 THALLIUM 0.00<br />

A9507 9 IN111 CAPROMAB 0.00<br />

A9508 9 I131 IODOBENGUATE, DX 0.00<br />

A9509 9 IODINE I-123 SOD IODI<strong>DE</strong> MIL 0.00<br />

A9510 9 TC99M DISOFENIN 0.00<br />

A9511 O TECHNETIUM TC 99M <strong>DE</strong>PREOTI<strong>DE</strong> 0.00<br />

A9512 9 TC99M PERTECHNETATE 0.00<br />

A9513 O TECHNETIUM TC-99M MEBROFENIN 0.00<br />

A9514 O TECHNETIUMTC99MPYROPHOSPHATE 0.00<br />

A9515 O TECHNETIUM TC-99M PENTETATE 0.00<br />

A9516 9 IODINE I-123 SOD IODI<strong>DE</strong> MIC 0.00<br />

A9517 9 I131 IODI<strong>DE</strong> CAP, RX 0.00<br />

A9518 O I-131 SODIUM IODI<strong>DE</strong> SOLUTION 0.00<br />

A9519 O TECHNETIUMTC-99MMACROAG ALBU 0.00<br />

A9520 O TECHNETIUMTC-99M SULFUR CLLD 0.00<br />

A9521 9 TC99M EXAMETAZIME 0.00<br />

A9522 O INDIUM111IBRITUMOMABTIUXETAN 0.00<br />

A9523 O YTTRIUM90IBRITUMOMABTIUXETAN 0.00<br />

A9524 9 I131 SERUM ALBUMIN, DX 0.00<br />

A9525 O LOW/ISO-OSMOLAR CONTRAST MAT 0.00<br />

A9526 9 NITROGEN N-13 AMMONIA 0.00<br />

A9527 9 IODINE I-125 SODIUM IODI<strong>DE</strong> 0.00<br />

A9528 9 IODINE I-131 IODI<strong>DE</strong> CAP, DX 0.00<br />

A9529 9 I131 IODI<strong>DE</strong> SOL, DX 0.00<br />

A9530 9 I131 IODI<strong>DE</strong> SOL, RX 0.00<br />

A9531 9 I131 MAX 100UCI 0.00<br />

A9532 9 I125 SERUM ALBUMIN, DX 0.00<br />

A9533 O I-131 TOSITUMOMAB DIAGNOSTIC 0.00<br />

A9534 O I-131 TOSITUMOMAB THERAPEUT 0.00<br />

A9535 9 INJECTION, METHYLENE BLUE 0.00

---

A9536 9 TC99M <strong>DE</strong>PREOTI<strong>DE</strong> 0.00<br />

A9537 9 TC99M MEBROFENIN 0.00<br />

A9538 9 TC99M PYROPHOSPHATE 0.00<br />

A9539 9 TC99M PENTETATE 0.00<br />

A9540 9 TC99M MAA 0.00<br />

A9541 9 TC99M SULFUR COLLOID 0.00<br />

A9542 9 IN111 IBRITUMOMAB, DX 0.00<br />

A9543 9 Y90 IBRITUMOMAB, RX 0.00<br />

A9544 9 I131 TOSITUMOMAB, DX 0.00<br />

A9545 9 I131 TOSITUMOMAB, RX 0.00<br />

A9546 9 CO57/58 0.00<br />

A9547 9 IN111 OXYQUINOLINE 0.00<br />

A9548 9 IN111 PENTETATE 0.00<br />

A9549 O TC99M ARCITUMOMAB 0.00<br />

A9550 9 TC99M GLUCEPTATE 0.00<br />

A9551 9 TC99M SUCCIMER 0.00<br />

A9552 9 F18 FDG 0.00<br />

A9553 9 CR51 CHROMATE 0.00<br />

A9554 9 I125 IOTHALAMATE, DX 0.00<br />

A9555 9 RB82 RUBIDIUM 0.00<br />

A9556 9 GA67 GALLIUM 0.00<br />

A9557 9 TC99M BICISATE 0.00<br />

A9558 9 XE133 XENON 10MCI 0.00<br />

A9559 9 CO57 CYANO 0.00<br />

A9560 9 TC99M LABELED RBC 0.00<br />

A9561 9 TC99M OXIDRONATE 0.00<br />

A9562 9 TC99M MERTIATI<strong>DE</strong> 0.00<br />

A9563 9 P32 NA PHOSPHATE 0.00<br />

A9564 9 P32 CHROMIC PHOSPHATE 0.00<br />

A9565 O IN111 PENTETREOTI<strong>DE</strong> 0.00<br />

A9566 9 TC99M FANOLESOMAB 0.00<br />

A9567 9 TECHNETIUM TC-99M AEROSOL 0.00<br />

A9568 9 TECHNETIUM TC99M ARCITUMOMAB 0.00<br />

A9569 9 TECHNETIUM TC-99M AUTO WBC 0.00<br />

A9570 9 INDIUM IN-111 AUTO WBC 0.00<br />

A9571 9 INDIUM IN-111 AUTO PLATELET 0.00<br />

A9572 9 INDIUM IN-111 PENTETREOTI<strong>DE</strong> 0.00<br />

A9576 9 INJ PROHANCE MULTIPACK 0.00<br />

A9577 9 INJ MULTIHANCE 0.00<br />

A9578 9 INJ MULTIHANCE MULTIPACK 0.00<br />

A9579 9 GAD-BASE MR CONTRAST NOS,1ML 0.00<br />

A9580 9 SODIUM FLUORI<strong>DE</strong> F-18 0.00<br />

A9600 9 SR89 STRONTIUM 0.00<br />

A9603 9 I-131SODIUMIODI<strong>DE</strong>CAP PER MCI 0.00<br />

A9605 9 SM 153 LEXIDRONM 0.00<br />

A9698 9 NON-RAD CONTRAST MATERIALNOC 0.00<br />

A9699 9 RADIOPHARM RX AGENT NOC 0.00<br />

A9700 9 ECHOCARDIOGRAPHY CONTRAST 0.00<br />

A9900 5 SUPPLY/ACCESSORY/SERVICE 0.00<br />

A9901 9 <strong>DE</strong>LIVERY/SET UP/DISPENSING 0.00

---

A9999 5 MISC DME SUPPLY OR ACCESS, NOS 0.00<br />

ASC0001 7 AMBULATORY SURGICAL CENTER 0.00<br />

ASC0002 7 AMBULATORY SURGICAL CENTER 0.00<br />

ASC0003 7 AMBULATORY SURGICAL CENTER 0.00<br />

ASC0004 7 AMBULATORY SURGICAL CENTER 0.00<br />

ASC0005 7 AMBULATORY SURGICAL CENTER 0.00<br />

ASC0006 7 AMBULATORY SURGICAL CENTER 0.00<br />

ASC0007 7 AMBULATORY SURGICAL CENTER 0.00<br />

ASC0008 7 AMBULATORY SURGICAL CENTER 0.00<br />

ASC0009 7 AMBULATORY SURGICAL CENTER 0.00<br />

B4034 3 ENTER FEED SUPKIT SYR BY DAY 5.60<br />

B4035 3 ENTERAL FEED SUPP PUMP PER D 10.67<br />

B4036 3 ENTERAL FEED SUP KIT GRAV BY 7.31<br />

B4081 3 ENTERAL NG TUBING W/ STYLET 19.78<br />

B4082 3 ENTERAL NG TUBING W/O STYLET 14.73<br />

B4083 3 ENTERAL STOMACH TUBE LEVINE 2.25<br />

B4084 O GASTROSTOMY/JEJUNOSTOMY TUBI 0.00<br />

B4085 9 GASTROSTOMY TUBE W/RING EACH 0.00<br />

B4086 O GASTROSTOMY/JEJUNOSTOMY TUBE 0.00<br />

B4087 6 GASTRO/JEJUNO TUBE, STD 0.00<br />

B4088 6 GASTRO/JEJUNO TUBE, LOW-PRO 0.00<br />

B4100 5 FOOD THICKENER ORAL 0.00<br />

B4102 6 EF ADULT FLUIDS AND ELECTRO 0.00<br />

B4103 6 EF PED FLUID AND ELECTROLYTE 0.00<br />

B4104 6 ADDITIVE FOR ENTERAL FORMULA 0.00<br />

B4149 6 EF BLEN<strong>DE</strong>RIZED FOODS 0.00<br />

B4150 3 EF COMPLET W/INTACT NUTRIENT 0.61<br />

B4151 O ENTERAL FORMULAE CAT1NATURAL 0.00<br />

B4152 3 EF CALORIE <strong>DE</strong>NSE>/=1.5KCAL 0.51<br />

B4153 3 EF HYDROLYZED/AMINO ACIDS 1.74<br />

B4154 3 EF SPEC METABOLIC NONINHERIT 1.12<br />

B4155 3 EF INCOMPLETE/MODULAR 0.89<br />

B4156 O ENTERAL FORMULAE CATEGORY VI 0.00<br />

B4157 6 EF SPECIAL METABOLIC INHERIT 0.00<br />

B4158 3 EF PED COMPLETE INTACT NUT 0.65<br />

B4159 6 EF PED COMPLETE SOY BASED 0.00<br />

B4160 6 EF PED CALORIC <strong>DE</strong>NSE>/=0.7KC 0.00<br />

B4161 3 EF PED HYDROLYZED/AMINO ACID 1.80<br />

B4162 6 EF PED SPECMETABOLIC INHERIT 0.00<br />

B4164 9 PARENTERAL 50% <strong>DE</strong>XTROSE SOLU 0.00<br />

B4168 9 PARENTERAL SOL AMINO ACID 3. 0.00<br />

B4172 9 PARENTERAL SOL AMINO ACID 5. 0.00<br />

B4176 9 PARENTERAL SOL AMINO ACID 7- 0.00<br />

B4178 9 PARENTERAL SOL AMINO ACID > 0.00<br />

B4180 9 PARENTERAL SOL CARB > 50% 0.00<br />

B4184 O PARENTERAL SOL LIPIDS 10% 0.00<br />

B4185 6 PARENTERAL SOL 10 GM LIPIDS 0.00<br />

B4186 O PARENTERAL SOL LIPIDS 20% 0.00<br />

B4189 9 PARENTERAL SOL AMINO ACID & 0.00<br />

B4193 9 PARENTERAL SOL 52-73 GM PROT 0.00

---

B4197 9 PARENTERAL SOL 74-100 GM PRO 0.00<br />

B4199 9 PARENTERAL SOL > 100GM PROTE 0.00<br />

B4216 9 PARENTERAL NUTRITION ADDITIV 0.00<br />

B4220 3 PARENTERAL SUPPLY KIT PREMIX 8.09<br />

B4222 O PARENTERAL SUPPLY KIT HOMEMI 0.00<br />

B4224 3 PARENTERAL ADMINISTRATION KI 25.29<br />

B5000 9 PARENTERAL SOL RENAL-AMIROSY 0.00<br />

B5100 9 PARENTERAL SOL HEPATIC-FREAM 0.00<br />

B5200 9 PARENTERAL SOL STRES-BRNCH C 0.00<br />

B9000 3 ENTER INFUSION PUMP W/O ALRM 988.00<br />

B9002 3 ENTERAL INFUSION PUMP W/ ALA 988.00<br />

B9004 3 PARENTERAL INFUS PUMP PORTAB 2,551.22<br />

B9006 3 PARENTERAL INFUS PUMP STATIO 1,970.80<br />

B9998 5 ENTERAL SUPP NOT OTHERWISE C 0.00<br />

B9999 5 PARENTERAL SUPP NOT OTHRWS C 0.00<br />

BONUS O MCO SPECIFIC CO<strong>DE</strong>: SMART START OUT 0.00<br />

C1000 9 PERCLOSCLOSR PROSTARARTVAS 0.00<br />

C1001 9 ACUNAV-DIAGNSTIC ULTRSND CA 0.00<br />

C1003 9 CATH, ABLATION, LIVEWIRE TC 0.00<br />

C1004 9 FAST-CATH,SWARTZ,SAFL,CSTA 0.00<br />

C1006 9 ARRAY POST CHAMB IOL 0.00<br />

C1007 9 AMS 700/AMBICOR PROSTHESIS 0.00<br />

C1008 9 UROLUME-IMPLT URETHRAL STNT 0.00<br />

C1009 9 PLASMA,CRYOPRECIPITATE-REDUC 0.00<br />

C1010 O BLOOD, L/R, CMV-NEG 0.00<br />

C1011 O PLATELETS, HLA-M, L/R, UNIT 0.00<br />

C1012 9 PLATELET CONC, L/R, IRRAD 0.00<br />

C1013 9 PLATELET CONC, L/R, UNIT 0.00<br />

C1014 9 PLATELET,APH/PHER, L/R, UNIT 0.00<br />

C1015 O PLT, PHER,L/R,CMV, IRRAD 0.00<br />

C1016 O BLOOD,L/R,FROZ/<strong>DE</strong>GLY/WASHED 0.00<br />

C1017 O PLT, APH/PHER,L/R,CMV-NEG 0.00<br />

C1018 O BLOOD, L/R, IRRADIATED 0.00<br />

C1019 9 PLT, APH/PHER, L/R, IRRAD 0.00<br />

C1020 O RBC, FRZ/<strong>DE</strong>G/WSH, L/R, IRRAD 0.00<br />

C1021 O RBC, L/R, CMV NEG, IRRAD 0.00<br />

C1022 O PLASMA, FRZ WITHIN 24 HOUR 0.00<br />

C1024 9 QUINOPRISTIN 10ML/DALFOPRIS 0.00<br />

C1025 9 MARINR CS CATH 0.00<br />

C1026 9 RF PERFRMR CATH 5F RF MARINR 0.00<br />

C1027 9 MAGIC X/SHORT RADIUS 14MM 0.00<br />

C1028 9 PRCIS TWST TRSNSVG ANCH SYS 0.00<br />

C1029 9 CRE GUI<strong>DE</strong>D BALLOON DIL CATH 0.00<br />

C1030 9 CTHTR:MRSHAL,BLU MAX UTR DMD 0.00<br />

C1031 9 MR COMP/MOD LEVEEN NED ELECT 0.00<br />

C1033 9 SONICATH MDL 37-410 0.00<br />

C1034 9 SURPASS, LONG30 SURPASS-CATH 0.00<br />

C1035 9 CATH, ULTRA ICE 0.00<br />

C1036 9 R PORT/RESERVOIR IMPL <strong>DE</strong>V 0.00<br />

C1037 9 VAXCELCHRONIC DIALYSIS CATH 0.00

---

C1038 9 ULTRACROSS IMAGING CATH 0.00<br />

C1039 9 WALLSTENT, RP/TRACH 0.00<br />

C1040 9 WALLSTENT, TIPS 0.00<br />

C1042 9 WALLSTENT, BILIARY 0.00<br />

C1043 9 ATHERECTOMY SYS, CORONARY 0.00<br />

C1045 9 I-131 MIBG(IOBEN-SULFATE)0.5 0.00<br />

C1047 9 NOGA/NAVI-STAR CATH 0.00<br />

C1048 9 NEUROCYBERNETICPROS:GEN 0.00<br />

C1050 9 PROSORBA COLUMN 0.00<br />

C1051 9 OASIS THROMBECTOMY CATH 0.00<br />

C1053 9 ENSITE 3000 CATHETER 0.00<br />

C1054 9 HYDROLYSER THROMB CATH 6/7F 0.00<br />

C1055 9 TRANSESOPH 210, 210-S CATH 0.00<br />

C1056 9 THERMACHOICE II CATH 0.00<br />

C1057 9 MICROMARK TISSUE MARKER 0.00<br />

C1058 9 TC 99M OXIDRONATE, PER VIAL 0.00<br />

C1059 9 CARTICEL,AUTO CULT-CHNDR CYT 0.00<br />

C1060 9 ACS MULTI-LINK TRISTAR STENT 0.00<br />

C1061 9 ACS VIKING GUIDING CATH 0.00<br />

C1063 9 ENDOTAK ENDURANCE EZ,RX LEAD 0.00<br />

C1064 9 I-131 CAP, EACH ADD MCI 0.00<br />

C1065 9 I-131 SOL, EACH ADD MCI 0.00<br />

C1066 9 IN 111 SATUMOMAB PEN<strong>DE</strong>TI<strong>DE</strong> 0.00<br />

C1067 9 MEGALINK BILIARY STENT 0.00<br />

C1068 9 PULSAR DDD PMKR 0.00<br />

C1069 9 DISCOVERY DR, PMKR 0.00<br />

C1071 9 PULSAR MAX, PULSAR SR PMKR 0.00<br />

C1072 9 GUIDANT:BLLN DIL CATH 0.00<br />

C1073 9 MORCELLATOR 0.00<br />

C1074 9 RX/OTW VIATRAC-PERI DIL CATH 0.00<br />

C1075 9 GUIDANT:LEAD,PMKR 0.00<br />

C1076 9 VENTAK MINI SC <strong>DE</strong>FIB 0.00<br />

C1077 9 VENTAK VR,PRIZM VR, SC <strong>DE</strong>FIB 0.00<br />

C1078 9 VENTAK:PRIZM,AV III DR <strong>DE</strong>FIB 0.00<br />

C1079 O CO 57/58 PER 0.5 UCI 0.00<br />

C1080 O I-131 TOSITUMOMAB, DX 0.00<br />

C1081 O I-131 TOSITUMOMAB, TX 0.00<br />

C1082 O IN-111 IBRITUMOMAB TIUXETAN 0.00<br />

C1083 O YTTRIUM 90 IBRITUMOMAB TIUXE 0.00<br />

C1084 9 <strong>DE</strong>NILEUKIN DIFTITOX, 300 MCG 0.00<br />

C1086 9 TEMOZOLOMI<strong>DE</strong>, 5 MG 0.00<br />

C1087 9 I-123 PER 100 UCI 0.00<br />

C1088 9 LASER OPTIC TR SYS 0.00<br />

C1089 9 CO 57, 0.5 MCI 0.00<br />

C1090 9 IN 111 CHLORI<strong>DE</strong>, PER MCI 0.00<br />

C1091 O IN111 OXYQUINOLINE,PER0.5MCI 0.00<br />

C1092 O IN 111 PENTETATE PER 0.5 MCI 0.00<br />

C1093 O TC99M FANOLESOMAB 0.00<br />

C1094 9 TC99MALBUMIN AGGR,PER 1.0MCI 0.00<br />

C1095 9 TC 99M <strong>DE</strong>PREOTI<strong>DE</strong>, PER VIAL 0.00

---

C1096 9 TC 99M EXAMETAZIME, PER DOSE 0.00<br />

C1097 9 TC 99M MEBROFENIN, PER VIAL 0.00<br />

C1098 9 TC 99M PENTETATE, PER VIAL 0.00<br />

C1099 9 TC 99M PYROPHOSPHATE,PER VIA 0.00<br />

C1100 9 MEDTRONIC AVE GT1 GUI<strong>DE</strong>WIRE 0.00<br />

C1101 9 MEDTRONIC AVE ZUMA GUI<strong>DE</strong>CATH 0.00<br />

C1102 9 SYNERGY NEUROSTIM GENRTR 0.00<br />

C1103 9 MICRO JEWEL <strong>DE</strong>FIBRILLATOR 0.00<br />

C1104 9 RF CONDUCTR ABLATION CATH 0.00<br />

C1105 9 SIGMA 300VDD PMKR 0.00<br />

C1106 9 SYNERGYEX PT PROGRMR 0.00<br />

C1107 9 TORQR,SOLOIST CATH 0.00<br />

C1109 9 IMPLANTABLE ANCHOR:ETHICON 0.00<br />

C1110 9 STABLE MAPPER,CATH ELECTR 0.00<br />

C1111 9 ANEURXAORT-UNI-ILIAC STNT 0.00<br />

C1112 9 ANEURX STENT GRAFT/<strong>DE</strong>L CATH 0.00<br />

C1113 9 TLNT ENDO SPRNG STNT GRFT SY 0.00<br />

C1114 9 TALNTSPRGSTNT+GRAF ENDO PROS 0.00<br />

C1115 9 5038S, 5038 5038L PACE LEAD 0.00<br />

C1116 9 CAPSURESP PACING LEAD 0.00<br />

C1117 9 ANCURE ENDOGRAFT <strong>DE</strong>L SYS 0.00<br />

C1118 9 SIGMA300DR LEGIIDR, PMKR 0.00<br />

C1119 9 SPRINT6932,6943 <strong>DE</strong>FIB LEAD 0.00<br />

C1120 9 SPRINT6942,6945 <strong>DE</strong>FIB LEAD 0.00<br />

C1121 9 GEM <strong>DE</strong>FIBRILLATOR 0.00<br />

C1122 O TC 99M ARCITUMOMAB PER VIAL 0.00<br />

C1123 9 GEM II VR <strong>DE</strong>FIBRILLATOR 0.00<br />

C1124 9 INTERSTIM TEST STIM KIT 0.00<br />

C1125 9 KAPPA 400SR,TOPAZ II SR PMKR 0.00<br />

C1126 9 KAPPA 700 DR, PMKR 0.00<br />

C1127 9 KAPPA 700SR, SC PMKR 0.00<br />

C1128 9 KAPPA 700D, RUBY IID PMKR 0.00<br />

C1129 9 KAPPA 700VDD, PMKR 0.00<br />

C1130 9 SIGMA200D, LGCY IID DC PMKR 0.00<br />

C1131 9 SIGMA 200DR, PMKR 0.00<br />

C1132 9 SIGMA 200 SR LEG II:SC PA 0.00<br />

C1133 9 SIGMA SR, VITA SR, PMKR 0.00<br />

C1134 9 SIGMA 300D PMKR 0.00<br />

C1135 9 ENTITY DR 5326L/R, DC, PMKR 0.00<br />

C1136 9 AFFINITY DR 5330L/R, DC, PMK 0.00<br />

C1137 9 CARDIOSEAL IMPLANT SYS 0.00<br />

C1143 9 ADDVENT MOD 2060BL, VDD 0.00<br />

C1144 9 AFNTY SP 5130,INTEGRITY SR 0.00<br />

C1145 9 ANGIO-SEAL 6FR,8FR 0.00<br />

C1146 9 VETT TUBE 0.00<br />

C1147 9 AV PLUS DX 1368:LEAD 0.00<br />

C1148 9 CONTOUR MD SC <strong>DE</strong>FIB 0.00<br />

C1149 9 ENTITY DC 5226R,PMKR 0.00<br />

C1151 9 PASSIVEPLUS DX LEAD, 10MDLS 0.00<br />

C1152 9 LIFESITE ACCESS SYSTEM 0.00

---

C1153 9 REGENCY SC+2402L PMKR 0.00<br />

C1154 9 SPL:SPO1,02,04-<strong>DE</strong>FIB LEAD 0.00<br />

C1155 9 REPLIFORM 8 SQ CM 0.00<br />

C1156 9 TR1102TRSR+2260L,2264L,5131 0.00<br />

C1157 9 TRILOGY DCT 23/8L PMKR 0.00<br />

C1158 9 TVL LEAD SV01,SV02,SV04 0.00<br />

C1159 9 TVL RV02, RV06,RV07:LEAD 0.00<br />

C1160 9 TVL-ADX 1559:LEAD 0.00<br />

C1161 9 TENDRIL DX, 1388 PACING LEAD 0.00<br />

C1162 9 TEMPODR TRILOGYDR+DC PMKR 0.00<br />

C1163 9 TENDRIL SDX, 1488T LEAD 0.00<br />

C1164 9 IODINE-125 BRACHYTX SEED 0.00<br />

C1166 O CYTARABINE LIPOSOMAL, 10 MG 0.00<br />

C1167 O EPIRUBICIN HCL, 2 MG 0.00<br />

C1170 9 ABBI DISP BIOPSY <strong>DE</strong>VICE 0.00<br />

C1171 9 AUTOSUTURE SITE MARKER STPLE 0.00<br />

C1172 9 SPACEMAKER DISSECT BALLOON 0.00<br />

C1173 9 COR STNTS540,S670,O-WIRE STN 0.00<br />

C1174 9 BARD BRACHYTX NEEDLE 0.00<br />

C1175 9 MIBB DISP BIOPSY <strong>DE</strong>VICE 0.00<br />

C1176 9 MAMMOTOME HH PROBE W/VAC SYS 0.00<br />

C1177 9 11-G MAMMOTOME PROBE 0.00<br />

C1178 O BUSULFAN IV, 6 MG 0.00<br />

C1179 9 14-G MAMMOTOME PROBE 0.00<br />

C1180 9 VIGOR SR, SC, PMKR 0.00<br />

C1181 9 MERIDIAN SSI, SC, PMKR 0.00<br />

C1182 9 PULSAR SSI, SC, PMKR 0.00<br />

C1183 9 JA<strong>DE</strong> IIS, SIGMA 300S, SC, PM 0.00<br />

C1184 9 SIGMA 200S, SC, PMKR 0.00<br />

C1188 9 I-131 CAP, PER 1-5 MCI 0.00<br />

C1200 O TC 99M SODIUM GLUCOHEPTONAT 0.00<br />

C1201 O TC 99M SUCCIMER, PER VIAL 0.00<br />

C1202 9 TC 99M SULFUR COLLOID, VIAL 0.00<br />

C1203 9 VERTEPORFIN FOR INJ 0.00<br />

C1205 9 TC 99M DISOFENIN, PER VIAL 0.00<br />

C1207 O OCTREOTI<strong>DE</strong> ACETATE <strong>DE</strong>POT 1MG 0.00<br />

C1300 9 HYPERBARIC OXYGEN 0.00<br />

C1302 9 SQ01: LEAD 0.00<br />

C1303 9 CAPSURE FIX 6940/4068-110 0.00<br />

C1304 9 SONCATH MDL 37-416,-418 0.00<br />

C1305 O APLIGRAF 0.00<br />

C1306 9 NEUROCYBERNETICPROS:LEAD 0.00<br />

C1311 9 TRILOGY DR+/DAO PMKR 0.00<br />

C1312 9 MAGIC WALLSTENT--MINI 0.00<br />

C1313 9 MAGIC MEDIUM,RADIUS 31MM 0.00<br />

C1314 9 MAGIC WALLSTENT--LONG 0.00<br />

C1315 9 VIGOR DR, MERIDIAN DR PMKR 0.00<br />

C1316 9 MERIDIAN DDD PMKR 0.00<br />

C1317 9 DISCOVERY SR, PMKR 0.00<br />

C1318 9 MERIDIAN SR PMKR 0.00

---

C1319 9 WALLSTENT: ENTERAL--60MM 0.00<br />

C1320 9 WALLSTENT: ILIAC 0.00<br />

C1321 9 PALATE/BASE OF TONGUE ELECTR 0.00<br />

C1322 9 TURBINATE SOMNOPLASTY ELECTR 0.00<br />

C1323 9 VAPR/T DISP ELECTRO<strong>DE</strong> 0.00<br />

C1324 9 LIGASURE DISPOSABLE ELECTROD 0.00<br />

C1325 9 PALLADIUM-103 SEED 0.00<br />

C1326 9 ANGIO-JET RHEOLYTIC THROMB 0.00<br />

C1328 9 ANS RENEW NS TRNSMTR 0.00<br />

C1329 9 VERSAPOINT DISP ELECTRO<strong>DE</strong> 0.00<br />

C1333 9 PALMAZ CORINTHIAN BIL STENT 0.00<br />

C1334 9 CROWN,MINI-CROWN,CROSSLC 0.00<br />

C1335 9 MESH, PROLENE 0.00<br />

C1336 9 CONSTANT FLOW IMP PUMP 0.00<br />

C1337 9 ISOMED 8472-20/35/60 0.00<br />

C1348 9 I-131 SOL, PER 1-6 MCI 0.00<br />

C1350 9 PROSTASEED I-125, PER SOURCE 0.00<br />

C1351 9 CAPSURE FIX LEAD 0.00<br />

C1352 9 GEM II DR 0.00<br />

C1353 9 ITREL INTERSTM NEUROSTIM+EXT 0.00<br />

C1354 9 KAPPA 400DR,DIAMOND II 820DR 0.00<br />

C1355 9 KAPPA 600DR, VITA DR 0.00<br />

C1356 9 PROFILE MD V-186HV3 SC <strong>DE</strong>FIB 0.00<br />

C1357 9 ANGSTROM MD V-190HV3 SC <strong>DE</strong>F 0.00<br />

C1358 9 AFFINITY DC 5230R, PMKR 0.00<br />

C1359 9 PULSAR,PULSAR MAX DR, PMKR 0.00<br />

C1360 9 OCULAR PHOTODYNAMIC TX 0.00<br />

C1361 9 REVEAL CARDIAC RECOR<strong>DE</strong>R 0.00<br />

C1362 9 HERCULINK,OTW,SDS BIL STNT 0.00<br />

C1363 9 GEM DR, DC, <strong>DE</strong>FIB 0.00<br />

C1364 9 PHOTON DR V-230HV3 DC <strong>DE</strong>FIB 0.00<br />

C1365 9 GUI<strong>DE</strong>WIRE, HI-TORQUE14/18/35 0.00<br />

C1366 9 GUI<strong>DE</strong>WIRE,PTCA,HI-TORQUE 0.00<br />

C1367 9 GUI<strong>DE</strong> WIRE, HI-TORQUECROSSIT 0.00<br />

C1368 9 ON-Q PAIN MGT SYS 0.00<br />

C1369 9 ANS RENEW STIM SYS RECVR 0.00<br />

C1370 9 TENSION-FREE VAGINAL TAPE 0.00<br />

C1371 9 SYMP NITINOL TRANSHEP BIL SY 0.00<br />

C1372 9 CORDIS NITINOL BIL STENT 0.00<br />

C1375 9 STENT, CORONARY, NIR 0.00<br />

C1376 9 ANS RENEW STIM SYS LEAD 0.00<br />

C1377 9 SPECIFY 3988 NEURO LEAD 0.00<br />

C1378 9 INTERSTIM TX 3080/3886 LEAD 0.00<br />

C1379 9 PISCES-QUAD 3887 LEAD 0.00<br />

C1420 9 STAPLETAC2 BONEW/<strong>DE</strong>RMIS 0.00<br />

C1421 9 STAPLETAC2 BONE WO <strong>DE</strong>RMIS 0.00<br />

C1450 9 ORTHOSPHERE ARTHROPLASTY 0.00<br />

C1451 9 ORTHOSPHERE ARTHROPLASTY KIT 0.00<br />

C1500 9 ATHERECTOMY SYS, PERIPHERAL 0.00<br />

C1700 9 AUTHEN MICK TP BRACHY NEEDLE 0.00

---

C1701 9 MEDTEC MT-BT-5201-25 NEEDLE 0.00<br />

C1702 9 WWMT BRACHY NEEDLE 0.00<br />

C1703 9 MENTOR PROSTATE BRACHY 0.00<br />

C1704 9 MT-BT-5001-25/5051-25 0.00<br />

C1705 9 BEST FLEXI BRACHY NEEDLE 0.00<br />

C1706 9 INDIGO PROSTATE SEEDING NDL 0.00<br />

C1707 9 VARISOURCE IMPLT NDL 0.00<br />

C1708 9 UROMED PROSTATE SEED NDL 0.00<br />

C1709 9 REMINGTON BRACHYTX NEEDLE 0.00<br />

C1710 9 US BIOPSY PROSTATE NEEDLE 0.00<br />

C1711 9 MD TECH BRACHYTX NEEDLE 0.00<br />

C1712 9 IMAGYN BRACHYTX NEEDLE 0.00<br />

C1713 9 ANCHOR/SCREW BN/BN,TIS/BN 0.00<br />

C1714 9 CATH, TRANS ATHERECTOMY, DIR 0.00<br />

C1715 9 BRACHYTHERAPY NEEDLE 0.00<br />

C1716 9 BRACHYTX, NON-STR, GOLD-198 0.00<br />

C1717 O BRACHYTX, NON-STR,HDR IR-192 0.00<br />

C1718 O BRACHYTX SOURCE, IODINE 125 0.00<br />

C1719 9 BRACHYTX, NS, NON-HDRIR-192 0.00<br />

C1720 O BRACHYTX SOUR, PALLADIUM 103 0.00<br />

C1721 9 AICD, DUAL CHAMBER 0.00<br />

C1722 9 AICD, SINGLE CHAMBER 0.00<br />

C1724 9 CATH, TRANS ATHEREC,ROTATION 0.00<br />

C1725 9 CATH, TRANSLUMIN NON-LASER 0.00<br />

C1726 9 CATH, BAL DIL, NON-VASCULAR 0.00<br />

C1727 9 CATH, BAL TIS DIS, NON-VAS 0.00<br />

C1728 9 CATH, BRACHYTX SEED ADM 0.00<br />

C1729 9 CATH, DRAINAGE 0.00<br />

C1730 9 CATH, EP, 19 OR FEW ELECT 0.00<br />

C1731 9 CATH, EP, 20 OR MORE ELEC 0.00<br />

C1732 9 CATH, EP, DIAG/ABL, 3D/VECT 0.00<br />

C1733 9 CATH, EP, OTHR THAN COOL-TIP 0.00<br />

C1750 9 CATH, HEMODIALYSIS,LONG-TERM 0.00<br />

C1751 9 CATH, INF, PER/CENT/MIDLINE 0.00<br />

C1752 9 CATH,HEMODIALYSIS,SHORT-TERM 0.00<br />

C1753 9 CATH, INTRAVAS ULTRASOUND 0.00<br />

C1754 9 CATHETER, INTRADISCAL 0.00<br />

C1755 9 CATHETER, INTRASPINAL 0.00<br />

C1756 9 CATH, PACING, TRANSESOPH 0.00<br />

C1757 9 CATH, THROMBECTOMY/EMBOLECT 0.00<br />

C1758 9 CATHETER, URETERAL 0.00<br />

C1759 9 CATH, INTRA ECHOCARDIOGRAPHY 0.00<br />

C1760 9 CLOSURE <strong>DE</strong>V, VASC 0.00<br />

C1762 9 CONN TISS, HUMAN(INC FASCIA) 0.00<br />

C1763 9 CONN TISS, NON-HUMAN 0.00<br />

C1764 9 EVENT RECOR<strong>DE</strong>R, CARDIAC 0.00<br />

C1765 9 ADHESION BARRIER 0.00<br />

C1766 9 INTRO/SHEATH,STRBLE,NON-PEEL 0.00<br />

C1767 9 GENERATOR, NEURO NON-RECHARG 0.00<br />

C1768 9 GRAFT, VASCULAR 0.00

---

C1769 9 GUI<strong>DE</strong> WIRE 0.00<br />

C1770 9 IMAGING COIL, MR, INSERTABLE 0.00<br />

C1771 9 REP <strong>DE</strong>V, URINARY, W/SLING 0.00<br />

C1772 9 INFUSION PUMP, PROGRAMMABLE 0.00<br />

C1773 9 RET <strong>DE</strong>V, INSERTABLE 0.00<br />

C1775 O FDG, PER DOSE (4-40 MCI/ML) 0.00<br />

C1776 9 JOINT <strong>DE</strong>VICE (IMPLANTABLE) 0.00<br />

C1777 9 LEAD, AICD, ENDO SINGLE COIL 0.00<br />

C1778 9 LEAD, NEUROSTIMULATOR 0.00<br />

C1779 9 LEAD, PMKR, TRANSVENOUS VDD 0.00<br />

C1780 9 LENS, INTRAOCULAR (NEW TECH) 0.00<br />

C1781 9 MESH (IMPLANTABLE) 0.00<br />

C1782 9 MORCELLATOR 0.00<br />

C1783 9 OCULAR IMP, AQUEOUS DRAIN <strong>DE</strong> 0.00<br />

C1784 9 OCULAR <strong>DE</strong>V, INTRAOP, <strong>DE</strong>T RET 0.00<br />

C1785 9 PMKR, DUAL, RATE-RESP 0.00<br />

C1786 9 PMKR, SINGLE, RATE-RESP 0.00<br />

C1787 9 PATIENT PROGR, NEUROSTIM 0.00<br />

C1788 9 PORT, INDWELLING, IMP 0.00<br />

C1789 9 PROSTHESIS, BREAST, IMP 0.00<br />

C1790 9 IRIDIUM 192 HDR 0.00<br />

C1791 9 ONCOSEED, RAPID STRAND I-125 0.00<br />

C1792 9 UROMED I-125 BRACHY SEED 0.00<br />

C1793 9 BARD INTERSOURCE P-103 SEED 0.00<br />

C1794 9 BARD ISOSEED P-103 SEED 0.00<br />

C1795 9 BARD BRACHYSOURCE I-125 0.00<br />

C1796 9 SOURCETECH MED I-125 0.00<br />

C1797 9 DRAXIMAGE I-125 SEED 0.00<br />

C1798 9 SYNCOR I-125 PHARMASEED 0.00<br />

C1799 9 I-PLANT I-125 BRACHYTX SEED 0.00<br />

C1800 9 PD-103 BRACHYTX SEED 0.00<br />

C1801 9 IOGOLD I-125 BRACHYTX SEED 0.00<br />

C1802 9 IRIDIUM 192 BRACHYTX SEEDS 0.00<br />

C1803 9 BEST IODINE 125 BRACHYTX SDS 0.00<br />

C1804 9 BEST PALLADIUM 103 SEEDS 0.00<br />

C1805 9 ISOSTAR IODINE-125 SEEDS 0.00<br />

C1806 9 BEST GOLD 198 BRACHYTX SEED 0.00<br />

C1810 9 D114S DILATATION CATH 0.00<br />

C1811 9 SUGICAL DYNAMICS ANCHORS 0.00<br />

C1812 9 OBL ANCHORS 0.00<br />

C1813 9 PROSTHESIS, PENILE, INFLATAB 0.00<br />

C1814 9 RETINAL TAMP, SILICONE OIL 0.00<br />

C1815 9 PROS, URINARY SPH, IMP 0.00<br />

C1816 9 RECEIVER/TRANSMITTER, NEURO 0.00<br />

C1817 9 SEPTAL <strong>DE</strong>FECT IMP SYS 0.00<br />

C1818 9 INTEGRATED KERATOPROSTHESIS 0.00<br />

C1819 9 TISSUE LOCALIZATION-EXCISION 0.00<br />

C1820 9 GENERATOR NEURO RECHG BAT SY 0.00<br />

C1821 9 INTERSPINOUS IMPLANT 0.00<br />

C1850 9 REPLIFORM 14/21 SQ CM 0.00

---

C1851 9 REPLIFORM 24/28 SQ CM 0.00<br />

C1852 9 TRANSCYTE, PER 247 SQ CM 0.00<br />

C1853 9 SUSPEND, PER 8/14 SQ CM 0.00<br />

C1854 9 SUSPEND, PER 24/28 SQ CM 0.00<br />

C1855 9 SUSPEND, PER 36 SQ CM 0.00<br />

C1856 9 SUSPEND, PER 48 SQ CM 0.00<br />

C1857 9 SUSPEND, PER 84 SQ CM 0.00<br />

C1858 9 DURA<strong>DE</strong>RM, PER 8/14 SQ CM 0.00<br />

C1859 9 DURA<strong>DE</strong>RM, PER 21/24/28 SQ CM 0.00<br />

C1860 9 DURA<strong>DE</strong>RM, PER 48 SQ CM 0.00<br />

C1861 9 DURA<strong>DE</strong>RM, PER 36 SQ CM 0.00<br />

C1862 9 DURA<strong>DE</strong>RM, PER 72 SQ CM 0.00<br />

C1863 9 DURA<strong>DE</strong>RM, PER 84 SQ CM 0.00<br />

C1864 9 SPERMATEX, PER 13.44 SQ CM 0.00<br />

C1865 9 FASLATA, PER 8/14 SQ CM 0.00<br />

C1866 9 FASLATA, PER 24/28 SQ CM 0.00<br />

C1867 9 FASLATA, PER 36/48 SQ CM 0.00<br />

C1868 9 FASLATA, PER 96 SQ CM 0.00<br />

C1869 9 GORE THYROPLASTY <strong>DE</strong>VICE 0.00<br />

C1870 9 <strong>DE</strong>RMMATRIX, PER 16 SQ CM 0.00<br />

C1871 9 <strong>DE</strong>RMMATRIX, 32 OR 64 SQ CM 0.00<br />

C1872 9 <strong>DE</strong>RMAGRAFT, PER 37.5 SQ CM 0.00<br />

C1873 9 BARD 3DMAX MESH 0.00<br />

C1874 9 STENT, COATED/COV W/<strong>DE</strong>L SYS 0.00<br />

C1875 9 STENT, COATED/COV W/O <strong>DE</strong>L SY 0.00<br />

C1876 9 STENT, NON-COA/NON-COV W/<strong>DE</strong>L 0.00<br />

C1877 9 STENT, NON-COAT/COV W/O <strong>DE</strong>L 0.00<br />

C1878 9 MATRL FOR VOCAL CORD 0.00<br />

C1879 O TISSUE MARKER, IMPLANTABLE 0.00<br />

C1880 9 VENA CAVA FILTER 0.00<br />

C1881 9 DIALYSIS ACCESS SYSTEM 0.00<br />

C1882 9 AICD, OTHER THAN SING/DUAL 0.00<br />

C1883 9 ADAPT/EXT, PACING/NEURO LEAD 0.00<br />

C1884 9 EMBOLIZATION PROTECT SYST 0.00<br />

C1885 9 CATH, TRANSLUMIN ANGIO LASER 0.00<br />

C1887 9 CATHETER, GUIDING 0.00<br />

C1888 9 ENDOVAS NON-CARDIAC ABL CATH 0.00<br />

C1891 9 INFUSION PUMP,NON-PROG, PERM 0.00<br />

C1892 9 INTRO/SHEATH,FIXED,PEEL-AWAY 0.00<br />

C1893 9 INTRO/SHEATH, FIXED,NON-PEEL 0.00<br />

C1894 9 INTRO/SHEATH, NON-LASER 0.00<br />

C1895 9 LEAD, AICD, ENDO DUAL COIL 0.00<br />

C1896 9 LEAD, AICD, NON SING/DUAL 0.00<br />

C1897 9 LEAD, NEUROSTIM TEST KIT 0.00<br />

C1898 9 LEAD, PMKR, OTHER THAN TRANS 0.00<br />

C1899 9 LEAD, PMKR/AICD COMBINATION 0.00<br />

C1900 9 LEAD, CORONARY VENOUS 0.00<br />

C1925 9 INJECTION, RISPERIDONE 0.00<br />

C1929 9 MAVERICK PTCA CATH 0.00<br />

C1930 9 COYOTE DIL CATH, 20/30/40MM 0.00

---

C1931 9 TALON DIL CATH 0.00<br />

C1932 9 SCIMED REMEDY DIL CATH 0.00<br />

C1933 9 OPTI-PLAST XL/CENTURION CATH 0.00<br />

C1934 9 ULTRAVERSE 3.5F BAL DIL CATH 0.00<br />

C1935 9 WORKHORSE PTA BAL CATH 0.00<br />

C1936 9 UROMAX ULTRA BAL DIL CATH 0.00<br />

C1937 9 SYNERGY/EXPLORER CATH 0.00<br />

C1938 9 UROFORCE BAL DIL CATH 0.00<br />

C1939 9 RAPTUR, NINJA PTCA DIL CATH 0.00<br />

C1940 9 POWERFLEX,OPTA 5/LP BAL CATH 0.00<br />

C1941 9 JUPITER PTA DIL CATH 0.00<br />

C1942 9 CORDIS MAXI LD PTA BAL CATH 0.00<br />

C1943 9 RXCROSSSAIL OTW OPENSAIL 0.00<br />

C1944 9 RAPID EXCHANGE BIL DIL CATH 0.00<br />

C1945 9 SAVVY PTA DIL CATH 0.00<br />

C1946 9 R1S RAPID DIL CATH 0.00<br />

C1947 9 GAZELLE BAL DIL CATH 0.00<br />

C1948 9 ORACLE MEGASONICS CATH 0.00<br />

C1949 9 ORACLE MEGASONICS CATH 0.00<br />

C1979 9 VISIONS PV/AVANAR US CATH 0.00<br />

C1980 9 ATLANTIS SR CORONARY CATH 0.00<br />

C1981 9 PTCA CATHETERS 0.00<br />

C2000 9 ORBITER ST STEERABLE CATH 0.00<br />

C2001 9 CONSTELLATION DIAG CATH 0.00<br />

C2002 9 IRVINE 5F INQUIRY EP CATH 0.00<br />

C2003 9 IRVINE 6F INQUIRY EP CATH 0.00<br />

C2004 9 EP CATH--OCTAPOLAR 0.00<br />

C2005 9 EP TIP CATH--HEXAPOLAR 0.00<br />

C2006 9 EP CATH--<strong>DE</strong>CAPOLAR 0.00<br />

C2007 9 IRVINE 6F LUMA-CATH EP CATH 0.00<br />

C2008 9 LUMA-CATH EP CATH 81910-15 0.00<br />

C<strong>2009</strong> 9 IRVINE 7F LUMA-CATH EP CATH 0.00<br />

C2010 9 FIXED CURVE EP CATH 0.00<br />

C2011 9 <strong>DE</strong>FLECTABLE TIP CATH--QUAD 0.00<br />

C2012 9 CELSIUS ABLN CATH 0.00<br />

C2013 9 CELSIUS LARGE ABLN CATH 0.00<br />

C2014 9 CELSIUS II ASYM ABLN CATH 0.00<br />

C2015 9 CELSIUS II SYM ABLN CATH 0.00<br />

C2016 9 NAVI-STAR DS, NAVI-STAR THER 0.00<br />

C2017 9 NAVI-STAR ABLN CATH 0.00<br />

C2018 9 POLARIS T ABLATION CATH 0.00<br />

C2019 9 EP <strong>DE</strong>FLECTABLE CATH 0.00<br />

C2020 9 BLAZER II XP ABLN CATH 0.00<br />

C2021 9 SILVERFLEX EP CATH 0.00<br />

C2022 9 CP CHILLI COOLED ABLN CATH 0.00<br />

C2023 9 CHILLI CLD ABLNCATH-STD,LG 0.00<br />

C2100 9 CP CS REFERENCE CATH 0.00<br />

C2101 9 CP RV REFERENCE CATH 0.00<br />

C2102 9 CP RADII 7F EP CATH 0.00<br />

C2103 9 CP RADII 7F EP CATH W/TRACK 0.00

---

C2104 9 LASSO <strong>DE</strong>FLECTABLE CATH 0.00<br />

C2151 9 VERIPATH GUIDING CATH 0.00<br />

C2152 9 CORDIS VISTA BRITE TIP CATH 0.00<br />

C2153 9 BARD VIKING CATH 0.00<br />

C2200 9 ARROW-TREROTOLA PTD CATH 0.00<br />

C2300 9 VARISOURCE STND CATH 0.00<br />

C2597 9 CLINICATH 16/18 SGL/DBL 0.00<br />

C2598 9 CLINICATH 18/20/24G--SINGLE 0.00<br />

C2599 9 CLINICATH 16/18 DOUBLE 0.00<br />

C2600 9 GOLD PROBE CATHETER 0.00<br />

C2601 9 BARD DL URETERAL CATH 0.00<br />

C2602 9 VITESSE LASER CATH 1.4/1.7MM 0.00<br />

C2603 9 VITESSE LASER CATH 2.0MM 0.00<br />

C2604 9 VITESSE E LASER CATH 2.0MM 0.00<br />

C2605 9 EXTREME LASER CATH 0.00<br />

C2606 9 SPINECATH XL CATHETER 0.00<br />

C2607 9 SPINECATH INTRADISCAL CATH 0.00<br />

C2608 9 SCIMED 6F WISEGUI<strong>DE</strong> CATHETER 0.00<br />

C2609 9 FLEXIMA BIL DRAINAGE CATH 0.00<br />

C2610 9 FLEXTIPPLUS INTRASPINAL CATH 0.00<br />

C2611 9 ALGOLINE INTRASPINAL CATH 0.00<br />

C2612 9 INDURA CATHETER 0.00<br />

C2614 9 PROBE, PERC LUMB DISC 0.00<br />

C2615 9 SEALANT, PULMONARY, LIQUID 0.00<br />

C2616 9 BRACHYTX, NON-STR,YTTRIUM-90 0.00<br />

C2617 9 STENT, NON-COR, TEM W/O <strong>DE</strong>L 0.00<br />

C2618 9 PROBE, CRYOABLATION 0.00<br />

C2619 9 PMKR, DUAL, NON RATE-RESP 0.00<br />

C2620 9 PMKR, SINGLE, NON RATE-RESP 0.00<br />

C2621 9 PMKR, OTHER THAN SING/DUAL 0.00<br />

C2622 9 PROSTHESIS, PENILE, NON-INF 0.00<br />

C2625 9 STENT, NON-COR, TEM W/<strong>DE</strong>L SY 0.00<br />

C2626 9 INFUSION PUMP, NON-PROG,TEMP 0.00<br />

C2627 9 CATH, SUPRAPUBIC/CYSTOSCOPIC 0.00<br />

C2628 9 CATHETER, OCCLUSION 0.00<br />

C2629 9 INTRO/SHEATH, LASER 0.00<br />

C2630 9 CATH, EP, COOL-TIP 0.00<br />

C2631 9 REP <strong>DE</strong>V, URINARY, W/O SLING 0.00<br />

C2632 O BRACHYTX SOL, I-125, PER MCI 0.00<br />

C2633 O BRACHYTX SOURCE, CESIUM-131 0.00<br />

C2634 9 BRACHYTX, NON-STR, HA, I-125 0.00<br />

C2635 9 BRACHYTX, NON-STR, HA, P-103 0.00<br />

C2636 9 BRACHY LINEAR, NON-STR,P-103 0.00<br />

C2637 9 BRACHY,NON-STR,YTTERBIUM-169 0.00<br />

C2638 9 BRACHYTX, STRAN<strong>DE</strong>D, I-125 0.00<br />

C2639 9 BRACHYTX, NON-STRAN<strong>DE</strong>D,I-125 0.00<br />

C2640 9 BRACHYTX, STRAN<strong>DE</strong>D, P-103 0.00<br />

C2641 9 BRACHYTX, NON-STRAN<strong>DE</strong>D,P-103 0.00<br />

C2642 9 BRACHYTX, STRAN<strong>DE</strong>D, C-131 0.00<br />

C2643 9 BRACHYTX, NON-STRAN<strong>DE</strong>D,C-131 0.00

---

C2676 9 RSPONSE CV CATHETER 0.00<br />

C2698 9 BRACHYTX, STRAN<strong>DE</strong>D, NOS 0.00<br />

C2699 9 BRACHYTX, NON-STRAN<strong>DE</strong>D, NOS 0.00<br />

C2700 9 MYCROPHYLAX PLUS SC <strong>DE</strong>FIB 0.00<br />

C2701 9 PHYLAX XM SC <strong>DE</strong>FIB 0.00<br />

C2702 9 VENTAK PRIZM 2 VR <strong>DE</strong>FIB 0.00<br />

C2703 9 VENTAK PRIZM VR HE <strong>DE</strong>FIB 0.00<br />

C2704 9 VENTAK MINI IV+ <strong>DE</strong>FIB 0.00<br />

C2801 9 <strong>DE</strong>FEN<strong>DE</strong>R IV DR 612 DC <strong>DE</strong>FIB 0.00<br />

C2802 9 PHYLAX AV 0.00<br />

C2803 9 VENTAK PRIZM DR HE <strong>DE</strong>FIB 0.00<br />

C2804 9 VENTAK PRIZM 2 DR <strong>DE</strong>FIB 0.00<br />

C2805 9 JEWEL AF 7250 <strong>DE</strong>FIB 0.00<br />

C2806 9 GEM VR 7227 <strong>DE</strong>FIB 0.00<br />

C2807 9 CONTAK CD 1823 0.00<br />

C2808 9 CONTAK TR 1241 0.00<br />

C3001 9 KAINOX SL/RV <strong>DE</strong>FIB LEAD 0.00<br />

C3002 9 EASYTRAK <strong>DE</strong>FIB LEAD 0.00<br />

C3003 9 ENDOTAK SQ ARAY XP LEAD 0.00<br />

C3004 9 INTERVENE <strong>DE</strong>FIB LEAD 0.00<br />

C3400 9 SILTEX SPECTRUM,CONTOUR PROF 0.00<br />

C3401 9 SALINE-FILLED SPECTRUM 0.00<br />

C3500 9 ALPHA I INF PRO 0.00<br />

C3510 9 AMS 800 URINARY PROS 0.00<br />

C3551 9 CHOICE/PT GRAPHIX/LUGE/TROOP 0.00<br />

C3552 9 HI-TORQUE WHISPER 0.00<br />

C3553 9 CORDIS GUI<strong>DE</strong>WIRES 0.00<br />

C3554 9 JINDO GUI<strong>DE</strong>WIRE 0.00<br />

C3555 9 WHOLEY HI-TORQUE PLUS GW 0.00<br />

C3556 9 WAVE/FLOWWIRE GUI<strong>DE</strong>WIRE 0.00<br />

C3557 9 HYTEK GUI<strong>DE</strong>WIRE 0.00<br />

C3800 9 SYNCHROMED EL INFUSION PUMP 0.00<br />

C3801 9 ARROW/MICROJECT PCA SYS 0.00<br />

C3851 9 ELASTIC UV IOLAA-4203T/TF/TL 0.00<br />

C4000 9 OPUS G 4621, 4624 SC PMKR 0.00<br />

C4001 9 OPUS S 4121/4124 SC PMKR 0.00<br />

C4002 9 TALENT 113 SC PMKR 0.00<br />

C4003 9 KAIROS SR SC PMKR 0.00<br />

C4004 9 ACTROS SR, ACTROSSR-B SC PMK 0.00<br />

C4005 9 PHILOS SR/SR-B SC PMKR 0.00<br />

C4006 9 PULSAR MAX II SR PMKR 0.00<br />

C4007 9 MARATHON SR PMKR 0.00<br />

C4008 9 DISCOVERY II SSI PMKR 0.00<br />

C4009 9 DISCOVERY II SR PMKR 0.00<br />

C4300 9 INTEGRITY AFX DR 5342 PMKR 0.00<br />

C4301 9 INTEGRITY AFX DR 5346 PMKR 0.00<br />

C4302 9 AFFINITY VDR 5430 PMKR 0.00<br />

C4303 9 BRIO 112 DC PMKR 0.00<br />

C4304 9 BRIO212,TALENT213/223DCPMKR 0.00<br />

C4305 9 BRIO 222 DC PMKR 0.00

---

C4306 9 BRIO 220 DC PMKR 0.00<br />

C4307 9 KAIROS DR DC PMKR 0.00<br />

C4308 9 INOS2, INOS2+ DC PMKR 0.00<br />

C4309 9 ACTROS DR,D,DR-A,SLR DC PMKR 0.00<br />

C4310 9 ACTROS DR-B DC PMKR 0.00<br />

C4311 9 PHILOS DR/DR-B/SLR DC PMKR 0.00<br />

C4312 9 PULSAR MAX II DR PMKR 0.00<br />

C4313 9 MARATHON DR PMKR 0.00<br />

C4314 9 MOMENTUM DR PMKR 0.00<br />

C4315 9 SELECTION AFM PMKR 0.00<br />

C4316 9 DISCOVERY II DR 0.00<br />

C4317 9 DISCOVERY II DDD 0.00<br />

C4600 9 SYNOX,POLYROX,ELOX,RETROX 0.00<br />

C4601 9 AESCULA LV PMKR LEAD 0.00<br />

C4602 9 TENDRIL SDX, 1488K PMKR LEAD 0.00<br />

C4603 9 OSCOR PR/FLEXION PMKR LEAD 0.00<br />

C4604 9 CRYSTALLINEACTFIX,CAPSUREFIX 0.00<br />

C4605 9 CAPSURE EPI PMKR LEAD 0.00<br />

C4606 9 FLEXTEND PMKR LEAD 0.00<br />

C4607 9 FINELINEII/EZ, THINLINEII/EZ 0.00<br />

C5000 9 BX VELOCITY W/HEPACOAT 0.00<br />

C5001 9 MEMOTHERM BIL STENT, SM, MED 0.00<br />

C5002 9 MEMOTHERM BIL STENT, LARGE 0.00<br />

C5003 9 MEMOTHERM BIL STENT, X-LARGE 0.00<br />

C5004 9 PALMAZCORINTHIAN IQ BIL STNT 0.00<br />

C5005 9 PALMAZCORINTHIAN IQ TRANS/BI 0.00<br />

C5006 9 PALMAZTRANS BIL STENTSYS-MED 0.00<br />

C5007 9 PALMAZTRANS XL BIL ST-40MM 0.00<br />

C5008 9 PALMAZTRANS XL BIL ST-50MM 0.00<br />

C5009 9 VISTAFLEX BILIARY STENT 0.00<br />

C5010 9 RAPID EXCHANGE BIL STENT SYS 0.00<br />

C5011 9 INTRASTENT, INTRASTENT LP 0.00<br />

C5012 9 INTRASTENT DOUBLESTRUT LD 0.00<br />

C5013 9 INTRASTENT DOUBLESTRUT, XS 0.00<br />

C5014 9 AVE BRIDGE STENTSYS10/17/28 0.00<br />

C5015 9 AVE/X3 BRIDGE SYS, 40-100 0.00<br />

C5016 9 BILIARY STENT SINGLE USE COV 0.00<br />

C5017 9 WALLSTENTRP-BIL-20/40/60/68 0.00<br />

C5018 9 WALLSTENTRP BIL--80/94MM 0.00<br />

C5019 9 FLEXIMA BIL STENT SYS 0.00<br />

C5020 9 SMART NITINOL STENT--20MM 0.00<br />

C5021 9 SMART NITINOL STENT--40/60MM 0.00<br />

C5022 9 SMART NITINOL STENT--80MM 0.00<br />

C5023 9 BX VELOCITY STENT--8/13MM 0.00<br />

C5024 9 BX VELOCITY STENT 0.00<br />

C5025 9 BX VELOCITY STENT--23MM 0.00<br />

C5026 9 BX VELOCITY STENT--28/33MM 0.00<br />

C5027 9 BX VELOCITY W/HEP--8/13MM 0.00<br />

C5028 9 BX VELOCITY W/HEP--18MM 0.00<br />

C5029 9 BX VELOCITY W/HEP--23MM 0.00

---

C5030 9 STENT, CORONARY, S660 9/12MM 0.00<br />

C5031 9 STENT, CORONARY, S660 15/18 0.00<br />

C5032 9 STENT,CORONARY, S660 24/30 0.00<br />

C5033 9 NIROYAL STNT SYS, 9MM 0.00<br />

C5034 9 NIROYAL STENT SYS, 12/15MM 0.00<br />

C5035 9 NIROYAL STENT SYS, 18MM 0.00<br />

C5036 9 NIROYAL STENT SYS, 25MM 0.00<br />

C5037 9 NIROYAL STENT SYS, 31MM 0.00<br />

C5038 9 BX VELOCITY STNT W/RAPTOR 0.00<br />

C5039 9 INTRACOIL PERIP STENT--40MM 0.00<br />

C5040 9 INTRACOIL PERIPH STENT--60MM 0.00<br />

C5041 9 BESTENT OVER-THE-WIRE24/30MM 0.00<br />

C5042 9 BESTENT OVER-THE-WIRE 18MM 0.00<br />

C5043 9 BESTENT OVER-THE-WIRE 15MM 0.00<br />

C5044 9 BESTENT OVER-THE-WIRE 9/12MM 0.00<br />

C5045 9 MULTILINK TETRA COR STENT SY 0.00<br />

C5046 9 RADIUS 20MM COR STENT 0.00<br />

C5047 9 NIROYAL ELITE COR STENT SYS 0.00<br />

C5048 9 GR II CORONARY STENT 0.00<br />

C5130 9 WILSON-COOK Z-STENT 0.00<br />

C5131 9 BARD COLORECTAL STENT--60MM 0.00<br />

C5132 9 BARD COLORECTAL STENT--80MM 0.00<br />

C5133 9 BARD COLORECTAL STENT-100MM 0.00<br />

C5134 9 ENTERAL WALLSTENT--90MM 0.00<br />

C5279 9 CONTOUR/PERCUFLEX STENT 0.00<br />

C5280 9 INLAY DBL URETERAL STENT 0.00<br />

C5281 9 WALLGRAFT TRACH SYS 70MM 0.00<br />

C5282 9 WALLGRAFT TRACH SYS 20/30/50 0.00<br />

C5283 9 WALLSTENT/RP TIPS--80MM 0.00<br />

C5284 9 WALLSTENT TRACHULTRAFLEX 0.00<br />

C5600 9 CLOSURE <strong>DE</strong>V, VASOSEAL ES 0.00<br />

C5601 9 VASOSEAL 1000 0.00<br />

C6001 9 COMPOSIX MESH 8/18 IN 0.00<br />

C6002 9 COMPOSIX MESH 32 IN 0.00<br />

C6003 9 COMPOSIX MESH 48 IN 0.00<br />

C6004 9 COMPOSIX MESH 80 IN 0.00<br />

C6005 9 COMPOSIX MESH 140 IN 0.00<br />

C6006 9 COMPOSIX MESH 144 IN 0.00<br />

C6012 9 PELVICOL COLLAGEN 8/14 SQ CM 0.00<br />

C6013 9 PELVICOL COLLAGEN 21/24/28 0.00<br />

C6014 9 PELVICOL COLLAGEN 40 SQ CM 0.00<br />

C6015 9 PELVICOL COLLAGEN 48 SQ CM 0.00<br />

C6016 9 PELVICOL COLLAGEN 96 SQ CM 0.00<br />

C6017 9 GORE-TEX DUALMESH 75/96 SQCM 0.00<br />

C6018 9 GORE-TEX DUALMESH 150SQCM 0.00<br />

C6019 9 GORE-TEX DUALMESH 285 SQCM 0.00<br />

C6020 9 GORE-TEX DUALMESH 432SQCM 0.00<br />

C6021 9 GORE-TEX DUALMESH 600 SQCM 0.00<br />

C6022 9 GORE-TEX DUALMESH 884 SQCM 0.00<br />

C6023 9 GORE-TEXPLUS 1MM,75/96 SQCM 0.00

---

C6024 9 GORE-TEXPLUS 1MM, 150 SQ CM 0.00<br />

C6025 9 GORE-TEXPLUS 1MM, 285 SQ CM 0.00<br />

C6026 9 GORE-TEXPLUS 1MM, 432 SQCM 0.00<br />

C6027 9 GORE-TEXPLUS 1MM, 600 SQCM 0.00<br />

C6028 9 GORE-TEXPLUS 1MM,884 SQ CM 0.00<br />

C6029 9 GORE-TEXPLUS 2MM, 150 SQ CM 0.00<br />

C6030 9 GORE-TEXPLUS 2MM, 285 SQ CM 0.00<br />

C6031 9 GORE-TEXPLUS 2MM, 432 SQ CM 0.00<br />

C6032 9 GORE-TEXPLUS 2MM, 600 SQ CM 0.00<br />

C6033 9 GORE-TEXPLUS 2MM,884 SQ CM 0.00<br />

C6034 9 BARD EPTFE: 150 SQ CM-2MM 0.00<br />

C6035 9 BARD EPTFE150SQCM-1MM,75-2MM 0.00<br />

C6036 9 BARD EPTFE: 50/75SQCM-1,2MM 0.00<br />

C6037 9 BARD EPFTE: 300SQ CM-1MM 0.00<br />

C6038 9 BARD EPTFE: 600SQ CM-1MM 0.00<br />

C6039 9 BARD EPTFE: 884 CM--1MM 0.00<br />

C6040 9 BARD EPTFE: 600SQ CM-2MM 0.00<br />

C6041 9 BARD EPTFE: 884SQ CM-2MM 0.00<br />

C6050 9 FEMALE SLING SYS W/WO MATRL 0.00<br />

C6051 9 STRATASIS SLING, 20/40CM 0.00<br />

C6052 9 STRATASIS SLING, 60CM 0.00<br />

C6053 9 SURGISIS SOFT GRAFT 0.00<br />

C6054 9 SURGISIS ENCHANCED GRAFT 0.00<br />

C6055 9 SURGISIS ENHANCED TISSUE 0.00<br />

C6056 9 SURGISIS SOFT TISSUE GRAFT 0.00<br />

C6057 9 SURGISIS HERNIA GRAFT 0.00<br />

C6058 9 SURGIPRO HERNIA PLUG,MED/LG 0.00<br />

C6080 9 MALE SLING SYS W/WO MATRL 0.00<br />

C6200 9 EXXCEL SFT EPTFE VAS GRAFT 0.00<br />

C6201 9 IMPRA VENAFLO-10/20CM 0.00<br />

C6202 9 IMPRA VENAFLO-30/40CM 0.00<br />

C6203 9 IMPRA VENAFLO-50CM/VT45 0.00<br />

C6204 9 IMPRA VENAFLO-STEPPED 0.00<br />

C6205 9 IMPRA CARBOFLO-10CM 0.00<br />

C6206 9 IMPRA CARBOFLO-20CM 0.00<br />

C6207 9 IMPRA CARBOFLO-30/34/40CM 0.00<br />

C6208 9 IMPRA CARBOFLO-40/50CM 0.00<br />

C6209 9 IMPRA CARBOFLO-CTRFLEX 0.00<br />

C6210 9 EXXCEL EPTFE VAS GRAFT 0.00<br />

C6300 9 VANGUARD III ENDOVAS GRAFT 0.00<br />

C6500 9 PREFACE GUIDING SHEATH 0.00<br />

C6501 9 SOFT TIP SHEATHS 0.00<br />

C6525 9 SPECTRANETICS LASER SHEATH 0.00<br />

C6600 9 MICRO LITHO FLEX PROBES 0.00<br />

C6650 9 FAST-CATH GUIDING INTRODUCER 0.00<br />

C6651 9 SEAL-AWAYGUIDING INTRODUCER 0.00<br />

C6652 9 BARD EXCALIBUR INTRODUCER 0.00<br />

C6700 9 FOCAL SEAL-L 0.00<br />

C8099 9 SPECTRANETICS LEAD LOCK <strong>DE</strong>V 0.00<br />

C8100 9 ADHESION BARRIER, ADCON-L 0.00

---

C8102 9 SURGIVISION ESOPH COIL 0.00<br />

C8103 9 CAPIO CAPTURING <strong>DE</strong>V 0.00<br />

C8500 9 ATHEROCATH-GTO 0.00<br />

C8501 9 VIGOR SSI, SC, PMKR 0.00<br />

C8502 9 LIVEWIRE STEERABLE EP CATH 0.00<br />

C8503 9 SYNCHROMED VAS CATH 0.00<br />

C8504 9 VASOSEAL HEMOSTASIS <strong>DE</strong>V 0.00<br />

C8505 9 SYNCHROMED INFUSION PUMP 0.00<br />

C8506 9 PMKR LEADS 4057M,4058M 0.00<br />

C8507 9 6721L/M/S,6939 LEAD 0.00<br />

C8508 9 CAPSURE 4965 <strong>DE</strong>FIB LEAD 0.00<br />

C8509 9 TRANSVENE 6933/6937 LEAD 0.00<br />

C8510 9 DP-3238 <strong>DE</strong>FIB LEAD 0.00<br />

C8511 9 ENDOTAK DSP <strong>DE</strong>FIB LEAD 0.00<br />

C8512 9 ON-POINT,PISCES-QUAD LEAD 0.00<br />

C8513 9 PISCES,RESUME II LEAD 0.00<br />

C8514 9 DURA II PENILE PROSTHESIS 0.00<br />

C8516 9 MENTOR ACU-FORM/MAL PROS 0.00<br />

C8518 9 VIGOR DDD DC PMKR 0.00<br />

C8519 9 VISTA DDD C PMKR 0.00<br />

C8520 9 LEGACY II S, SC, PMKR 0.00<br />

C8521 9 MEDTRONIC MATTRIX RCVR/TRMR 0.00<br />

C8522 9 PALMAZ BAL STENT 0.00<br />

C8523 9 WALLSTENT TRANS BIL 0.00<br />

C8524 9 WALLSTENT ESOP 0.00<br />

C8525 9 WALLSTENT ESOPH--DOUBLE 0.00<br />

C8526 9 OPTIPLAST XT PTA CATH 0.00<br />

C8528 9 MS CLASSIQUE BL DIL CATH 0.00<br />

C8529 9 CRISTA CATH II <strong>DE</strong>F 20-POLE 0.00<br />

C8530 9 GEL-FILLED/SMOOTH MAMMARY PR 0.00<br />

C8531 9 WILSON-COOK ESOPH Z-STENT 0.00<br />

C8532 9 ULTRAFLEX ESOPHAGEAL PROS 0.00<br />

C8533 9 SYNCHROMED VAS CATH 8700A/V 0.00<br />

C8534 9 AMS 650 PENILE PROSTHESIS 0.00<br />

C8535 9 ZA/SPIRAL Z BIL STENT 0.00<br />

C8536 9 ESOPH Z METAL STENT 0.00<br />

C8539 9 QUANTUM DIL BALLOON 0.00<br />

C8540 9 FLEX-EZ BAL DILATOR 0.00<br />

C8541 9 CARSON/PASSPRT DIL CATH 0.00<br />

C8542 9 URETHRAMAX DIL CATH 0.00<br />

C8543 9 AMPLATZ RENAL DIL 0.00<br />

C8550 9 LIVEWIRE 5F, 7F EP CATH 0.00<br />

C8551 9 LIVEWIRE 7F DUO-<strong>DE</strong>CAPOLAR 0.00<br />

C8552 9 SANTURO FIXED CURVE CATH 0.00<br />

C8597 9 WISDOM ST GUI<strong>DE</strong>WIRE 0.00<br />

C8598 9 SV GUI<strong>DE</strong>WIRE-5/8/14CM 0.00<br />

C8599 9 STABILIZER XS GUI<strong>DE</strong>WIRE 0.00<br />

C8600 9 SHINOBI PLUS GUI<strong>DE</strong>WIRE 0.00<br />

C8650 9 XL CHECK-FLO INTRODUCER 0.00<br />

C8724 9 OCTAD NEURO LEAD 0.00

---

C8725 9 SYMMIX NEURO LEAD 0.00<br />

C8748 9 ENDOTAK SQ PATCH <strong>DE</strong>FIB LEAD 0.00<br />

C8749 9 ENDOTAK SQ ARRAY <strong>DE</strong>FIB LEAD 0.00<br />

C8750 9 UNITY VDDR DC PMKR 0.00<br />

C8775 9 2188 COR PMKR LEAD 0.00<br />

C8776 9 INNOMEDICA PMKR LEAD 0.00<br />

C8777 9 UNIPASS PMKR LEAD 0.00<br />

C8800 9 LG PALMAZ BIL STENT 0.00<br />

C8801 9 GIANTURCO BIL Z STENT 0.00<br />

C8802 9 OASIS STENT INTRO SYS 0.00<br />

C8830 9 GIANTURCO-ROUBIN COR SNT 0.00<br />

C8890 9 PERFLUORON, 2ML 0.00<br />

C8891 9 PERFLUORON, 5/7ML 0.00<br />

C8900 9 MRA W/CONT, ABD 0.00<br />

C8901 9 MRA W/O CONT, ABD 0.00<br />

C8902 9 MRA W/O FOL W/CONT, ABD 0.00<br />

C8903 9 MRI W/CONT, BREAST, UNI 0.00<br />

C8904 9 MRI W/O CONT, BREAST, UNI 0.00<br />

C8905 9 MRI W/O FOL W/CONT, BRST, UN 0.00<br />

C8906 9 MRI W/CONT, BREAST, BI 0.00<br />

C8907 9 MRI W/O CONT, BREAST, BI 0.00<br />

C8908 9 MRI W/O FOL W/CONT, BREAST, 0.00<br />

C8909 9 MRA W/CONT, CHEST 0.00<br />

C8910 9 MRA W/O CONT, CHEST 0.00<br />

C8911 9 MRA W/O FOL W/CONT, CHEST 0.00<br />

C8912 9 MRA W/CONT, LWR EXT 0.00<br />

C8913 9 MRA W/O CONT, LWR EXT 0.00<br />

C8914 9 MRA W/O FOL W/CONT, LWR EXT 0.00<br />

C8918 9 MRA W/CONT, PELVIS 0.00<br />

C8919 9 MRA W/O CONT, PELVIS 0.00<br />

C8920 9 MRA W/O FOL W/CONT, PELVIS 0.00<br />

C8921 9 TTE W OR W/O FOL W/CONT, COM 0.00<br />

C8922 9 TTE W OR W/O FOL W/CONT, F/U 0.00<br />

C8923 9 2D TTE W OR W/O FOL W/CON,CO 0.00<br />

C8924 9 2D TTE W OR W/O FOL W/CON,FU 0.00<br />

C8925 9 2D TEE W OR W/O FOL W/CON,IN 0.00<br />

C8926 9 TEE W OR W/O FOL W/CONT,CONG 0.00<br />

C8927 9 TEE W OR W/O FOL W/CONT, MON 0.00<br />

C8928 9 TTE W OR W/O FOL W/CON,STRES 0.00<br />

C8929 9 TTE W OR WO FOL WCON,DOPPLER 0.00<br />

C8930 9 TTE W OR W/O CONTR, CONT ECG 0.00<br />

C8950 O INTRAVENOUS INFUSION FOR THERAPY/ 0.00<br />

C8951 O INTRAVENOUS INFUSION FOR THERAPY/ 0.00<br />

C8952 O THERAPEUTIC, PROPHYLACTIC OR DIAGN 0.00<br />

C8953 O CHEMOTHERAPY ADMINISTRATION, INTRA 0.00<br />

C8954 O CHEMOTHERAPY ADMINISTRATION, INTRA 0.00<br />

C8955 O CHEMOTHERAPY ADMINISTRATION, INTRA 0.00<br />

C8956 9 REFILLING AND MAINTENANCE OF PORTA 0.00<br />

C8957 9 INTRAVENOUS INFUSION FOR THERAPY/ 0.00<br />

C9000 O NA CHROMATECR51, PER 0.25MCI 0.00

---

C9001 9 LINEZOLID INJ, 200MG 0.00<br />

C9002 9 TENECTEPLASE, 50MG/VIAL 0.00<br />

C9003 O PALIVIZUMAB, PER 50 MG 0.00<br />

C9004 9 GEMTUZUMAB OZOGAMICIN INJ,5M 0.00<br />

C9005 9 RETEPLASE INJ, HALF-KIT,18.8 0.00<br />

C9006 9 TACROLIMUS INJ, PER 5 MG 0.00<br />

C9007 O BACLOFEN INTRATHECAL KIT-1AM 0.00<br />

C9008 O BACLOFEN REFILL KIT-500MCG 0.00<br />

C9009 O BACLOFEN REFILL KIT-2000MCG 0.00<br />

C9010 O BACLOFEN REFILL KIT--4000MCG 0.00<br />

C9011 9 CAFFEINE CITRATE, INJ, 1ML 0.00<br />

C9013 O CO 57 COBALTOUS CHLORI<strong>DE</strong> 0.00<br />

C9019 9 CASPOFUNGIN ACETATE, 5 MG 0.00<br />

C9020 9 SIROLIMUS TABLET, 1 MG 0.00<br />

C9100 9 IODINATED I-131 ALBUMIN 0.00<br />

C9102 O 51 NA CHROMATE, 50MCI 0.00<br />

C9103 O NA IOTHALAMATE I-125, 10 UCI 0.00<br />

C9104 9 ANTI-THYMOCYTE GLOBULIN,25MG 0.00<br />

C9105 O HEP B IMM GLOB, PER 1 ML 0.00<br />

C9106 9 SIROLIMUS 1MG/ML 0.00<br />

C9107 9 TINZAPARIN SODIUM, 2ML VIAL 0.00<br />

C9108 9 THYROTROPIN ALFA, 1.1 MG 0.00<br />

C9109 O TIROFIBAN HCL, 6.25 MG 0.00<br />

C9110 9 ALEMTUZUMAB, PER 10MG/ML 0.00<br />

C9111 O INJ, BIVALIRUDIN, 250MG VIAL 0.00<br />

C9112 O PERFLUTREN LIPID MICRO, 2ML 0.00<br />

C9113 9 INJ PANTOPRAZOLE SODIUM, VIA 0.00<br />

C9114 9 NESIRITI<strong>DE</strong>, PER 1.5 MG VIAL 0.00<br />

C9115 9 INJ, ZOLEDRONIC ACID, 2 MG 0.00<br />

C9116 O ERTAPENEM SODIUM, PER 1 GM 0.00<br />

C9119 O INJECTION, PEGFILGRASTIM 0.00<br />

C9120 O INJECTION, FULVESTRANT 0.00<br />

C9121 9 INJECTION, ARGATROBAN 0.00<br />

C9123 O TRANSCYTE, PER 247 SQ CM 0.00<br />

C9124 O INJECTION, DAPTOMYCIN 0.00<br />

C9125 O INJECTION, RISPERIDONE 0.00<br />

C9126 O INJECTION, NATALIZUMAB 0.00<br />

C9200 O ORCEL, PER 36 CM2 0.00<br />

C9201 O <strong>DE</strong>RMAGRAFT, PER 37.5 SQ CM 0.00<br />

C9202 O OCTAFLUOROPROPANE 0.00<br />

C9203 O PERFLEXANE LIPID MICRO 0.00<br />

C9205 O OXALIPLATIN 0.00<br />

C9206 O INTEGRA, PER CM2 0.00<br />

C9207 O INJECTION, BORTEZOMIB 0.00<br />

C9208 O INJECTION, AGALSIDASE BETA 0.00<br />

C9209 O INJECTION, LARONIDASE 0.00<br />

C9210 O INJECTION, PALONOSETRON HCL 0.00<br />

C9211 O INJ, ALEFACEPT, IV 0.00<br />

C9212 O INJ, ALEFACEPT, IM 0.00<br />

C9213 O INJECTION, PEMETREXED 0.00

---

C9214 O INJECTION, BEVACIZUMAB 0.00<br />

C9215 O INJECTION, CETUXIMAB 0.00<br />

C9216 O ABARELIX, INJECT SUSPENSION 0.00<br />

C9217 O INJECTION, OMALIZUMAB 0.00<br />

C9218 O INJECTION, AZACITIDINE 0.00<br />

C9220 O SODIUM HYALURONATE 0.00<br />

C9221 O GRAFTJACKET REG MATRIX 0.00<br />

C9222 O GRAFTJACKET SFTTIS 0.00<br />

C9224 O INJECTION, GALSULFASE 0.00<br />

C9225 O FLUOCINOLONE ACETONI<strong>DE</strong> 0.00<br />

C9227 O INJECTION, MICAFUNGIN SODIUM, PER 0.00<br />

C9228 O INJECTION, TIGECYCLINE, PER 1 MG 0.00<br />

C9229 O INJECTION, IBANDRONATE SODIUM, PER 0.00<br />

C9230 O INJECTION, ABATACEPT, PER 10 MG 0.00<br />

C9231 O INJECTION, <strong>DE</strong>CITABINE, PER 1 MG 0.00<br />

C9232 O INJECTION, IDURSULFASE 0.00<br />

C9233 O INJECTION, RANIBIZUMAB 0.00<br />

C9234 O INJ, ALGLUCOSIDASE ALFA 0.00<br />

C9235 O INJECTION, PANITUMUMAB 0.00<br />

C9238 O INJ, LEVETIRACETAM 0.00<br />

C9239 O INJ, TEMSIROLIMUS 0.00<br />

C9241 O INJ DORIPENEM 10 MG 0.00<br />

C9245 9 INJECTION, ROMIPLOSTIM 0.00<br />

C9246 9 INJ, GADOXETATE DISODIUM 0.00<br />

C9247 9 INJ, IOBENGUANE, I-123, DX 0.00<br />

C9248 9 INJ, CLEVIDIPINE BUTYRATE 0.00<br />

C9350 O POROUS COLLAGEN TUBE PER CM 0.00<br />

C9351 O ACELLULAR <strong>DE</strong>RM TISSUE PERCM2 0.00<br />

C9352 9 NEURAGEN NERVE GUI<strong>DE</strong>, PER CM 0.00<br />

C9353 9 NEURAWRAP NERVE PROTECTOR,CM 0.00<br />

C9356 9 TENOGLI<strong>DE</strong> TENDON PROT, CM2 0.00<br />

C9358 9 SURGIMEND, 0.5CM2 0.00<br />

C9359 9 IMPLANT, BONE VOID FILLER 0.00<br />

C9399 9 UNCLASSIFIED DRUGS OR BIOLOGICALS 0.00<br />

C9400 O THALLOUS CHLORI<strong>DE</strong>, BRAND 0.00<br />

C9401 O STRONTIUM-89 CHLORI<strong>DE</strong>,BRAND 0.00<br />

C9402 O TH I131 SO IODI<strong>DE</strong> CAP, BRAND 0.00<br />

C9403 O DX I131 SO IODI<strong>DE</strong> CAP, BRAND 0.00<br />

C9404 O DX I131 SO IODI<strong>DE</strong> SOL, BRAND 0.00<br />

C9405 O TH I131 SO IODI<strong>DE</strong> SOL, BRAND 0.00<br />

C9408 9 FDG, BRAND, PER DOSE 0.00<br />

C9410 O <strong>DE</strong>XRAZOXANE HCL INJ, BRAND 0.00<br />

C9411 O PAMIDRONATE DISODIUM, BRAND 0.00<br />

C9412 O GANCICLOVIR IMPLANT, BRAND 0.00<br />

C9413 O SODIUM HYALURONATE INJ, BRAND 0.00<br />

C9414 O ETOPOSI<strong>DE</strong> ORAL, BRAND 0.00<br />

C9415 O DOXORUBIC HCL CHEMO, BRAND 0.00<br />

C9416 9 BCG LIVE INTRAVESICAL, BRAND 0.00<br />

C9417 O BLEOMYCIN SULFATE INJ, BRAND 0.00<br />

C9418 O CISPLATIN INJ, BRAND 0.00

---

C9419 O INJ CLADRIBINE, BRAND 0.00<br />

C9420 O CYCLOPHOSPHAMI<strong>DE</strong> INJ, BRAND 0.00<br />

C9421 O CYCLOPHOSPHAMI<strong>DE</strong> LYO, BRAND 0.00<br />

C9422 O CYTARABINE HCL INJ, BRAND 0.00<br />

C9423 O DACARBAZINE INJ, BRAND 0.00<br />

C9424 O DAUNORUBICIN, BRAND 0.00<br />

C9425 O ETOPOSI<strong>DE</strong> INJ, BRAND 0.00<br />

C9426 O FLOXURIDINE INJ, BRAND 0.00<br />

C9427 O IFOSFOMI<strong>DE</strong> INJ, BRAND 0.00<br />

C9428 O MESNA INJECTION, BRAND 0.00<br />

C9429 O IDARUBICIN HCL INJ, BRAND 0.00<br />

C9430 O LEUPROLI<strong>DE</strong> ACETATE INJ, BRAN 0.00<br />

C9431 O PACLITAXEL INJ, BRAND 0.00<br />

C9432 O MITOMYCIN INJ, BRAND 0.00<br />

C9433 O THIOTEPA INJ, BRAND 0.00<br />

C9434 9 GALLIUM GA 67, BRAND 0.00<br />

C9435 O GONADORELIN HYDROCH, BRAND 0.00<br />

C9436 O AZATHIOPRINE PARENTERAL,BRND 0.00<br />

C9437 O CARMUS BISCHL NITRO INJ 0.00<br />

C9438 O CYCLOSPORINE ORAL, BRAND 0.00<br />

C9439 O DIETHYLSTILBESTROL INJECTION 0.00<br />

C9500 9 PLATELETS, IRRAD, EA UNIT 0.00<br />

C9501 9 PLATELETS, PHERESIS, EA UNIT 0.00<br />

C9502 9 PLATELETS, PHER/IRRAD, EA UN 0.00<br />

C9503 O FRESH FROZEN PLASMA, EA UNIT 0.00<br />

C9504 9 RBC, <strong>DE</strong>GLYCEROLIZED, EA UNIT 0.00<br />

C9505 9 RBC, IRRADIATED, EACH UNIT 0.00<br />

C9700 9 WATER INDUCED THERMO 0.00<br />

C9701 O STRETTA SYSTEM 0.00<br />

C9702 9 CHKMATE/NOVOST/GALILEO BRACH 0.00<br />

C9703 O BARD ENDOSCOPIC SUTURING SYS 0.00<br />

C9704 O INJ INERT SUBS UPPER GI 0.00<br />

C9708 9 PREVIEW TX PLANNING SOFTWARE 0.00<br />

C9711 O H.E.L.P. APHERESIS SYSTEM 0.00<br />

C9712 O INSERT PH CAPSULE, GERD 0.00<br />

C9713 O NON-CONTACT LASER VAP PROSTA 0.00<br />

C9714 O BREAST INTERS RAD TX, IMMED 0.00<br />

C9715 O BREAST INTERS RAD TX, <strong>DE</strong>LAY 0.00<br />

C9716 9 RADIOFREQUENCY ENERGY TO ANUS 0.00<br />

C9718 O KYPHOPLASTY, FIRST VERTEBRA 0.00<br />

C9719 O KYPHOPLASTY, EACH ADDL 0.00<br />

C9720 O HE ESW TX, TENNIS ELBOW 0.00<br />

C9721 O HE ESW TX, PLANTAR FASCIITIS 0.00<br />

C9722 O KV IMAGING W/IR TRACKING 0.00<br />

C9723 O DYN IR PERF IMG 0.00<br />

C9724 9 EPS GAST CARDIA PLIC 0.00<br />

C9725 9 PLACE ENDORECTAL APP 0.00<br />

C9726 9 RXT BREAST APPL PLACE/REMOV 0.00<br />

C9727 9 INSERT PALATE IMPLANTS 0.00<br />

C9728 9 PLACE <strong>DE</strong>VICE/MARKER, NON PRO 0.00

---

C9898 9 INPNT STAY RADIOLABELED ITEM 0.00<br />

C9899 9 INPT IMPLANT PROS <strong>DE</strong>V,NO COV 0.00<br />

CEDCL O MCO SPECIFIC CO<strong>DE</strong>: SMART START COM 0.00<br />

CEDRV O MCO SPECIFIC CO<strong>DE</strong>: SMART START CHI 0.00<br />

D0110 O INITIAL ORAL EXAMINATION 0.00<br />

D0120 1 PERIODIC ORAL EVALUATION 0.00<br />

D0130 O EMERGENCY ORAL EXAMINATION 0.00<br />

D0140 1 LIMIT ORAL EVAL PROBLM FOCUS 0.00<br />

D0145 1 ORAL EVALUATION, PT < 3YRS 0.00<br />

D0150 1 COMPREHENSVE ORAL EVALUATION 0.00<br />

D0160 1 EXTENSV ORAL EVAL PROB FOCUS 0.00<br />

D0170 1 RE-EVAL,EST PT,PROBLEM FOCUS 0.00<br />

D0180 9 COMP PERIODONTAL EVALUATION 0.00<br />

D0210 1 INTRAOR COMPLETE FILM SERIES 0.00<br />

D0220 1 INTRAORAL PERIAPICAL FIRST F 0.00<br />

D0230 1 INTRAORAL PERIAPICAL EA ADD 0.00<br />

D0240 1 INTRAORAL OCCLUSAL FILM 0.00<br />

D0250 1 EXTRAORAL FIRST FILM 0.00<br />

D0260 1 EXTRAORAL EA ADDITIONAL FILM 0.00<br />

D0270 1 <strong>DE</strong>NTAL BITEWING SINGLE FILM 0.00<br />

D0272 1 <strong>DE</strong>NTAL BITEWINGS TWO FILMS 0.00<br />

D0273 1 BITEWINGS - THREE FILMS 0.00<br />

D0274 1 <strong>DE</strong>NTAL BITEWINGS FOUR FILMS 0.00<br />

D0275 9 BITEWINGS-EACH ADDITIONAL FILM 0.00<br />

D0277 1 VERT BITEWINGS-SEV TO EIGHT 0.00<br />

D0290 1 <strong>DE</strong>NTAL FILM SKULL/FACIAL BON 0.00<br />

D0310 1 <strong>DE</strong>NTAL SALIOGRAPHY 0.00<br />

D0320 1 <strong>DE</strong>NTAL TMJ ARTHROGRAM INCL I 0.00<br />

D0321 1 <strong>DE</strong>NTAL OTHER TMJ FILMS 0.00<br />

D0322 1 <strong>DE</strong>NTAL TOMOGRAPHIC SURVEY 0.00<br />

D0330 1 <strong>DE</strong>NTAL PANORAMIC FILM 0.00<br />

D0340 1 <strong>DE</strong>NTAL CEPHALOMETRIC FILM 0.00<br />

D0350 9 ORAL/FACIAL PHOTO IMAGES 0.00<br />

D0360 1 CONE BEAM CT 0.00<br />

D0362 1 CONE BEAM, TWO DIMENSIONAL 0.00<br />

D0363 1 CONE BEAM, THREE DIMENSIONAL 0.00<br />

D0410 9 BACTERIOLOGIC STUDIES FOR <strong>DE</strong>TERMINA 0.00<br />

D0415 9 COLLECTION OF MICROORGANISMS 0.00<br />

D0416 9 VIRAL CULTURE 0.00<br />

D0417 9 COLLECT & PREP SALIVA SAMPLE 0.00<br />

D0418 9 ANALYSIS OF SALIVA SAMPLE 0.00<br />

D0420 9 CARIES SUSCEPTIBILITY TESTS 0.00<br />

D0421 9 GEN TST SUSCEPT ORAL DISEASE 0.00<br />

D0425 9 CARRIES SUSCEPTIBILITY TESTS 0.00<br />

D0431 9 DIAG TST <strong>DE</strong>TECT MUCOS ABNORM 0.00<br />

D0460 1 PULP VITALITY TEST 0.00<br />

D0470 1 DIAGNOSTIC CASTS 0.00<br />

D0471 9 DIAGNOSTIC PHOTOGRAPHS 0.00<br />

D0472 1 GROSS EXAM, PREP & REPORT 0.00<br />

D0473 1 MICRO EXAM, PREP & REPORT 0.00

---

D0474 1 MICRO W EXAM OF SURG MARGINS 0.00<br />

D0475 9 <strong>DE</strong>CALCIFICATION PROCEDURE 0.00<br />

D0476 9 SPEC STAINS FOR MICROORGANIS 0.00<br />

D0477 9 SPEC STAINS NOT FOR MICROORG 0.00<br />

D0478 9 IMMUNOHISTOCHEMICAL STAINS 0.00<br />

D0479 9 TISSUE IN-SITU HYBRIDIZATION 0.00<br />

D0480 1 CYTOPATH SMEAR PREP & REPORT 0.00<br />

D0481 9 ELECTRON MICROSCOPY DIAGNOST 0.00<br />

D0482 9 DIRECT IMMUNOFLUORESCENCE 0.00<br />

D0483 9 INDIRECT IMMUNOFLUORESCENCE 0.00<br />

D0484 9 CONSULT SLI<strong>DE</strong>S PREP ELSEWHER 0.00<br />

D0485 9 CONSULT INC PREP OF SLI<strong>DE</strong>S 0.00<br />

D0486 9 ACCESSION OF BRUSH BIOPSY 0.00<br />

D0501 O HISTOPATHOLOGIC EXAMINATIONS 0.00<br />

D0502 1 OTHER ORAL PATHOLOGY PROCEDU 0.00<br />

D0999 1 UNSPECIFIED DIAGNOSTIC PROCE 0.00<br />

D1110 1 <strong>DE</strong>NTAL PROPHYLAXIS ADULT 0.00<br />

D1120 1 <strong>DE</strong>NTAL PROPHYLAXIS CHILD 0.00<br />

D1201 O TOPICAL FLUOR W PROPHY CHILD 0.00<br />

D1202 9 TOPICAL APPLICATION OF FLUORI<strong>DE</strong> (IN 0.00<br />

D1203 1 TOPICAL APP FLUORI<strong>DE</strong> CHILD 0.00<br />

D1204 1 TOPICAL APP FLUORI<strong>DE</strong> ADULT 0.00<br />

D1205 O TOPICAL FLUORI<strong>DE</strong> W/ PROPHY A 0.00<br />

D1206 1 TOPICAL FLUORI<strong>DE</strong> VARNISH 0.00<br />

D1310 9 NUTRI COUNSEL-CONTROL CARIES 0.00<br />

D1320 1 TOBACCO COUNSELING 0.00<br />

D1330 9 ORAL HYGIENE INSTRUCTION 0.00<br />

D1351 1 <strong>DE</strong>NTAL SEALANT PER TOOTH 0.00<br />

D1510 1 SPACE MAINTAINER FXD UNILAT 0.00<br />

D1515 1 FIXED BILAT SPACE MAINTAINER 0.00<br />

D1520 1 REMOVE UNILAT SPACE MAINTAIN 0.00<br />

D1525 1 REMOVE BILAT SPACE MAINTAIN 0.00<br />

D1550 1 RECEMENT SPACE MAINTAINER 0.00<br />

D1555 1 REMOVE FIX SPACE MAINTAINER 0.00<br />

D2110 O AMALGAM ONE SURFACE PRIMARY 0.00<br />

D2120 O AMALGAM TWO SURFACES PRIMARY 0.00<br />

D2130 O AMALGAM THREE SURFACES PRIMA 0.00<br />

D2131 O AMALGAM FOUR/MORE SURF PRIMA 0.00<br />

D2140 1 AMALGAM ONE SURFACE PERMANEN 0.00<br />

D2150 1 AMALGAM TWO SURFACES PERMANE 0.00<br />

D2160 1 AMALGAM THREE SURFACES PERMA 0.00<br />

D2161 1 AMALGAM 4 OR > SURFACES PERM 0.00<br />

D2210 9 SILCATE CEMENT PER RESTORAT 0.00<br />

D2330 1 RESIN ONE SURFACE-ANTERIOR 0.00<br />

D2331 1 RESIN TWO SURFACES-ANTERIOR 0.00<br />

D2332 1 RESIN THREE SURFACES-ANTERIO 0.00<br />

D2335 1 RESIN 4/> SURF OR W INCIS AN 0.00<br />

D2336 O COMPOSITE RESIN CROWN 0.00<br />

D2337 O COMPO RESIN CROWN ANT-PERM 0.00<br />

D2380 O RESIN ONE SURF POSTER PRIMAR 0.00

---

D2381 O RESIN TWO SURF POSTER PRIMAR 0.00<br />

D2382 O RESIN THREE/MORE SURF POST P 0.00<br />

D2385 O RESIN ONE SURF POSTER PERMAN 0.00<br />

D2386 O RESIN TWO SURF POSTER PERMAN 0.00<br />

D2387 O RESIN THREE/MORE SURF POST P 0.00<br />

D2388 O RESIN FOUR/MORE, POST PERM 0.00<br />

D2390 1 ANT RESIN-BASED CMPST CROWN 0.00<br />

D2391 1 POST 1 SRFC RESINBASED CMPST 0.00<br />

D2392 1 POST 2 SRFC RESINBASED CMPST 0.00<br />

D2393 1 POST 3 SRFC RESINBASED CMPST 0.00<br />

D2394 1 POST >=4SRFC RESINBASE CMPST 0.00<br />

D2410 9 <strong>DE</strong>NTAL GOLD FOIL ONE SURFACE 0.00<br />

D2420 9 <strong>DE</strong>NTAL GOLD FOIL TWO SURFACE 0.00<br />

D2430 9 <strong>DE</strong>NTAL GOLD FOIL THREE SURFA 0.00<br />

D2510 9 <strong>DE</strong>NTAL INLAY METALIC 1 SURF 0.00<br />

D2520 9 <strong>DE</strong>NTAL INLAY METALLIC 2 SURF 0.00<br />

D2530 9 <strong>DE</strong>NTAL INLAY METL 3/MORE SUR 0.00<br />

D2540 O ONLAY-METALLIC-PER TOOTH (IN ADDITI 0.00<br />

D2542 9 <strong>DE</strong>NTAL ONLAY METALLIC 2 SURF 0.00<br />

D2543 9 <strong>DE</strong>NTAL ONLAY METALLIC 3 SURF 0.00<br />

D2544 9 <strong>DE</strong>NTAL ONLAY METL 4/MORE SUR 0.00<br />

D2610 9 INLAY PORCELAIN/CERAMIC 1 SU 0.00<br />

D2620 9 INLAY PORCELAIN/CERAMIC 2 SU 0.00<br />

D2630 9 <strong>DE</strong>NTAL ONLAY PORC 3/MORE SUR 0.00<br />

D2642 9 <strong>DE</strong>NTAL ONLAY PORCELIN 2 SURF 0.00<br />

D2643 9 <strong>DE</strong>NTAL ONLAY PORCELIN 3 SURF 0.00<br />

D2644 9 <strong>DE</strong>NTAL ONLAY PORC 4/MORE SUR 0.00<br />

D2650 9 <strong>DE</strong>NTAL INLAY RESIN ONE SURFACE 0.00<br />

D2651 9 <strong>DE</strong>NTAL INLAY RESIN 2 SURFACES 0.00<br />

D2652 9 <strong>DE</strong>NTAL INLAY RESIN 3 OR MORE SURFA 0.00<br />

D2662 9 <strong>DE</strong>NTAL ONLAY RESIN 2 SURFACE 0.00<br />

D2663 9 <strong>DE</strong>NTAL ONLAY RESIN 3 SURFACE 0.00<br />

D2664 9 <strong>DE</strong>NTAL ONLAY RESIN 4/MRE SUR 0.00<br />

D2710 1 CROWN RESIN-BASED INDIRECT 0.00<br />

D2712 1 CROWN 3/4 RESIN-BASED COMPOS 0.00<br />

D2720 9 CROWN RESIN W/ HIGH NOBLE ME 0.00<br />

D2721 1 CROWN RESIN W/ BASE METAL 0.00<br />

D2722 1 CROWN RESIN W/ NOBLE METAL 0.00<br />

D2740 9 CROWN PORCELAIN/CERAMIC SUBS 0.00<br />

D2750 9 CROWN PORCELAIN W/ H NOBLE M 0.00<br />

D2751 1 CROWN PORCELAIN FUSED BASE M 0.00<br />

D2752 1 CROWN PORCELAIN W/ NOBLE MET 0.00<br />

D2780 9 CROWN 3/4 CAST HI NOBLE MET 0.00<br />

D2781 1 CROWN 3/4 CAST BASE METAL 0.00<br />

D2782 1 CROWN 3/4 CAST NOBLE METAL 0.00<br />

D2783 9 CROWN 3/4 PORCELAIN/CERAMIC 0.00<br />

D2790 9 CROWN FULL CAST HIGH NOBLE M 0.00<br />

D2791 1 CROWN FULL CAST BASE METAL 0.00<br />

D2792 1 CROWN FULL CAST NOBLE METAL 0.00<br />

D2794 9 CROWN-TITANIUM 0.00

---

D2799 1 PROVISIONAL CROWN 0.00<br />

D2810 9 CROWN 3/4 CAST METALLIC 0.00<br />

D2910 1 RECEMENT INLAY ONLAY OR PART 0.00<br />

D2915 1 RECEMENT CAST OR PREFAB POST 0.00<br />

D2920 1 <strong>DE</strong>NTAL RECEMENT CROWN 0.00<br />

D2930 1 PREFAB STNLSS STEEL CRWN PRI 0.00<br />

D2931 1 PREFAB STNLSS STEEL CROWN PE 0.00<br />

D2932 1 PREFABRICATED RESIN CROWN 0.00<br />

D2933 1 PREFAB STAINLESS STEEL CROWN 0.00<br />

D2934 1 PREFAB STEEL CROWN PRIMARY 0.00<br />

D2940 1 <strong>DE</strong>NTAL SEDATIVE FILLING 0.00<br />

D2950 1 CORE BUILD-UP INCL ANY PINS 0.00<br />

D2951 1 TOOTH PIN RETENTION 0.00<br />

D2952 1 POST AND CORE CAST + CROWN 0.00<br />

D2953 1 EACH ADDTNL CAST POST 0.00<br />

D2954 1 PREFAB POST/CORE + CROWN 0.00<br />

D2955 1 POST REMOVAL 0.00<br />

D2957 1 EACH ADDTNL PREFAB POST 0.00<br />

D2960 9 LAMINATE LABIAL VENEER 0.00<br />

D2961 9 LAMINATE LABIAL VENEER 0.00<br />

D2962 9 LAMINATE LABIAL VENEER 0.00<br />

D2970 1 TEMPORARY- FRACTURED TOOTH 0.00<br />

D2971 9 ADD PROC CONSTRUCT NEW CROWN 0.00<br />

D2975 9 COPING 0.00<br />

D2980 1 CROWN REPAIR 0.00<br />

D2999 1 <strong>DE</strong>NTAL UNSPEC RESTORATIVE PR 0.00<br />

D3110 1 PULP CAP DIRECT 0.00<br />

D3120 1 PULP CAP INDIRECT 0.00<br />

D3220 1 THERAPEUTIC PULPOTOMY 0.00<br />

D3221 1 GROSS PULPAL <strong>DE</strong>BRI<strong>DE</strong>MENT 0.00<br />

D3222 1 PART PULP FOR APEXOGENESIS 0.00<br />

D3230 1 PULPAL THERAPY ANTERIOR PRIM 0.00<br />

D3240 1 PULPAL THERAPY POSTERIOR PRI 0.00<br />

D3310 1 END THXPY, ANTERIOR TOOTH 0.00<br />

D3320 1 END THXPY, BICUSPID TOOTH 0.00<br />

D3330 1 END THXPY, MOLAR 0.00<br />

D3331 9 NON-SURG TX ROOT CANAL OBS 0.00<br />

D3332 1 INCOMPLETE ENDODONTIC TX 0.00<br />

D3333 1 INTERNAL ROOT REPAIR 0.00<br />

D3340 9 FOUR OR MORE CANALS (EXCLUDING FINA 0.00<br />

D3346 1 RETREAT ROOT CANAL ANTERIOR 0.00<br />

D3347 1 RETREAT ROOT CANAL BICUSPID 0.00<br />

D3348 1 RETREAT ROOT CANAL MOLAR 0.00<br />

D3350 9 APEXIFICATION (PER TREATMENT VISIT) 0.00<br />

D3351 1 APEXIFICATION/RECALC INITIAL 0.00<br />

D3352 1 APEXIFICATION/RECALC INTERIM 0.00<br />

D3353 1 APEXIFICATION/RECALC FINAL 0.00<br />

D3410 1 APICOECT/PERIRAD SURG ANTER 0.00<br />

D3411 9 APICOECTOMY (PER TOOTH) - EACH ADDI 0.00<br />

D3421 1 ROOT SURGERY BICUSPID 0.00

---

D3425 1 ROOT SURGERY MOLAR 0.00<br />

D3426 1 ROOT SURGERY EA ADD ROOT 0.00<br />

D3430 1 RETROGRA<strong>DE</strong> FILLING 0.00<br />

D3440 9 APICAL CURETTAGE 0.00<br />

D3450 1 ROOT AMPUTATION 0.00<br />

D3460 9 ENDODONTIC ENDOSSEOUS IMPLAN 0.00<br />

D3470 1 INTENTIONAL REPLANTATION 0.00<br />

D3910 1 ISOLATION- TOOTH W RUBB DAM 0.00<br />

D3920 9 TOOTH SPLITTING 0.00<br />

D3940 9 RECALCIFICATION OR REPAIR (PERFORAT 0.00<br />

D3950 9 CANAL PREP/FITTING OF DOWEL 0.00<br />

D3960 9 BLEACHING OF DISCOLORED TOOT 0.00<br />

D3999 1 ENDODONTIC PROCEDURE 0.00<br />

D4210 1 GINGIVECTOMY/PLASTY PER QUAD 0.00<br />

D4211 1 GINGIVECTOMY/PLASTY PER TOOT 0.00<br />

D4220 O GINGIVAL CURETTAGE PER QUADR 0.00<br />

D4230 1 ANA CROWN EXP 4 OR> PER QUAD 0.00<br />

D4231 1 ANA CROWN EXP 1-3 PER QUAD 0.00<br />

D4240 1 GINGIVAL FLAP PROC W/ PLANIN 0.00<br />

D4241 1 GNGVL FLAP W ROOTPLAN 1-3 TH 0.00<br />

D4245 1 APICALLY POSITIONED FLAP 0.00<br />

D4249 1 CROWN LENGTHEN HARD TISSUE 0.00<br />

D4260 1 OSSEOUS SURGERY PER QUADRANT 0.00<br />

D4261 1 OSSEOUS SURGL-3TEETHPERQUAD 0.00<br />

D4262 O BONE REPLACEMENT GRAFT-MULTIPLE SIT 0.00<br />

D4263 1 BONE REPLCE GRAFT FIRST SITE 0.00<br />

D4264 1 BONE REPLCE GRAFT EACH ADD 0.00<br />

D4265 1 BIO MTRLS TO AID SOFT/OS REG 0.00<br />

D4266 1 GUI<strong>DE</strong>D TISS REGEN RESORBLE 0.00<br />

D4267 1 GUI<strong>DE</strong>D TISS REGEN NONRESORB 0.00<br />

D4268 1 SURGICAL REVISION PROCEDURE 0.00<br />

D4270 1 PEDICLE SOFT TISSUE GRAFT PR 0.00<br />

D4271 1 FREE SOFT TISSUE GRAFT PROC 0.00<br />

D4272 9 APICALLY REPOSITIONING FLAP PROCEDU 0.00<br />

D4273 1 SUBEPITHELIAL TISSUE GRAFT 0.00<br />

D4274 1 DISTAL/PROXIMAL WEDGE PROC 0.00<br />

D4275 1 SOFT TISSUE ALLOGRAFT 0.00<br />

D4276 1 CON TISSUE W DBLE PED GRAFT 0.00<br />

D4320 1 PROVISION SPLNT INTRACORONAL 0.00<br />

D4321 1 PROVISIONAL SPLINT EXTRACORO 0.00<br />

D4340 9 PERIODONTAL SCALING AND ROOT PLANIN 0.00<br />

D4341 1 PERIODONTAL SCALING & ROOT 0.00<br />

D4342 1 PERIODONTAL SCALING 1-3TEETH 0.00<br />

D4355 1 FULL MOUTH <strong>DE</strong>BRI<strong>DE</strong>MENT 0.00<br />

D4381 1 LOCALIZED <strong>DE</strong>LIVERY ANTIMICRO 0.00<br />

D4910 1 PERIODONTAL MAINT PROCEDURES 0.00<br />

D4920 1 UNSCHEDULED DRESSING CHANGE 0.00<br />

D4999 1 UNSPECIFIED PERIODONTAL PROC 0.00<br />

D5110 1 <strong>DE</strong>NTURES COMPLETE MAXILLARY 0.00<br />

D5120 1 <strong>DE</strong>NTURES COMPLETE MANDIBLE 0.00

---

D5130 1 <strong>DE</strong>NTURES IMMEDIAT MAXILLARY 0.00<br />

D5140 1 <strong>DE</strong>NTURES IMMEDIAT MANDIBLE 0.00<br />

D5211 1 <strong>DE</strong>NTURES MAXILL PART RESIN 0.00<br />

D5212 1 <strong>DE</strong>NTURES MAND PART RESIN 0.00<br />

D5213 1 <strong>DE</strong>NTURES MAXILL PART METAL 0.00<br />

D5214 1 <strong>DE</strong>NTURES MANDIBL PART METAL 0.00<br />

D5215 9 UPPER PARTIAL - HIGH NOBLE CAST BAS 0.00<br />

D5216 9 LOWER PARTIAL - HIGH NOBLE CAST BAS 0.00<br />

D5225 1 MAXILLARY PART <strong>DE</strong>NTURE FLEX 0.00<br />

D5226 1 MANDIBULAR PART <strong>DE</strong>NTURE FLEX 0.00<br />

D5280 9 REMOVABLE UNILATERAL PARTIAL <strong>DE</strong>NTUR 0.00<br />

D5281 9 REMOVABLE PARTIAL <strong>DE</strong>NTURE 0.00<br />

D5410 1 <strong>DE</strong>NTURES ADJUST CMPLT MAXIL 0.00<br />

D5411 1 <strong>DE</strong>NTURES ADJUST CMPLT MAND 0.00<br />

D5421 1 <strong>DE</strong>NTURES ADJUST PART MAXILL 0.00<br />

D5422 1 <strong>DE</strong>NTURES ADJUST PART MANDBL 0.00<br />

D5510 1 <strong>DE</strong>NTUR REPR BROKEN COMPL BAS 0.00<br />

D5520 1 REPLACE <strong>DE</strong>NTURE TEETH COMPLT 0.00<br />

D5610 1 <strong>DE</strong>NTURES REPAIR RESIN BASE 0.00<br />

D5620 1 REP PART <strong>DE</strong>NTURE CAST FRAME 0.00<br />

D5630 1 REP PARTIAL <strong>DE</strong>NTURE CLASP 0.00<br />

D5640 1 REPLACE PART <strong>DE</strong>NTURE TEETH 0.00<br />

D5650 1 ADD TOOTH TO PARTIAL <strong>DE</strong>NTURE 0.00<br />

D5660 1 ADD CLASP TO PARTIAL <strong>DE</strong>NTURE 0.00<br />

D5670 1 REPLC TTH&ACRLC ON MTL FRMWK 0.00<br />

D5671 1 REPLC TTH&ACRLC MANDIBULAR 0.00<br />

D5710 9 <strong>DE</strong>NTURES REBASE CMPLT MAXIL 0.00<br />

D5711 9 <strong>DE</strong>NTURES REBASE CMPLT MAND 0.00<br />

D5720 9 <strong>DE</strong>NTURES REBASE PART MAXILL 0.00<br />

D5721 9 <strong>DE</strong>NTURES REBASE PART MANDBL 0.00<br />

D5730 1 <strong>DE</strong>NTURE RELN CMPLT MAXIL CH 0.00<br />

D5731 1 <strong>DE</strong>NTURE RELN CMPLT MAND CHR 0.00<br />

D5740 1 <strong>DE</strong>NTURE RELN PART MAXIL CHR 0.00<br />

D5741 1 <strong>DE</strong>NTURE RELN PART MAND CHR 0.00<br />

D5750 1 <strong>DE</strong>NTURE RELN CMPLT MAX LAB 0.00<br />

D5751 1 <strong>DE</strong>NTURE RELN CMPLT MAND LAB 0.00<br />

D5760 1 <strong>DE</strong>NTURE RELN PART MAXIL LAB 0.00<br />

D5761 1 <strong>DE</strong>NTURE RELN PART MAND LAB 0.00<br />

D5810 1 <strong>DE</strong>NTURE INTERM CMPLT MAXILL 0.00<br />

D5811 1 <strong>DE</strong>NTURE INTERM CMPLT MANDBL 0.00<br />

D5820 1 <strong>DE</strong>NTURE INTERM PART MAXILL 0.00<br />

D5821 1 <strong>DE</strong>NTURE INTERM PART MANDBL 0.00<br />

D5850 1 <strong>DE</strong>NTURE TISS CONDITN MAXILL 0.00<br />

D5851 1 <strong>DE</strong>NTURE TISS CONDTIN MANDBL 0.00<br />

D5860 9 OVER<strong>DE</strong>NTURE COMPLETE 0.00<br />

D5861 9 OVER<strong>DE</strong>NTURE PARTIAL 0.00<br />

D5862 9 PRECISION ATTACHMENT 0.00<br />

D5867 9 REPLACEMENT OF PRECISION ATT 0.00<br />

D5875 9 PROSTHESIS MODIFICATION 0.00<br />

D5899 1 REMOVABLE PROSTHODONTIC PROC 0.00

---

D5911 1 FACIAL MOULAGE SECTIONAL 0.00<br />

D5912 1 FACIAL MOULAGE COMPLETE 0.00<br />

D5913 1 NASAL PROSTHESIS 0.00<br />

D5914 1 AURICULAR PROSTHESIS 0.00<br />

D5915 1 ORBITAL PROSTHESIS 0.00<br />

D5916 1 OCULAR PROSTHESIS 0.00<br />

D5917 9 COMPOSITE FACIAL PROSTHESIS 0.00<br />

D5918 9 REPLACEMENT PROSTHESIS 0.00<br />

D5919 1 FACIAL PROSTHESIS 0.00<br />

D5920 9 OCULAR IMPLANT 0.00<br />

D5921 9 ORBITAL IMPLANT 0.00<br />

D5922 1 NASAL SEPTAL PROSTHESIS 0.00<br />

D5923 1 OCULAR PROSTHESIS INTERIM 0.00<br />

D5924 1 CRANIAL PROSTHESIS 0.00<br />

D5925 1 FACIAL AUGMENTATION IMPLANT 0.00<br />

D5926 1 REPLACEMENT NASAL PROSTHESIS 0.00<br />

D5927 1 AURICULAR REPLACEMENT 0.00<br />

D5928 1 ORBITAL REPLACEMENT 0.00<br />

D5929 1 FACIAL REPLACEMENT 0.00<br />

D5931 1 SURGICAL OBTURATOR 0.00<br />

D5932 1 POSTSURGICAL OBTURATOR 0.00<br />

D5933 1 REFITTING OF OBTURATOR 0.00<br />

D5934 1 MANDIBULAR FLANGE PROSTHESIS 0.00<br />

D5935 1 MANDIBULAR <strong>DE</strong>NTURE PROSTH 0.00<br />

D5936 1 TEMP OBTURATOR PROSTHESIS 0.00<br />

D5937 1 TRISMUS APPLIANCE 0.00<br />

D5951 1 FEEDING AID 0.00<br />

D5952 1 PEDIATRIC SPEECH AID 0.00<br />

D5953 1 ADULT SPEECH AID 0.00<br />

D5954 1 SUPERIMPOSED PROSTHESIS 0.00<br />

D5955 1 PALATAL LIFT PROSTHESIS 0.00<br />

D5956 9 OBTURATOR 0.00<br />

D5957 9 SPEECH BULB 0.00<br />

D5958 1 INTRAORAL CON <strong>DE</strong>F INTER PLT 0.00<br />

D5959 1 INTRAORAL CON <strong>DE</strong>F MOD PALAT 0.00<br />

D5960 1 MODIFY SPEECH AID PROSTHESIS 0.00<br />

D5971 9 SIMPLE IMPLANT 0.00<br />

D5972 9 COMPLEX IMPLANT 0.00<br />

D5973 9 SUBPERIOSTEAL IMPLANT 0.00<br />

D5974 9 ENDOSSEOUS IMPLANT (IN THE BONE) 0.00<br />

D5976 9 MANDIBULAR STAPLE IMPLANT 0.00<br />

D5982 9 SURGICAL STENT 0.00<br />

D5983 9 RADIATION APPLICATOR 0.00<br />

D5984 9 RADIATION SHIELD 0.00<br />

D5985 9 RADIATION CONE LOCATOR 0.00<br />

D5986 1 FLUORI<strong>DE</strong> APPLICATOR 0.00<br />

D5987 1 COMMISSURE SPLINT 0.00<br />

D5988 1 SURGICAL SPLINT 0.00<br />

D5991 1 TOPICAL MEDICAMENT CARRIER 0.00<br />

D5999 1 MAXILLOFACIAL PROSTHESIS 0.00

---

D6010 9 ODONTICS ENDOSTEAL IMPLANT 0.00<br />

D6012 9 ENDOSTEAL IMPLANT 0.00<br />

D6020 O ODONTICS ABUTMENT PLACEMENT 0.00<br />

D6040 9 SURGICAL PLACEMENT:EPOSTEAL IMPLAN 0.00<br />

D6050 9 SURGICAL PLACEMENT TRANSOSTEAL 0.00<br />

D6053 9 IMPLNT/ABTMNT SPPRT REMV DNT 0.00<br />

D6054 9 IMPLNT/ABTMNT SPPRT REMVPRTL 0.00<br />

D6055 9 <strong>DE</strong>NTAL IMPLANT SUPPORTED BAR 0.00<br />

D6056 9 PREFABRICATED ABUTMENT 0.00<br />

D6057 9 CUSTOM ABUTMENT 0.00<br />

D6058 9 ABUTMENT SUPPORTED CROWN 0.00<br />

D6059 9 ABUTMENT SUPPORTED MTL CROWN 0.00<br />

D6060 9 ABUTMENT SUPPORTED MTL CROWN 0.00<br />

D6061 9 ABUTMENT SUPPORTED MTL CROWN 0.00<br />

D6062 9 ABUTMENT SUPPORTED MTL CROWN 0.00<br />

D6063 9 ABUTMENT SUPPORTED MTL CROWN 0.00<br />

D6064 9 ABUTMENT SUPPORTED MTL CROWN 0.00<br />

D6065 9 IMPLANT SUPPORTED CROWN 0.00<br />

D6066 9 IMPLANT SUPPORTED MTL CROWN 0.00<br />

D6067 9 IMPLANT SUPPORTED MTL CROWN 0.00<br />

D6068 9 ABUTMENT SUPPORTED RETAINER 0.00<br />

D6069 9 ABUTMENT SUPPORTED RETAINER 0.00<br />

D6070 9 ABUTMENT SUPPORTED RETAINER 0.00<br />

D6071 9 ABUTMENT SUPPORTED RETAINER 0.00<br />

D6072 9 ABUTMENT SUPPORTED RETAINER 0.00<br />

D6073 9 ABUTMENT SUPPORTED RETAINER 0.00<br />

D6074 9 ABUTMENT SUPPORTED RETAINER 0.00<br />

D6075 9 IMPLANT SUPPORTED RETAINER 0.00<br />

D6076 9 IMPLANT SUPPORTED RETAINER 0.00<br />

D6077 9 IMPLANT SUPPORTED RETAINER 0.00<br />

D6078 9 IMPLNT/ABUT SUPRTD FIXD <strong>DE</strong>NT 0.00<br />

D6079 9 IMPLNT/ABUT SUPRTD FIXD <strong>DE</strong>NT 0.00<br />

D6080 9 IMPLANT MAINTENANCE PROCEDURES INC 0.00<br />

D6090 9 REPAIR IMPLANT SUPPORTED PROSTHESI 0.00<br />

D6091 9 REPL SEMI/PRECISION ATTACH 0.00<br />

D6092 9 RECEMENT SUPP CROWN 0.00<br />

D6093 9 RECEMENT SUPP PART <strong>DE</strong>NTURE 0.00<br />

D6094 9 ABUT SUPPORT CROWN TITANIUM 0.00<br />

D6095 9 ODONTICS REPR ABUTMENT 0.00<br />

D6100 9 IMPLANT REMOVAL, BY REPORT. 0.00<br />

D6190 9 RADIO/SURGICAL IMPLANT IN<strong>DE</strong>X 0.00<br />

D6194 9 ABUT SUPPORT RETAINER TITANI 0.00<br />

D6199 9 UNSPECIFIED IMPLANT PROCEDURE, BY 0.00<br />

D6205 9 PONTIC-INDIRECT RESIN BASED 0.00<br />

D6210 9 PROSTHODONT HIGH NOBLE METAL 0.00<br />

D6211 1 BRIDGE BASE METAL CAST 0.00<br />

D6212 1 BRIDGE NOBLE METAL CAST 0.00<br />

D6214 9 PONTIC TITANIUM 0.00<br />

D6240 9 BRIDGE PORCELAIN HIGH NOBLE 0.00<br />

D6241 1 BRIDGE PORCELAIN BASE METAL 0.00

---

D6242 1 BRIDGE PORCELAIN NOBEL METAL 0.00<br />

D6245 9 BRIDGE PORCELAIN/CERAMIC 0.00<br />

D6250 9 BRIDGE RESIN W/HIGH NOBLE 0.00<br />

D6251 1 BRIDGE RESIN BASE METAL 0.00<br />

D6252 1 BRIDGE RESIN W/NOBLE METAL 0.00<br />

D6253 9 PROVISIONAL PONTIC 0.00<br />

D6519 9 INLAY/ONLAY PORCE/CERAMIC 0.00<br />

D6520 9 <strong>DE</strong>NTAL RETAINER TWO SURFACES 0.00<br />

D6530 9 RETAINER METALLIC 3+ SURFACE 0.00<br />

D6540 O ONLAY-METALLIC-PER TOOTH (IN ADDITI 0.00<br />

D6543 9 <strong>DE</strong>NTAL RETAINR ONLAY 3 SURF 0.00<br />

D6544 9 <strong>DE</strong>NTAL RETAINR ONLAY 4/MORE 0.00<br />

D6545 1 <strong>DE</strong>NTAL RETAINR CAST METL 0.00<br />

D6548 9 PORCELAIN/CERAMIC RETAINER 0.00<br />

D6600 9 PORCELAIN/CERAMIC INLAY 2SRF 0.00<br />

D6601 9 PORC/CERAM INLAY >= 3 SURFAC 0.00<br />

D6602 9 CST HGH NBLE MTL INLAY 2 SRF 0.00<br />

D6603 9 CST HGH NBLE MTL INLAY >=3SR 0.00<br />

D6604 9 CST BSE MTL INLAY 2 SURFACES 0.00<br />

D6605 9 CST BSE MTL INLAY >= 3 SURFA 0.00<br />

D6606 9 CAST NOBLE METAL INLAY 2 SUR 0.00<br />

D6607 9 CST NOBLE MTL INLAY >=3 SURF 0.00<br />

D6608 9 ONLAY PORC/CRMC 2 SURFACES 0.00<br />

D6609 9 ONLAY PORC/CRMC >=3 SURFACES 0.00<br />

D6610 9 ONLAY CST HGH NBL MTL 2 SRFC 0.00<br />

D6611 9 ONLAY CST HGH NBL MTL >=3SRF 0.00<br />

D6612 9 ONLAY CST BASE MTL 2 SURFACE 0.00<br />

D6613 9 ONLAY CST BASE MTL >=3 SURFA 0.00<br />

D6614 9 ONLAY CST NBL MTL 2 SURFACES 0.00<br />

D6615 9 ONLAY CST NBL MTL >=3 SURFAC 0.00<br />

D6624 9 INLAY TITANIUM 0.00<br />

D6634 9 ONLAY TITANIUM 0.00<br />

D6710 9 CROWN-INDIRECT RESIN BASED 0.00<br />

D6720 9 RETAIN CROWN RESIN W HI NBLE 0.00<br />

D6721 1 CROWN RESIN W/BASE METAL 0.00<br />

D6722 1 CROWN RESIN W/NOBLE METAL 0.00<br />

D6740 9 CROWN PORCELAIN/CERAMIC 0.00<br />

D6750 9 CROWN PORCELAIN HIGH NOBLE 0.00<br />

D6751 1 CROWN PORCELAIN BASE METAL 0.00<br />

D6752 1 CROWN PORCELAIN NOBLE METAL 0.00<br />

D6780 9 CROWN 3/4 HIGH NOBLE METAL 0.00<br />

D6781 9 CROWN 3/4 CAST BASED METAL 0.00<br />

D6782 9 CROWN 3/4 CAST NOBLE METAL 0.00<br />

D6783 9 CROWN 3/4 PORCELAIN/CERAMIC 0.00<br />

D6790 9 CROWN FULL HIGH NOBLE METAL 0.00<br />

D6791 1 CROWN FULL BASE METAL CAST 0.00<br />

D6792 1 CROWN FULL NOBLE METAL CAST 0.00<br />

D6793 9 PROVISIONAL RETAINER CROWN 0.00<br />

D6794 9 CROWN TITANIUM 0.00<br />

D6920 9 <strong>DE</strong>NTAL CONNECTOR BAR 0.00

---

D6930 1 <strong>DE</strong>NTAL RECEMENT BRIDGE 0.00<br />

D6940 9 STRESS BREAKER 0.00<br />

D6950 9 PRECISION ATTACHMENT 0.00<br />

D6970 9 POST & CORE PLUS RETAINER 0.00<br />

D6971 O CAST POST BRIDGE RETAINER 0.00<br />

D6972 1 PREFAB POST & CORE PLUS RETA 0.00<br />

D6973 9 CORE BUILD UP FOR RETAINER, INCLUD 0.00<br />

D6975 9 COPING METAL 0.00<br />

D6976 9 EACH ADDTNL CAST POST 0.00<br />

D6977 9 EACH ADDTL PREFAB POST 0.00<br />

D6980 1 BRIDGE REPAIR 0.00<br />

D6985 1 PEDIATRIC PARTIAL <strong>DE</strong>NTURE FX 0.00<br />

D6999 1 FIXED PROSTHODONTIC PROC 0.00<br />

D7110 O ORAL SURGERY SINGLE TOOTH 0.00<br />

D7111 1 EXTRACTION CORONAL REMNANTS 0.00<br />

D7120 O EACH ADD TOOTH EXTRACTION 0.00<br />

D7130 O TOOTH ROOT REMOVAL 0.00<br />

D7140 1 EXTRACTION ERUPTED TOOTH/EXR 0.00<br />

D7210 1 REM IMP TOOTH W MUCOPER FLP 0.00<br />

D7220 1 IMPACT TOOTH REMOV SOFT TISS 0.00<br />

D7230 1 IMPACT TOOTH REMOV PART BONY 0.00<br />

D7240 1 IMPACT TOOTH REMOV COMP BONY 0.00<br />

D7241 1 IMPACT TOOTH REM BONY W/COMP 0.00<br />

D7250 1 TOOTH ROOT REMOVAL 0.00<br />

D7260 1 ORAL ANTRAL FISTULA CLOSURE 0.00<br />

D7261 1 PRIMARY CLOSURE SINUS PERF 0.00<br />

D7270 1 TOOTH REIMPLANTATION 0.00<br />

D7271 O TOOTH IMPLANTATION 0.00<br />

D7272 1 TOOTH TRANSPLANTATION 0.00<br />

D7280 1 EXPOSURE IMPACT TOOTH ORTHOD 0.00<br />

D7281 O EXPOSURE TOOTH AID ERUPTION 0.00<br />

D7282 1 MOBILIZE ERUPTED/MALPOS TOOT 0.00<br />

D7283 1 PLACE <strong>DE</strong>VICE IMPACTED TOOTH 0.00<br />

D7285 9 BIOPSY OF ORAL TISSUE HARD 0.00<br />

D7286 9 BIOPSY OF ORAL TISSUE SOFT 0.00<br />

D7287 9 EXFOLIATIVE CYTOLOG COLLECT 0.00<br />

D7288 9 BRUSH BIOPSY 0.00<br />

D7290 1 REPOSITIONING OF TEETH 0.00<br />

D7291 1 TRANSSEPTAL FIBEROTOMY 0.00<br />

D7292 9 SCREW RETAINED PLATE 0.00<br />

D7293 9 TEMP ANCHORAGE <strong>DE</strong>V W FLAP 0.00<br />

D7294 9 TEMP ANCHORAGE <strong>DE</strong>V W/O FLAP 0.00<br />

D7310 1 ALVEOPLASTY W/ EXTRACTION 0.00<br />

D7311 1 ALVEOLOPLASTY W/EXTRACT 1-3 0.00<br />

D7320 1 ALVEOPLASTY W/O EXTRACTION 0.00<br />

D7321 1 ALVEOLOPLASTY NOT W/EXTRACTS 0.00<br />

D7340 1 VESTIBULOPLASTY RIDGE EXTENS 0.00<br />

D7350 1 VESTIBULOPLASTY EXTEN GRAFT 0.00<br />

D7410 9 RAD EXC LESION UP TO 1.25 CM 0.00<br />

D7411 9 EXCISION BENIGN LESION>1.25C 0.00

---

D7412 9 EXCISION BENIGN LESION COMPL 0.00<br />

D7413 9 EXCISION MALIG LESION1.25CM 0.00<br />

D7415 9 EXCISION MALIG LES COMPLICAT 0.00<br />

D7420 9 LESION > 1.25 CM 0.00<br />

D7430 9 EXC BENIGN TUMOR TO 1.25 CM 0.00<br />

D7431 9 BENIGN TUMOR EXC > 1.25 CM 0.00<br />

D7440 9 MALIG TUMOR EXC TO 1.25 CM 0.00<br />

D7441 9 MALIG TUMOR > 1.25 CM 0.00<br />

D7450 9 REM ODONTOGEN CYST TO 1.25CM 0.00<br />

D7451 9 REM ODONTOGEN CYST > 1.25 CM 0.00<br />

D7460 9 REM NONODONTO CYST TO 1.25CM 0.00<br />

D7461 9 REM NONODONTO CYST > 1.25 CM 0.00<br />

D7465 9 LESION <strong>DE</strong>STRUCTION 0.00<br />

D7470 9 REM EXOSTOSIS MAXILLA/MANDIB 0.00<br />

D7471 9 REM EXOSTOSIS ANY SITE 0.00<br />

D7472 9 REMOVAL OF TORUS PALATINUS 0.00<br />

D7473 9 REMOVE TORUS MANDIBULARIS 0.00<br />

D7480 9 PARTIAL OSTECTOMY 0.00<br />

D7485 9 SURG REDUCT OSSEOUSTUBEROSIT 0.00<br />

D7490 9 MAXILLA OR MANDIBLE RESECTIO 0.00<br />

D7510 1 I&D ABSC INTRAORAL SOFT TISS 0.00<br />

D7511 1 INCISION/DRAIN ABSCESS INTRA 0.00<br />

D7520 1 I&D ABSCESS EXTRAORAL 0.00<br />

D7521 1 INCISION/DRAIN ABSCESS EXTRA 0.00<br />

D7530 1 REMOVAL FB SKIN/AREOLAR TISS 0.00<br />

D7540 1 REMOVAL OF FB REACTION 0.00<br />

D7550 1 REMOVAL OF SLOUGHED OFF BONE 0.00<br />

D7560 1 MAXILLARY SINUSOTOMY 0.00<br />

D7610 9 MAXILLA OPEN REDUCT SIMPLE 0.00<br />

D7620 9 CLSD REDUCT SIMPL MAXILLA FX 0.00<br />

D7630 9 OPEN RED SIMPL MANDIBLE FX 0.00<br />

D7640 9 CLSD RED SIMPL MANDIBLE FX 0.00<br />

D7650 9 OPEN RED SIMP MALAR/ZYGOM FX 0.00<br />

D7660 9 CLSD RED SIMP MALAR/ZYGOM FX 0.00<br />

D7670 9 CLOSD RDUCTN SPLINT ALVEOLUS 0.00<br />

D7671 9 ALVEOLUS OPEN REDUCTION 0.00<br />

D7680 9 REDUCT SIMPLE FACIAL BONE FX 0.00<br />

D7710 9 MAXILLA OPEN REDUCT COMPOUND 0.00<br />

D7720 9 CLSD REDUCT COMPD MAXILLA FX 0.00<br />

D7730 9 OPEN REDUCT COMPD MANDBLE FX 0.00<br />

D7740 9 CLSD REDUCT COMPD MANDBLE FX 0.00<br />

D7750 9 OPEN RED COMP MALAR/ZYGMA FX 0.00<br />

D7760 9 CLSD RED COMP MALAR/ZYGMA FX 0.00<br />

D7770 9 OPEN REDUC COMPD ALVEOLUS FX 0.00<br />

D7771 9 ALVEOLUS CLSD REDUC STBLZ TE 0.00<br />

D7780 9 REDUCT COMPND FACIAL BONE FX 0.00<br />

D7810 9 TMJ OPEN REDUCT-DISLOCATION 0.00<br />

D7820 9 CLOSED TMP MANIPULATION 0.00<br />

D7830 9 TMJ MANIPULATION UN<strong>DE</strong>R ANEST 0.00

---

D7840 9 REMOVAL OF TMJ CONDYLE 0.00<br />

D7850 9 TMJ MENISCECTOMY 0.00<br />

D7852 9 DISC REPAIR 0.00<br />

D7854 9 SYNOVECTOMY 0.00<br />

D7856 9 MYOTOMY 0.00<br />

D7858 9 JOINT RECONSTRUCTION 0.00<br />

D7860 9 TMJ CUTTING INTO JOINT 0.00<br />

D7865 9 ARTHROPLASTY 0.00<br />

D7870 9 TMJ ASPIRATION JOINT FLUID 0.00<br />

D7871 9 LYSIS + LAVAGE W CATHETERS 0.00<br />

D7872 9 ARTHROSCOPY- DIAGNOSIS WITH 0.00<br />

D7873 9 ARTHOSCOPY- SURGICAL: LAVAGE AND 0.00<br />

D7874 9 ARTHROSCOPY- SURGICAL: DISC REPOSI 0.00<br />

D7875 9 ARTHROSCOPY- SURGICAL: SYNOVECTOMY 0.00<br />

D7876 9 ARTHROSCOPY- SURGICAL: DISCECTOMY 0.00<br />

D7877 9 ARTHROSCOPY- SURGICAL <strong>DE</strong>BRI<strong>DE</strong>MENT 0.00<br />

D7880 1 OCCLUSAL ORTHOTIC APPLIANCE 0.00<br />

D7899 1 TMJ UNSPECIFIED THERAPY 0.00<br />

D7910 1 <strong>DE</strong>NT SUTUR RECENT WND TO 5CM 0.00<br />

D7911 1 <strong>DE</strong>NTAL SUTURE WOUND TO 5 CM 0.00<br />

D7912 1 SUTURE COMPLICATE WND > 5 CM 0.00<br />

D7920 9 <strong>DE</strong>NTAL SKIN GRAFT 0.00<br />

D7940 9 RESHAPING BONE ORTHOGNATHIC 0.00<br />

D7941 9 BONE CUTTING RAMUS CLOSED 0.00<br />

D7942 9 BONE CUTTING RAMUS OPEN 0.00<br />

D7943 9 CUTTING RAMUS OPEN W/GRAFT 0.00<br />

D7944 9 BONE CUTTING SEGMENTED 0.00<br />

D7945 9 BONE CUTTING BODY MANDIBLE 0.00<br />

D7946 9 RECONSTRUCTION MAXILLA TOTAL 0.00<br />

D7947 9 RECONSTRUCT MAXILLA SEGMENT 0.00<br />

D7948 9 RECONSTRUCT MIDFACE NO GRAFT 0.00<br />

D7949 9 RECONSTRUCT MIDFACE W/GRAFT 0.00<br />

D7950 9 MANDIBLE GRAFT 0.00<br />

D7951 9 SINUS AUG W BONE/BONE SUP 0.00<br />

D7953 9 BONE REPLACEMENT GRAFT 0.00<br />

D7955 9 REPAIR MAXILLOFACIAL <strong>DE</strong>FECTS 0.00<br />

D7960 1 FRENULECTOMY/FRENULOTOMY 0.00<br />

D7963 1 FRENULOPLASTY 0.00<br />

D7970 1 EXCISION HYPERPLASTIC TISSUE 0.00<br />

D7971 1 EXCISION PERICORONAL GINGIVA 0.00<br />

D7972 9 SURG REDCT FIBROUS TUBEROSIT 0.00<br />

D7980 9 SIALOLITHOTOMY 0.00<br />

D7981 9 EXCISION OF SALIVARY GLAND 0.00<br />

D7982 9 SIALODOCHOPLASTY 0.00<br />

D7983 9 CLOSURE OF SALIVARY FISTULA 0.00<br />

D7990 9 EMERGENCY TRACHEOTOMY 0.00<br />

D7991 9 <strong>DE</strong>NTAL CORONOI<strong>DE</strong>CTOMY 0.00<br />

D7992 9 EMINENECTOMY 0.00<br />

D7993 O IMPLANT-FACIAL BONES (HOMOLOGOUS, H 0.00<br />

D7994 O IMPLANT-OTHER THAN FACIAL BONES 0.00

---

D7995 9 SYNTHETIC GRAFT FACIAL BONES 0.00<br />

D7996 9 IMPLANT MANDIBLE FOR AUGMENT 0.00<br />

D7997 1 APPLIANCE REMOVAL 0.00<br />

D7998 9 INTRAORAL PLACE OF FIX <strong>DE</strong>V 0.00<br />

D7999 1 ORAL SURGERY PROCEDURE 0.00<br />

D8010 1 LIMITED <strong>DE</strong>NTAL TX PRIMARY 0.00<br />

D8020 1 LIMITED <strong>DE</strong>NTAL TX TRANSITION 0.00<br />

D8030 1 LIMITED <strong>DE</strong>NTAL TX ADOLESCENT 0.00<br />

D8040 1 LIMITED <strong>DE</strong>NTAL TX ADULT 0.00<br />

D8050 1 INTERCEP <strong>DE</strong>NTAL TX PRIMARY 0.00<br />

D8060 1 INTERCEP <strong>DE</strong>NTAL TX TRANSITN 0.00<br />

D8070 1 COMPRE <strong>DE</strong>NTAL TX TRANSITION 0.00<br />

D8080 3 COMPRE <strong>DE</strong>NTAL TX ADOLESCENT 1,585.00<br />

D8090 1 COMPRE <strong>DE</strong>NTAL TX ADULT 0.00<br />

D8110 O REMOVABLE APPLIANCE THERAPY 0.00<br />

D8120 O FIXED APPLIANCE THERAPY 0.00<br />

D8210 1 ORTHODONTIC REM APPLIANCE TX 0.00<br />

D8220 1 FIXED APPLIANCE THERAPY HABT 0.00<br />

D8360 O REMOVABLE APPLIANCE THERAPY 0.00<br />

D8370 O FIXED APPLIANCE THERAPY 0.00<br />

D8460 O CLASS I MALOCCLUSION 0.00<br />

D8470 O CLASS II MALOCCLUSION 0.00<br />

D8480 O CLASS III MALOCCLUSION 0.00<br />

D8560 O CLASS I MALOCCLUSION 0.00<br />

D8570 O CLASS II MALOCCLUSION 0.00<br />

D8580 O CLASS III MALOCCLUSION 0.00<br />

D8650 O TREATMENT OF THE ATYPICAL OR EXTEND 0.00<br />

D8660 3 PREORTHODONTIC TX VISIT 225.00<br />

D8670 3 PERIODIC ORTHODONTC TX VISIT 465.00<br />

D8680 1 ORTHODONTIC RETENTION 0.00<br />

D8690 1 ORTHODONTIC TREATMENT 0.00<br />

D8691 1 REPAIR ORTHO APPLIANCE 0.00<br />

D8692 1 REPLACEMENT RETAINER 0.00<br />

D8693 9 REBOND/CEMENT/REPAIR RETAIN 0.00<br />

D8750 O POST-TREATMENT STABILIZATION 0.00<br />

D8999 1 ORTHODONTIC PROCEDURE 0.00<br />

D9110 1 TX <strong>DE</strong>NTAL PAIN MINOR PROC 0.00<br />

D9120 1 FIX PARTIAL <strong>DE</strong>NTURE SECTION 0.00<br />

D9210 1 <strong>DE</strong>NT ANESTHESIA W/O SURGERY 0.00<br />

D9211 9 REGIONAL BLOCK ANESTHESIA 0.00<br />

D9212 9 TRIGEMINAL BLOCK ANESTHESIA 0.00<br />

D9215 9 LOCAL ANESTHESIA 0.00<br />

D9220 1 GENERAL ANESTHESIA 0.00<br />

D9221 1 GENERAL ANESTHESIA EA AD 15M 0.00<br />

D9230 1 ANALGESIA 0.00<br />

D9240 9 INTRAVENOUS SEDATION 0.00<br />

D9241 1 INTRAVENOUS SEDATION 0.00<br />

D9242 1 IV SEDATION EA AD 30 M 0.00<br />

D9248 1 SEDATION (NON-IV) 0.00<br />

D9310 1 <strong>DE</strong>NTAL CONSULTATION 0.00

---

D9410 9 <strong>DE</strong>NTAL HOUSE CALL 0.00<br />

D9420 9 HOSPITAL CALL 0.00<br />

D9430 9 OFFICE VISIT DURING HOURS 0.00<br />

D9440 1 OFFICE VISIT AFTER HOURS 0.00<br />

D9450 9 CASE PRESENTATION TX PLAN 0.00<br />

D9610 1 <strong>DE</strong>NT THERAPEUTIC DRUG INJECT 0.00<br />

D9612 1 THERA PAR DRUGS 2 OR > ADMIN 0.00<br />

D9630 9 OTHER DRUGS/MEDICAMENTS 0.00<br />

D9910 1 <strong>DE</strong>NT APPL <strong>DE</strong>SENSITIZING MED 0.00<br />

D9911 1 APPL <strong>DE</strong>SENSITIZING RESIN 0.00<br />

D9920 1 BEHAVIOR MANAGEMENT 0.00<br />

D9930 1 TREATMENT OF COMPLICATIONS 0.00<br />

D9940 1 <strong>DE</strong>NTAL OCCLUSAL GUARD 0.00<br />

D9941 9 FABRICATION ATHLETIC GUARD 0.00<br />

D9942 9 REPAIR/RELINE OCCLUSAL GUARD 0.00<br />

D9950 9 OCCLUSION ANALYSIS 0.00<br />

D9951 9 LIMITED OCCLUSAL ADJUSTMENT 0.00<br />

D9952 9 COMPLETE OCCLUSAL ADJUSTMENT 0.00<br />

D9960 9 COMPLETION OF CLAIM FORM 0.00<br />

D9970 9 ENAMEL MICROABRASION 0.00<br />

D9971 9 ODONTOPLASTY 1-2 TEETH 0.00<br />

D9972 9 EXTRNL BLEACHING PER ARCH 0.00<br />

D9973 9 EXTRNL BLEACHING PER TOOTH 0.00<br />

D9974 9 INTRNL BLEACHING PER TOOTH 0.00<br />

D9999 1 ADJUNCTIVE PROCEDURE 0.00<br />

DCD03 O MCO SPECIFIC CO<strong>DE</strong>: <strong>DE</strong>VELOPMENTAL CE 0.00<br />

DCP01 O MCO SPECIFIC CO<strong>DE</strong>: PARENT INFANT PR 0.00<br />

DCT02 O MCO SPECIFIC CO<strong>DE</strong>: TODDLER PROGRAM 0.00<br />

E0100 3 CANE ADJUST/FIXED WITH TIP 20.16<br />

E0105 3 CANE ADJUST/FIXED QUAD/3 PRO 46.99<br />

E0110 3 CRUTCH FOREARM PAIR 69.54<br />

E0111 3 CRUTCH FOREARM EACH 50.95<br />

E0112 3 CRUTCH UN<strong>DE</strong>RARM PAIR WOOD 35.40<br />

E0113 3 CRUTCH UN<strong>DE</strong>RARM EACH WOOD 20.21<br />

E0114 3 CRUTCH UN<strong>DE</strong>RARM PAIR NO WOOD 45.15<br />

E0116 3 CRUTCH UN<strong>DE</strong>RARM EACH NO WOOD 22.76<br />

E0117 5 UN<strong>DE</strong>RARM SPRINGASSIST CRUTCH 0.00<br />

E0118 6 CRUTCH SUBSTITUTE 0.00<br />

E0130 3 WALKER RIGID ADJUST/FIXED HT 57.13<br />

E0135 3 WALKER FOLDING ADJUST/FIXED 77.57<br />

E0140 6 WALKER W TRUNK SUPPORT 0.00<br />

E0141 3 RIGID WHEELED WALKER ADJ/FIX 110.30<br />

E0142 O WALKER RIGID WHEELED WITH SE 0.00<br />

E0143 3 WALKER FOLDING WHEELED W/O S 115.02<br />

E0144 3 ENCLOSED WALKER W REAR SEAT 304.66<br />

E0145 O WALKER WHLED SEAT/CRUTCH ATT 0.00<br />

E0146 O FOLDING WALKER WHEELS W SEAT 0.00<br />

E0147 3 WALKER VARIABLE WHEEL RESIST 549.91<br />

E0148 3 HEAVYDUTY WALKER NO WHEELS 121.55<br />

E0149 3 HEAVY DUTY WHEELED WALKER 213.53

---

E0150 9 UN<strong>DE</strong>RARM PAD, CRUTCH, REPLACEMENT, 0.00<br />

E0151 9 HANDGRIP, CANE, CRUTCH, OR WALKER R 0.00<br />

E0152 9 TIP, CANE OR CRUTCH WALKER REPLACEM 0.00<br />

E0153 3 FOREARM CRUTCH PLATFORM ATTA 66.38<br />

E0154 3 WALKER PLATFORM ATTACHMENT 66.38<br />

E0155 3 WALKER WHEEL ATTACHMENT,PAIR 30.20<br />

E0156 3 WALKER SEAT ATTACHMENT 25.29<br />

E0157 3 WALKER CRUTCH ATTACHMENT 66.61<br />

E0158 3 WALKER LEG EXTEN<strong>DE</strong>RS SET OF4 30.78<br />

E0159 9 BRAKE FOR WHEELED WALKER 0.00<br />

E0160 3 SITZ TYPE BATH OR EQUIPMENT 31.62<br />

E0161 3 SITZ BATH/EQUIPMENT W/FAUCET 25.09<br />

E0162 3 SITZ BATH CHAIR 139.39<br />

E0163 3 COMMO<strong>DE</strong> CHAIR WITH FIXED ARM 98.08<br />

E0164 O COMMO<strong>DE</strong> CHAIR MOBILE FIXED A 0.00<br />

E0165 3 COMMO<strong>DE</strong> CHAIR WITH <strong>DE</strong>TACHARM 144.20<br />

E0166 O COMMO<strong>DE</strong> CHAIR MOBILE <strong>DE</strong>TACH 0.00<br />

E0167 3 COMMO<strong>DE</strong> CHAIR PAIL OR PAN 10.11<br />

E0168 3 HEAVYDUTY/WI<strong>DE</strong> COMMO<strong>DE</strong> CHAIR 144.38<br />

E0169 O SEATLIFT INCORP COMMO<strong>DE</strong>CHAIR 0.00<br />

E0170 6 COMMO<strong>DE</strong> CHAIR ELECTRIC 0.00<br />

E0171 6 COMMO<strong>DE</strong> CHAIR NON-ELECTRIC 0.00<br />

E0172 6 SEAT LIFT MECHANISM TOILET 0.00<br />

E0175 3 COMMO<strong>DE</strong> CHAIR FOOT REST 53.86<br />

E0176 O AIR PRESSRE PAD/CUSHION NONP 0.00<br />

E0177 O WATER PRESS PAD/CUSHION NONP 0.00<br />

E0178 O GEL PRESSRE PAD/CUSHION NONP 0.00<br />

E0179 O DRY PRESSRE PAD/CUSHION NONP 0.00<br />

E0180 O PRESS PAD ALTERNATING W PUMP 0.00<br />

E0181 3 PRESS PAD ALTERNATING W/ PUM 304.20<br />

E0182 3 REPLACE PUMP, ALT PRESS PAD 235.90<br />

E0183 9 FLOTATION PAD FOR WHEELCHAIR 0.00<br />

E0184 3 DRY PRESSURE MATTRESS 186.27<br />

E0185 3 GEL PRESSURE MATTRESS PAD 306.01<br />

E0186 3 AIR PRESSURE MATTRESS 182.80<br />

E0187 3 WATER PRESSURE MATTRESS 209.20<br />

E0188 3 SYNTHETIC SHEEPSKIN PAD 23.85<br />

E0189 3 LAMBSWOOL SHEEPSKIN PAD 36.30<br />

E0190 6 POSITIONING CUSHION 0.00<br />

E0191 3 PROTECTOR HEEL OR ELBOW 9.56<br />

E0192 O PAD WHEELCHR LOW PRESS/POSIT 0.00<br />

E0193 3 POWERED AIR FLOTATION BED 6,956.30<br />

E0194 3 AIR FLUIDIZED BED 0.00<br />

E0195 9 REPLACEMENT PAD FOR USE WITH MEDICA 0.00<br />

E0196 3 GEL PRESSURE MATTRESS 287.60<br />

E0197 3 AIR PRESSURE PAD FOR MATTRES 211.98<br />

E0198 3 WATER PRESSURE PAD FOR MATTR 211.98<br />

E0199 3 DRY PRESSURE PAD FOR MATTRES 30.66<br />

E0200 3 HEAT LAMP WITHOUT STAND 75.85<br />

E0202 3 PHOTOTHERAPY LIGHT W/ PHOTOM 564.10

---

E0203 5 THERAPEUTIC LIGHTBOX TABLETP 0.00<br />

E0205 3 HEAT LAMP WITH STAND 157.81<br />

E0210 3 ELECTRIC HEAT PAD STANDARD 31.22<br />

E0215 3 ELECTRIC HEAT PAD MOIST 67.77<br />

E0217 3 WATER CIRC HEAT PAD W PUMP 403.72<br />

E0218 9 WATER CIRC COLD PAD W PUMP 0.00<br />

E0220 3 HOT WATER BOTTLE 6.89<br />

E0221 5 INFRARED HEATING PAD SYSTEM 0.00<br />

E0225 3 HYDROCOLLATOR UNIT 316.04<br />

E0230 3 ICE CAP OR COLLAR 6.89<br />

E0231 5 WOUND WARMING <strong>DE</strong>VICE 0.00<br />

E0232 5 WARMING CARD FOR NWT 0.00<br />

E0235 3 PARAFFIN BATH UNIT PORTABLE 155.40<br />

E0236 3 PUMP FOR WATER CIRCULATING P 358.90<br />

E0237 O WATER CIRCULATING HEAT/COLD PAD WIT 0.00<br />

E0238 3 HEAT PAD NON-ELECTRIC MOIST 25.87<br />

E0239 3 HYDROCOLLATOR UNIT PORTABLE 430.35<br />

E0240 6 BATH/SHOWER CHAIR 0.00<br />

E0241 5 BATH TUB WALL RAIL 0.00<br />

E0242 5 BATH TUB RAIL FLOOR 0.00<br />

E0243 5 TOILET RAIL 0.00<br />

E0244 5 TOILET SEAT RAISED 0.00<br />

E0245 5 TUB STOOL OR BENCH 0.00<br />

E0246 5 TRANSFER TUB RAIL ATTACHMENT 0.00<br />

E0247 6 TRANS BENCH W/WO COMM OPEN 0.00<br />

E0248 6 HDTRANS BENCH W/WO COMM OPEN 0.00<br />

E0249 3 PAD WATER CIRCULATING HEAT U 95.29<br />

E0250 3 HOSP BED FIXED HT W/ MATTRES 880.70<br />

E0251 3 HOSP BED FIXD HT W/O MATTRES 667.40<br />

E0252 9 HOSPITAL BED, FIXED HEIGHT, WITH MA 0.00<br />

E0255 3 HOSPITAL BED VAR HT W/ MATTR 1,058.30<br />

E0256 3 HOSPITAL BED VAR HT W/O MATT 706.90<br />

E0260 3 HOSP BED SEMI-ELECTR W/ MATT 1,512.70<br />

E0261 3 HOSP BED SEMI-ELECTR W/O MAT 1,233.60<br />

E0265 3 HOSP BED TOTAL ELECTR W/ MAT 1,800.70<br />

E0266 3 HOSP BED TOTAL ELEC W/O MATT 1,359.80<br />

E0270 9 HOSPITAL BED INSTITUTIONAL T 0.00<br />

E0271 3 MATTRESS INNERSPRING 212.42<br />

E0272 3 MATTRESS FOAM RUBBER 186.47<br />

E0273 5 BED BOARD 0.00<br />

E0274 5 OVER-BED TABLE 0.00<br />

E0275 3 BED PAN STANDARD 14.64<br />

E0276 3 BED PAN FRACTURE 12.73<br />

E0277 3 POWERED PRES-REDU AIR MATTRS 1.00<br />

E0280 3 BED CRADLE 35.40<br />

E0290 3 HOSP BED FX HT W/O RAILS W/M 673.30<br />

E0291 3 HOSP BED FX HT W/O RAIL W/O 489.00<br />

E0292 3 HOSP BED VAR HT W/O RAIL W/O 701.60<br />

E0293 3 HOSP BED VAR HT W/O RAIL W/ 644.30<br />

E0294 3 HOSP BED SEMI-ELECT W/ MATTR 1,177.20

---

E0295 3 HOSP BED SEMI-ELECT W/O MATT 1,147.10<br />

E0296 3 HOSP BED TOTAL ELECT W/ MATT 1,479.10<br />

E0297 3 HOSP BED TOTAL ELECT W/O MAT 1,077.10<br />

E0298 O HEAVYDUTY/XTRA WI<strong>DE</strong> HOSP BED 0.00<br />

E0300 6 ENCLOSED PED CRIB HOSP GRA<strong>DE</strong> 0.00<br />

E0301 6 HD HOSP BED, 350-600 LBS 0.00<br />

E0302 6 EX HD HOSP BED > 600 LBS 0.00<br />

E0303 6 HOSP BED HVY DTY XTRA WI<strong>DE</strong> 0.00<br />

E0304 6 HOSP BED XTRA HVY DTY X WI<strong>DE</strong> 0.00<br />

E0305 3 RAILS BED SI<strong>DE</strong> HALF LENGTH 160.00<br />

E0310 3 RAILS BED SI<strong>DE</strong> FULL LENGTH 185.74<br />

E0315 9 BED ACCESSORY BRD/TBL/SUPPRT 0.00<br />

E0316 5 BED SAFETY ENCLOSURE 0.00<br />

E0325 3 URINAL MALE JUG-TYPE 9.67<br />

E0326 3 URINAL FEMALE JUG-TYPE 9.48<br />

E0328 6 PED HOSPITAL BED, MANUAL 0.00<br />

E0329 6 PED HOSPITAL BED SEMI/ELECT 0.00<br />

E0350 9 CONTROL UNIT BOWEL SYSTEM 0.00<br />

E0352 9 DISPOSABLE PACK W/BOWEL SYST 0.00<br />

E0370 9 AIR ELEVATOR FOR HEEL 0.00<br />

E0371 5 NONPOWER MATTRESS OVERLAY 0.00<br />

E0372 3 POWERED AIR MATTRESS OVERLAY 0.00<br />

E0373 5 NONPOWERED PRESSURE MATTRESS 0.00<br />

E0400 O OXYGEN CONTENTS, GASEOUS, PER CUBIC 0.00<br />

E0405 O OXYGEN CONTENTS, GASEOUS, PER 100 C 0.00<br />

E0410 O OXYGEN CONTENTS, LIQUID, PER POUND 0.00<br />

E0415 O OXYGEN CONTENTS, LIQUID, PER 100 PO 0.00<br />

E0416 O OXYGEN REFILL FOR PORTABLE GASEOUS 0.00<br />

E0424 3 STATIONARY COMPRESSED GAS 02 1.00<br />

E0425 5 GAS SYSTEM STATIONARY COMPRE 0.00<br />

E0430 5 OXYGEN SYSTEM GAS PORTABLE 0.00<br />

E0431 3 PORTABLE GASEOUS 02 0.00<br />

E0434 3 PORTABLE LIQUID 02 1.00<br />

E0435 5 OXYGEN SYSTEM LIQUID PORTABL 0.00<br />

E0439 3 STATIONARY LIQUID 02 1.00<br />

E0440 5 OXYGEN SYSTEM LIQUID STATION 0.00<br />

E0441 3 OXYGEN CONTENTS, GASEOUS 148.00<br />

E0442 3 OXYGEN CONTENTS, LIQUID 148.00<br />

E0443 3 PORTABLE 02 CONTENTS, GAS 18.31<br />

E0444 3 PORTABLE 02 CONTENTS, LIQUID 18.31<br />

E0445 3 OXIMETER NON-INVASIVE 1.00<br />

E0450 3 VOL CONTROL VENT INVASIV INT 1.00<br />

E0451 O VOLUME VENTILATOR; PORTABLE (INCLUD 0.00<br />

E0452 O INTERMIT ASSIS <strong>DE</strong>VICE W CPAP 0.00<br />

E0453 9 VENTILATOR 12 HRS/LESS PER D 0.00<br />

E0454 O PRESSURE VENTILATOR 0.00<br />

E0455 O OXYGEN TENT EXCL CROUP/PED T 0.00<br />

E0457 3 CHEST SHELL 0.00<br />

E0458 9 NEGATIVE PRESSURE PUMP 0.00<br />

E0459 3 CHEST WRAP 458.40

---

E0460 O NEG PRESS VENT PORTABL/STATN 0.00<br />

E0461 5 VOL CONTROL VENT NONINV INT 0.00<br />

E0462 3 ROCKING BED W/ OR W/O SI<strong>DE</strong> R 2,625.00<br />

E0463 6 PRESS SUPP VENT INVASIVE INT 0.00<br />

E0464 6 PRESS SUPP VENT NONINV INT 0.00<br />

E0470 3 RAD W/O BACKUP NON-INV INTFC 0.00<br />

E0471 3 RAD W/BACKUP NON INV INTRFC 0.00<br />

E0472 6 RAD W BACKUP INVASIVE INTRFC 0.00<br />

E0480 3 PERCUSSOR ELECT/PNEUM HOME M 395.80<br />

E0481 5 INTRPULMNRY PERCUSS VENT SYS 0.00<br />

E0482 5 COUGH STIMULATING <strong>DE</strong>VICE 0.00<br />

E0483 5 CHEST COMPRESSION GEN SYSTEM 0.00<br />

E0484 3 NON-ELEC OSCILLATORY PEP DVC 36.92<br />

E0485 6 ORAL <strong>DE</strong>VICE/APPLIANCE PREFAB 0.00<br />

E0486 6 ORAL <strong>DE</strong>VICE/APPLIANCE CUSFAB 0.00<br />

E0487 6 ELECTRONIC SPIROMETER 0.00<br />

E0500 3 IPPB ALL TYPES 0.00<br />

E0505 9 IPPB MACHINES WITH MANUAL VALVES EL 0.00<br />

E0510 9 IPPB MACHINES WITH AUTOMATIC VALVES 0.00<br />

E0515 9 IPPB MACHINES WITH AUTOMATIC VALVES 0.00<br />

E0550 3 HUMIDIF EXTENS SUPPLE W IPPB 451.60<br />

E0555 9 HUMIDIFIER FOR USE W/ REGULA 0.00<br />

E0560 3 HUMIDIFIER SUPPLEMENTAL W/ I 164.09<br />

E0561 3 HUMIDIFIER NONHEATED W PAP 107.00<br />

E0562 3 HUMIDIFIER HEATED USED W PAP 301.22<br />

E0565 3 COMPRESSOR AIR POWER SOURCE 467.20<br />

E0570 3 NEBULIZER WITH COMPRESSION 177.80<br />

E0571 5 AEROSOL COMPRESSOR FOR SVNEB 0.00<br />

E0572 5 AEROSOL COMPRESSOR ADJUST PR 0.00<br />

E0574 5 ULTRASONIC GENERATOR W SVNEB 0.00<br />

E0575 3 NEBULIZER ULTRASONIC 530.00<br />

E0580 9 NEBULIZER FOR USE W/ REGULAT 0.00<br />

E0585 3 NEBULIZER W/ COMPRESSOR & HE 315.90<br />

E0590 O DISPENSING FEE DME NEB DRUG 0.00<br />

E0600 3 SUCTION PUMP PORTAB HOM MODL 1.00<br />

E0601 3 CONT AIRWAY PRESSURE <strong>DE</strong>VICE 0.00<br />

E0602 9 MANUAL BREAST PUMP 0.00<br />

E0603 3 ELECTRIC BREAST PUMP 742.80<br />

E0604 5 HOSP GRA<strong>DE</strong> ELEC BREAST PUMP 0.00<br />

E0605 3 VAPORIZER ROOM TYPE 25.29<br />

E0606 3 DRAINAGE BOARD POSTURAL 175.60<br />

E0607 9 BLOOD GLUCOSE MONITOR HOME 0.00<br />

E0608 O APNEA MONITOR 0.00<br />

E0609 O BLOOD GLUC MON W/SPECIAL FEA 0.00<br />

E0610 3 PACEMAKER MONITR AUDIBLE/VIS 227.56<br />

E0615 3 PACEMAKER MONITR DIGITAL/VIS 403.28<br />

E0616 9 CARDIAC EVENT RECOR<strong>DE</strong>R 0.00<br />

E0617 5 AUTOMATIC EXT <strong>DE</strong>FIBRILLATOR 0.00<br />

E0618 3 APNEA MONITOR 3,000.00<br />

E0619 3 APNEA MONITOR W RECOR<strong>DE</strong>R 1.00

---

E0620 9 CAP BLD SKIN PIERCING LASER 0.00<br />

E0621 3 PATIENT LIFT SLING OR SEAT 91.83<br />

E0625 5 PATIENT LIFT BATHROOM OR TOI 0.00<br />

E0627 3 SEAT LIFT INCORP LIFT-CHAIR 316.39<br />

E0628 3 SEAT LIFT FOR PT FURN-ELECTR 316.39<br />

E0629 3 SEAT LIFT FOR PT FURN-NON-EL 316.39<br />

E0630 3 PATIENT LIFT HYDRAULIC 917.70<br />

E0635 3 PATIENT LIFT ELECTRIC 936.90<br />

E0636 5 PT SUPPORT & POSITIONING SYS 0.00<br />

E0637 6 COMBINATION SIT TO STAND SYS 0.00<br />

E0638 6 STANDING FRAME SYS 0.00<br />

E0639 6 MOVEABLE PATIENT LIFT SYSTEM 0.00<br />

E0640 6 FIXED PATIENT LIFT SYSTEM 0.00<br />

E0641 6 MULTI-POSITION STND FRAM SYS 0.00<br />

E0642 6 DYNAMIC STANDING FRAME 0.00<br />

E0650 3 PNEUMA COMPRESOR NON-SEGMENT 689.02<br />

E0651 3 PNEUM COMPRESSOR SEGMENTAL 878.65<br />

E0652 3 PNEUM COMPRES W/CAL PRESSURE 5,012.71<br />

E0655 3 PNEUMATIC APPLIANCE HALF ARM 87.76<br />

E0656 6 SEGMENTAL PNEUMATIC TRUNK 0.00<br />

E0657 6 SEGMENTAL PNEUMATIC CHEST 0.00<br />

E0660 3 PNEUMATIC APPLIANCE FULL LEG 139.07<br />

E0665 3 PNEUMATIC APPLIANCE FULL ARM 111.40<br />

E0666 3 PNEUMATIC APPLIANCE HALF LEG 112.29<br />

E0667 3 SEG PNEUMATIC APPL FULL LEG 309.75<br />

E0668 3 SEG PNEUMATIC APPL FULL ARM 359.33<br />

E0669 3 SEG PNEUMATIC APPLI HALF LEG 166.53<br />

E0670 O SEGMENTAL PNEUMATIC APPLIANCE FOR U 0.00<br />

E0671 9 PRESSURE PNEUM APPL FULL LEG 0.00<br />

E0672 9 PRESSURE PNEUM APPL FULL ARM 0.00<br />

E0673 9 PRESSURE PNEUM APPL HALF LEG 0.00<br />

E0675 6 PNEUMATIC COMPRESSION <strong>DE</strong>VICE 0.00<br />

E0676 6 INTER LIMB COMPRESS <strong>DE</strong>V NOS 0.00<br />

E0690 O ULTRAVIOLET CABINET 0.00<br />

E0691 5 UVL PNL 2 SQ FT OR LESS 0.00<br />

E0692 5 UVL SYS PANEL 4 FT 0.00<br />

E0693 5 UVL SYS PANEL 6 FT 0.00<br />

E0694 5 UVL MD CABINET SYS 6 FT 0.00<br />

E0700 5 SAFETY EQUIPMENT 0.00<br />

E0701 O HELMET W FACE GUARD PREFAB 0.00<br />

E0705 6 TRANSFER <strong>DE</strong>VICE 0.00<br />

E0710 5 RESTRAINTS ANY TYPE 0.00<br />

E0720 3 TENS TWO LEAD 314.34<br />

E0730 3 TENS FOUR LEAD 354.51<br />

E0731 3 CONDUCTIVE GARMENT FOR TENS/ 341.24<br />

E0740 9 INCONTINENCE TREATMENT SYSTM 0.00<br />

E0744 3 NEUROMUSCULAR STIM FOR SCOLI 824.90<br />

E0745 3 NEUROMUSCULAR STIM FOR SHOCK 806.30<br />

E0746 O ELECTROMYOGRAPH BIOFEEDBACK 0.00<br />

E0747 3 ELEC OSTEOGEN STIM NOT SPINE 3,774.74

---

E0748 3 ELEC OSTEOGEN STIM SPINAL 3,890.70<br />

E0749 O ELEC OSTEOGEN STIM IMPLANTED 0.00<br />

E0750 O IMPLANTABLE ELECTRICAL NERVE STIMUL 0.00<br />

E0751 9 PULSE GENERATOR OR RECEIVER 0.00<br />

E0752 O NEUROSTIMULATOR ELECTRO<strong>DE</strong> 0.00<br />

E0753 9 NEUROSTIMULATOR ELECTRO<strong>DE</strong>S 0.00<br />

E0754 O PULSEGENERATOR PT PROGRAMMER 0.00<br />

E0755 5 ELECTRONIC SALIVARY REFLEX S 0.00<br />

E0756 O IMPLANTABLE PULSE GENERATOR 0.00<br />

E0757 O IMPLANTABLE RF RECEIVER 0.00<br />

E0758 O EXTERNAL RF TRANSMITTER 0.00<br />

E0759 O REPLACE RDFRQUNCY TRANSMITTR 0.00<br />

E0760 9 OSTEOGEN ULTRASOUND STIMLTOR 0.00<br />

E0761 5 NONTHERM ELECTROMGNTC <strong>DE</strong>VICE 0.00<br />

E0762 6 TRANS ELEC JT STIM <strong>DE</strong>V SYS 0.00<br />

E0764 6 FUNCTIONAL NEUROMUSCULARSTIM 0.00<br />

E0765 5 NERVE STIMULATOR FOR TX N&V 0.00<br />

E0769 6 ELECTRIC WOUND TREATMENT <strong>DE</strong>V 0.00<br />

E0770 6 FUNCTIONAL ELECTRIC STIM NOS 0.00<br />

E0776 3 IV POLE 136.96<br />

E0779 3 AMB INFUSION PUMP MECHANICAL 15.67<br />

E0780 3 MECH AMB INFUSION PUMP

---

E0943 O CERVICAL PILLOW 0.00<br />

E0944 3 PELVIC BELT/HARNESS/BOOT 43.89<br />

E0945 3 BELT/HARNESS EXTREMITY 42.41<br />

E0946 3 FRACTURE FRAME DUAL W CROSS 532.90<br />

E0947 3 FRACTURE FRAME ATTACHMNTS PE 580.20<br />

E0948 3 FRACTURE FRAME ATTACHMNTS CE 561.19<br />

E0950 3 TRAY 99.45<br />

E0951 3 LOOP HEEL 18.02<br />

E0952 3 TOE LOOP/HOL<strong>DE</strong>R, EACH 18.02<br />

E0953 O PNEUMATIC TIRE 0.00<br />

E0954 O WHEELCHAIR SEMI-PNEUMATIC CA 0.00<br />

E0955 6 CUSHIONED HEADREST 0.00<br />

E0956 6 W/C LATERAL TRUNK/HIP SUPPOR 0.00<br />

E0957 6 W/C MEDIAL THIGH SUPPORT 0.00<br />

E0958 3 WHLCHR ATT- CONV 1 ARM DRIVE 393.10<br />

E0959 3 AMPUTEE ADAPTER 84.59<br />

E0960 6 W/C SHOUL<strong>DE</strong>R HARNESS/STRAPS 0.00<br />

E0961 3 WHEELCHAIR BRAKE EXTENSION 27.82<br />

E0962 O WHEELCHAIR 1 INCH CUSHION 0.00<br />

E0963 O WHEELCHAIR 2 INCH CUSHION 0.00<br />

E0964 O WHEELCHAIR 3 INCH CUSHION 0.00<br />

E0965 O WHEELCHAIR 4 INCH CUSHION 0.00<br />

E0966 3 WHEELCHAIR HEAD REST EXTENSI 61.94<br />

E0967 3 MANUAL WC HAND RIM W PROJECT 126.41<br />

E0968 3 WHEELCHAIR COMMO<strong>DE</strong> SEAT 161.60<br />

E0969 3 WHEELCHAIR NARROWING <strong>DE</strong>VICE 139.86<br />

E0970 3 WHEELCHAIR NO. 2 FOOTPLATES 46.08<br />

E0971 3 WHEELCHAIR ANTI-TIPPING <strong>DE</strong>VI 62.90<br />

E0972 O TRANSFER BOARD OR <strong>DE</strong>VICE 0.00<br />

E0973 3 W/CH ACCESS <strong>DE</strong>T ADJ ARMREST 109.99<br />

E0974 3 W/CH ACCESS ANTI-ROLLBACK 75.59<br />

E0975 O WHEELCHAIR REINFORCED SEAT U 0.00<br />

E0976 O WHEELCHAIR REINFORCED BACK U 0.00<br />

E0977 O WHEELCHAIR WEDGE CUSHION 0.00<br />

E0978 3 W/C ACC,SAF BELT PELV STRAP 42.81<br />

E0979 O WHEELCHAIR BELT WITH VELCRO 0.00<br />

E0980 3 WHEELCHAIR SAFETY VEST 31.62<br />

E0981 6 SEAT UPHOLSTERY, REPLACEMENT 0.00<br />

E0982 6 BACK UPHOLSTERY, REPLACEMENT 0.00<br />

E0983 6 ADD PWR JOYSTICK 0.00<br />

E0984 6 ADD PWR TILLER 0.00<br />

E0985 6 W/C SEAT LIFT MECHANISM 0.00<br />

E0986 6 MAN W/C PUSH-RIM POW ASSIST 0.00<br />

E0990 3 WHELLCHAIR ELEVATING LEG RES 112.35<br />

E0991 O WHEELCHAIR UPHOLSTRY SEAT 0.00<br />

E0992 3 WHEELCHAIR SOLID SEAT INSERT 88.48<br />

E0993 O WHEELCHAIR BACK UPHOLSTERY 0.00<br />

E0994 3 WHEELCHAIR ARM REST 15.18<br />

E0995 3 WHEELCHAIR CALF REST 25.29<br />

E0996 O WHEELCHAIR TIRE SOLID 0.00

---

E0997 O WHEELCHAIR CASTER W/ A FORK 0.00<br />

E0998 O WHEELCHAIR CASTER W/O A FORK 0.00<br />

E0999 O WHEELCHR PNEUMATIC TIRE W/WH 0.00<br />

E1000 O WHEELCHAIR TIRE PNEUMATIC CA 0.00<br />

E1001 O WHEELCHAIR WHEEL 0.00<br />

E1002 6 PWR SEAT TILT 0.00<br />

E1003 6 PWR SEAT RECLINE 0.00<br />

E1004 6 PWR SEAT RECLINE MECH 0.00<br />

E1005 6 WHEELCHAIR ACCESSORY, POWER SEAT 0.00<br />

E1006 6 PWR SEAT COMBO W/O SHEAR 0.00<br />

E1007 3 PWR SEAT COMBO W/SHEAR 8,741.27<br />

E1008 3 PWR SEAT COMBO PWR SHEAR 8,742.05<br />

E1009 6 ADD MECH LEG ELEVATION 0.00<br />

E1010 6 ADD PWR LEG ELEVATION 0.00<br />

E1011 5 PED WC MODIFY WIDTH ADJUSTM 0.00<br />

E1012 O INT SEAT SYS PLANAR PED W/C 0.00<br />

E1013 O INT SEAT SYS CONTOUR PED W/C 0.00<br />

E1014 5 RECLINING BACK ADD PED W/C 0.00<br />

E1015 5 SHOCK ABSORBER FOR MAN W/C 0.00<br />

E1016 5 SHOCK ABSORBER FOR POWER W/C 0.00<br />

E1017 5 HD SHCK ABSRBR FOR HD MAN WC 0.00<br />

E1018 5 HD SHCK ABSRBER FOR HD POWWC 0.00<br />

E1019 O HD FEATURE POWER SEAT 0.00<br />

E1020 5 RESIDUAL LIMB SUPPORT SYSTEM 0.00<br />

E1021 O EX HD FEATURE POWER SEAT 0.00<br />

E1025 O PEDWC LAT/THOR SUP NOCONTOUR 0.00<br />

E1026 O PEDWC CONTOURED LAT/THOR SUP 0.00<br />

E1027 O PED WC LAT/ANT SUPPORT 0.00<br />

E1028 3 W/C MANUAL SWINGAWAY 206.54<br />

E1029 6 W/C VENT TRAY FIXED 0.00<br />

E1030 6 W/C VENT TRAY GIMBALED 0.00<br />

E1031 3 ROLLABOUT CHAIR WITH CASTERS 455.00<br />

E1035 5 PATIENT TRANSFER SYSTEM 0.00<br />

E1037 5 TRANSPORT CHAIR, PED SIZE 0.00<br />

E1038 5 TRANSPORT CHAIR PT WT300LB 0.00<br />

E1050 3 WHELCHR FXD FULL LENGTH ARMS 917.40<br />

E1060 3 WHEELCHAIR <strong>DE</strong>TACHABLE ARMS 1,135.60<br />

E1065 O WHEELCHAIR POWER ATTACHMENT 0.00<br />

E1066 O WHEELCHAIR BATTERY CHARGER 0.00<br />

E1069 O WHEELCHAIR <strong>DE</strong>EP CYCLE BATTER 0.00<br />

E1070 3 WHEELCHAIR <strong>DE</strong>TACHABLE FOOT R 838.60<br />

E1083 3 HEMI-WHEELCHAIR FIXED ARMS 709.40<br />

E1084 3 HEMI-WHEELCHAIR <strong>DE</strong>TACHABLE A 883.70<br />

E1085 3 HEMI-WHEELCHAIR FIXED ARMS 623.40<br />

E1086 3 HEMI-WHEELCHAIR <strong>DE</strong>TACHABLE A 757.10<br />

E1087 3 WHEELCHAIR LIGHTWT FIXED ARM 1,139.60<br />

E1088 3 WHEELCHAIR LIGHTWEIGHT <strong>DE</strong>T A 1,358.29<br />

E1089 3 WHEELCHAIR LIGHTWT FIXED ARM 1,082.80<br />

E1090 3 WHEELCHAIR LIGHTWEIGHT <strong>DE</strong>T A 1,042.60

---

E1091 3 WHEELCHAIR YOUTH 751.00<br />

E1092 3 WHEELCHAIR WI<strong>DE</strong> W/ LEG RESTS 1,157.70<br />

E1093 3 WHEELCHAIR WI<strong>DE</strong> W/ FOOT REST 995.60<br />

E1100 3 WHCHR S-RECL FXD ARM LEG RES 935.10<br />

E1110 3 WHEELCHAIR SEMI-RECL <strong>DE</strong>TACH 778.30<br />

E1130 3 WHLCHR STAND FXD ARM FT REST 420.70<br />

E1140 3 WHEELCHAIR STANDARD <strong>DE</strong>TACH A 647.00<br />

E1150 3 WHEELCHAIR STANDARD W/ LEG R 735.00<br />

E1160 3 WHEELCHAIR FIXED ARMS 563.00<br />

E1161 5 MANUAL ADULT WC W TILTINSPAC 0.00<br />

E1170 3 WHLCHR AMPU FXD ARM LEG REST 804.60<br />

E1171 3 WHEELCHAIR AMPUTEE W/O LEG R 643.40<br />

E1172 3 WHEELCHAIR AMPUTEE <strong>DE</strong>TACH AR 827.40<br />

E1180 3 WHEELCHAIR AMPUTEE W/ FOOT R 776.00<br />

E1190 3 WHEELCHAIR AMPUTEE W/ LEG RE 1,054.70<br />

E1195 3 WHEELCHAIR AMPUTEE HEAVY DUT 961.90<br />

E1200 3 WHEELCHAIR AMPUTEE FIXED ARM 689.20<br />

E1210 O WHLCHR MOTO FUL ARM LEG REST 0.00<br />

E1211 O WHEELCHAIR MOTORIZED W/ <strong>DE</strong>T 0.00<br />

E1212 O WHEELCHAIR MOTORIZED W FULL 0.00<br />

E1213 O WHEELCHAIR MOTORIZED W/ <strong>DE</strong>T 0.00<br />

E1220 5 WHLCHR SPECIAL SIZE/CONSTRC 0.00<br />

E1221 3 WHEELCHAIR SPEC SIZE W FOOT 428.10<br />

E1222 3 WHEELCHAIR SPEC SIZE W/ LEG 610.70<br />

E1223 3 WHEELCHAIR SPEC SIZE W FOOT 666.80<br />

E1224 3 WHEELCHAIR SPEC SIZE W/ LEG 731.10<br />

E1225 3 MANUAL SEMI-RECLINING BACK 407.20<br />

E1226 3 MANUAL FULLY RECLINING BACK 522.01<br />

E1227 3 WHEELCHAIR SPEC SZ SPEC HT A 265.23<br />

E1228 3 WHEELCHAIR SPEC SZ SPEC HT B 214.50<br />

E1229 6 PEDIATRIC WHEELCHAIR NOS 0.00<br />

E1230 3 POWER OPERATED VEHICLE 1,946.92<br />

E1231 5 RIGID PED W/C TILT-IN-SPACE 0.00<br />

E1232 5 FOLDING PED WC TILT-IN-SPACE 0.00<br />

E1233 5 RIG PED WC TLTNSPC W/O SEAT 0.00<br />

E1234 5 FLD PED WC TLTNSPC W/O SEAT 0.00<br />

E1235 5 RIGID PED WC ADJUSTABLE 0.00<br />

E1236 5 FOLDING PED WC ADJUSTABLE 0.00<br />

E1237 5 RGD PED WC ADJSTABL W/O SEAT 0.00<br />

E1238 5 FLD PED WC ADJSTABL W/O SEAT 0.00<br />

E1239 6 PED POWER WHEELCHAIR NOS 0.00<br />

E1240 3 WHCHR LITWT <strong>DE</strong>T ARM LEG REST 928.10<br />

E1250 3 WHEELCHAIR LIGHTWT FIXED ARM 684.70<br />

E1260 3 WHEELCHAIR LIGHTWT FOOT REST 713.70<br />

E1270 3 WHEELCHAIR LIGHTWEIGHT LEG R 604.40<br />

E1280 3 WHCHR H-DUTY <strong>DE</strong>T ARM LEG RES 1,005.00<br />

E1285 3 WHEELCHAIR HEAVY DUTY FIXED 923.50<br />

E1290 3 WHEELCHAIR HVY DUTY <strong>DE</strong>TACH A 958.20<br />

E1295 3 WHEELCHAIR HEAVY DUTY FIXED 1,046.20<br />

E1296 3 WHEELCHAIR SPECIAL SEAT HEIG 399.82

---

E1297 3 WHEELCHAIR SPECIAL SEAT <strong>DE</strong>PT 85.07<br />

E1298 3 WHEELCHAIR SPEC SEAT <strong>DE</strong>PTH/W 365.36<br />

E1300 5 WHIRLPOOL PORTABLE 0.00<br />

E1310 3 WHIRLPOOL NON-PORTABLE 2,054.39<br />

E1340 3 REPAIR FOR DME, PER 15 MIN 25.00<br />

E1350 O REPAIR OR NON-ROUTINE SERVICE (E.G. 0.00<br />

E1353 5 OXYGEN SUPPLIES REGULATOR 0.00<br />

E1354 6 WHEELED CART, PORT CYL/CONC 0.00<br />

E1355 3 OXYGEN SUPPLIES STAND/RACK 46.67<br />

E1356 O BREATHING CIRCUITS 0.00<br />

E1357 6 BATTERY CHARGER, PORT CONC 0.00<br />

E1358 6 DC POWER ADAPTER, PORT CONC 0.00<br />

E1372 3 OXY SUPPL HEATER FOR NEBULIZ 155.98<br />

E1375 O OXYGEN SUPPL NEBULIZER PORTA 0.00<br />

E1377 O OXYGEN CONCENTRATOR TO 244 C 0.00<br />

E1378 O OXYGEN CONCENTRATOR TO 488 C 0.00<br />

E1379 O OXYGEN CONCENTRATOR TO 732 C 0.00<br />

E1380 O OXYGEN CONCENTRATOR TO 976 C 0.00<br />

E1381 O OXYGEN CONCENTRAT TO 1220 CU 0.00<br />

E1382 O OXYGEN CONCENTRAT TO 1464 CU 0.00<br />

E1383 O OXYGEN CONCENTRAT TO 1708 CU 0.00<br />

E1384 O OXYGEN CONCENTRAT TO 1952 CU 0.00<br />

E1385 O OXYGEN CONCENTRATOR > 1952 C 0.00<br />

E1388 O OXYGEN CONCENTRATOR, EQUIVALENT TO 0.00<br />

E1389 O OXYGEN CONCENTRATOR, EQUIVALENT TO 0.00<br />

E1390 3 OXYGEN CONCENTRATOR 0.00<br />

E1391 6 OXYGEN CONCENTRATOR 0.00<br />

E1392 6 PORTABLE OXYGEN CONCENTRATOR 0.00<br />

E1393 O OXYGEN CONCENTRATOR, EQUIVALENT TO 0.00<br />

E1394 O OXYGEN CONCENTRATOR, EQUIVALENT TO 0.00<br />

E1395 O OXYGEN CONCENTRATOR, EQUIVALENT TO 0.00<br />

E1396 O OXYGEN CONCENTRATOR, EQUIVALENT TO 0.00<br />

E1399 3 DURABLE MEDICAL EQUIPMENT MI 325.00<br />

E1400 9 OXYGEN CONCENTRATOR < 2 LITE 0.00<br />

E1401 O OXYGEN CONCENTRATOR 2-3 LITE 0.00<br />

E1402 O OXYGEN CONCENTRATOR 3-4 LITE 0.00<br />

E1403 O OXYGEN CONCENTRATOR 4-5 LITE 0.00<br />

E1404 9 OXYGEN CONCENTRATOR > 5 LITE 0.00<br />

E1405 5 O2/WATER VAPOR ENRICH W/HEAT 0.00<br />

E1406 5 O2/WATER VAPOR ENRICH W/O HE 0.00<br />

E1500 9 CENTRIFUGE 0.00<br />

E1510 5 KIDNEY DIALYSATE <strong>DE</strong>LIVRY SYS 0.00<br />

E1520 5 HEPARIN INFUSION PUMP 0.00<br />

E1530 5 REPLACEMENT AIR BUBBLE <strong>DE</strong>TEC 0.00<br />

E1540 5 REPLACEMENT PRESSURE ALARM 0.00<br />

E1550 5 BATH CONDUCTIVITY METER 0.00<br />

E1560 5 REPLACE BLOOD LEAK <strong>DE</strong>TECTOR 0.00<br />

E1570 5 ADJUSTABLE CHAIR FOR ESRD PT 0.00<br />

E1575 5 TRANSDUCER PROTECT/FLD BAR 0.00<br />

E1580 5 UNIPUNCTURE CONTROL SYSTEM 0.00

---

E1590 5 HEMODIALYSIS MACHINE 0.00<br />

E1592 5 AUTO INTERM PERITONEAL DIALY 0.00<br />

E1594 5 CYCLER DIALYSIS MACHINE 0.00<br />

E1600 5 <strong>DE</strong>LI/INSTALL CHRG HEMO EQUIP 0.00<br />

E1610 5 REVERSE OSMOSIS H2O PURI SYS 0.00<br />

E1615 5 <strong>DE</strong>IONIZER H2O PURI SYSTEM 0.00<br />

E1620 5 REPLACEMENT BLOOD PUMP 0.00<br />

E1625 5 WATER SOFTENING SYSTEM 0.00<br />

E1630 5 RECIPROCATING PERITONEAL DIA 0.00<br />

E1632 5 WEARABLE ARTIFICIAL KIDNEY 0.00<br />

E1634 6 PERITONEAL DIALYSIS CLAMP 0.00<br />

E1635 5 COMPACT TRAVEL HEMODIALYZER 0.00<br />

E1636 5 SORBENT CARTRIDGES PER 10 0.00<br />

E1637 9 HEMOSTATS FOR DIALYSIS, EACH 0.00<br />

E1638 9 PERI DIALYSIS HEATING PAD 0.00<br />

E1639 9 DIALYSIS SCALE 0.00<br />

E1640 O REPLACEMENT COMPONENTS FOR D 0.00<br />

E1699 5 DIALYSIS EQUIPMENT NOC 0.00<br />

E1700 O JAW MOTION REHAB SYSTEM 0.00<br />

E1701 O REPL CUSHIONS FOR JAW MOTION 0.00<br />

E1702 O REPL MEASR SCALES JAW MOTION 0.00<br />

E1800 9 ADJUST ELBOW EXT/FLEX <strong>DE</strong>VICE 0.00<br />

E1801 9 SPS ELBOW <strong>DE</strong>VICE 0.00<br />

E1802 5 ADJST FOREARM PRO/SUP <strong>DE</strong>VICE 0.00<br />

E1805 9 ADJUST WRIST EXT/FLEX <strong>DE</strong>VICE 0.00<br />

E1806 9 SPS WRIST <strong>DE</strong>VICE 0.00<br />

E1810 9 ADJUST KNEE EXT/FLEX <strong>DE</strong>VICE 0.00<br />

E1811 9 SPS KNEE <strong>DE</strong>VICE 0.00<br />

E1812 6 KNEE EXT/FLEX W ACT RES CTRL 0.00<br />

E1815 9 ADJUST ANKLE EXT/FLEX <strong>DE</strong>VICE 0.00<br />

E1816 9 SPS ANKLE <strong>DE</strong>VICE 0.00<br />

E1818 9 SPS FOREARM <strong>DE</strong>VICE 0.00<br />

E1820 9 SOFT INTERFACE MATERIAL 0.00<br />

E1821 9 REPLACEMENT INTERFACE SPSD 0.00<br />

E1825 9 ADJUST FINGER EXT/FLEX <strong>DE</strong>VC 0.00<br />

E1830 9 ADJUST TOE EXT/FLEX <strong>DE</strong>VICE 0.00<br />

E1840 9 ADJ SHOUL<strong>DE</strong>R EXT/FLEX <strong>DE</strong>VICE 0.00<br />

E1841 6 STATIC STR SHLDR <strong>DE</strong>V ROM ADJ 0.00<br />

E1900 O SPEECH COMMUNICATION <strong>DE</strong>VICE 0.00<br />

E1902 5 AAC NON-ELECTRONIC BOARD 0.00<br />

E2000 3 GASTRIC SUCTION PUMP HME MDL 1.00<br />

E2100 5 BLD GLUCOSE MONITOR W VOICE 0.00<br />

E2101 5 BLD GLUCOSE MONITOR W LANCE 0.00<br />

E2120 6 PULSE GEN SYS TX ENDOLYMP FL 0.00<br />

E2201 6 MAN W/CH ACC SEAT W>=20"

---

E2207 6 CRUTCH AND CANE HOL<strong>DE</strong>R 0.00<br />

E2208 6 CYLIN<strong>DE</strong>R TANK CARRIER 0.00<br />

E2209 6 ARM TROUGH EACH 0.00<br />

E2210 6 WHEELCHAIR BEARINGS 0.00<br />

E2211 6 PNEUMATIC PROPULSION TIRE 0.00<br />

E2212 6 PNEUMATIC PROP TIRE TUBE 0.00<br />

E2213 6 PNEUMATIC PROP TIRE INSERT 0.00<br />

E2214 6 PNEUMATIC CASTER TIRE EACH 0.00<br />

E2215 6 PNEUMATIC CASTER TIRE TUBE 0.00<br />

E2216 6 FOAM FILLED PROPULSION TIRE 0.00<br />

E2217 6 FOAM FILLED CASTER TIRE EACH 0.00<br />

E2218 6 FOAM PROPULSION TIRE EACH 0.00<br />

E2219 6 FOAM CASTER TIRE ANY SIZE EA 0.00<br />

E2220 6 SOLID PROPULSION TIRE EACH 0.00<br />

E2221 6 SOLID CASTER TIRE EACH 0.00<br />

E2222 6 SOLID CASTER INTEGRATED WHL 0.00<br />

E2223 6 VALVE REPLACEMENT ONLY EACH 0.00<br />

E2224 6 PROPULSION WHL EXCLU<strong>DE</strong>S TIRE 0.00<br />

E2225 6 CASTER WHEEL EXCLU<strong>DE</strong>S TIRE 0.00<br />

E2226 6 CASTER FORK REPLACEMENT ONLY 0.00<br />

E2227 6 GEAR REDUCTION DRIVE WHEEL 0.00<br />

E2228 6 MWC ACC, WHEELCHAIR BRAKE 0.00<br />

E2230 6 MANUAL STANDING SYSTEM 0.00<br />

E2231 6 SOLID SEAT SUPPORT BASE 0.00<br />

E2291 6 PLANAR BACK FOR PED SIZE WC 0.00<br />

E2292 6 PLANAR SEAT FOR PED SIZE WC 0.00<br />

E2293 6 CONTOUR BACK FOR PED SIZE WC 0.00<br />

E2294 6 CONTOUR SEAT FOR PED SIZE WC 0.00<br />

E2295 6 PED DYNAMIC SEATING FRAME 0.00<br />

E2300 6 PWR SEAT ELEVATION SYS 0.00<br />

E2301 6 PWR STANDING 0.00<br />

E2310 6 ELECTRO CONNECT BTW CONTROL 0.00<br />

E2311 3 ELECTRO CONNECT BTW 2 SYS 2,369.20<br />

E2312 6 MINI-PROP REMOTE JOYSTICK 0.00<br />

E2313 6 PWC HARNESS, EXPAND CONTROL 0.00<br />

E2320 O HAND CHIN CONTROL 0.00<br />

E2321 6 HAND INTERFACE JOYSTICK 0.00<br />

E2322 6 MULT MECH SWITCHES 0.00<br />

E2323 6 SPECIAL JOYSTICK HANDLE 0.00<br />

E2324 6 CHIN CUP INTERFACE 0.00<br />

E2325 6 SIP AND PUFF INTERFACE 0.00<br />

E2326 6 BREATH TUBE KIT 0.00<br />

E2327 6 HEAD CONTROL INTERFACE MECH 0.00<br />

E2328 6 HEAD/EXTREMITY CONTROL INTER 0.00<br />

E2329 6 HEAD CONTROL NONPROPORTIONAL 0.00<br />

E2330 6 HEAD CONTROL PROXIMITY SWITC 0.00<br />

E2331 6 ATTENDANT CONTROL 0.00<br />

E2340 6 W/C WDTH 20-23 IN SEAT FRAME 0.00<br />

E2341 6 W/C WDTH 24-27 IN SEAT FRAME 0.00<br />

E2342 6 W/C DPTH 20-21 IN SEAT FRAME 0.00

---

E2343 6 W/C DPTH 22-25 IN SEAT FRAME 0.00<br />

E2351 6 ELECTRONIC SGD INTERFACE 0.00<br />

E2360 3 22NF NONSEALED LEADACID 112.34<br />

E2361 3 22NF SEALED LEADACID BATTERY 139.47<br />

E2362 3 GR24 NONSEALED LEADACID 91.98<br />

E2363 3 GR24 SEALED LEADACID BATTERY 186.00<br />

E2364 3 U1NONSEALED LEADACID BATTERY 112.34<br />

E2365 3 U1 SEALED LEADACID BATTERY 112.17<br />

E2366 3 BATTERY CHARGER, SINGLE MO<strong>DE</strong> 263.62<br />

E2367 3 BATTERY CHARGER, DUAL MO<strong>DE</strong> 419.07<br />

E2368 6 POWER WC MOTOR REPLACEMENT 0.00<br />

E2369 6 PWR WC GEAR BOX REPLACEMENT 0.00<br />

E2370 6 PWR WC MOTOR/GEAR BOX COMBO 0.00<br />

E2371 6 GR27 SEALED LEADACID BATTERY 0.00<br />

E2372 6 GR27 NON-SEALED LEADACID 0.00<br />

E2373 6 HAND/CHIN CTRL SPEC JOYSTICK 0.00<br />

E2374 6 HAND/CHIN CTRL STD JOYSTICK 0.00<br />

E2375 6 NON-EXPANDABLE CONTROLLER 0.00<br />

E2376 6 EXPANDABLE CONTROLLER, REPL 0.00<br />

E2377 6 EXPANDABLE CONTROLLER, INITL 0.00<br />

E2381 6 PNEUM DRIVE WHEEL TIRE 0.00<br />

E2382 6 TUBE, PNEUM WHEEL DRIVE TIRE 0.00<br />

E2383 6 INSERT, PNEUM WHEEL DRIVE 0.00<br />

E2384 6 PNEUMATIC CASTER TIRE 0.00<br />

E2385 6 TUBE, PNEUMATIC CASTER TIRE 0.00<br />

E2386 6 FOAM FILLED DRIVE WHEEL TIRE 0.00<br />

E2387 6 FOAM FILLED CASTER TIRE 0.00<br />

E2388 6 FOAM DRIVE WHEEL TIRE 0.00<br />

E2389 6 FOAM CASTER TIRE 0.00<br />

E2390 6 SOLID DRIVE WHEEL TIRE 0.00<br />

E2391 6 SOLID CASTER TIRE 0.00<br />

E2392 6 SOLID CASTER TIRE, INTEGRATE 0.00<br />

E2393 6 VALVE, PNEUMATIC TIRE TUBE 0.00<br />

E2394 6 DRIVE WHEEL EXCLU<strong>DE</strong>S TIRE 0.00<br />

E2395 6 CASTER WHEEL EXCLU<strong>DE</strong>S TIRE 0.00<br />

E2396 6 CASTER FORK 0.00<br />

E2397 6 PWC ACC, LITH-BASED BATTERY 0.00<br />

E2399 6 NOC INTERFACE 0.00<br />

E2402 6 NEG PRESS WOUND THERAPY PUMP 0.00<br />

E2500 6 SGD DIGITIZED PRE-REC 8MIN 20MIN 40 MIN 0.00<br />

E2508 6 SGD SPELLING PHYS CONTACT 0.00<br />

E2510 6 SGD W MULTI METHODS MSG/ACCS 0.00<br />

E2511 6 SGD SFTWRE PRGRM FOR PC/PDA 0.00<br />

E2512 6 SGD ACCESSORY, MOUNTING SYS 0.00<br />

E2599 6 SGD ACCESSORY NOC 0.00<br />

E2601 6 GEN W/C CUSHION WDTH < 22 IN 0.00<br />

E2602 6 GEN W/C CUSHION WDTH >=22 IN 0.00

---

E2603 6 SKIN PROTECT WC CUS WD =22IN 0.00<br />

E2605 6 POSITION WC CUSH WDTH =22 IN 0.00<br />

E2607 6 SKIN PRO/POS WC CUS WD =22IN 0.00<br />

E2609 6 CUSTOM FABRICATE W/C CUSHION 0.00<br />

E2610 6 POWERED W/C CUSHION 0.00<br />

E2611 6 GEN USE BACK CUSH WDTH =22IN 0.00<br />

E2613 6 POSITION BACK CUSH WD =22IN 0.00<br />

E2615 6 POS BACK POST/LAT WDTH =22IN 0.00<br />

E2617 6 CUSTOM FAB W/C BACK CUSHION 0.00<br />

E2618 O WC ACC SOLID SEAT SUPP BASE 0.00<br />

E2619 6 REPLACE COVER W/C SEAT CUSH 0.00<br />

E2620 6 WC PLANAR BACK CUSH WD =22IN 0.00<br />

E4610 9 LANCET <strong>DE</strong>VICE 0.00<br />

E8000 6 POSTERIOR GAIT TRAINER 0.00<br />

E8001 6 UPRIGHT GAIT TRAINER 0.00<br />

E8002 6 ANTERIOR GAIT TRAINER 0.00<br />

EDUCW O MCO SPECIFIC CO<strong>DE</strong>: SMART START INDI 0.00<br />

EDURN O MCO SPECIFIC CO<strong>DE</strong>: SMART START INDI 0.00<br />

EDUSW O MCO SPECIFIC CO<strong>DE</strong>: SMART START INDI 0.00<br />

EXRCL O MCO SPECIFIC CO<strong>DE</strong>: SMART START PRE 0.00<br />

FS001 O MCO SPECIFIC CO<strong>DE</strong>: FULL BABY FIRST 0.00<br />

FS002 O MCO SPECIFIC CO<strong>DE</strong>: LATE REFERRAL BA 0.00<br />

FS003 O MCO SPECIFIC CO<strong>DE</strong>: PARTIAL BABY FIR 0.00<br />

FS100 O MCO SPECIFIC CO<strong>DE</strong>: PREGNANT MOTHER 0.00<br />

FS104 O MCO SPECIFIC CO<strong>DE</strong>: SMART START, PRE 0.00<br />

FS105 O MCO SPECIFIC CO<strong>DE</strong>: SMART START, PRE 0.00<br />

FS106 O MCO SPECIFIC CO<strong>DE</strong>: SMART START, PRE 0.00<br />

FS107 O MCO SPECIFIC CO<strong>DE</strong>: SMART START, PRE 0.00<br />

FS108 O MCO SPECIFIC CO<strong>DE</strong>: SMART START, PRE 0.00<br />

FS109 O MCO SPECIFIC CO<strong>DE</strong>: SMART START, PRE 0.00<br />

FS110 O MCO SPECIFIC CO<strong>DE</strong>: RESOURCE MOTHER' 0.00<br />

FS111 O MCO SPECIFIC CO<strong>DE</strong>: RESOURCE MOTHER' 0.00<br />

FS112 O MCO SPECIFIC CO<strong>DE</strong>: RSEOURCE MOTHER' 0.00<br />

FS912 O MCO SPECIFIC CO<strong>DE</strong>: NEOCATE 1+, 100 0.00<br />

FS913 O MCO SPECIFIC CO<strong>DE</strong>: NEOCATE 1+, 8 OU 0.00<br />

G0001 O DRAWING BLOOD FOR SPECIMEN 0.00<br />

G0002 9 TEMPORARY URINARY CATHETER 0.00<br />

G0004 9 ECG TRANSM PHYS REVIEW & INT 0.00<br />

G0005 9 ECG 24 HOUR RECORDING 0.00<br />

G0006 9 ECG TRANSMISSION & ANALYSIS 0.00<br />

G0007 9 ECG PHY REVIEW & INTERPRET 0.00<br />

G0008 9 ADMIN INFLUENZA VIRUS VAC 0.00<br />

G0009 9 ADMIN PNEUMOCOCCAL VACCINE 0.00

---

G0010 9 ADMIN HEPATITIS B VACCINE 0.00<br />

G0015 9 POST SYMPTOM ECG TRACING 0.00<br />

G0016 9 POST SYMPTOM ECG MD REVIEW 0.00<br />

G0020 O IMPRESSION AND CUSTOM PREPARATION; 0.00<br />

G0021 O IMPRESSION AND CUSTOM PREPARATION; 0.00<br />

G0025 O COLLAGEN SKIN TEST KIT 0.00<br />

G0026 O FECAL LEUKOCYTE EXAMINATION 0.00<br />

G0027 9 SEMEN ANALYSIS 0.00<br />

G0030 O PET IMAGING PREV PET SINGLE 0.00<br />

G0031 O PET IMAGING PREV PET MULTPLE 0.00<br />

G0032 O PET FOLLOW SPECT 78464 SINGL 0.00<br />

G0033 O PET FOLLOW SPECT 78464 MULT 0.00<br />

G0034 O PET FOLLOW SPECT 76865 SINGL 0.00<br />

G0035 O PET FOLLOW SPECT 78465 MULT 0.00<br />

G0036 O PET FOLLOW CORNRY ANGIO SING 0.00<br />

G0037 O PET FOLLOW CORNRY ANGIO MULT 0.00<br />

G0038 O PET FOLLOW MYOCARD PERF SING 0.00<br />

G0039 O PET FOLLOW MYOCARD PERF MULT 0.00<br />

G0040 O PET FOLLOW STRESS ECHO SINGL 0.00<br />

G0041 O PET FOLLOW STRESS ECHO MULT 0.00<br />

G0042 O PET FOLLOW VENTRICULOGM SING 0.00<br />

G0043 O PET FOLLOW VENTRICULOGM MULT 0.00<br />

G0044 O PET FOLLOWING REST ECG SINGL 0.00<br />

G0045 O PET FOLLOWING REST ECG MULT 0.00<br />

G0046 O PET FOLLOW STRESS ECG SINGL 0.00<br />

G0047 O PET FOLLOW STRESS ECG MULT 0.00<br />

G0050 9 RESIDUAL URINE BY ULTRASOUND 0.00<br />

G0051 9 <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

G0052 9 <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

G0053 9 <strong>DE</strong>STRUCTION BY ANY METHOD, INCLUDIN 0.00<br />

G0054 O BLOOD CHOLESTEROL TEST, BY CHOLESTE 0.00<br />

G0055 O GLUCOSE POST DOSE (INCLU<strong>DE</strong>S GLUCOSE 0.00<br />

G0056 O GLUCOSE TOLERANCE TEST (GTT), BY DI 0.00<br />

G0057 O GLUCOSE TOLERANCE TEST (GTT), BY DI 0.00<br />

G0058 O AUTOMATED MULTICHANNEL TEST; 20 CLI 0.00<br />

G0059 O AUTOMATED MULTICHANNEL TEST; 21 CLI 0.00<br />

G0060 O AUTOMATED MULTICHANNEL TEST, 22 CLI 0.00<br />

G0061 O LUNG VOLUME REDUCTION SURGERY (REDU 0.00<br />

G0062 9 PERIPHERAL SKELETAL BONE MINERAL <strong>DE</strong> 0.00<br />

G0063 9 CENTRAL SKELETAL BONE MINERAL <strong>DE</strong>NSI 0.00<br />

G0064 9 PHYSICIAN SUPERVISION OF A PATIENT 0.00<br />

G0065 9 PHYSICIAN SUPERVISION OF A HOSPICE 0.00<br />

G0066 9 PHYSICIAN SUPERVISION OF A NURSING 0.00<br />

G0071 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0072 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0073 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0074 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0075 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0076 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0077 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00

---

G0078 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0079 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0080 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0081 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0082 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0083 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0084 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0085 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0086 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0087 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0088 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 0.00<br />

G0089 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0090 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0091 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0092 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0093 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0094 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 0.00<br />

G0101 9 CA SCREEN;PELVIC/BREAST EXAM 0.00<br />

G0102 9 PROSTATE CA SCREENING; DRE 0.00<br />

G0103 9 PSA, TOTAL SCREENING 0.00<br />

G0104 9 CA SCREEN;FLEXI SIGMOIDSCOPE 0.00<br />

G0105 9 COLORECTAL SCRN; HI RISK IND 0.00<br />

G0106 9 COLON CA SCREEN;BARIUM ENEMA 0.00<br />

G0107 O CA SCREEN; FECAL BLOOD TEST 0.00<br />

G0108 9 DIAB MANAGE TRN PER INDIV 0.00<br />

G0109 9 DIAB MANAGE TRN IND/GROUP 0.00<br />

G0110 O NETT PULM-REHAB EDUC; IND 0.00<br />

G0111 O NETT PULM-REHAB EDUC; GROUP 0.00<br />

G0112 O NETT;NUTRITION GUID, INITIAL 0.00<br />

G0113 O NETT;NUTRITION GUID,SUBSEQNT 0.00<br />

G0114 O NETT; PSYCHOSOCIAL CONSULT 0.00<br />

G0115 O NETT; PSYCHOLOGICAL TESTING 0.00<br />

G0116 O NETT; PSYCHOSOCIAL COUNSEL 0.00<br />

G0117 9 GLAUCOMA SCRN HGH RISK DIREC 0.00<br />

G0118 9 GLAUCOMA SCRN HGH RISK DIREC 0.00<br />

G0120 9 COLON CA SCRN; BARIUM ENEMA 0.00<br />

G0121 9 COLON CA SCRN NOT HI RSK IND 0.00<br />

G0122 9 COLON CA SCRN; BARIUM ENEMA 0.00<br />

G0123 3 SCREEN CERV/VAG THIN LAYER 28.00<br />

G0124 9 SCREEN C/V THIN LAYER BY MD 0.00<br />

G0125 O PET IMAGE PULMONARY NODULE 0.00<br />

G0126 9 LUNG IMAGE (PET) STAGING 0.00<br />

G0127 9 TRIM NAIL(S) 0.00<br />

G0128 9 CORF SKILLED NURSING SERVICE 0.00<br />

G0129 9 PARTIAL HOSP PROG SERVICE 0.00<br />

G0130 9 SINGLE ENERGY X-RAY STUDY 0.00<br />

G0131 9 CT SCAN, BONE <strong>DE</strong>NSITY STUDY 0.00<br />

G0132 9 CT SCAN, BONE <strong>DE</strong>NSITY STUDY 0.00<br />

G0141 9 SCR C/V CYTO,AUTOSYS AND MD 0.00<br />

G0143 9 SCR C/V CYTO,THINLAYER,RESCR 0.00

---

G0144 9 SCR C/V CYTO,THINLAYER,RESCR 0.00<br />

G0145 9 SCR C/V CYTO,THINLAYER,RESCR 0.00<br />

G0147 9 SCR C/V CYTO, AUTOMATED SYS 0.00<br />

G0148 9 SCR C/V CYTO, AUTOSYS, RESCR 0.00<br />

G0151 7 HHCP-SERV OF PT,EA 15 MIN 0.00<br />

G0152 7 HHCP-SERV OF OT,EA 15 MIN 0.00<br />

G0153 7 HHCP-SVS OF S/L PATH,EA 15MN 0.00<br />

G0154 7 HHCP-SVS OF RN,EA 15 MIN 0.00<br />

G0155 9 HHCP-SVS OF CSW,EA 15 MIN 0.00<br />

G0156 7 HHCP-SVS OF AI<strong>DE</strong>,EA 15 MIN 0.00<br />

G0159 9 PERC <strong>DE</strong>CLOT DIALYSIS GRAFT 0.00<br />

G0160 9 CRYO. ABLATION, PROSTATE 0.00<br />

G0161 9 ECHO GUI<strong>DE</strong> FOR CRYO PROBES 0.00<br />

G0163 9 PET FOR REC OF COLORECTAL CA 0.00<br />

G0164 9 PET FOR LYMPHOMA STAGING 0.00<br />

G0165 9 PET,REC OF MELANOMA/MET CA 0.00<br />

G0166 9 EXTRNL COUNTERPULSE, PER TX 0.00<br />

G0167 O HYPERBARIC OZ TX;NO MD REQRD 0.00<br />

G0168 9 WOUND CLOSURE BY ADHESIVE 0.00<br />

G0169 9 REMOVAL TISSUE; NO ANESTHSIA 0.00<br />

G0170 9 SKIN BIOGRAFT 0.00<br />

G0171 9 SKIN BIOGRAFT ADD-ON 0.00<br />

G0172 9 PHP;TRAIN & ED, PER DAY 0.00<br />

G0173 9 LINEAR ACC STEREO RADSUR COM 0.00<br />

G0174 9 INTENSITYMODULATEDRADIATION 0.00<br />

G0175 7 OPPS SERVICE,SCHED TEAM CONF 0.00<br />

G0176 3 OPPS/PHP;ACTIVITY THERAPY 10,128.26<br />

G0177 O OPPS/PHP; TRAIN & EDUC SERV 0.00<br />

G0178 9 INTENSITYMODULATEDRADIATION 0.00<br />

G0179 9 MD RECERTIFICATION HHA PT 0.00<br />

G0180 9 MD CERTIFICATION HHA PATIENT 0.00<br />

G0181 9 HOME HEALTH CARE SUPERVISION 0.00<br />

G0182 9 HOSPICE CARE SUPERVISION 0.00<br />

G0183 9 <strong>DE</strong>STRUCTION OF LOCALIZED LESION OF 0.00<br />

G0184 9 OCULAR PHOTDYNAMICTX 2ND EYE 0.00<br />

G0185 9 TRANSPUPPILLARY THERMOTX 0.00<br />

G0186 9 DSTRY EYE LESN,FDR VSSL TECH 0.00<br />

G0187 9 DSTRY MCLR DRUSEN,PHOTOCOAG 0.00<br />

G0188 9 XRAY LWR EXTRMTY-FULL LNGTH 0.00<br />

G0190 9 IMMUNIZATION ADMINISTRATION 0.00<br />

G0191 9 IMMUNIZATION ADMIN,EACH ADD 0.00<br />

G0192 9 IMMUNIZATION ORAL/INTRANASAL 0.00<br />

G0193 9 ENDOSCOPICSTUDYSWALLOWFUNCTN 0.00<br />

G0194 9 SENSORYTESTINGENDOSCOPICSTUD 0.00<br />

G0195 9 CLINICALEVALSWALLOWINGFUNCT 0.00<br />

G0196 9 EVALOFSWALLOWINGWITHRADIOOPA 0.00<br />

G0197 9 EVALOFPTFORPRESCIPSPEECH<strong>DE</strong>VI 0.00<br />

G0198 9 PATIENTADAPATION&TRAINFORSPE 0.00<br />

G0199 9 REEVALUATIONOFPATIENTUSESPEC 0.00<br />

G0200 9 EVALOFPATIENTPRESCIPOFVOICEP 0.00

---

G0201 9 MODIFORTRAININGINUSEVOICEPRO 0.00<br />

G0202 3 SCREENINGMAMMOGRAPHYDIGITAL 136.60<br />

G0204 3 DIAGNOSTICMAMMOGRAPHYDIGITAL 154.48<br />

G0206 3 DIAGNOSTICMAMMOGRAPHYDIGITAL 123.32<br />

G0210 O PET IMG WHOLEBODY DXLUNG 0.00<br />

G0211 O PET IMG WHOLBODY INIT LUNG 0.00<br />

G0212 O PET IMG WHOLEBOD RESTAG LUNG 0.00<br />

G0213 O PET IMG WHOLBODY DX 0.00<br />

G0214 O PET IMG WHOLEBOD INIT 0.00<br />

G0215 O PETIMG WHOLEBOD RESTAG 0.00<br />

G0216 O PET IMG WHOLEBOD DX MELANOMA 0.00<br />

G0217 O PET IMG WHOLEBOD INIT MELAN 0.00<br />

G0218 O PET IMG WHOLEBOD RESTAG MELA 0.00<br />

G0219 9 PET IMG WHOLBOD MELANO NONCO 0.00<br />

G0220 O PET IMG WHOLEBOD DX LYMPHOMA 0.00<br />

G0221 O PET IMAG WHOLBOD INIT LYMPHO 0.00<br />

G0222 O PET IMAG WHOLBOD RESTA LYMPH 0.00<br />

G0223 O PET IMAG WHOLBOD REG DX HEAD 0.00<br />

G0224 O PET IMAG WHOLBOD REG INI HEA 0.00<br />

G0225 O PET WHOL RESTAG HEADNECKONLY 0.00<br />

G0226 O PET IMG WHOLBODY DX ESOPHAGL 0.00<br />

G0227 O PET IMG WHOLBOD INI ESOPHAGE 0.00<br />

G0228 O PET IMG WHOLBOD RESTG ESOPHA 0.00<br />

G0229 O PET IMG METABOLOC BRAIN PRES 0.00<br />

G0230 O PET MYOCARD VIABILITY POST 0.00<br />

G0231 O PET WHBD COLOREC; GAMMA CAM 0.00<br />

G0232 O PET WHBD LYMPHOMA; GAMMA CAM 0.00<br />

G0233 O PET WHBD MELANOMA; GAMMA CAM 0.00<br />

G0234 O PET WHBD PULM NOD; GAMMA CAM 0.00<br />

G0235 6 PET NOT OTHERWISE SPECIFIED 0.00<br />

G0236 O DIGITAL FILM CONVERT DIAG MA 0.00<br />

G0237 9 THERAPEUTIC PROCD STRG ENDUR 0.00<br />

G0238 9 OTH RESP PROC, INDIV 0.00<br />

G0239 9 OTH RESP PROC, GROUP 0.00<br />

G0240 9 CRITIC CARE BY MD TRANSPORT 0.00<br />

G0241 9 EACH ADDITIONAL 30 MINUTES 0.00<br />

G0242 O MULTISOURCE PHOTON STER PLAN 0.00<br />

G0243 O MULTISOUR PHOTON STERO TREAT 0.00<br />

G0244 O OBSERV CARE BY FACILITY TOPT 0.00<br />

G0245 9 INITIAL FOOT EXAM PT LOPS 0.00<br />

G0246 9 FOLLOWUP EVAL OF FOOT PT LOP 0.00<br />

G0247 9 ROUTINE FOOTCARE PT W LOPS 0.00<br />

G0248 9 <strong>DE</strong>MONSTRATE USE HOME INR MON 0.00<br />

G0249 9 PROVI<strong>DE</strong> INR TEST MATER/EQUIP 0.00<br />

G0250 9 MD INR TEST REVIE INTER MGMT 0.00<br />

G0251 9 LINEAR ACC BASED STERO RADIO 0.00<br />

G0252 3 PET IMAGING INITIAL DX 521.95<br />

G0253 O PET IMAGE BRST <strong>DE</strong>CTION RECUR 0.00<br />

G0254 O PET IMAGE BRST EVAL TO TX 0.00<br />

G0255 5 CURRENT PERCEP THRESHOLD TST 0.00

---

G0256 O PROSTATE BRACHY W PALLADIUM 0.00<br />

G0257 5 UNSCHED DIALYSIS ESRD PT HOS 0.00<br />

G0258 O IV INFUSION DURING OBS STAY 0.00<br />

G0259 5 INJECT FOR SACROILIAC JOINT 0.00<br />

G0260 5 INJ FOR SACROILIAC JT ANESTH 0.00<br />

G0261 O PROSTATE BRACHY W IODINE SEE 0.00<br />

G0262 O SM INTESTINAL IMAGE CAPSULE 0.00<br />

G0263 O ADM WITH CHF, CP, ASTHMA 0.00<br />

G0264 O ASSMT OTR CHF, CP, ASTHMA 0.00<br />

G0265 O CRYOPRESEVATION FREEZE+STORA 0.00<br />

G0266 O THAWING + EXPANSION FROZ CEL 0.00<br />

G0267 O BONE MARROW OR PSC HARVEST 0.00<br />

G0268 9 REMOVAL OF IMPACTED WAX MD 0.00<br />

G0269 5 OCCLUSIVE <strong>DE</strong>VICE IN VEIN ART 0.00<br />

G0270 5 MNT SUBS TX FOR CHANGE DX 0.00<br />

G0271 5 GROUP MNT 2 OR MORE 30 MINS 0.00<br />

G0272 O NASO/ORO GASTRIC TUBE PL MD 0.00<br />

G0273 O PRETX PLANNING, NON-HODGKINS 0.00<br />

G0274 O RADIOPHARM TX, NON-HODGKINS 0.00<br />

G0275 3 RENAL ANGIO, CARDIAC CATH 13.49<br />

G0278 3 ILIAC ART ANGIO,CARDIAC CATH 13.85<br />

G0279 O EXCORP SHOCK TX, ELBOW EPI 0.00<br />

G0280 O EXCORP SHOCK TX OTHER THAN 0.00<br />

G0281 5 ELEC STIM UNATTEND FOR PRESS 0.00<br />

G0282 5 ELECT STIM WOUND CARE NOT PD 0.00<br />

G0283 9 ELEC STIM OTHER THAN WOUND 0.00<br />

G0288 3 RECON, CTA FOR SURG PLAN 234.70<br />

G0289 3 ARTHRO, LOOSE BODY + CHONDRO 84.90<br />

G0290 5 DRUG-ELUTING STENTS, SINGLE 0.00<br />

G0291 5 DRUG-ELUTING STENTS,EACH ADD 0.00<br />

G0292 O ADM EXP DRUGS,CLINICAL TRIAL 0.00<br />

G0293 9 NON-COV SURG PROC,CLIN TRIAL 0.00<br />

G0294 9 NON-COV PROC, CLINICAL TRIAL 0.00<br />

G0295 9 ELECTROMAGNETIC THERAPY ONC 0.00<br />

G0296 O PET IMGE RESTAG THYROD CANCE 0.00<br />

G0297 O INSERT SINGLE CHAMBER/CD 0.00<br />

G0298 O INSERT DUAL CHAMBER/CD 0.00<br />

G0299 O INSER/REPOS SINGLE ICD+LEADS 0.00<br />

G0300 O INSERT REPOSIT LEAD DUAL+GEN 0.00<br />

G0302 9 PRE-OP SERVICE LVRS COMPLETE 0.00<br />

G0303 9 PRE-OP SERVICE LVRS 10-15DOS 0.00<br />

G0304 9 PRE-OP SERVICE LVRS 1-9 DOS 0.00<br />

G0305 9 POST OP SERVICE LVRS MIN 6 0.00<br />

G0306 9 CBC/DIFFWBC W/O PLATELET 0.00<br />

G0307 9 CBC WITHOUT PLATELET 0.00<br />

G0308 O ESRD RELATED SVC 4+MO < 2YRS 0.00<br />

G0309 O ESRD RELATED SVC 2-3MO

---

G0313 O ESRD RELATED SVS 1 MON 2-11Y 0.00<br />

G0314 O ESRD RELATED SVS 4+ MO 12-19 0.00<br />

G0315 O ESRD RELATED SVS 2-3MO/12-19 0.00<br />

G0316 O ESRD RELATED SVS 1VIS/12-19Y 0.00<br />

G0317 O ESRD RELATED SVS 4+MO 20+YRS 0.00<br />

G0318 O ESRD RELATED SVS 2-3 MO 20+Y 0.00<br />

G0319 O ESRD RELATED SVS 1VISIT 20+Y 0.00<br />

G0320 O ESD RELATED SVS HOME UNDR 2 0.00<br />

G0321 O ESRDRELATEDSVS HOME MO 2-11Y 0.00<br />

G0322 O ESRD RELATED SVS HOM MO12-19 0.00<br />

G0323 O ESRD RELATED SVS HOME MO 20+ 0.00<br />

G0324 O ESRD RELATE SVS HOME/DY8HRS PU 0.00<br />

G0362 O EACH ADD SEQUENTIAL INFUSION 0.00<br />

G0363 O IRRIGATE IMPLANTED VENOUS <strong>DE</strong> 0.00<br />

G0364 3 BONE MARROW ASPIRATE &BIOPSY 12.24<br />

G0365 9 VESSEL MAPPING HEMO ACCESS 0.00<br />

G0366 O EKG FOR INITIAL PREVENT EXAM 0.00<br />

G0367 O EKG TRACING FOR INITIAL PREV 0.00

---

G0368 O EKG INTERPRET & REPORT PREVE 0.00<br />

G0369 O SUPPLYING FEE FOR THE INITIAL SUPP 0.00<br />

G0370 O SUPPLYING FEE FOR EACH SUPPLIED PR 0.00<br />

G0371 O DISPENSING FEE FOR A 30 DAY PERIOD 0.00<br />

G0372 9 MD SERVICE REQUIRED FOR PMD 0.00<br />

G0374 O DISPENSING FEE FOR EACH DISPENSED 0.00<br />

G0375 O SMOKE/TOBACCO COUNSELNG 3-10 0.00<br />

G0376 O SMOKE/TOBACCO COUNSELING >10 0.00<br />

G0378 9 HOSPITAL OBSERVATION PER HR 0.00<br />

G0379 9 DIRECT ADMIT HOSPITAL OBSERV 0.00<br />

G0380 9 LEV 1 HOSP TYPE B ED VISIT 0.00<br />

G0381 9 LEV 2 HOSP TYPE B ED VISIT 0.00<br />

G0382 9 LEV 3 HOSP TYPE B ED VISIT 0.00<br />

G0383 9 LEV 4 HOSP TYPE B ED VISIT 0.00<br />

G0384 9 LEV 5 HOSP TYPE B ED VISIT 0.00<br />

G0389 6 ULTRASOUND EXAM AAA SCREEN 0.00<br />

G0390 9 TRAUMA RESPONS W/HOSP CRITI 0.00<br />

G0392 3 AV FISTULA OR GRAFT ARTERIAL 476.40<br />

G0393 3 AV FISTULA OR GRAFT VENOUS 304.63<br />

G0394 O BLOOD OCCULT TEST,COLORECTAL 0.00<br />

G0396 9 ALCOHOL/SUBS INTERV 15-30MN 0.00<br />

G0397 9 ALCOHOL/SUBS INTERV >30 MIN 0.00<br />

G0398 9 HOME SLEEP TEST/TYPE 2 PORTA 0.00<br />

G0399 9 HOME SLEEP TEST/TYPE 3 PORTA 0.00<br />

G0400 9 HOME SLEEP TEST/TYPE 4 PORTA 0.00<br />

G0402 9 INITIAL PREVENTIVE EXAM 0.00<br />

G0403 9 EKG FOR INITIAL PREVENT EXAM 0.00<br />

G0404 9 EKG TRACING FOR INITIAL PREV 0.00<br />

G0405 9 EKG INTERPRET & REPORT PREVE 0.00<br />

G0406 9 TELHEALTH INPT CONSULT 15MIN 0.00<br />

G0407 9 TELHEATH INPT CONSULT 25MIN 0.00<br />

G0408 9 TELHEALTH INPT CONSULT 35MIN 0.00<br />

G0409 9 CORF RELATED SERV 15 MINS EA 0.00<br />

G0410 9 GRP PSYCH PARTIAL HOSP 45-50 0.00<br />

G0411 9 INTER ACTIVE GRP PSYCH PARTI 0.00<br />

G0412 9 OPEN TX ILIAC SPINE UNI/BIL 0.00<br />

G0413 9 PELVIC RING FRACTURE UNI/BIL 0.00<br />

G0414 9 PELVIC RING FX TREAT INT FIX 0.00<br />

G0415 9 OPEN TX POST PELVIC FXCTURE 0.00<br />

G0416 6 SAT BIOPSY PROSTATE 1-20 SPC 0.00<br />

G0417 6 SAT BIOPSY PROSTATE 21-40 0.00<br />

G0418 6 SAT BIOPSY PROSTATE 41-60 0.00<br />

G0419 6 SAT BIOPSY PROSTATE: >60 0.00<br />

G3001 6 ADMIN + SUPPLY, TOSITUMOMAB 0.00<br />

G8006 9 AMI PT RECD ASPIRIN AT ARRIV 0.00<br />

G8007 9 AMI PT DID NOT RECEIV ASPIRI 0.00<br />

G8008 9 AMI PT INELIGIBLE FOR ASPIRI 0.00<br />

G8009 9 AMI PT RECD BBLOCK AT ARR 0.00<br />

G8010 9 AMI PT DID NOT REC BBLOCK 0.00<br />

G8011 9 AMI PT INELIG BBLOC AT ARRIV 0.00

---

G8012 9 PNEUM PT RECV ANTIBIOTIC 4 H 0.00<br />

G8013 9 PNEUM PT W/O ANTIBIOTIC 4 HR 0.00<br />

G8014 9 PNEUM PT NOT ELIG ANTIBIOTIC 0.00<br />

G8015 9 DIABETIC PT W/ HBA1C>9% 0.00<br />

G8016 9 DIABETIC PT W/ HBA1C= 100MG/DL 0.00<br />

G8020 9 DIAB PT W/LDL< 100MG/DL 0.00<br />

G8021 9 DIAB PT INELIG FOR LDL MEAS 0.00<br />

G8022 9 CARE NOT PROVI<strong>DE</strong>D FOR LDL 0.00<br />

G8023 9 DM PT W BP>=140/80 0.00<br />

G8024 9 DIABETIC PT WBP100MG/DL 0.00<br />

G8040 9 CAD PT W/LDL=65% 0.00<br />

G8076 9 ESRD PT W/ DIALY OF URROR=33 0.00<br />

G8079 9 ESRD PT W/HCT

---

G8085 9 ESRD PT INELIG AUTO AV FISTU 0.00<br />

G8093 9 COPD PT REC SMOKING CESSAT 0.00<br />

G8094 9 COPD PT W/O SMOKE CESSAT INT 0.00<br />

G8099 9 OSTEOPO PT GIVEN CA+VITD SUP 0.00<br />

G8100 9 OSTEOP PT INELIG FOR CA+VITD 0.00<br />

G8103 9 NEW DX OSTEO PT W/ANTIRESORP 0.00<br />

G8104 9 OSTEO PT INELIG FOR ANTIRESO 0.00<br />

G8106 9 BONE <strong>DE</strong>NS MEAS TEST PERF 0.00<br />

G8107 9 BONE <strong>DE</strong>NS MEAS TEST INELIG 0.00<br />

G8108 9 PT RECEIV INFLUENZA VACC 0.00<br />

G8109 9 PT W/O INFLUENZA VACC 0.00<br />

G8110 9 PT INELIG FOR INFLUENZA VACC 0.00<br />

G8111 9 PT RECEIV MAMMOGRAM 0.00<br />

G8112 9 PT NOT DOC MAMMOGRAM 0.00<br />

G8113 9 PT INELIGIBLE MAMMOGRAPHY 0.00<br />

G8114 9 CARE NOT PROVI<strong>DE</strong>D FOR MAMOGR 0.00<br />

G8115 9 PT RECEIV PNEUMO VACC 0.00<br />

G8116 9 PT DID NOT REC PNEUMO VACC 0.00<br />

G8117 9 PT WAS INELIG FOR PNEUMO VAC 0.00<br />

G8126 9 PT TREAT W/ANTI<strong>DE</strong>PRESS12WKS 0.00<br />

G8127 9 PT NOT TREAT W/ANTI<strong>DE</strong>PRES12W 0.00<br />

G8128 9 PT INELIG FOR ANTI<strong>DE</strong>PRES MED 0.00<br />

G8129 9 PT TREAT W/ANTI<strong>DE</strong>PRES FOR 6M 0.00<br />

G8130 9 PT NOT TREAT W/ANTI<strong>DE</strong>PRES 6M 0.00<br />

G8131 9 PT INELIG FOR ANTI<strong>DE</strong>PRES MED 0.00<br />

G8152 9 PT W/AB 1 HR PRIOR TO INCISI 0.00<br />

G8153 9 PT NOT DOC FOR AB 1 HR PRIOR 0.00<br />

G8154 9 PT INELIGI FOR AB THERAPY 0.00<br />

G8155 9 PT RECD THROMBOEMB PROPHYLAX 0.00<br />

G8156 9 PT DID NOT REC THROMBOEMBO 0.00<br />

G8157 9 PT INELIGI FOR THROMBOLISM 0.00<br />

G8158 O PT RECD CABG W/ IMA 0.00<br />

G8159 9 PT W/CABG W/O IMA 0.00<br />

G8160 O PT INELIG FOR CABG W/IMA 0.00<br />

G8161 O ISO CABG PT REC PREOP BBLOCK 0.00<br />

G8162 9 ISO CABG PT W/O PREOP BBLOCK 0.00<br />

G8163 O ISO CABG PT INELIG FOR PREO 0.00<br />

G8164 9 ISO CABG PT W/PROLNG INTUB 0.00<br />

G8165 9 ISO CABG PT W/O PROLNG INTUB 0.00<br />

G8166 9 ISO CABG REQ SURG REXPO 0.00<br />

G8167 9 ISO CABG W/O SURG EXPLO 0.00<br />

G8170 9 CEA/EXT BYPASS PT ON ASPIRIN 0.00<br />

G8171 9 PT W/CAROT ENDARCT/EXT BYPAS 0.00<br />

G8172 9 CEA/EXT BYPASS PT NOT ON ASP 0.00<br />

G8182 9 CAD PT CARE NOT PROV LDL 0.00<br />

G8183 9 HF/ATRIAL FIB PT ON WARFARIN 0.00<br />

G8184 9 HF/ATRIAL FIB PT INELIG WARF 0.00<br />

G8185 9 OSTEOARTH PT W/ ASSESS PAIN 0.00<br />

G8186 9 OSTEOARTH PT INELIG ASSESS 0.00<br />

G8191 O ANTIBIOTIC GIVEN PRIOR SURG 0.00

---

G8192 O ANTIB GIVEN PRIOR SURG INCIS 0.00<br />

G8193 9 ANTIBIO NOT DOC PRIOR SURG 0.00<br />

G8194 O PT NOT ELIG FOR ANTIBIOTIC 0.00<br />

G8195 O ANTIBIOTIC GIVEN PRIOR SURG 0.00<br />

G8196 9 ANTIBIO NOT DOCUM PRIOR SURG 0.00<br />

G8197 O ANTIB OR<strong>DE</strong>R PRIOR TO SURG 0.00<br />

G8198 O CEFAZOLIN DOCUMENTED OR<strong>DE</strong>RED 0.00<br />

G8199 O CEFAZOLIN GIVEN PROPHYLAXIS 0.00<br />

G8200 9 CEFAZOLIN NOT DOCUM PROPHY 0.00<br />

G8201 O PT NOT ELIGI FOR CEFAZOLIN 0.00<br />

G8202 O OR<strong>DE</strong>R GIVEN TO D/C ANTIBIO 0.00<br />

G8203 O ANTIB WAS D/C 24HRS SURG TIM 0.00<br />

G8204 9 MD NOT DOC OR<strong>DE</strong>R TO D/C ANTI 0.00<br />

G8205 O PT NOT ELIGI FOR PROPH ANTIB 0.00<br />

G8206 O MD DOC PROPHYLACTIC AB GIVEN 0.00<br />

G8207 O CLINI DOC OR<strong>DE</strong>R TO D/C ANTIB 0.00<br />

G8208 O CLINI DOC AB WAS D/C 48 H 0.00<br />

G8209 9 CLINICIAN DID NOT DOC 0.00<br />

G8210 O CLINI DOC PT INELIGIB ANTI 0.00<br />

G8211 O CLINI DOC PROPH AB GIV 0.00<br />

G8212 O CLINI OR<strong>DE</strong>R GIVEN FOR VTE 0.00<br />

G8213 O CLINI GIVEN VTE PROP 0.00<br />

G8214 9 CLINI NOT DOC OR<strong>DE</strong>R VTE 0.00<br />

G8215 O CLINI DOC PT INELIG VTE 0.00<br />

G8216 O PT RECEIVED DVT PROPHYLAXIS 0.00<br />

G8217 9 PT NOT RECEIVED DVT PROPH 0.00<br />

G8218 O PT INELIG DVT PROPHYLAXIS 0.00<br />

G8219 9 RECEIVED DVT PROPH DAY 2 0.00<br />

G8220 9 PT NOT REC DVT PROPH DAY 2 0.00<br />

G8221 9 PT INELIG FOR DVT PROPH 0.00<br />

G8222 O PT PRESCRIBE PLATELET AT D/C 0.00<br />

G8223 9 PT NOT DOC FOR PRESC ANTIPLA 0.00<br />

G8224 O PT INELIG FOR ANTIPLAT PROPH 0.00<br />

G8225 O PT PRESCRIB ANTICOAG AT D/C 0.00<br />

G8226 9 PT NO PRESCR ANTICOA AT D/C 0.00<br />

G8227 O PT NOT DOC TO HAVE PERM/AF 0.00<br />

G8228 O CLIN PT INELIG ANTICOAG D/C 0.00<br />

G8229 O PT DOC TO HAVE ADMIN T-PA 0.00<br />

G8230 O PT INELIG T-PA ISCH STROK>3H 0.00<br />

G8231 9 PT NOT DOC FOR ADMIN T-PA 0.00<br />

G8232 O PT RECEIVED DYSPHAGIA SCREEN 0.00<br />

G8234 9 PT NOT DOC DYSPHAGIA SCREEN 0.00<br />

G8235 O PT RECEIVED NPO 0.00<br />

G8236 O PT INELIG DYSPHAGIA SCREEN 0.00<br />

G8237 O PT DOC REC REHAB SERV 0.00<br />

G8238 9 PT NOT DOC TO REC REHAB SERV 0.00<br />

G8239 O INTER CAROTID STENOSIS

---

G8243 9 PT NOT DOC MRI/CT W/O LESION 0.00<br />

G8245 O CLINI DOC PRESE/ABS ALARM 0.00<br />

G8246 9 PT INELIG HX W NEW/CHG MOLE 0.00<br />

G8247 O PT W/ALARM SYMP UPPER ENDO 0.00<br />

G8248 9 PT W/ONE ALARM SYMP NOT DOC 0.00<br />

G8249 O PT INELIG FOR UPPER ENDO 0.00<br />

G8250 O PT W/BARRETTS ESOPH ENDO RE 0.00<br />

G8251 9 PT NOT DOC W/BARRETTS, ENDO 0.00<br />

G8252 O PT INELIG FOR ESOPHAG BIOP 0.00<br />

G8253 O PT REC OR<strong>DE</strong>R FOR BARIUM 0.00<br />

G8254 9 PT W/NO DOC OR<strong>DE</strong>R FOR BARIUM 0.00<br />

G8255 O CLINI DOC PT INELIG BAR SWAL 0.00<br />

G8256 O CLINI DOC REV D/C MEDS W/MED 0.00<br />

G8257 9 PT NOT DOC REV MEDS D/C 0.00<br />

G8258 O PT INELIG FOR D/C MEDS REV 0.00<br />

G8259 O PT DOC TO HAV <strong>DE</strong>CISION MAKER 0.00<br />

G8260 9 PT NOT DOC TO HAVE <strong>DE</strong>C MAKER 0.00<br />

G8261 O CLIN DOC PT INELIG <strong>DE</strong>C MAKER 0.00<br />

G8262 O PT DOC ASSESS URINY INCON 0.00<br />

G8263 9 PT NOT DOC ASSESS URINARY IN 0.00<br />

G8264 O PT INELIG ASSESS URINARY INC 0.00<br />

G8265 O PT DOC REC CHARC URIN INCON 0.00<br />

G8266 9 PT NOT DOC CHARC URIN INCON 0.00<br />

G8267 O PT DOC REC PLAN URINARY INCO 0.00<br />

G8268 9 PT NOT DOC REC CARE URIN INC 0.00<br />

G8269 O CLIN NOT PROV CARE URIN INCO 0.00<br />

G8270 O PT RECEIV SCREEN FOR FALL 0.00<br />

G8271 9 PT NO DOC SCREEN FALL 0.00<br />

G8272 O CLIN DOC PT INELIG FALL RISK 0.00<br />

G8273 O CLIN NOT PROV CARE SCRE FALL 0.00<br />

G8274 9 CLINI NOT DOC PRES/ABS ALARM 0.00<br />

G8275 O PT HX W/ NEW MOLES 0.00<br />

G8276 9 PT NOT DOC MOLE CHANGE 0.00<br />

G8277 O PT INELIG FOR ASSESS MOLE 0.00<br />

G8278 O PT DOC REC PE SKIN 0.00<br />

G8279 9 PT NOT DOC REC PE 0.00<br />

G8280 O PT INELIG PE SKIN 0.00<br />

G8281 O PT REC COUNSEL FOR SELF-EXAM 0.00<br />

G8282 9 PT NOT DOC TO REC COUNS 0.00<br />

G8283 O PT INELIG FOR COUNSEL 0.00<br />

G8284 O PT DOC TO REC PRES OSTEO 0.00<br />

G8285 9 PT DID NOT REC PRES OSTEO 0.00<br />

G8286 O PT INELIG TO REC PRES OSTEO 0.00<br />

G8287 O CLIN NOT PROV CARE FOR PHARM 0.00<br />

G8288 O PT DOC REC CA/VIT D 0.00<br />

G8289 9 PT NOT DOC REC CA/VIT D 0.00<br />

G8290 O CLIN DOC PT INELIG CA/VIT D 0.00<br />

G8291 O CLIN NO PRO CARE PT CA/VIT D 0.00<br />

G8292 O COPD PT W/SPIR RESULTS 0.00<br />

G8293 9 COPD PT W/O SPIR RESULTS 0.00

---

G8294 O COPD PT INELIG SPIR RESULTS 0.00<br />

G8295 O COPD PT DOC BRONCH THER 0.00<br />

G8296 9 COPD PT NOT DOC BRONCH THER 0.00<br />

G8297 O COPD PT INELIG BRONCH THERAP 0.00<br />

G8298 9 PT DOC OPTIC NERVE EVAL 0.00<br />

G8299 9 PT NOT DOC OPTIC NERV EVAL 0.00<br />

G8300 O PT INELIG FOR OPTIC NERV EVA 0.00<br />

G8301 O CLIN NOT PROV CARE POAG 0.00<br />

G8302 9 PT DOC W/ TARGET IOP 0.00<br />

G8303 9 PT NOT DOC W/ IOP 0.00<br />

G8304 9 CLIN DOC PT INELIG IOP 0.00<br />

G8305 9 CLIN NOT PROV CARE POAG 0.00<br />

G8306 9 POAG W/ IOP REC CARE PLAN 0.00<br />

G8307 9 POAG W/ IOP NO CARE PLAN 0.00<br />

G8308 9 POAG W/ IOP NOT DOC PLAN 0.00<br />

G8309 O PT DOC REC ANTIOXIDANT 0.00<br />

G8310 9 PT NOT DOC REC ANTIOX 0.00<br />

G8311 O PT INELIG FOR ANTIOXIDANT 0.00<br />

G8312 O CLIN NO PROV CARE FOR ANTIOX 0.00<br />

G8313 O PT DOC REC MACULAR EXAM 0.00<br />

G8314 9 PT NOT DOC TO REC MAC EXAM 0.00<br />

G8315 O CLIN DOC PT INELIG MAC EXAM 0.00<br />

G8316 O CLIN NO PRO CARE FOR MAC <strong>DE</strong>G 0.00<br />

G8317 O PT DOC TO HAVE VISUAL FUNC 0.00<br />

G8318 9 PT DOC NOT HAVE VISUAL FUNC 0.00<br />

G8319 O PT INELIG FOR VIS FUNC STAT 0.00<br />

G8320 O CLIN NOT PROV CARE CATARAC 0.00<br />

G8321 O PT DOC TO PRE AXIAL LENG 0.00<br />

G8322 9 PT NOT DOC PRE AXIAL LENG 0.00<br />

G8323 O PT INELIG FOR PRE SURG AXIAL 0.00<br />

G8324 O CLIN NOT PROV CARE FOR IOL 0.00<br />

G8325 O PT REC FUND EXAM PRIOR SURG 0.00<br />

G8326 9 PT NOT DOC REC FUNDUS EXAM 0.00<br />

G8327 O PT INELIG FOR PRE SURG FUNDU 0.00<br />

G8328 O CLIN NOT PROV CARE FUND EVAL 0.00<br />

G8329 O PT DOC REC DILATED MACULAR 0.00<br />

G8330 9 PT NOT DOC REC DILATED MAC 0.00<br />

G8331 O PT INELIG DILATE FUNDUS 0.00<br />

G8332 O CLIN PROV NO CARE DIABETIC R 0.00<br />

G8333 O PT DOC TO HAVE MACULAR EXAM 0.00<br />

G8334 9 DOC OF MACULAR NOT GIV MD 0.00<br />

G8335 O CLIN DOC PT INELIG MACULAR 0.00<br />

G8336 O CLIN DID NOT PRO CARE DIABET 0.00<br />

G8337 O CLIN DOC PT WAS TEST OSTEO 0.00<br />

G8338 9 CLIN NOT DOC PT TEST OSTEO 0.00<br />

G8339 O PT INELIG FOR TEST OSTEO 0.00<br />

G8340 O PT DOC HAVE <strong>DE</strong>XA 0.00<br />

G8341 9 PT NOT DOC FOR <strong>DE</strong>XA 0.00<br />

G8342 O CLIN DOC PT INELIG <strong>DE</strong>XA 0.00<br />

G8343 O CLIN NOT PROV CARE <strong>DE</strong>XA 0.00

---

G8344 O PT DOC HAVE <strong>DE</strong>XA PERFORM 0.00<br />

G8345 9 PT NOT DOC HAVE <strong>DE</strong>XA 0.00<br />

G8346 O CLIN DOC PT INELIG <strong>DE</strong>XA 0.00<br />

G8347 O CLIN NOT PROV CARE <strong>DE</strong>XA 0.00<br />

G8351 9 PT NOT DOC ECG 0.00<br />

G8354 9 PT NOT REC ASPIRIN PRIOR ER 0.00<br />

G8357 9 PT NOT DOC TO HAVE ECG 0.00<br />

G8360 9 PT NOT DOC VITAL SIGNS RECOR 0.00<br />

G8362 9 PT NOT DOC 02 SAT ASSESS 0.00<br />

G8365 9 PT NOT DOC MENTAL STATUS 0.00<br />

G8367 9 PT NOT DOC HAVE EMPIRIC AB 0.00<br />

G8370 9 ASTHMA PT W SURVEY NOT DOCUM 0.00<br />

G8371 9 CHEMOTHER NOT REC STG3 COLON 0.00<br />

G8372 9 CHEMOTHER REC STG3 COLON CA 0.00<br />

G8373 9 CHEMO PLAN DOCUMEN PRIOR CHE 0.00<br />

G8374 9 CHEMO PLAN NOT DOC PRIOR CHE 0.00<br />

G8375 9 CLL PT W/O DOC FLOW CYTOMETR 0.00<br />

G8376 9 BRST CA PT INELIG TAMOXIFEN 0.00<br />

G8377 9 MD DOC COLON CA PT INELIG CH 0.00<br />

G8378 9 MD DOC PT INELIG RADIATION 0.00<br />

G8379 9 DOC RADIAT TX RECOM 12MO OV 0.00<br />

G8380 9 PT W STGIC-3BRST CA NOT REC 0.00<br />

G8381 9 PT W STGIC-3BRST CA REC TAM 0.00<br />

G8382 9 MM PT W/O DOC IV BISPHOPHON 0.00<br />

G8383 9 NO DOC RADIATION REC 12MO OV 0.00<br />

G8384 9 BASE CYTOGEN TEST MDS NOTPER 0.00<br />

G8385 9 DIABET PT NO DO HGB A1C 12M 0.00<br />

G8386 9 DIABET PT NODOC LDLIPROTEI 0.00<br />

G8387 9 ESRD PT W HCT/HGB NOT DOCUME 0.00<br />

G8388 9 ESRD PT W URR/KTV NOTDOC ELI 0.00<br />

G8389 9 MDS PT NO DOC FE ST PRIO EPO 0.00<br />

G8390 9 DIABETIC W/O DOCUMENT BP 12M 0.00<br />

G8391 9 PT W ASTHMA NO DOC MED OR TX 0.00<br />

G8395 9 LVEF>=40% DOC NORMAL OR MILD 0.00<br />

G8396 9 LVEF NOT PERFORMED 0.00<br />

G8397 9 DIL MACULA/FUNDUS EXAM/W DOC 0.00<br />

G8398 9 DIL MACULAR/FUNDUS NOT PERFO 0.00<br />

G8399 9 PT W/DXA DOCUMENT OR OR<strong>DE</strong>R 0.00<br />

G8400 9 PT W/DXA NO DOCUMENT OR OR<strong>DE</strong> 0.00<br />

G8401 9 PT INELIG OSTEO SCREEN MEASU 0.00<br />

G8402 9 SMOKE PREVEN INTERVEN COUNSE 0.00<br />

G8403 9 SMOKE PREVEN NOCOUNSEL 0.00<br />

G8404 9 LOW EXTEMITY NEUR EXAM DOCUM 0.00<br />

G8405 9 LOW EXTEMITY NEUR NOT PERFOR 0.00<br />

G8406 9 PT INELIG LOWER EXTREM NEURO 0.00<br />

G8407 9 ABI DOCUMENTED 0.00<br />

G8408 9 ABI NOT DOCUMENTED 0.00<br />

G8409 9 PT INELIG FOR ABI MEASURE 0.00<br />

G8410 9 EVAL ON FOOT DOCUMENTED 0.00<br />

G8415 9 EVAL ON FOOT NOT PERFORMED 0.00

---

G8416 9 PT INELIG FOOTWEAR EVALUATIO 0.00<br />

G8417 9 CALC BMI ABV UP PARAM F/U 0.00<br />

G8418 9 CALC BMI BLW LOW PARAM F/U 0.00<br />

G8419 9 CALC BMI OUT NRM PARAM NOF/U 0.00<br />

G8420 9 CALC BMI NORM PARAMETERS 0.00<br />

G8421 9 BMI NOT CALCULATED 0.00<br />

G8422 9 PT INELIG BMI CALCULATION 0.00<br />

G8423 9 PT SCREEN FLU VAC & COUNSEL 0.00<br />

G8424 9 FLU VACCINE NOT SCREEN 0.00<br />

G8425 9 FLU VACCINE SCREEN NOT CURRE 0.00<br />

G8426 9 PT NOT APPROP SCREEN & COUNC 0.00<br />

G8427 9 DOC MEDS VERIFIED W/PT OR RE 0.00<br />

G8428 9 MEDS DOCUMENT W/O VERIFICA 0.00<br />

G8429 9 INCOMPLETE DOC PT ON MEDS 0.00<br />

G8430 9 PT INELIG MED CHECK 0.00<br />

G8431 9 POS CLIN <strong>DE</strong>PRES SCRN F/U DOC 0.00<br />

G8432 9 CLIN <strong>DE</strong>PRESSION SCREEN NOT D 0.00<br />

G8433 9 PT INELIG; SCRN CLIN <strong>DE</strong>P 0.00<br />

G8434 9 COGNITIVE IMPAIRMENT SCREEN 0.00<br />

G8435 9 COGNITIVE SCREEN NOT DOCUMEN 0.00<br />

G8436 9 PT INELIG FOR COGNITIVE IMPA 0.00<br />

G8437 9 CARE PLAN <strong>DE</strong>VELOP & DOCUMENT 0.00<br />

G8438 9 PT INELIG FOR <strong>DE</strong>VLP CARE PLN 0.00<br />

G8439 9 CARE PLAN <strong>DE</strong>VELP & NOT DOCUM 0.00<br />

G8440 9 PAIN ASSESS F/U PLN DOCUMENT 0.00<br />

G8441 9 NO DOCUMENT OF PAIN ASSESS 0.00<br />

G8442 9 PT INELIG PAIN ASSESSMENT 0.00<br />

G8443 9 PRESCRIPTION BY E-PRESCRIB S 0.00<br />

G8445 9 PRESCRIP NOT GEN AT ENCOUNTE 0.00<br />

G8446 9 SOME PRESCRIB PRINT OR CALL 0.00<br />

G8447 9 PT VIS DOC USE CCHIT CER EHR 0.00<br />

G8448 9 PT VIS DOC W/NON-CCHIT EHR 0.00<br />

G8449 9 PT NOT DOC W/EMR DUE TO SYST 0.00<br />

G8450 9 BETA-BLOC RX PT W/ABN LVEF 0.00<br />

G8451 9 PT W/ABN LVEF INELIG B-BLOC 0.00<br />

G8452 9 PT W/ABN LVEF B-BLOC NO RX 0.00<br />

G8453 9 TOB USE CESS INT COUNSEL 0.00<br />

G8454 9 TOB USE CESS INT NO COUNSEL 0.00<br />

G8455 9 CURRENT TOBACCO SMOKER 0.00<br />

G8456 9 SMOKELESS TOBACCO USER 0.00<br />

G8457 9 CUR TOBACCO NON-USER 0.00<br />

G8458 9 PT INELIG GENO NO ANTVIR TX 0.00<br />

G8459 9 DOC PT REC ANTIVIR TREAT 0.00<br />

G8460 9 PT INELIG RNA NO ANTVIR TX 0.00<br />

G8461 9 PT REC ANTIVIR TREAT HEP C 0.00<br />

G8462 9 PT INELIG COUNS NO ANTVIR TX 0.00<br />

G8463 9 PT REC ANTIVIRAL TREAT DOC 0.00<br />

G8464 9 PT INELIG; LO TO NO DTER RSK 0.00<br />

G8465 9 HIGH RISK RECURRENCE PRO CA 0.00<br />

G8466 9 PT INELIG SUIC; MDD REMIS 0.00

---

G8467 9 NEW DX INIT/REC EPISO<strong>DE</strong> MDD 0.00<br />

G8468 9 ACE/ARB RX PT W/ABN LVEF 0.00<br />

G8469 9 PT W/ABN LVEF INELIG ACE/ARB 0.00<br />

G8470 9 PT W/ NORMAL LVEF 0.00<br />

G8471 9 LVEF NOT PERFORMED/DOC 0.00<br />

G8472 9 ACE/ARB NO RX PT W/ABN LVEF 0.00<br />

G8473 9 ACE/ARB THXPY RX'D 0.00<br />

G8474 9 ACE/ARB NOT RX'D; DOC REAS 0.00<br />

G8475 9 ACE/ARB THXPY NOT RX'D 0.00<br />

G8476 9 BP SYS =80 0.00<br />

G8478 9 BP NOT PERFORMED/DOC 0.00<br />

G8479 9 MD RX'D ACE/ARB THXPY 0.00<br />

G8480 9 PT INELIG ACE/ARB THXPY 0.00<br />

G8481 9 MD NOT RX'D ACE/ARB THXPY 0.00<br />

G8482 9 FLU IMMUNIZE OR<strong>DE</strong>R/ADMIN 0.00<br />

G8483 9 FLU IMM NO ORD/ADMIN DOC REA 0.00<br />

G8484 9 FLU IMMUNIZE NO OR<strong>DE</strong>R/ADMIN 0.00<br />

G8485 9 REPORT, DIABETES MEASURES 0.00<br />

G8486 9 REPORT, PREV CARE MEASURES 0.00<br />

G8487 9 REPORT CKD MEASURES 0.00<br />

G8488 9 REPORT ESRD MEASURES 0.00<br />

G8489 9 CAD MEASURES GRP 0.00<br />

G8490 9 RA MEASURES GRP 0.00<br />

G8491 9 HIV/AIDS MEASURES GRP 0.00<br />

G8492 9 PREV CARE MEASURES GRP 0.00<br />

G8493 9 BACK PAIN MEASURES GRP 0.00<br />

G8494 9 DM MEAS QUAL ACT PERFORM 0.00<br />

G8495 9 CKD MEAS QUAL ACT PERFORM 0.00<br />

G8496 9 PC MEAS QUAL ACT PERFORM 0.00<br />

G8497 9 CABG MEAS QUAL ACT PERFORM 0.00<br />

G8498 9 CAD MEAS QUAL ACT PERFORM 0.00<br />

G8499 9 RA MEAS QUAL ACT PERFORM 0.00<br />

G8500 9 HIV MEAS QUAL ACT PERFORM 0.00<br />

G8501 9 PERIO MEAS QUAL ACT PERFORM 0.00<br />

G8502 9 BP MEAS QUAL ACT PERFORM 0.00<br />

G8503 9 DOC PROPH ANTIBX W/IN 1 HR 0.00<br />

G8504 9 DOC ORD PRO ANTBX W/IN 1 HR 0.00<br />

G8505 9 NO DOC PROPH ANTIBX W/IN 1HR 0.00<br />

G8506 9 PT REC ACE/ARB 0.00<br />

G8507 9 PT INELIG PT VERIF MEDS 0.00<br />

G8508 9 PT INELIG; PAIN ASSES NO F/U 0.00<br />

G8509 9 PAIN ASSESS NO F/U PLN DOC 0.00<br />

G8510 9 PT INELIG NEG SCRN <strong>DE</strong>PRES 0.00<br />

G8511 9 CLIN <strong>DE</strong>PRES SCRN NO F/U DOC 0.00<br />

G8512 9 PAIN SEV QUANT PRESENT 0.00<br />

G8513 9 ABI MEAS & DOC 0.00<br />

G8514 9 PT INELIG; ABI MEASURE 0.00<br />

G8515 9 NO ABI MEASUREMENT 0.00<br />

G8516 9 SCRN FAL RSK >2 FAL OR W/INJ 0.00

---

G8517 9 SCRN FALL RSK;

---

G9024 O CHEMOTHERAPY ASSESSMENT FOR NAUSEA 0.00<br />

G9025 O CHEMOTHERAPY ASSESSMENT FOR PAIN 0.00<br />

G9026 O CHEMOTHERAPY ASSESSMENT FOR PAIN 0.00<br />

G9027 O CHEMOTHERAPY ASSESSMENT FOR PAIN 0.00<br />

G9028 O CHEMOTHERAPY ASSESSMENT FOR PAIN 0.00<br />

G9029 O CHEMOTHERAPY ASSESSMENT FOR LACK O 0.00<br />

G9030 O CHEMOTHERAPY ASSESSMENT FOR LACK O 0.00<br />

G9031 O CHEMOTHERAPY ASSESSMENT FOR LACK O 0.00<br />

G9032 O CHEMOTHERAPY ASSESSMENT FOR LACK O 0.00<br />

G9033 9 AMANTADINE HCL ORAL BRAND 0.00<br />

G9034 9 SERVICES PROVI<strong>DE</strong>D BY OCCUPATIONAL 0.00<br />

G9035 9 SERVICES PROVI<strong>DE</strong>D BY ORIENTATION 0.00<br />

G9036 9 SERVICES PROVI<strong>DE</strong>D BY LOW VISION TH 0.00<br />

G9037 9 SERVICES PROVI<strong>DE</strong>D BY REHABILITATIO 0.00<br />

G9041 9 LOW VISION REHAB OCCUPATIONA 0.00<br />

G9042 9 LOW VISION REHAB ORIENT/MOBI 0.00<br />

G9043 9 LOW VISION LOWVISION THERAPI 0.00<br />

G9044 9 LOW VISION REHABILATE TEACHE 0.00<br />

G9050 9 ONCOLOGY WORK-UP EVALUATION 0.00<br />

G9051 9 ONCOLOGY TX <strong>DE</strong>CISION-MGMT 0.00<br />

G9052 9 ONC SURVEILLANCE FOR DISEASE 0.00<br />

G9053 9 ONC EXPECTANT MANAGEMENT PT 0.00<br />

G9054 9 ONC SUPERVISION PALLIATIVE 0.00<br />

G9055 9 ONC VISIT UNSPECIFIED NOS 0.00<br />

G9056 9 ONC PRAC MGMT ADHERES GUI<strong>DE</strong> 0.00<br />

G9057 9 ONC PRACT MGMT DIFFERS TRIAL 0.00<br />

G9058 9 ONC PRAC MGMT DISAGREE W/GUI 0.00<br />

G9059 9 ONC PRAC MGMT PT OPT ALTERNA 0.00<br />

G9060 9 ONC PRAC MGMT DIF PT COMORB 0.00<br />

G9061 9 ONC PRAC COND NOADD BY GUI<strong>DE</strong> 0.00<br />

G9062 9 ONC PRAC GUI<strong>DE</strong> DIFFERS NOS 0.00<br />

G9063 9 ONC DX NSCLC STGI NO DX PROG 0.00<br />

G9064 9 ONC DX NSCLC STG2 NO DX PROG 0.00<br />

G9065 9 ONC DX NSCLC STG3A NODX PROG 0.00<br />

G9066 9 ONC DX NSCLC STG3B-4 METASTA 0.00<br />

G9067 9 ONC DX NSCLC DX UNKNOWN NOS 0.00<br />

G9068 9 ONC DX NSCLC/SCLC LIMITED 0.00<br />

G9069 9 ONC DX SCLC/NSCLC EXT AT DX 0.00<br />

G9070 9 ONC DX SCLC/NSCLC EXT UNKNWN 0.00<br />

G9071 9 ONC DX BRST STG1 2B NO DX PR 0.00<br />

G9072 9 ONC DX BRST STG1-2 NOPROGRES 0.00<br />

G9073 9 ONC DX BRST STG3-W/PROGRES 0.00<br />

G9074 9 ONC DX BRST STG3-NOPROGRESS 0.00<br />

G9075 9 ONC DX BRST METASTIC/ RECUR 0.00<br />

G9076 O ONC DX BRST UNKNOWN NOS 0.00<br />

G9077 9 ONC DX PROSTATE T1NO PROGRES 0.00<br />

G9078 9 ONC DX PROSTATE T2NO PROGRES 0.00<br />

G9079 9 ONC DX PROSTATE T3B-T4NOPROG 0.00<br />

G9080 9 ONC DX PROSTATE W/RISE PSA 0.00<br />

G9081 O ONC DX PROSTATE METS NO CAST 0.00

---

G9082 O ONC DX PROSTATE CASTRATE MET 0.00<br />

G9083 9 ONC DX PROSTATE UNKNWN NOS 0.00<br />

G9084 9 ONC DX COLON T1-3,N1-2,NO PR 0.00<br />

G9085 9 ONC DX COLON T4, N0 W/O PROG 0.00<br />

G9086 9 ONC DX COLON T1-4 NO DX PROG 0.00<br />

G9087 9 ONC DX COLON RADIOLG EVID DX 0.00<br />

G9088 9 ONC DX COLON M1/METS W/O RAD 0.00<br />

G9089 9 ONC DX COLON EXTENT UNKNOWN 0.00<br />

G9090 9 ONC DX RECTAL T1-2 NO PROGR 0.00<br />

G9091 9 ONC DX RECTAL T3 N0 NO PROG 0.00<br />

G9092 9 ONC DX RECTAL T1-3,N1-2NOPRG 0.00<br />

G9093 9 ONC DX RECTAL T4,N,M0 NO PRG 0.00<br />

G9094 9 ONC DX RECTAL M1 W/METS PROG 0.00<br />

G9095 9 ONC DX RECTAL EXTENT UNKNWN 0.00<br />

G9096 9 ONC DX ESOPHAG T1-T3 NOPROG 0.00<br />

G9097 9 ONC DX ESOPHAGEAL T4 NO PROG 0.00<br />

G9098 9 ONC DX ESOPHAGEAL METS RECUR 0.00<br />

G9099 9 ONC DX ESOPHAGEAL UNKNOWN 0.00<br />

G9100 9 ONC DX GASTRIC NO RECURRENCE 0.00<br />

G9101 9 ONC DX GASTRIC P R1-R2NOPROG 0.00<br />

G9102 9 ONC DX GASTRIC UNRESECTABLE 0.00<br />

G9103 9 ONC DX GASTRIC RECURRENT 0.00<br />

G9104 9 ONC DX GASTRIC UNKNOWN NOS 0.00<br />

G9105 9 ONC DX PANCREATC P R0 RES NO 0.00<br />

G9106 9 ONC DX PANCREATC P R1/R2 NO 0.00<br />

G9107 9 ONC DX PANCREATIC UNRESECTAB 0.00<br />

G9108 9 ONC DX PANCREATIC UNKNWN NOS 0.00<br />

G9109 9 ONC DX HEAD/NECK T1-T2NO PRG 0.00<br />

G9110 9 ONC DX HEAD/NECK T3-4 NOPROG 0.00<br />

G9111 9 ONC DX HEAD/NECK M1 METS REC 0.00<br />

G9112 9 ONC DX HEAD/NECK EXT UNKNOWN 0.00<br />

G9113 9 ONC DX OVARIAN STG1A-B NO PR 0.00<br />

G9114 9 ONC DX OVARIAN STG1A-B OR 2 0.00<br />

G9115 9 ONC DX OVARIAN STG3/4 NOPROG 0.00<br />

G9116 9 ONC DX OVARIAN RECURRENCE 0.00<br />

G9117 9 ONC DX OVARIAN UNKNOWN NOS 0.00<br />

G9118 O ONC DX NHL STG 1-2 NOT RELAP 0.00<br />

G9119 O ONC DX NHL STG 3-4 NOT RELAP 0.00<br />

G9120 O ONC DX NHL TRANS TO LG BCELL 0.00<br />

G9121 O ONC NHLSTG 1-2 NO RELAP NO 0.00<br />

G9122 O ONC DX NHL STG 3/4NO RELAP 0.00<br />

G9123 9 ONC DX NHL LGE BCELL RELAP 0.00<br />

G9124 9 ONC DX NHL RELAPSE/REFRACTOR 0.00<br />

G9125 9 ONC DX NHL STG UNKNOWN 0.00<br />

G9126 9 ONC DX OVARIAN STG IA/B 0.00<br />

G9127 O ONC DX MULTI MYELOMA STAGE I 0.00<br />

G9128 9 ONC DX MULT MYELOMA STG2 HIG 0.00<br />

G9129 9 ONC DX MULT MYELOMA UNKWN OP 0.00<br />

G9130 9 ONC DX MULTI MYELOMA UNKNOWN 0.00<br />

G9131 9 ONC DX BRST UNKNOWN NOS 0.00

---

G9132 9 ONC DX PROSTATE METS NO CAST 0.00<br />

G9133 9 ONC DX PROSTATE CLINICAL MET 0.00<br />

G9134 9 ONC NHLSTG 1-2 NO RELAP NO 0.00<br />

G9135 9 ONC DX NHL STG 3-4 NOT RELAP 0.00<br />

G9136 9 ONC DX NHL TRANS TO LG BCELL 0.00<br />

G9137 9 ONC DX NHL RELAPSE/REFRACTOR 0.00<br />

G9138 9 ONC DX NHL STG UNKNOWN 0.00<br />

G9139 9 ONC DX CML DX STATUS UNKNOWN 0.00<br />

G9140 9 FRONTIER EXTEN<strong>DE</strong>D STAY <strong>DE</strong>MO 0.00<br />

H0001 7 ALCOHOL AND/OR DRUG ASSESS 0.00<br />

H0002 7 ALCOHOL AND/OR DRUG SCREENIN 0.00<br />

H0003 9 ALCOHOL AND/OR DRUG SCREENIN 0.00<br />

H0004 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0005 7 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0006 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0007 7 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0008 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0009 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0010 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0011 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0012 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0013 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0014 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0015 7 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0016 9 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0017 7 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0018 7 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0019 7 ALCOHOL AND/OR DRUG SERVICES 0.00<br />

H0020 3 ALCOHOL AND/OR DRUG SERVICES 4.00<br />

H0021 9 ALCOHOL AND/OR DRUG TRAINING 0.00<br />

H0022 9 ALCOHOL AND/OR DRUG INTERVEN 0.00<br />

H0023 9 ALCOHOL AND/OR DRUG OUTREACH 0.00<br />

H0024 9 ALCOHOL AND/OR DRUG PREVENTI 0.00<br />

H0025 9 ALCOHOL AND/OR DRUG PREVENTI 0.00<br />

H0026 9 ALCOHOL AND/OR DRUG PREVENTI 0.00<br />

H0027 9 ALCOHOL AND/OR DRUG PREVENTI 0.00<br />

H0028 9 ALCOHOL AND/OR DRUG PREVENTI 0.00<br />

H0029 9 ALCOHOL AND/OR DRUG PREVENTI 0.00<br />

H0030 9 ALCOHOL AND/OR DRUG HOTLINE 0.00<br />

H0031 7 MH HEALTH ASSESS BY NON-MD 0.00<br />

H0032 7 MH SVC PLAN <strong>DE</strong>V BY NON-MD 0.00<br />

H0033 9 ORAL MED ADM DIRECT OBSERVE 0.00<br />

H0034 9 MED TRNG & SUPPORT PER 15MIN 0.00<br />

H0035 9 MH PARTIAL HOSP TX UN<strong>DE</strong>R 24H 0.00<br />

H0036 9 COMM PSY FACE-FACE PER 15MIN 0.00<br />

H0037 7 COMM PSY SUP TX PGM PER DIEM 0.00<br />

H0038 9 SELF-HELP/PEER SVC PER 15MIN 0.00<br />

H0039 7 ASSER COM TX FACE-FACE/15MIN 0.00<br />

H0040 9 ASSERT COMM TX PGM PER DIEM 0.00<br />

H0041 9 FOS C CHLD NON-THER PER DIEM 0.00

---

H0042 9 FOS C CHLD NON-THER PER MON 0.00<br />

H0043 7 SUPPORTED HOUSING, PER DIEM 0.00<br />

H0044 9 SUPPORTED HOUSING, PER MONTH 0.00<br />

H0045 9 RESPITE NOT-IN-HOME PER DIEM 0.00<br />

H0046 7 MENTAL HEALTH SERVICE, NOS 0.00<br />

H0047 9 ALCOHOL/DRUG ABUSE SVC NOS 0.00<br />

H0048 9 SPEC COLL NON-BLOOD:A/D TEST 0.00<br />

H0049 9 ALCOHOL/DRUG SCREENING 0.00<br />

H0050 9 ALCOHOL/DRUG SERVICE 15 MIN 0.00<br />

H1000 9 PRENATAL CARE ATRISK ASSESSM 0.00<br />

H1001 9 ANTEPARTUM MANAGEMENT 0.00<br />

H1002 9 CARECOORDINATION PRENATAL 0.00<br />

H1003 9 PRENATAL AT RISK EDUCATION 0.00<br />

H1004 9 FOLLOW UP HOME VISIT/PRENTAL 0.00<br />

H1005 9 PRENATALCARE ENHANCED SRV PK 0.00<br />

H1010 9 NONMED FAMILY PLANNING ED 0.00<br />

H1011 9 FAMILY ASSESSMENT 0.00<br />

H2000 9 COMP MULTIDISIPLN EVALUATION 0.00<br />

H2001 9 REHABILITATION PROGRAM 1/2 D 0.00<br />

H2010 9 COMPREHENSIVE MED SVC 15 MIN 0.00<br />

H2011 7 CRISIS INTERVEN SVC, 15 MIN 0.00<br />

H2012 7 BEHAV HLTH DAY TREAT, PER HR 0.00<br />

H2013 9 PSYCH HLTH FAC SVC, PER DIEM 0.00<br />

H2014 9 SKILLS TRAIN AND <strong>DE</strong>V, 15 MIN 0.00<br />

H2015 9 COMP COMM SUPP SVC, 15 MIN 0.00<br />

H2016 7 COMP COMM SUPP SVC, PER DIEM 0.00<br />

H2017 9 PSYSOC REHAB SVC, PER 15 MIN 0.00<br />

H2018 7 PSYSOC REHAB SVC, PER DIEM 0.00<br />

H2019 9 THER BEHAV SVC, PER 15 MIN 0.00<br />

H2020 7 THER BEHAV SVC, PER DIEM 0.00<br />

H2021 9 COM WRAP-AROUND SV, 15 MIN 0.00<br />

H2022 9 COM WRAP-AROUND SV, PER DIEM 0.00<br />

H2023 9 SUPPPORTED EMPLOY, PER 15 MIN 0.00<br />

H2024 7 SUPPORTED EMPLOY, PER DIEM 0.00<br />

H2025 9 SUPP MAINT EMPLOY, 15 MIN 0.00<br />

H2026 9 SUPP MAINT EMPLOY, PER DIEM 0.00<br />

H2027 7 PSYCHOED SVC, PER 15 MIN 0.00<br />

H2028 9 SEX OFFEND TX SVC, 15 MIN 0.00<br />

H2029 9 SEX OFFEND TX SVC, PER DIEM 0.00<br />

H2030 9 MH CLUBHOUSE SVC, PER 15 MIN 0.00<br />

H2031 9 MH CLUBHOUSE SVC, PER DIEM 0.00<br />

H2032 9 ACTIVITY THERAPY, PER 15 MIN 0.00<br />

H2033 9 MULTISYS THER/JUVENILE 15MIN 0.00<br />

H2034 9 A/D HALFWAY HOUSE, PER DIEM 0.00<br />

H2035 7 A/D TX PROGRAM, PER HOUR 0.00<br />

H2036 7 A/D TX PROGRAM, PER DIEM 0.00<br />

H2037 9 <strong>DE</strong>V <strong>DE</strong>LAY PREV DP CH, 15 MIN 0.00<br />

H5010 9 THERAPY, INDIVIDUAL, BY SOCIAL WORK 0.00<br />

H5020 9 PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER 0.00<br />

H5025 9 PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER 0.00

---

H5030 9 OTHER SERVICES BY SOCIAL WORKER, PS 0.00<br />

H5040 9 RESI<strong>DE</strong>NTIAL CARE IN PUBLIC INSTITUT 0.00<br />

H5050 9 RESI<strong>DE</strong>NTIAL CARE IN PRIVATE INSTITU 0.00<br />

H5060 9 PUBLIC SPECIAL SCHOOLS OR DAY CARE 0.00<br />

H5090 9 SPECIAL CLASS PRIVATE 0.00<br />

H5100 9 SPECIAL CLASS PRIVATE PROPRIETARY 0.00<br />

H5110 9 SUMMER TREATMENT CAMP 0.00<br />

H5120 9 SPECIALIZED CARE NURSING HOME, CONV 0.00<br />

H5130 9 VISITING TEACHER SERVICES 0.00<br />

H5160 9 READING THERAPY 0.00<br />

H5170 9 OTHER SPECIAL EDUCATION OR VOCATION 0.00<br />

H5180 9 TRANSPORTATION FOR HANDICAPPED 0.00<br />

H5190 9 NURSING CARE, HOME 0.00<br />

H5200 9 NURSING CARE, OTHER 0.00<br />

H5220 9 REHABILITATIVE EVALUATION, 0-20 MIN 0.00<br />

H5230 9 REHABILITATIVE EVALUATION, 21-40 MI 0.00<br />

H5240 9 REHABILITATIVE EVALUATION, 41-60 MI 0.00<br />

H5299 9 REHABILITATIVE EVALUATION, NOT OTHE 0.00<br />

H5300 9 OCCUPATIONAL THERAPY, EXCLUDING INI 0.00<br />

HI010 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI011 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI012 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI013 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI014 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI020 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI021 O MCO SPECIFIC: HOME INFUSION PACKAGE 0.00<br />

HI022 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI023 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI024 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI030 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI031 O MCO SCPECIFIC CO<strong>DE</strong>: HOME INFUSION P 0.00<br />

HI032 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI033 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI034 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI040 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI041 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI042 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI043 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI044 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI050 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI060 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI070 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI080 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION, S 0.00<br />

HI081 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION, S 0.00<br />

HI082 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION, S 0.00<br />

HI090 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI091 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI092 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI093 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI094 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00

---

HI100 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI110 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI120 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION, E 0.00<br />

HI130 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI140 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI160 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI170 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI171 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI172 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI180 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HI190 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION PA 0.00<br />

HM1CW O MCO SPECIFIC CO<strong>DE</strong>: SMART START INIT 0.00<br />

HM1RN O MCO SPECIFIC CO<strong>DE</strong>: SMART START INIT 0.00<br />

HM1SW O MCO SPECIFIC CO<strong>DE</strong>: SMART START INIT 0.00<br />

HM2CW O MCO SPECIFIC CO<strong>DE</strong>: SMART START POST 0.00<br />

HM2RN O MCO SPECIFIC CO<strong>DE</strong>: SMART START POST 0.00<br />

HM2SW O MCO SPECIFIC CO<strong>DE</strong>: SMART START POST 0.00<br />

J0110 O ADMINISTRATION OF INJECTION, INCLUD 0.00<br />

J0120 5 TETRACYCLIN INJECTION 0.00<br />

J0128 6 ABARELIX INJECTION 0.00<br />

J0129 3 ABATACEPT INJECTION 18.58<br />

J0130 6 ABCIXIMAB INJECTION 0.00<br />

J0132 5 ACETYLCYSTEINE INJECTION 0.00<br />

J0133 5 ACYCLOVIR INJECTION 0.00<br />

J0135 6 ADALIMUMAB INJECTION 0.00<br />

J0150 3 INJECTION A<strong>DE</strong>NOSINE 6 MG 9.62<br />

J0151 5 A<strong>DE</strong>NOSINE INJECTION 0.00<br />

J0152 6 A<strong>DE</strong>NOSINE INJECTION 0.00<br />

J0170 6 ADRENALIN EPINEPHRIN INJECT 0.00<br />

J0180 6 AGALSIDASE BETA INJECTION 0.00<br />

J0190 5 INJ BIPERI<strong>DE</strong>N LACTATE/5 MG 0.00<br />

J0200 9 ALATROFLOXACIN MESYLATE 0.00<br />

J0205 5 ALGLUCERASE INJECTION 0.00<br />

J0207 6 AMIFOSTINE 0.00<br />

J0210 5 METHYLDOPATE HCL INJECTION 0.00<br />

J0215 6 ALEFACEPT 0.00<br />

J0220 6 INJECTION, ALGLUCOSIDASE ALFA, 0.00<br />

J0230 O INJECTION, ALLERGY <strong>DE</strong>SENSITIZATION, 0.00<br />

J0240 O INJECTION, ALLERGY <strong>DE</strong>SENSITIZATION, 0.00<br />

J0256 5 ALPHA 1 PROTEINASE INHIBITOR 0.00<br />

J0270 9 ALPROSTADIL FOR INJECTION 0.00<br />

J0275 9 ALPROSTADIL URETHRAL SUPPOS 0.00<br />

J0278 5 AMIKACIN SULFATE INJECTION 0.00<br />

J0280 6 AMINOPHYLLIN 250 MG INJ 0.00<br />

J0282 5 AMIODARONE HCL 0.00<br />

J0285 5 AMPHOTERICIN B 0.00<br />

J0286 O AMPHOTERICIN B LIPID COMPLEX 0.00<br />

J0287 6 AMPHOTERICIN B LIPID COMPLEX 0.00<br />

J0288 5 AMPHO B CHOLESTERYL SULFATE 0.00<br />

J0289 6 AMPHOTERICIN B LIPOSOME INJ 0.00

---

J0290 6 AMPICILLIN 500 MG INJ 0.00<br />

J0295 6 AMPICILLIN SODIUM PER 1.5 GM 0.00<br />

J0300 5 AMOBARBITAL 125 MG INJ 0.00<br />

J0330 6 SUCCINYCHOLINE CHLORI<strong>DE</strong> INJ 0.00<br />

J0340 O NANDROLON PHENPROPIONATE INJ 0.00<br />

J0348 6 ANIDULAFUNGIN INJECTION 0.00<br />

J0350 5 INJECTION ANISTREPLASE 30 U 0.00<br />

J0360 5 HYDRALAZINE HCL INJECTION 0.00<br />

J0364 6 APOMORPHINE HYDROCHLORI<strong>DE</strong> 0.00<br />

J0365 5 APROTONIN, 10,000 KIU 0.00<br />

J0380 5 INJ METARAMINOL BITARTRATE 0.00<br />

J0390 5 CHLOROQUINE INJECTION 0.00<br />

J0395 5 ARBUTAMINE HCL INJECTION 0.00<br />

J0400 6 INJECTION, ARIPIPRAZOLE, INTRAMUSC 0.00<br />

J0456 6 AZITHROMYCIN 0.00<br />

J0460 6 ATROPINE SULFATE INJECTION 0.00<br />

J0470 5 DIMECAPROL INJECTION 0.00<br />

J0475 6 BACLOFEN 10 MG INJECTION 0.00<br />

J0480 5 BASILIXIMAB 0.00<br />

J0500 5 DICYCLOMINE INJECTION 0.00<br />

J0510 O BENZQUINAMI<strong>DE</strong> INJECTION 0.00<br />

J0515 5 INJ BENZTROPINE MESYLATE 0.00<br />

J0520 5 BETHANECHOL CHLORI<strong>DE</strong> INJECT 0.00<br />

J0530 5 PENICILLIN G BENZATHINE INJ 0.00<br />

J0540 5 PENICILLIN G BENZATHINE INJ 0.00<br />

J0550 5 PENICILLIN G BENZATHINE INJ 0.00<br />

J0560 5 PENICILLIN G BENZATHINE INJ 0.00<br />

J0570 3 PENICILLIN G BENZATHINE INJ 13.60<br />

J0580 5 PENICILLIN G BENZATHINE INJ 0.00<br />

J0583 6 BIVALIRUDIN 0.00<br />

J0585 6 BOTULINUM TOXIN A PER UNIT 0.00<br />

J0587 6 BOTULINUM TOXIN TYPE B 0.00<br />

J0590 O ETHYLNOREPINEPHRINE HCL INJ 0.00<br />

J0592 5 BUPRENORPHINE HYDROCHLORI<strong>DE</strong> 0.00<br />

J0594 6 BUSULFAN INJECTION 0.00<br />

J0595 6 BUTORPHANOL TARTRATE 1 MG 0.00<br />

J0600 5 E<strong>DE</strong>TATE CALCIUM DISODIUM INJ 0.00<br />

J0610 6 CALCIUM GLUCONATE INJECTION 0.00<br />

J0620 5 CALCIUM GLYCER & LACT/10 ML 0.00<br />

J0630 5 CALCITONIN SALMON INJECTION 0.00<br />

J0635 O CALCITRIOL INJECTION 0.00<br />

J0636 5 INJ CALCITRIOL PER 0.1 MCG 0.00<br />

J0637 5 CASPOFUNGIN ACETATE 0.00<br />

J0640 3 LEUCOVORIN CALCIUM INJECTION 1.95<br />

J0641 6 LEVOLEUCOVORIN INJECTION 0.00<br />

J0670 3 INJ MEPIVACAINE HCL/10 ML 1.82<br />

J0680 O INJECTION, <strong>DE</strong>SLANOSI<strong>DE</strong>, UP TO 0.4 M 0.00<br />

J0690 6 CEFAZOLIN SODIUM INJECTION 0.00<br />

J0692 6 CEFEPIME HCL FOR INJECTION 0.00<br />

J0694 6 CEFOXITIN SODIUM INJECTION 0.00

---

J0695 O CEFONOCID SODIUM INJECTION 0.00<br />

J0696 3 CEFTRIAXONE SODIUM INJECTION 13.78<br />

J0697 5 STERILE CEFUROXIME INJECTION 0.00<br />

J0698 5 CEFOTAXIME SODIUM INJECTION 0.00<br />

J0700 O INJECTION, BETAMETHASONE, UP TO 6 M 0.00<br />

J0702 6 BETAMETHASONE ACET&SOD PHOSP 0.00<br />

J0704 5 BETAMETHASONE SOD PHOSP/4 MG 0.00<br />

J0706 5 CAFFEINE CITRATE INJECTION 0.00<br />

J0710 5 CEPHAPIRIN SODIUM INJECTION 0.00<br />

J0713 5 INJ CEFTAZIDIME PER 500 MG 0.00<br />

J0715 5 CEFTIZOXIME SODIUM / 500 MG 0.00<br />

J0720 5 CHLORAMPHENICOL SODIUM INJEC 0.00<br />

J0725 5 CHORIONIC GONADOTROPIN/1000U 0.00<br />

J0730 O CHLORPHENIRAMIN MALEATE INJ 0.00<br />

J0735 5 CLONIDINE HYDROCHLORI<strong>DE</strong> 0.00<br />

J0740 6 CIDOFOVIR INJECTION 0.00<br />

J0743 6 CILASTATIN SODIUM INJECTION 0.00<br />

J0744 6 CIPROFLOXACIN IV 0.00<br />

J0745 5 INJ CO<strong>DE</strong>INE PHOSPHATE /30 MG 0.00<br />

J0760 6 COLCHICINE INJECTION 0.00<br />

J0770 5 COLISTIMETHATE SODIUM INJ 0.00<br />

J0780 5 PROCHLORPERAZINE INJECTION 0.00<br />

J0790 O INJECTION, NIKETHAMI<strong>DE</strong>, UP TO 1.5 M 0.00<br />

J0795 5 CORTICORELIN OVINE TRIFLUTAL 0.00<br />

J0800 6 CORTICOTROPIN INJECTION 0.00<br />

J0810 O CORTISONE INJECTION 0.00<br />

J0820 O INJECTION, CORTIGEL 40, UP TO 40 UN 0.00<br />

J0830 O INJECTION, CORTROPHIN ZINC HYDROXID 0.00<br />

J0835 6 INJ COSYNTROPIN PER 0.25 MG 0.00<br />

J0840 O INJECTION, WARFARIN SODIUM, UP TO 5 0.00<br />

J0850 6 CYTOMEGALOVIRUS IMM IV /VIAL 0.00<br />

J0878 6 DAPTOMYCIN INJECTION 0.00<br />

J0880 O DARBEPOETIN ALFA INJECTION 0.00<br />

J0881 6 DARBEPOETIN ALFA, NON-ESRD 0.00<br />

J0882 5 DARBEPOETIN ALFA, ESRD USE 0.00<br />

J0885 6 EPOETIN ALFA, NON-ESRD 0.00<br />

J0886 5 EPOETIN ALFA 1000 UNITS ESRD 0.00<br />

J0894 6 <strong>DE</strong>CITABINE INJECTION 0.00<br />

J0895 5 <strong>DE</strong>FEROXAMINE MESYLATE INJ 0.00<br />

J0900 5 TESTOSTERONE ENANTHATE INJ 0.00<br />

J0945 5 BROMPHENIRAMINE MALEATE INJ 0.00<br />

J0970 5 ESTRADIOL VALERATE INJECTION 0.00<br />

J1000 5 <strong>DE</strong>PO-ESTRADIOL CYPIONATE INJ 0.00<br />

J1020 6 METHYLPREDNISOLONE 20 MG INJ 0.00<br />

J1030 6 METHYLPREDNISOLONE 40 MG INJ 0.00<br />

J1040 3 METHYLPREDNISOLONE 80 MG INJ 10.57<br />

J1050 5 MEDROXYPROGESTERONE INJ 0.00<br />

J1051 6 MEDROXYPROGESTERONE INJ 0.00<br />

J1055 6 MEDRXYPROGESTER ACETATE INJ 0.00<br />

J1056 3 MA/EC CONTRACEPTIVEINJECTION 22.50

---

J1060 5 TESTOSTERONE CYPIONATE 1 ML 0.00<br />

J1070 5 TESTOSTERONE CYPIONAT 100 MG 0.00<br />

J1080 5 TESTOSTERONE CYPIONAT 200 MG 0.00<br />

J1090 O TESTOSTERONE CYPIONATE 50 MG 0.00<br />

J1094 6 INJ <strong>DE</strong>XAMETHASONE ACETATE 0.00<br />

J1095 5 INJ <strong>DE</strong>XAMETHASONE ACETATE 0.00<br />

J1100 6 <strong>DE</strong>XAMETHASONE SODIUM PHOS 0.00<br />

J1110 6 INJ DIHYDROERGOTAMINE MESYLT 0.00<br />

J1120 5 ACETAZOLAMID SODIUM INJECTIO 0.00<br />

J1155 O INJECTION, DIGITOXIN 0.00<br />

J1160 5 DIGOXIN INJECTION 0.00<br />

J1162 5 DIGOXIN IMMUNE FAB (OVINE) 0.00<br />

J1165 5 PHENYTOIN SODIUM INJECTION 0.00<br />

J1170 6 HYDROMORPHONE INJECTION 0.00<br />

J1180 5 DYPHYLLINE INJECTION 0.00<br />

J1190 5 <strong>DE</strong>XRAZOXANE HCL INJECTION 0.00<br />

J1200 6 DIPHENHYDRAMINE HCL INJECTIO 0.00<br />

J1205 5 CHLOROTHIAZI<strong>DE</strong> SODIUM INJ 0.00<br />

J1212 5 DIMETHYL SULFOXI<strong>DE</strong> 50% 50 ML 0.00<br />

J1230 5 METHADONE INJECTION 0.00<br />

J1240 5 DIMENHYDRINATE INJECTION 0.00<br />

J1245 3 DIPYRIDAMOLE INJECTION 7.52<br />

J1250 6 INJ DOBUTAMINE HCL/250 MG 0.00<br />

J1260 6 DOLASETRON MESYLATE 0.00<br />

J1265 5 DOPAMINE INJECTION 0.00<br />

J1267 6 DORIPENEM INJECTION 0.00<br />

J1270 5 INJECTION, DOXERCALCIFEROL 0.00<br />

J1300 6 ECULIZUMAB INJECTION 0.00<br />

J1320 5 AMITRIPTYLINE INJECTION 0.00<br />

J1324 6 ENFUVIRTI<strong>DE</strong> INJECTION 0.00<br />

J1325 6 EPOPROSTENOL INJECTION 0.00<br />

J1327 5 EPTIFIBATI<strong>DE</strong> INJECTION 0.00<br />

J1330 5 ERGONOVINE MALEATE INJECTION 0.00<br />

J1335 6 ERTAPENEM INJECTION 0.00<br />

J1340 O INJECTION, AQUEOUS OR SALINE PLACEB 0.00<br />

J1350 O INJECTION, ERYTHROMYCIN-IM, UP TO 1 0.00<br />

J1360 O INJECTION, ERTHROMYCIN-IV, UP TO 50 0.00<br />

J1362 O ERYTHROMYCIN GLUCEP / 250 MG 0.00<br />

J1364 5 ERYTHRO LACTOBIONATE /500 MG 0.00<br />

J1380 5 ESTRADIOL VALERATE 10 MG INJ 0.00<br />

J1390 5 ESTRADIOL VALERATE 20 MG INJ 0.00<br />

J1410 6 INJ ESTROGEN CONJUGATE 25 MG 0.00<br />

J1430 6 ETHANOLAMINE OLEATE 100 MG 0.00<br />

J1435 5 INJECTION ESTRONE PER 1 MG 0.00<br />

J1436 5 ETIDRONATE DISODIUM INJ 0.00<br />

J1438 5 ETANERCEPT INJECTION 0.00<br />

J1440 6 FILGRASTIM 300 MCG INJECITON 0.00<br />

J1441 3 FILGRASTIM 480 MCG INJECTION 274.45<br />

J1450 5 FLUCONAZOLE 0.00<br />

J1451 5 FOMEPIZOLE, 15 MG 0.00

---

J1452 5 INTRAOCULAR FOMIVIRSEN NA 0.00<br />

J1453 6 FOSAPREPITANT INJECTION 0.00<br />

J1455 6 FOSCARNET SODIUM INJECTION 0.00<br />

J1457 6 GALLIUM NITRATE INJECTION 0.00<br />

J1458 6 GALSULFASE INJECTION 0.00<br />

J1459 6 INJ IVIG PRIVIGEN 500 MG 0.00<br />

J1460 5 GAMMA GLOBULIN 1 CC INJ 0.00<br />

J1470 5 GAMMA GLOBULIN 2 CC INJ 0.00<br />

J1480 5 GAMMA GLOBULIN 3 CC INJ 0.00<br />

J1490 5 GAMMA GLOBULIN 4 CC INJ 0.00<br />

J1500 5 GAMMA GLOBULIN 5 CC INJ 0.00<br />

J1510 5 GAMMA GLOBULIN 6 CC INJ 0.00<br />

J1520 5 GAMMA GLOBULIN 7 CC INJ 0.00<br />

J1530 5 GAMMA GLOBULIN 8 CC INJ 0.00<br />

J1540 5 GAMMA GLOBULIN 9 CC INJ 0.00<br />

J1550 5 GAMMA GLOBULIN 10 CC INJ 0.00<br />

J1560 5 GAMMA GLOBULIN > 10 CC INJ 0.00<br />

J1561 6 IMMUNE GLOBULIN 500 MG 0.00<br />

J1562 6 VIVAGLOBIN, INJ 0.00<br />

J1563 O IV IMMUNE GLOBULIN 0.00<br />

J1564 O IMMUNE GLOBULIN 10 MG 0.00<br />

J1565 5 RSV-IVIG 0.00<br />

J1566 5 IMMUNE GLOBULIN, POW<strong>DE</strong>R 0.00<br />

J1567 O IMMUNE GLOBULIN, LIQUID 0.00<br />

J1568 6 OCTAGAM INJECTION 0.00<br />

J1569 6 GAMMAGARD LIQUID INJECTION 0.00<br />

J1570 6 GANCICLOVIR SODIUM INJECTION 0.00<br />

J1571 6 HEPAGAM B IM INJECTION 0.00<br />

J1572 6 FLEBOGAMMA INJECTION 0.00<br />

J1573 6 HEPAGAM B INTRAVENOUS, INJ 0.00<br />

J1580 6 GARAMYCIN GENTAMICIN INJ 0.00<br />

J1590 5 GATIFLOXACIN INJECTION 0.00<br />

J1595 6 INJECTION GLATIRAMER ACETATE 0.00<br />

J1600 5 GOLD SODIUM THIOMALEATE INJ 0.00<br />

J1610 5 GLUCAGON HYDROCHLORI<strong>DE</strong>/1 MG 0.00<br />

J1620 5 GONADORELIN HYDROCH/ 100 MCG 0.00<br />

J1625 O INJECTION, GRANISETRON HYDROCHLORID 0.00<br />

J1626 6 GRANISETRON HCL INJECTION 0.00<br />

J1630 5 HALOPERIDOL INJECTION 0.00<br />

J1631 5 HALOPERIDOL <strong>DE</strong>CANOATE INJ 0.00<br />

J1640 5 INJECTION, HEMIN, 1 MG 0.00<br />

J1642 6 INJ HEPARIN SODIUM PER 10 U 0.00<br />

J1644 6 INJ HEPARIN SODIUM PER 1000U 0.00<br />

J1645 5 DALTEPARIN SODIUM 0.00<br />

J1650 6 INJ ENOXAPARIN SODIUM 0.00<br />

J1652 5 FONDAPARINUX SODIUM 0.00<br />

J1655 6 TINZAPARIN SODIUM INJECTION 0.00<br />

J1660 O INJECTION, HISTAMINE, UP TO 2.75 MG 0.00<br />

J1670 5 TETANUS IMMUNE GLOBULIN INJ 0.00<br />

J1675 5 HISTRELIN ACETATE 0.00

---

J1690 O PREDNISOLONE TEBUTATE INJ 0.00<br />

J1700 5 HYDROCORTISONE ACETATE INJ 0.00<br />

J1710 5 HYDROCORTISONE SODIUM PH INJ 0.00<br />

J1720 6 HYDROCORTISONE SODIUM SUCC I 0.00<br />

J1730 5 DIAZOXI<strong>DE</strong> INJECTION 0.00<br />

J1739 O HYDROXYPROGESTERONE CAP 125 0.00<br />

J1740 6 IBANDRONATE SODIUM INJECTION 0.00<br />

J1741 O HYDROXYPROGESTERONE CAP 250 0.00<br />

J1742 5 IBUTILI<strong>DE</strong> FUMARATE INJECTION 0.00<br />

J1743 6 IDURSULFASE INJECTION 0.00<br />

J1745 3 INFLIXIMAB INJECTION 57.08<br />

J1750 O IRON <strong>DE</strong>XTRAN 0.00<br />

J1751 O IRON <strong>DE</strong>XTRAN 165 INJECTION 0.00<br />

J1752 O IRON <strong>DE</strong>XTRAN 267 INJECTION 0.00<br />

J1755 O IRON SUCROSE INJECTION 0.00<br />

J1756 6 IRON SUCROSE INJECTION 0.00<br />

J1760 O IRON <strong>DE</strong>XTRAN 2 CC INJ 0.00<br />

J1770 O IRON <strong>DE</strong>XTRAN 5 CC INJ 0.00<br />

J1780 O IRON <strong>DE</strong>XTRAN 10 CC INJ 0.00<br />

J1785 5 INJECTION IMIGLUCERASE /UNIT 0.00<br />

J1790 5 DROPERIDOL INJECTION 0.00<br />

J1800 5 PROPRANOLOL INJECTION 0.00<br />

J1810 5 DROPERIDOL/FENTANYL INJ 0.00<br />

J1815 6 INSULIN INJECTION 0.00<br />

J1817 5 INSULIN FOR INSULIN PUMP USE 0.00<br />

J1820 O INSULIN INJECTION 0.00<br />

J1825 6 INTERFERON BETA-1A 0.00<br />

J1830 5 INTERFERON BETA-1B / .25 MG 0.00<br />

J1835 5 INTRACONAZOLE INJECTION 0.00<br />

J1840 5 KANAMYCIN SULFATE 500 MG INJ 0.00<br />

J1850 5 KANAMYCIN SULFATE 75 MG INJ 0.00<br />

J1885 6 KETOROLAC TROMETHAMINE INJ 0.00<br />

J1890 5 CEPHALOTHIN SODIUM INJECTION 0.00<br />

J1910 O KUTAPRESSIN INJECTION 0.00<br />

J1930 O PROPIOMAZINE INJECTION 0.00<br />

J1931 6 LARONIDASE INJECTION 0.00<br />

J1940 6 FUROSEMI<strong>DE</strong> INJECTION 0.00<br />

J1945 5 LEPIRUDIN 0.00<br />

J1950 5 LEUPROLI<strong>DE</strong> ACETATE /3.75 MG 0.00<br />

J1953 6 LEVETIRACETAM INJECTION 0.00<br />

J1955 5 INJ LEVOCARNITINE PER 1 GM 0.00<br />

J1956 6 LEVOFLOXACIN INJECTION 0.00<br />

J1960 5 LEVORPHANOL TARTRATE INJ 0.00<br />

J1970 O METHOTRIMEPRAZINE INJECTION 0.00<br />

J1980 5 HYOSCYAMINE SULFATE INJ 0.00<br />

J1990 5 CHLORDIAZEPOXI<strong>DE</strong> INJECTION 0.00<br />

J2000 O LIDOCAINE INJECTION 0.00<br />

J2001 6 LIDOCAINE INJECTION 0.00<br />

J2010 5 LINCOMYCIN INJECTION 0.00<br />

J2020 5 LINEZOLID INJECTION 0.00

---

J2050 O INJECTION, LIVER, UP TO 20 MCG 0.00<br />

J2060 6 LORAZEPAM INJECTION 0.00<br />

J2100 O INJECTION, LUMINAL SODIUM, UP TO 12 0.00<br />

J2150 6 MANNITOL INJECTION 0.00<br />

J2160 O INJECTION, CYCLIZINE LACTATE, UP TO 0.00<br />

J2170 6 MECASERMIN INJECTION 0.00<br />

J2175 6 MEPERIDINE HYDROCHL /100 MG 0.00<br />

J2180 5 MEPERIDINE/PROMETHAZINE INJ 0.00<br />

J2185 6 MEROPENEM 0.00<br />

J2190 O INJECTION, MERSALYL WITH THEOPHYLLI 0.00<br />

J2210 5 METHYLERGONOVIN MALEATE INJ 0.00<br />

J2220 5 INJECTION, METHYLANDROSTENEDIOL, AL 0.00<br />

J2240 O METOCURINE IODI<strong>DE</strong> INJECTION 0.00<br />

J2248 6 MICAFUNGIN SODIUM INJECTION 0.00<br />

J2250 6 INJ MIDAZOLAM HYDROCHLORI<strong>DE</strong> 0.00<br />

J2260 5 INJECTION, MILRINONE LACTATE 5MG 0.00<br />

J2270 6 MORPHINE SULFATE INJECTION 0.00<br />

J2271 5 MORPHINE SO4 INJECTION 100MG 0.00<br />

J2275 5 MORPHINE SULFATE INJECTION 0.00<br />

J2278 5 ZICONOTI<strong>DE</strong> INJECTION 0.00<br />

J2280 6 INJ, MOXIFLOXACIN 100 MG 0.00<br />

J2300 3 INJ NALBUPHINE HYDROCHLORI<strong>DE</strong> 1.55<br />

J2310 6 INJ NALOXONE HYDROCHLORI<strong>DE</strong> 0.00<br />

J2315 6 NALTREXONE, <strong>DE</strong>POT FORM 0.00<br />

J2320 5 NANDROLONE <strong>DE</strong>CANOATE 50 MG 0.00<br />

J2321 5 NANDROLONE <strong>DE</strong>CANOATE 100 MG 0.00<br />

J2322 5 NANDROLONE <strong>DE</strong>CANOATE 200 MG 0.00<br />

J2323 6 NATALIZUMAB INJECTION 0.00<br />

J2324 O NESIRITI<strong>DE</strong> 0.00<br />

J2325 5 NESIRITI<strong>DE</strong> INJECTION 0.00<br />

J2330 O THIOTHIXENE INJECTION 0.00<br />

J2350 O NIACINAMI<strong>DE</strong>/NIACIN INJECTION 0.00<br />

J2352 O OCTREOTI<strong>DE</strong> ACETATE INJECTION 0.00<br />

J2353 6 OCTREOTI<strong>DE</strong> INJECTION, <strong>DE</strong>POT 0.00<br />

J2354 6 OCTREOTI<strong>DE</strong> INJ, NON-<strong>DE</strong>POT 0.00<br />

J2355 5 OPRELVEKIN INJECTION 0.00<br />

J2357 6 OMALIZUMAB INJECTION 0.00<br />

J2360 5 ORPHENADRINE INJECTION 0.00<br />

J2370 5 PHENYLEPHRINE HCL INJECTION 0.00<br />

J2400 5 CHLOROPROCAINE HCL INJECTION 0.00<br />

J2405 6 ONDANSETRON HCL INJECTION 0.00<br />

J2410 5 OXYMORPHONE HCL INJECTION 0.00<br />

J2425 5 PALIFERMIN INJECTION 0.00<br />

J2430 5 PAMIDRONATE DISODIUM /30 MG 0.00<br />

J2440 5 PAPAVERIN HCL INJECTION 0.00<br />

J2460 5 OXYTETRACYCLINE INJECTION 0.00<br />

J2469 6 PALONOSETRON HCL 0.00<br />

J2480 O HYDROCHLORI<strong>DE</strong>S OF OPIUM INJ 0.00<br />

J2490 O INJECTION, PARAL<strong>DE</strong>HY<strong>DE</strong>, UP TO 5 ML 0.00<br />

J2495 O INJECTION, TRIDIHEXETHYL CHLORI<strong>DE</strong> P 0.00

---

J2500 O PARICALCITOL 0.00<br />

J2501 5 PARICALCITOL 0.00<br />

J2503 5 PEGAPTANIB SODIUM INJECTION 0.00<br />

J2504 5 PEGA<strong>DE</strong>MASE BOVINE, 25 IU 0.00<br />

J2505 6 INJECTION, PEGFILGRASTIM 6MG 0.00<br />

J2510 5 PENICILLIN G PROCAINE INJ 0.00<br />

J2512 O INJ PENTAGASTRIN PER 2 ML 0.00<br />

J2513 5 PENTASTARCH 10% SOLUTION 0.00<br />

J2515 6 PENTOBARBITAL SODIUM INJ 0.00<br />

J2520 5 INJECTION, THIOPENTAL SODIUM 0.00<br />

J2540 6 PENICILLIN G POTASSIUM INJ 0.00<br />

J2543 5 PIPERACILLIN/TAZOBACTAM 0.00<br />

J2545 9 PENTAMIDINE NON-COMP UNIT 0.00<br />

J2550 6 PROMETHAZINE HCL INJECTION 0.00<br />

J2560 5 PHENOBARBITAL SODIUM INJ 0.00<br />

J2590 5 OXYTOCIN INJECTION 0.00<br />

J2595 O INJECTION, VASOPRESSIN TANNATE 0.00<br />

J2597 5 INJ <strong>DE</strong>SMOPRESSIN ACETATE 0.00<br />

J2600 O INJECTION, POSTERIOR PITUITARY, UP 0.00<br />

J2640 O PREDNISOLONE SODIUM PH INJ 0.00<br />

J2650 5 PREDNISOLONE ACETATE INJ 0.00<br />

J2670 5 TOTAZOLINE HCL INJECTION 0.00<br />

J2672 O INJECTION, PROPANTHELINE BROMI<strong>DE</strong> 0.00<br />

J2675 O INJ PROGESTERONE PER 50 MG 0.00<br />

J2680 5 FLUPHENAZINE <strong>DE</strong>CANOATE 25 MG 0.00<br />

J2690 5 PROCAINAMI<strong>DE</strong> HCL INJECTION 0.00<br />

J2700 6 OXACILLIN SODIUM INJECITON 0.00<br />

J2710 5 NEOSTIGMINE METHYLSLFTE INJ 0.00<br />

J2720 5 INJ PROTAMINE SULFATE/10 MG 0.00<br />

J2724 6 PROTEIN C CONCENTRATE 0.00<br />

J2725 5 INJ PROTIRELIN PER 250 MCG 0.00<br />

J2730 5 PRALIDOXIME CHLORI<strong>DE</strong> INJ 0.00<br />

J2760 9 PHENTOLAINE MESYLATE INJ 0.00<br />

J2765 3 METOCLOPRAMI<strong>DE</strong> HCL INJECTION 1.30<br />

J2770 5 QUINUPRISTIN/DALFOPRISTIN 0.00<br />

J2778 6 RANIBIZUMAB INJECTION 0.00<br />

J2780 6 RANITIDINE HYDROCHLORI<strong>DE</strong> INJ 0.00<br />

J2783 6 RASBURICASE 0.00<br />

J2785 6 REGA<strong>DE</strong>NOSON INJECTION 0.00<br />

J2788 6 RHO D IMMUNE GLOBULIN 50 MCG 0.00<br />

J2790 6 RHO D IMMUNE GLOBULIN INJ 0.00<br />

J2791 6 RHOPHYLAC INJECTION 0.00<br />

J2792 6 RHO(D) IMMUNE GLOBULIN H, SD 0.00<br />

J2794 6 RISPERIDONE, LONG ACTING 0.00<br />

J2795 5 ROPIVACAINE HCL INJECTION 0.00<br />

J2800 5 METHOCARBAMOL INJECTION 0.00<br />

J2805 5 SINCALI<strong>DE</strong> INJECTION 0.00<br />

J2810 5 INJ THEOPHYLLINE PER 40 MG 0.00<br />

J2820 6 SARGRAMOSTIM INJECTION 0.00<br />

J2825 O INJECTION, SARRACENIA PURPUREA PLAN 0.00

---

J2850 5 INJ SECRETIN SYNTHETIC HUMAN 0.00<br />

J2860 O SECOBARBITAL SODIUM INJ 0.00<br />

J2910 5 AUROTHIOGLUCOSE INJECITON 0.00<br />

J2914 O INJECTION, SODIUM SALICYLATE 0.00<br />

J2915 O NA FERRIC GLUCONATE COMPLEX 0.00<br />

J2916 5 NA FERRIC GLUCONATE COMPLEX 0.00<br />

J2920 6 METHYLPREDNISOLONE INJECTION 0.00<br />

J2930 6 METHYLPREDNISOLONE INJECTION 0.00<br />

J2940 5 SOMATREM INJECTION 0.00<br />

J2941 5 SOMATROPIN INJECTION 0.00<br />

J2950 5 PROMAZINE HCL INJECITON 0.00<br />

J2970 O METHICILLIN SODIUM INJECTION 0.00<br />

J2993 5 RETEPLASE INJECTION 0.00<br />

J2994 9 RETEPLASE DOUBLE BOLUS 0.00<br />

J2995 5 INJ STREPTOKINASE /250000 IU 0.00<br />

J2996 O ALTEPLASE RECOMBINANT INJ 0.00<br />

J2997 6 ALTEPLASE RECOMBINANT 0.00<br />

J3000 6 STREPTOMYCIN INJECTION 0.00<br />

J3005 O INJECTION, STRONTIUM-89 CHLORI<strong>DE</strong>, P 0.00<br />

J3010 3 FENTANYL CITRATE INJECITON 0.62<br />

J3030 5 SUMATRIPTAN SUCCINATE / 6 MG 0.00<br />

J3050 O INJECTION, <strong>DE</strong>CAMETHONIUM BROMI<strong>DE</strong>, U 0.00<br />

J3070 5 PENTAZOCINE INJECTION 0.00<br />

J3080 O CHLORPROTHIXENE INJECTION 0.00<br />

J3100 O TENECTEPLASE INJECTION 0.00<br />

J3101 9 TENECTEPLASE INJECTION 0.00<br />

J3105 5 TERBUTALINE SULFATE INJ 0.00<br />

J3110 6 TERIPARATI<strong>DE</strong> INJECTION 0.00<br />

J3120 5 TESTOSTERONE ENANTHATE INJ 0.00<br />

J3130 5 TESTOSTERONE ENANTHATE INJ 0.00<br />

J3140 5 TESTOSTERONE SUSPENSION INJ 0.00<br />

J3150 5 TESTOSTERON PROPIONATE INJ 0.00<br />

J3180 O INJECTION, TETANUS TOXOID, UP TO 1 0.00<br />

J3230 5 CHLORPROMAZINE HCL INJECTION 0.00<br />

J3240 5 THYROTROPIN INJECTION 0.00<br />

J3243 6 TIGECYCLINE INJECTION 0.00<br />

J3245 O TIROFIBAN HYDROCHLORI<strong>DE</strong> 0.00<br />

J3246 6 TIROFIBAN HCL 0.00<br />

J3250 5 TRIMETHOBENZAMI<strong>DE</strong> HCL INJ 0.00<br />

J3260 5 TOBRAMYCIN SULFATE INJECTION 0.00<br />

J3265 5 INJECTION TORSEMI<strong>DE</strong> 10 MG/ML 0.00<br />

J3270 O IMIPRAMINE HCL INJECTION 0.00<br />

J3280 5 THIETHYLPERAZINE MALEATE INJ 0.00<br />

J3285 5 TREPROSTINIL INJECTION 0.00<br />

J3300 O INJECTION, TRIAMCINOLONE ACETONI<strong>DE</strong>, 0.00<br />

J3301 3 TRIAMCINOLONE ACET INJ NOS 1.40<br />

J3302 5 TRIAMCINOLONE DIACETATE INJ 0.00<br />

J3303 6 TRIAMCINOLONE HEXACETONL INJ 0.00<br />

J3305 5 INJ TRIMETREXATE GLUCORONATE 0.00<br />

J3310 5 PERPHENAZINE INJECITON 0.00

---

J3315 5 TRIPTORELIN PAMOATE 0.00<br />

J3320 5 SPECTINOMYCN DI-HCL INJ 0.00<br />

J3340 O INJECTION, CRYPTENAMINE ACETATE, UP 0.00<br />

J3350 5 UREA INJECTION 0.00<br />

J3355 9 UROFOLLITROPIN, 75 IU 0.00<br />

J3360 5 DIAZEPAM INJECTION 0.00<br />

J3364 5 UROKINASE 5000 IU INJECTION 0.00<br />

J3365 5 UROKINASE 250,000 IU INJ 0.00<br />

J3370 6 VANCOMYCIN HCL INJECITON 0.00<br />

J3380 O INJECTION, ISOXSUPRINE HCL, UP TO 1 0.00<br />

J3390 O METHOXAMINE INJECTION 0.00<br />

J3395 O VERTEPORFIN INJECTION 0.00<br />

J3396 6 VERTEPORFIN INJECTION 0.00<br />

J3400 5 TRIFLUPROMAZINE HCL INJ 0.00<br />

J3410 6 HYDROXYZINE HCL INJECITON 0.00<br />

J3411 6 THIAMINE HCL 100 MG 0.00<br />

J3415 6 PYRIDOXINE HCL 100 MG 0.00<br />

J3420 6 VITAMIN B12 INJECTION 0.00<br />

J3430 5 VITAMIN K PHYTONADIONE INJ 0.00<br />

J3450 O MEPHENTERMINE SULFATE INJ 0.00<br />

J3465 6 INJECTION, VORICONAZOLE 0.00<br />

J3470 5 HYALURONIDASE INJECTION 0.00<br />

J3471 5 OVINE, UP TO 999 USP UNITS 0.00<br />

J3472 5 OVINE, 1000 USP UNITS 0.00<br />

J3473 6 HYALURONIDASE RECOMBINANT 0.00<br />

J3475 6 INJ MAGNESIUM SULFATE 0.00<br />

J3480 6 INJ POTASSIUM CHLORI<strong>DE</strong> 0.00<br />

J3485 5 ZIDOVUDINE 0.00<br />

J3486 6 ZIPRASIDONE MESYLATE 0.00<br />

J3487 6 ZOLEDRONIC ACID 0.00<br />

J3488 6 RECLAST INJECTION 0.00<br />

J3490 5 DRUGS UNCLASSIFIED INJECTION 0.00<br />

J3500 O VITAMIN THERAPY 0.00<br />

J3520 5 E<strong>DE</strong>TATE DISODIUM PER 150 MG 0.00<br />

J3530 9 NASAL VACCINE INHALATION 0.00<br />

J3535 9 METERED DOSE INHALER DRUG 0.00<br />

J3540 O AUTOGENOUS BLOOD EXTRACT, INTRAVENO 0.00<br />

J3550 O INTRA-ARTERIAL OXYGEN INJECTION 0.00<br />

J3560 O ADRENAL CORTEX EXTRACT 0.00<br />

J3570 9 LAETRILE AMYGDALIN VIT B17 0.00<br />

J3590 5 UNCLASSIFIED BIOLOGICS 0.00<br />

J6015 O TYPHUS 0.00<br />

J7010 O VIAL OF ALLERGY VACCINE, SINGLE DOS 0.00<br />

J7020 O VIAL OF ALLERGY VACCINE, MULTIPLE D 0.00<br />

J7030 6 NORMAL SALINE SOLUTION INFUS 0.00<br />

J7040 6 NORMAL SALINE SOLUTION INFUS 0.00<br />

J7042 6 5% <strong>DE</strong>XTROSE/NORMAL SALINE 0.00<br />

J7050 6 NORMAL SALINE SOLUTION INFUS 0.00<br />

J7051 O STERILE SALINE/WATER 0.00<br />

J7060 5 5% <strong>DE</strong>XTROSE/WATER 0.00

---

J7070 5 D5W INFUSION 0.00<br />

J7080 O INFUSION, ALBUMISOL 5%, 500 ML VIAL 0.00<br />

J7090 O INFUSION, ALBUMISOL 25%, 50 ML VIAL 0.00<br />

J7100 5 <strong>DE</strong>XTRAN 40 INFUSION 0.00<br />

J7110 5 <strong>DE</strong>XTRAN 75 INFUSION 0.00<br />

J7120 5 RINGERS LACTATE INFUSION 0.00<br />

J7130 5 HYPERTONIC SALINE SOLUTION 0.00<br />

J7140 9 PRESCRIPTION DRUG, ORAL, DISPENSED 0.00<br />

J7150 9 PRESCRIPTION DRUG, ORAL CHEMOTHERAP 0.00<br />

J7186 6 ANTIHEMOPHILIC VIII/VWF COMP 0.00<br />

J7187 6 HUMATE-P, INJ 0.00<br />

J7188 O INJ VONWILLEBRAND FACTOR IU 0.00<br />

J7189 5 FACTOR VIIA 0.00<br />

J7190 5 FACTOR VIII 0.00<br />

J7191 5 FACTOR VIII (PORCINE) 0.00<br />

J7192 5 FACTOR VIII RECOMBINANT 0.00<br />

J7193 5 FACTOR IX NON-RECOMBINANT 0.00<br />

J7194 5 FACTOR IX COMPLEX 0.00<br />

J7195 5 FACTOR IX RECOMBINANT 0.00<br />

J7196 O OTHR HEMOPHILIA CLOT FACTORS 0.00<br />

J7198 5 ANTI-INHIBITOR 0.00<br />

J7199 5 HEMOPHILIA CLOT FACTOR NOC 0.00<br />

J7300 9 INTRAUT COPPER CONTRACEPTIVE 0.00<br />

J7302 6 LEVONORGESTREL IU CONTRACEPT 0.00<br />

J7303 6 CONTRACEPTIVE VAGINAL RING 0.00<br />

J7304 9 CONTRACEPTIVE HORMONE PATCH 0.00<br />

J7306 9 LEVONORGESTREL IMPLANT SYS 0.00<br />

J7307 6 ETONOGESTREL IMPLANT SYSTEM 0.00<br />

J7308 9 AMINOLEVULINIC ACID HCL TOP 0.00<br />

J7310 9 GANCICLOVIR LONG ACT IMPLANT 0.00<br />

J7311 9 FLUOCINOLONE ACETONI<strong>DE</strong> IMPLT 0.00<br />

J7315 O SODIUM HYALURONATE INJECTION 0.00<br />

J7316 O SODIUM HYALURONATE INJECTION 0.00<br />

J7317 O SODIUM HYALURONATE INJECTION 0.00<br />

J7319 O SODIUM HYALURONATE INJECTION 0.00<br />

J7321 6 HYALGAN/SUPARTZ INJ PER DOSE 0.00<br />

J7322 6 SYNVISC INJ PER DOSE 0.00<br />

J7323 6 EUFLEXXA INJ PER DOSE 0.00<br />

J7324 6 ORTHOVISC INJ PER DOSE 0.00<br />

J7330 9 CULTURED CHONDROCYTES IMPLNT 0.00<br />

J7340 O METABOLIC ACTIVE D/E TISSUE 0.00<br />

J7341 O NON-HUMAN, METABOLIC TISSUE 0.00<br />

J7342 O METABOLICALLY ACTIVE TISSUE 0.00<br />

J7343 O NONMETABOLIC ACT D/E TISSUE 0.00<br />

J7344 O NONMETABOLIC ACTIVE TISSUE 0.00<br />

J7345 O NON-HUMAN, NON-METAB TISSUE 0.00<br />

J7346 O INJECTABLE HUMAN TISSUE 0.00<br />

J7347 O INTEGRA MATRIX TISSUE 0.00<br />

J7348 O TISSUEMEND TISSUE 0.00<br />

J7349 O PRIMATRIX TISSUE 0.00

---

J7350 O INJECTABLE HUMAN TISSUE 0.00<br />

J7500 9 AZATHIOPRINE ORAL 50MG 0.00<br />

J7501 5 AZATHIOPRINE PARENTERAL 0.00<br />

J7502 9 CYCLOSPORINE ORAL 100 MG 0.00<br />

J7503 O CYCLOSPORINE PARENTERAL 0.00<br />

J7504 5 LYMPHOCYTE IMMUNE GLOBULIN 0.00<br />

J7505 5 MONOCLONAL ANTIBODIES 0.00<br />

J7506 9 PREDNISONE ORAL 0.00<br />

J7507 9 TACROLIMUS ORAL PER 1 MG 0.00<br />

J7508 O TACROLIMUS ORAL PER 5 MG 0.00<br />

J7509 9 METHYLPREDNISOLONE ORAL 0.00<br />

J7510 9 PREDNISOLONE ORAL PER 5 MG 0.00<br />

J7511 5 ANTITHYMOCYTE GLOBULN RABBIT 0.00<br />

J7513 5 DACLIZUMAB, PARENTERAL 0.00<br />

J7515 9 CYCLOSPORINE ORAL 25 MG 0.00<br />

J7516 5 CYCLOSPORIN PARENTERAL 250MG 0.00<br />

J7517 9 MYCOPHENOLATE MOFETIL ORAL 0.00<br />

J7518 9 MYCOPHENOLIC ACID 0.00<br />

J7520 9 SIROLIMUS, ORAL 0.00<br />

J7525 5 TACROLIMUS INJECTION 0.00<br />

J7599 5 IMMUNOSUPPRESSIVE DRUG NOC 0.00<br />

J7602 O ALBUTEROL INH NON-COMP CON 0.00<br />

J7603 O ALBUTEROL INH NON-COMP U D 0.00<br />

J7604 9 ACETYLCYSTEINE COMP UNIT 0.00<br />

J7605 9 ARFORMOTEROL NON-COMP UNIT 0.00<br />

J7606 9 FORMOTEROL FUMARATE, INH 0.00<br />

J7607 9 LEVALBUTEROL COMP CON 0.00<br />

J7608 9 ACETYLCYSTEINE NON-COMP UNIT 0.00<br />

J7609 9 ALBUTEROL COMP UNIT 0.00<br />

J7610 9 ALBUTEROL COMP CON 0.00<br />

J7611 9 ALBUTEROL NON-COMP CON 0.00<br />

J7612 9 LEVALBUTEROL NON-COMP CON 0.00<br />

J7613 9 ALBUTEROL NON-COMP UNIT 0.00<br />

J7614 9 LEVALBUTEROL NON-COMP UNIT 0.00<br />

J7615 9 LEVALBUTEROL COMP UNIT 0.00<br />

J7616 O ALBUTEROL COMPOUND SOLUTION 0.00<br />

J7617 O LEVALBUTEROL COMPOUN<strong>DE</strong>D SOL 0.00<br />

J7618 O ALBUTEROL INH SOL CON 0.00<br />

J7619 O ALBUTEROL INH SOL U D 0.00<br />

J7620 9 ALBUTEROL IPRATROP NON-COMP 0.00<br />

J7621 O (LEVO)ALBUTEROL/IPRA-BROMI<strong>DE</strong> 0.00<br />

J7622 9 BECLOMETHASONE COMP UNIT 0.00<br />

J7624 9 BETAMETHASONE COMP UNIT 0.00<br />

J7625 O ALBUTEROL SULFATE .5% INJ 0.00<br />

J7626 9 BU<strong>DE</strong>SONI<strong>DE</strong> NON-COMP UNIT 0.00<br />

J7627 9 BU<strong>DE</strong>SONI<strong>DE</strong> COMP UNIT 0.00<br />

J7628 9 BITOLTEROL MESYLATE COMP CON 0.00<br />

J7629 9 BITOLTEROL MESYLATE COMP UNT 0.00<br />

J7630 O CROMOLYN SODIUM INJECITON 0.00<br />

J7631 9 CROMOLYN SODIUM NONCOMP UNIT 0.00

---

J7632 9 CROMOLYN SODIUM COMP UNIT 0.00<br />

J7633 9 BU<strong>DE</strong>SONI<strong>DE</strong> NON-COMP CON 0.00<br />

J7634 9 BU<strong>DE</strong>SONI<strong>DE</strong> COMP CON 0.00<br />

J7635 9 ATROPINE COMP CON 0.00<br />

J7636 9 ATROPINE COMP UNIT 0.00<br />

J7637 9 <strong>DE</strong>XAMETHASONE COMP CON 0.00<br />

J7638 9 <strong>DE</strong>XAMETHASONE COMP UNIT 0.00<br />

J7639 9 DORNASE ALFA NON-COMP UNIT 0.00<br />

J7640 9 FORMOTEROL COMP UNIT 0.00<br />

J7641 9 FLUNISOLI<strong>DE</strong> COMP UNIT 0.00<br />

J7642 9 GLYCOPYRROLATE COMP CON 0.00<br />

J7643 9 GLYCOPYRROLATE COMP UNIT 0.00<br />

J7644 9 IPRATROPIUM BROMI<strong>DE</strong> NON-COMP 0.00<br />

J7645 9 IPRATROPIUM BROMI<strong>DE</strong> 0.00<br />

J7647 9 ISOETHARINE COMP CON 0.00<br />

J7648 9 ISOETHARINE NON-COMP CON 0.00<br />

J7649 9 ISOETHARINE NON-COMP UNIT 0.00<br />

J7650 9 ISOETHARINE COMP UNIT 0.00<br />

J7651 O ISOETHARINE HCL .125% INJ 0.00<br />

J7652 O ISOETHARINE HCL .167% INJ 0.00<br />

J7653 O ISOETHARINE HCL .2%/ INJ 0.00<br />

J7654 O ISOETHARINE HCL .25% INJ 0.00<br />

J7655 O ISOETHARINE HCL 1% INJ 0.00<br />

J7657 9 ISOPROTERENOL COMP CON 0.00<br />

J7658 9 ISOPROTERENOL NON-COMP CON 0.00<br />

J7659 9 ISOPROTERENOL NON-COMP UNIT 0.00<br />

J7660 9 ISOPROTERENOL COMP UNIT 0.00<br />

J7665 O ISOPROTERENOL HCL 1% INJ 0.00<br />

J7667 9 METAPROTERENOL COMP CON 0.00<br />

J7668 9 METAPROTERENOL NON-COMP CON 0.00<br />

J7669 9 METAPROTERENOL NON-COMP UNIT 0.00<br />

J7670 9 METAPROTERENOL COMP UNIT 0.00<br />

J7672 O METAPROTERENOL SULFATE .6% 0.00<br />

J7674 9 METHACHOLINE CHLORI<strong>DE</strong>, NEB 0.00<br />

J7675 O METAPROTERENOL SULFATE 5% 0.00<br />

J7676 9 PENTAMIDINE COMP UNIT DOSE 0.00<br />

J7680 9 TERBUTALINE SULF COMP CON 0.00<br />

J7681 9 TERBUTALINE SULF COMP UNIT 0.00<br />

J7682 9 TOBRAMYCIN NON-COMP UNIT 0.00<br />

J7683 9 TRIAMCINOLONE COMP CON 0.00<br />

J7684 9 TRIAMCINOLONE COMP UNIT 0.00<br />

J7685 9 TOBRAMYCIN COMP UNIT 0.00<br />

J7699 O INHALATION SOLUTION FOR DME 0.00<br />

J7799 O NON-INHALATION DRUG FOR DME 0.00<br />

J8498 9 ANTIEMETIC RECTAL/SUPP NOS 0.00<br />

J8499 9 ORAL PRESCRIP DRUG NON CHEMO 0.00<br />

J8501 9 ORAL APREPITANT 0.00<br />

J8510 9 ORAL BUSULFAN 0.00<br />

J8515 9 CABERGOLINE, ORAL 0.25MG 0.00<br />

J8520 9 CAPECITABINE, ORAL, 150 MG 0.00

---

J8521 9 CAPECITABINE, ORAL, 500 MG 0.00<br />

J8530 9 CYCLOPHOSPHAMI<strong>DE</strong> ORAL 25 MG 0.00<br />

J8540 9 ORAL <strong>DE</strong>XAMETHASONE 0.00<br />

J8560 9 ETOPOSI<strong>DE</strong> ORAL 50 MG 0.00<br />

J8565 9 GEFITINIB ORAL 0.00<br />

J8597 9 ANTIEMETIC DRUG ORAL NOS 0.00<br />

J8600 9 MELPHALAN ORAL 2 MG 0.00<br />

J8610 9 METHOTREXATE ORAL 2.5 MG 0.00<br />

J8650 9 NABILONE ORAL 0.00<br />

J8700 9 TEMOZOLMI<strong>DE</strong> 0.00<br />

J8705 9 TOPOTECAN ORAL 0.00<br />

J8999 9 ORAL PRESCRIPTION DRUG CHEMO 0.00<br />

J9001 6 DOXORUBICIN HCL LIPOSOME INJ 0.00<br />

J9010 O ALEMTUZUMAB INJECTION 0.00<br />

J9015 5 AL<strong>DE</strong>SLEUKIN INJECTION 0.00<br />

J9017 5 ARSENIC TRIOXI<strong>DE</strong> INJECTION 0.00<br />

J9020 6 ASPARAGINASE INJECTION 0.00<br />

J9025 6 AZACITIDINE INJECTION 0.00<br />

J9027 5 CLOFARABINE INJECTION 0.00<br />

J9031 6 BCG LIVE INTRAVESICAL VAC 0.00<br />

J9033 6 BENDAMUSTINE INJECTION 0.00<br />

J9035 6 BEVACIZUMAB INJECTION 0.00<br />

J9040 6 BLEOMYCIN SULFATE INJECTION 0.00<br />

J9041 6 BORTEZOMIB INJECTION 0.00<br />

J9045 6 CARBOPLATIN INJECTION 0.00<br />

J9050 5 CARMUSTINE INJECTION 0.00<br />

J9055 6 CETUXIMAB INJECTION 0.00<br />

J9060 6 CISPLATIN 10 MG INJECITON 0.00<br />

J9062 6 CISPLATIN 50 MG INJECITON 0.00<br />

J9065 5 INJ CLADRIBINE PER 1 MG 0.00<br />

J9070 5 CYCLOPHOSPHAMI<strong>DE</strong> 100 MG INJ 0.00<br />

J9080 5 CYCLOPHOSPHAMI<strong>DE</strong> 200 MG INJ 0.00<br />

J9090 6 CYCLOPHOSPHAMI<strong>DE</strong> 500 MG INJ 0.00<br />

J9091 6 CYCLOPHOSPHAMI<strong>DE</strong> 1.0 GRM INJ 0.00<br />

J9092 5 CYCLOPHOSPHAMI<strong>DE</strong> 2.0 GRM INJ 0.00<br />

J9093 3 CYCLOPHOSPHAMI<strong>DE</strong> LYOPHILIZED 5.16<br />

J9094 5 CYCLOPHOSPHAMI<strong>DE</strong> LYOPHILIZED 0.00<br />

J9095 5 CYCLOPHOSPHAMI<strong>DE</strong> LYOPHILIZED 0.00<br />

J9096 5 CYCLOPHOSPHAMI<strong>DE</strong> LYOPHILIZED 0.00<br />

J9097 5 CYCLOPHOSPHAMI<strong>DE</strong> LYOPHILIZED 0.00<br />

J9098 6 CYTARABINE LIPOSOME INJ 0.00<br />

J9100 6 CYTARABINE HCL 100 MG INJ 0.00<br />

J9110 6 CYTARABINE HCL 500 MG INJ 0.00<br />

J9120 5 DACTINOMYCIN INJECTION 0.00<br />

J9130 6 DACARBAZINE 100 MG INJ 0.00<br />

J9140 6 DACARBAZINE 200 MG INJ 0.00<br />

J9150 6 DAUNORUBICIN INJECTION 0.00<br />

J9151 5 DAUNORUBICIN CITRATE INJ 0.00<br />

J9160 5 <strong>DE</strong>NILEUKIN DIFTITOX INJ 0.00<br />

J9165 5 DIETHYLSTILBESTROL INJECTION 0.00

---

J9170 6 DOCETAXEL INJECTION 0.00<br />

J9175 5 ELLIOTTS B SOLUTION PER ML 0.00<br />

J9178 6 INJ, EPIRUBICIN HCL, 2 MG 0.00<br />

J9180 O EPIRUBICIN HCL INJECTION 0.00<br />

J9181 6 ETOPOSI<strong>DE</strong> INJECTION 0.00<br />

J9182 O ETOPOSI<strong>DE</strong> 100 MG INJ 0.00<br />

J9185 5 FLUDARABINE PHOSPHATE INJ 0.00<br />

J9190 6 FLUOROURACIL INJECTION 0.00<br />

J9200 5 FLOXURIDINE INJECTION 0.00<br />

J9201 6 GEMCITABINE HCL INJECTION 0.00<br />

J9202 6 GOSERELIN ACETATE IMPLANT 0.00<br />

J9206 6 IRINOTECAN INJECTION 0.00<br />

J9207 6 IXABEPILONE INJECTION 0.00<br />

J9208 5 IFOSFOMI<strong>DE</strong> INJECTION 0.00<br />

J9209 5 MESNA INJECTION 0.00<br />

J9211 5 IDARUBICIN HCL INJECTION 0.00<br />

J9212 5 INTERFERON ALFACON-1 INJ 0.00<br />

J9213 5 INTERFERON ALFA-2A INJ 0.00<br />

J9214 6 INTERFERON ALFA-2B INJ 0.00<br />

J9215 5 INTERFERON ALFA-N3 INJ 0.00<br />

J9216 5 INTERFERON GAMMA 1-B INJ 0.00<br />

J9217 3 LEUPROLI<strong>DE</strong> ACETATE SUSPNSION 515.00<br />

J9218 5 LEUPROLI<strong>DE</strong> ACETATE INJECITON 0.00<br />

J9219 5 LEUPROLI<strong>DE</strong> ACETATE IMPLANT 0.00<br />

J9225 5 VANTAS IMPLANT 0.00<br />

J9226 6 SUPPRELIN LA IMPLANT 0.00<br />

J9230 5 MECHLORETHAMINE HCL INJ 0.00<br />

J9240 O MEDROXYPROGESTERONE ACETATE, 100 MG 0.00<br />

J9245 5 INJ MELPHALAN HYDROCHL 50 MG 0.00<br />

J9250 5 METHOTREXATE SODIUM INJ 0.00<br />

J9260 6 METHOTREXATE SODIUM INJ 0.00<br />

J9261 6 NELARABINE INJECTION 0.00<br />

J9263 6 OXALIPLATIN 0.00<br />

J9265 6 PACLITAXEL INJECTION 0.00<br />

J9266 5 PEGASPARGASE INJECTION 0.00<br />

J9268 5 PENTOSTATIN INJECTION 0.00<br />

J9270 5 PLICAMYCIN (MITHRAMYCIN) INJ 0.00<br />

J9280 6 MITOMYCIN 5 MG INJ 0.00<br />

J9290 5 MITOMYCIN 20 MG INJ 0.00<br />

J9291 5 MITOMYCIN 40 MG INJ 0.00<br />

J9293 5 MITOXANTRONE HYDROCHL / 5 MG 0.00<br />

J9295 O POLYESTRADIOL PHOSPHATE 40 MG 0.00<br />

J9300 5 GEMTUZUMAB OZOGAMICIN INJ 0.00<br />

J9303 6 PANITUMUMAB INJECTION 0.00<br />

J9305 6 PEMETREXED INJECTION 0.00<br />

J9310 6 RITUXIMAB INJECTION 0.00<br />

J9320 5 STREPTOZOCIN INJECTION 0.00<br />

J9330 6 TEMSIROLIMUS INJECTION 0.00<br />

J9340 5 THIOTEPA INJECTION 0.00<br />

J9350 6 TOPOTECAN INJECTION 0.00

---

J9355 6 TRASTUZUMAB INJECTION 0.00<br />

J9357 5 VALRUBICIN INJECTION 0.00<br />

J9360 6 VINBLASTINE SULFATE INJ 0.00<br />

J9370 6 VINCRISTINE SULFATE 1 MG INJ 0.00<br />

J9375 6 VINCRISTINE SULFATE 2 MG INJ 0.00<br />

J9380 5 VINCRISTINE SULFATE 5 MG INJ 0.00<br />

J9390 6 VINORELBINE TARTRATE INJ 0.00<br />

J9395 6 INJECTION, FULVESTRANT 0.00<br />

J9600 5 PORFIMER SODIUM INJECTION 0.00<br />

J9999 5 CHEMOTHERAPY DRUG 0.00<br />

K0001 3 STANDARD WHEELCHAIR 532.70<br />

K0002 5 STND HEMI (LOW SEAT) WHLCHR 0.00<br />

K0003 3 LIGHTWEIGHT WHEELCHAIR 0.00<br />

K0004 3 HIGH STRENGTH LTWT WHLCHR 1.00<br />

K0005 3 ULTRALIGHTWEIGHT WHEELCHAIR 1,839.61<br />

K0006 5 HEAVY DUTY WHEELCHAIR 0.00<br />

K0007 5 EXTRA HEAVY DUTY WHEELCHAIR 0.00<br />

K0008 9 CSTM MANUAL WHEELCHAIR/BASE 0.00<br />

K0009 5 OTHER MANUAL WHEELCHAIR/BASE 0.00<br />

K0010 5 STND WT FRAME POWER WHLCHR 0.00<br />

K0011 5 STND WT PWR WHLCHR W CONTROL 0.00<br />

K0012 5 LTWT PORTBL POWER WHLCHR 0.00<br />

K0013 9 CUSTOM POWER WHLCHR BASE 0.00<br />

K0014 5 OTHER POWER WHLCHR BASE 0.00<br />

K0015 3 <strong>DE</strong>TACH NON-ADJUS HGHT ARMRST 180.80<br />

K0016 O <strong>DE</strong>TACH ADJUST ARMRST CMPLETE 0.00<br />

K0017 3 <strong>DE</strong>TACH ADJUST ARMREST BASE 50.85<br />

K0018 3 <strong>DE</strong>TACH ADJUST ARMRST UPPER 28.41<br />

K0019 3 ARM PAD EACH 14.58<br />

K0020 3 FIXED ADJUST ARMREST PAIR 46.23<br />

K0021 O ANTI-TIPPING <strong>DE</strong>VICE EACH 0.00<br />

K0022 O REINFORCED BACK UPHOLSTERY 0.00<br />

K0023 O PLANR BACK INSRT FOAM W/STRP 0.00<br />

K0024 O PLNR BACK INSRT FOAM W/HRDWR 0.00<br />

K0025 O HOOK-ON HEADREST EXTENSION 0.00<br />

K0026 O BACK UPHOLST LGTWT WHLCHR 0.00<br />

K0027 O BACK UPHOLST OTHER WHLCHR 0.00<br />

K0028 O MANUAL FULLY RECLINING BACK 0.00<br />

K0029 O REINFORCED SEAT UPHOLSTERY 0.00<br />

K0030 O SOLID PLNR SEAT SNGL DNSFOAM 0.00<br />

K0031 O SAFETY BELT/PELVIC STRAP 0.00<br />

K0032 O SEAT UPHOLS LGTWT WHLCHR 0.00<br />

K0033 O SEAT UPHOLSTERY OTHER WHLCHR 0.00<br />

K0034 O HEEL LOOP EACH 0.00<br />

K0035 O HEEL LOOP WITH ANKLE STRAP 0.00<br />

K0036 O TOE LOOP EACH 0.00<br />

K0037 3 HIGH MOUNT FLIP-UP FOOTREST 47.93<br />

K0038 3 LEG STRAP EACH 24.14<br />

K0039 3 LEG STRAP H STYLE EACH 53.61<br />

K0040 3 ADJUSTABLE ANGLE FOOTPLATE 74.30

---

K0041 3 LARGE SIZE FOOTPLATE EACH 52.65<br />

K0042 3 STANDARD SIZE FOOTPLATE EACH 36.25<br />

K0043 3 FTRST LOWER EXTENSION TUBE 19.44<br />

K0044 3 FTRST UPPER HANGER BRACKET 16.56<br />

K0045 3 FOOTREST COMPLETE ASSEMBLY 56.34<br />

K0046 3 ELEVAT LEGRST LOW EXTENSION 19.44<br />

K0047 3 ELEVAT LEGRST UP HANGR BRACK 76.10<br />

K0048 O ELEVATE LEGREST COMPLETE 0.00<br />

K0049 O CALF PAD EACH 0.00<br />

K0050 3 RATCHET ASSEMBLY 32.34<br />

K0051 3 CAM RELESE ASSEM FTRST/LGRST 52.35<br />

K0052 3 SWINGAWAY <strong>DE</strong>TACH FOOTREST 91.98<br />

K0053 3 ELEVATE FOOTREST ARTICULATE 101.51<br />

K0054 O SEAT WDTH 10-12/15/17/20 WC 0.00<br />

K0055 O SEAT DPTH 15/17/18 LTWT WC 0.00<br />

K0056 3 SEAT HT =21 LTWT WC 94.63<br />

K0057 O SEAT WDTH 19/20 HVY DTY WC 0.00<br />

K0058 O SEAT DPTH 17/18 POWER WC 0.00<br />

K0059 O PLASTIC COATED HANDRIM EACH 0.00<br />

K0060 O STEEL HANDRIM EACH 0.00<br />

K0061 O ALUMINUM HANDRIM EACH 0.00<br />

K0062 O HANDRIM 8-10 VERT/OBLIQ PROJ 0.00<br />

K0063 O HNDRM 12-16 VERT/OBLIQ PROJ 0.00<br />

K0064 O ZERO PRESSURE TUBE FLAT FREE 0.00<br />

K0065 3 SPOKE PROTECTORS 44.24<br />

K0066 O SOLID TIRE ANY SIZE EACH 0.00<br />

K0067 O PNEUMATIC TIRE ANY SIZE EACH 0.00<br />

K0068 O PNEUMATIC TIRE TUBE EACH 0.00<br />

K0069 3 REAR WHL COMPLETE SOLID TIRE 99.42<br />

K0070 3 REAR WHL COMPL PNEUM TIRE 182.26<br />

K0071 3 FRONT CASTR COMPL PNEUM TIRE 108.71<br />

K0072 3 FRNT CSTR CMPL SEM-PNEUM TIR 65.43<br />

K0073 3 CASTER PIN LOCK EACH 34.63<br />

K0074 O PNEUMATIC CASTER TIRE EACH 0.00<br />

K0075 O SEMI-PNEUMATIC CASTER TIRE 0.00<br />

K0076 O SOLID CASTER TIRE EACH 0.00<br />

K0077 3 FRONT CASTER ASSEM COMPLETE 58.56<br />

K0078 O PNEUMATIC CASTER TIRE TUBE 0.00<br />

K0079 O WHEEL LOCK EXTENSION PAIR 0.00<br />

K0080 O ANTI-ROLLBACK <strong>DE</strong>VICE PAIR 0.00<br />

K0081 O WHEEL LOCK ASSEMBLY COMPLETE 0.00<br />

K0082 O 22 NF NONSEALED LEADACID 0.00<br />

K0083 O 22NF SEALED LEADACID BATTERY 0.00<br />

K0084 O GR24 NONSEALED LEADACID 0.00<br />

K0085 O GR 24 SEALED LEAD ACID BATTERY 0.00<br />

K0086 O U1NONSEALED LEADACID BATTERY 0.00<br />

K0087 O U1 SEALED LEADACID BATTERY 0.00<br />

K0088 O BATTERY CHARGER, SINGLE MO<strong>DE</strong> 0.00<br />

K0089 O BATTERY CHARGER, DUAL MO<strong>DE</strong> 0.00<br />

K0090 O REAR TIRE POWER WHEELCHAIR 0.00

---

K0091 O REAR TIRE TUBE POWER WHLCHR 0.00<br />

K0092 O REAR ASSEM CMPLT POWR WHLCHR 0.00<br />

K0093 O REAR ZERO PRESSURE TIRE TUBE 0.00<br />

K0094 O WHEEL TIRE FOR POWER BASE 0.00<br />

K0095 O WHEEL TIRE TUBE EACH BASE 0.00<br />

K0096 O WHEEL ASSEM POWR BASE COMPLT 0.00<br />

K0097 O WHEEL ZERO PRESURE TIRE TUBE 0.00<br />

K0098 3 DRIVE BELT POWER WHEELCHAIR 27.07<br />

K0099 O PWR WHEELCHAIR FRONT CASTER 0.00<br />

K0100 O AMPUTEE ADAPTER PAIR 0.00<br />

K0101 O ONE-ARM DRIVE ATTACHMENT 0.00<br />

K0102 O CRUTCH AND CANE HOL<strong>DE</strong>R 0.00<br />

K0103 O TRANSFER BOARD < 25" 0.00<br />

K0104 O CYLIN<strong>DE</strong>R TANK CARRIER 0.00<br />

K0105 3 IV HANGER 98.94<br />

K0106 O ARM TROUGH EACH 0.00<br />

K0107 O WHEELCHAIR TRAY 0.00<br />

K0108 5 W/C COMPONENT-ACCESSORY NOS 0.00<br />

K0109 9 CUSTOMIZE WHLCHR BASE FRAME 0.00<br />

K0110 9 SUPPLIES FOR MAINTENANCE OF DRUG IN 0.00<br />

K0111 9 SUPPLIES FOR EXTERNAL DRUG INFUSION 0.00<br />

K0112 O TRUNK VEST SUPPRT INNR FRAME 0.00<br />

K0113 O TRUNK VEST SUPRT W/O INR FRM 0.00<br />

K0114 O WHLCHR BACK SUPRT INR FRAME 0.00<br />

K0115 O BACK MODULE ORTHOTIC SYSTEM 0.00<br />

K0116 O BACK & SEAT MODUL ORTHOT SYS 0.00<br />

K0117 O UNLISTED ITEM, ORTHOTIC SEATING, BA 0.00<br />

K0118 O TENS SUPPLIES - ONE MONTH SUPPLY FO 0.00<br />

K0119 9 AZATHIOPRINE ORAL TAB 50 MG 0.00<br />

K0120 9 AZATHIOPRINE PRENTRL 100 MG 0.00<br />

K0121 9 CYCLOSPORINE ORAL 25 MG 0.00<br />

K0122 9 CYCLOSPORINE PRENTRL 250 MG 0.00<br />

K0123 9 IMUN/ANTITYMOCYT GLOB 250 MG 0.00<br />

K0124 9 MONOCLONAL ANTIBODIES - PARENTERAL, 0.00<br />

K0125 9 PREDNISONE - ORAL, 5 MG 0.00<br />

K0126 9 REPLACE SOFT INTERFACE MATERIAL, MU 0.00<br />

K0127 9 REPLACE SOFT INTERFACE MATERIAL, AN 0.00<br />

K0128 9 REPLACE SOFT INTERFACE MATERIAL, FO 0.00<br />

K0129 9 ANKLE CONTRACTURE SPLINT 0.00<br />

K0130 9 FOOT DROP SPLINT, RECUMBENT POSITIO 0.00<br />

K0131 O SPRING-POWERED <strong>DE</strong>VICE FOR LANCET 0.00<br />

K0132 O MALE EXTERNAL CATHETER WITH OR WITH 0.00<br />

K0133 O INTERMITTENT URINARY CATHETER, DISP 0.00<br />

K0134 O INTERMITTENT URINARY CATHETER, DISP 0.00<br />

K0135 O INTERMITTENT URINARY CATHETER, REUS 0.00<br />

K0136 O INTERMITTENT URINARY CATHETER, REUS 0.00<br />

K0137 9 SKIN BARRIER LIQUID PER OZ 0.00<br />

K0138 9 SKIN BARRIER PASTE PER OZ 0.00<br />

K0139 9 SKIN BARRIER POW<strong>DE</strong>R PER OZ 0.00<br />

K0140 9 ACETYLCYSTEINE, COMPOUN<strong>DE</strong>D, PER MG, 0.00

---

K0141 9 ALBUTEROL SULFATE, COMPOUN<strong>DE</strong>D, PER 0.00<br />

K0142 9 CROMOLYN SODIUM, COMPOUN<strong>DE</strong>D, PER MG 0.00<br />

K0143 9 ISOETHARINE HYDROCHLORI<strong>DE</strong>, COMPOUND 0.00<br />

K0144 9 ISOPROTHERENOL HYDROCHLORI<strong>DE</strong>, COMPO 0.00<br />

K0145 9 METAPROTERENOL, COMPOUN<strong>DE</strong>D, PER MG, 0.00<br />

K0146 9 TERBUTALINE, COMPOUN<strong>DE</strong>D, PER MG, IN 0.00<br />

K0147 O GASTROSTOMY TUBE, SILICONE WITH SLI 0.00<br />

K0148 O HYDROGEL DRESSING, EACH 0.00<br />

K0149 O HYDROCOLLOID DRESSING, EACH 0.00<br />

K0150 O ALGINATE DRESSING, EACH 0.00<br />

K0151 O FOAM DRESSING, EACH 0.00<br />

K0152 9 PASTES, POW<strong>DE</strong>RS, GRANULES, BEADS, C 0.00<br />

K0153 O COMPOSITE DRESSING, EACH 0.00<br />

K0154 9 WOUND POUCH, EACH 0.00<br />

K0162 O PROGRESSIVE LENS, EACH LENS 0.00<br />

K0163 9 VACUUM ERECTION SYSTEM 0.00<br />

K0164 O OROPHARYNGEAL SUCTION CATHETER, EAC 0.00<br />

K0165 O TRACHEOSTOMY CARE KIT FOR ESTABLISH 0.00<br />

K0166 O METHYLPREDNISOLONE - ORAL, 4 MG 0.00<br />

K0167 O PREDNISOLONE - ORAL, 5 MG 0.00<br />

K0168 9 DISPOSABLE NEBULIZER SET 0.00<br />

K0169 9 DISPOSABLE NEBULIZER SMALL 0.00<br />

K0170 9 NON DISPOSABLE NEBULIZER SET 0.00<br />

K0171 9 FILTERED NEBULIZER SET 0.00<br />

K0172 9 DISPOSABLE NEBULIZER UNFILL 0.00<br />

K0173 9 DISPOSABLE NEBULIZER PREFILL 0.00<br />

K0174 9 RESERVOIR BOTTLE W NEBULIZER 0.00<br />

K0175 9 DISPOSABLE CORRUGATED TUBING 0.00<br />

K0176 9 NON DISPOS CORRUGATED TUBING 0.00<br />

K0177 9 WATER COLLEC <strong>DE</strong>V W NEBULIZER 0.00<br />

K0178 9 DISPOSBL FILTER W COMPRESSOR 0.00<br />

K0179 9 NON-DISPOS FILTER W/COMPRESS 0.00<br />

K0180 9 AEROSOL MASK WITH NEBULIZER 0.00<br />

K0181 9 DOME & MOUTHPIECE W/ NEBULIZ 0.00<br />

K0182 9 WATER DISTILLED W/ NEBULIZER 0.00<br />

K0183 O NASAL APPLICATION <strong>DE</strong>VICE 0.00<br />

K0184 O NASAL PILLOW OR FACE SEAL 0.00<br />

K0185 O POS AIRWAY PRESSURE HEADGEAR 0.00<br />

K0186 O POS AIRWAY PRSSURE CHINSTRAP 0.00<br />

K0187 O POS AIRWAY PRESSURE TUBING 0.00<br />

K0188 O POS AIRWAY PRESSURE FILTER 0.00<br />

K0189 O FILTER NONDISPOSABLE W PAP 0.00<br />

K0190 9 DISPOSABLE CANISTER W/PUMP 0.00<br />

K0191 9 NON-DISPOSBL CANISTER W/PUMP 0.00<br />

K0192 9 TUBING USED W/ SUCTION PUMP 0.00<br />

K0193 9 AIRWAY PRESSURE <strong>DE</strong>V/W HMDFER 0.00<br />

K0194 9 ASSIST <strong>DE</strong>VICE W/HUMIDIFIER 0.00<br />

K0195 3 ELEVATING WHLCHAIR LEG RESTS 0.00<br />

K0196 9 ALGINATE DRESSING, WOUND COVER, PAD 0.00<br />

K0197 9 ALGINATE DRESSING, WOUND COVER, PAD 0.00

---

K0198 9 ALGINATE DRESSING, WOUND COVER, PAD 0.00<br />

K0199 9 ALGINATE DRESSING, WOUND FILLER, PE 0.00<br />

K0203 9 COMPOSITE DRESSING, PAD SIZE 16 SQ. 0.00<br />

K0204 9 COMPOSITE DRESSING, PAD SIZE MORE T 0.00<br />

K0205 9 COMPOSITE DRESSING, PAD SIZE MORE T 0.00<br />

K0206 9 CONTACT LAYER, 16 SQ. IN. OR LESS, 0.00<br />

K0207 9 CONTACT LAYER, MORE THAN 16 BUT LES 0.00<br />

K0208 9 CONTACT LAYER, MORE THAN 48 SQ. IN. 0.00<br />

K0209 9 FOAM DRESSING, WOUND COVER, PAD SIZ 0.00<br />

K0210 9 FOAM DRESSING, WOUND COVER, PAD SIZ 0.00<br />

K0211 9 FOAM DRESSING, WOUND COVER, PAD SIZ 0.00<br />

K0212 9 FOAM DRESSING, WOUND COVER, PAD SIZ 0.00<br />

K0213 9 FOAM DRESSING, WOUND COVER, PAD SIZ 0.00<br />

K0214 9 FOAM DRESSING, WOUND COVER, PAD SIZ 0.00<br />

K0215 9 FOAM DRESSING, WOUND FILLER, PER GR 0.00<br />

K0216 9 GAUZE, NON-IMPREGNATED, NON-STERILE 0.00<br />

K0217 9 GAUZE, NON-IMPREGNATED, NON-STERILE 0.00<br />

K0218 9 GAUZE, NON-IMPREGNATED, NON-STERILE 0.00<br />

K0219 9 GAUZE, NON-IMPREGNATED, PAD SIZE 16 0.00<br />

K0220 9 GAUZE, NON-IMPREGNATED, PAD SIZE MO 0.00<br />

K0221 9 GAUZE, NON-IMPREGNATED, PAD SIZE MO 0.00<br />

K0222 9 GAUZE, IMPREGNATED, OTHER THAN WATE 0.00<br />

K0223 9 GAUZE, IMPREGNATED, OTHER THAN WATE 0.00<br />

K0224 9 GAUZE, IMPREGNATED, OTHER THAN WATE 0.00<br />

K0228 9 GAUZE, IMPREGNATED, WATER OR NORMAL 0.00<br />

K0229 9 GAUZE, IMPREGNATED, WATER OR NORMAL 0.00<br />

K0230 9 GAUZE, IMPREGNATED, WATER OR NORMAL 0.00<br />

K0234 9 HYDROCOLLOID DRESSING, WOUND COVER, 0.00<br />

K0235 9 HYDROCOLLOID DRESSING, WOUND COVER, 0.00<br />

K0236 9 HYDROCOLLOID DRESSING, WOUND COVER, 0.00<br />

K0237 9 HYDROCOLLOID DRESSING, WOUND COVER, 0.00<br />

K0238 9 HYDROCOLLOID DRESSING, WOUND COVER, 0.00<br />

K0239 9 HYDROCOLLOID DRESSING, WOUND COVER, 0.00<br />

K0240 9 HYDROCOLLOID DRESSING, WOUND FILLER 0.00<br />

K0241 9 HYDROCOLLOID DRESSING, WOUND FILLER 0.00<br />

K0242 9 HYDROGEL DRESSING, WOUND COVER, PAD 0.00<br />

K0243 9 HYDROGEL DRESSING, WOUND COVER, PAD 0.00<br />

K0244 9 HYDROGEL DRESSING, WOUND COVER, PAD 0.00<br />

K0245 9 HYDROGEL DRESSING, WOUND COVER, PAD 0.00<br />

K0246 9 HYDROGEL DRESSING, WOUND COVER, PAD 0.00<br />

K0247 9 HYDROGEL DRESSING, WOUND COVER, PAD 0.00<br />

K0248 9 HYDROGEL DRESSING, WOUND FILLER, GE 0.00<br />

K0249 9 HYDROGEL DRESSING, WOUND FILLER, DR 0.00<br />

K0250 9 SKIN SEALANTS, PROTECTANTS, MOISTUR 0.00<br />

K0251 9 SPECIALTY ABSORPTIVE DRESSING, WOUN 0.00<br />

K0252 9 SPECIALTY ABSORPTIVE DRESSING, WOUN 0.00<br />

K0253 9 SPECIALTY ABSORPTIVE DRESSING, WOUN 0.00<br />

K0254 9 SPECIALTY ABSORPTIVE DRESSING, WOUN 0.00<br />

K0255 9 SPECIALTY ABSORPTIVE DRESSING, WOUN 0.00<br />

K0256 9 SPECIALTY ABSORPTIVE DRESSING, WOUN 0.00

---

K0257 9 TRANSPARENT FILM, 16 SQ. IN. OR LES 0.00<br />

K0258 9 TRANSPARENT FILM, MORE THAN 16 BUT 0.00<br />

K0259 9 TRANSPARENT FILM, MORE THAN 48 SQ. 0.00<br />

K0260 9 WOUND CLEANSERS, ANY TYPE, ANY SIZE 0.00<br />

K0261 9 WOUND FILLER, NOT ELSEWHERE CLASSIF 0.00<br />

K0262 9 WOUND FILLER, NOT ELSEWHERE CLASSIF 0.00<br />

K0263 9 GAUZE, ELASTIC, NON-STERILE, ALL T 0.00<br />

K0264 9 GAUZE, NON-ELASTIC, NON-STERILE, PE 0.00<br />

K0265 9 TAPE, ALL TYPES, PER 18 SQUARE INCH 0.00<br />

K0266 9 GAUZE, IMPREGNATED, OTHER THAN WATE 0.00<br />

K0267 O REPLACEMENT BATTERY, ANY TYPE, FOR 0.00<br />

K0268 O HUMIDIFIER NONHEATED W PAP 0.00<br />

K0269 9 AEROSOL COMPRESSOR CPAP <strong>DE</strong>V 0.00<br />

K0270 9 ULTRASONIC GENERATOR W NEBUL 0.00<br />

K0271 9 POUCH, DRAINABLE; WITH FACEPLATE AT 0.00<br />

K0272 9 POUCH, DRAINABLE; WITHOUT FACEPLATE 0.00<br />

K0273 9 POUCH, URINARY; WITH FACEPLATE ATTA 0.00<br />

K0274 9 POUCH, URINARY; WITHOUT FACEPLATE A 0.00<br />

K0275 9 OSTOMY FACEPLATE; CONVEX; REUSABLE; 0.00<br />

K0276 9 OSTOMY FACEPLATE; CONVEX; CUSTOM FI 0.00<br />

K0277 9 SKIN BARRIER SOLID 4X4 EQUIV 0.00<br />

K0278 9 SKIN BARRIER WITH FLANGE 0.00<br />

K0279 9 SKIN BARRIER EXTEN<strong>DE</strong>D WEAR 0.00<br />

K0280 9 EXTENSION DRAINAGE TUBING 0.00<br />

K0281 9 LUBRICANT CATHETER INSERTION 0.00<br />

K0283 9 SALINE SOLUTION DISPENSER 0.00<br />

K0284 9 EXTERNAL INFUSION PUMP REUSE 0.00<br />

K0285 9 REPAIR OF PROSTHETIC <strong>DE</strong>VICE, LABOR 0.00<br />

K0400 9 SKIN SUPPORT ATTACHMENT EACH 0.00<br />

K0401 9 DIABETIC <strong>DE</strong>LUXE SHOE 0.00<br />

K0402 9 GAUZE, NON-IMPREGNATED, STERILE, PA 0.00<br />

K0403 9 GAUZE, NON-IMPREGNATED, STERILE, PA 0.00<br />

K0404 9 GAUZE, NON-IMPREGNATED, STERILE, PA 0.00<br />

K0405 9 GAUZE, ELASTIC, STERILE, ALL TYPES, 0.00<br />

K0406 9 GAUZE, NON-ELASTIC, STERILE, PER LI 0.00<br />

K0407 9 URINARY CATH SKIN ATTACHMENT 0.00<br />

K0408 9 URINARY CATH LEG STRAP 0.00<br />

K0409 9 STERILE H2O IRRIGATION SOLUT 0.00<br />

K0410 9 MALE EXT CATH W/ADH COATING 0.00<br />

K0411 9 MALE EXT CATH W/ADH STRIP 0.00<br />

K0412 9 MYCOPHENOLATE MOFETIL 25O MG 0.00<br />

K0413 O NON-POWERED, ADVANCED PRESSURE-REDU 0.00<br />

K0414 O POWERED AIR OVERLAY FOR MATTRESS, S 0.00<br />

K0415 O RX ANTIEMETIC DRG, ORAL NOS 0.00<br />

K0416 O RX ANTIEMETIC DRG,RECTAL NOS 0.00<br />

K0417 9 MECH INFUS PUMP SHT TRM DRUG 0.00<br />

K0418 9 ORAL CYCLOSPORIN 0.00<br />

K0419 9 DRAINABLE PLSTIC PCH W FCPLT 0.00<br />

K0420 9 DRAINABLE RUBBER PCH W FCPLT 0.00<br />

K0421 9 DRAINABLE PLSTIC PCH W/O FP 0.00

---

K0422 9 DRAINABLE RUBBER PCH W/O FP 0.00<br />

K0423 9 URINARY PLSTIC POUCH W FCPLT 0.00<br />

K0424 9 URINARY RUBBER POUCH W FCPLT 0.00<br />

K0425 9 URINARY PLSTIC POUCH W/O FP 0.00<br />

K0426 9 URINARY HVY PLSTC PCH W/O FP 0.00<br />

K0427 9 URINARY RUBBER POUCH W/O FP 0.00<br />

K0428 9 OSTOMY FACEPLT/SILICONE RING 0.00<br />

K0429 9 SKIN BARRIER SOLID EXT WEAR 0.00<br />

K0430 9 SKIN BARRIER W FLANG EX WEAR 0.00<br />

K0431 9 CLOSED POUCH W ST WEAR BAR 0.00<br />

K0432 9 DRAINABLE PCH W EX WEAR BAR 0.00<br />

K0433 9 DRAINABLE PCH W ST WEAR BAR 0.00<br />

K0434 9 DRAINABLE PCH EX WEAR CONVEX 0.00<br />

K0435 9 URINARY POUCH W EX WEAR BAR 0.00<br />

K0436 9 URINARY POUCH W ST WEAR BAR 0.00<br />

K0437 9 URINE PCH W EX WEAR BAR CONV 0.00<br />

K0438 9 OSTOMY POUCH LIQ <strong>DE</strong>ODORANT 0.00<br />

K0439 9 OSTOMY POUCH SOLID <strong>DE</strong>ODORANT 0.00<br />

K0440 9 NASAL PROSTHESIS 0.00<br />

K0441 9 MIDFACIAL PROSTHESIS 0.00<br />

K0442 9 ORBITAL PROSTHESIS 0.00<br />

K0443 9 UPPER FACIAL PROSTHESIS 0.00<br />

K0444 9 HEMI-FACIAL PROSTHESIS 0.00<br />

K0445 9 AURICULAR PROSTHESIS 0.00<br />

K0446 9 PARTIAL FACIAL PROSTHESIS 0.00<br />

K0447 9 NASAL SEPTAL PROSTHESIS 0.00<br />

K0448 9 UNSPEC MAXILLOFACIAL PROSTH 0.00<br />

K0449 9 REPAIR MAXILLOFACIAL PROSTH 0.00<br />

K0450 9 LIQ ADHES FOR FACIAL PROSTH 0.00<br />

K0451 9 ADHESIVE REMOVER WIPES 0.00<br />

K0452 O WHEELCHAIR BEARINGS 0.00<br />

K0453 9 AMPHOTERICIN B 0.00<br />

K0455 9 PUMP UNINTERRUPTED INFUSION 0.00<br />

K0456 O HEAVYDUTY/XTRA WI<strong>DE</strong> HOSP BED 0.00<br />

K0457 O HEAVYDUTY/WI<strong>DE</strong> COMMO<strong>DE</strong> CHAIR 0.00<br />

K0458 O HEAVYDUTY WALKER NO WHEELS 0.00<br />

K0459 O HEAVY DUTY WHEELED WALKER 0.00<br />

K0460 O WC POWER ADD-ON JOYSTICK 0.00<br />

K0461 O WC POWER ADD-ON TILLER CNTRL 0.00<br />

K0462 9 TEMPORARY REPLACEMENT EQPMNT 0.00<br />

K0501 9 AEROSOL COMPRESSOR FOR SVNEB 0.00<br />

K0503 9 ACETYLCYSTEINE INH SOL U D 0.00<br />

K0504 9 ALBUTEROL INH SOL CON 0.00<br />

K0505 9 ALBUTEROL INH SOL U D 0.00<br />

K0506 9 ATROPINE INH SOL CON 0.00<br />

K0507 9 ATROPINE INH SOL U D 0.00<br />

K0508 9 BITOLTEROL MES INH SOL CON 0.00<br />

K0509 9 BITOLTEROL MES INH SOL U D 0.00<br />

K0511 9 CROMOLYN SODIUM INH SOL U D 0.00<br />

K0512 9 <strong>DE</strong>XAMETHASONE INH SOL CON 0.00

---

K0513 9 <strong>DE</strong>XAMETHASONE INH SOL U D 0.00<br />

K0514 9 DORNASE ALPHA INH SOL U D 0.00<br />

K0515 9 GLYCOPYRROLATE INH SOL CON 0.00<br />

K0516 9 GLYCOPYRROLATE INH SOL U D 0.00<br />

K0518 9 IPRATROPIUM BROM INH SOL U D 0.00<br />

K0519 9 ISOETHARINE HCL INH SOL CON 0.00<br />

K0520 9 ISOETHARINE HCL INH SOL U D 0.00<br />

K0521 9 ISOPROTERENOLHCL INH SOL CON 0.00<br />

K0522 9 ISOPROTERENOLHCL INH SOL U D 0.00<br />

K0523 9 METAPROTERENOL INH SOL CON 0.00<br />

K0524 9 METAPROTERENOL INH SOL U D 0.00<br />

K0525 9 TERBUTALINE SO4 INH SOL CON 0.00<br />

K0526 9 TERBUTALINE SO4 INH SOL U D 0.00<br />

K0527 9 TRIAMCINOLONE INH SOL CON 0.00<br />

K0528 9 TRIAMCINOLONE INH SOL U D 0.00<br />

K0529 9 STERILE H20 OR NSS W LV NEB 0.00<br />

K0530 9 NEBULIZER NOT USED W OXYGEN 0.00<br />

K0531 O HEATED HUMIDIFIER USED W PAP 0.00<br />

K0532 O NONINVASIVE ASSIST WO BACKUP 0.00<br />

K0533 O NONINVASIVE ASSIST W BACKUP 0.00<br />

K0534 O INVASIVE ASSIST W BACKUP 0.00<br />

K0538 O NEG PRESSURE WND THRPY PUMP 0.00<br />

K0539 O NEG PRES WND THRPY DSG SET 0.00<br />

K0540 O NEG PRES WND THRP CANISTER 0.00<br />

K0541 O SGD PRERECOR<strong>DE</strong>D MSG 8 MIN 0.00<br />

K0543 O SGD MSG FORMED BY SPELLING 0.00<br />

K0544 O SGD W MULTI METHODS MSG/ACCS 0.00<br />

K0545 O SGD SFTWRE PRGRM FOR PC/PDA 0.00<br />

K0546 O SGD ACCESSORY,MOUNTING SYSTM 0.00<br />

K0547 O SGD ACCESSORY NOC 0.00<br />

K0549 O HOSPITAL BED, HEAVY DUTY, EXTRA WI 0.00<br />

K0550 O HOSPITAL BED, EXTRA HEAVY DUTY, EX 0.00<br />

K0551 9 RESIDUAL LIMB SUPPORT SYSTEM 0.00<br />

K0552 6 SUPPLY/EXT INF PUMP SYR TYPE 0.00<br />

K0556 O SOCKET INSERT W LOCK MECH 0.00<br />

K0557 O SOCKET INSERT W/O LOCK MECH 0.00<br />

K0558 O INTL CUSTM CONG/ATYP INSERT 0.00<br />

K0559 O INITIAL CUSTOM SOCKET INSERT 0.00<br />

K0561 9 NONPECTIN BASED OSTOMY PASTE 0.00<br />

K0562 9 PECTIN BASED OSTOMY PASTE 0.00<br />

K0563 O OSTOMY SKIN BARRIER WITH FLANGE (S 0.00<br />

K0565 O OSTOMY SKIN BARRIER WITH FLANGE (S 0.00<br />

K0570 O BUILT IN CONVEXITY, 4X INCHES OR S 0.00<br />

K0572 O TAPE, NON WATERPROOF, PER 18 SQUAR 0.00<br />

K0573 O TAPE, WATERPROOF, PER 18 SQUARE IN 0.00<br />

K0581 O OST PCH CLSD W BARRIER/FILTR 0.00<br />

K0582 O OST PCH W BAR/BLTINCONV/FLTR 0.00<br />

K0583 O OST PCH CLSD W/O BAR W FILTR 0.00<br />

K0584 O OST PCH FOR BAR W FLANGE/FLT 0.00

---

K0585 O OST PCH CLSD FOR BAR W LK FL 0.00<br />

K0586 O OST PCH FOR BAR W LK FL/FLTR 0.00<br />

K0587 O OST PCH DRAIN W BAR & FILTER 0.00<br />

K0588 O OST PCH DRAIN FOR BARRIER FL 0.00<br />

K0589 O OST PCH DRAIN 2 PIECE SYSTEM 0.00<br />

K0590 O OST PCH DRAIN/BARR LK FLNG/F 0.00<br />

K0591 O URINE OST POUCH W FAUCET/TAP 0.00<br />

K0592 O URINE OST POUCH W BLTINCONV 0.00<br />

K0593 O OST URINE PCH W B/BLTIN CONV 0.00<br />

K0594 O OST PCH URINE W BARRIER/TAPV 0.00<br />

K0595 O OS PCH URINE W BAR/FANGE/TAP 0.00<br />

K0596 O URINE OST PCH BAR W LOCK FLN 0.00<br />

K0597 O OST PCH URINE W LOCK FLNG/FT 0.00<br />

K0600 O FUNCTIONAL NEUROMUSCULARSTIM 0.00<br />

K0601 6 REPL BATT SILVER OXI<strong>DE</strong> 1.5 V 0.00<br />

K0602 6 REPL BATT SILVER OXI<strong>DE</strong> 3 V 0.00<br />

K0603 6 REPL BATT ALKALINE 1.5 V 0.00<br />

K0604 6 REPL BATT LITHIUM 3.6 V 0.00<br />

K0605 6 REPL BATT LITHIUM 4.5 V 0.00<br />

K0606 6 AED GARMENT W ELEC ANALYSIS 0.00<br />

K0607 6 REPL BATT FOR AED 0.00<br />

K0608 6 REPL GARMENT FOR AED 0.00<br />

K0609 6 REPL ELECTRO<strong>DE</strong> FOR AED 0.00<br />

K0618 O TLSO 2 PIECE RIGID SHELL 0.00<br />

K0619 O TLSO 3 PIECE RIGID SHELL 0.00<br />

K0620 O TUBULAR ELASTIC DRESSING 0.00<br />

K0627 O CERVICAL PNEUM TRAC EQUIP 0.00<br />

K0628 O MULT <strong>DE</strong>NS INSERT DIRECT FORM 0.00<br />

K0629 O MULT <strong>DE</strong>NS INSERT CUSTOM MOLD 0.00<br />

K0630 O SIO FLEX PELVISACRAL PREFAB 0.00<br />

K0631 O SIO FLEX PELVISACRAL CUSTOM 0.00<br />

K0632 O SIO PANEL PREFAB 0.00<br />

K0633 O SIO PANEL CUSTOM 0.00<br />

K0634 O LO FLEXIBLE L1 BELOW L5 PRE 0.00<br />

K0635 O LO SAG STAYS/PANELS PRE-FAB 0.00<br />

K0636 O LO SAGITT RIGID PANEL PREFAB 0.00<br />

K0637 O LO FLEX W/O RIGID STAYS PRE 0.00<br />

K0638 O LSO FLEX W/RIGID STAYS CUST 0.00<br />

K0639 O LSO POST RIGID PANEL PRE 0.00<br />

K0640 O LSO SAG-CORO RIGID FRAME PRE 0.00<br />

K0641 O LSO SAG-COR RIGID FRAME CUST 0.00<br />

K0642 O LSO FLEXION CONTROL PREFAB 0.00<br />

K0643 O LSO FLEXION CONTROL CUSTOM 0.00<br />

K0644 O LSO SAGIT RIGID PANEL PREFAB 0.00<br />

K0645 O LSO SAGITTAL RIGID PANEL CUS 0.00<br />

K0646 O LSO SAG-CORONAL PANEL PREFAB 0.00<br />

K0647 O LSO SAG-CORONAL PANEL CUSTOM 0.00<br />

K0648 O LSO S/C SHELL/PANEL PREFAB 0.00<br />

K0649 O LSO S/C SHELL/PANEL CUSTOM 0.00<br />

K0650 O GEN W/C CUSHION WIDTH LESS THAN 22 0.00

---

K0651 O GEN W/C CUSHION WIDTH GREATER THAN 0.00<br />

K0652 O SKIN PROTECT W/C CUS WD LESS THAN2 0.00<br />

K0653 O SKIN PROTECT W/C CUS WD GREATER TH 0.00<br />

K0654 O POSITION W/C CUSH WIDTH LESS THAN2 0.00<br />

K0655 O POSITION W/C CUSH WIDTH GREATER TH 0.00<br />

K0656 O SKIN PRO/POS W/C CUS WD LESS THAN2 0.00<br />

K0657 O SKIN PRO/POS W/C CUS WD GREATER TH 0.00<br />

K0658 O CUSTOM FABRICATE W/C CUSHION 0.00<br />

K0659 O POWERED W/C CUSHION 0.00<br />

K0660 O GEN USE BACK CUSH WIDTH LESS THAN2 0.00<br />

K0661 O GEN USE BACK CUSH WIDTH GREATER TH 0.00<br />

K0662 O POSITION BACK CUSH WDTH LESS THAN2 0.00<br />

K0663 O POSITION BACK CUSH WDTH GREATER TH 0.00<br />

K0664 O POS BACK POST/LAT WIDTH LESS THAN2 0.00<br />

K0665 O POS BACK POST/LAT WIDTH GREATER TH 0.00<br />

K0666 O CUSTOM FAB W/C BACK CUSHION 0.00<br />

K0667 O MT HARDWRE MAN/LIGHT PWR W/C 0.00<br />

K0668 O REP ACE COVER W/C SEAT CUSH 0.00<br />

K0669 6 SEAT/BACK CUS NO SADMERC VER 0.00<br />

K0670 O STANCE PHASE ONLY 0.00<br />

K0672 6 REMOVABLE SOFT INTERFACE LE 0.00<br />

K0730 6 CTRL DOSE INH DRUG <strong>DE</strong>LIV SYS 0.00<br />

K0733 6 12-24HR SEALED LEAD ACID 0.00<br />

K0734 6 ADJ SKIN PRO W/C CUS WD=22IN 0.00<br />

K0736 6 ADJ SKIN PRO/POS WC CUS=22Ê 0.00<br />

K0738 6 PORTABLE GAS OXYGEN SYSTEM 0.00<br />

K0800 6 POV GROUP 1 STD UP TO 300LBS 0.00<br />

K0801 6 POV GROUP 1 HD 301-450 LBS 0.00<br />

K0802 6 POV GROUP 1 VHD 451-600 LBS 0.00<br />

K0806 6 POV GROUP 2 STD UP TO 300LBS 0.00<br />

K0807 6 POV GROUP 2 HD 301-450 LBS 0.00<br />

K0808 6 POV GROUP 2 VHD 451-600 LBS 0.00<br />

K0812 6 POWER OPERATED VEHICLE NOC 0.00<br />

K0813 6 PWC GP 1 STD PORT SEAT/BACK 0.00<br />

K0814 6 PWC GP 1 STD PORT CAP CHAIR 0.00<br />

K0815 6 PWC GP 1 STD SEAT/BACK 0.00<br />

K0816 6 PWC GP 1 STD CAP CHAIR 0.00<br />

K0820 6 PWC GP 2 STD PORT SEAT/BACK 0.00<br />

K0821 6 PWC GP 2 STD PORT CAP CHAIR 0.00<br />

K0822 6 PWC GP 2 STD SEAT/BACK 0.00<br />

K0823 6 PWC GP 2 STD CAP CHAIR 0.00<br />

K0824 6 PWC GP 2 HD SEAT/BACK 0.00<br />

K0825 6 PWC GP 2 HD CAP CHAIR 0.00<br />

K0826 6 PWC GP 2 VHD SEAT/BACK 0.00<br />

K0827 6 PWC GP VHD CAP CHAIR 0.00<br />

K0828 6 PWC GP 2 XTRA HD SEAT/BACK 0.00<br />

K0829 6 PWC GP 2 XTRA HD CAP CHAIR 0.00<br />

K0830 6 PWC GP2 STD SEAT ELEVATE S/B 0.00

---

K0831 6 PWC GP2 STD SEAT ELEVATE CAP 0.00<br />

K0835 6 PWC GP2 STD SING POW OPT S/B 0.00<br />

K0836 6 PWC GP2 STD SING POW OPT CAP 0.00<br />

K0837 6 PWC GP 2 HD SING POW OPT S/B 0.00<br />

K0838 6 PWC GP 2 HD SING POW OPT CAP 0.00<br />

K0839 6 PWC GP2 VHD SING POW OPT S/B 0.00<br />

K0840 6 PWC GP2 XHD SING POW OPT S/B 0.00<br />

K0841 6 PWC GP2 STD MULT POW OPT S/B 0.00<br />

K0842 6 PWC GP2 STD MULT POW OPT CAP 0.00<br />

K0843 6 PWC GP2 HD MULT POW OPT S/B 0.00<br />

K0848 6 PWC GP 3 STD SEAT/BACK 0.00<br />

K0849 6 PWC GP 3 STD CAP CHAIR 0.00<br />

K0850 6 PWC GP 3 HD SEAT/BACK 0.00<br />

K0851 6 PWC GP 3 HD CAP CHAIR 0.00<br />

K0852 6 PWC GP 3 VHD SEAT/BACK 0.00<br />

K0853 6 PWC GP 3 VHD CAP CHAIR 0.00<br />

K0854 6 PWC GP 3 XHD SEAT/BACK 0.00<br />

K0855 6 PWC GP 3 XHD CAP CHAIR 0.00<br />

K0856 6 PWC GP3 STD SING POW OPT S/B 0.00<br />

K0857 6 PWC GP3 STD SING POW OPT CAP 0.00<br />

K0858 6 PWC GP3 HD SING POW OPT S/B 0.00<br />

K0859 6 PWC GP3 HD SING POW OPT CAP 0.00<br />

K0860 6 PWC GP3 VHD SING POW OPT S/B 0.00<br />

K0861 6 PWC GP3 STD MULT POW OPT S/B 0.00<br />

K0862 6 PWC GP3 HD MULT POW OPT S/B 0.00<br />

K0863 6 PWC GP3 VHD MULT POW OPT S/B 0.00<br />

K0864 6 PWC GP3 XHD MULT POW OPT S/B 0.00<br />

K0868 6 PWC GP 4 STD SEAT/BACK 0.00<br />

K0869 6 PWC GP 4 STD CAP CHAIR 0.00<br />

K0870 6 PWC GP 4 HD SEAT/BACK 0.00<br />

K0871 6 PWC GP 4 VHD SEAT/BACK 0.00<br />

K0877 6 PWC GP4 STD SING POW OPT S/B 0.00<br />

K0878 6 PWC GP4 STD SING POW OPT CAP 0.00<br />

K0879 6 PWC GP4 HD SING POW OPT S/B 0.00<br />

K0880 6 PWC GP4 VHD SING POW OPT S/B 0.00<br />

K0884 6 PWC GP4 STD MULT POW OPT S/B 0.00<br />

K0885 6 PWC GP4 STD MULT POW OPT CAP 0.00<br />

K0886 6 PWC GP4 HD MULT POW S/B 0.00<br />

K0890 6 PWC GP5 PED SING POW OPT S/B 0.00<br />

K0891 6 PWC GP5 PED MULT POW OPT S/B 0.00<br />

K0898 6 POWER WHEELCHAIR NOC 0.00<br />

K0899 9 POW MOBIL <strong>DE</strong>V NO SADMERC 0.00<br />

KKEVL O MCO SPECIFIC CO<strong>DE</strong>: DPH KIDS KARE IN 0.00<br />

KKTX1 O MCO SPECIFIC CO<strong>DE</strong>: DPH KIDS KARE TE 0.00<br />

KKTX2 O MCO SPECIFIC CO<strong>DE</strong>: DPH KIDS KARE TE 0.00<br />

L0100 O CRANIAL ORTHOSIS/HELMET MOLD 0.00<br />

L0101 O ONE-ARM DRIVE ATTACHMENT, EACH 0.00<br />

L0110 O CRANIAL ORTHOSIS/HELMET NONM 0.00<br />

L0112 6 CRANIAL CERVICAL ORTHOSIS 0.00<br />

L0113 6 CRANIAL CERVICAL TORTICOLLIS 0.00

---

L0120 3 CERV FLEXIBLE NON-ADJUSTABLE 20.07<br />

L0130 3 FLEX THERMOPLASTIC COLLAR MO 141.92<br />

L0140 3 CERVICAL SEMI-RIGID ADJUSTAB 46.91<br />

L0150 3 CERV SEMI-RIG ADJ MOL<strong>DE</strong>D CHN 86.11<br />

L0160 3 CERV SEMI-RIG WIRE OCC/MAND 112.45<br />

L0170 3 CERVICAL COLLAR MOL<strong>DE</strong>D TO PT 463.04<br />

L0172 3 CERV COL THERMPLAS FOAM 2 PI 100.39<br />

L0174 3 CERV COL FOAM 2 PIECE W THOR 197.24<br />

L0180 3 CER POST COL OCC/MAN SUP ADJ 273.50<br />

L0190 3 CERV COLLAR SUPP ADJ CERV BA 355.67<br />

L0200 3 CERV COL SUPP ADJ BAR & THOR 370.78<br />

L0210 3 THORACIC RIB BELT 34.05<br />

L0220 3 THOR RIB BELT CUSTOM FABRICA 101.25<br />

L0300 O TLSO FLEX SURGICAL SUPPORT 0.00<br />

L0310 O TLSO FLEXIBLE CUSTOM FABRICA 0.00<br />

L0315 O TLSO FLEX ELAS RIGID POST PA 0.00<br />

L0317 O TLSO FLEX HYPEXT ELAS POST P 0.00<br />

L0320 O TLSO A-P CONTRL W APRON FRNT 0.00<br />

L0321 O TLSO ANTI-POST-CNTRL PREFAB 0.00<br />

L0330 O TLSO ANT-POS-LATERAL CONTROL 0.00<br />

L0331 O TLSO ANT-POST-LAT CNTRL PRFB 0.00<br />

L0340 O TLSO A-P-L-ROTARY WITH APRON 0.00<br />

L0350 O TLSO FLEX COMPRESS JACKET CU 0.00<br />

L0360 O TLSO FLEX COMPRESS JACKET MO 0.00<br />

L0370 O TLSO A-P-L-ROTARY HYPEREXTEN 0.00<br />

L0380 O TLSO A-P-L-ROT W/ POS EXTENS 0.00<br />

L0390 O TLSO A-P-L CONTROL MOL<strong>DE</strong>D 0.00<br />

L0391 O TLSO ANT-POST-LAT-ROT CNTRL 0.00<br />

L0400 O TLSO A-P-L W INTERFACE MATER 0.00<br />

L0410 O TLSO A-P-L TWO PIECE CONSTR 0.00<br />

L0420 O TLSO A-P-L 2 PIECE W INTERFA 0.00<br />

L0430 6 TLSO A-P-L W INTERFACE CUSTM 0.00<br />

L0440 O TLSO A-P-L OVERLAP FRNT CUST 0.00<br />

L0450 5 TLSO FLEX PREFAB THORACIC 0.00<br />

L0452 5 TLSO FLEX CUSTOM FAB THORACI 0.00<br />

L0454 5 TLSO FLEX PREFAB SACROCOC-T9 0.00<br />

L0456 5 TLSO FLEX PREFAB 0.00<br />

L0458 5 TLSO 2MOD SYMPHIS-XIPHO PRE 0.00<br />

L0460 5 TLSO2MOD SYMPHYSIS-STERN PRE 0.00<br />

L0462 3 TLSO 3MOD SACRO-SCAP PRE 1,050.90<br />

L0464 5 TLSO 4MOD SACRO-SCAP PRE 0.00<br />

L0466 5 TLSO RIGID FRAME PRE SOFT AP 0.00<br />

L0468 5 TLSO RIGID FRAME PREFAB PELV 0.00<br />

L0470 5 TLSO RIGID FRAME PRE SUBCLAV 0.00<br />

L0472 5 TLSO RIGID FRAME HYPEREX PRE 0.00<br />

L0474 5 TLSO RIGID FRAME PRE PELVIC 0.00<br />

L0476 O TLSO FLEXION COMPRES JAC PRE 0.00<br />

L0478 O TLSO FLEXION COMPRES JAC CUS 0.00<br />

L0480 5 TLSO RIGID PLASTIC CUSTOM FA 0.00<br />

L0482 5 TLSO RIGID LINED CUSTOM FAB 0.00

---

L0484 5 TLSO RIGID PLASTIC CUST FAB 0.00<br />

L0486 5 TLSO RIGIDLINED CUST FAB TWO 0.00<br />

L0488 5 TLSO RIGID LINED PRE ONE PIE 0.00<br />

L0490 5 TLSO RIGID PLASTIC PRE ONE 0.00<br />

L0491 6 TLSO 2 PIECE RIGID SHELL 0.00<br />

L0492 6 TLSO 3 PIECE RIGID SHELL 0.00<br />

L0500 O LSO FLEX SURGICAL SUPPORT 0.00<br />

L0510 O LSO FLEXIBLE CUSTOM FABRICAT 0.00<br />

L0515 O LSO FLEX ELAS W/ RIG POST PA 0.00<br />

L0520 O LSO A-P-L CONTROL WITH APRON 0.00<br />

L0530 O LSO ANT-POS CONTROL W APRON 0.00<br />

L0540 O LSO LUMBAR FLEXION A-P-L 0.00<br />

L0550 O LSO A-P-L CONTROL MOL<strong>DE</strong>D 0.00<br />

L0560 O LSO A-P-L W INTERFACE 0.00<br />

L0561 O PREFAB LSO 0.00<br />

L0565 O LSO A-P-L CONTROL CUSTOM 0.00<br />

L0600 O SACROILIAC FLEX SURG SUPPORT 0.00<br />

L0610 O SACROILIAC FLEXIBLE CUSTM FA 0.00<br />

L0620 O SACROILIAC SEMI-RIG W APRON 0.00<br />

L0621 6 SIO FLEX PELVISACRAL PREFAB 0.00<br />

L0622 6 SIO FLEX PELVISACRAL CUSTOM 0.00<br />

L0623 6 SIO PANEL PREFAB 0.00<br />

L0624 6 SIO PANEL CUSTOM 0.00<br />

L0625 6 LO FLEXIBL L1-BELOW L5 PRE 0.00<br />

L0626 6 LO SAG STAYS/PANELS PRE-FAB 0.00<br />

L0627 6 LO SAGITT RIGID PANEL PREFAB 0.00<br />

L0628 6 LO FLEX W/O RIGID STAYS PRE 0.00<br />

L0629 6 LSO FLEX W/RIGID STAYS CUST 0.00<br />

L0630 3 LSO POST RIGID PANEL PRE 127.26<br />

L0631 6 LSO SAG-CORO RIGID FRAME PRE 0.00<br />

L0632 6 LSO SAG RIGID FRAME CUST 0.00<br />

L0633 6 LSO FLEXION CONTROL PREFAB 0.00<br />

L0634 6 LSO FLEXION CONTROL CUSTOM 0.00<br />

L0635 6 LSO SAGIT RIGID PANEL PREFAB 0.00<br />

L0636 6 LSO SAGITTAL RIGID PANEL CUS 0.00<br />

L0637 6 LSO SAG-CORONAL PANEL PREFAB 0.00<br />

L0638 6 LSO SAG-CORONAL PANEL CUSTOM 0.00<br />

L0639 6 LSO S/C SHELL/PANEL PREFAB 0.00<br />

L0640 6 LSO S/C SHELL/PANEL CUSTOM 0.00<br />

L0700 3 CTLSO A-P-L CONTROL MOL<strong>DE</strong>D 1,467.79<br />

L0710 3 CTLSO A-P-L CONTROL W/ INTER 1,499.54<br />

L0810 3 HALO CERVICAL INTO JCKT VEST 1,875.37<br />

L0820 3 HALO CERVICAL INTO BODY JACK 1,683.27<br />

L0830 3 HALO CERV INTO MILWAUKEE TYP 2,372.22<br />

L0859 6 MRI COMPATIBLE SYSTEM 0.00<br />

L0860 O MAGNETIC RESONANC IMAGE COMP 0.00<br />

L0861 6 HALO REPL LINER/INTERFACE 0.00<br />

L0900 O TORSO/PTOSIS SUPPORT 0.00<br />

L0910 O TORSO & PTOSIS SUPP CUSTM FA 0.00<br />

L0920 O TORSO/PENDULOUS ABD SUPPORT 0.00

---

L0930 O PENDULOUS ABDOMEN SUPP CUSTM 0.00<br />

L0940 O TORSO/POSTSURGICAL SUPPORT 0.00<br />

L0950 O POST SURG SUPPORT CUSTOM FAB 0.00<br />

L0960 O POST SURGICAL SUPPORT PADS 0.00<br />

L0970 3 TLSO CORSET FRONT 96.55<br />

L0972 3 LSO CORSET FRONT 86.71<br />

L0974 3 TLSO FULL CORSET 128.76<br />

L0976 3 LSO FULL CORSET 114.81<br />

L0978 3 AXILLARY CRUTCH EXTENSION 151.56<br />

L0980 3 PERONEAL STRAPS PAIR 16.53<br />

L0982 3 STOCKING SUPP GRIPS SET OF F 11.69<br />

L0984 3 PROTECTIVE BODY SOCK EACH 48.54<br />

L0986 O SPINAL ORTH ABDM PNL PREFAB 0.00<br />

L0999 5 ADD TO SPINAL ORTHOSIS NOS 0.00<br />

L1000 3 CTLSO MILWAUKE INITIAL MO<strong>DE</strong>L 1,472.64<br />

L1001 6 CTLSO INFANT IMMOBILIZER 0.00<br />

L1005 5 TENSION BASED SCOLIOSIS ORTH 0.00<br />

L1010 3 CTLSO AXILLA SLING 48.19<br />

L1020 3 KYPHOSIS PAD 62.06<br />

L1025 3 KYPHOSIS PAD FLOATING 118.46<br />

L1030 3 LUMBAR BOLSTER PAD 45.67<br />

L1040 3 LUMBAR OR LUMBAR RIB PAD 59.77<br />

L1050 3 STERNAL PAD 72.03<br />

L1060 3 THORACIC PAD 86.42<br />

L1070 3 TRAPEZIUS SLING 84.40<br />

L1080 3 OUTRIGGER 47.48<br />

L1085 3 OUTRIGGER BIL W/ VERT EXTENS 128.42<br />

L1090 3 LUMBAR SLING 84.96<br />

L1100 3 RING FLANGE PLASTIC/LEATHER 135.65<br />

L1110 3 RING FLANGE PLAS/LEATHER MOL 183.38<br />

L1120 3 COVERS FOR UPRIGHT EACH 31.00<br />

L1200 3 FURNSH INITIAL ORTHOSIS ONLY 1,124.98<br />

L1210 3 LATERAL THORACIC EXTENSION 187.88<br />

L1220 3 ANTERIOR THORACIC EXTENSION 179.47<br />

L1230 3 MILWAUKEE TYPE SUPERSTRUCTUR 460.04<br />

L1240 3 LUMBAR <strong>DE</strong>ROTATION PAD 62.18<br />

L1250 3 ANTERIOR ASIS PAD 62.18<br />

L1260 3 ANTERIOR THORACIC <strong>DE</strong>ROTATION 63.50<br />

L1270 3 ABDOMINAL PAD 64.52<br />

L1280 3 RIB GUSSET (ELASTIC) EACH 74.19<br />

L1290 3 LATERAL TROCHANTERIC PAD 58.74<br />

L1300 3 BODY JACKET MOLD TO PATIENT 1,322.50<br />

L1310 3 POST-OPERATIVE BODY JACKET 1,358.90<br />

L1499 5 SPINAL ORTHOSIS NOS 0.00<br />

L1500 3 THKAO MOBILITY FRAME 1,363.82<br />

L1510 3 THKAO STANDING FRAME 862.81<br />

L1520 3 THKAO SWIVEL WALKER 1,638.02<br />

L1600 3 ABDUCT HIP FLEX FREJKA W CVR 92.52<br />

L1610 3 ABDUCT HIP FLEX FREJKA COVR 40.82<br />

L1620 3 ABDUCT HIP FLEX PAVLIK HARNE 115.65

---

L1630 3 ABDUCT CONTROL HIP SEMI-FLEX 121.67<br />

L1640 3 PELV BAND/SPREAD BAR THIGH C 370.37<br />

L1650 3 HO ABDUCTION HIP ADJUSTABLE 187.41<br />

L1652 5 HO BI THIGHCUFFS W SPRDR BAR 0.00<br />

L1660 3 HO ABDUCTION STATIC PLASTIC 122.87<br />

L1680 3 PELVIC & HIP CONTROL THIGH C 874.83<br />

L1685 3 POST-OP HIP ABDUCT CUSTOM FA 892.79<br />

L1686 3 HO POST-OP HIP ABDUCTION 824.39<br />

L1690 3 COMBINATION BILATERAL HO 1,449.30<br />

L1700 3 LEG PERTHES ORTH TORONTO TYP 1,096.46<br />

L1710 3 LEGG PERTHES ORTH NEWINGTON 1,283.53<br />

L1720 3 LEGG PERTHES ORTHOSIS TRILAT 946.12<br />

L1730 3 LEGG PERTHES ORTH SCOTTISH R 812.63<br />

L1750 O LEGG PERTHES SLING 0.00<br />

L1755 3 LEGG PERTHES PATTEN BOTTOM T 1,289.59<br />

L1800 3 KNEE ORTHOSES ELAS W STAYS 52.19<br />

L1810 3 KO ELASTIC WITH JOINTS 70.71<br />

L1815 3 ELASTIC WITH CONDYLAR PADS 74.89<br />

L1820 3 KO ELAS W/ CONDYLE PADS & JO 109.56<br />

L1825 3 KO ELASTIC KNEE CAP 48.39<br />

L1830 3 KO IMMOBILIZER CANVAS LONGIT 66.62<br />

L1831 6 KNEE ORTH POS LOCKING JOINT 0.00<br />

L1832 3 KO ADJ JNT POS RIGID SUPPORT 507.82<br />

L1834 3 KO W/0 JOINT RIGID MOL<strong>DE</strong>D TO 557.35<br />

L1836 5 RIGID KO WO JOINTS 0.00<br />

L1840 3 KO <strong>DE</strong>ROT ANT CRUCIATE CUSTOM 742.41<br />

L1843 3 KO SINGLE UPRIGHT CUSTOM FIT 672.48<br />

L1844 3 KO W/ADJ JT ROT CNTRL MOL<strong>DE</strong>D 1,165.61<br />

L1845 3 KO W/ ADJ FLEX/EXT ROTAT CUS 697.85<br />

L1846 3 KO W ADJ FLEX/EXT ROTAT MOLD 791.83<br />

L1847 3 KO ADJUSTABLE W AIR CHAMBERS 431.07<br />

L1850 3 KO SWEDISH TYPE 218.25<br />

L1855 O KO PLAS DOUB UPRIGHT JNT MOL 0.00<br />

L1858 O KO POLYCENTRIC PNEUMATIC PAD 0.00<br />

L1860 3 KO SUPRACONDYLAR SOCKET MOLD 770.45<br />

L1870 O KO DOUB UPRIGHT LACERS MOL<strong>DE</strong> 0.00<br />

L1880 O KO DOUB UPRIGHT CUFFS/LACERS 0.00<br />

L1885 O KNEE UPRIGHT W/RESISTANCE 0.00<br />

L1900 3 AFO SPRNG WIR DRSFLX CALF BD 193.70<br />

L1901 5 PREFAB ANKLE ORTHOSIS 0.00<br />

L1902 3 AFO ANKLE GAUNTLET 66.93<br />

L1904 3 AFO MOL<strong>DE</strong>D ANKLE GAUNTLET 402.52<br />

L1906 3 AFO MULTILIGAMENTUS ANKLE SU 86.35<br />

L1907 6 AFO SUPRAMALLEOLAR CUSTOM 0.00<br />

L1910 3 AFO SING BAR CLASP ATTACH SH 196.12<br />

L1920 3 AFO SING UPRIGHT W/ ADJUST S 251.01<br />

L1930 3 AFO PLASTIC 169.85<br />

L1932 6 AFO RIG ANT TIB PREFAB TCF/= 0.00<br />

L1940 3 AFO MOL<strong>DE</strong>D TO PATIENT PLASTI 355.08<br />

L1945 3 AFO MOL<strong>DE</strong>D PLAS RIG ANT TIB 848.95

---

L1950 3 AFO SPIRAL MOL<strong>DE</strong>D TO PT PLAS 562.89<br />

L1951 6 AFO SPIRAL PREFABRICATED 0.00<br />

L1960 3 AFO POS SOLID ANK PLASTIC MO 424.55<br />

L1970 3 AFO PLASTIC MOL<strong>DE</strong>D W/ANKLE J 510.90<br />

L1971 6 AFO W/ANKLE JOINT, PREFAB 0.00<br />

L1980 3 AFO SING SOLID STIRRUP CALF 263.51<br />

L1990 3 AFO DOUB SOLID STIRRUP CALF 320.05<br />

L2000 3 KAFO SING FRE STIRR THI/CALF 758.23<br />

L2005 6 KAFO SNG/DBL MECHANICAL ACT 0.00<br />

L2010 3 KAFO SNG SOLID STIRRUP W/O J 707.32<br />

L2020 3 KAFO DBL SOLID STIRRUP BAND/ 890.63<br />

L2030 3 KAFO DBL SOLID STIRRUP W/O J 808.48<br />

L2034 6 KAFO PLA SIN UP W/WO K/A CUS 0.00<br />

L2035 3 KAFO PLASTIC PEDIATRIC SIZE 131.14<br />

L2036 3 KAFO PLAS DOUB FREE KNEE MOL 1,380.47<br />

L2037 3 KAFO PLAS SING FREE KNEE MOL 1,287.91<br />

L2038 3 KAFO W/O JOINT MULTI-AXIS AN 1,308.30<br />

L2039 O KAFO,PLSTIC,MEDLAT ROTAT CON 0.00<br />

L2040 3 HKAFO TORSION BIL ROT STRAPS 158.68<br />

L2050 3 HKAFO TORSION CABLE HIP PELV 342.03<br />

L2060 3 HKAFO TORSION BALL BEARING J 416.86<br />

L2070 3 HKAFO TORSION UNILAT ROT STR 107.04<br />

L2080 3 HKAFO UNILAT TORSION CABLE 258.25<br />

L2090 3 HKAFO UNILAT TORSION BALL BR 314.84<br />

L2102 O AFO TIBIAL FX CAST PLSTR MOL 0.00<br />

L2104 O AFO TIB FX CAST SYNTHETIC MO 0.00<br />

L2106 3 AFO TIB FX CAST PLASTER MOLD 488.18<br />

L2108 3 AFO TIB FX CAST MOL<strong>DE</strong>D TO PT 850.00<br />

L2112 3 AFO TIBIAL FRACTURE SOFT 390.97<br />

L2114 3 AFO TIB FX SEMI-RIGID 490.39<br />

L2116 3 AFO TIBIAL FRACTURE RIGID 564.23<br />

L2122 O KAFO FEM FX CAST PLASTER MOL 0.00<br />

L2124 O KAFO FEM FX CAST SYNTHET MOL 0.00<br />

L2126 3 KAFO FEM FX CAST THERMOPLAS 943.82<br />

L2128 3 KAFO FEM FX CAST MOL<strong>DE</strong>D TO P 1,336.53<br />

L2132 3 KAFO FEMORAL FX CAST SOFT 724.60<br />

L2134 3 KAFO FEM FX CAST SEMI-RIGID 773.23<br />

L2136 3 KAFO FEMORAL FX CAST RIGID 922.89<br />

L2180 3 PLAS SHOE INSERT W ANK JOINT 86.13<br />

L2182 3 DROP LOCK KNEE 71.37<br />

L2184 3 LIMITED MOTION KNEE JOINT 97.56<br />

L2186 3 ADJ MOTION KNEE JNT LERMAN T 135.31<br />

L2188 3 QUADRILATERAL BRIM 259.14<br />

L2190 3 WAIST BELT 66.96<br />

L2192 3 PELVIC BAND & BELT THIGH FLA 294.02<br />

L2200 3 LIMITED ANKLE MOTION EA JNT 34.14<br />

L2210 3 DORSIFLEXION ASSIST EACH JOI 49.41<br />

L2220 3 DORSI & PLANTAR FLEX ASS/RES 58.80<br />

L2230 3 SPLIT FLAT CALIPER STIRR & P 55.09<br />

L2232 6 ROCKER BOTTOM, CONTACT AFO 0.00

---

L2240 3 ROUND CALIPER AND PLATE ATTA 68.19<br />

L2250 3 FOOT PLATE MOL<strong>DE</strong>D STIRRUP AT 276.47<br />

L2260 3 REINFORCED SOLID STIRRUP 143.93<br />

L2265 3 LONG TONGUE STIRRUP 84.55<br />

L2270 3 VARUS/VALGUS STRAP PAD<strong>DE</strong>D/LI 39.65<br />

L2275 3 PLASTIC MOD LOW EXT PAD/LINE 93.48<br />

L2280 3 MOL<strong>DE</strong>D INNER BOOT 326.87<br />

L2300 3 ABDUCTION BAR JOINTED ADJUST 204.94<br />

L2310 3 ABDUCTION BAR-STRAIGHT 102.64<br />

L2320 3 NON-MOL<strong>DE</strong>D LACER 147.73<br />

L2330 3 LACER MOL<strong>DE</strong>D TO PATIENT MO<strong>DE</strong> 309.23<br />

L2335 3 ANTERIOR SWING BAND 190.92<br />

L2340 3 PRE-TIBIAL SHELL MOL<strong>DE</strong>D TO P 413.33<br />

L2350 3 PROSTHETIC TYPE SOCKET MOL<strong>DE</strong> 713.86<br />

L2360 3 EXTEN<strong>DE</strong>D STEEL SHANK 37.15<br />

L2370 3 PATTEN BOTTOM 240.71<br />

L2375 3 TORSION ANK & HALF SOLID STI 101.69<br />

L2380 3 TORSION STRAIGHT KNEE JOINT 88.39<br />

L2385 3 STRAIGHT KNEE JOINT HEAVY DU 96.17<br />

L2387 6 ADD LE POLY KNEE CUSTOM KAFO 0.00<br />

L2390 3 OFFSET KNEE JOINT EACH 80.51<br />

L2395 3 OFFSET KNEE JOINT HEAVY DUTY 112.34<br />

L2397 3 SUSPENSION SLEEVE LOWER EXT 87.53<br />

L2405 3 KNEE JOINT DROP LOCK EA JNT 65.34<br />

L2415 3 KNEE JOINT CAM LOCK EACH JOI 91.03<br />

L2425 3 KNEE DISC/DIAL LOCK/ADJ FLEX 107.43<br />

L2430 3 KNEE JNT RATCHET LOCK EA JNT 107.43<br />

L2435 O KNEE JOINT POLYCENTRIC JOINT 0.00<br />

L2492 3 KNEE LIFT LOOP DROP LOCK RIN 97.54<br />

L2500 3 THI/GLUT/ISCHIA WGT BEARING 233.34<br />

L2510 3 TH/WGHT BEAR QUAD-LAT BRIM M 523.55<br />

L2520 3 TH/WGHT BEAR QUAD-LAT BRIM C 345.37<br />

L2525 3 TH/WGHT BEAR NAR M-L BRIM MO 931.80<br />

L2526 3 TH/WGHT BEAR NAR M-L BRIM CU 531.72<br />

L2530 3 THIGH/WGHT BEAR LACER NON-MO 168.70<br />

L2540 3 THIGH/WGHT BEAR LACER MOL<strong>DE</strong>D 303.55<br />

L2550 3 THIGH/WGHT BEAR HIGH ROLL CU 206.21<br />

L2570 3 HIP CLEVIS TYPE 2 POSIT JNT 341.99<br />

L2580 3 PELVIC CONTROL PELVIC SLING 333.23<br />

L2600 3 HIP CLEVIS/THRUST BEARING FR 182.48<br />

L2610 3 HIP CLEVIS/THRUST BEARING LO 193.28<br />

L2620 3 PELVIC CONTROL HIP HEAVY DUT 217.32<br />

L2622 3 HIP JOINT ADJUSTABLE FLEXION 246.37<br />

L2624 3 HIP ADJ FLEX EXT ABDUCT CONT 237.76<br />

L2627 3 PLASTIC MOLD RECIPRO HIP & C 1,297.39<br />

L2628 3 METAL FRAME RECIPRO HIP & CA 1,276.17<br />

L2630 3 PELVIC CONTROL BAND & BELT U 177.79<br />

L2640 3 PELVIC CONTROL BAND & BELT B 241.29<br />

L2650 3 PELV & THOR CONTROL GLUTEAL 102.75<br />

L2660 3 THORACIC CONTROL THORACIC BA 133.82

---

L2670 3 THORAC CONT PARASPINAL UPRIG 129.79<br />

L2680 3 THORAC CONT LAT SUPPORT UPRI 120.23<br />

L2750 3 PLATING CHROME/NICKEL PR BAR 60.02<br />

L2755 3 CARBON GRAPHITE LAMINATION 97.91<br />

L2760 3 EXTENSION PER EXTENSION PER 43.62<br />

L2768 5 ORTHO SI<strong>DE</strong>BAR DISCONNECT 0.00<br />

L2770 3 LOW EXT ORTHOSIS PER BAR/JNT 44.33<br />

L2780 3 NON-CORROSIVE FINISH 48.59<br />

L2785 3 DROP LOCK RETAINER EACH 22.86<br />

L2795 3 KNEE CONTROL FULL KNEECAP 61.97<br />

L2800 3 KNEE CAP MEDIAL OR LATERAL P 95.24<br />

L2810 3 KNEE CONTROL CONDYLAR PAD 74.77<br />

L2820 3 SOFT INTERFACE BELOW KNEE SE 62.35<br />

L2830 3 SOFT INTERFACE ABOVE KNEE SE 67.46<br />

L2840 3 TIBIAL LENGTH SOCK FX OR EQU 39.88<br />

L2850 3 FEMORAL LGTH SOCK FX OR EQUA 44.46<br />

L2860 O TORSION MECHANISM KNEE/ANKLE 0.00<br />

L2999 5 LOWER EXTREMITY ORTHOSIS NOS 0.00<br />

L3000 3 FT INSERT UCB BERKELEY SHELL 80.00<br />

L3001 5 FOOT INSERT REMOV MOL<strong>DE</strong>D SPE 0.00<br />

L3002 5 FOOT INSERT PLASTAZOTE OR EQ 0.00<br />

L3003 5 FOOT INSERT SILICONE GEL EAC 0.00<br />

L3010 5 FOOT LONGITUDINAL ARCH SUPPO 0.00<br />

L3020 3 FOOT LONGITUD/METATARSAL SUP 155.91<br />

L3030 5 FOOT ARCH SUPPORT REMOV PREM 0.00<br />

L3031 6 FOOT LAMIN/PREPREG COMPOSITE 0.00<br />

L3040 5 FT ARCH SUPRT PREMOLD LONGIT 0.00<br />

L3050 5 FOOT ARCH SUPP PREMOLD METAT 0.00<br />

L3060 5 FOOT ARCH SUPP LONGITUD/META 0.00<br />

L3070 5 ARCH SUPRT ATT TO SHO LONGIT 0.00<br />

L3080 5 ARCH SUPP ATT TO SHOE METATA 0.00<br />

L3090 5 ARCH SUPP ATT TO SHOE LONG/M 0.00<br />

L3100 5 HALLUS-VALGUS NGHT DYNAMIC S 0.00<br />

L3140 5 ABDUCTION ROTATION BAR SHOE 0.00<br />

L3150 5 ABDUCT ROTATION BAR W/O SHOE 0.00<br />

L3160 5 SHOE STYLED POSITIONING <strong>DE</strong>V 0.00<br />

L3170 5 FOOT PLASTIC HEEL STABILIZER 0.00<br />

L3201 5 OXFORD W SUPINAT/PRONAT INF 0.00<br />

L3202 5 OXFORD W/ SUPINAT/PRONATOR C 0.00<br />

L3203 5 OXFORD W/ SUPINATOR/PRONATOR 0.00<br />

L3204 5 HIGHTOP W/ SUPP/PRONATOR INF 0.00<br />

L3206 5 HIGHTOP W/ SUPP/PRONATOR CHI 0.00<br />

L3207 5 HIGHTOP W/ SUPP/PRONATOR JUN 0.00<br />

L3208 5 SURGICAL BOOT EACH INFANT 0.00<br />

L3209 5 SURGICAL BOOT EACH CHILD 0.00<br />

L3211 5 SURGICAL BOOT EACH JUNIOR 0.00<br />

L3212 5 BENESCH BOOT PAIR INFANT 0.00<br />

L3213 5 BENESCH BOOT PAIR CHILD 0.00<br />

L3214 5 BENESCH BOOT PAIR JUNIOR 0.00<br />

L3215 3 ORTHOPEDIC FTWEAR LADIES OXF 86.72

---

L3216 5 ORTHOPED LADIES SHOES DPTH I 0.00<br />

L3217 5 LADIES SHOES HIGHTOP <strong>DE</strong>PTH I 0.00<br />

L3218 O LADIES SURGICAL BOOT EACH 0.00<br />

L3219 3 ORTHOPEDIC MENS SHOES OXFORD 89.02<br />

L3221 5 ORTHOPEDIC MENS SHOES DPTH I 0.00<br />

L3222 5 MENS SHOES HIGHTOP <strong>DE</strong>PTH INL 0.00<br />

L3223 O MENS SURGICAL BOOT EACH 0.00<br />

L3224 3 WOMAN'S SHOE OXFORD BRACE 47.77<br />

L3225 3 MAN'S SHOE OXFORD BRACE 49.05<br />

L3230 5 CUSTOM SHOES <strong>DE</strong>PTH INLAY 0.00<br />

L3250 5 CUSTOM MOLD SHOE REMOV PROST 0.00<br />

L3251 5 SHOE MOL<strong>DE</strong>D TO PT SILICONE S 0.00<br />

L3252 5 SHOE MOL<strong>DE</strong>D PLASTAZOTE CUST 0.00<br />

L3253 5 SHOE MOL<strong>DE</strong>D PLASTAZOTE CUST 0.00<br />

L3254 5 ORTH FOOT NON-STNDARD SIZE/W 0.00<br />

L3255 5 ORTH FOOT NON-STANDARD SIZE/ 0.00<br />

L3257 5 ORTH FOOT ADD CHARGE SPLIT S 0.00<br />

L3260 5 AMBULATORY SURGICAL BOOT EAC 0.00<br />

L3265 5 PLASTAZOTE SANDAL EACH 0.00<br />

L3300 5 SHO LIFT TAPER TO METATARSAL 0.00<br />

L3310 5 SHOE LIFT ELEV HEEL/SOLE NEO 0.00<br />

L3320 5 SHOE LIFT ELEV HEEL/SOLE COR 0.00<br />

L3330 5 LIFTS ELEVATION METAL EXTENS 0.00<br />

L3332 5 SHOE LIFTS TAPERED TO ONE-HA 0.00<br />

L3334 5 SHOE LIFTS ELEVATION HEEL /I 0.00<br />

L3340 5 SHOE WEDGE SACH 0.00<br />

L3350 5 SHOE HEEL WEDGE 0.00<br />

L3360 5 SHOE SOLE WEDGE OUTSI<strong>DE</strong> SOLE 0.00<br />

L3370 5 SHOE SOLE WEDGE BETWEEN SOLE 0.00<br />

L3380 5 SHOE CLUBFOOT WEDGE 0.00<br />

L3390 5 SHOE OUTFLARE WEDGE 0.00<br />

L3400 5 SHOE METATARSAL BAR WEDGE RO 0.00<br />

L3410 5 SHOE METATARSAL BAR BETWEEN 0.00<br />

L3420 5 FULL SOLE/HEEL WEDGE BTWEEN 0.00<br />

L3430 5 SHO HEEL COUNT PLAST REINFOR 0.00<br />

L3440 5 HEEL LEATHER REINFORCED 0.00<br />

L3450 5 SHOE HEEL SACH CUSHION TYPE 0.00<br />

L3455 5 SHOE HEEL NEW LEATHER STANDA 0.00<br />

L3460 5 SHOE HEEL NEW RUBBER STANDAR 0.00<br />

L3465 5 SHOE HEEL THOMAS WITH WEDGE 0.00<br />

L3470 5 SHOE HEEL THOMAS EXTEND TO B 0.00<br />

L3480 5 SHOE HEEL PAD & <strong>DE</strong>PRESS FOR 0.00<br />

L3485 5 SHOE HEEL PAD REMOVABLE FOR 0.00<br />

L3500 5 ORTHO SHOE ADD LEATHER INSOL 0.00<br />

L3510 5 ORTHOPEDIC SHOE ADD RUB INSL 0.00<br />

L3520 5 O SHOE ADD FELT W LEATH INSL 0.00<br />

L3530 5 ORTHO SHOE ADD HALF SOLE 0.00<br />

L3540 5 ORTHO SHOE ADD FULL SOLE 0.00<br />

L3550 5 O SHOE ADD STANDARD TOE TAP 0.00<br />

L3560 5 O SHOE ADD HORSESHOE TOE TAP 0.00

---

L3570 5 O SHOE ADD INSTEP EXTENSION 0.00<br />

L3580 5 O SHOE ADD INSTEP VELCRO CLO 0.00<br />

L3590 5 O SHOE CONVERT TO SOF COUNTE 0.00<br />

L3595 5 ORTHO SHOE ADD MARCH BAR 0.00<br />

L3600 5 TRANS SHOE CALIP PLATE EXIST 0.00<br />

L3610 3 TRANS SHOE CALIPER PLATE NEW 30.00<br />

L3620 5 TRANS SHOE SOLID STIRRUP EXI 0.00<br />

L3630 5 TRANS SHOE SOLID STIRRUP NEW 0.00<br />

L3640 5 SHOE <strong>DE</strong>NNIS BROWNE SPLINT BO 0.00<br />

L3649 5 ORTHOPEDIC SHOE MODIFICA NOS 0.00<br />

L3650 3 SHL<strong>DE</strong>R FIG 8 ABDUCT RESTRAIN 47.75<br />

L3651 5 PREFAB SHOUL<strong>DE</strong>R ORTHOSIS 0.00<br />

L3652 5 PREFAB DBL SHOUL<strong>DE</strong>R ORTHOSIS 0.00<br />

L3660 3 ABDUCT RESTRAINER CANVAS&WEB 72.21<br />

L3670 3 ACROMIO/CLAVICULAR CANVAS&WE 95.42<br />

L3671 6 SO CAP <strong>DE</strong>SIGN W/O JNTS CF 0.00<br />

L3672 6 SO AIRPLANE W/O JNTS CF 0.00<br />

L3673 6 SO AIRPLANE W/JOINT CF 0.00<br />

L3675 3 CANVAS VEST SO 119.70<br />

L3677 5 SO HARD PLASTIC STABILIZER 0.00<br />

L3700 3 ELBOW ORTHOSES ELAS W STAYS 49.04<br />

L3701 3 PREFAB ELBOW ORTHOSIS 14.56<br />

L3702 6 EO W/O JOINTS CF 0.00<br />

L3710 3 ELBOW ELASTIC WITH METAL JOI 109.80<br />

L3720 3 FOREARM/ARM CUFFS FREE MOTIO 489.89<br />

L3730 3 FOREARM/ARM CUFFS EXT/FLEX A 633.36<br />

L3740 3 CUFFS ADJ LOCK W/ ACTIVE CON 750.90<br />

L3760 3 EO WITHJOINT, PREFABRICATED 341.11<br />

L3762 5 RIGID EO WO JOINTS 0.00<br />

L3763 6 EWHO RIGID W/O JNTS CF 0.00<br />

L3764 6 EWHO W/JOINT(S) CF 0.00<br />

L3765 6 EWHFO RIGID W/O JNTS CF 0.00<br />

L3766 6 EWHFO W/JOINT(S) CF 0.00<br />

L3800 O WHFO SHORT OPPONEN NO ATTACH 0.00<br />

L3805 O WHFO LONG OPPONENS NO ATTACH 0.00<br />

L3806 6 WHFO W/JOINT(S) CUSTOM FAB 0.00<br />

L3807 3 WHFO,NO JOINT, PREFABRICATED 170.55<br />

L3808 6 WHFO, RIGID W/O JOINTS 0.00<br />

L3810 O WHFO THUMB ABDUCTION BAR 0.00<br />

L3815 O WHFO SECOND M.P. ABDUCTION A 0.00<br />

L3820 O WHFO IP EXT ASST W/ MP EXT S 0.00<br />

L3825 O WHFO M.P. EXTENSION STOP 0.00<br />

L3830 O WHFO M.P. EXTENSION ASSIST 0.00<br />

L3835 O WHFO M.P. SPRING EXTENSION A 0.00<br />

L3840 O WHFO SPRING SWIVEL THUMB 0.00<br />

L3845 O WHFO THUMB IP EXT ASS W/ MP 0.00<br />

L3850 O ACTION WRIST W/ DORSIFLEX AS 0.00<br />

L3855 O WHFO ADJ M.P. FLEXION CONTRO 0.00<br />

L3860 O WHFO ADJ M.P. FLEX CTRL & I. 0.00<br />

L3890 O TORSION MECHANISM WRIST/ELBO 0.00

---

L3900 3 HINGE EXTENSION/FLEX WRIST/F 994.57<br />

L3901 3 HINGE EXT/FLEX WRIST FINGER 1,129.43<br />

L3902 O WHFO EXT POWER COMPRESS GAS 0.00<br />

L3904 3 WHFO ELECTRIC CUSTOM FITTED 2,057.53<br />

L3905 6 WHO W/NONTORSION JNT(S) CF 0.00<br />

L3906 3 WHO W/O JOINTS CF 300.34<br />

L3907 O WHFO WRST GAUNTLT THMB SPICA 0.00<br />

L3908 3 WRIST COCK-UP NON-MOL<strong>DE</strong>D 47.27<br />

L3909 5 PREFAB WRIST ORTHOSIS 0.00<br />

L3910 O WHFO SWANSON <strong>DE</strong>SIGN 0.00<br />

L3911 5 PREFAB HAND FINGER ORTHOSIS 0.00<br />

L3912 3 FLEX GLOVE W/ELASTIC FINGER 81.88<br />

L3913 6 HFO W/O JOINTS CF 0.00<br />

L3914 O WHO WRIST EXTENSION COCK-UP 0.00<br />

L3915 6 WHO W NONTOR JNT(S) PREFAB 0.00<br />

L3916 O WHFO WRIST EXTENS W/ OUTRIGG 0.00<br />

L3917 6 PREFAB METACARPL FX ORTHOSIS 0.00<br />

L3918 O HFO KNUCKLE BEN<strong>DE</strong>R 0.00<br />

L3919 6 HO W/O JOINTS CF 0.00<br />

L3920 O KNUCKLE BEN<strong>DE</strong>R WITH OUTRIGGE 0.00<br />

L3921 6 HFO W/JOINT(S) CF 0.00<br />

L3922 O KNUCKLE BEND 2 SEG TO FLEX J 0.00<br />

L3923 3 HFO W/O JOINTS PF 25.99<br />

L3924 O OPPENHEIMER 0.00<br />

L3925 6 FO PIP/DIP WITH JOINT/SPRING 0.00<br />

L3926 O THOMAS SUSPENSION 0.00<br />

L3927 6 FO PIP/DIP W/O JOINT/SPRING 0.00<br />

L3928 O FINGER EXTENSION W/ CLOCK SP 0.00<br />

L3929 6 HFO NONTORSION JOINT, PREFAB 0.00<br />

L3930 O FINGER EXTENSION WITH WRIST 0.00<br />

L3931 6 WHFO NONTORSION JOINT PREFAB 0.00<br />

L3932 O SAFETY PIN SPRING WIRE 0.00<br />

L3933 6 FO W/O JOINTS CF 0.00<br />

L3934 O SAFETY PIN MODIFIED 0.00<br />

L3935 6 FO NONTORSION JOINT CF 0.00<br />

L3936 O PALMER 0.00<br />

L3938 O DORSAL WRIST 0.00<br />

L3940 O DORSAL WRIST W/ OUTRIGGER AT 0.00<br />

L3942 O REVERSE KNUCKLE BEN<strong>DE</strong>R 0.00<br />

L3944 O REVERSE KNUCKLE BEND W/ OUTR 0.00<br />

L3946 O HFO COMPOSITE ELASTIC 0.00<br />

L3948 O FINGER KNUCKLE BEN<strong>DE</strong>R 0.00<br />

L3950 O OPPENHEIMER W/ KNUCKLE BEND 0.00<br />

L3952 O OPPENHEIMER W/ REV KNUCKLE 2 0.00<br />

L3954 O SPREADING HAND 0.00<br />

L3956 5 ADD JOINT UPPER EXT ORTHOSIS 0.00<br />

L3960 3 SEWHO AIRPLAN <strong>DE</strong>SIG ABDU POS 516.83<br />

L3961 6 SEWHO CAP <strong>DE</strong>SIGN W/O JNTS CF 0.00<br />

L3962 3 SEWHO ERBS PALSEY <strong>DE</strong>SIGN ABD 504.11<br />

L3963 O MOL<strong>DE</strong>D W/ ARTICULATING ELBOW 0.00

---

L3964 3 SEO MOBILE ARM SUP ATT TO WC 594.21<br />

L3965 3 ARM SUPP ATT TO WC RANCHO TY 948.19<br />

L3966 3 MOBILE ARM SUPPORTS RECLININ 714.31<br />

L3967 6 SEWHO AIRPLANE W/O JNTS CF 0.00<br />

L3968 3 FRICTION DAMPENING ARM SUPP 903.93<br />

L3969 3 MONOSUSPENSION ARM/HAND SUPP 615.05<br />

L3970 3 ELEVAT PROXIMAL ARM SUPPORT 252.86<br />

L3971 6 SEWHO CAP <strong>DE</strong>SIGN W/JNT(S) CF 0.00<br />

L3972 3 OFFSET/LAT ROCKER ARM W/ ELA 160.79<br />

L3973 6 SEWHO AIRPLANE W/JNT(S) CF 0.00<br />

L3974 3 MOBILE ARM SUPPORT SUPINATOR 136.38<br />

L3975 6 SEWHFO CAP <strong>DE</strong>SIGN W/O JNT CF 0.00<br />

L3976 6 SEWHFO AIRPLANE W/O JNTS CF 0.00<br />

L3977 6 SEWHFO CAP <strong>DE</strong>SGN W/JNT(S) CF 0.00<br />

L3978 6 SEWHFO AIRPLANE W/JNT(S) CF 0.00<br />

L3980 3 UPP EXT FX ORTHOSIS HUMERAL 224.99<br />

L3982 3 UPPER EXT FX ORTHOSIS RAD/UL 262.29<br />

L3984 3 UPPER EXT FX ORTHOSIS WRIST 241.83<br />

L3985 O FOREARM HAND FX ORTH W/ WR H 0.00<br />

L3986 O HUMERAL RAD/ULNA WRIST FX OR 0.00<br />

L3995 3 SOCK FRACTURE OR EQUAL EACH 25.05<br />

L3999 5 UPPER LIMB ORTHOSIS NOS 0.00<br />

L4000 3 REPL GIRDLE MILWAUKEE ORTH 988.41<br />

L4002 6 REPLACE STRAP, ANY ORTHOSIS 0.00<br />

L4010 3 REPLACE TRILATERAL SOCKET BR 481.87<br />

L4020 3 REPLACE QUADLAT SOCKET BRIM 673.89<br />

L4030 3 REPLACE SOCKET BRIM CUST FIT 362.50<br />

L4040 3 REPLACE MOL<strong>DE</strong>D THIGH LACER 295.81<br />

L4045 3 REPLACE NON-MOL<strong>DE</strong>D THIGH LAC 235.52<br />

L4050 3 REPLACE MOL<strong>DE</strong>D CALF LACER 296.42<br />

L4055 3 REPLACE NON-MOL<strong>DE</strong>D CALF LACE 191.94<br />

L4060 3 REPLACE HIGH ROLL CUFF 228.18<br />

L4070 3 REPLACE PROX & DIST UPRIGHT 202.07<br />

L4080 3 REPL MET BAND KAFO-AFO PROX 82.87<br />

L4090 3 REPL MET BAND KAFO-AFO CALF/ 65.40<br />

L4100 3 REPL LEATH CUFF KAFO PROX TH 85.87<br />

L4110 3 REPL LEATH CUFF KAFO-AFO CAL 64.70<br />

L4130 3 REPLACE PRETIBIAL SHELL 362.78<br />

L4200 O REPAIR OF ORTHOTIC <strong>DE</strong>VICE, HOURLY R 0.00<br />

L4205 3 ORTHO DVC REPAIR PER 15 MIN 6.25<br />

L4210 5 ORTH <strong>DE</strong>V REPAIR/REPL MINOR P 0.00<br />

L4310 O MULT-PODUS/EQ ORTH PREP MGMT 0.00<br />

L4320 O LOW EXT MGMT SYS FT POS AFO 0.00<br />

L4350 3 ANKLE CONTROL ORTHOSI PREFAB 71.87<br />

L4360 3 PNEUMATI WALKING BOOT PREFAB 220.93<br />

L4370 3 PNEUMATIC FULL LEG SPLINT 146.11<br />

L4380 3 PNEUMATIC KNEE SPLINT 82.45<br />

L4386 3 NON-PNEUM WALK BOOT PREFAB 124.58<br />

L4390 O REPLACE MULTI-PODUS SPLINT 0.00<br />

L4392 3 REPLACE AFO SOFT INTERFACE 17.63

---

L4394 3 REPLACE FOOT DROP SPINT 12.87<br />

L4396 3 STATIC AFO 125.77<br />

L4398 3 FOOT DROP SPLINT RECUMBENT 57.91<br />

L5000 3 SHO INSERT W ARCH TOE FILLER 426.36<br />

L5010 3 MOLD SOCKET ANK HGT W/ TOE F 931.27<br />

L5020 3 TIBIAL TUBERCLE HGT W/ TOE F 1,515.92<br />

L5050 3 ANK SYMES MOLD SCKT SACH FT 1,755.51<br />

L5060 3 SYMES MET FR LEATH SOCKET AR 2,112.77<br />

L5100 3 MOL<strong>DE</strong>D SOCKET SHIN SACH FOOT 1,828.78<br />

L5105 3 PLAST SOCKET JTS/THGH LACER 2,902.64<br />

L5150 3 MOLD SCKT EXT KNEE SHIN SACH 2,686.23<br />

L5160 3 MOLD SOCKET BENT KNEE SHIN S 2,921.76<br />

L5200 3 KNE SING AXIS FRIC SHIN SACH 2,545.10<br />

L5210 3 NO KNEE/ANKLE JOINTS W/ FT B 1,856.19<br />

L5220 3 NO KNEE JOINT WITH ARTIC ALI 2,109.89<br />

L5230 3 FEM FOCAL <strong>DE</strong>FIC CONSTANT FRI 2,909.97<br />

L5250 3 HIP CANAD SING AXI CONS FRIC 3,968.93<br />

L5270 3 TILT TABLE LOCKING HIP SING 3,934.16<br />

L5280 3 HEMIPELVECT CANAD SING AXIS 3,894.82<br />

L5300 O BK SACH SOFT COVER & FINISH 0.00<br />

L5301 5 BK MOLD SOCKET SACH FT ENDO 0.00<br />

L5310 O KNEE DISART SACH SOFT CV/FIN 0.00<br />

L5311 5 KNEE DISART, SACH FT, ENDO 0.00<br />

L5320 O AK OPEN END SACH SOFT CV/FIN 0.00<br />

L5321 5 AK OPEN END SACH 0.00<br />

L5330 O HIP CANADIAN SACH SFT CV/FIN 0.00<br />

L5331 5 HIP DISART CANADIAN SACH FT 0.00<br />

L5340 O HEMIPELVECTOMY CANAD CV/FIN 0.00<br />

L5341 5 HEMIPELVECTOMY CANADIAN SACH 0.00<br />

L5400 3 POSTOP DRESS & 1 CAST CHG BK 920.64<br />

L5410 3 POSTOP DSG BK EA ADD CAST CH 403.36<br />

L5420 3 POSTOP DSG & 1 CAST CHG AK/D 1,162.72<br />

L5430 3 POSTOP DSG AK EA ADD CAST CH 513.24<br />

L5450 3 POSTOP APP NON-WGT BEAR DSG 328.33<br />

L5460 3 POSTOP APP NON-WGT BEAR DSG 483.92<br />

L5500 3 INIT BK PTB PLASTER DIRECT 982.44<br />

L5505 3 INIT AK ISCHAL PLSTR DIRECT 1,330.47<br />

L5510 3 PREP BK PTB PLASTER MOL<strong>DE</strong>D 1,113.65<br />

L5520 3 PERP BK PTB THERMOPLS DIRECT 1,100.03<br />

L5530 3 PREP BK PTB THERMOPLS MOL<strong>DE</strong>D 1,392.40<br />

L5535 3 PREP BK PTB OPEN END SOCKET 1,372.22<br />

L5540 3 PREP BK PTB LAMINATED SOCKET 1,448.99<br />

L5560 3 PREP AK ISCHIAL PLAST MOL<strong>DE</strong>D 1,486.72<br />

L5570 3 PREP AK ISCHIAL DIRECT FORM 1,545.67<br />

L5580 3 PREP AK ISCHIAL THERMO MOLD 1,804.46<br />

L5585 3 PREP AK ISCHIAL OPEN END 1,957.15<br />

L5590 3 PREP AK ISCHIAL LAMINATED 1,838.87<br />

L5595 3 HIP DISARTIC SACH THERMOPLS 3,232.24<br />

L5600 3 HIP DISART SACH LAMINAT MOLD 3,525.47<br />

L5610 3 ABOVE KNEE HYDRACA<strong>DE</strong>NCE 1,583.72

---

L5611 3 AK 4 BAR LINK W/FRIC SWING 1,232.45<br />

L5613 3 AK 4 BAR LING W/HYDRAUL SWIG 1,874.64<br />

L5614 3 4-BAR LINK ABOVE KNEE W/SWNG 1,267.18<br />

L5616 3 AK UNIV MULTIPLEX SYS FRICT 1,038.91<br />

L5617 3 AK/BK SELF-ALIGNING UNIT EA 420.17<br />

L5618 3 TEST SOCKET SYMES 242.04<br />

L5620 3 TEST SOCKET BELOW KNEE 212.67<br />

L5622 3 TEST SOCKET KNEE DISARTICULA 324.80<br />

L5624 3 TEST SOCKET ABOVE KNEE 309.88<br />

L5626 3 TEST SOCKET HIP DISARTICULAT 435.56<br />

L5628 3 TEST SOCKET HEMIPELVECTOMY 412.54<br />

L5629 3 BELOW KNEE ACRYLIC SOCKET 315.05<br />

L5630 3 SYME TYP EXPANDABL WALL SCKT 343.30<br />

L5631 3 AK/KNEE DISARTIC ACRYLIC SOC 410.52<br />

L5632 3 SYMES TYPE PTB BRIM <strong>DE</strong>SIGN S 169.85<br />

L5634 3 SYMES TYPE POSTER OPENING SO 232.68<br />

L5636 3 SYMES TYPE MEDIAL OPENING SO 194.91<br />

L5637 3 BELOW KNEE TOTAL CONTACT 260.35<br />

L5638 3 BELOW KNEE LEATHER SOCKET 372.27<br />

L5639 3 BELOW KNEE WOOD SOCKET 873.31<br />

L5640 3 KNEE DISARTICULAT LEATHER SO 531.69<br />

L5642 3 ABOVE KNEE LEATHER SOCKET 476.00<br />

L5643 3 HIP FLEX INNER SOCKET EXT FR 1,190.58<br />

L5644 3 ABOVE KNEE WOOD SOCKET 451.81<br />

L5645 3 BK FLEX INNER SOCKET EXT FRA 610.34<br />

L5646 3 BELOW KNEE CUSHION SOCKET 419.12<br />

L5647 3 BELOW KNEE SUCTION SOCKET 608.48<br />

L5648 3 ABOVE KNEE CUSHION SOCKET 503.62<br />

L5649 3 ISCH CONTAINMT/NARROW M-L SO 1,528.91<br />

L5650 3 TOT CONTACT AK/KNEE DISART S 373.43<br />

L5651 3 AK FLEX INNER SOCKET EXT FRA 918.63<br />

L5652 3 SUCTION SUSP AK/KNEE DISART 333.50<br />

L5653 3 KNEE DISART EXPAND WALL SOCK 445.19<br />

L5654 3 SOCKET INSERT SYMES 253.68<br />

L5655 3 SOCKET INSERT BELOW KNEE 214.80<br />

L5656 3 SOCKET INSERT KNEE ARTICULAT 302.59<br />

L5658 3 SOCKET INSERT ABOVE KNEE 294.67<br />

L5660 O SOCK INSRT SYME SILICONE GEL 0.00<br />

L5661 3 MULTI-DUROMETER SYMES 512.05<br />

L5662 O SOCKET INSERT BK SILICONE GE 0.00<br />

L5663 O SOCK KNEE DISARTIC SILICONE 0.00<br />

L5664 O SOCKET INSERT AK SILICONE GE 0.00<br />

L5665 3 MULTI-DUROMETER BELOW KNEE 391.67<br />

L5666 3 BELOW KNEE CUFF SUSPENSION 58.20<br />

L5667 O SOCKET INSERT W LOCK LOWER 0.00<br />

L5668 3 SOCKET INSERT W/O LOCK LOWER 77.71<br />

L5669 O BELOW KNEE SOCKET W/O LOCK 0.00<br />

L5670 3 BK MOL<strong>DE</strong>D SUPRACONDYLAR SUSP 236.56<br />

L5671 5 BK/AK LOCKING MECHANISM 0.00<br />

L5672 3 BK REMOVABLE MEDIAL BRIM SUS 289.06

---

L5673 6 SOCKET INSERT W LOCK MECH 0.00<br />

L5674 O BK SUSPENSION SLEEVE 0.00<br />

L5675 O BK HEAVY DUTY SUSP SLEEVE 0.00<br />

L5676 3 BK KNEE JOINTS SINGLE AXIS P 277.19<br />

L5677 3 BK KNEE JOINTS POLYCENTRIC P 377.16<br />

L5678 3 BK JOINT COVERS PAIR 30.37<br />

L5679 6 SOCKET INSERT W/O LOCK MECH 0.00<br />

L5680 3 BK THIGH LACER NON-MOL<strong>DE</strong>D 264.93<br />

L5681 6 INTL CUSTM CONG/LATYP INSERT 0.00<br />

L5682 3 BK THIGH LACER GLUT/ISCHIA M 478.39<br />

L5683 6 INITIAL CUSTOM SOCKET INSERT 0.00<br />

L5684 3 BK FORK STRAP 36.81<br />

L5685 6 BELOW KNEE SUS/SEAL SLEEVE 0.00<br />

L5686 3 BK BACK CHECK 49.66<br />

L5688 3 BK WAIST BELT WEBBING 46.72<br />

L5690 3 BK WAIST BELT PAD<strong>DE</strong>D AND LIN 90.49<br />

L5692 3 AK PELVIC CONTROL BELT LIGHT 105.02<br />

L5694 3 AK PELVIC CONTROL BELT PAD/L 138.77<br />

L5695 3 AK SLEEVE SUSP NEOPRENE/EQUA 145.59<br />

L5696 3 AK/KNEE DISARTIC PELVIC JOIN 159.10<br />

L5697 3 AK/KNEE DISARTIC PELVIC BAND 64.62<br />

L5698 3 AK/KNEE DISARTIC SILESIAN BA 80.36<br />

L5699 3 SHOUL<strong>DE</strong>R HARNESS 142.63<br />

L5700 3 REPLACE SOCKET BELOW KNEE 2,203.73<br />

L5701 3 REPLACE SOCKET ABOVE KNEE 2,733.93<br />

L5702 3 REPLACE SOCKET HIP 3,445.70<br />

L5703 6 SYMES ANKLE W/O (SACH) FOOT 0.00<br />

L5704 3 CUSTOM SHAPE COVER BK 449.33<br />

L5705 3 CUSTOM SHAPE COVER AK 823.79<br />

L5706 3 CUSTOM SHAPE CVR KNEE DISART 803.52<br />

L5707 3 CUSTOM SHAPE CVR HIP DISART 1,079.50<br />

L5710 3 KNE-SHIN EXO SNG AXI MNL LOC 275.12<br />

L5711 3 KNEE-SHIN EXO MNL LOCK ULTRA 417.34<br />

L5712 3 KNEE-SHIN EXO FRICT SWG & ST 329.61<br />

L5714 3 KNEE-SHIN EXO VARIABLE FRICT 339.91<br />

L5716 3 KNEE-SHIN EXO MECH STANCE PH 557.52<br />

L5718 3 KNEE-SHIN EXO FRCT SWG & STA 696.84<br />

L5722 3 KNEE-SHIN PNEUM SWG FRCT EXO 727.18<br />

L5724 3 KNEE-SHIN EXO FLUID SWING PH 1,154.61<br />

L5726 3 KNEE-SHIN EXT JNTS FLD SWG E 1,516.14<br />

L5728 3 KNEE-SHIN FLUID SWG & STANCE 1,888.89<br />

L5780 3 KNEE-SHIN PNEUM/HYDRA PNEUM 910.73<br />

L5781 5 LOWER LIMB PROS VACUUM PUMP 0.00<br />

L5782 5 HD LOW LIMB PROS VACUUM PUMP 0.00<br />

L5785 3 EXOSKELETAL BK ULTRALT MATER 397.43<br />

L5790 3 EXOSKELETAL AK ULTRA-LIGHT M 550.01<br />

L5795 3 EXOSKEL HIP ULTRA-LIGHT MATE 821.31<br />

L5810 3 ENDOSKEL KNEE-SHIN MNL LOCK 382.08<br />

L5811 3 ENDO KNEE-SHIN MNL LCK ULTRA 557.88<br />

L5812 3 ENDO KNEE-SHIN FRCT SWG & ST 432.41

---

L5814 3 ENDO KNEE-SHIN HYDRAL SWG PH 2,788.88<br />

L5816 3 ENDO KNEE-SHIN POLYC MCH STA 650.54<br />

L5818 3 ENDO KNEE-SHIN FRCT SWG & ST 734.59<br />

L5822 3 ENDO KNEE-SHIN PNEUM SWG FRC 1,425.17<br />

L5824 3 ENDO KNEE-SHIN FLUID SWING P 1,173.08<br />

L5826 3 MINIATURE KNEE JOINT 2,368.56<br />

L5828 3 ENDO KNEE-SHIN FLUID SWG/STA 2,236.15<br />

L5830 3 ENDO KNEE-SHIN PNEUM/SWG PHA 1,588.87<br />

L5840 3 MULTI-AXIAL KNEE/SHIN SYSTEM 2,801.79<br />

L5845 3 KNEE-SHIN SYS STANCE FLEXION 1,345.96<br />

L5846 O KNEE-SHIN SYS MICROPROCESSOR 0.00<br />

L5847 O MICROPROCESSOR CNTRL FEATURE 0.00<br />

L5848 5 KNEE-SHIN SYS HYDRAUL STANCE 0.00<br />

L5850 3 ENDO AK/HIP KNEE EXTENS ASSI 101.61<br />

L5855 3 MECH HIP EXTENSION ASSIST 236.23<br />

L5856 6 ELEC KNEE-SHIN SWING/STANCE 0.00<br />

L5857 6 ELEC KNEE-SHIN SWING ONLY 0.00<br />

L5858 6 STANCE PHASE ONLY 0.00<br />

L5910 3 ENDO BELOW KNEE ALIGNABLE SY 279.01<br />

L5920 3 ENDO AK/HIP ALIGNABLE SYSTEM 405.87<br />

L5925 3 ABOVE KNEE MANUAL LOCK 257.02<br />

L5930 3 HIGH ACTIVITY KNEE FRAME 2,527.60<br />

L5940 3 ENDO BK ULTRA-LIGHT MATERIAL 383.70<br />

L5950 3 ENDO AK ULTRA-LIGHT MATERIAL 648.20<br />

L5960 3 ENDO HIP ULTRA-LIGHT MATERIA 776.46<br />

L5962 3 BELOW KNEE FLEX COVER SYSTEM 449.63<br />

L5964 3 ABOVE KNEE FLEX COVER SYSTEM 805.38<br />

L5966 3 HIP FLEXIBLE COVER SYSTEM 1,037.45<br />

L5968 3 MULTIAXIAL ANKLE W DORSIFLEX 2,728.85<br />

L5970 3 FOOT EXTERNAL KEEL SACH FOOT 167.93<br />

L5971 6 SACH FOOT, REPLACEMENT 0.00<br />

L5972 3 FLEXIBLE KEEL FOOT 269.59<br />

L5974 3 FOOT SINGLE AXIS ANKLE/FOOT 227.45<br />

L5975 3 COMBO ANKLE/FOOT PROSTHESIS 348.14<br />

L5976 3 ENERGY STORING FOOT 428.39<br />

L5978 3 FT PROSTH MULTIAXIAL ANKL/FT 223.23<br />

L5979 3 MULTI-AXIAL ANKLE/FT PROSTH 1,791.29<br />

L5980 3 FLEX FOOT SYSTEM 2,836.17<br />

L5981 3 FLEX-WALK SYS LOW EXT PROSTH 2,451.49<br />

L5982 3 EXOSKELETAL AXIAL ROTATION U 442.22<br />

L5984 3 ENDOSKELETAL AXIAL ROTATION 438.30<br />

L5985 3 LWR EXT DYNAMIC PROSTH PYLON 212.05<br />

L5986 3 MULTI-AXIAL ROTATION UNIT 487.29<br />

L5987 3 SHANK FT W VERT LOAD PYLON 5,402.07<br />

L5988 3 VERTICAL SHOCK REDUCING PYLO 1,500.16<br />

L5989 O PYLON W ELCTRNC FORCE SENSOR 0.00<br />

L5990 5 USER ADJUSTABLE HEEL HEIGHT 0.00<br />

L5993 O HEAVY DUTY FEATURE, FOOT 0.00<br />

L5994 O HEAVY DUTY FEATURE, KNEE 0.00<br />

L5995 O LOWER EXT PROS HEAVYDUTY FEA 0.00

---

L5999 5 LOWR EXTREMITY PROSTHES NOS 0.00<br />

L6000 3 PAR HAND ROBIN-AIDS THUM REM 1,016.37<br />

L6010 3 HAND ROBIN-AIDS LITTLE/RING 1,131.05<br />

L6020 3 PART HAND ROBIN-AIDS NO FING 1,054.53<br />

L6025 5 PART HAND DISART MYOELECTRIC 0.00<br />

L6050 3 WRST MLD SCK FLX HNG TRI PAD 1,453.10<br />

L6055 3 WRST MOLD SOCK W/EXP INTERFA 2,309.76<br />

L6100 3 ELB MOLD SOCK FLEX HINGE PAD 1,472.21<br />

L6110 3 ELBOW MOLD SOCK SUSPENSION T 1,561.53<br />

L6120 3 ELBOW MOLD DOUB SPLT SOC STE 1,819.73<br />

L6130 3 ELBOW STUMP ACTIVATED LOCK H 1,980.21<br />

L6200 3 ELBOW MOLD OUTSID LOCK HINGE 2,086.82<br />

L6205 3 ELBOW MOL<strong>DE</strong>D W/ EXPAND INTER 3,477.47<br />

L6250 3 ELBOW INTER LOC ELBOW FORARM 2,054.13<br />

L6300 3 SHL<strong>DE</strong>R DISART INT LOCK ELBOW 2,849.88<br />

L6310 3 SHOUL<strong>DE</strong>R PASSIVE RESTOR COMP 2,343.65<br />

L6320 3 SHOUL<strong>DE</strong>R PASSIVE RESTOR CAP 1,307.24<br />

L6350 3 THORACIC INTERN LOCK ELBOW 2,996.21<br />

L6360 3 THORACIC PASSIVE RESTOR COMP 2,459.71<br />

L6370 3 THORACIC PASSIVE RESTOR CAP 1,851.78<br />

L6380 3 POSTOP DSG CAST CHG WRST/ELB 1,000.12<br />

L6382 3 POSTOP DSG CAST CHG ELB DIS/ 1,196.80<br />

L6384 3 POSTOP DSG CAST CHG SHL<strong>DE</strong>R/T 1,460.42<br />

L6386 3 POSTOP EA CAST CHG & REALIGN 350.22<br />

L6388 3 POSTOP APPLICAT RIGID DSG ON 336.28<br />

L6400 3 BELOW ELBOW PROSTH TISS SHAP 1,778.70<br />

L6450 3 ELB DISART PROSTH TISS SHAP 2,358.38<br />

L6500 3 ABOVE ELBOW PROSTH TISS SHAP 2,360.31<br />

L6550 3 SHLDR DISAR PROSTH TISS SHAP 2,916.91<br />

L6570 3 SCAP THORAC PROSTH TISS SHAP 3,539.21<br />

L6580 3 WRIST/ELBOW BOW<strong>DE</strong>N CABLE MOL 1,235.42<br />

L6582 3 WRIST/ELBOW BOW<strong>DE</strong>N CBL DIR F 1,052.79<br />

L6584 3 ELBOW FAIR LEAD CABLE MOL<strong>DE</strong>D 1,705.33<br />

L6586 3 ELBOW FAIR LEAD CABLE DIR FO 1,491.81<br />

L6588 3 SHDR FAIR LEAD CABLE MOL<strong>DE</strong>D 2,462.65<br />

L6590 3 SHDR FAIR LEAD CABLE DIRECT 2,252.61<br />

L6600 3 POLYCENTRIC HINGE PAIR 151.99<br />

L6605 3 SINGLE PIVOT HINGE PAIR 141.87<br />

L6610 3 FLEXIBLE METAL HINGE PAIR 127.35<br />

L6611 6 ADDITIONAL SWITCH, EXT POWER 0.00<br />

L6615 3 DISCONNECT LOCKING WRIST UNI 157.03<br />

L6616 3 DISCONNECT INSERT LOCKING WR 66.15<br />

L6620 3 FLEXION/EXTENSION WRIST UNIT 246.46<br />

L6621 6 FLEX/EXT WRIST W/WO FRICTION 0.00<br />

L6623 3 SPRING-ASS ROT WRST W/ LATCH 564.15<br />

L6624 6 FLEX/EXT/ROTATION WRIST UNIT 0.00<br />

L6625 3 ROTATION WRST W/ CABLE LOCK 410.51<br />

L6628 3 QUICK DISCONN HOOK ADAPTER O 419.48<br />

L6629 3 LAMINATION COLLAR W/ COUPLIN 111.91<br />

L6630 3 STAINLESS STEEL ANY WRIST 164.86

---

L6632 3 LATEX SUSPENSION SLEEVE EACH 54.98<br />

L6635 3 LIFT ASSIST FOR ELBOW 152.70<br />

L6637 3 NUDGE CONTROL ELBOW LOCK 316.97<br />

L6638 5 ELEC LOCK ON MANUAL PW ELBOW 0.00<br />

L6639 6 HEAVY DUTY ELBOW FEATURE 0.00<br />

L6640 3 SHOUL<strong>DE</strong>R ABDUCTION JOINT PAI 216.31<br />

L6641 3 EXCURSION AMPLIFIER PULLEY T 143.76<br />

L6642 3 EXCURSION AMPLIFIER LEVER TY 204.69<br />

L6645 3 SHOUL<strong>DE</strong>R FLEXION-ABDUCTION J 248.55<br />

L6646 5 MULTIPO LOCKING SHOUL<strong>DE</strong>R JNT 0.00<br />

L6647 5 SHOUL<strong>DE</strong>R LOCK ACTUATOR 0.00<br />

L6648 5 EXT PWRD SHL<strong>DE</strong>R LOCK/UNLOCK 0.00<br />

L6650 3 SHOUL<strong>DE</strong>R UNIVERSAL JOINT 258.92<br />

L6655 3 STANDARD CONTROL CABLE EXTRA 57.46<br />

L6660 3 HEAVY DUTY CONTROL CABLE 70.21<br />

L6665 3 TEFLON OR EQUAL CABLE LINING 40.14<br />

L6670 3 HOOK TO HAND CABLE ADAPTER 38.06<br />

L6672 3 HARNESS CHEST/SHL<strong>DE</strong>R SADDLE 128.98<br />

L6675 3 HARNESS FIGURE OF 8 SING CON 91.86<br />

L6676 3 HARNESS FIGURE OF 8 DUAL CON 92.77<br />

L6677 6 UE TRIPLE CONTROL HARNESS 0.00<br />

L6680 3 TEST SOCK WRIST DISART/BEL E 177.47<br />

L6682 3 TEST SOCK ELBW DISART/ABOVE 198.90<br />

L6684 3 TEST SOCKET SHLDR DISART/THO 266.63<br />

L6686 3 SUCTION SOCKET 495.85<br />

L6687 3 FRAME TYP SOCKET BEL ELBOW/W 441.23<br />

L6688 3 FRAME TYP SOCK ABOVE ELB/DIS 426.80<br />

L6689 3 FRAME TYP SOCKET SHOUL<strong>DE</strong>R DI 515.42<br />

L6690 3 FRAME TYP SOCK INTERSCAP-THO 558.16<br />

L6691 3 REMOVABLE INSERT EACH 333.79<br />

L6692 3 SILICONE GEL INSERT OR EQUAL 427.78<br />

L6693 3 LOCKINGELBOW FOREARM CNTRBAL 2,131.93<br />

L6694 6 ELBOW SOCKET INS USE W/LOCK 0.00<br />

L6695 6 ELBOW SOCKET INS USE W/O LCK 0.00<br />

L6696 6 CUS ELBO SKT IN FOR CON/ATYP 0.00<br />

L6697 6 CUS ELBO SKT IN NOT CON/ATYP 0.00<br />

L6698 6 BELOW/ABOVE ELBOW LOCK MECH 0.00<br />

L6700 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #3 0.00<br />

L6703 6 TERM <strong>DE</strong>V, PASSIVE HAND MITT 0.00<br />

L6704 6 TERM <strong>DE</strong>V, SPORT/REC/WORK ATT 0.00<br />

L6705 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #5 0.00<br />

L6706 6 TERM <strong>DE</strong>V MECH HOOK VOL OPEN 0.00<br />

L6707 6 TERM <strong>DE</strong>V MECH HOOK VOL CLOSE 0.00<br />

L6708 6 TERM <strong>DE</strong>V MECH HAND VOL OPEN 0.00<br />

L6709 6 TERM <strong>DE</strong>V MECH HAND VOL CLOSE 0.00<br />

L6710 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #5X 0.00<br />

L6711 6 PED TERM <strong>DE</strong>V, HOOK, VOL OPEN 0.00<br />

L6712 6 PED TERM <strong>DE</strong>V, HOOK, VOL CLOS 0.00<br />

L6713 6 PED TERM <strong>DE</strong>V, HAND, VOL OPEN 0.00<br />

L6714 6 PED TERM <strong>DE</strong>V, HAND, VOL CLOS 0.00

---

L6715 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #5XA 0.00<br />

L6720 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #6 0.00<br />

L6721 6 HOOK/HAND, HVY DTY, VOL OPEN 0.00<br />

L6722 6 HOOK/HAND, HVY DTY, VOL CLOS 0.00<br />

L6725 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #7 0.00<br />

L6730 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #7LO 0.00<br />

L6735 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #8 0.00<br />

L6740 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #8X 0.00<br />

L6745 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #88X 0.00<br />

L6750 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #10P 0.00<br />

L6755 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #10X 0.00<br />

L6765 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #12P 0.00<br />

L6770 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #99X 0.00<br />

L6775 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L#555 0.00<br />

L6780 O TERMINAL <strong>DE</strong>VICE MO<strong>DE</strong>L #SS555 0.00<br />

L6790 O HOOKS-ACCU HOOK OR EQUAL 0.00<br />

L6795 O HOOKS-2 LOAD OR EQUAL 0.00<br />

L6800 O HOOKS-APRL VC OR EQUAL 0.00<br />

L6805 3 TERM <strong>DE</strong>V MODIFIER WRIST UNIT 275.35<br />

L6806 O TRS GRIP VC OR EQUAL 0.00<br />

L6807 O TERM <strong>DE</strong>VICE GRIP1/2 OR EQUAL 0.00<br />

L6808 O TERM <strong>DE</strong>VICE INFANT OR CHILD 0.00<br />

L6809 O TRS SUPER SPORT PASSIVE 0.00<br />

L6810 3 TERM <strong>DE</strong>V PRECISION PINCH <strong>DE</strong>V 150.10<br />

L6825 O HANDS DORRANCE VO 0.00<br />

L6830 O HAND APRL VC 0.00<br />

L6835 O HAND SIERRA VO 0.00<br />

L6840 O HAND BECKER IMPERIAL 0.00<br />

L6845 O HAND BECKER LOCK GRIP 0.00<br />

L6850 O TERM DVC-HAND BECKER PLYLITE 0.00<br />

L6855 O HAND ROBIN-AIDS VO 0.00<br />

L6860 O HAND ROBIN-AIDS VO SOFT 0.00<br />

L6865 O HAND PASSIVE HAND 0.00<br />

L6867 O HAND <strong>DE</strong>TROIT INFANT HAND 0.00<br />

L6868 O PASSIVE INF HAND STEEPER/HOS 0.00<br />

L6870 O HAND CHILD MITT 0.00<br />

L6872 O HAND NYU CHILD HAND 0.00<br />

L6873 O HAND MECH INF STEEPER OR EQU 0.00<br />

L6875 O HAND BOCK VC 0.00<br />

L6880 O HAND BOCK VO 0.00<br />

L6881 5 TERM <strong>DE</strong>V AUTO GRASP FEATURE 0.00<br />

L6882 9 MICROPROCESSOR CONTROL UPLMB 0.00<br />

L6883 6 REPLC SOCKT BELOW E/W DISA 0.00<br />

L6884 6 REPLC SOCKT ABOVE ELBOW DISA 0.00<br />

L6885 6 REPLC SOCKT SHLDR DIS/INTERC 0.00<br />

L6890 3 PREFAB GLOVE FOR TERM <strong>DE</strong>VICE 130.10<br />

L6895 3 CUSTOM GLOVE FOR TERM <strong>DE</strong>VICE 473.54<br />

L6900 3 HAND RESTORAT THUMB/1 FINGER 1,228.99<br />

L6905 3 HAND RESTORATION MULTIPLE FI 1,206.52<br />

L6910 3 HAND RESTORATION NO FINGERS 1,238.56

---

L6915 3 HAND RESTORATION REPLACMNT G 478.87<br />

L6920 3 WRIST DISARTICUL SWITCH CTRL 5,896.34<br />

L6925 3 WRIST DISART MYOELECTRONIC C 6,464.09<br />

L6930 3 BELOW ELBOW SWITCH CONTROL 5,578.08<br />

L6935 3 BELOW ELBOW MYOELECTRONIC CT 6,600.69<br />

L6940 3 ELBOW DISARTICULATION SWITCH 7,272.04<br />

L6945 3 ELBOW DISART MYOELECTRONIC C 8,133.63<br />

L6950 3 ABOVE ELBOW SWITCH CONTROL 7,706.82<br />

L6955 3 ABOVE ELBOW MYOELECTRONIC CT 9,372.94<br />

L6960 3 SHLDR DISARTIC SWITCH CONTRO 9,950.82<br />

L6965 3 SHLDR DISARTIC MYOELECTRONIC 11,398.65<br />

L6970 3 INTERSCAPULAR-THOR SWITCH CT 12,251.26<br />

L6975 3 INTERSCAP-THOR MYOELECTRONIC 13,525.58<br />

L7007 6 ADULT ELECTRIC HAND 0.00<br />

L7008 6 PEDIATRIC ELECTRIC HAND 0.00<br />

L7009 6 ADULT ELECTRIC HOOK 0.00<br />

L7010 O HAND OTTO BACK STEEPER/EQ SW 0.00<br />

L7015 O HAND SYS TEKNIK VILLAGE SWIT 0.00<br />

L7020 O ELECTRONIC GREIFER SWITCH CT 0.00<br />

L7025 O ELECTRON HAND MYOELECTRONIC 0.00<br />

L7030 O HAND SYS TEKNIK VILL MYOELEC 0.00<br />

L7035 O ELECTRON GREIFER MYOELECTRO 0.00<br />

L7040 3 PREHENSILE ACTUATOR 2,225.23<br />

L7045 3 PEDIATRIC ELECTRIC HOOK 1,236.40<br />

L7160 O ELECTRONIC ELBOW, BOSTON OR EQUAL, 0.00<br />

L7165 O ELECTRONIC ELBOW, BOSTON OR EQUAL, 0.00<br />

L7170 3 ELECTRONIC ELBOW HOSMER SWIT 4,485.23<br />

L7180 3 ELECTRONIC ELBOW SEQUENTIAL 26,708.37<br />

L7181 6 ELECTRONIC ELBO SIMULTANEOUS 0.00<br />

L7185 3 ELECTRON ELBOW ADOLESCENT SW 4,592.13<br />

L7186 3 ELECTRON ELBOW CHILD SWITCH 7,012.55<br />

L7190 3 ELBOW ADOLESCENT MYOELECTRON 5,978.78<br />

L7191 3 ELBOW CHILD MYOELECTRONIC CT 7,553.10<br />

L7260 3 ELECTRON WRIST ROTATOR OTTO 1,945.02<br />

L7261 3 ELECTRON WRIST ROTATOR UTAH 3,581.46<br />

L7266 3 SERVO CONTROL STEEPER OR EQU 757.35<br />

L7272 3 ANALOGUE CONTROL UNB OR EQUA 1,688.10<br />

L7274 3 PROPORTIONAL CTL 12 VOLT UTA 5,406.56<br />

L7360 3 SIX VOLT BAT OTTO BOCK/EQ EA 228.56<br />

L7362 3 BATTERY CHRGR SIX VOLT OTTO 205.92<br />

L7364 3 TWELVE VOLT BATTERY UTAH/EQU 380.62<br />

L7366 3 BATTERY CHRGR 12 VOLT UTAH/E 512.77<br />

L7367 5 REPLACEMNT LITHIUM IONBATTER 0.00<br />

L7368 5 LITHIUM ION BATTERY CHARGER 0.00<br />

L7400 6 ADD UE PROST BE/WD, ULTLITE 0.00<br />

L7401 6 ADD UE PROST A/E ULTLITE MAT 0.00<br />

L7402 6 ADD UE PROST S/D ULTLITE MAT 0.00<br />

L7403 6 ADD UE PROST B/E ACRYLIC 0.00<br />

L7404 6 ADD UE PROST A/E ACRYLIC 0.00<br />

L7405 6 ADD UE PROST S/D ACRYLIC 0.00

---

L7499 5 UPPER EXTREMITY PROSTHES NOS 0.00<br />

L7500 5 PROSTHETIC DVC REPAIR HOURLY 0.00<br />

L7510 5 PROSTHETIC <strong>DE</strong>VICE REPAIR REP 0.00<br />

L7520 3 REPAIR PROSTHESIS PER 15 MIN 6.25<br />

L7600 6 PROSTHETIC DONNING SLEEVE 0.00<br />

L7611 O PED TERM <strong>DE</strong>V, HOOK, VOL OPEN 0.00<br />

L7612 O PED TERM <strong>DE</strong>V, HOOK, VOL CLOS 0.00<br />

L7613 O PED TERM <strong>DE</strong>V, HAND, VOL OPEN 0.00<br />

L7614 O PED TERM <strong>DE</strong>V, HAND, VOL CLOS 0.00<br />

L7621 O HOOK/HAND, HVY DTY, VOL OPEN 0.00<br />

L7622 O HOOK/HAND, HVY DTY, VOL CLOS 0.00<br />

L7900 9 VACUUM ERECTION SYSTEM 0.00<br />

L8000 3 MASTECTOMY BRA 27.93<br />

L8001 5 BREAST PROSTHESIS BRA & FORM 0.00<br />

L8002 5 BRST PRSTH BRA & BILAT FORM 0.00<br />

L8010 3 MASTECTOMY SLEEVE 46.39<br />

L8015 3 EXT BREASTPROSTHESIS GARMENT 45.02<br />

L8020 3 MASTECTOMY FORM 191.37<br />

L8030 3 BREAST PROSTHESIS SILICONE/E 247.69<br />

L8035 3 CUSTOM BREAST PROSTHESIS 2,751.16<br />

L8039 5 BREAST PROSTHESIS NOS 0.00<br />

L8040 3 NASAL PROSTHESIS 1,294.46<br />

L8041 3 MIDFACIAL PROSTHESIS 1,560.25<br />

L8042 3 ORBITAL PROSTHESIS 1,753.08<br />

L8043 3 UPPER FACIAL PROSTHESIS 1,963.45<br />

L8044 3 HEMI-FACIAL PROSTHESIS 2,173.82<br />

L8045 3 AURICULAR PROSTHESIS 1,517.49<br />

L8046 3 PARTIAL FACIAL PROSTHESIS 1,402.47<br />

L8047 3 NASAL SEPTAL PROSTHESIS 718.77<br />

L8048 5 UNSPEC MAXILLOFACIAL PROSTH 0.00<br />

L8049 3 REPAIR MAXILLOFACIAL PROSTH 15.69<br />

L8100 O COMPRESSION STOCKING BK18-30 0.00<br />

L8110 O COMPRESSION STOCKING BK30-40 0.00<br />

L8120 O COMPRESSION STOCKING BK40-50 0.00<br />

L8130 O GC STOCKING THIGHLNGTH 18-30 0.00<br />

L8140 O GC STOCKING THIGHLNGTH 30-40 0.00<br />

L8150 O GC STOCKING THIGHLNGTH 40-50 0.00<br />

L8160 O GC STOCKING FULL LNGTH 18-30 0.00<br />

L8170 O GC STOCKING FULL LNGTH 30-40 0.00<br />

L8180 O GC STOCKING FULL LNGTH 40-50 0.00<br />

L8190 O GC STOCKING WAISTLNGTH 18-30 0.00<br />

L8195 O GC STOCKING WAISTLNGTH 30-40 0.00<br />

L8200 O GC STOCKING WAISTLNGTH 40-50 0.00<br />

L8210 O GC STOCKING CUSTOM MA<strong>DE</strong> 0.00<br />

L8220 O GC STOCKING LYMPHE<strong>DE</strong>MA 0.00<br />

L8230 O GC STOCKING GARTER BELT 0.00<br />

L8239 O G COMPRESSION STOCKING NOS 0.00<br />

L8300 3 TRUSS SINGLE W/ STANDARD PAD 64.52<br />

L8310 3 TRUSS DOUBLE W/ STANDARD PAD 101.87<br />

L8320 3 TRUSS ADDITION TO STD PAD WA 45.67

---

L8330 3 TRUSS ADD TO STD PAD SCROTAL 37.77<br />

L8400 3 SHEATH BELOW KNEE 13.28<br />

L8410 3 SHEATH ABOVE KNEE 17.75<br />

L8415 3 SHEATH UPPER LIMB 17.44<br />

L8417 3 PROS SHEATH/SOCK W GEL CUSHN 56.42<br />

L8420 3 PROSTHETIC SOCK MULTI PLY BK 15.68<br />

L8430 3 PROSTHETIC SOCK MULTI PLY AK 16.93<br />

L8435 3 PROS SOCK MULTI PLY UPPER LM 16.09<br />

L8440 3 SHRINKER BELOW KNEE 31.99<br />

L8460 3 SHRINKER ABOVE KNEE 50.98<br />

L8465 3 SHRINKER UPPER LIMB 45.15<br />

L8470 3 PROS SOCK SINGLE PLY BK 5.11<br />

L8480 3 PROS SOCK SINGLE PLY AK 7.04<br />

L8485 3 PROS SOCK SINGLE PLY UPPER L 8.84<br />

L8490 O AIR SEAL SUCTION RETEN SYSTM 0.00<br />

L8499 5 UNLISTED MISC PROSTHETIC SER 0.00<br />

L8500 3 ARTIFICIAL LARYNX 673.10<br />

L8501 3 TRACHEOSTOMY SPEAKING VALVE 92.40<br />

L8505 5 ARTIFICIAL LARYNX, ACCESSORY 0.00<br />

L8507 5 TRACH-ESOPH VOICE PROS PT IN 0.00<br />

L8509 5 TRACH-ESOPH VOICE PROS MD IN 0.00<br />

L8510 5 VOICE AMPLIFIER 0.00<br />

L8511 6 INDWELLING TRACH INSERT 0.00<br />

L8512 6 GEL CAP FOR TRACH VOICE PROS 0.00<br />

L8513 6 TRACH PROS CLEANING <strong>DE</strong>VICE 0.00<br />

L8514 6 REPL TRACH PUNCTURE DILATOR 0.00<br />

L8515 6 GEL CAP APP <strong>DE</strong>VICE FOR TRACH 0.00<br />

L8603 9 COLLAGEN IMP URINARY 2.5 ML 0.00<br />

L8604 9 <strong>DE</strong>XTRANOMER/HYALURONIC ACID 0.00<br />

L8606 3 SYNTHETIC IMPLNT URINARY 1ML 166.75<br />

L8609 6 ARTIFICIAL CORNEA 0.00<br />

L8614 9 COCHLEAR <strong>DE</strong>VICE, 0.00<br />

L8615 6 COCH IMPLANT HEADSET REPLACE 0.00<br />

L8616 6 COCH IMPLANT MICROPHONE REPL 0.00<br />

L8617 6 COCH IMPLANT TRANS COIL REPL 0.00<br />

L8618 6 COCH IMPLANT TRAN CABLE REPL 0.00<br />

L8619 3 REPLACE COCHLEAR PROCESSOR 6,403.44<br />

L8620 O REPL LITHIUM ION BATTERY 0.00<br />

L8621 6 REPL ZINC AIR BATTERY 0.00<br />

L8622 6 REPL ALKALINE BATTERY 0.00<br />

L8623 6 LITH ION BATT CID,NON-EARLVL 0.00<br />

L8624 6 LITH ION BATT CID, EAR LEVEL 0.00<br />

L8630 9 METACARPOPHALANGEAL JOINT IMPLANT 0.00<br />

L8631 9 MCP JOINT REPL 2 PC OR MORE 0.00<br />

L8641 9 METATARSAL JOINT IMPLANT 0.00<br />

L8642 9 HALLUX IMPLANT 0.00<br />

L8658 9 INTERPHALANGEAL JOINT SPACER, SILI 0.00<br />

L8659 9 INTERPHALANGEAL JOINT REPL 0.00<br />

L8670 9 VASCULAR GRAFT MATERIAL, SYNTHETIC 0.00<br />

L8680 9 IMPLANTABLE NEUROSTIMULATOR ELECTR 0.00

---

L8681 6 PT PRGRM FOR IMPLT NEUROSTIM 0.00<br />

L8682 6 IMPLT NEUROSTIM RADIOFQ REC 0.00<br />

L8683 6 RADIOFQ TRSMTR FOR IMPLT NEU 0.00<br />

L8684 6 RADIOF TRSMTR IMPLT SCRL NEU 0.00<br />

L8685 9 IMPLT NROSTM PLS GEN SNG REC 0.00<br />

L8686 9 IMPLT NROSTM PLS GEN SNG NON 0.00<br />

L8687 9 IMPLT NROSTM PLS GEN DUA REC 0.00<br />

L8688 9 IMPLT NROSTM PLS GEN DUA NON 0.00<br />

L8689 6 EXTERNAL RECHARG SYS INTERN 0.00<br />

L8690 9 AUD OSSEO <strong>DE</strong>V, INT/EXT COMP 0.00<br />

L8691 6 AUD OSSEO <strong>DE</strong>V EXT SND PROCES 0.00<br />

L8695 6 EXTERNAL RECHARG SYS EXTERN 0.00<br />

L8699 9 PROSTHETIC IMPLANT NOS 0.00<br />

L9900 5 O&P SUPPLY/ACCESSORY/SERVICE 0.00<br />

L9999 O SALES TAX, ORTHOTIC/PROSTHETIC/OTHE 0.00<br />

M0005 9 OFFICE VISITS WITH TWO OR MORE MODA 0.00<br />

M0006 9 OFFICE VISITS WITH ONE OF THE ABOVE 0.00<br />

M0007 9 OFFICE VISITS INCLUDING COMBINATION 0.00<br />

M0008 9 OFFICE VISIT INCLUDING COMBINATION 0.00<br />

M0009 9 NOT OTHERWISE CLASSIFIED, OFFICE VI 0.00<br />

M0019 9 NOT OTHERWISE CLASSIFIED, HOME VISI 0.00<br />

M0021 9 PER DIEM INPATIENT HOSPITAL CARE WH 0.00<br />

M0022 9 I.C.U. CARE FOLLOW-UP WHEN ONE OR 0.00<br />

M0023 9 ROUTINE NEWBORN CARE, INHOSPITAL, I 0.00<br />

M0024 9 CHEMOTHERAPY(FOR MALIGNANCIES, FOLL 0.00<br />

M0029 9 NOT OTHERWISE CLASSIFIED, HOSPITAL 0.00<br />

M0039 9 NOT OTHERWISE CLASSIFIED, SNF, ECF, 0.00<br />

M0049 9 NOT OTHERWISE CLASSIFIED, NH, BOARD 0.00<br />

M0059 9 NOT OTHERWISE CLASSIFIED, EMERGENCY 0.00<br />

M0064 9 BRIEF OFFICE VISIT FOR THE SOLE PU 0.00<br />

M0070 9 INSULIN SHOCK THERAPY, HYPOGLYCEMIA 0.00<br />

M0071 9 ORTHOMOLECULAR THERAPY 0.00<br />

M0072 9 IMMUNOTHERAPY FOR MALIGNANT DISEASE 0.00<br />

M0075 9 CELLULAR THERAPY 0.00<br />

M0076 9 PROLOTHERAPY 0.00<br />

M0080 9 HYPERTHERMIA THERAPY (TO INCLU<strong>DE</strong> SY 0.00<br />

M0100 9 INTRAGASTRIC HYPOTHERMIA 0.00<br />

M0101 9 FOOT CARE HYGIENIC/PM 0.00<br />

M0260 9 TONSILLECTOMY, WITH OR WITHOUT A<strong>DE</strong>N 0.00<br />

M0261 9 TONSILLECTOMY, WITH OR WITHOUT A<strong>DE</strong>N 0.00<br />

M0300 9 IV CHELATIONTHERAPY 0.00<br />

M0301 9 FABRIC WRAPPING OF ANEURYSM 0.00<br />

M0520 9 ELECTRONIC PACEMAKER ANALYSIS, PULS 0.00<br />

M0525 9 SINGLE LEAD EKG WITH ANALYSIS OF PA 0.00<br />

M0526 9 COMPUTER TRACING AND INTERPRETATION 0.00<br />

M0530 9 CARDIAC EVENTS RECOR<strong>DE</strong>R, ELECTROCAR 0.00<br />

M0535 9 CARDIAC EVENTS RECOR<strong>DE</strong>R, ELECTROCAR 0.00<br />

M0540 9 SIGNAL-AVERAGING EKG 0.00<br />

M0560 9 PNEUMOPLETHYSMOGRAPHY VENOUS OCCLUS 0.00<br />

M0575 9 ELECTROENCEPHALOGRAM (EEG), INTERPR 0.00

---

M0580 9 TRANSTELEPHONIC ELECTROENCEPHALOGRA 0.00<br />

M0585 9 ACHILLES REFLEX RESPONSE, ELECTRICA 0.00<br />

M0590 9 MONITORING ECG, EEG OR PRESSURE IN 0.00<br />

M0601 9 PSYCHOLOGICAL TESTING, WITH WRITTEN 0.00<br />

M0702 9 BRIEF, OSTEOPATHIC MANIPULATIVE THE 0.00<br />

M0704 9 LIMITED, OSTEOPATHIC MANIPULATIVE T 0.00<br />

M0706 9 INTERMEDIATE OSTEOPATHIC MANIPULATI 0.00<br />

M0708 9 EXTEN<strong>DE</strong>D OSTEOPATHIC MANIPULATIVE T 0.00<br />

M0710 9 COMPREHENSIVE OSTEOPATHIC MANIPULAT 0.00<br />

M0722 9 BRIEF INPATIENT HOSPITAL OMT (UP TO 0.00<br />

M0724 9 LIMITED INPATIENT HOSPITAL OMT (UP 0.00<br />

M0726 9 INTERMEDIATE INPATIENT HOSPITAL OMT 0.00<br />

M0728 9 EXTEN<strong>DE</strong>D INPATIENT HOSPITAL OMT (UP 0.00<br />

M0730 9 COMPREHENSIVE INPATIENT HOSPITAL OM 0.00<br />

M0799 9 PHYSICAL MEDICINE, NOT OTHERWISE CL 0.00<br />

M0900 9 EXCISION, REVISION OR REMOVAL OF A- 0.00<br />

M0910 9 INSERTION CATHETERS FEMORAL VEIN, U 0.00<br />

M0945 9 OUTPATIENT DIALYSIS RELATED PHYSICI 0.00<br />

M0974 9 SELF DIALYSIS TRAINING, ANY MO<strong>DE</strong>, C 0.00<br />

M0978 9 SELF DIALYSIS TRAINING, ANY MO<strong>DE</strong>, C 0.00<br />

ORVCW O MCO SPECIFIC CO<strong>DE</strong>: SMART START OUR 0.00<br />

ORVRN O MCO SPECIFIC CO<strong>DE</strong>: SMART START OUTR 0.00<br />

ORVSW O MCO SPECIFIC CO<strong>DE</strong>: SMART START OUTR 0.00<br />

P2028 9 CEPHALIN FLOCULATION TEST 0.00<br />

P2029 9 CONGO RED BLOOD TEST 0.00<br />

P2031 9 HAIR ANALYSIS 0.00<br />

P2032 9 ICTERUS IN<strong>DE</strong>X, BLOOD 0.00<br />

P2033 9 BLOOD THYMOL TURBIDITY 0.00<br />

P2038 9 BLOOD MUCOPROTEIN 0.00<br />

P3000 9 SCREEN PAP BY TECH W MD SUPV 0.00<br />

P3001 9 SCREENING PAP SMEAR BY PHYS 0.00<br />

P7001 9 CULTURE BACTERIAL URINE 0.00<br />

P7020 9 VACCINE, AUTOGENOUS (MEDICAL NECESS 0.00<br />

P9005 9 ADMINISTRATION FEE CHARGE BY A PROV 0.00<br />

P9006 9 MULTIPLE PATHOLOGY SERVICES 0.00<br />

P9007 9 HANDLING CHARGE FOR PURCHASED LAB S 0.00<br />

P9010 9 WHOLE BLOOD FOR TRANSFUSION 0.00<br />

P9011 9 BLOOD SPLIT UNIT 0.00<br />

P9012 9 CRYOPRECIPITATE EACH UNIT 0.00<br />

P9013 9 UNIT/S BLOOD FIBRINOGEN 0.00<br />

P9014 9 GAMMA GLOBULIN 1 ML 0.00<br />

P9015 9 RH IMMUNE GLOBULIN 1 ML 0.00<br />

P9016 9 RBC LEUKOCYTES REDUCED 0.00<br />

P9017 9 PLASMA 1 DONOR FRZ W/IN 8 HR 0.00<br />

P9018 9 PLASMA PROTEIN FRACT, UNIT 0.00<br />

P9019 9 PLATELETS, EACH UNIT 0.00<br />

P9020 9 PLAELET RICH PLASMA UNIT 0.00<br />

P9021 9 RED BLOOD CELLS UNIT 0.00<br />

P9022 9 WASHED RED BLOOD CELLS UNIT 0.00<br />

P9023 9 FROZEN PLASMA, POOLED, SD 0.00

---

P9024 9 FACTOR VIII DILUTION, EACH BOTTLE. 0.00<br />

P9031 9 PLATELETS LEUKOCYTES REDUCED 0.00<br />

P9032 9 PLATELETS, IRRADIATED 0.00<br />

P9033 9 PLATELETS LEUKOREDUCED IRRAD 0.00<br />

P9034 9 PLATELETS, PHERESIS 0.00<br />

P9035 9 PLATELET PHERES LEUKOREDUCED 0.00<br />

P9036 9 PLATELET PHERESIS IRRADIATED 0.00<br />

P9037 9 PLATE PHERES LEUKOREDU IRRAD 0.00<br />

P9038 9 RBC IRRADIATED 0.00<br />

P9039 9 RBC <strong>DE</strong>GLYCEROLIZED 0.00<br />

P9040 9 RBC LEUKOREDUCED IRRADIATED 0.00<br />

P9041 9 ALBUMIN (HUMAN),5%, 50ML 0.00<br />

P9042 9 ALBUMIN (HUMAN), 25% 0.00<br />

P9043 9 PLASMA PROTEIN FRACT,5%,50ML 0.00<br />

P9044 9 CRYOPRECIPITATEREDUCEDPLASMA 0.00<br />

P9045 9 ALBUMIN (HUMAN), 5%, 250 ML 0.00<br />

P9046 9 ALBUMIN (HUMAN), 25%, 20 ML 0.00<br />

P9047 9 ALBUMIN (HUMAN), 25%, 50ML 0.00<br />

P9048 9 PLASMAPROTEIN FRACT,5%,250ML 0.00<br />

P9050 9 GRANULOCYTES, PHERESIS UNIT 0.00<br />

P9051 9 BLOOD, L/R, CMV-NEG 0.00<br />

P9052 9 PLATELETS, HLA-M, L/R, UNIT 0.00<br />

P9053 9 PLT, PHER, L/R CMV-NEG, IRR 0.00<br />

P9054 9 BLOOD, L/R, FROZ/<strong>DE</strong>GLY/WASH 0.00<br />

P9055 9 PLT, APH/PHER, L/R, CMV-NEG 0.00<br />

P9056 9 BLOOD, L/R, IRRADIATED 0.00<br />

P9057 9 RBC, FRZ/<strong>DE</strong>G/WSH, L/R, IRRAD 0.00<br />

P9058 9 RBC, L/R, CMV-NEG, IRRAD 0.00<br />

P9059 9 PLASMA, FRZ BETWEEN 8-24HOUR 0.00<br />

P9060 9 FR FRZ PLASMA DONOR RETESTED 0.00<br />

P9603 9 ONE-WAY ALLOW PRORATED MILES 0.00<br />

P9604 9 ONE-WAY ALLOW PRORATED TRIP 0.00<br />

P9605 O ROUTINE VENIPUNCTURE FOR COLLECTION 0.00<br />

P9610 9 URINE SPECIMEN COLLECT SINGL 0.00<br />

P9612 9 CATHETERIZE FOR URINE SPEC 0.00<br />

P9615 9 URINE SPECIMEN COLLECT MULT 0.00<br />

PEDCL O MCO SPECIFIC CO<strong>DE</strong>: SMART START PREN 0.00<br />

Q0033 9 LINOZ V. BOWEN AMBULANCE REIMBURSE 0.00<br />

Q0034 9 ADMIN OF INFLUENZA VACCINE 0.00<br />

Q0035 9 CARDIOKYMOGRAPHY 0.00<br />

Q0036 O OXYGEN CONCENTRATOR, HIGH HUMIDITY 0.00<br />

Q0037 5 OXYGEN AND WATER VAPOR ENRICHING SY 0.00<br />

Q0038 O OXYGEN CONTENTS, GASEOUS, PER UNIT 0.00<br />

Q0039 9 OXYGEN CONTENTS, LIQUID, PER UNIT, 0.00<br />

Q0040 O PORTABLE OXYGEN CONTENTS, GASEOUS P 0.00<br />

Q0041 O PORTABLE OXYGEN CONTENTS, LIQUID, P 0.00<br />

Q0042 O STATIONARY COMPRESSED GAS SYSTEM RE 0.00<br />

Q0043 O STATIONARY LIQUID OXYGEN SYSTEM REN 0.00<br />

Q0045 9 ANESTHESIA FOR IRI<strong>DE</strong>CTOMY 0.00<br />

Q0046 9 PORTABLE LIQUID OXYGEN SYSTEM RENTA 0.00

---

Q0047 9 ANESTHESIA FOR BLEPHAROPLASTY 0.00<br />

Q0066 9 ASSESSMENT OF CARDIAC OUTPUT BY ELE 0.00<br />

Q0068 9 EXTRACORPEAL PLASMAPHERESIS 0.00<br />

Q0081 9 INFUSION THER OTHER THAN CHE 0.00<br />

Q0082 9 ACTIVITY THERAPY W/PARTIAL H 0.00<br />

Q0083 9 CHEMO BY OTHER THAN INFUSION 0.00<br />

Q0084 9 CHEMOTHERAPY BY INFUSION 0.00<br />

Q0085 9 CHEMO BY BOTH INFUSION AND O 0.00<br />

Q0086 O PHYSICAL THERAPY EVALUATION/ 0.00<br />

Q0091 9 OBTAINING SCREEN PAP SMEAR 0.00<br />

Q0092 O SET UP PORT XRAY EQUIPMENT 0.00<br />

Q0093 O FILGRASTIM (G-CSF), PER 100 MCG 0.00<br />

Q0094 O SARGRAMOSTIM (GM-CSF), PER 250 MCG 0.00<br />

Q0095 O URINE PREGNANCY TESTS, VISUAL COLOR 0.00<br />

Q0096 O OVULATION TEST KITS, VISUAL COLOR C 0.00<br />

Q0097 O HEMOGLOBIN; BY COPPER SULFATE METHO 0.00<br />

Q0098 O GLUCOSE, BLOOD; BY GLUCOSE MONITORI 0.00<br />

Q0100 O URINALYSIS BY DIP STICK OR TABLET F 0.00<br />

Q0101 O MICROHEMATOCRIT, SPUN 0.00<br />

Q0102 O SEDIMENTATION RATE, ERYTHROCYTE; NO 0.00<br />

Q0103 9 PHYSICAL THERAPY EVALUATION, INITIA 0.00<br />

Q0104 9 PHYSICAL THERAPY RE-EVALUATION, PER 0.00<br />

Q0109 9 OCCUPATIONAL THERAPY EVALUATION, IN 0.00<br />

Q0110 9 OCCUPATIONAL THERAPY RE-EVALUATION, 0.00<br />

Q0111 O WET MOUNTS/ W PREPARATIONS 0.00<br />

Q0112 O POTASSIUM HYDROXI<strong>DE</strong> PREPS 0.00<br />

Q0113 O PINWORM EXAMINATIONS 0.00<br />

Q0114 9 FERN TEST 0.00<br />

Q0115 9 POST-COITAL MUCOUS EXAM 0.00<br />

Q0116 O HEMOGLOBIN BY SINGLE ANALYTE INSTRU 0.00<br />

Q0117 9 FOR DIABETICS ONLY, FITTING (INCLUD 0.00<br />

Q0118 9 FOR DIABETICS ONLY, FITTING (INCLUD 0.00<br />

Q0119 9 FOR DIABETICS ONLY, MULTIPLE <strong>DE</strong>NSIT 0.00<br />

Q0120 9 FOR DIABETICS ONLY, MODIFICATION (I 0.00<br />

Q0121 9 FOR DIABETICS ONLY, MODIFICATION (I 0.00<br />

Q0122 9 FOR DIABETICS ONLY, MODIFICATION (I 0.00<br />

Q0123 9 FOR DIABETICS ONLY, MODIFICATION (I 0.00<br />

Q0132 9 DISPENSING FEE DME NEB DRUG 0.00<br />

Q0136 O NON ESRD EPOETIN ALPHA INJ 0.00<br />

Q0137 O INJECTION, DARBEPOETIN ALFA 0.00<br />

Q0138 O INJECTION, <strong>DE</strong>XAMETHASONE ACETATE, 1 0.00<br />

Q0144 9 AZITHROMYCIN DIHYDRATE, ORAL 0.00<br />

Q0156 9 HUMAN ALBUMIN 5% 0.00<br />

Q0157 O HUMAN ALBUMIN 25% 0.00<br />

Q0160 9 FACTOR IX NON-RECOMBINANT 0.00<br />

Q0161 9 FACTOR IX RECOMBINANT 0.00<br />

Q0163 9 DIPHENHYDRAMINE HCL 50MG 0.00<br />

Q0164 9 PROCHLORPERAZINE MALEATE 5MG 0.00<br />

Q0165 9 PROCHLORPERAZINE MALEATE10MG 0.00<br />

Q0166 9 GRANISETRON HCL 1 MG ORAL 0.00

---

Q0167 9 DRONABINOL 2.5MG ORAL 0.00<br />

Q0168 9 DRONABINOL 5MG ORAL 0.00<br />

Q0169 9 PROMETHAZINE HCL 12.5MG ORAL 0.00<br />

Q0170 9 PROMETHAZINE HCL 25 MG ORAL 0.00<br />

Q0171 9 CHLORPROMAZINE HCL 10MG ORAL 0.00<br />

Q0172 9 CHLORPROMAZINE HCL 25MG ORAL 0.00<br />

Q0173 9 TRIMETHOBENZAMI<strong>DE</strong> HCL 250MG 0.00<br />

Q0174 9 THIETHYLPERAZINE MALEATE10MG 0.00<br />

Q0175 9 PERPHENAZINE 4MG ORAL 0.00<br />

Q0176 9 PERPHENAZINE 8MG ORAL 0.00<br />

Q0177 9 HYDROXYZINE PAMOATE 25MG 0.00<br />

Q0178 9 HYDROXYZINE PAMOATE 50MG 0.00<br />

Q0179 9 ONDANSETRON HCL 8 MG ORAL 0.00<br />

Q0180 9 DOLASETRON MESYLATE ORAL 0.00<br />

Q0181 9 UNSPECIFIED ORAL ANTI-EMETIC 0.00<br />

Q0182 O NONMETABOLIC ACT D/E TISSUE 0.00<br />

Q0183 O NONMETABOLIC ACTIVE TISSUE 0.00<br />

Q0184 9 METABOLICALLY ACTIVE TISSUE 0.00<br />

Q0185 9 METABOLIC ACTIVE D/E TISSUE 0.00<br />

Q0186 9 PARAMEDIC INTERCEPT, RURAL 0.00<br />

Q0187 O FACTOR VIIA RECOMBINANT 0.00<br />

Q0480 9 DRIVER PNEUMATIC VAD, REP 0.00<br />

Q0481 9 MICROPRCSR CU ELEC VAD, REP 0.00<br />

Q0482 9 MICROPRCSR CU COMBO VAD, REP 0.00<br />

Q0483 9 MONITOR ELEC VAD, REP 0.00<br />

Q0484 9 MONITOR ELEC OR COMB VAD REP 0.00<br />

Q0485 9 MONITOR CABLE ELEC VAD, REP 0.00<br />

Q0486 9 MON CABLE ELEC/PNEUM VAD REP 0.00<br />

Q0487 9 LEADS ANY TYPE VAD, REP ONLY 0.00<br />

Q0488 9 PWR PACK BASE ELEC VAD, REP 0.00<br />

Q0489 9 PWR PCK BASE COMBO VAD, REP 0.00<br />

Q0490 9 EMR PWR SOURCE ELEC VAD, REP 0.00<br />

Q0491 9 EMR PWR SOURCE COMBO VAD REP 0.00<br />

Q0492 9 EMR PWR CBL ELEC VAD, REP 0.00<br />

Q0493 9 EMR PWR CBL COMBO VAD, REP 0.00<br />

Q0494 9 EMR HD PMP ELEC/COMBO, REP 0.00<br />

Q0495 9 CHARGER ELEC/COMBO VAD, REP 0.00<br />

Q0496 9 BATTERY ELEC/COMBO VAD, REP 0.00<br />

Q0497 9 BAT CLPS ELEC/COMB VAD, REP 0.00<br />

Q0498 9 HOLSTER ELEC/COMBO VAD, REP 0.00<br />

Q0499 9 BELT/VEST ELEC/COMBO VAD REP 0.00<br />

Q0500 9 FILTERS ELEC/COMBO VAD, REP 0.00<br />

Q0501 9 SHWR COV ELEC/COMBO VAD, REP 0.00<br />

Q0502 9 MOBILITY CART PNEUM VAD, REP 0.00<br />

Q0503 9 BATTERY PNEUM VAD REPLACEMNT 0.00<br />

Q0504 9 PWR ADPT PNEUM VAD, REP VEH 0.00<br />

Q0505 9 MISCL SUPPLY/ACCESSORY VAD 0.00<br />

Q0510 9 DISPENS FEE IMMUNOSUPRESSIVE 0.00<br />

Q0511 9 SUP FEE ANTIEM,ANTICA,IMMUNO 0.00<br />

Q0512 9 PX SUP FEE ANTI-CAN SUB PRES 0.00

---

Q0513 9 DISP FEE INHAL DRUGS/30 DAYS 0.00<br />

Q0514 9 DISP FEE INHAL DRUGS/90 DAYS 0.00<br />

Q0515 5 SERMORELIN ACETATE INJECTION 0.00<br />

Q1001 O NTIOL CATEGORY 1 0.00<br />

Q1002 O NTIOL CATEGORY 2 0.00<br />

Q1003 9 NTIOL CATEGORY 3 0.00<br />

Q1004 9 NTIOL CATEGORY 4 0.00<br />

Q1005 9 NTIOL CATEGORY 5 0.00<br />

Q2001 O ORAL CABERGOLINE 0.5 MG 0.00<br />

Q2002 O ELLIOTTS B SOLUTION PER ML 0.00<br />

Q2003 O APROTININ, 10,000 KIU 0.00<br />

Q2004 5 BLAD<strong>DE</strong>R CALCULI IRRIG SOL 0.00<br />

Q2005 O CORTICORELIN OVINE TRIFLUTAT 0.00<br />

Q2006 O DIGOXIN IMMUNE FAB (OVINE) 0.00<br />

Q2007 O ETHANOLAMINE OLEATE 100 MG 0.00<br />

Q2008 O FOMEPIZOLE, 15 MG 0.00<br />

Q<strong>2009</strong> 5 FOSPHENYTOIN, 50 MG 0.00<br />

Q2010 O GLATIRAMER ACETATE, PER DOSE 0.00<br />

Q2011 O HEMIN, PER 1 MG 0.00<br />

Q2012 O PEGA<strong>DE</strong>MASE BOVINE, 25 IU 0.00<br />

Q2013 O PENTASTARCH 10% SOLUTION 0.00<br />

Q2014 O SERMORELIN ACETATE, 0.5 MG 0.00<br />

Q2015 O SOMATREM, 5 MG 0.00<br />

Q2016 O SOMATROPIN, 1 MG 0.00<br />

Q2017 5 TENIPOSI<strong>DE</strong>, 50 MG 0.00<br />

Q2018 O UROFOLLITROPIN, 75 IU 0.00<br />

Q2019 O BASILIXIMAB 0.00<br />

Q2020 O HISTRELIN ACETATE 0.00<br />

Q2021 O LEPIRUDIN 0.00<br />

Q2022 O VONWILLEBRANDFACTRCMPLXPERIU 0.00<br />

Q3000 O RUBIDIUM RB 82 0.00<br />

Q3001 5 BRACHYTHERAPY RADIOELEMENTS 0.00<br />

Q3002 O GALLIUM GA 67 0.00<br />

Q3003 O TECHNETIUM TC99M BICISATE 0.00<br />

Q3004 O XENON XE 133 0.00<br />

Q3005 O TECHNETIUM TC99M MERTIATI<strong>DE</strong> 0.00<br />

Q3006 O TECHNETIUM TC99M GLUCEPATATE 0.00<br />

Q3007 O SODIUM PHOSPHATE P32 0.00<br />

Q3008 O INDIUM 111-IN PENTETREOTI<strong>DE</strong> 0.00<br />

Q3009 O TECHNETIUM TC99M OXIDRONATE 0.00<br />

Q3010 O TECHNETIUM TC99MLABELEDRBCS 0.00<br />

Q3011 O CHROMIC PHOSPHATE P32 0.00<br />

Q3012 O CYANOCOBALAMIN COBALT CO57 0.00<br />

Q3014 9 TELEHEALTH FACILITY FEE 0.00<br />

Q3017 9 ALS ASSESSMENT 0.00<br />

Q3019 O ALS EMER TRANS NO ALS SERV 0.00<br />

Q3020 O ALS NONEMER TRANS NO ALS SER 0.00<br />

Q3021 5 PED HEPATITIS B VACCINE INJ 0.00<br />

Q3022 5 HEPATITIS B VACCINE ADULT DS 0.00<br />

Q3023 5 INJECTION HEPATITIS BVACCINE 0.00

---

Q3025 5 IM INJ INTERFERON BETA 1-A 0.00<br />

Q3026 5 SUBC INJ INTERFERON BETA-1A 0.00<br />

Q3031 9 COLLAGEN SKIN TEST 0.00<br />

Q4001 9 CAST SUP BODY CAST PLASTER 0.00<br />

Q4002 9 CAST SUP BODY CAST FIBERGLAS 0.00<br />

Q4003 9 CAST SUP SHOUL<strong>DE</strong>R CAST PLSTR 0.00<br />

Q4004 9 CAST SUP SHOUL<strong>DE</strong>R CAST FBRGL 0.00<br />

Q4005 9 CAST SUP LONG ARM ADULT PLST 0.00<br />

Q4006 9 CAST SUP LONG ARM ADULT FBRG 0.00<br />

Q4007 9 CAST SUP LONG ARM PED PLSTER 0.00<br />

Q4008 9 CAST SUP LONG ARM PED FBRGLS 0.00<br />

Q4009 9 CAST SUP SHT ARM ADULT PLSTR 0.00<br />

Q4010 9 CAST SUP SHT ARM ADULT FBRGL 0.00<br />

Q4011 9 CAST SUP SHT ARM PED PLASTER 0.00<br />

Q4012 9 CAST SUP SHT ARM PED FBRGLAS 0.00<br />

Q4013 9 CAST SUP GAUNTLET PLASTER 0.00<br />

Q4014 9 CAST SUP GAUNTLET FIBERGLASS 0.00<br />

Q4015 9 CAST SUP GAUNTLET PED PLSTER 0.00<br />

Q4016 9 CAST SUP GAUNTLET PED FBRGLS 0.00<br />

Q4017 9 CAST SUP LNG ARM SPLINT PLST 0.00<br />

Q4018 9 CAST SUP LNG ARM SPLINT FBRG 0.00<br />

Q4019 9 CAST SUP LNG ARM SPLNT PED P 0.00<br />

Q4020 9 CAST SUP LNG ARM SPLNT PED F 0.00<br />

Q4021 9 CAST SUP SHT ARM SPLINT PLST 0.00<br />

Q4022 9 CAST SUP SHT ARM SPLINT FBRG 0.00<br />

Q4023 9 CAST SUP SHT ARM SPLNT PED P 0.00<br />

Q4024 9 CAST SUP SHT ARM SPLNT PED F 0.00<br />

Q4025 9 CAST SUP HIP SPICA PLASTER 0.00<br />

Q4026 9 CAST SUP HIP SPICA FIBERGLAS 0.00<br />

Q4027 9 CAST SUP HIP SPICA PED PLSTR 0.00<br />

Q4028 9 CAST SUP HIP SPICA PED FBRGL 0.00<br />

Q4029 9 CAST SUP LONG LEG PLASTER 0.00<br />

Q4030 9 CAST SUP LONG LEG FIBERGLASS 0.00<br />

Q4031 9 CAST SUP LNG LEG PED PLASTER 0.00<br />

Q4032 9 CAST SUP LNG LEG PED FBRGLS 0.00<br />

Q4033 9 CAST SUP LNG LEG CYLIN<strong>DE</strong>R PL 0.00<br />

Q4034 9 CAST SUP LNG LEG CYLIN<strong>DE</strong>R FB 0.00<br />

Q4035 9 CAST SUP LNGLEG CYLNDR PED P 0.00<br />

Q4036 9 CAST SUP LNGLEG CYLNDR PED F 0.00<br />

Q4037 9 CAST SUP SHRT LEG PLASTER 0.00<br />

Q4038 9 CAST SUP SHRT LEG FIBERGLASS 0.00<br />

Q4039 9 CAST SUP SHRT LEG PED PLSTER 0.00<br />

Q4040 9 CAST SUP SHRT LEG PED FBRGLS 0.00<br />

Q4041 9 CAST SUP LNG LEG SPLNT PLSTR 0.00<br />

Q4042 9 CAST SUP LNG LEG SPLNT FBRGL 0.00<br />

Q4043 9 CAST SUP LNG LEG SPLNT PED P 0.00<br />

Q4044 9 CAST SUP LNG LEG SPLNT PED F 0.00<br />

Q4045 9 CAST SUP SHT LEG SPLNT PLSTR 0.00<br />

Q4046 9 CAST SUP SHT LEG SPLNT FBRGL 0.00<br />

Q4047 9 CAST SUP SHT LEG SPLNT PED P 0.00

---

Q4048 9 CAST SUP SHT LEG SPLNT PED F 0.00<br />

Q4049 9 FINGER SPLINT, STATIC 0.00<br />

Q4050 9 CAST SUPPLIES UNLISTED 0.00<br />

Q4051 9 SPLINT SUPPLIES MISC 0.00<br />

Q4054 O DARBEPOETIN ALFA, ESRD USE 0.00<br />

Q4055 O EPOETIN ALFA, ESRD USE 0.00<br />

Q4075 O ACYCLOVIR, 5 MG 0.00<br />

Q4076 O DOPAMINE HCL, 40 MG 0.00<br />

Q4077 O TREPROSTINIL, 1 MG 0.00<br />

Q4079 O NATALIZUMAB INJECTION 0.00<br />

Q4080 9 ILOPROST NON-COMP UNIT DOSE 0.00<br />

Q4081 6 EPOETIN ALFA, 100 UNITS ESRD 0.00<br />

Q4082 9 DRUG/BIO NOC PART B DRUG CAP 0.00<br />

Q4083 O HYALURONAN OR <strong>DE</strong>RIVATIVE, HYALGAN 0.00<br />

Q4084 O HYALURONAN OR <strong>DE</strong>RIVATIVE, SYNVISC, 0.00<br />

Q4085 6 HYALURONAN OR <strong>DE</strong>RIVATIVE, EUFLEXXA 0.00<br />

Q4086 O HYALURONAN OR <strong>DE</strong>RIVATIVE, ORTHVISC 0.00<br />

Q4096 O INJECTION, VON WILLEBRAND FACTOR C 0.00<br />

Q4097 O INJECTION, IMMUNE GLOBULIN (PRIVIG 0.00<br />

Q4098 O INJECTION, IRON <strong>DE</strong>XTRAN, 50 MG 0.00<br />

Q4099 O FORMOTEROL FUMARATE INHALATION UD 0.00<br />

Q4100 9 SKIN SUBSTITUTE, NOS 0.00<br />

Q4101 9 APLIGRAF SKIN SUB 0.00<br />

Q4102 9 OASIS WOUND MATRIX SKIN SUB 0.00<br />

Q4103 9 OASIS BURN MATRIX SKIN SUB 0.00<br />

Q4104 9 INTEGRA BMWD SKIN SUB 0.00<br />

Q4105 9 INTEGRA DRT SKIN SUB 0.00<br />

Q4106 9 <strong>DE</strong>RMAGRAFT SKIN SUB 0.00<br />

Q4107 9 GRAFTJACKET SKIN SUB 0.00<br />

Q4108 9 INTEGRA MATRIX SKIN SUB 0.00<br />

Q4109 9 TISSUEMEND SKIN SUB 0.00<br />

Q4110 9 PRIMATRIX SKIN SUB 0.00<br />

Q4111 9 GAMMAGRAFT SKIN SUB 0.00<br />

Q4112 9 CYMETRA ALLOGRAFT 0.00<br />

Q4113 9 GRAFTJACKET EXPRESS ALLOGRAF 0.00<br />

Q4114 9 INTEGRA FLOWABLE WOUND MATRI 0.00<br />

Q5001 9 HOSPICE IN PATIENT HOME 0.00<br />

Q5002 9 HOSPICE IN ASSISTED LIVING 0.00<br />

Q5003 9 HOSPICE IN LT/NON-SKILLED NF 0.00<br />

Q5004 9 HOSPICE IN SNF 0.00<br />

Q5005 9 HOSPICE, INPATIENT HOSPITAL 0.00<br />

Q5006 9 HOSPICE IN HOSPICE FACILITY 0.00<br />

Q5007 9 HOSPICE IN LTCH 0.00<br />

Q5008 9 HOSPICE IN INPATIENT PSYCH 0.00<br />

Q5009 9 HOSPICE CARE, NOS 0.00<br />

Q9920 O EPOETIN WITH HCT

---

Q9925 O EPOETIN WITH HCT = 25 0.00<br />

Q9926 O EPOETIN WITH HCT = 26 0.00<br />

Q9927 O EPOETIN WITH HCT = 27 0.00<br />

Q9928 O EPOETIN WITH HCT = 28 0.00<br />

Q9929 O EPOETIN WITH HCT = 29 0.00<br />

Q9930 O EPOETIN WITH HCT = 30 0.00<br />

Q9931 O EPOETIN WITH HCT = 31 0.00<br />

Q9932 O EPOETIN WITH HCT = 32 0.00<br />

Q9933 O EPOETIN WITH HCT = 33 0.00<br />

Q9934 O EPOETIN WITH HCT = 34 0.00<br />

Q9935 O EPOETIN WITH HCT = 35 0.00<br />

Q9936 O EPOETIN WITH HCT = 36 0.00<br />

Q9937 O EPOETIN WITH HCT = 37 0.00<br />

Q9938 O EPOETIN WITH HCT = 38 0.00<br />

Q9939 O EPOETIN WITH HCT = 39 0.00<br />

Q9940 O EPOETIN WITH HCT >= 40 0.00<br />

Q9945 O LOCM = 400 MG/ML IODINE,1ML 0.00<br />

Q9952 O INJ GAD-BASE MR CONTRAST,1ML 0.00<br />

Q9953 9 INJ FE-BASED MR CONTRAST,1ML 0.00<br />

Q9954 9 ORAL MR CONTRAST, 100 ML 0.00<br />

Q9955 5 INJ PERFLEXANE LIP MICROS,ML 0.00<br />

Q9956 5 INJ OCTAFLUOROPROPANE MIC,ML 0.00<br />

Q9957 5 INJ PERFLUTREN LIP MICROS,ML 0.00<br />

Q9958 9 HOCM = 400MG/ML IODINE, 1ML 0.00<br />

Q9965 9 LOCM 100-199MG/ML IODINE,1ML 0.00<br />

Q9966 9 LOCM 200-299MG/ML IODINE,1ML 0.00<br />

Q9967 9 LOCM 300-399MG/ML IODINE,1ML 0.00<br />

R0059 9 NOT OTHERWISE CLASSIFIED, CHEST 0.00<br />

R0065 9 CIRCULATION TIME, RADIONUCLI<strong>DE</strong> STUD 0.00<br />

R0070 9 TRANSPORT PORTABLE X-RAY 0.00<br />

R0075 9 TRANSPORT PORT X-RAY MULTIPL 0.00<br />

R0076 9 TRANSPORT PORTABLE EKG 0.00<br />

R0085 9 MULTIPLE RADIOLOGY SERVICES 0.00<br />

S0009 O INJECTION, BUTORPHANOL TARTR 0.00<br />

S0010 O INJECTION, SOMATREM, 5 MG 0.00<br />

S0011 O INJECTION, SOMATROPIN, 5 MG 0.00<br />

S0012 9 BUTORPHANOL TARTRATE, NASAL 0.00<br />

S0014 9 TACRINE HYDROCHLORI<strong>DE</strong>, 10 MG 0.00

---

S0016 O INJECTION, AMIKACIN SULFATE 0.00<br />

S0017 5 INJECTION, AMINOCAPROIC ACID 0.00<br />

S0020 5 INJECTION, BUPIVICAINE HYDRO 0.00<br />

S0021 5 INJECTION, CEFOPERAZONE SOD 0.00<br />

S0023 5 INJECTION, CIMETIDINE HYDROC 0.00<br />

S0024 O INJECTION, CIPROFLOXACIN 0.00<br />

S0028 5 INJECTION, FAMOTIDINE, 20 MG 0.00<br />

S0029 O INJECTION, FLUCONAZOLE 0.00<br />

S0030 5 INJECTION, METRONIDAZOLE 0.00<br />

S0032 5 INJECTION, NAFCILLIN SODIUM 0.00<br />

S0034 5 INJECTION, OFLOXACIN, 400 MG 0.00<br />

S0039 5 INJECTION, SULFAMETHOXAZOLE 0.00<br />

S0040 5 INJECTION, TICARCILLIN DISOD 0.00<br />

S0071 O INJECTION, ACYCLOVIR SODIUM 0.00<br />

S0072 O INJECTION, AMIKACIN SULFATE 0.00<br />

S0073 5 INJECTION, AZTREONAM, 500 MG 0.00<br />

S0074 5 INJECTION, CEFOTETAN DISODIU 0.00<br />

S0077 5 INJECTION, CLINDAMYCIN PHOSP 0.00<br />

S0078 5 INJECTION, FOSPHENYTOIN SODI 0.00<br />

S0079 O OCTREOTI<strong>DE</strong> 100 MCG 0.00<br />

S0080 5 INJECTION, PENTAMIDINE ISETH 0.00<br />

S0081 5 INJECTION, PIPERACILLIN SODI 0.00<br />

S0085 O INJECTION, GATIFLOXACIN 0.00<br />

S0086 O INJECTION, VERTEPORFIN, 15MG 0.00<br />

S0087 O ALEMTUZUMAB 30 MG 0.00<br />

S0088 9 IMATINIB 100 MG 0.00<br />

S0090 9 SIL<strong>DE</strong>NAFIL CITRATE, 25 MG 0.00<br />

S0091 5 GRANISETRON 1MG 0.00<br />

S0092 9 HYDROMORPHONE 250 MG 0.00<br />

S0093 9 MORPHINE 500 MG 0.00<br />

S0096 O INJECTION, ITRACONAZOLE, 200 0.00<br />

S0097 O INJECTION, IBUTILI<strong>DE</strong> FUMARAT 0.00<br />

S0098 O INJECTION, SODIUM FERRIC GLU 0.00<br />

S0104 9 ZIDOVUDINE ORAL 100 MG 0.00<br />

S0106 9 BUPROPION HCL SR 60 TABLETS 0.00<br />

S0107 O INJ, OMALIZUMAB 25 MG 0.00<br />

S0108 9 MERCAPTOPURINE 50 MG 0.00<br />

S0109 9 METHADONE ORAL 5 MG 0.00<br />

S0114 O TREPROSTINIL SODIUM INJECT 0.00<br />

S0115 O BORTEZOMIB 3.5 MG 0.00<br />

S0116 O BEVACIZUMAB, 100MG 0.00<br />

S0117 9 TRETINOIN TOPICAL 5G 0.00<br />

S0118 O ZICONOTI<strong>DE</strong> INJ 0.00<br />

S0122 9 INJ MENOTROPINS 75 IU 0.00<br />

S0124 O INJ UROFOLLITROPIN 75 IU 0.00<br />

S0126 9 INJ FOLLITROPIN ALFA 75 IU 0.00<br />

S0128 9 INJ FOLLITROPIN BETA 75 IU 0.00<br />

S0130 O INJ C GONADOTROPIN 5000 IU 0.00<br />

S0132 9 INJ GANIRELIX ACETAT 250 MCG 0.00<br />

S0133 O HISTRELIN IMPLANT 0.00

---

S0135 5 PEGFILGRASTIM INJECTION 6MG 0.00<br />

S0136 9 CLOZAPINE, 25 MG 0.00<br />

S0137 9 DIDANOSINE, 25 MG 0.00<br />

S0138 9 FINASTERI<strong>DE</strong>, 5 MG 0.00<br />

S0139 9 MINOXIDIL, 10 MG 0.00<br />

S0140 9 SAQUINAVIR, 200 MG 0.00<br />

S0141 O ZALCITABINE, 0.375 MG 0.00<br />

S0142 9 COLISTIMETHATE INH SOL MG 0.00<br />

S0143 O AZTREONAM, INH SOL GRAM 0.00<br />

S0145 5 PEG INTERFERON ALFA-2A/180 0.00<br />

S0146 5 PEG INTERFERON ALFA-2B/10 0.00<br />

S0147 O ALGLUCOSIDASE ALFA 20 MG 0.00<br />

S0155 5 EPOPROSTENOL DILUTANT 0.00<br />

S0156 5 EXEMESTANE, 25 MG 0.00<br />

S0157 9 BECAPLERMIN GEL 1%, 0.5 GM 0.00<br />

S0158 O INJECTION LARONIDASE 0.00<br />

S0159 O INJECTION AGALSIDASE 0.00<br />

S0160 9 <strong>DE</strong>XTROAMPHETAMINE 0.00<br />

S0161 5 CALCITROL 0.00<br />

S0162 5 INJECTION EFALIZUMAB 0.00<br />

S0163 O INJECTION RISPERIDONELA 0.00<br />

S0164 5 INJECTION PANTOPRAZOLE 0.00<br />

S0165 O INJECTION ABARELIX 0.00<br />

S0166 9 INJ OLANZAPINE 2.5MG 0.00<br />

S0167 O INJ APOMORPHINE HCL 1MG 0.00<br />

S0168 O INJ AZACITIDINE 100 MG 0.00<br />

S0170 9 ANASTROZOLE 1 MG 0.00<br />

S0171 5 BUMETANI<strong>DE</strong> 0.5 MG 0.00<br />

S0172 9 CHLORAMBUCIL 2 MG 0.00<br />

S0173 O <strong>DE</strong>XAMETHASONE 4 MG 0.00<br />

S0174 9 DOLASETRON 50 MG 0.00<br />

S0175 9 FLUTAMI<strong>DE</strong> 125 MG 0.00<br />

S0176 9 HYDROXYUREA 500 MG 0.00<br />

S0177 9 LEVAMISOLE 50 MG 0.00<br />

S0178 9 LOMUSTINE 10 MG 0.00<br />

S0179 9 MEGESTROL 20 MG 0.00<br />

S0180 O ETONOGESTREL IMPLANT SYSTEM 0.00<br />

S0181 9 ONDANSETRON 4 MG 0.00<br />

S0182 9 PROCARBAZINE 5 MG 0.00<br />

S0183 9 PROCHLORPERAZINE 5 MG 0.00<br />

S0187 9 TAMOXIFEN 10 MG 0.00<br />

S0189 9 TESTOSTERONE PELLET 75 MG 0.00<br />

S0190 5 MIFEPRISTONE, ORAL, 200 MG 0.00<br />

S0191 5 MISOPROSTOL, ORAL, 200 MCG 0.00<br />

S0194 9 VITAMIN SUPPL 100 CAPS 0.00<br />

S0195 5 PNEUMOCOCCAL CONJUGATE VAC 0.00<br />

S0196 9 POLY-L-LACTIC ACID 1ML FACE 0.00<br />

S0197 9 PRENATAL VITAMINS 30 DAY 0.00<br />

S0198 O INJ PEGAPTANIB 0.3 MG 0.00<br />

S0199 9 MEDICALLY INDUCED ABORTION BY ORAL 0.00

---

S0201 9 PARTIAL HOSPITALIZATION SERV 0.00<br />

S0206 9 SURGERY IN OFFICE 0.00<br />

S0207 9 PARAMEDICINTERCEP NONHOSPALS 0.00<br />

S0208 9 PARAMED INTRCEPT NONVOL 0.00<br />

S0209 3 WC VAN MILEAGE PER MI 0.42<br />

S0215 3 NONEMERG TRANSP MILEAGE 0.42<br />

S0220 6 MEDICAL CONFERENCE BY PHYSIC 0.00<br />

S0221 6 MEDICAL CONFERENCE, 60 MIN 0.00<br />

S0250 9 COMP GERIATR ASSMT TEAM 0.00<br />

S0255 9 HOSPICE REFER VISIT NONMD 0.00<br />

S0257 9 END OF LIFE COUNSELING 0.00<br />

S0260 9 H&P FOR SURGERY 0.00<br />

S0265 9 GENETIC COUNSEL 15 MINS 0.00<br />

S0270 9 HOME STD CASE RATE 30 DAYS 0.00<br />

S0271 9 HOME HOSPICE CASE 30 DAYS 0.00<br />

S0272 9 HOME EPISODIC CASE 30 DAYS 0.00<br />

S0273 9 MD HOME VISIT OUTSI<strong>DE</strong> CAP 0.00<br />

S0274 9 NURSE PRACTR VISIT OUTS CAP 0.00<br />

S0302 9 COMPLETED EPSDT 0.00<br />

S0310 9 HOSPITALIST VISIT 0.00<br />

S0315 9 DISEASE MANAGEMENT PROGRAM 0.00<br />

S0316 9 FOLLOW-UP/REASSESSMENT 0.00<br />

S0317 9 DISEASE MGMT PER DIEM 0.00<br />

S0320 9 RN TELEPHONE CALLS TO DMP 0.00<br />

S0340 9 LIFESTYLE MOD 1ST STAGE 0.00<br />

S0341 9 LIFESTYLE MOD 2 OR 3 STAGE 0.00<br />

S0342 9 LIFESTYLE MOD 4TH STAGE 0.00<br />

S0345 9 HOME ECG MONITRNG GLOBAL 24H 0.00<br />

S0346 9 HOME ECG MONITRNG TECH 24HR 0.00<br />

S0347 9 HOME ECG MONITRNG PROF 24HR 0.00<br />

S0390 5 ROUT FOOT CARE PER VISIT 0.00<br />

S0395 9 IMPRESSION CASTING FT 0.00<br />

S0400 9 GLOBAL ESWL KIDNEY 0.00<br />

S0500 6 DISPOS CONT LENS 0.00<br />

S0504 9 SINGL PRSCRP LENS 0.00<br />

S0506 9 BIFOC PRSCP LENS 0.00<br />

S0508 9 TRIFOC PRSCRP LENS 0.00<br />

S0510 9 NON-PRSCRP LENS 0.00<br />

S0512 6 DAILY CONT LENS 0.00<br />

S0514 9 COLOR CONT LENS 0.00<br />

S0515 9 SCLERAL LENS LIQUID BANDAGE 0.00<br />

S0516 6 SAFETY FRAMES 0.00<br />

S0518 9 SUNGLASS FRAMES 0.00<br />

S0580 3 POLYCARB LENS 18.96<br />

S0581 6 NONSTND LENS 0.00<br />

S0590 9 MISC INTEGRAL LENS SERV 0.00<br />

S0592 6 COMP CONT LENS EVAL 0.00<br />

S0595 9 NEW LENSES IN PTS OLD FRAME 0.00<br />

S0601 9 SCREENING PROCTOSCOPY 0.00<br />

S0605 9 DIGITAL RECTAL EXAMINATION, 0.00

---

S0610 3 ANNUAL GYNECOLOGICAL EXAMINA 63.00<br />

S0612 3 ANNUAL GYNECOLOGICAL EXAMINA 60.80<br />

S0613 9 ANN BREAST EXAM 0.00<br />

S0618 9 AUDIOMETRY FOR HEARING AID 0.00<br />

S0620 6 ROUTINE OPHTHALMOLOGICAL EXA 0.00<br />

S0621 6 ROUTINE OPHTHALMOLOGICAL EXA 0.00<br />

S0622 9 PHYS EXAM FOR COLLEGE 0.00<br />

S0625 9 DIGITAL SCREENING RETINA 0.00<br />

S0630 9 REMOVAL OF SUTURES 0.00<br />

S0800 9 LASER IN SITU KERATOMILEUSIS 0.00<br />

S0810 9 PHOTOREFRACTIVE KERATECTOMY 0.00<br />

S0812 9 PHOTOTHERAP KERATECT 0.00<br />

S0820 O COMPUTERIZED CORNEAL TOPOGRA 0.00<br />

S0830 O ULTRASOUND PACHYMETRY 0.00<br />

S1001 9 <strong>DE</strong>LUXE ITEM 0.00<br />

S1002 9 CUSTOM ITEM 0.00<br />

S1015 9 IV TUBING EXTENSION SET 0.00<br />

S1016 9 NON-PVC INTRAVENOUS ADMINIST 0.00<br />

S1025 O INHAL NITRIC OXI<strong>DE</strong> NEONATE 0.00<br />

S1030 9 GLUC MONITOR PURCHASE 0.00<br />

S1031 9 GLUC MONITOR RENTAL 0.00<br />

S1040 6 CRANIAL REMOLDING ORTHOSIS 0.00<br />

S2050 9 DONOR ENTERECTOMY, WITH PREP 0.00<br />

S2052 9 TRANSPLANTATION OF SMALL INT 0.00<br />

S2053 9 TRANSPLANTATION OF SMALL INT 0.00<br />

S2054 9 TRANSPLANTATION OF MULTIVISC 0.00<br />

S2055 9 HARVESTING OF DONOR MULTIVIS 0.00<br />

S2060 9 LOBAR LUNG TRANSPLANTATION 0.00<br />

S2061 9 DONOR LOBECTOMY (LUNG) 0.00<br />

S2065 9 SIMULT PANC KIDN TRANS 0.00<br />

S2066 9 BREAST GAP FLAP RECONST 0.00<br />

S2067 9 BREAST "STACKED" DIEP/GAP 0.00<br />

S2068 9 BREAST DIEP OR SIEA FLAP 0.00<br />

S2070 9 CYSTO LASER TX URETERAL CALC 0.00<br />

S2075 O LAP INC/VENT HERNIA REPAIR 0.00<br />

S2076 O LAP UMBILICAL HERNIA REPAIR 0.00<br />

S2077 O LAP MESH IMPLANT HERN REP 0.00<br />

S2078 O LAP SUPRACERV HYSTERECTOMY 0.00<br />

S2079 9 LAP ESOPHAGOMYOTOMY 0.00<br />

S2080 9 LAUP 0.00<br />

S2082 O LAP ADJUSTABLE GASTRIC BAND 0.00<br />

S2083 9 ADJUSTMENT GASTRIC BAND 0.00<br />

S2085 O LAPAROSCOP GASTRIC BYPASS 0.00<br />

S2090 O OPEN CRYOSURG RENAL 0.00<br />

S2091 O PERC CRYOSURG RENAL 0.00<br />

S2095 9 TRANSCATH EMBOLIZ MICROSPHER 0.00<br />

S2102 9 ISLET CELL TISSUE TRANSPLANT 0.00<br />

S2103 9 ADRENAL TISSUE TRANSPLANT 0.00<br />

S2107 5 ADOPTIVE IMMUNOTHERAPY 0.00<br />

S2109 9 AUTOLOGOUS CHONDROCYTE TRANS 0.00

---

S2112 9 KNEE ARTHROSCP HARV 0.00<br />

S2113 O ARTHRO CHONDROCYTE IMPLANT 0.00<br />

S2114 O ARTHROSC SH TENO<strong>DE</strong>SIS BICEPS 0.00<br />

S2115 9 PERIACETABULAR OSTEOTOMY 0.00<br />

S2117 9 ARTHROEREISIS, SUBTALAR 0.00<br />

S2118 9 TOTAL HIP RESURFACING 0.00<br />

S2120 9 LOW <strong>DE</strong>NSITY LIPOPROTEIN(LDL) 0.00<br />

S2130 O ERA OF REFLUX SAPHENOUS VEIN 0.00<br />

S2131 O LASER ABLAT SAPHENOUS VEIN 0.00<br />

S2135 O NEUROLYSIS INTERSPACE FOOT 0.00<br />

S2140 9 CORD BLOOD HARVESTING 0.00<br />

S2142 9 CORD BLOOD-<strong>DE</strong>RIVED STEM-CELL 0.00<br />

S2150 9 BMT HARV/TRANSPL 28D PKG 0.00<br />

S2152 9 SOLID ORGAN TRANSPL PKG 0.00<br />

S2180 9 DONOR LEUKOCYTE INFUSION 0.00<br />

S2190 9 SUBCUTANEOUS IMPLANTATION OF 0.00<br />

S2202 9 ECHOSCLEROTHERAPY 0.00<br />

S2204 9 TRANSMYOCARDIAL LASER REVASC 0.00<br />

S2205 9 MINIMALLY INVASIVE DIRECT CO 0.00<br />

S2206 9 MINIMALLY INVASIVE DIRECT CO 0.00<br />

S2207 9 MINIMALLY INVASIVE DIRECT CO 0.00<br />

S2208 9 MINIMALLY INVASIVE DIRECT CO 0.00<br />

S2209 9 MINIMALLY INVASIVE DIRECT CO 0.00<br />

S2210 9 CRYOSURGICAL ABLATION (IN SI 0.00<br />

S2211 O TRANSV CAROTID STENT PLACEMT 0.00<br />

S2213 O IMPLANT GASTRIC STIM 0.00<br />

S2215 O UGI ENDOSCOPY INJ IMPLANT 0.00<br />

S2220 9 THROMBECTOMY, CORONARY 0.00<br />

S2225 9 MYRINGOTOMY LASER-ASSIST 0.00<br />

S2230 9 IMPLANT SEMI-IMP HEAR 0.00<br />

S2235 9 IMPLANT AUDITORY BRAIN IMP 0.00<br />

S2250 O UTERINE ARTERY EMBOLIZ 0.00<br />

S2260 9 INDUCED ABORTION 17-24 WEEKS 0.00<br />

S2262 O ABORTION MATERNAL INDIC 25W 0.00<br />

S2265 9 INDUCED ABORTION 25-28 WKS 0.00<br />

S2266 9 INDUCED ABORTION 29-31 WKS 0.00<br />

S2267 9 INDUCED ABORTION 32 OR MORE 0.00<br />

S2270 9 INSERTION VAGINAL CYLIN<strong>DE</strong>R 0.00<br />

S2300 9 ARTHROSCOPY, SHOUL<strong>DE</strong>R, SURGI 0.00<br />

S2325 6 HIP CORE <strong>DE</strong>COMPRESSION 0.00<br />

S2340 9 CHEMO<strong>DE</strong>NERVATION OF ABDUCTOR 0.00<br />

S2341 9 CHEMO<strong>DE</strong>NERV ADDUCT VOCAL 0.00<br />

S2342 9 NASAL ENDOSCOP PO <strong>DE</strong>BRID 0.00<br />

S2344 9 ENDOSC BALLOON SINUPLASTY 0.00<br />

S2348 9 <strong>DE</strong>COMPRESS DISC RF LUMBAR 0.00<br />

S2350 9 DISKECTOMY, ANTERIOR, WITH D 0.00<br />

S2351 9 DISKECTOMY, ANTERIOR, WITH D 0.00<br />

S2360 9 VERTEBROPLAST CERV 1ST 0.00<br />

S2361 9 VERTEBROPLAST CERV ADDL 0.00<br />

S2362 O KYPHOPLASTY, FIRST VERTEBRA 0.00

---

S2363 O KYPHOPLASTY, EACH ADDL 0.00<br />

S2370 O INTRADISCAL ELECTROTHERMAL 0.00<br />

S2371 O EACH ADDITIONAL INTERSPACE 0.00<br />

S2400 5 FETAL SURG CONGEN HERNIA 0.00<br />

S2401 9 FETAL SURG URIN TRAC OBSTR 0.00<br />

S2402 9 FETAL SURG CONG CYST MALF 0.00<br />

S2403 9 FETAL SURG PULMON SEQUEST 0.00<br />

S2404 9 FETAL SURG MYELOMENINGO 0.00<br />

S2405 5 FETAL SURG SACROCOC TERATOMA 0.00<br />

S2409 9 FETAL SURG NOC 0.00<br />

S2411 9 FETOSCOP LASER THER TTTS 0.00<br />

S2900 9 ROBOTIC SURGICAL SYSTEM 0.00<br />

S3000 9 BILAT DIL RETINAL EXAM 0.00<br />

S3005 9 EVAL SELF-ASSESS <strong>DE</strong>PRESSION 0.00<br />

S3600 9 STAT LAB 0.00<br />

S3601 9 STAT LAB HOME/NF 0.00<br />

S3620 9 NEWBORN METABOLIC SCREENING 0.00<br />

S3625 9 MATERNAL TRIPLE SCREEN TEST 0.00<br />

S3626 9 MATERNAL SERUM QUAD SCREEN 0.00<br />

S3628 6 PLACENTAL ALPHA MICROGLOBULIN-1RAP 0.00<br />

S3630 9 EOSINOPHIL BLOOD COUNT 0.00<br />

S3645 9 HIV-1 ANTIBODY TESTING OF OR 0.00<br />

S3650 9 SALIVA TEST, HORMONE LEVEL; 0.00<br />

S3652 9 SALIVA TEST, HORMONE LEVEL; 0.00<br />

S3655 9 ANTISPERM ANTIBODIES TEST 0.00<br />

S3700 9 BLAD<strong>DE</strong>R TUMOR-ASSOCIATED 0.00<br />

S3701 O NMP-22 ASSAY 0.00<br />

S3708 9 GASTROINTESTINAL FAT ABSORPT 0.00<br />

S3711 9 CIRCULATING TUMOR CELL TEST 0.00<br />

S3800 9 GENETIC TESTING ALS 0.00<br />

S3818 9 BRCA1 GENE ANAL 0.00<br />

S3819 9 BRCA2 GENE ANAL 0.00<br />

S3820 9 COMP BRCA1/BRCA2 0.00<br />

S3822 9 SING MUTATION BRST/OVAR 0.00<br />

S3823 9 3 MUTATION BRST/OVAR 0.00<br />

S3828 9 COMP MLH1 GENE 0.00<br />

S3829 9 COMP MLH2 GENE 0.00<br />

S3830 9 GENE TEST HNPCC COMP 0.00<br />

S3831 9 GENE TEST HNPCC SINGLE 0.00<br />

S3833 9 COMP APC SEQUENCE 0.00<br />

S3834 9 SING MUTATION APC 0.00<br />

S3835 9 GENE TEST CYSTIC FIBROSIS 0.00<br />

S3837 9 GENE TEST HEMOCHROMATO 0.00<br />

S3840 9 DNA ANALYSIS RET-ONCOGENE 0.00<br />

S3841 9 GENE TEST RETINOBLASTOMA 0.00<br />

S3842 9 GENE TEST HIPPEL-LINDAU 0.00<br />

S3843 9 DNA ANALYSIS FACTOR V 0.00<br />

S3844 9 DNA ANALYSIS <strong>DE</strong>AFNESS 0.00<br />

S3845 9 GENE TEST ALPHA-THALASSEMIA 0.00<br />

S3846 9 GENE TEST BETA-THALASSEMIA 0.00

---

S3847 9 GENE TEST TAY-SACHS 0.00<br />

S3848 9 GENE TEST GAUCHER 0.00<br />

S3849 9 GENE TEST NIEMANN-PICK 0.00<br />

S3850 9 GENE TEST SICKLE CELL 0.00<br />

S3851 9 GENE TEST CANAVAN 0.00<br />

S3852 9 DNA ANALYSIS APOE ALZHEIMER 0.00<br />

S3853 9 GENE TEST MYO MUSCLR DYST 0.00<br />

S3854 9 GENE PROFILE PANEL BREAST 0.00<br />

S3855 9 GENE TEST PRESENILIN-1 GENE 0.00<br />

S3860 9 GENET TEST CARDIAC ION-COMP 0.00<br />

S3861 9 GENETIC TEST BRUGADA 0.00<br />

S3862 9 GENET TEST CARDIAC ION-SPEC 0.00<br />

S3890 9 FECAL DNA ANALYSIS 0.00<br />

S3900 9 SURFACE EMG 0.00<br />

S3902 9 BALLISTOCARDIOGRAM 0.00<br />

S3904 9 MASTERS TWO STEP 0.00<br />

S3905 9 AUTO HANDHELD DIAG NERV TEST 0.00<br />

S3906 9 TRANSFUSION, DIRECT, BLOOD 0.00<br />

S4005 9 INTERIM LABOR FACILITY GLOBA 0.00<br />

S4011 9 IVF PACKAGE 0.00<br />

S4013 9 COMPL GIFT CASE RATE 0.00<br />

S4014 9 COMPL ZIFT CASE RATE 0.00<br />

S4015 9 COMPLETE IVF NOS CASE RATE 0.00<br />

S4016 9 FROZEN IVF CASE RATE 0.00<br />

S4017 9 IVF CANC A STIM CASE RATE 0.00<br />

S4018 9 F EMB TRNS CANC CASE RATE 0.00<br />

S4020 9 IVF CANC A ASPIR CASE RATE 0.00<br />

S4021 9 IVF CANC P ASPIR CASE RATE 0.00<br />

S4022 9 ASST OOCYTE FERT CASE RATE 0.00<br />

S4023 9 INCOMPL DONOR EGG CASE RATE 0.00<br />

S4025 9 DONOR SERV IVF CASE RATE 0.00<br />

S4026 9 PROCURE DONOR SPERM 0.00<br />

S4027 9 STORE PREV FROZ EMBRYOS 0.00<br />

S4028 9 MICROSURG EPI SPERM ASP 0.00<br />

S4030 9 SPERM PROCURE INIT VISIT 0.00<br />

S4031 9 SPERM PROCURE SUBS VISIT 0.00<br />

S4035 9 STIMULATED IUI CASE RATE 0.00<br />

S4036 O INTRAVAG CULT CASE RATE 0.00<br />

S4037 9 CRYO EMBRYO TRANSF CASE RATE 0.00<br />

S4040 9 MONIT STORE CRYO EMBRYO 30 D 0.00<br />

S4042 9 OVULATION MGMT PER CYCLE 0.00<br />

S4386 O EARLY INTERVENTION 0.00<br />

S4516 O MULTI-DISCIPLINARY ASSESSMENT/EVALU 0.00<br />

S4518 5 ENVIROMENTAL LEAD TESTING 0.00<br />

S4981 9 INSERT LEVONORGESTREL IUS 0.00<br />

S4989 9 CONTRACEPT IUD 0.00<br />

S4990 9 NICOTINE PATCH LEGEND 0.00<br />

S4991 9 NICOTINE PATCH NONLEGEND 0.00<br />

S4993 9 CONTRACEPTIVE PILLS FOR BC 0.00<br />

S4995 9 SMOKING CESSATION GUM 0.00

---

S5000 9 PRESCRIPTION DRUG, GENERIC 0.00<br />

S5001 9 PRESCRIPTION DRUG,BRAND NAME 0.00<br />

S5002 9 FAT EMULSION 10% IN 250 ML 0.00<br />

S5003 9 FAT EMULSION 20% IN 250 ML 0.00<br />

S5010 9 5% <strong>DE</strong>XTROSE AND 0.45% SALINE 0.00<br />

S5011 9 5% <strong>DE</strong>XTROSE IN LACTATED RING 0.00<br />

S5012 9 5% <strong>DE</strong>XTROSE WITH POTASSIUM 0.00<br />

S5013 9 5%<strong>DE</strong>XTROSE/0.45%SALINE1000ML 0.00<br />

S5014 9 D5W/0.45NS W KCL AND MGS04 0.00<br />

S5016 9 ANTIBIOTIC ADMIN SUPPLIES W/ 0.00<br />

S5017 9 ANTIBIOTIC ADMINSUPPLIES W/O 0.00<br />

S5018 9 PAIN THERAPY ADMIN SUPPLIES 0.00<br />

S5019 9 CHEMOTHERAPY ADMIN SUPPLIES 0.00<br />

S5020 9 CHEMOTHERAPY ADMIN SUPPLIES 0.00<br />

S5021 9 HYDRATION THERAPY ADMIN SUPP 0.00<br />

S5022 9 GROWTH HORMONE THERAPY 0.00<br />

S5025 9 INFUSION PUMP RENTAL,PERDIEM 0.00<br />

S5035 9 HIT ROUTINE <strong>DE</strong>VICE MAINT 0.00<br />

S5036 9 HIT <strong>DE</strong>VICE REPAIR 0.00<br />

S5100 9 ADULT DAYCARE SERVICES 15 MIN 0.00<br />

S5101 7 ADULT DAY CARE PER HALF DAY 0.00<br />

S5102 7 ADULY DAY CARE PER DIEM 0.00<br />

S5105 7 CENTERBASED DAYCARE PERDIEM 0.00<br />

S5108 9 HOMECARE TRAIN PT 15 MIN 0.00<br />

S5109 9 HOMECARE TRAIN PT SESSION 0.00<br />

S5110 9 FAMILY HOMECARE TRAINING 15M 0.00<br />

S5111 9 FAMILY HOMECARE TRAIN SESSION 0.00<br />

S5115 9 NONFAMILY HOMECARE TRAIN 15M 0.00<br />

S5116 9 NON FAMILY HC TRAIN SESSION 0.00<br />

S5120 9 CHORE SERVICES PER 15 MIN 0.00<br />

S5121 9 CHORE SERVICES PER DIEM 0.00<br />

S5125 9 ATTENDANT CARE SERVICES 15 M 0.00<br />

S5126 9 ATTENDANT CARE SERVICE 15M 0.00<br />

S5130 7 HOMAKER SERVICE NOS PER 15M 0.00<br />

S5131 9 HOMEMAKER SERVICE NOS PER 15 M 0.00<br />

S5135 9 ADULT COMPANION CARE PER 15M 0.00<br />

S5136 9 ADULT COMPANION CARE PER DIEM 0.00<br />

S5140 7 ADULT FOSTER CARE PER DIEM 0.00<br />

S5141 9 ADULT FOSTER CARE PER MONTH 0.00<br />

S5145 7 CHILD FOSTERCARE TH PER DIEM 0.00<br />

S5146 9 THER FOSTERCARE CHILD MONTH 0.00<br />

S5150 9 UNSKILLED RESPITE CARE 15M 0.00<br />

S5151 9 UNSKILLED RESPIT CARE DIEM 0.00<br />

S5160 7 EMERGENCY RESPONSE SYSTEM ERS INST 0.00<br />

S5161 7 EMERGENCY RESPONSE SYSTEM ERS PER 0.00<br />

S5162 7 EMERGENCY RESPONSE SYSTEM PURCHASE 0.00<br />

S5165 5 HOME MODIFICATIONS PER SERV 0.00<br />

S5170 9 HOME<strong>DE</strong>LIVERED PREPARED MEAL 0.00<br />

S5175 9 LAUNDRY SERV EXT PROF OR<strong>DE</strong>R 0.00<br />

S5180 9 HH RESPIRATORY THRPY IN EVAL 0.00

---

S5181 9 HH RESIRATORY THRPY NOS DAY 0.00<br />

S5185 9 MED REMIN<strong>DE</strong>R SER PER MONTH 0.00<br />

S5190 6 WELLNESS ASSESSMENT BY NONPH 0.00<br />

S5199 9 PERSONAL CARE ITEM NOS EACH 0.00<br />

S5497 9 HIT CATH CARE NOC 0.00<br />

S5498 9 HIT SIMPLE CATH CARE 0.00<br />

S5501 9 HIT COMPLEX CATH CARE 0.00<br />

S5502 9 HIT INTERIM CATH CARE 0.00<br />

S5503 9 MAINTENANCE OF IMPLANTED VAS 0.00<br />

S5517 9 HIT <strong>DE</strong>CLOTTING KIT 0.00<br />

S5518 9 HIT CATH REPAIR KIT 0.00<br />

S5520 9 HIT PICC INSERT KIT 0.00<br />

S5521 9 HIT MIDLINE CATH INSERT KIT 0.00<br />

S5522 9 HIT PICC INSERT NO SUPP 0.00<br />

S5523 9 HIP MIDLINE CATH INSERT KIT 0.00<br />

S5550 6 INSULIN RAPID 5 U 0.00<br />

S5551 6 INSULIN MOST RAPID 5 U 0.00<br />

S5552 6 INSULIN INTERMED 5 U 0.00<br />

S5553 6 INSULIN LONG ACTING 5 U 0.00<br />

S5560 6 INSULIN REUSE PEN 1.5 ML 0.00<br />

S5561 6 INSULIN REUSE PEN 3 ML 0.00<br />

S5565 9 INSULIN CARTRIDGE 150 U 0.00<br />

S5566 9 INSULIN CARTRIDGE 300 U 0.00<br />

S5570 9 INSULIN DISPOS PEN 1.5 ML 0.00<br />

S5571 9 INSULIN DISPOS PEN 3 ML 0.00<br />

S8001 9 RADIOFREQUENCY STIMULATION 0.00<br />

S8004 O WHOLEBODY RADIOPHARM TRGCELL 0.00<br />

S8030 9 TANTALUM RING APPLICATION 0.00<br />

S8035 9 MAGNETIC SOURCE IMAGING 0.00<br />

S8037 9 MRCP 0.00<br />

S8040 9 TOPOGRAPHIC BRAIN MAPPING 0.00<br />

S8042 5 MRI LOW FIELD 0.00<br />

S8048 9 ISOLATED LIMB PERFUSION 0.00<br />

S8049 9 INTRAOPERATIVE RADIATION THE 0.00<br />

S8055 9 US GUIDANCE FETAL REDUCT 0.00<br />

S8060 9 SUPPLY OF CONTRAST MATERIAL 0.00<br />

S8075 O CAD OF DIGITAL MAMMOGR 0.00<br />

S8080 9 SCINTIMAMMOGRAPHY 0.00<br />

S8085 9 FLUORINE-18 FLUORO<strong>DE</strong>OXYGLUCO 0.00<br />

S8092 9 ELECTRON BEAM COMPUTED TOMOG 0.00<br />

S8093 O CT ANGIOGRAPHY CORONARY 0.00<br />

S8095 O WIG (FOR MEDICALLY-INDUCED H 0.00<br />

S8096 9 PORTABLE PEAK FLOW METER 0.00<br />

S8097 9 ASTHMA KIT 0.00<br />

S8100 9 SPACER WITHOUT MASK 0.00<br />

S8101 9 SPACER WITH MASK 0.00<br />

S8105 O OXIMETER FOR MEASURING BLOOD 0.00<br />

S8110 9 PEAK EXPIRATORY FLOW RATE (P 0.00<br />

S8120 9 O2 CONTENTS GAS CUBIC FT 0.00<br />

S8121 9 O2 CONTENTS LIQUID LB 0.00

---

S8180 O TRACH SHOWER PROTECTOR 0.00<br />

S8181 O TRACH TUBE HOL<strong>DE</strong>R 0.00<br />

S8182 O HUMIDIFIER NON-SERVO 0.00<br />

S8183 O HUMIDIFIER DUAL SERVO 0.00<br />

S8185 9 FLUTTER <strong>DE</strong>VICE 0.00<br />

S8186 9 SWIVEL ADAPTOR 0.00<br />

S8189 9 TRACH SUPPLY NOC 0.00<br />

S8190 9 ELECTRONIC SPIROMETER 0.00<br />

S8200 9 CHEST COMPRESSION VEST 0.00<br />

S8205 9 CHEST COMPRESSION SYSTEM GEN 0.00<br />

S8210 9 MUCUS TRAP 0.00<br />

S8260 O ORAL ORTHOTIC FOR TREATMENT 0.00<br />

S8262 5 MANDIB ORTHO REPOS <strong>DE</strong>VICE 0.00<br />

S8265 5 HABERMAN FEE<strong>DE</strong>R 0.00<br />

S8270 9 ENURESIS ALARM 0.00<br />

S8300 9 SACRAL NERVE STIMULATION TES 0.00<br />

S8301 9 INFECT CONTROL SUPPLIES NOS 0.00<br />

S8400 9 INCONTINENCE PANTS, EACH 0.00<br />

S8401 O CHILD-SIZE DIAPER 0.00<br />

S8402 9 DIAPERS, EACH 0.00<br />

S8403 O ADULT-SIZE PULL-UP BRIEF 0.00<br />

S8404 9 CHILD-SIZE PULL-UP BRIEF 0.00<br />

S8405 O INCONTINENCE LINERS, EACH 0.00<br />

S8415 9 SUPPLIES FOR HOME <strong>DE</strong>LIVERY 0.00<br />

S8420 9 CUSTOM GRADIENT SLEEV/GLOV 0.00<br />

S8421 9 READY GRADIENT SLEEV/GLOV 0.00<br />

S8422 9 CUSTOM GRAD SLEEVE MED 0.00<br />

S8423 9 CUSTOM GRAD SLEEVE HEAVY 0.00<br />

S8424 9 READY GRADIENT SLEEVE 0.00<br />

S8425 9 CUSTOM GRAD GLOVE MED 0.00<br />

S8426 9 CUSTOM GRAD GLOVE HEAVY 0.00<br />

S8427 9 READY GRADIENT GLOVE 0.00<br />

S8428 9 READY GRADIENT GAUNTLET 0.00<br />

S8429 9 GRADIENT PRESSURE WRAP 0.00<br />

S8430 9 PADDING FOR COMPRSSN BDG 0.00<br />

S8431 9 COMPRESSION BANDAGE 0.00<br />

S8433 O SKIN SUPPORT/BREAST PROSTH 0.00<br />

S8450 9 SPLINT DIGIT 0.00<br />

S8451 9 SPLINT WRIST OR ANKLE 0.00<br />

S8452 9 SPLINT ELBOW 0.00<br />

S8460 9 CAMISOLE POST-MAST 0.00<br />

S8490 9 100 INSULIN SYRINGES 0.00<br />

S8940 9 HIPPOTHERAPY PER SESSION 0.00<br />

S8945 O PT PHONOPHORESIS 30 MINS 0.00<br />

S8948 6 LOW-LEVEL LASER TRMT 15 MIN 0.00<br />

S8950 9 COMPLEX LYMPHE<strong>DE</strong>MA THERAPY, 0.00<br />

S8990 9 PT OR MANIP FOR MAINT 0.00<br />

S8999 9 RESUSCITATION BAG 0.00<br />

S9001 9 HOME UTERINE MONITOR WITH OR 0.00<br />

S9007 9 ULTRAFILTRATION MONITOR 0.00

---

S9015 9 AUTOMATED EEG MONITORING 0.00<br />

S9022 O DIGITAL SUBTRACTION ANGIOGRA 0.00<br />

S9023 9 XENON REGIONAL CEREBRAL BLOO 0.00<br />

S9024 9 PARANASAL SINUS ULTRASOUND 0.00<br />

S9025 9 OMNICARDIOGRAM/CARDIOINTEGRA 0.00<br />

S9033 9 GAIT ANALYSIS 0.00<br />

S9034 5 ESWL FOR GALLSTONES 0.00<br />

S9035 9 MEDICAL EQUIPMENT OR SUPPLIE 0.00<br />

S9055 9 PROCUREN OR OTHER GROWTH FAC 0.00<br />

S9056 9 COMA STIMULATION PER DIEM 0.00<br />

S9061 9 MEDICAL SUPPLIES AND EQUIPME 0.00<br />

S9075 9 SMOKING CESSATION TREATMENT 0.00<br />

S9083 7 URGENT CARE CENTER GLOBAL 0.00<br />

S9085 9 MENISCAL ALLOGRAFT TRANSPLAN 0.00<br />

S9088 9 SERVICES PROVI<strong>DE</strong>D IN URGENT 0.00<br />

S9090 9 VERTEBRAL AXIAL <strong>DE</strong>COMPRESSIO 0.00<br />

S9092 O CANOLITH REPOSITIONING 0.00<br />

S9097 9 HOME VISIT WOUND CARE 0.00<br />

S9098 9 HOME PHOTOTHERAPY VISIT 0.00<br />

S9105 5 EVALUATION BY OCULARIST 0.00<br />

S9109 9 CHF TELEMONITORING MONTH 0.00<br />

S9117 9 BACK SCHOOL VISIT 0.00<br />

S9122 7 HOME HEALTH AI<strong>DE</strong> OR CERTIFIE 0.00<br />

S9123 3 NURSING CARE IN HOME RN 51.50<br />

S9124 3 NURSING CARE, IN THE HOME; B 46.14<br />

S9125 7 RESPITE CARE, IN THE HOME, P 0.00<br />

S9126 9 HOSPICE CARE, IN THE HOME, P 0.00<br />

S9127 7 SOCIAL WORK VISIT, IN THE HO 0.00<br />

S9128 3 SPEECH THERAPY, IN THE HOME, 43.50<br />

S9129 3 OCCUPATIONAL THERAPY, IN THE 43.50<br />

S9131 3 PT IN THE HOME PER DIEM 43.50<br />

S9140 9 DIABETIC MANAGEMENT PROGRAM, 0.00<br />

S9141 9 DIABETIC MANAGEMENT PROGRAM, 0.00<br />

S9145 5 INSULIN PUMP INITIATION 0.00<br />

S9152 9 SPEECH THERAPY, RE-EVAL 0.00<br />

S9200 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9208 9 HOME MGMT PRETERM LABOR 0.00<br />

S9209 9 HOME MGMT PPROM 0.00<br />

S9210 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9211 5 HOME MGMT GEST HYPERTENSION 0.00<br />

S9212 9 HM POSTPAR HYPER PER DIEM 0.00<br />

S9213 9 HM PREECLAMP PER DIEM 0.00<br />

S9214 9 HM GEST DM PER DIEM 0.00<br />

S9216 9 GEST HYPER W NURS DIEM 0.00<br />

S9217 9 POSTPAR HYPER W NURS DIEM 0.00<br />

S9218 9 PREECLAMP W NURS DIEM 0.00<br />

S9220 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9225 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9230 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9300 9 NURSING SERVICES AND ALL NEC 0.00

---

S9308 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9310 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9325 9 HIT PAIN MGMT PER DIEM 0.00<br />

S9326 9 HIT CONT PAIN PER DIEM 0.00<br />

S9327 9 HIT INT PAIN PER DIEM 0.00<br />

S9328 9 HIT PAIN IMP PUMP DIEM 0.00<br />

S9329 9 HIT CHEMO PER DIEM 0.00<br />

S9330 9 HIT CONT CHEM DIEM 0.00<br />

S9331 9 HIT INTERMIT CHEMO DIEM 0.00<br />

S9335 9 HT HEMODIALYSIS DIEM 0.00<br />

S9336 9 HIT CONT ANTICOAG DIEM 0.00<br />

S9338 9 HIT IMMUNOTHERAPY DIEM 0.00<br />

S9339 9 HIT PERITON DIALYSIS DIEM 0.00<br />

S9340 9 HIT ENTERAL PER DIEM 0.00<br />

S9341 9 HIT ENTERAL GRAV DIEM 0.00<br />

S9342 9 HIT ENTERAL PUMP DIEM 0.00<br />

S9343 9 HIT ENTERAL BOLUS NURS 0.00<br />

S9345 9 HIT ANTI-HEMOPHIL DIEM 0.00<br />

S9346 9 HIT ALPHA-1-PROTEINAS DIEM 0.00<br />

S9347 9 HIT LONGTERM INFUSION DIEM 0.00<br />

S9348 9 HIT SYMPATHOMIM DIEM 0.00<br />

S9349 9 HIT TOCOLYSIS DIEM 0.00<br />

S9351 9 HIT CONT ANTIEMETIC DIEM 0.00<br />

S9353 9 HIT CONT INSULIN DIEM 0.00<br />

S9355 9 HIT CHELATION DIEM 0.00<br />

S9357 9 HIT ENZYME REPLACE DIEM 0.00<br />

S9359 9 HIT ANTI-TNF PER DIEM 0.00<br />

S9361 9 HIT DIURETIC INFUS DIEM 0.00<br />

S9363 9 HIT ANTI-SPASMOTIC DIEM 0.00<br />

S9364 9 HIT TPN TOTAL DIEM 0.00<br />

S9365 9 HIT TPN 1 LITER DIEM 0.00<br />

S9366 9 HIT TPN 2 LITER DIEM 0.00<br />

S9367 9 HIT TPN 3 LITER DIEM 0.00<br />

S9368 9 HIT TPN OVER 3L DIEM 0.00<br />

S9370 9 HT INJ ANTIEMETIC DIEM 0.00<br />

S9372 9 HT INJ ANTICOAG DIEM 0.00<br />

S9373 9 HIT HYDRA TOTAL DIEM 0.00<br />

S9374 9 HIT HYDRA 1 LITER DIEM 0.00<br />

S9375 9 HIT HYDRA 2 LITER DIEM 0.00<br />

S9376 9 HIT HYDRA 3 LITER DIEM 0.00<br />

S9377 9 HIT HYDRA OVER 3L DIEM 0.00<br />

S9379 9 HIT NOC PER DIEM 0.00<br />

S9381 9 HIT HIGH RISK/ESCORT 0.00<br />

S9395 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9401 9 ANTICOAG CLINIC PER SESSION 0.00<br />

S9420 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9423 9 NURSING SERVICES, PATIENT AS 0.00<br />

S9425 9 NURSING SERVICES AND ALL NEC 0.00<br />

S9430 9 PHARMACY COMP/DISP SERV 0.00<br />

S9433 9 MEDICAL FOOD ORAL 100% NUTR 0.00

---

S9434 6 MOD SOLID FOOD SUPPL 0.00<br />

S9435 9 MEDICAL FOODS FOR INBORN ERR 0.00<br />

S9436 9 LAMAZE CLASS 0.00<br />

S9437 9 CHILDBIRTH REFRESHER CLASS 0.00<br />

S9438 9 CESAREAN BIRTH CLASS 0.00<br />

S9439 9 VBAC CLASS 0.00<br />

S9441 9 ASTHMA EDUCATION 0.00<br />

S9442 9 BIRTHING CLASS 0.00<br />

S9443 9 LACTATION CLASS 0.00<br />

S9444 9 PARENTING CLASS 0.00<br />

S9445 7 PT EDUCATION NOC INDIVID 0.00<br />

S9446 9 PT EDUCATION NOC GROUP 0.00<br />

S9447 9 INFANT SAFETY CLASS 0.00<br />

S9449 9 WEIGHT MGMT CLASS 0.00<br />

S9451 9 EXERCISE CLASS 0.00<br />

S9452 9 NUTRITION CLASS 0.00<br />

S9453 9 SMOKING CESSATION CLASS 0.00<br />

S9454 9 STRESS MGMT CLASS 0.00<br />

S9455 9 DIABETIC MANAGEMENT PROGRAM, 0.00<br />

S9460 9 DIABETIC MANAGEMENT PROGRAM, 0.00<br />

S9465 9 DIABETIC MANAGEMENT PROGRAM, 0.00<br />

S9470 3 NUTRITIONAL COUNSELING, DIET 44.00<br />

S9472 9 CARDIAC REHABILITATION PROGR 0.00<br />

S9473 9 PULMONARY REHABILITATION PRO 0.00<br />

S9474 9 ENTEROSTOMAL THERAPY BY A RE 0.00<br />

S9475 9 AMBULATORY SETTING SUBSTANCE 0.00<br />

S9476 9 VESTIBULAR REHAB PER DIEM 0.00<br />

S9480 9 INTENSIVE OUTPATIENT PSYCHIA 0.00<br />

S9482 9 FAMILY STABILIZATION 15 MIN 0.00<br />

S9484 7 CRISIS INTERVENTION PER HOUR 0.00<br />

S9485 9 CRISIS INTERVENTION MENTAL H 0.00<br />

S9490 9 HIT CORTICOSEROID DIEM 0.00<br />

S9494 9 HIT ANTIBIOTIC TOTAL DIEM 0.00<br />

S9497 9 HIT ANTIBIOTIC Q3H DIEM 0.00<br />

S9500 9 HIT ANTIBIOTIC Q24H DIEM 0.00<br />

S9501 9 HIT ANTIBIOTIC Q12H DIEM 0.00<br />

S9502 9 HIT ANTIBIOTIC Q8H DIEM 0.00<br />

S9503 9 HIT ANTIBIOTIC Q6H DIEM 0.00<br />

S9504 9 HIT ANTIBIOTIC Q4H DIEM 0.00<br />

S9524 O NURSING SERVICES RELATED TO 0.00<br />

S9526 9 SKILLED NURSING VISITS FOR 0.00<br />

S9527 9 INSERTION OF A PERIPHERALLY 0.00<br />

S9528 9 INSERTION OF MIDLINE CENTRAL 0.00<br />

S9529 9 VENIPUNCTURE HOME/SNF 0.00<br />

S9533 9 PAIN MANAGEMENT, INTRAVENOUS 0.00<br />

S9535 9 ADMINISTRATION OF HEMATOPOIE 0.00<br />

S9537 9 HT HEM HORM INJ DIEM 0.00<br />

S9538 9 HIT BLOOD PRODUCTS DIEM 0.00<br />

S9539 9 ADMINISTRATION OF ANTIBIOTIC 0.00<br />

S9542 9 HT INJ NOC PER DIEM 0.00

---

S9543 O ADMINISTRATION OF MEDICATION 0.00<br />

S9545 9 ADMINISTRATION OF IMMUNE GLO 0.00<br />

S9546 O HOME INF BLOOD PROD NURS SER 0.00<br />

S9550 9 HOME IV THERAPY, HYDRATION 0.00<br />

S9555 9 ADDITIONAL HOME INFUSION 0.00<br />

S9558 9 HT INJ GROWTH HORM DIEM 0.00<br />

S9559 9 HIT INJ INTERFERON DIEM 0.00<br />

S9560 9 HT INJ HORMONE DIEM 0.00<br />

S9562 9 PALIVIZUMAB HOME INJ PERDIEM 0.00<br />

S9590 9 IN HOME IRRIGATION THERAPY 0.00<br />

S9800 9 HT RN PER HOUR 0.00<br />

S9802 O SPECIALTY DRUG ADMIN/NSG SRV 0.00<br />

S9803 O EACH ADDITIONAL HOUR 0.00<br />

S9806 O RN INFUSION SUITE VISIT 0.00<br />

S9810 9 HT PHARM PER HOUR 0.00<br />

S9900 9 CHRISTIAN SCI PRACT VISIT 0.00<br />

S9970 9 HEALTH CLUB MEMBERSHIP YR 0.00<br />

S9975 9 TRANSPLANT RELATED PER DIEM 0.00<br />

S9976 9 LODGING PER DIEM 0.00<br />

S9977 9 MEALS PER DIEM 0.00<br />

S9981 9 MED RECORD COPY ADMIN 0.00<br />

S9982 9 MED RECORD COPY PER PAGE 0.00<br />

S9986 9 NOT MEDICALLY NECESSARY SVC 0.00<br />

S9988 9 SERV PART OF PHASE I TRIAL 0.00<br />

S9989 9 SERVICES OUTSI<strong>DE</strong> US 0.00<br />

S9990 9 SERVICES PROVI<strong>DE</strong>D AS PART OF 0.00<br />

S9991 9 SERVICES PROVI<strong>DE</strong>D AS PART OF 0.00<br />

S9992 9 TRANSPORTATION COSTS TO AND 0.00<br />

S9994 9 LODGING COSTS (E.G. HOTEL CH 0.00<br />

S9996 9 MEALS FOR CLINICAL TRIAL PAR 0.00<br />

S9999 9 SALES TAX 0.00<br />

SARCW O MCO SPECIFIC CO<strong>DE</strong>: SMART START SUBS 0.00<br />

SARRN O MCO SPECIFIC CO<strong>DE</strong>: SMART START SUBS 0.00<br />

SARSW O MCO SPECIFIC CO<strong>DE</strong>: SMART START SUBS 0.00<br />

T1000 7 PRIVATE DUTY/IN<strong>DE</strong>PEN<strong>DE</strong>NT NSG 0.00<br />

T1001 7 NURSING ASSESSMENT/EVALUATN 0.00<br />

T1002 3 RN SERVICES UP TO 15 MINUTES 19.00<br />

T1003 9 LPN/LVN SERVICES UP TO 15MIN 0.00<br />

T1004 9 NSG AI<strong>DE</strong> SERVICE UP TO 15MIN 0.00<br />

T1005 7 RESPITE CARE SERVICE 15 MIN 0.00<br />

T1006 9 FAMILY/COUPLE COUNSELING 0.00<br />

T1007 9 TREATMENT PLAN <strong>DE</strong>VELOPMENT 0.00<br />

T1008 O DAY TREATMENT FOR INDIVIDUAL 0.00<br />

T1009 9 CHILD SITTING SERVICES 0.00<br />

T1010 9 MEALS WHEN RECEIVE SERVICES 0.00<br />

T1011 O ALCOHOL/SUBSTANCE ABUSE NOC 0.00<br />

T1012 9 ALCOHOL/SUBSTANCE ABUSE SKIL 0.00<br />

T1013 9 SIGN LANG/ORAL INTERPRETER 0.00<br />

T1014 9 TELEHEALTH TRANSMIT, PER MIN 0.00<br />

T1015 9 CLINIC SERVICE 0.00

---

T1016 9 CASE MANAGEMENT 0.00<br />

T1017 9 TARGETED CASE MANAGEMENT 0.00<br />

T1018 9 SCHOOL-BASED IEP SER BUNDLED 0.00<br />

T1019 9 PERSONAL CARE SER PER 15 MIN 0.00<br />

T1020 9 PERSONAL CARE SER PER DIEM 0.00<br />

T1021 9 HH AI<strong>DE</strong> OR CN AI<strong>DE</strong> PER VISIT 0.00<br />

T1022 9 CONTRACTED SERVICES PER DAY 0.00<br />

T1023 7 PROGRAM INTAKE ASSESSMENT 0.00<br />

T1024 3 TEAM EVALUATION & MANAGEMENT 1,429.81<br />

T1025 9 PED COMPR CARE PKG, PER DIEM 0.00<br />

T1026 9 PED COMPR CARE PKG, PER HOUR 0.00<br />

T1027 9 FAMILY TRAINING & COUNSELING 0.00<br />

T1028 9 HOME ENVIRONMENT ASSESSMENT 0.00<br />

T1029 5 DWELLING LEAD INVESTIGATION 0.00<br />

T1030 9 RN HOME CARE PER DIEM 0.00<br />

T1031 9 LPN HOME CARE PER DIEM 0.00<br />

T1035 9 UTILITY SERVICES WAIVER 0.00<br />

T1500 O REUSABLE DIAPER/PANT 0.00<br />

T1502 9 MEDICATION ADMIN VISIT 0.00<br />

T1503 9 MED ADMIN, NOT ORAL/INJECT 0.00<br />

T1999 9 NOC RETAIL ITEMS ANDSUPPLIES 0.00<br />

T2001 3 NONEMERGENCY TRANSPORTATION ATTEND 10.10<br />

T2002 7 N-ET; PER DIEM 0.00<br />

T2003 3 NON-EMERGENCY TRANSPORTATION; ENCOU 10.10<br />

T2004 9 N-ET; COMMERC CARRIER PASS 0.00<br />

T2005 9 N-ET; STRETCHER VAN 0.00<br />

T2006 O AMB RESPONSE & TRT, NO TRANS 0.00<br />

T2007 9 NON-EMER TRANSPORT WAIT TIME 0.00<br />

T2010 9 PASRR LEVEL I 0.00<br />

T2011 9 PASRR LEVEL II 0.00<br />

T2012 9 HABIL. ED. WAIVER; PER DIEM 0.00<br />

T2013 9 HABIL. ED. WAIVER, PER HOUR 0.00<br />

T2014 7 HABIL. PREVOC WAIVER, PER D 0.00<br />

T2015 7 HABIL. PREVOC WAIVER PER HR 0.00<br />

T2016 7 HABIL., RES. WAIVER PER DIEM 0.00<br />

T2017 9 HABIL., RES. WAIVER 15 MIN 0.00<br />

T2018 7 HABIL. SUP EMPL WAIVER/DAY 0.00<br />

T2019 9 HABIL. SUP EMPL WAIVER 15 MIN 0.00<br />

T2020 7 DAY HABIL WAIVER PER DIEM 0.00<br />

T2021 9 DAY HABIL WAIVER PER 15 MIN 0.00<br />

T2022 7 CASE MANAGEMENT, PER MONTH 0.00<br />

T2023 9 TARGETED CASE MGMT PER MONTH 0.00<br />

T2024 9 SERV ASMNT/CARE PLAN WAIVER 0.00<br />

T2025 7 WAIVER SERVICE, NOS 0.00<br />

T2026 9 SPECIAL CHILDCARE WAIVER/D 0.00<br />

T2027 9 SPEC CHILDCARE WAIVER 15 MIN 0.00<br />

T2028 9 SPECIAL SUPPLY, NOS WAIVER 0.00<br />

T2029 9 SPECIAL MED EQUIP, NOS WAIVER 0.00<br />

T2030 9 ASSIST LIVING WAIVER/MONTH 0.00<br />

T2031 9 ASSIST LIVING WAIVER/D 0.00

---

T2032 9 RES CARE, NOS WAIVER/MONTH 0.00<br />

T2033 7 RES, NOS WAIVER PER DIEM 0.00<br />

T2034 9 CRISIS INTERVEN WAIVER/D 0.00<br />

T2035 9 UTILITY SERVICES WAIVER 0.00<br />

T2036 9 CAMP OVERNITE WAIVER/SESSION 0.00<br />

T2037 9 CAMP DAY WAIVER/SESSION 0.00<br />

T2038 9 COMM TRANS WAIVER/SERVICE 0.00<br />

T2039 9 VEHICLE MOD WAIVER/SERVICE 0.00<br />

T2040 9 FINANCIAL MGT WAIVER/15 MIN 0.00<br />

T2041 9 SUPPORT BROKER WAIVER/15 MIN 0.00<br />

T2042 9 HOSPICE ROUTINE HOME CARE 0.00<br />

T2043 9 HOSPICE CONTINUOUS HOME CARE 0.00<br />

T2044 9 HOSPICE RESPITE CARE 0.00<br />

T2045 9 HOSPICE GENERAL CARE 0.00<br />

T2046 9 HOSPICE LONG TERM CARE, R&B 0.00<br />

T2048 9 BH LTC RES R&B, PER DIEM 0.00<br />

T2049 9 N-ET; STRETCHER VAN, MILEAGE 0.00<br />

T2101 9 BREAST MILK PROC/STORE/DIST 0.00<br />

T4521 3 ADULT SIZE BRIEF/DIAPER SM 0.50<br />

T4522 3 ADULT SIZE BRIEF/DIAPER MED 0.50<br />

T4523 3 ADULT SIZE BRIEF/DIAPER LG 0.74<br />

T4524 3 ADULT SIZE BRIEF/DIAPER XL 0.88<br />

T4525 3 ADULT SIZE PULL-ON SM 0.50<br />

T4526 3 ADULT SIZE PULL-ON MED 0.50<br />

T4527 3 ADULT SIZE PULL-ON LG 0.74<br />

T4528 3 ADULT SIZE PULL-ON XL 0.88<br />

T4529 3 PED SIZE BRIEF/DIAPER SM/MED 0.25<br />

T4530 3 PED SIZE BRIEF/DIAPER LG 0.37<br />

T4531 3 PED SIZE PULL-ON SM/MED 0.25<br />

T4532 3 PED SIZE PULL-ON LG 0.37<br />

T4533 3 YOUTH SIZE BRIEF/DIAPER 0.47<br />

T4534 3 YOUTH SIZE PULL-ON 0.47<br />

T4535 3 DISPOSABLE LINER/SHIELD/PAD 0.33<br />

T4536 9 REUSABLE PULL-ON ANY SIZE 0.00<br />

T4537 9 REUSABLE UN<strong>DE</strong>RPAD BED SIZE 0.00<br />

T4538 9 DIAPER SERV REUSABLE DIAPER 0.00<br />

T4539 9 REUSE DIAPER/BRIEF ANY SIZE 0.00<br />

T4540 9 REUSABLE UN<strong>DE</strong>RPAD CHAIR SIZE 0.00<br />

T4541 3 LARGE DISPOSABLE UN<strong>DE</strong>RPAD 0.54<br />

T4542 3 SMALL DISPOSABLE UN<strong>DE</strong>RPAD 0.20<br />

T4543 6 DISP BARIATRIC BRIEF/DIAPER 0.00<br />

T5001 6 POSITION SEAT SPEC ORTH NEED 0.00<br />

T5999 9 SUPPLY, NOS 0.00<br />

TBEVL O MCO SPECIFIC CO<strong>DE</strong>: DPH INITIAL EVAL 0.00<br />

TBTXA O MCO SPECIFIC CO<strong>DE</strong>: DPH TB TREATMENT 0.00<br />

TBTXS O MCO SPECIFIC CO<strong>DE</strong>: DPH TB TREATMENT 0.00<br />

TI10H O PART C SPECIFIC CO<strong>DE</strong>: INTERPERIODIC 0.00<br />

TI11H O PART C SPECIFIC CO<strong>DE</strong>: INTERPERIODIC 0.00<br />

TI12H O PART C SPECIFIC CO<strong>DE</strong>: INTERPERIODIC 0.00<br />

TI13H 7 PART C SPECIFIC CO<strong>DE</strong>: INTERPERIODIC 0.00

---

TI420 O MCO SPECIFIC CO<strong>DE</strong>: INTERPERIODIC CO 0.00<br />

TI42H O INTERPERIODIC CONSULTATION BY A PHY 0.00<br />

TI430 O MCO SPECIFIC CO<strong>DE</strong>: INTERPERIODIC CO 0.00<br />

TI43H O INTERPERIODIC CONSULTATION BY A OCC 0.00<br />

TI440 O MCO SPECIFIC CO<strong>DE</strong>: INTERPERIODIC CO 0.00<br />

TI44H O INTERPERIODIC CONSULTATION BY A SPE 0.00<br />

TV10H O PART C SPECIFIC CO<strong>DE</strong>: TREATMENT VIS 0.00<br />

TV11H O PART C SPECIFIC CO<strong>DE</strong>: TREATMENT VIS 0.00<br />

TV12H O PART C SPECIFIC CO<strong>DE</strong>: TREATMENT VIS 0.00<br />

TV420 O MCO SPECIFIC CO<strong>DE</strong>: TRANSDISCIPLINAR 0.00<br />

TV42H O TRANSDISCIPLINARY VISIT BY A PHYSIC 0.00<br />

TV430 O MCO SPECIFIC CO<strong>DE</strong>: TRANSDISCIPLINAR 0.00<br />

TV43H O TRANSDISCIPLINARY VISIT BY A OCCUPA 0.00<br />

TV440 O MCO SPECIFIC CO<strong>DE</strong>: TRANSDISCIPLINAR 0.00<br />

TV44H O TRANSDISCIPLINARY VISIT BY A SPEECH 0.00<br />

V2020 3 VISION SVCS FRAMES PURCHASES 49.74<br />

V2025 6 EYEGLASSES <strong>DE</strong>LUX FRAMES 0.00<br />

V2100 3 LENS SPHER SINGLE PLANO 4.00 38.15<br />

V2101 3 SINGLE VISN SPHERE 4.12-7.00 40.00<br />

V2102 3 SINGL VISN SPHERE 7.12-20.00 58.93<br />

V2103 3 SPHEROCYLINDR 4.00D/12-2.00D 35.97<br />

V2104 3 SPHEROCYLINDR 4.00D/2.12-4D 38.98<br />

V2105 3 SPHEROCYLIN<strong>DE</strong>R 4.00D/4.25-6D 43.37<br />

V2106 3 SPHEROCYLIN<strong>DE</strong>R 4.00D/>6.00D 48.13<br />

V2107 3 SPHEROCYLIN<strong>DE</strong>R 4.25D/12-2D 44.62<br />

V2108 3 SPHEROCYLIN<strong>DE</strong>R 4.25D/2.12-4D 47.40<br />

V2109 3 SPHEROCYLIN<strong>DE</strong>R 4.25D/4.25-6D 52.44<br />

V2110 3 SPHEROCYLIN<strong>DE</strong>R 4.25D/OVER 6D 51.74<br />

V2111 3 SPHEROCYLINDR 7.25D/.25-2.25 53.06<br />

V2112 3 SPHEROCYLINDR 7.25D/2.25-4D 58.86<br />

V2113 3 SPHEROCYLINDR 7.25D/4.25-6D 1.79<br />

V2114 3 SPHEROCYLIN<strong>DE</strong>R OVER 12.00D 71.89<br />

V2115 3 LENS LENTICULAR BIFOCAL 63.63<br />

V2116 O NONASPHERIC LENS BIFOCAL 0.00<br />

V2117 O ASPHERIC LENS BIFOCAL 0.00<br />

V2118 3 LENS ANISEIKONIC SINGLE 77.56<br />

V2121 6 LENTICULAR LENS, SINGLE 0.00<br />

V2199 6 LENS SINGLE VISION NOT OTH C 0.00<br />

V2200 3 LENS SPHER BIFOC PLANO 4.00D 52.57<br />

V2201 3 LENS SPHERE BIFOCAL 4.12-7.0 57.57<br />

V2202 3 LENS SPHERE BIFOCAL 7.12-20. 69.55<br />

V2203 3 LENS SPHCYL BIFOCAL 4.00D/.1 54.25<br />

V2204 3 LENS SPHCY BIFOCAL 4.00D/2.1 57.19<br />

V2205 3 LENS SPHCY BIFOCAL 4.00D/4.2 61.83<br />

V2206 3 LENS SPHCY BIFOCAL 4.00D/OVE 66.43<br />

V2207 3 LENS SPHCY BIFOCAL 4.25-7D/. 58.71<br />

V2208 3 LENS SPHCY BIFOCAL 4.25-7/2. 62.97<br />

V2209 3 LENS SPHCY BIFOCAL 4.25-7/4. 67.36<br />

V2210 3 LENS SPHCY BIFOCAL 4.25-7/OV 75.32<br />

V2211 3 LENS SPHCY BIFO 7.25-12/.25- 72.60

---

V2212 3 LENS SPHCYL BIFO 7.25-12/2.2 72.60<br />

V2213 3 LENS SPHCYL BIFO 7.25-12/4.2 68.64<br />

V2214 3 LENS SPHCYL BIFOCAL OVER 12. 88.57<br />

V2215 3 LENS LENTICULAR BIFOCAL 75.38<br />

V2216 O LENS LENTICULAR NONASPHERIC 0.00<br />

V2217 O LENS LENTICULAR ASPHERIC BIF 0.00<br />

V2218 3 LENS ANISEIKONIC BIFOCAL 106.98<br />

V2219 3 LENS BIFOCAL SEG WIDTH OVER 47.09<br />

V2220 3 LENS BIFOCAL ADD OVER 3.25D 38.19<br />

V2221 6 LENTICULAR LENS, BIFOCAL 0.00<br />

V2299 6 LENS BIFOCAL SPECIALITY 0.00<br />

V2300 3 LENS SPHERE TRIFOCAL 4.00D 62.84<br />

V2301 3 LENS SPHERE TRIFOCAL 4.12-7. 73.64<br />

V2302 3 LENS SPHERE TRIFOCAL 7.12-20 86.73<br />

V2303 3 LENS SPHCY TRIFOCAL 4.0/.12- 57.57<br />

V2304 3 LENS SPHCY TRIFOCAL 4.0/2.25 67.29<br />

V2305 3 LENS SPHCY TRIFOCAL 4.0/4.25 77.94<br />

V2306 3 LENS SPHCYL TRIFOCAL 4.00/>6 82.73<br />

V2307 3 LENS SPHCY TRIFOCAL 4.25-7/. 76.36<br />

V2308 3 LENS SPHC TRIFOCAL 4.25-7/2. 79.36<br />

V2309 3 LENS SPHC TRIFOCAL 4.25-7/4. 82.96<br />

V2310 3 LENS SPHC TRIFOCAL 4.25-7/>6 88.00<br />

V2311 3 LENS SPHC TRIFO 7.25-12/.25- 79.49<br />

V2312 3 LENS SPHC TRIFO 7.25-12/2.25 79.95<br />

V2313 3 LENS SPHC TRIFO 7.25-12/4.25 82.94<br />

V2314 3 LENS SPHCYL TRIFOCAL OVER 12 106.56<br />

V2315 3 LENS LENTICULAR TRIFOCAL 94.65<br />

V2316 O LENS LENTICULAR NONASPHERIC 0.00<br />

V2317 O LENS LENTICULAR ASPHERIC TRI 0.00<br />

V2318 3 LENS ANISEIKONIC TRIFOCAL 148.07<br />

V2319 3 LENS TRIFOCAL SEG WIDTH > 28 52.52<br />

V2320 3 LENS TRIFOCAL ADD OVER 3.25D 55.41<br />

V2321 6 LENTICULAR LENS, TRIFOCAL 0.00<br />

V2399 6 LENS TRIFOCAL SPECIALITY 0.00<br />

V2410 3 LENS VARIAB ASPHERICITY SING 82.58<br />

V2430 3 LENS VARIABLE ASPHERICITY BI 92.26<br />

V2499 6 VARIABLE ASPHERICITY LENS 0.00<br />

V2500 3 CONTACT LENS PMMA SPHERICAL 85.97<br />

V2501 3 CNTCT LENS PMMA-TORIC/PRISM 116.84<br />

V2502 3 CONTACT LENS PMMA BIFOCAL 153.78<br />

V2503 3 CNTCT LENS PMMA COLOR VISION 148.27<br />

V2510 3 CNTCT GAS PERMEABLE SPHERICL 116.23<br />

V2511 3 CNTCT TORIC PRISM BALLAST 150.69<br />

V2512 3 CNTCT LENS GAS PERMBL BIFOCL 185.42<br />

V2513 3 CONTACT LENS EXTEN<strong>DE</strong>D WEAR 151.11<br />

V2520 3 CONTACT LENS HYDROPHILIC 107.68<br />

V2521 3 CNTCT LENS HYDROPHILIC TORIC 169.90<br />

V2522 3 CNTCT LENS HYDROPHIL BIFOCL 151.60<br />

V2523 3 CNTCT LENS HYDROPHIL EXTEND 149.83<br />

V2530 3 CONTACT LENS GAS IMPERMEABLE 202.40

---

V2531 3 CONTACT LENS GAS PERMEABLE 421.66<br />

V2599 6 CONTACT LENS/ES OTHER TYPE 0.00<br />

V2600 6 HAND HELD LOW VISION AIDS 0.00<br />

V2610 6 SINGLE LENS SPECTACLE MOUNT 0.00<br />

V2615 6 TELESCOP/OTHR COMPOUND LENS 0.00<br />

V2620 9 PROSTHETIC, EYE, GLASS, STOCK 0.00<br />

V2621 9 PROSTHETIC, EYE PLASTIC, STOCK 0.00<br />

V2622 9 PROSTHETIC, EYE, GLASS, CUSTOM 0.00<br />

V2623 3 PLASTIC EYE PROSTH CUSTOM 712.05<br />

V2624 3 POLISHING ARTIFICAL EYE 64.39<br />

V2625 3 ENLARGEMNT OF EYE PROSTHESIS 293.59<br />

V2626 3 REDUCTION OF EYE PROSTHESIS 158.26<br />

V2627 3 SCLERAL COVER SHELL 1,022.12<br />

V2628 3 FABRICATION & FITTING 241.34<br />

V2629 6 PROSTHETIC EYE OTHER TYPE 0.00<br />

V2630 6 ANTER CHAMBER INTRAOCUL LENS 0.00<br />

V2631 6 IRIS SUPPORT INTRAOCLR LENS 0.00<br />

V2632 6 POST CHMBR INTRAOCULAR LENS 0.00<br />

V2700 3 BALANCE LENS 42.70<br />

V2702 9 <strong>DE</strong>LUXE LENS FEATURE 0.00<br />

V2710 3 GLASS/PLASTIC SLAB OFF PRISM 59.65<br />

V2715 3 PRISM LENS/ES 9.76<br />

V2718 3 FRESNELL PRISM PRESS-ON LENS 23.48<br />

V2730 3 SPECIAL BASE CURVE 16.73<br />

V2740 O ROSE TINT PLASTIC 0.00<br />

V2741 O NON-ROSE TINT PLASTIC 0.00<br />

V2742 O ROSE TINT GLASS 0.00<br />

V2743 O NON-ROSE TINT GLASS 0.00<br />

V2744 5 TINT PHOTOCHROMATIC LENS/ES 0.00<br />

V2745 9 TINT, ANY COLOR/SOLID/GRAD 0.00<br />

V2750 5 ANTI-REFLECTIVE COATING 0.00<br />

V2755 9 UV LENS/ES 0.00<br />

V2756 9 EYE GLASS CASE 0.00<br />

V2760 3 SCRATCH RESISTANT COATING 16.31<br />

V2761 9 MIRROR COATING 0.00<br />

V2762 9 POLARIZATION, ANY LENS 0.00<br />

V2770 9 OCCLU<strong>DE</strong>R LENS/ES 0.00<br />

V2780 9 OVERSIZE LENS/ES 0.00<br />

V2781 9 PROGRESSIVE LENS PER LENS 0.00<br />

V2782 6 LENS, 1.54-1.65 P/1.60-1.79G 0.00<br />

V2783 6 LENS, >= 1.66 P/>=1.80 G 0.00<br />

V2784 3 LENS POLYCARB OR EQUAL 37.16<br />

V2785 6 CORNEAL TISSUE PROCESSING 0.00<br />

V2786 9 OCCUPATIONAL MULTIFOCAL LENS 0.00<br />

V2787 9 ASTIGMATISM-CORRECT FUNCTION 0.00<br />

V2788 9 PRESBYOPIA-CORRECT FUNCTION 0.00<br />

V2790 6 AMNIOTIC MEMBRANE 0.00<br />

V2797 9 VIS ITEM/SVC IN OTHER CO<strong>DE</strong> 0.00<br />

V2799 6 MISCELLANEOUS VISION SERVICE 0.00<br />

V5000 9 BASIC AUDIOLOGIC ASSESSMENT - HEARI 0.00

---

V5001 9 COMPREHENSIVE AUDIOLOGIC ASSESSMENT 0.00<br />

V5002 9 ASSESSMENT OF VESTIBULAR AND/OR AUD 0.00<br />

V5003 9 ASSESSMENT OF VESTIBULAR AND/OR AUD 0.00<br />

V5008 3 HEARING SCREENING 16.00<br />

V5010 9 ASSESSMENT FOR HEARING AID 0.00<br />

V5011 9 HEARING AID FITTING/CHECKING 0.00<br />

V5012 9 COMPLETE COCHLEAR IMPLANT REHABILIT 0.00<br />

V5014 5 HEARING AID REPAIR/MODIFYING 0.00<br />

V5016 9 UNLISTED AUDIOLOGIC PROCEDURE (SPEC 0.00<br />

V5020 9 CONFORMITY EVALUATION 0.00<br />

V5030 5 BODY-WORN HEARING AID AIR 0.00<br />

V5040 5 BODY-WORN HEARING AID BONE 0.00<br />

V5050 5 HEARING AID MONAURAL IN EAR 0.00<br />

V5060 5 BEHIND EAR HEARING AID 0.00<br />

V5070 5 GLASSES AIR CONDUCTION 0.00<br />

V5080 5 GLASSES BONE CONDUCTION 0.00<br />

V5090 3 HEARING AID DISPENSING FEE 400.00<br />

V5095 5 IMPLANT MID EAR HEARING PROS 0.00<br />

V5100 5 BODY-WORN BILAT HEARING AID 0.00<br />

V5110 9 HEARING AID DISPENSING FEE 0.00<br />

V5120 5 BODY-WORN BINAUR HEARING AID 0.00<br />

V5130 5 IN EAR BINAURAL HEARING AID 0.00<br />

V5140 5 BEHIND EAR BINAUR HEARING AI 0.00<br />

V5150 5 GLASSES BINAURAL HEARING AID 0.00<br />

V5160 9 DISPENSING FEE BINAURAL 0.00<br />

V5170 5 WITHIN EAR CROS HEARING AID 0.00<br />

V5180 5 BEHIND EAR CROS HEARING AID 0.00<br />

V5190 5 GLASSES CROS HEARING AID 0.00<br />

V5200 9 CROS HEARING AID DISPENS FEE 0.00<br />

V5210 5 IN EAR BICROS HEARING AID 0.00<br />

V5220 5 BEHIND EAR BICROS HEARING AI 0.00<br />

V5230 5 GLASSES BICROS HEARING AID 0.00<br />

V5240 9 DISPENSING FEE BICROS 0.00<br />

V5241 9 DISPENSING FEE, MONAURAL 0.00<br />

V5242 5 HEARING AID, MONAURAL, CIC 0.00<br />

V5243 5 HEARING AID, MONAURAL, ITC 0.00<br />

V5244 5 HEARING AID, PROG, MON, CIC 0.00<br />

V5245 5 HEARING AID, PROG, MON, ITC 0.00<br />

V5246 5 HEARING AID, PROG, MON, ITE 0.00<br />

V5247 5 HEARING AID, PROG, MON, BTE 0.00<br />

V5248 5 HEARING AID, BINAURAL, CIC 0.00<br />

V5249 5 HEARING AID, BINAURAL, ITC 0.00<br />

V5250 5 HEARING AID, PROG, BIN, CIC 0.00<br />

V5251 5 HEARING AID, PROG, BIN, ITC 0.00<br />

V5252 5 HEARING AID, PROG, BIN, ITE 0.00<br />

V5253 5 HEARING AID, PROG, BIN, BTE 0.00<br />

V5254 5 HEARING ID, DIGIT, MON, CIC 0.00<br />

V5255 5 HEARING AID, DIGIT, MON, ITC 0.00<br />

V5256 5 HEARING AID, DIGIT, MON, ITE 0.00<br />

V5257 5 HEARING AID, DIGIT, MON, BTE 0.00

---

V5258 5 HEARING AID, DIGIT, BIN, CIC 0.00<br />

V5259 5 HEARING AID, DIGIT, BIN, ITC 0.00<br />

V5260 5 HEARING AID, DIGIT, BIN, ITE 0.00<br />

V5261 5 HEARING AID, DIGIT, BIN, BTE 0.00<br />

V5262 5 HEARING AID, DISP, MONAURAL 0.00<br />

V5263 5 HEARING AID, DISP, BINAURAL 0.00<br />

V5264 9 EAR MOLD/INSERT 0.00<br />

V5265 9 EAR MOLD/INSERT, DISP 0.00<br />

V5266 5 BATTERY FOR HEARING <strong>DE</strong>VICE 0.00<br />

V5267 5 HEARING AID SUPPLY/ACCESSORY 0.00<br />

V5268 9 ALD TELEPHONE AMPLIFIER 0.00<br />

V5269 9 ALERTING <strong>DE</strong>VICE, ANY TYPE 0.00<br />

V5270 9 ALD, TV AMPLIFIER, ANY TYPE 0.00<br />

V5271 9 ALD, TV CAPTION <strong>DE</strong>CO<strong>DE</strong>R 0.00<br />

V5272 9 TDD 0.00<br />

V5273 9 ALD FOR COCHLEAR IMPLANT 0.00<br />

V5274 9 ALD UNSPECIFIED 0.00<br />

V5275 9 EAR IMPRESSION 0.00<br />

V5298 5 HEARING AID NOC 0.00<br />

V5299 9 HEARING SERVICE 0.00<br />

V5301 9 BASIC ASSESSMENT OF SPECIFIC SINGLE 0.00<br />

V5310 9 COMPREHENSIVE ASSESSMENT OF SPEECH, 0.00<br />

V5321 9 ASSESSMENT FOR ORAL OR LARYNGEAL PR 0.00<br />

V5322 9 ASSESSMENT FOR AUGMENTATIVE COMMUNI 0.00<br />

V5330 9 TREATMENT FOR SPEECH, LANGUAGE, ORA 0.00<br />

V5335 9 REPAIR/MODIFICATION OF ORAL OR LARY 0.00<br />

V5336 5 REPAIR COMMUNICATION <strong>DE</strong>VICE 0.00<br />

V5360 9 UNLISTED SPEECH-LANGUAGE SERVICE (S 0.00<br />

V5362 3 SPEECH SCREENING 16.00<br />

V5363 3 LANGUAGE SCREENING 16.00<br />

V5364 3 DYSPHAGIA SCREENING 16.00<br />

W5950 O MCO SPECIFIC CO<strong>DE</strong>: INTAKE/RISK ASSE 0.00<br />

W9026 O HOSPITAL VISIT,INITIAL,OUTPATIENT;E 0.00<br />

W9045 O ER SUPPORT SERVICES,SPECIAL NON-EME 0.00<br />

W9047 O ER SUPPORT SERVICES, SPECIAL EMERGE 0.00<br />

W9049 O HOSPITAL OUTPATIENT CLINIC VISIT 0.00<br />

W9057 O RURAL HEALTH CLINIC VISIT 0.00<br />

WW101 O OFFICE VISIT COPAY 0.00<br />

WW102 O EMERGENCY ROOM COPAY 0.00<br />

WW103 O VISION CARE COPAY 0.00<br />

WW104 O TRANSPORTATION COPAY 0.00<br />

WW105 O INPATIENT HOSPITAL VISIT OR PROCEDU 0.00<br />

WW106 O OUTPATIENT HOSPITAL CO-PAY, EXCLUDI 0.00<br />

WW201 O INJECTION, AMPICILLIN SODIUM AND SU 0.00<br />

WW202 O INJECTION, AMPICILLIN SODIUM AND SU 0.00<br />

WW203 O INJECTION, LEUCOVORIN CALCIUM, UP T 0.00<br />

WW204 O INJECTION, CYTOVENE, UP TO 500 MG 0.00<br />

WW205 O INJECTION, HEPARIN SODIUM, UP TO 50 0.00<br />

WW206 O INJECTION, HEPARIN SODIUM, UP TO 10 0.00<br />

WW207 O INJECTION, HEPARIN SODIUM, UP TO 20 0.00

---

WW208 O INJECTION, PROMETHAZINE HCL, UP TO 0.00<br />

WW209 O INJECTION, NALBUPHINE, UP TO 20 MG. 0.00<br />

WW210 O INJECTION, LORAZEPAN, UP TO 2 MG. 0.00<br />

WW211 O INJECTION, CEFTAZADIME, UP TO 500 M 0.00<br />

WW212 O INJECTION, CEFTAZADIME, UP TO 1,000 0.00<br />

WW213 O INFECTION, STINGING INSECT VENOM, S 0.00<br />

WW214 O INJECTION, STINGING INSECT VENOM, M 0.00<br />

WW215 O INJECTION, POISON IVY/ OAK, PROPHYL 0.00<br />

WW216 O INJECTION, LONG ACTING ADRENALIN, U 0.00<br />

WW217 O INJECTION, LEUPROLI<strong>DE</strong> ACETATE <strong>DE</strong>POT 0.00<br />

WW218 O INJECTION, LEUPROLI<strong>DE</strong> ACETATE <strong>DE</strong>POT 0.00<br />

WW219 O INJECTION, HEPARIN SODIUM FLUSH, UP 0.00<br />

WW220 O INJECTION, KETOROLAC TROMETHAMINE, 0.00<br />

WW221 O INJECTION, KETOROLAC TROMETHAMINE, 0.00<br />

WW222 O INJECTION, MARCAINE HCL, UP TO 10CC 0.00<br />

WW223 O INJECTION, ONDANSETRON HCL, UP TO 1 0.00<br />

WW224 O IMMUNIZATION, ACTIVE; DIPHTHEIA AND 0.00<br />

WW225 O INJECTION, <strong>DE</strong>PO-PROVERA, 150 MG/ML 0.00<br />

WW226 O IMMUNIZATION, ACTIVE; DPT AND HIB 0.00<br />

WW227 O INJECTION, MIDAZOLAM, UP TO 10 MG. 0.00<br />

WW228 O INJECTION, FLUMAZENIL, UP TO 0.5 MG 0.00<br />

WW229 O INJECTION, NALOXONE HCL, UP TO O.4 0.00<br />

WW230 O INJECTION, KYTRIL, 1MG/ML 0.00<br />

WW231 O INJECTION, HEPARIN SODIUM, PER 100 0.00<br />

WW232 O INJECTION, <strong>DE</strong>XAMETHASONE ACETATE, 1 0.00<br />

WW301 O ROUTINE GYNECOLOGICAL EVALUATION IN 0.00<br />

WW302 O ROUTINE GYNECOLOGICAL EVALUATION IN 0.00<br />

WW303 O INITIAL ANTEPARTUM CARE 0.00<br />

WW304 O USE OF A BIRTHING CENTER FACILITY F 0.00<br />

WW305 O USE OF A BIRTHING CENTER FACILITY W 0.00<br />

WW310 O INSERTION OF HORMONAL CONTRACEPTIVE 0.00<br />

WW311 O REMOVAL OF HORMONAL CONTRACEPTIVE I 0.00<br />

WW312 O PROVISION AND INSERTION OF VAGINAL 0.00<br />

WW313 O INSERTION OF VAGINAL RING CONTAININ 0.00<br />

WW351 O HOSPITAL BASED EMERGENCY ROOM PHYSI 0.00<br />

WW401 O METHADONE CLINIC SERVICES 0.00<br />

WW402 O OPIOID MEDICATION DISPENSING FOR IN 0.00<br />

WW403 O OPIOID THERAPY PHYSICAL EVALUATION 0.00<br />

WW404 O OPIOID DOSAGE MONITORING FOR INDIVI 0.00<br />

WW430 O CHRONIC RENAL DISEASE PROGRAM-NEPRO 0.00<br />

WW451 O INSERTION OF AN EPIDURAL OR SUBARAC 0.00<br />

WW452 O RE-INJECTION OF A NARCOTIC INTO AN 0.00<br />

WW453 O MAINTENANCE OF INTRAVENOUS ACCESS C 0.00<br />

WW501 O VISION PROGRAM UN<strong>DE</strong>R EPSDT - ROUTIN 0.00<br />

WW502 O VISION PROGRAM UN<strong>DE</strong>R EPSDT - PROVIS 0.00<br />

WW503 O VISION PROGRAM UN<strong>DE</strong>R EPSDT - PROVIS 0.00<br />

WW504 O EPSDT/VISION-CONTACT LENS TO CORREC 0.00<br />

WW505 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-PROVISIO 0.00<br />

WW506 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-STOCK SI 0.00<br />

WW507 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-PROVISIO 0.00

---

WW508 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-STOCK SI 0.00<br />

WW509 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-PROVISIO 0.00<br />

WW510 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-NON-STOC 0.00<br />

WW511 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-PROVISIO 0.00<br />

WW512 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-NON-STOC 0.00<br />

WW513 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-PROVISIO 0.00<br />

WW514 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-BIFOCAL 0.00<br />

WW515 O VISION PROGARM UN<strong>DE</strong>R EPSDT-PROVISIO 0.00<br />

WW516 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-BIFOCAL 0.00<br />

WW517 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-PROVISIO 0.00<br />

WW518 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-BIFOCAL 0.00<br />

WW519 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-REPLACEM 0.00<br />

WW520 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-POLYCARB 0.00<br />

WW521 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-PHOTO GR 0.00<br />

WW522 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-REPLACEM 0.00<br />

WW523 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-REPLACEM 0.00<br />

WW524 O VISION PROGRAM UN<strong>DE</strong>R EPSDT-UNLISTED 0.00<br />

WW531 O EPSDT SCREENING WITHOUT TREATMENT R 0.00<br />

WW532 O EPSDT SCREENING WITHOUT TREATMENT R 0.00<br />

WW533 O EPSDT SCREENING WITHOUT TREATMENT R 0.00<br />

WW534 O EPSDT SCREENING WITHOUT TREATMENT R 0.00<br />

WW535 O EPSDT SCREENING WITHOUT TREATMENT R 0.00<br />

WW536 O EPSDT SCREENING WITH TREATMENT REFE 0.00<br />

WW537 O EPSDT SCREENING WITH TREATMENT REFE 0.00<br />

WW538 O EPSDT SCREENING WITH TREATMENT REFE 0.00<br />

WW539 O EPSDT SCREENING WITH TREATMENT REFE 0.00<br />

WW540 O EPSDT SCREENING WITH TREATMENT REFE 0.00<br />

WW571 O DPH SPECIAL <strong>DE</strong>NTAL CLINIC REFERRALS 0.00<br />

WW572 O EPSDT - TOTAL YEARLY <strong>DE</strong>NTAL CARE FO 0.00<br />

WW573 O <strong>DE</strong>NTAL CARE FOR INDIVIDUALS, EPSDT, 0.00<br />

WW574 O <strong>DE</strong>NTAL SERVICES FOR SPECIAL NEEDS P 0.00<br />

WW575 O ENVIRONMENTAL INSPECTION FOR SOURCE 0.00<br />

WW601 O POTENTIAL ACUITY METER (PAM) 0.00<br />

WW651 O COMMUNITY SUPPORT SERVICES - MENTAL 0.00<br />

WW652 O PSYCHOSOCIAL REHABILITATION CENTER 0.00<br />

WW653 O RESI<strong>DE</strong>NTIAL REHABILITATION MENTAL H 0.00<br />

WW654 O PERSONAL CARE-DADAMH APPROVED C.S.S 0.00<br />

WW655 O COMMUNITY SUPPORT SERVICES-ALCOHOL 0.00<br />

WW660 O PHYS SERVICE DADAMH COMM MENTAL HEA 0.00<br />

WW661 O PHYS SUPERVISED DADAMH COMM MENTAL 0.00<br />

WW663 O PHYS SUPERVISED DADAMH CMHC SERVICE 0.00<br />

WW664 O PHYSICIAN SERVICE - DADAMH COMMUNIT 0.00<br />

WW665 O PHYS. SUPERVISED DADAMH COMMUNITY M 0.00<br />

WW668 O EPSDT BEHAVIORAL HEALTH SERVICES, A 0.00<br />

WW701 O PRIVATE DUTY NURSE, EMPLOYED BY AGE 0.00<br />

WW702 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,E 0.00<br />

WW703 O PRIVATE DUTY NURSE,SELF-EMPLOYED,PE 0.00<br />

WW704 O PRIVATE DUTY NURSE,SELF-EMPLOYED, P 0.00<br />

WW705 O PRIVATE DUTY NURSE, SELF-EMPLOYED, 0.00<br />

WW706 O PRIVATE DUTY NURSE, SELF-EMPLOYED, 0.00

---

WW707 O PRIVATE DUTY NURSE,SELF-EMPLOYED,PE 0.00<br />

WW708 O PRIVATE DUTY NURSE,SELF-EMPLOYED,PE 0.00<br />

WW709 O PRIVATE DUTY NURSE,SELF-EMPLOYED, P 0.00<br />

WW710 O PRIVATE DUTY NURSE,SELF-EMPLOYED,PE 0.00<br />

WW711 O PRIVATE DUTY NURSE,SELF-EMPLOYED,PE 0.00<br />

WW712 O PRIVATE DUTY NURSE,SELF-EMPLOYED, P 0.00<br />

WW713 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW714 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW715 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW716 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW717 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW718 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW719 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW720 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW721 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW722 O EPSDT EXTEN<strong>DE</strong>D PRIVATE DUTY NURSE,S 0.00<br />

WW751 O 'PULMONARY EVALUATION AND DIAGNOSTI 0.00<br />

WW752 O MULTICHANNEL RECORDING OF 3 TO 5 PH 0.00<br />

WW753 O MULTICHANNEL RECORDING OF 6 TO 12 P 0.00<br />

WW754 O 4 HR OVERNIGHT GROWTH HORMONE TEST; 0.00<br />

WW755 O 12 HR OVERNIGHT GROWTH HORMONE TEST 0.00<br />

WW797 O ENTERAL FORMULAE NOC 0.00<br />

WW798 O DISPOSABLE INCONTINENCE PRODUCTS ME 0.00<br />

WW799 O DIAPERS THAT ARE MEDICALLY NECESSAR 0.00<br />

WW800 O EPSDT NON-STATE PLAN SUPPLIES FOR U 0.00<br />

WW801 O MISCELLANEOUS SUPPLIES 0.00<br />

WW802 O EPSDT 0.00<br />

WW803 O NEEDLE WASTE UNIT (ALL SIZES) - IV 0.00<br />

WW804 O INJECTION CAPS 0.00<br />

WW805 O HUBER NEEDLE (ALL SIZES) 0.00<br />

WW806 O SYRINGES (ALL TYPES) 0.00<br />

WW808 O ADMINISTRATION SET-INCLU<strong>DE</strong>S TUBING 0.00<br />

WW809 O IV TUBING - ALL SIZES & TYPES 0.00<br />

WW810 O CLAMP SCISSORS 0.00<br />

WW811 O INTRAVENOUS CATHETER -ANGIO CATH, B 0.00<br />

WW812 O IV START KIT 0.00<br />

WW813 O IV CATHETER DRESSING KIT 0.00<br />

WW814 O PEAK EXPIRATORY FLOW METER, EPSDT, 0.00<br />

WW815 O MOUTHPIECE FOR PEAK FLOW METER, BOX 0.00<br />

WW816 O LANCET <strong>DE</strong>VICE 0.00<br />

WW821 O FE<strong>DE</strong>RALLY QUALIFIED HEALTH CENTER E 0.00<br />

WW822 O LINE MAINTENANCE-WEEKLY-SINGLE LUME 0.00<br />

WW823 O LINE MAINTENANCE-WEEKLY-DOUBLE LUME 0.00<br />

WW824 O LINE MAINTENANCE-WEEKLY-TRIPLE LUME 0.00<br />

WW825 O PROTECTED NEEDLE HOUSING 0.00<br />

WW826 O THERMOMETER-MERCURY 0.00<br />

WW827 O HIBICLENS- 4 OZ 0.00<br />

WW828 O TUBEX HOL<strong>DE</strong>R 0.00<br />

WW829 O CHEMO SPILL KIT-INCLU<strong>DE</strong>S SAFETY GLA 0.00<br />

WW830 O VIAL ADAPTER 0.00

---

WW831 O PICC INSERTION TRAY 0.00<br />

WW838 O ENURESIS ALARM FOR AGES 4-20 0.00<br />

WW839 O PHOTOTHERAPY BLANKET 0.00<br />

WW840 9 CARBON ELECTRO<strong>DE</strong>S FOR APNEA MONITOR 0.00<br />

WW841 O STICKY ELECTRO<strong>DE</strong>S FOR APNEA MONITOR 0.00<br />

WW842 O FOAM/VELCRO BELT FOR USE WITH CARBO 0.00<br />

WW843 9 LEAD WIRES FOR APNEA MONITOR-1 SET 0.00<br />

WW844 O PULSE OXIMETER 0.00<br />

WW845 O OXIBANDS - FOR USE WITH PULSE OXIME 0.00<br />

WW846 O OXISENSOR / PROBE - FOR USE WITH PU 0.00<br />

WW847 O MEMORY MONITOR - RENTAL - INCLU<strong>DE</strong>S 0.00<br />

WW848 O SKIN LEVEL GASTROSTOMY KIT 0.00<br />

WW849 O ADAPTER FOR SKIN LEVEL GASTROSTOMY 0.00<br />

WW850 O OXYGEN CONTENT, LIQUID, PER POUND 0.00<br />

WW851 O OXYGEN CONTENT, GASEOUS, PER EACH D 0.00<br />

WW852 O OXYGEN CONTENT, GASEOUS, PER EACH E 0.00<br />

WW853 O OXYGEN CONTENT, GASEOUS, PER EACH H 0.00<br />

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WW855 O OXYGEN CONTENT, GASEOUS, PER EACH C 0.00<br />

WW856 O STATIONARY COMPRESSED GAS SYSTEM; I 0.00<br />

WW858 O STATIONARY LIQUID OXYGEN SYSTEM, IN 0.00<br />

WW860 O OXYGEN CONCENTRATOR 0.00<br />

WW870 O REPAIR OF PATIENT OWNED DURABLE MED 0.00<br />

WW871 O EPSDT NON-STATE PLAN ORTHOTIC/PROST 0.00<br />

WW880 O ARGININGE POW<strong>DE</strong>R 0.00<br />

WW881 O SPECIAL NEEDS EQUIPMENT - MISCELLAN 0.00<br />

WW900 O HEARING ASSESSMENT-EPSDT SCHOOL BAS 0.00<br />

WW901 O VISION ASSESSMENT-EPSDT SCHOOL BASE 0.00<br />

WW902 O IMMUNIZATION ASSESSMENT-EPSDT SCHOO 0.00<br />

WW903 O <strong>DE</strong>VELOPMENTAL/ORTHOPEDIC ASSESSMENT 0.00<br />

WW904 O <strong>DE</strong>NTAL ASSESSMENT-EPSDT SCHOOL BASE 0.00<br />

WW905 O HEALTH EDUCATION ASSESSMENT-EPSDT S 0.00<br />

WW906 O <strong>DE</strong>NTAL HEALTH EDUCATION-EPSDT SCHOO 0.00<br />

WW910 O INDIVIDUAL NURSING TREATMENT-EPSDT 0.00<br />

WW920 O OCCUPATIONAL THERAPY EVALUATION-EPS 0.00<br />

WW921 O INDIVIDUAL OCCUPATIONAL THERAPY TRE 0.00<br />

WW922 O GROUP OCCUPATIONAL THERAPY TREATMEN 0.00<br />

WW930 O PHYSICAL THERAPY ASSESSMENT-EPSDT S 0.00<br />

WW931 O INDIVIDUAL PHYSICAL THERAPY TREATME 0.00<br />

WW932 O GROUP PHYSICAL THERAPY TREATMENT-EP 0.00<br />

WW936 O ICT PLACEMENT FOR 0-0-S RTC-BASED B 0.00<br />

WW937 O ICT PLACEMENT FOR 0-0-S RTC-BASED B 0.00<br />

WW938 O ICT PLACEMENT FOR O-O-S RTC-BASED B 0.00<br />

WW939 O ICT PLACEMENT FOR 0-0-S RTC-BASED B 0.00<br />

WW940 O MENTAL HEALTH TREATMENT ASSESSMENT- 0.00<br />

WW941 O INDIVIDUAL MENTAL HEALTH TREATMENT 0.00<br />

WW942 O GROUP MENTAL HEALTH TREATMENT THERA 0.00<br />

WW943 O FAMILY MENTAL HEALTH TREATMENT THER 0.00<br />

WW944 O INDIVIDUAL MENTAL HEALTH CO-TREATME 0.00<br />

WW945 O GROUP MENTAL HEALTH CO-TREATMENT TH 0.00

---

WW946 O FAMILY MENTAL HEALTH CO-TREATMENT T 0.00<br />

WW947 O MENTAL HEALTH CASE CONSULTATION-EPS 0.00<br />

WW948 O AU CLAIR BEHAVIORAL THERAPY, EPSDT 0.00<br />

WW950 O SPEECH, LANGUAGE AND HEARING ASSESS 0.00<br />

WW951 O INDIVIDUAL SPEECH/LANGUAGE THERAPY- 0.00<br />

WW952 O INDIVIDUAL HEARING THERAPY-EPSDT SC 0.00<br />

WW953 O GROUP SPEECH/LANGUAGE THERAPY-EPSDT 0.00<br />

WW954 O INDIVUDUAL SPEECH/LANGUAGE CO-TREAT 0.00<br />

WW955 O INDIVIDUAL HEARING CO-TREATMENT THE 0.00<br />

WW956 O GROUP SPEECH/LANGAUAGE CO-TREATMENT 0.00<br />

WW960 O TRANSPORTATION,ROUND TRIP-EPSDT SCH 0.00<br />

WW967 O ASSESSMENT OF HIGHER CEREBRAL FUNCT 0.00<br />

WW968 O PDDN EARLY INTERVENTION THERAPIES, 0.00<br />

WW969 O EARLY INTERVENTION MULTI-DISCIPLINA 0.00<br />

WW970 O CHILD <strong>DE</strong>VELOPMENT ORIENTED FAMILY T 0.00<br />

WW975 O MENTAL HEALTH TREATMENT EVALUATION, 0.00<br />

WW976 O INDIVIDUAL MENTAL HEALTH TREATMENT 0.00<br />

WW980 O SPEECH/LANGUAGE/HEARING SCREEN, EPS 0.00<br />

WW981 O SPEECH/LANGUAGE/HEARING COMPREHENSI 0.00<br />

WW982 O SPEECH/LANGUAGE/HEARING INDIVIDUAL 0.00<br />

WW983 O GROUP SPEECH/LANGUAGE/HEARING THERA 0.00<br />

WW985 O OCCUPATIONAL THERAPY SCREEN, EPSDT, 0.00<br />

WW986 O OCCUPATIONAL THERAPY EVALUATION, CO 0.00<br />

WW987 O OCCUPATIONAL THERAPY TREATMENT, IND 0.00<br />

WW990 O PHYSICAL THERAPY SCREEN, EPSDT, AGE 0.00<br />

WW991 O PHYSICAL THERAPY EVALUATION, COMPRE 0.00<br />

WW992 O INDIVIDUAL PHYSICAL THERAPY TREATME 0.00<br />

WW995 O INITIAL NUTRITION CONSULTATION 0.00<br />

WW996 O NUTRITION COUNSELING 0.00<br />

WW997 O ASTHMA REHABILITATION CASE MANAGEME 0.00<br />

WW998 O NURSING SERVICES, INTERMITTENT, EPS 0.00<br />

WW999 O EPSDT CASE MANAGEMENT SERVICE FOR C 0.00<br />

X0019 O MCO SPECIFIC CO<strong>DE</strong>: PRIVATE DUTY NUR 0.00<br />

YY001 O NURSING HOME ANCILLARIES - OXYGEN H 0.00<br />

YY002 O NURSING HOME ANCILLARIES - OXYGEN P 0.00<br />

YY003 O NURSING HOME ANCILLARIES - OXYGEN C 0.00<br />

YY004 O NURSING HOME ANCILLARIES - PHYSICAL 0.00<br />

YY005 O NURSING HOME ANCILLARIES - PHYSICAL 0.00<br />

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YY009 O NURSING HOME ANCILLARIES - OCCUPATI 0.00<br />

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YY102 O EXTEN<strong>DE</strong>D PREGNANCY-NUTRITION PER FI 0.00<br />

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YY201 O HOSPICE - ROUTINE HOME CARE PER DAY 0.00<br />

YY202 O HOSPICE - CONTINUOUS HOME CARE PER 0.00<br />

YY203 O HOSPICE - INPATIENT RESPIT CARE PER 0.00<br />

YY204 O HOSPICE - GENERAL INPATIENT CARE PE 0.00<br />

YY205 O HOSPICE - NURSING HOME ROOM AND BOA 0.00

---

YY301 O FAMILY AND CHILDREN'S SERVICES CLIN 0.00<br />

YY302 O FAMILY AND CHILDREN'S SERVICES NURS 0.00<br />

YY303 O FAMILY AND CHILDREN'S SERVICES NURS 0.00<br />

YY304 O FAMILY AND CHILDREN'S SERVICES EPSD 0.00<br />

YY401 O DPH SPECIALTY AUDIOLOGY CLINIC VISI 0.00<br />

YY402 O DPH SPECIALTY CARDIAC CLINIC VISIT 0.00<br />

YY403 O DPH SPECIALTY ORTHOPEDIC CLINIC VIS 0.00<br />

YY404 O DPH SPECIALTY NEUROLOGY CLINIC VISI 0.00<br />

YY405 O DPH SPECIALTY SPEECH CLINIC VISIT 0.00<br />

YY406 O DPH GENERAL MEDICAL CLINIC VISIT 0.00<br />

YY407 O DPH URINALYSIS 0.00<br />

YY408 O DPH PRENATAL CLINIC VISIT 0.00<br />

YY409 O DPH TUBERCULOSIS CLINIC VISIT 0.00<br />

YY410 O DPH STD CLINIC VISIT 0.00<br />

YY411 O DPH ENHANCED CARE FOR AT-RISK CHILD 0.00<br />

YY431 O DPH - SPECIALTY FAMILY PLANNING CLI 0.00<br />

YY432 O DPH - SPECIALTY FAMILY PLANNING CLI 0.00<br />

YY433 O DPH - SPECIALTY FAMILY PLANNING CLI 0.00<br />

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YY441 O DPH - SUPPLIED DIAPHRAGM 0.00<br />

YY442 O DPH - SUPPLIED FOAM 0.00<br />

YY443 O DPH - SUPPLIED BIRTH CONTROL PILLS 0.00<br />

YY444 O DPH - SUPPLIED IUD 0.00<br />

YY445 O DPH - SUPPLIED PREGNANCY TEST 0.00<br />

YY471 O DPH - HEALTH SCREENING - AGE 35 TO 0.00<br />

YY472 O DPH - HEALTH SCREENING - AGE 50 TO 0.00<br />

YY473 O DPH - HEALTH SCREENING - AGE 60 AND 0.00<br />

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YY502 O TRANSPORTATION IN VEHICLE OTHER THA 0.00<br />

YY503 O TRANSPORTATION IN VEHICLE OTHER THA 0.00<br />

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YY514 O AMBULANCE, NEONATAL EMERGENCY TRANS 0.00<br />

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YY522 O TRANSPORTATION IN VEHICLE OTHER THA 0.00<br />

YY523 O TRANSPORTATION IN VEHICLE OTHER THA 0.00

---

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YY565 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

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YY579 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

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YY582 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

YY583 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

YY584 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

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YY587 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

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YY600 O HOME AND COMMUNITY-BASED SERVICES W 0.00<br />

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YY613 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

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YY615 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

YY616 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

YY617 O HOME AND COMMUNITY-BASED WAIVER FOR 0.00<br />

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YY619 O HCBS WAIVER FOR THE MENTALLY RETARD 0.00<br />

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YY634 O HOME AND COMMUNITY-BASED SERVICES W 0.00

---

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YY637 O HOME AND COMMUNITY-BASED SERVICES W 0.00<br />

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YY655 O HOME AND COMMUNITY - BASED SERVICES 0.00<br />

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YY663 O HOME AND COMMUNITY-BASED WAIVER FOR 0.00<br />

YY664 O HOME & COMMUNITY BASED SERVICES FOR 0.00<br />

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YY704 O HOME HEALTH - PHYSICAL THERAPY TREA 0.00<br />

YY705 O HOME HEALTH - OCCUPATIONAL THERAPY 0.00<br />

YY706 O HOME HEALTH - OCCUPATIONAL THERAPY 0.00<br />

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YY713 O HOME HEALTH-PHYSICAL THERAPY TREATM 0.00<br />

YY714 O HOME HEALTH-OCCUPATIONAL THERAPY EV 0.00<br />

YY715 O HOME HEALTH-OCCUPATIONAL THERAPY TR 0.00<br />

YY716 O HOME HEALTH-SPEECH THERAPY EVALUATI 0.00<br />

YY717 O HOME HEALTH-SPEECH THERAPY TREATMEN 0.00<br />

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YY719 O HOME HEALTH-SKILLED NURSE VISIT-HCB 0.00<br />

YY720 O HOME HEALTH-PHYSICAL THERAPY EVALUA 0.00

---

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YY724 O HOME HEALTH-SPEECH THERAPY EVALUATI 0.00<br />

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YY762 O DRUG/ALCOHOL GROUP OUTPATIENT SERVI 0.00<br />

YY763 O DRUG/ALCOHOL TREATMENT PROGRAM IN A 0.00<br />

YY764 7 DRUG\ALCOHOL PARTIAL DAY TREATMENT 0.00<br />

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YY808 O PRESCRIBED PEDIATRIC EXTEN<strong>DE</strong>D CARE 0.00<br />

YY822 O VFC IMMUNIZATION CO<strong>DE</strong> CREATED FOR L 0.00<br />

YY850 O DAY HEALTH & REHAB FOR MR & DD CLIE 0.00<br />

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YY852 O DAY HEALTH AND REHABILITATION FOR N 0.00<br />

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YY921 O MONTHLY CAPITATED RATE, PEDIATRIC M 0.00<br />

Z0402 O PORTABLE OXYGEN REFILL (13 TO 28 CU 0.00<br />

Z0406 O H TANK REFILL (151-282 CU. FT.) 0.00<br />

Z0445 O OXYGEN CONCENTRATOR 0.00<br />

Z0526 O WARM-N-FORM ORTHOSIS 0.00<br />

Z3255 O ORTHOPEDIC SHOES ATTACHED TO BRACE 0.00<br />

Z4442 O TRACHEOSTOMY SUCTION KIT 0.00<br />

Z4443 O TRACHEOSTOMY SUCTION CATHETER 0.00<br />

ZE001 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZE002 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZH003 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00

---

ZH004 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZH005 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZH010 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZH011 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZH020 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZH021 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZM001 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZR001 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00<br />

ZR002 O MCO SPECIFIC CO<strong>DE</strong>: HOME INFUSION SE 0.00

---

Pricing Action Codes<br />

Pricing Action Code Pricing Action Description<br />

1 PAY PERCENTAGE OF BILLED AMOUNT.<br />

3 LOWER OF BILLED OR ALLOWED AMOUNT.<br />

5 MANUAL PRICE - INDIVIDUAL CONSI<strong>DE</strong>RATION. SET EDIT TO SUSPEND.<br />

6 MANUAL PRICE - NO REASONABLE CHARGE ESTABLISHED. SET EDIT TO SUSPEND.<br />

7 ONLY LEVEL I PRICING SHOULD BE USED. SET EDIT TO SUSPEND.<br />

9 NON-COVERED. SET EDIT TO AUTO<strong>DE</strong>NY.<br />

LOWER OF BILLED AMOUNT OR ((RVU + BILLED UNITS) X CONVERSION FACTOR DOLLAR<br />

A<br />

AMOUNT) .<br />

O OBSOLETE. SET EDIT TO AUTO<strong>DE</strong>NY.

---

Procedure Code Description Pricing Percent<br />

D0120 PERIODIC ORAL EVALUATION 85.00<br />

D0140 LIMIT ORAL EVAL PROBLM FOCUS 85.00<br />

D0145 ORAL EVALUATION, PT < 3YRS 85.00<br />

D0150 COMPREHENSVE ORAL EVALUATION 85.00<br />

D0160 EXTENSV ORAL EVAL PROB FOCUS 85.00<br />

D0170 RE-EVAL,EST PT,PROBLEM FOCUS 85.00<br />

D0210 INTRAOR COMPLETE FILM SERIES 85.00<br />

D0220 INTRAORAL PERIAPICAL FIRST F 85.00<br />

D0230 INTRAORAL PERIAPICAL EA ADD 85.00<br />

D0240 INTRAORAL OCCLUSAL FILM 85.00<br />

D0250 EXTRAORAL FIRST FILM 85.00<br />

D0260 EXTRAORAL EA ADDITIONAL FILM 85.00<br />

D0270 <strong>DE</strong>NTAL BITEWING SINGLE FILM 85.00<br />

D0272 <strong>DE</strong>NTAL BITEWINGS TWO FILMS 85.00<br />

D0273 BITEWINGS - THREE FILMS 85.00<br />

D0274 <strong>DE</strong>NTAL BITEWINGS FOUR FILMS 85.00<br />

D0277 VERT BITEWINGS-SEV TO EIGHT 85.00<br />

D0290 <strong>DE</strong>NTAL FILM SKULL/FACIAL BON 85.00<br />

D0310 <strong>DE</strong>NTAL SALIOGRAPHY 85.00<br />

D0320 <strong>DE</strong>NTAL TMJ ARTHROGRAM INCL I 85.00<br />

D0321 <strong>DE</strong>NTAL OTHER TMJ FILMS 85.00<br />

D0322 <strong>DE</strong>NTAL TOMOGRAPHIC SURVEY 85.00<br />

D0330 <strong>DE</strong>NTAL PANORAMIC FILM 85.00<br />

D0340 <strong>DE</strong>NTAL CEPHALOMETRIC FILM 85.00<br />

D0360 CONE BEAM CT 85.00<br />

D0362 CONE BEAM, TWO DIMENSIONAL 85.00<br />

D0363 CONE BEAM, THREE DIMENSIONAL 85.00<br />

D0460 PULP VITALITY TEST 85.00<br />

D0470 DIAGNOSTIC CASTS 85.00<br />

D0472 GROSS EXAM, PREP & REPORT 85.00<br />

D0473 MICRO EXAM, PREP & REPORT 85.00<br />

D0474 MICRO W EXAM OF SURG MARGINS 85.00<br />

D0480 CYTOPATH SMEAR PREP & REPORT 85.00<br />

D0502 OTHER ORAL PATHOLOGY PROCEDU 85.00<br />

D0999 UNSPECIFIED DIAGNOSTIC PROCE 85.00<br />

D1110 <strong>DE</strong>NTAL PROPHYLAXIS ADULT 85.00<br />

D1120 <strong>DE</strong>NTAL PROPHYLAXIS CHILD 85.00<br />

D1203 TOPICAL APP FLUORI<strong>DE</strong> CHILD 85.00<br />

D1204 TOPICAL APP FLUORI<strong>DE</strong> ADULT 85.00<br />

D1206 TOPICAL FLUORI<strong>DE</strong> VARNISH 85.00<br />

D1320 TOBACCO COUNSELING 85.00<br />

D1351 <strong>DE</strong>NTAL SEALANT PER TOOTH 85.00<br />

D1510 SPACE MAINTAINER FXD UNILAT 85.00<br />

D1515 FIXED BILAT SPACE MAINTAINER 85.00<br />

D1520 REMOVE UNILAT SPACE MAINTAIN 85.00<br />

D1525 REMOVE BILAT SPACE MAINTAIN 85.00<br />

D1550 RECEMENT SPACE MAINTAINER 85.00<br />

D1555 REMOVE FIX SPACE MAINTAINER 85.00<br />

D2140 AMALGAM ONE SURFACE PERMANEN 85.00

---

D2150 AMALGAM TWO SURFACES PERMANE 85.00<br />

D2160 AMALGAM THREE SURFACES PERMA 85.00<br />

D2161 AMALGAM 4 OR > SURFACES PERM 85.00<br />

D2330 RESIN ONE SURFACE-ANTERIOR 85.00<br />

D2331 RESIN TWO SURFACES-ANTERIOR 85.00<br />

D2332 RESIN THREE SURFACES-ANTERIO 85.00<br />

D2335 RESIN 4/> SURF OR W INCIS AN 85.00<br />

D2390 ANT RESIN-BASED CMPST CROWN 85.00<br />

D2391 POST 1 SRFC RESINBASED CMPST 85.00<br />

D2392 POST 2 SRFC RESINBASED CMPST 85.00<br />

D2393 POST 3 SRFC RESINBASED CMPST 85.00<br />

D2394 POST >=4SRFC RESINBASE CMPST 85.00<br />

D2710 CROWN RESIN-BASED INDIRECT 85.00<br />

D2712 CROWN 3/4 RESIN-BASED COMPOS 85.00<br />

D2721 CROWN RESIN W/ BASE METAL 85.00<br />

D2722 CROWN RESIN W/ NOBLE METAL 85.00<br />

D2751 CROWN PORCELAIN FUSED BASE M 85.00<br />

D2752 CROWN PORCELAIN W/ NOBLE MET 85.00<br />

D2781 CROWN 3/4 CAST BASE METAL 85.00<br />

D2782 CROWN 3/4 CAST NOBLE METAL 85.00<br />

D2791 CROWN FULL CAST BASE METAL 85.00<br />

D2792 CROWN FULL CAST NOBLE METAL 85.00<br />

D2799 PROVISIONAL CROWN 85.00<br />

D2910 RECEMENT INLAY ONLAY OR PART 85.00<br />

D2915 RECEMENT CAST OR PREFAB POST 85.00<br />

D2920 <strong>DE</strong>NTAL RECEMENT CROWN 85.00<br />

D2930 PREFAB STNLSS STEEL CRWN PRI 85.00<br />

D2931 PREFAB STNLSS STEEL CROWN PE 85.00<br />

D2932 PREFABRICATED RESIN CROWN 85.00<br />

D2933 PREFAB STAINLESS STEEL CROWN 85.00<br />

D2934 PREFAB STEEL CROWN PRIMARY 85.00<br />

D2940 <strong>DE</strong>NTAL SEDATIVE FILLING 85.00<br />

D2950 CORE BUILD-UP INCL ANY PINS 85.00<br />

D2951 TOOTH PIN RETENTION 85.00<br />

D2952 POST AND CORE CAST + CROWN 85.00<br />

D2953 EACH ADDTNL CAST POST 85.00<br />

D2954 PREFAB POST/CORE + CROWN 85.00<br />

D2955 POST REMOVAL 85.00<br />

D2957 EACH ADDTNL PREFAB POST 85.00<br />

D2970 TEMPORARY- FRACTURED TOOTH 85.00<br />

D2980 CROWN REPAIR 85.00<br />

D2999 <strong>DE</strong>NTAL UNSPEC RESTORATIVE PR 85.00<br />

D3110 PULP CAP DIRECT 85.00<br />

D3120 PULP CAP INDIRECT 85.00<br />

D3220 THERAPEUTIC PULPOTOMY 85.00<br />

D3221 GROSS PULPAL <strong>DE</strong>BRI<strong>DE</strong>MENT 85.00<br />

D3222 PART PULP FOR APEXOGENESIS 85.00<br />

D3230 PULPAL THERAPY ANTERIOR PRIM 85.00<br />

D3240 PULPAL THERAPY POSTERIOR PRI 85.00<br />

D3310 END THXPY, ANTERIOR TOOTH 85.00

---

D3320 END THXPY, BICUSPID TOOTH 85.00<br />

D3330 END THXPY, MOLAR 85.00<br />

D3332 INCOMPLETE ENDODONTIC TX 85.00<br />

D3333 INTERNAL ROOT REPAIR 85.00<br />

D3346 RETREAT ROOT CANAL ANTERIOR 85.00<br />

D3347 RETREAT ROOT CANAL BICUSPID 85.00<br />

D3348 RETREAT ROOT CANAL MOLAR 85.00<br />

D3351 APEXIFICATION/RECALC INITIAL 85.00<br />

D3352 APEXIFICATION/RECALC INTERIM 85.00<br />

D3353 APEXIFICATION/RECALC FINAL 85.00<br />

D3410 APICOECT/PERIRAD SURG ANTER 85.00<br />

D3421 ROOT SURGERY BICUSPID 85.00<br />

D3425 ROOT SURGERY MOLAR 85.00<br />

D3426 ROOT SURGERY EA ADD ROOT 85.00<br />

D3430 RETROGRA<strong>DE</strong> FILLING 85.00<br />

D3450 ROOT AMPUTATION 85.00<br />

D3470 INTENTIONAL REPLANTATION 85.00<br />

D3910 ISOLATION- TOOTH W RUBB DAM 85.00<br />

D3999 ENDODONTIC PROCEDURE 85.00<br />

D4210 GINGIVECTOMY/PLASTY PER QUAD 85.00<br />

D4211 GINGIVECTOMY/PLASTY PER TOOT 85.00<br />

D4230 ANA CROWN EXP 4 OR> PER QUAD 85.00<br />

D4231 ANA CROWN EXP 1-3 PER QUAD 85.00<br />

D4240 GINGIVAL FLAP PROC W/ PLANIN 85.00<br />

D4241 GNGVL FLAP W ROOTPLAN 1-3 TH 85.00<br />

D4245 APICALLY POSITIONED FLAP 85.00<br />

D4249 CROWN LENGTHEN HARD TISSUE 85.00<br />

D4260 OSSEOUS SURGERY PER QUADRANT 85.00<br />

D4261 OSSEOUS SURGL-3TEETHPERQUAD 85.00<br />

D4263 BONE REPLCE GRAFT FIRST SITE 85.00<br />

D4264 BONE REPLCE GRAFT EACH ADD 85.00<br />

D4265 BIO MTRLS TO AID SOFT/OS REG 85.00<br />

D4266 GUI<strong>DE</strong>D TISS REGEN RESORBLE 85.00<br />

D4267 GUI<strong>DE</strong>D TISS REGEN NONRESORB 85.00<br />

D4268 SURGICAL REVISION PROCEDURE 85.00<br />

D4270 PEDICLE SOFT TISSUE GRAFT PR 85.00<br />

D4271 FREE SOFT TISSUE GRAFT PROC 85.00<br />

D4273 SUBEPITHELIAL TISSUE GRAFT 85.00<br />

D4274 DISTAL/PROXIMAL WEDGE PROC 85.00<br />

D4275 SOFT TISSUE ALLOGRAFT 85.00<br />

D4276 CON TISSUE W DBLE PED GRAFT 85.00<br />

D4320 PROVISION SPLNT INTRACORONAL 85.00<br />

D4321 PROVISIONAL SPLINT EXTRACORO 85.00<br />

D4341 PERIODONTAL SCALING & ROOT 85.00<br />

D4342 PERIODONTAL SCALING 1-3TEETH 85.00<br />

D4355 FULL MOUTH <strong>DE</strong>BRI<strong>DE</strong>MENT 85.00<br />

D4381 LOCALIZED <strong>DE</strong>LIVERY ANTIMICRO 85.00<br />

D4910 PERIODONTAL MAINT PROCEDURES 85.00<br />

D4920 UNSCHEDULED DRESSING CHANGE 85.00<br />

D4999 UNSPECIFIED PERIODONTAL PROC 85.00

---

D5110 <strong>DE</strong>NTURES COMPLETE MAXILLARY 85.00<br />

D5120 <strong>DE</strong>NTURES COMPLETE MANDIBLE 85.00<br />

D5130 <strong>DE</strong>NTURES IMMEDIAT MAXILLARY 85.00<br />

D5140 <strong>DE</strong>NTURES IMMEDIAT MANDIBLE 85.00<br />

D5211 <strong>DE</strong>NTURES MAXILL PART RESIN 85.00<br />

D5212 <strong>DE</strong>NTURES MAND PART RESIN 85.00<br />

D5213 <strong>DE</strong>NTURES MAXILL PART METAL 85.00<br />

D5214 <strong>DE</strong>NTURES MANDIBL PART METAL 85.00<br />

D5225 MAXILLARY PART <strong>DE</strong>NTURE FLEX 85.00<br />

D5226 MANDIBULAR PART <strong>DE</strong>NTURE FLEX 85.00<br />

D5410 <strong>DE</strong>NTURES ADJUST CMPLT MAXIL 85.00<br />

D5411 <strong>DE</strong>NTURES ADJUST CMPLT MAND 85.00<br />

D5421 <strong>DE</strong>NTURES ADJUST PART MAXILL 85.00<br />

D5422 <strong>DE</strong>NTURES ADJUST PART MANDBL 85.00<br />

D5510 <strong>DE</strong>NTUR REPR BROKEN COMPL BAS 85.00<br />

D5520 REPLACE <strong>DE</strong>NTURE TEETH COMPLT 85.00<br />

D5610 <strong>DE</strong>NTURES REPAIR RESIN BASE 85.00<br />

D5620 REP PART <strong>DE</strong>NTURE CAST FRAME 85.00<br />

D5630 REP PARTIAL <strong>DE</strong>NTURE CLASP 85.00<br />

D5640 REPLACE PART <strong>DE</strong>NTURE TEETH 85.00<br />

D5650 ADD TOOTH TO PARTIAL <strong>DE</strong>NTURE 85.00<br />

D5660 ADD CLASP TO PARTIAL <strong>DE</strong>NTURE 85.00<br />

D5670 REPLC TTH&ACRLC ON MTL FRMWK 85.00<br />

D5671 REPLC TTH&ACRLC MANDIBULAR 85.00<br />

D5730 <strong>DE</strong>NTURE RELN CMPLT MAXIL CH 85.00<br />

D5731 <strong>DE</strong>NTURE RELN CMPLT MAND CHR 85.00<br />

D5740 <strong>DE</strong>NTURE RELN PART MAXIL CHR 85.00<br />

D5741 <strong>DE</strong>NTURE RELN PART MAND CHR 85.00<br />

D5750 <strong>DE</strong>NTURE RELN CMPLT MAX LAB 85.00<br />

D5751 <strong>DE</strong>NTURE RELN CMPLT MAND LAB 85.00<br />

D5760 <strong>DE</strong>NTURE RELN PART MAXIL LAB 85.00<br />

D5761 <strong>DE</strong>NTURE RELN PART MAND LAB 85.00<br />

D5810 <strong>DE</strong>NTURE INTERM CMPLT MAXILL 85.00<br />

D5811 <strong>DE</strong>NTURE INTERM CMPLT MANDBL 85.00<br />

D5820 <strong>DE</strong>NTURE INTERM PART MAXILL 85.00<br />

D5821 <strong>DE</strong>NTURE INTERM PART MANDBL 85.00<br />

D5850 <strong>DE</strong>NTURE TISS CONDITN MAXILL 85.00<br />

D5851 <strong>DE</strong>NTURE TISS CONDTIN MANDBL 85.00<br />

D5899 REMOVABLE PROSTHODONTIC PROC 85.00<br />

D5911 FACIAL MOULAGE SECTIONAL 85.00<br />

D5912 FACIAL MOULAGE COMPLETE 85.00<br />

D5913 NASAL PROSTHESIS 85.00<br />

D5914 AURICULAR PROSTHESIS 85.00<br />

D5915 ORBITAL PROSTHESIS 85.00<br />

D5916 OCULAR PROSTHESIS 85.00<br />

D5919 FACIAL PROSTHESIS 85.00<br />

D5922 NASAL SEPTAL PROSTHESIS 85.00<br />

D5923 OCULAR PROSTHESIS INTERIM 85.00<br />

D5924 CRANIAL PROSTHESIS 85.00<br />

D5925 FACIAL AUGMENTATION IMPLANT 85.00

---

D5926 REPLACEMENT NASAL PROSTHESIS 85.00<br />

D5927 AURICULAR REPLACEMENT 85.00<br />

D5928 ORBITAL REPLACEMENT 85.00<br />

D5929 FACIAL REPLACEMENT 85.00<br />

D5931 SURGICAL OBTURATOR 85.00<br />

D5932 POSTSURGICAL OBTURATOR 85.00<br />

D5933 REFITTING OF OBTURATOR 85.00<br />

D5934 MANDIBULAR FLANGE PROSTHESIS 85.00<br />

D5935 MANDIBULAR <strong>DE</strong>NTURE PROSTH 85.00<br />

D5936 TEMP OBTURATOR PROSTHESIS 85.00<br />

D5937 TRISMUS APPLIANCE 85.00<br />

D5951 FEEDING AID 85.00<br />

D5952 PEDIATRIC SPEECH AID 85.00<br />

D5953 ADULT SPEECH AID 85.00<br />

D5954 SUPERIMPOSED PROSTHESIS 85.00<br />

D5955 PALATAL LIFT PROSTHESIS 85.00<br />

D5958 INTRAORAL CON <strong>DE</strong>F INTER PLT 85.00<br />

D5959 INTRAORAL CON <strong>DE</strong>F MOD PALAT 85.00<br />

D5960 MODIFY SPEECH AID PROSTHESIS 85.00<br />

D5986 FLUORI<strong>DE</strong> APPLICATOR 85.00<br />

D5987 COMMISSURE SPLINT 85.00<br />

D5988 SURGICAL SPLINT 85.00<br />

D5991 TOPICAL MEDICAMENT CARRIER 85.00<br />

D5999 MAXILLOFACIAL PROSTHESIS 85.00<br />

D6211 BRIDGE BASE METAL CAST 85.00<br />

D6212 BRIDGE NOBLE METAL CAST 85.00<br />

D6241 BRIDGE PORCELAIN BASE METAL 85.00<br />

D6242 BRIDGE PORCELAIN NOBEL METAL 85.00<br />

D6251 BRIDGE RESIN BASE METAL 85.00<br />

D6252 BRIDGE RESIN W/NOBLE METAL 85.00<br />

D6545 <strong>DE</strong>NTAL RETAINR CAST METL 85.00<br />

D6721 CROWN RESIN W/BASE METAL 85.00<br />

D6722 CROWN RESIN W/NOBLE METAL 85.00<br />

D6751 CROWN PORCELAIN BASE METAL 85.00<br />

D6752 CROWN PORCELAIN NOBLE METAL 85.00<br />

D6791 CROWN FULL BASE METAL CAST 85.00<br />

D6792 CROWN FULL NOBLE METAL CAST 85.00<br />

D6930 <strong>DE</strong>NTAL RECEMENT BRIDGE 85.00<br />

D6972 PREFAB POST & CORE PLUS RETA 85.00<br />

D6980 BRIDGE REPAIR 85.00<br />

D6985 PEDIATRIC PARTIAL <strong>DE</strong>NTURE FX 85.00<br />

D6999 FIXED PROSTHODONTIC PROC 85.00<br />

D7111 EXTRACTION CORONAL REMNANTS 85.00<br />

D7140 EXTRACTION ERUPTED TOOTH/EXR 85.00<br />

D7210 REM IMP TOOTH W MUCOPER FLP 85.00<br />

D7220 IMPACT TOOTH REMOV SOFT TISS 85.00<br />

D7230 IMPACT TOOTH REMOV PART BONY 85.00<br />

D7240 IMPACT TOOTH REMOV COMP BONY 85.00<br />

D7241 IMPACT TOOTH REM BONY W/COMP 85.00<br />

D7250 TOOTH ROOT REMOVAL 85.00

---

D7260 ORAL ANTRAL FISTULA CLOSURE 85.00<br />

D7261 PRIMARY CLOSURE SINUS PERF 85.00<br />

D7270 TOOTH REIMPLANTATION 85.00<br />

D7272 TOOTH TRANSPLANTATION 85.00<br />

D7280 EXPOSURE IMPACT TOOTH ORTHOD 85.00<br />

D7282 MOBILIZE ERUPTED/MALPOS TOOT 85.00<br />

D7283 PLACE <strong>DE</strong>VICE IMPACTED TOOTH 85.00<br />

D7290 REPOSITIONING OF TEETH 85.00<br />

D7291 TRANSSEPTAL FIBEROTOMY 85.00<br />

D7310 ALVEOPLASTY W/ EXTRACTION 85.00<br />

D7311 ALVEOLOPLASTY W/EXTRACT 1-3 85.00<br />

D7320 ALVEOPLASTY W/O EXTRACTION 85.00<br />

D7321 ALVEOLOPLASTY NOT W/EXTRACTS 85.00<br />

D7340 VESTIBULOPLASTY RIDGE EXTENS 85.00<br />

D7350 VESTIBULOPLASTY EXTEN GRAFT 85.00<br />

D7510 I&D ABSC INTRAORAL SOFT TISS 85.00<br />

D7511 INCISION/DRAIN ABSCESS INTRA 85.00<br />

D7520 I&D ABSCESS EXTRAORAL 85.00<br />

D7521 INCISION/DRAIN ABSCESS EXTRA 85.00<br />

D7530 REMOVAL FB SKIN/AREOLAR TISS 85.00<br />

D7540 REMOVAL OF FB REACTION 85.00<br />

D7550 REMOVAL OF SLOUGHED OFF BONE 85.00<br />

D7560 MAXILLARY SINUSOTOMY 85.00<br />

D7880 OCCLUSAL ORTHOTIC APPLIANCE 85.00<br />

D7899 TMJ UNSPECIFIED THERAPY 85.00<br />

D7910 <strong>DE</strong>NT SUTUR RECENT WND TO 5CM 85.00<br />

D7911 <strong>DE</strong>NTAL SUTURE WOUND TO 5 CM 85.00<br />

D7912 SUTURE COMPLICATE WND > 5 CM 85.00<br />

D7960 FRENULECTOMY/FRENULOTOMY 85.00<br />

D7963 FRENULOPLASTY 85.00<br />

D7970 EXCISION HYPERPLASTIC TISSUE 85.00<br />

D7971 EXCISION PERICORONAL GINGIVA 85.00<br />

D7997 APPLIANCE REMOVAL 85.00<br />

D7999 ORAL SURGERY PROCEDURE 85.00<br />

D8010 LIMITED <strong>DE</strong>NTAL TX PRIMARY 85.00<br />

D8020 LIMITED <strong>DE</strong>NTAL TX TRANSITION 85.00<br />

D8030 LIMITED <strong>DE</strong>NTAL TX ADOLESCENT 85.00<br />

D8040 LIMITED <strong>DE</strong>NTAL TX ADULT 85.00<br />

D8050 INTERCEP <strong>DE</strong>NTAL TX PRIMARY 85.00<br />

D8060 INTERCEP <strong>DE</strong>NTAL TX TRANSITN 85.00<br />

D8070 COMPRE <strong>DE</strong>NTAL TX TRANSITION 85.00<br />

D8090 COMPRE <strong>DE</strong>NTAL TX ADULT 85.00<br />

D8210 ORTHODONTIC REM APPLIANCE TX 85.00<br />

D8220 FIXED APPLIANCE THERAPY HABT 85.00<br />

D8680 ORTHODONTIC RETENTION 85.00<br />

D8690 ORTHODONTIC TREATMENT 85.00<br />

D8691 REPAIR ORTHO APPLIANCE 85.00<br />

D8692 REPLACEMENT RETAINER 85.00<br />

D8999 ORTHODONTIC PROCEDURE 85.00<br />

D9110 TX <strong>DE</strong>NTAL PAIN MINOR PROC 85.00

---

D9120 FIX PARTIAL <strong>DE</strong>NTURE SECTION 85.00<br />

D9210 <strong>DE</strong>NT ANESTHESIA W/O SURGERY 85.00<br />

D9220 GENERAL ANESTHESIA 85.00<br />

D9221 GENERAL ANESTHESIA EA AD 15M 85.00<br />

D9230 ANALGESIA 85.00<br />

D9241 INTRAVENOUS SEDATION 85.00<br />

D9242 IV SEDATION EA AD 30 M 85.00<br />

D9248 SEDATION (NON-IV) 85.00<br />

D9310 <strong>DE</strong>NTAL CONSULTATION 85.00<br />

D9440 OFFICE VISIT AFTER HOURS 85.00<br />

D9610 <strong>DE</strong>NT THERAPEUTIC DRUG INJECT 85.00<br />

D9612 THERA PAR DRUGS 2 OR > ADMIN 85.00<br />

D9910 <strong>DE</strong>NT APPL <strong>DE</strong>SENSITIZING MED 85.00<br />

D9911 APPL <strong>DE</strong>SENSITIZING RESIN 85.00<br />

D9920 BEHAVIOR MANAGEMENT 85.00<br />

D9930 TREATMENT OF COMPLICATIONS 85.00<br />

D9940 <strong>DE</strong>NTAL OCCLUSAL GUARD 85.00<br />

D9999 ADJUNCTIVE PROCEDURE 85.00

---

Fee Schedule Relative Value Unit (RVU)<br />

Procedure Code Description RVU RVU Coeff Value<br />

00100 ANESTH, SALIVARY GLAND 5.00 16.05<br />

00102 ANESTH, REPAIR OF CLEFT LIP 6.00 16.05<br />

00103 ANESTH, BLEPHAROPLASTY 5.00 16.05<br />

00104 ANESTH, ELECTROSHOCK 4.00 16.05<br />

00120 ANESTH, EAR SURGERY 4.00 16.05<br />

00124 ANESTH, EAR EXAM 4.00 16.05<br />

00126 ANESTH, TYMPANOTOMY 4.00 16.05<br />

00140 ANESTH, PROCEDURES ON EYE 5.00 16.05<br />

00142 ANESTH, LENS SURGERY 6.00 16.05<br />

00144 ANESTH, CORNEAL TRANSPLANT 6.00 16.05<br />

00145 ANESTH, VITREORETINAL SURG 6.00 16.05<br />

00147 ANESTH, IRI<strong>DE</strong>CTOMY 4.00 16.05<br />

00148 ANESTH, EYE EXAM 4.00 16.05<br />

00160 ANESTH, NOSE/SINUS SURGERY 5.00 16.05<br />

00162 ANESTH, NOSE/SINUS SURGERY 7.00 16.05<br />

00164 ANESTH, BIOPSY OF NOSE 4.00 16.05<br />

00170 ANESTH, PROCEDURE ON MOUTH 5.00 16.05<br />

00172 ANESTH, CLEFT PALATE REPAIR 6.00 16.05<br />

00174 ANESTH, PHARYNGEAL SURGERY 6.00 16.05<br />

00176 ANESTH, PHARYNGEAL SURGERY 7.00 16.05<br />

00190 ANESTH, FACE/SKULL BONE SURG 5.00 16.05<br />

00192 ANESTH, FACIAL BONE SURGERY 7.00 16.05<br />

00210 ANESTH, CRANIAL SURG NOS 11.00 16.05<br />

00211 ANESTH, CRAN SURG, HEMOTOMA 10.00 16.05<br />

00212 ANESTH, SKULL DRAINAGE 5.00 16.05<br />

00214 ANESTH, SKULL DRAINAGE 9.00 16.05<br />

00215 ANESTH, SKULL REPAIR/FRACT 9.00 16.05<br />

00216 ANESTH, HEAD VESSEL SURGERY 15.00 16.05<br />

00218 ANESTH, SPECIAL HEAD SURGERY 13.00 16.05<br />

00220 ANESTH, INTRCRN NERVE 10.00 16.05<br />

00222 ANESTH, HEAD NERVE SURGERY 6.00 16.05<br />

00300 ANESTH, HEAD/NECK/PTRUNK 5.00 16.05<br />

00320 ANESTH, NECK ORGAN, 1 & OVER 6.00 16.05<br />

00322 ANESTH, BIOPSY OF THYROID 3.00 16.05<br />

00326 ANESTH, LARYNX/TRACH, < 1 YR 7.00 16.05<br />

00350 ANESTH, NECK VESSEL SURGERY 10.00 16.05<br />

00352 ANESTH, NECK VESSEL SURGERY 5.00 16.05<br />

00400 ANESTH, SKIN, EXT/PER/ATRUNK 3.00 16.05<br />

00402 ANESTH, SURGERY OF BREAST 5.00 16.05<br />

00404 ANESTH, SURGERY OF BREAST 5.00 16.05<br />

00406 ANESTH, SURGERY OF BREAST 13.00 16.05<br />

00410 ANESTH, CORRECT HEART RHYTHM 4.00 16.05<br />

00450 ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 5.00 16.05<br />

00452 ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 6.00 16.05<br />

00454 ANESTH, COLLAR BONE BIOPSY 3.00 16.05<br />

00470 ANESTH, REMOVAL OF RIB 6.00 16.05<br />

00472 ANESTH, CHEST WALL REPAIR 10.00 16.05

---

00474 ANESTH, SURGERY OF RIB(S) 13.00 16.05<br />

00500 ANESTH, ESOPHAGEAL SURGERY 15.00 16.05<br />

00520 ANESTH, CHEST PROCEDURE 6.00 16.05<br />

00522 ANESTH, CHEST LINING BIOPSY 4.00 16.05<br />

00524 ANESTH, CHEST DRAINAGE 4.00 16.05<br />

00528 ANESTH, CHEST PARTITION VIEW 8.00 16.05<br />

00530 ANESTH, PACEMAKER INSERTION 4.00 16.05<br />

00532 ANESTH, VASCULAR ACCESS 4.00 16.05<br />

00534 ANESTH, CARDIOVERTER/<strong>DE</strong>FIB 7.00 16.05<br />

00537 ANESTH, CARDIAC ELECTROPHYS 10.00 16.05<br />

00539 ANESTH,TRACHEOBRONCHIAL RECONSTRUC 18.00 16.05<br />

00540 ANESTH, CHEST SURGERY 13.00 16.05<br />

00541 ANESTH, ONE LUNG VENTILATION 15.00 16.05<br />

00542 ANESTH, RELEASE OF LUNG 15.00 16.05<br />

00546 ANESTH, LUNG,CHEST WALL SURG 15.00 16.05<br />

00548 ANESTH, TRACHEA,BRONCHI SURG 17.00 16.05<br />

00550 ANESTH, STERNAL <strong>DE</strong>BRI<strong>DE</strong>MENT 10.00 16.05<br />

00560 ANESTH, HEART SURG W/O PUMP 15.00 16.05<br />

00561 ANESTH, HEART SURG < AGE 1 25.00 16.05<br />

00562 ANESTH HRT SURG W/PMP AGE 1+ 20.00 16.05<br />

00563 ANESTH, HEART SURG W/ARREST 25.00 16.05<br />

00566 ANESTH, CABG W/O PUMP 25.00 16.05<br />

00567 ANESTH, CABG W/PUMP 18.00 16.05<br />

00580 ANESTH, HEART/LUNG TRANSPLNT 20.00 16.05<br />

00600 ANESTH, SPINE, CORD SURGERY 10.00 16.05<br />

00604 ANESTH, SITTING PROCEDURE 13.00 16.05<br />

00620 ANESTH, SPINE, CORD SURGERY 10.00 16.05<br />

00622 ANESTH, REMOVAL OF NERVES 13.00 16.05<br />

00625 ANES SPINE TRANTHOR W/O VENT 13.00 16.05<br />

00626 ANES, SPINE TRANSTHOR W/VENT 15.00 16.05<br />

00630 ANESTH, SPINE, CORD SURGERY 8.00 16.05<br />

00632 ANESTH, REMOVAL OF NERVES 7.00 16.05<br />

00635 ANESTH, LUMBAR PUNCTURE 4.00 16.05<br />

00640 ANESTH, SPINE MANIPULATION 3.00 16.05<br />

00670 ANESTH, SPINE, CORD SURGERY 13.00 16.05<br />

00700 ANESTH, ABDOMINAL WALL SURG 4.00 16.05<br />

00702 ANESTH, FOR LIVER BIOPSY 4.00 16.05<br />

00730 ANESTH, ABDOMINAL WALL SURG 5.00 16.05<br />

00740 ANESTH, UPPER GI VISUALIZE 5.00 16.05<br />

00750 ANESTH, REPAIR OF HERNIA 4.00 16.05<br />

00752 ANESTH, REPAIR OF HERNIA 6.00 16.05<br />

00754 ANESTH, REPAIR OF HERNIA 7.00 16.05<br />

00756 ANESTH, REPAIR OF HERNIA 7.00 16.05<br />

00770 ANESTH, BLOOD VESSEL REPAIR 15.00 16.05<br />

00790 ANESTH, SURG UPPER ABDOMEN 7.00 16.05<br />

00792 ANESTH, HEMORR/EXCISE LIVER 7.00 16.05<br />

00794 ANESTH, PANCREAS REMOVAL 13.00 16.05<br />

00796 ANESTH, FOR LIVER TRANSPLANT 30.00 16.05<br />

00797 ANESTH, SURGERY FOR OBESITY 10.00 16.05<br />

00800 ANESTH, ABDOMINAL WALL SURG 4.00 16.05

---

00802 ANESTH, FAT LAYER REMOVAL 5.00 16.05<br />

00810 ANESTH, LOW INTESTINE SCOPE 5.00 16.05<br />

00820 ANESTH, ABDOMINAL WALL SURG 5.00 16.05<br />

00830 ANESTH, REPAIR OF HERNIA 4.00 16.05<br />

00832 ANESTH, REPAIR OF HERNIA 6.00 16.05<br />

00834 ANESTH, HERNIA REPAIR< 1 YR 5.00 16.05<br />

00836 ANESTH HERNIA REPAIR PREEMIE 6.00 16.05<br />

00840 ANESTH, SURG LOWER ABDOMEN 6.00 16.05<br />

00842 ANESTH, AMNIOCENTESIS 4.00 16.05<br />

00844 ANESTH, PELVIS SURGERY 7.00 16.05<br />

00846 ANESTH, HYSTERECTOMY 8.00 16.05<br />

00848 ANESTH, PELVIC ORGAN SURG 8.00 16.05<br />

00851 ANESTH, TUBAL LIGATION 6.00 16.05<br />

00860 ANESTH, SURGERY OF ABDOMEN 6.00 16.05<br />

00862 ANESTH, KIDNEY/URETER SURG 7.00 16.05<br />

00864 ANESTH, REMOVAL OF BLAD<strong>DE</strong>R 8.00 16.05<br />

00865 ANESTH, REMOVAL OF PROSTATE 7.00 16.05<br />

00866 ANESTH, REMOVAL OF ADRENAL 10.00 16.05<br />

00868 ANESTH, KIDNEY TRANSPLANT 10.00 16.05<br />

00870 ANESTH, BLAD<strong>DE</strong>R STONE SURG 5.00 16.05<br />

00872 ANESTH KIDNEY STONE <strong>DE</strong>STRUCT 7.00 16.05<br />

00873 ANESTH KIDNEY STONE <strong>DE</strong>STRUCT 5.00 16.05<br />

00880 ANESTH, ABDOMEN VESSEL SURG 15.00 16.05<br />

00882 ANESTH, MAJOR VEIN LIGATION 10.00 16.05<br />

00902 ANESTH, ANORECTAL SURGERY 5.00 16.05<br />

00904 ANESTH, PERINEAL SURGERY 7.00 16.05<br />

00906 ANESTH, REMOVAL OF VULVA 4.00 16.05<br />

00908 ANESTH, REMOVAL OF PROSTATE 6.00 16.05<br />

00910 ANESTH, BLAD<strong>DE</strong>R SURGERY 3.00 16.05<br />

00912 ANESTH, BLAD<strong>DE</strong>R TUMOR SURG 5.00 16.05<br />

00914 ANESTH, REMOVAL OF PROSTATE 5.00 16.05<br />

00916 ANESTH, BLEEDING CONTROL 5.00 16.05<br />

00918 ANESTH, STONE REMOVAL 5.00 16.05<br />

00920 ANESTH, GENITALIA SURGERY 3.00 16.05<br />

00921 ANESTH, VASECTOMY 3.00 16.05<br />

00922 ANESTH, SPERM DUCT SURGERY 6.00 16.05<br />

00924 ANESTH, TESTIS EXPLORATION 4.00 16.05<br />

00926 ANESTH, REMOVAL OF TESTIS 4.00 16.05<br />

00928 ANESTH, REMOVAL OF TESTIS 6.00 16.05<br />

00930 ANESTH, TESTIS SUSPENSION 4.00 16.05<br />

00932 ANESTH, AMPUTATION OF PENIS 4.00 16.05<br />

00934 ANESTH, PENIS, NO<strong>DE</strong>S REMOVAL 6.00 16.05<br />

00936 ANESTH, PENIS, NO<strong>DE</strong>S REMOVAL 8.00 16.05<br />

00940 ANESTH, VAGINAL PROCEDURES 3.00 16.05<br />

00942 ANESTH, SURG ON VAG/URETHRAL 4.00 16.05<br />

00944 ANESTH, VAGINAL HYSTERECTOMY 6.00 16.05<br />

00948 ANESTH, REPAIR OF CERVIX 4.00 16.05<br />

00950 ANESTH, VAGINAL ENDOSCOPY 5.00 16.05<br />

00952 ANESTH, HYSTEROSCOPE/GRAPH 4.00 16.05<br />

01112 ANESTH, BONE ASPIRATE/BX 5.00 16.05

---

01120 ANESTH, PELVIS SURGERY 6.00 16.05<br />

01130 ANESTH, BODY CAST PROCEDURE 3.00 16.05<br />

01140 ANESTH, AMPUTATION AT PELVIS 15.00 16.05<br />

01150 ANESTH, PELVIC TUMOR SURGERY 10.00 16.05<br />

01160 ANESTH, PELVIS PROCEDURE 4.00 16.05<br />

01170 ANESTH, PELVIS SURGERY 8.00 16.05<br />

01173 ANESTH, FX REPAIR, PELVIS 12.00 16.05<br />

01180 ANESTH, PELVIS NERVE REMOVAL 3.00 16.05<br />

01190 ANESTH, PELVIS NERVE REMOVAL 4.00 16.05<br />

01200 ANESTH, HIP JOINT PROCEDURE 4.00 16.05<br />

01202 ANESTH, ARTHROSCOPY OF HIP 4.00 16.05<br />

01210 ANESTH, HIP JOINT SURGERY 6.00 16.05<br />

01212 ANESTH, HIP DISARTICULATION 10.00 16.05<br />

01214 ANESTH, HIP ARTHROPLASTY 8.00 16.05<br />

01215 ANESTH, REVISE HIP REPAIR 10.00 16.05<br />

01220 ANESTH, PROCEDURE ON FEMUR 4.00 16.05<br />

01230 ANESTH, SURGERY OF FEMUR 6.00 16.05<br />

01232 ANESTH, AMPUTATION OF FEMUR 5.00 16.05<br />

01234 ANESTH, RADICAL FEMUR SURG 8.00 16.05<br />

01250 ANESTH, UPPER LEG SURGERY 4.00 16.05<br />

01260 ANESTH, UPPER LEG VEINS SURG 3.00 16.05<br />

01270 ANESTH, THIGH ARTERIES SURG 8.00 16.05<br />

01272 ANESTH, FEMORAL ARTERY SURG 4.00 16.05<br />

01274 ANESTH, FEMORAL EMBOLECTOMY 6.00 16.05<br />

01320 ANESTH, KNEE AREA SURGERY 4.00 16.05<br />

01340 ANESTH, KNEE AREA PROCEDURE 4.00 16.05<br />

01360 ANESTH, KNEE AREA SURGERY 5.00 16.05<br />

01380 ANESTH, KNEE JOINT PROCEDURE 3.00 16.05<br />

01382 ANESTH, DX KNEE ARTHROSCOPY 3.00 16.05<br />

01390 ANESTH, KNEE AREA PROCEDURE 3.00 16.05<br />

01392 ANESTH, KNEE AREA SURGERY 4.00 16.05<br />

01400 ANESTH, KNEE JOINT SURGERY 4.00 16.05<br />

01402 ANESTH, KNEE ARTHROPLASTY 7.00 16.05<br />

01404 ANESTH, AMPUTATION AT KNEE 5.00 16.05<br />

01420 ANESTH, KNEE JOINT CASTING 3.00 16.05<br />

01430 ANESTH, KNEE VEINS SURGERY 3.00 16.05<br />

01432 ANESTH, KNEE VESSEL SURG 6.00 16.05<br />

01440 ANESTH, KNEE ARTERIES SURG 8.00 16.05<br />

01442 ANESTH, KNEE ARTERY SURG 8.00 16.05<br />

01444 ANESTH, KNEE ARTERY REPAIR 8.00 16.05<br />

01462 ANESTH, LOWER LEG PROCEDURE 3.00 16.05<br />

01464 ANESTH, ANKLE/FT ARTHROSCOPY 3.00 16.05<br />

01470 ANESTH, LOWER LEG SURGERY 3.00 16.05<br />

01472 ANESTH, ACHILLES TENDON SURG 5.00 16.05<br />

01474 ANESTH, LOWER LEG SURGERY 5.00 16.05<br />

01480 ANESTH, LOWER LEG BONE SURG 3.00 16.05<br />

01482 ANESTH, RADICAL LEG SURGERY 4.00 16.05<br />

01484 ANESTH, LOWER LEG REVISION 4.00 16.05<br />

01486 ANESTH, ANKLE REPLACEMENT 7.00 16.05<br />

01490 ANESTH, LOWER LEG CASTING 3.00 16.05

---

01500 ANESTH, LEG ARTERIES SURG 8.00 16.05<br />

01502 ANESTH, LWR LEG EMBOLECTOMY 6.00 16.05<br />

01520 ANESTH, LOWER LEG VEIN SURG 3.00 16.05<br />

01522 ANESTH, LOWER LEG VEIN SURG 5.00 16.05<br />

01610 ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 5.00 16.05<br />

01620 ANESTH, SHOUL<strong>DE</strong>R PROCEDURE 4.00 16.05<br />

01622 ANES DX SHOUL<strong>DE</strong>R ARTHROSCOPY 4.00 16.05<br />

01630 ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 5.00 16.05<br />

01632 ANESTH, SURGERY OF SHOUL<strong>DE</strong>R 6.00 16.05<br />

01634 ANESTH, SHOUL<strong>DE</strong>R JOINT AMPUT 9.00 16.05<br />

01636 ANESTH, FOREQUARTER AMPUT 15.00 16.05<br />

01638 ANESTH, SHOUL<strong>DE</strong>R REPLACEMENT 10.00 16.05<br />

01650 ANESTH, SHOUL<strong>DE</strong>R ARTERY SURG 6.00 16.05<br />

01652 ANESTH, SHOUL<strong>DE</strong>R VESSEL SURG 10.00 16.05<br />

01654 ANESTH, SHOUL<strong>DE</strong>R VESSEL SURG 8.00 16.05<br />

01656 ANESTH, ARM-LEG VESSEL SURG 10.00 16.05<br />

01670 ANESTH, SHOUL<strong>DE</strong>R VEIN SURG 4.00 16.05<br />

01680 ANESTH, SHOUL<strong>DE</strong>R CASTING 3.00 16.05<br />

01682 ANESTH, AIRPLANE CAST 4.00 16.05<br />

01710 ANESTH, ELBOW AREA SURGERY 3.00 16.05<br />

01712 ANESTH, UPPR ARM TENDON SURG 5.00 16.05<br />

01714 ANESTH, UPPR ARM TENDON SURG 5.00 16.05<br />

01716 ANESTH, BICEPS TENDON REPAIR 5.00 16.05<br />

01730 ANESTH, UPPR ARM PROCEDURE 3.00 16.05<br />

01732 ANESTH, DX ELBOW ARTHROSCOPY 3.00 16.05<br />

01740 ANESTH, UPPER ARM SURGERY 4.00 16.05<br />

01742 ANESTH, HUMERUS SURGERY 5.00 16.05<br />

01744 ANESTH, HUMERUS REPAIR 5.00 16.05<br />

01756 ANESTH, RADICAL HUMERUS SURG 6.00 16.05<br />

01758 ANESTH, HUMERAL LESION SURG 5.00 16.05<br />

01760 ANESTH, ELBOW REPLACEMENT 7.00 16.05<br />

01770 ANESTH, UPPR ARM ARTERY SURG 6.00 16.05<br />

01772 ANESTH, UPPR ARM EMBOLECTOMY 6.00 16.05<br />

01780 ANESTH, UPPER ARM VEIN SURG 3.00 16.05<br />

01782 ANESTH, UPPR ARM VEIN REPAIR 4.00 16.05<br />

01810 ANESTH, LOWER ARM SURGERY 3.00 16.05<br />

01820 ANESTH, LOWER ARM PROCEDURE 3.00 16.05<br />

01829 ANESTH, DX WRIST ARTHROSCOPY 3.00 16.05<br />

01830 ANESTH, LOWER ARM SURGERY 3.00 16.05<br />

01832 ANESTH, WRIST REPLACEMENT 6.00 16.05<br />

01840 ANESTH, LWR ARM ARTERY SURG 6.00 16.05<br />

01842 ANESTH, LWR ARM EMBOLECTOMY 6.00 16.05<br />

01844 ANESTH, VASCULAR SHUNT SURG 6.00 16.05<br />

01850 ANESTH, LOWER ARM VEIN SURG 3.00 16.05<br />

01852 ANESTH, LWR ARM VEIN REPAIR 4.00 16.05<br />

01860 ANESTH, LOWER ARM CASTING 3.00 16.05<br />

01916 ANESTH, DX ARTERIOGRAPHY 6.00 16.05<br />

01920 ANESTH, CATHETERIZE HEART 7.00 16.05<br />

01922 ANESTH, CAT OR MRI SCAN 7.00 16.05<br />

01924 ANES, THER INTERVEN RAD, ART 6.00 16.05

---

01925 ANES, THER INTERVEN RAD, CAR 8.00 16.05<br />

01926 ANES, TX INTERV RAD HRT/CRAN 10.00 16.05<br />

01930 ANES, THER INTERVEN RAD, VEI 5.00 16.05<br />

01931 ANES, THER INTERVEN RAD, TIP 6.00 16.05<br />

01932 ANES, TX INTERV RAD, TH VEIN 8.00 16.05<br />

01933 ANES, TX INTERV RAD, CRAN V 10.00 16.05<br />

01935 ANESTH, PERC IMG DX SP PROC 5.00 16.05<br />

01936 ANESTH, PERC IMG TX SP PROC 5.00 16.05<br />

01951 ANESTH, BURN, LESS 4 PERCENT 3.00 16.05<br />

01952 ANESTH, BURN, 4-9 PERCENT 5.00 16.05<br />

01958 ANESTH, ANTEPARTUM MANIPUL 5.00 16.05<br />

01960 ANESTH, VAGINAL <strong>DE</strong>LIVERY 5.00 16.05<br />

01961 ANESTH, CS <strong>DE</strong>LIVERY 7.00 16.05<br />

01962 ANESTH, EMER HYSTERECTOMY 5.00 16.05<br />

01963 ANESTH, CS HYSTERECTOMY 8.00 16.05<br />

01965 ANESTH, INC/MISSED AB PROC 4.00 16.05<br />

01966 ANESTH, INDUCED AB PROCEDURE 4.00 16.05<br />

01967 ANESTH/ANALG, VAG <strong>DE</strong>LIVERY 5.00 16.05<br />

01968 ANES/ANALG CS <strong>DE</strong>LIVER ADD-ON 3.00 16.05<br />

01969 ANESTH/ANALG CS HYST ADD-ON 5.00 16.05<br />

01990 SUPPORT FOR ORGAN DONOR 7.00 16.05<br />

01991 ANESTH, NERVE BLOCK/INJ 3.00 16.05<br />

01992 ANESTH, N BLOCK/INJ, PRONE 5.00 16.05<br />

10040 ACNE SURGERY 2.12 1.00<br />

10060 DRAINAGE OF SKIN ABSCESS 2.32 1.00<br />

10061 DRAINAGE OF SKIN ABSCESS 4.18 1.00<br />

10080 DRAINAGE OF PILONIDAL CYST 2.41 1.00<br />

10081 DRAINAGE OF PILONIDAL CYST 4.18 1.00<br />

10120 REMOVE FOREIGN BODY 2.31 1.00<br />

10121 REMOVE FOREIGN BODY 4.76 1.00<br />

10140 DRAINAGE OF HEMATOMA/FLUID 3.03 1.00<br />

10160 PUNCTURE DRAINAGE OF LESION 2.44 1.00<br />

10180 COMPLEX DRAINAGE, WOUND 4.51 1.00<br />

11000 <strong>DE</strong>BRI<strong>DE</strong> INFECTED SKIN 0.86 1.00<br />

11001 <strong>DE</strong>BRI<strong>DE</strong> INFECTED SKIN ADD-ON 0.44 1.00<br />

11004 <strong>DE</strong>BRI<strong>DE</strong> GENITALIA & PERINEUM 15.02 1.00<br />

11005 <strong>DE</strong>BRI<strong>DE</strong> ABDOM WALL 19.87 1.00<br />

11006 <strong>DE</strong>BRI<strong>DE</strong> GENIT/PER/ABDOM WALL 18.78 1.00<br />

11008 REMOVE MESH FROM ABD WALL 7.27 1.00<br />

11010 <strong>DE</strong>BRI<strong>DE</strong> SKIN, FX 7.33 1.00<br />

11011 <strong>DE</strong>BRI<strong>DE</strong> SKIN/MUSCLE, FX 7.86 1.00<br />

11012 <strong>DE</strong>BRI<strong>DE</strong> SKIN/MUSCLE/BONE, FX 11.50 1.00<br />

11040 <strong>DE</strong>BRI<strong>DE</strong> SKIN, PARTIAL 0.74 1.00<br />

11041 <strong>DE</strong>BRI<strong>DE</strong> SKIN, FULL 0.96 1.00<br />

11042 <strong>DE</strong>BRI<strong>DE</strong> SKIN/TISSUE 1.27 1.00<br />

11043 <strong>DE</strong>BRI<strong>DE</strong> TISSUE/MUSCLE 5.96 1.00<br />

11044 <strong>DE</strong>BRI<strong>DE</strong> TISSUE/MUSCLE/BONE 8.21 1.00<br />

11055 TRIM SKIN LESION 0.62 1.00<br />

11056 TRIM SKIN LESIONS, 2 TO 4 0.87 1.00<br />

11057 TRIM SKIN LESIONS, OVER 4 1.14 1.00

---

11100 BIOPSY, SKIN LESION 1.22 1.00<br />

11101 BIOPSY, SKIN ADD-ON 0.62 1.00<br />

11200 REMOVAL OF SKIN TAGS 1.66 1.00<br />

11201 REMOVE SKIN TAGS ADD-ON 0.43 1.00<br />

11300 SHAVE SKIN LESION 0.75 1.00<br />

11301 SHAVE SKIN LESION 1.27 1.00<br />

11302 SHAVE SKIN LESION 1.57 1.00<br />

11303 SHAVE SKIN LESION 1.85 1.00<br />

11305 SHAVE SKIN LESION 0.98 1.00<br />

11306 SHAVE SKIN LESION 1.46 1.00<br />

11307 SHAVE SKIN LESION 1.69 1.00<br />

11308 SHAVE SKIN LESION 2.08 1.00<br />

11310 SHAVE SKIN LESION 1.09 1.00<br />

11311 SHAVE SKIN LESION 1.58 1.00<br />

11312 SHAVE SKIN LESION 1.81 1.00<br />

11313 SHAVE SKIN LESION 2.44 1.00<br />

11400 EXC TR-EXT B9+MARG 0.5 < CM 1.84 1.00<br />

11401 EXC TR-EXT B9+MARG 0.6-1 CM 2.44 1.00<br />

11402 EXC TR-EXT B9+MARG 1.1-2 CM 2.69 1.00<br />

11403 EXC TR-EXT B9+MARG 2.1-3 CM 3.42 1.00<br />

11404 EXC TR-EXT B9+MARG 3.1-4 CM 3.80 1.00<br />

11406 EXC TR-EXT B9+MARG > 4.0 CM 5.66 1.00<br />

11420 EXC H-F-NK-SP B9+MARG 0.5 < 2.02 1.00<br />

11421 EXC H-F-NK-SP B9+MARG 0.6-1 2.71 1.00<br />

11422 EXC H-F-NK-SP B9+MARG 1.1-2 3.24 1.00<br />

11423 EXC H-F-NK-SP B9+MARG 2.1-3 3.78 1.00<br />

11424 EXC H-F-NK-SP B9+MARG 3.1-4 4.39 1.00<br />

11426 EXC H-F-NK-SP B9+MARG > 4 CM 6.69 1.00<br />

11440 EXC FACE-MM B9+MARG 0.5 < CM 2.41 1.00<br />

11441 EXC FACE-MM B9+MARG 0.6-1 CM 3.15 1.00<br />

11442 EXC FACE-MM B9+MARG 1.1-2 CM 3.51 1.00<br />

11443 EXC FACE-MM B9+MARG 2.1-3 CM 4.36 1.00<br />

11444 EXC FACE-MM B9+MARG 3.1-4 CM 5.60 1.00<br />

11446 EXC FACE-MM B9+MARG > 4 CM 7.91 1.00<br />

11450 REMOVAL, SWEAT GLAND LESION 5.70 1.00<br />

11451 REMOVAL, SWEAT GLAND LESION 7.61 1.00<br />

11462 REMOVAL, SWEAT GLAND LESION 5.48 1.00<br />

11463 REMOVAL, SWEAT GLAND LESION 7.70 1.00<br />

11470 REMOVAL, SWEAT GLAND LESION 6.51 1.00<br />

11471 REMOVAL, SWEAT GLAND LESION 8.28 1.00<br />

11600 EXC TR-EXT MLG+MARG 0.5 < CM 2.73 1.00<br />

11601 EXC TR-EXT MLG+MARG 0.6-1 CM 3.50 1.00<br />

11602 EXC TR-EXT MLG+MARG 1.1-2 CM 3.81 1.00<br />

11603 EXC TR-EXT MLG+MARG 2.1-3 CM 4.53 1.00<br />

11604 EXC TR-EXT MLG+MARG 3.1-4 CM 4.98 1.00<br />

11606 EXC TR-EXT MLG+MARG > 4 CM 7.43 1.00<br />

11620 EXC H-F-NK-SP MLG+MARG 0.5 < 2.75 1.00<br />

11621 EXC H-F-NK-SP MLG+MARG 0.6-1 3.54 1.00<br />

11622 EXC H-F-NK-SP MLG+MARG 1.1-2 4.07 1.00<br />

11623 EXC H-F-NK-SP MLG+MARG 2.1-3 5.03 1.00

---

11624 EXC H-F-NK-SP MLG+MARG 3.1-4 5.77 1.00<br />

11626 EXC H-F-NK-SP MLG+MAR > 4 CM 7.37 1.00<br />

11640 EXC FACE-MM MALIG+MARG 0.5 < 2.93 1.00<br />

11641 EXC FACE-MM MALIG+MARG 0.6-1 3.85 1.00<br />

11642 EXC FACE-MM MALIG+MARG 1.1-2 4.54 1.00<br />

11643 EXC FACE-MM MALIG+MARG 2.1-3 5.67 1.00<br />

11644 EXC FACE-MM MALIG+MARG 3.1-4 7.12 1.00<br />

11646 EXC FACE-MM MLG+MARG > 4 CM 10.12 1.00<br />

11719 TRIM NAIL(S) 0.25 1.00<br />

11720 <strong>DE</strong>BRI<strong>DE</strong> NAIL, 1-5 0.46 1.00<br />

11721 <strong>DE</strong>BRI<strong>DE</strong> NAIL, 6 OR MORE 0.78 1.00<br />

11730 REMOVAL OF NAIL PLATE 1.60 1.00<br />

11732 REMOVE NAIL PLATE, ADD-ON 0.82 1.00<br />

11740 DRAIN BLOOD FROM UN<strong>DE</strong>R NAIL 0.80 1.00<br />

11750 REMOVAL OF NAIL BED 4.44 1.00<br />

11752 REMOVE NAIL BED/FINGER TIP 6.71 1.00<br />

11755 BIOPSY, NAIL UNIT 2.21 1.00<br />

11760 REPAIR OF NAIL BED 3.42 1.00<br />

11762 RECONSTRUCTION OF NAIL BED 5.28 1.00<br />

11765 EXCISION OF NAIL FOLD, TOE 1.67 1.00<br />

11770 REMOVAL OF PILONIDAL LESION 4.47 1.00<br />

11771 REMOVAL OF PILONIDAL LESION 10.22 1.00<br />

11772 REMOVAL OF PILONIDAL LESION 13.43 1.00<br />

11900 INJECTION INTO SKIN LESIONS 0.77 1.00<br />

11901 AD<strong>DE</strong>D SKIN LESIONS INJECTION 1.20 1.00<br />

11920 CORRECT SKIN COLOR <strong>DE</strong>FECTS 2.94 1.00<br />

11921 CORRECT SKIN COLOR <strong>DE</strong>FECTS 3.48 1.00<br />

11922 CORRECT SKIN COLOR <strong>DE</strong>FECTS 0.80 1.00<br />

11950 THERAPY FOR CONTOUR <strong>DE</strong>FECTS 1.27 1.00<br />

11951 THERAPY FOR CONTOUR <strong>DE</strong>FECTS 1.73 1.00<br />

11952 THERAPY FOR CONTOUR <strong>DE</strong>FECTS 2.57 1.00<br />

11954 THERAPY FOR CONTOUR <strong>DE</strong>FECTS 2.93 1.00<br />

11960 INSERT TISSUE EXPAN<strong>DE</strong>R(S) 22.81 1.00<br />

11970 REPLACE TISSUE EXPAN<strong>DE</strong>R 15.06 1.00<br />

11971 REMOVE TISSUE EXPAN<strong>DE</strong>R(S) 7.44 1.00<br />

11975 INSERT CONTRACEPTIVE CAP 2.10 1.00<br />

11976 REMOVAL OF CONTRACEPTIVE CAP 2.57 1.00<br />

11977 REMOVAL/REINSERT CONTRA CAP 4.68 1.00<br />

11980 IMPLANT HORMONE PELLET(S) 2.12 1.00<br />

11981 INSERT DRUG IMPLANT <strong>DE</strong>VICE 2.23 1.00<br />

11982 REMOVE DRUG IMPLANT <strong>DE</strong>VICE 2.71 1.00<br />

11983 REMOVE/INSERT DRUG IMPLANT 4.92 1.00<br />

12001 REPAIR SUPERFICIAL WOUND(S) 2.62 1.00<br />

12002 REPAIR SUPERFICIAL WOUND(S) 2.92 1.00<br />

12004 REPAIR SUPERFICIAL WOUND(S) 3.44 1.00<br />

12005 REPAIR SUPERFICIAL WOUND(S) 4.28 1.00<br />

12006 REPAIR SUPERFICIAL WOUND(S) 5.43 1.00<br />

12007 REPAIR SUPERFICIAL WOUND(S) 6.22 1.00<br />

12011 REPAIR SUPERFICIAL WOUND(S) 2.71 1.00<br />

12013 REPAIR SUPERFICIAL WOUND(S) 3.10 1.00

---

12014 REPAIR SUPERFICIAL WOUND(S) 3.73 1.00<br />

12015 REPAIR SUPERFICIAL WOUND(S) 4.68 1.00<br />

12016 REPAIR SUPERFICIAL WOUND(S) 5.71 1.00<br />

12017 REPAIR SUPERFICIAL WOUND(S) 6.90 1.00<br />

12018 REPAIR SUPERFICIAL WOUND(S) 8.27 1.00<br />

12020 CLOSURE OF SPLIT WOUND 4.78 1.00<br />

12021 CLOSURE OF SPLIT WOUND 3.47 1.00<br />

12031 INTMD WND REPAIR S/TR/EXT 3.71 1.00<br />

12032 INTMD WND REPAIR S/TR/EXT 4.69 1.00<br />

12034 INTMD WND REPAIR S/TR/EXT 4.91 1.00<br />

12035 INTMD WND REPAIR S/TR/EXT 5.96 1.00<br />

12036 INTMD WND REPAIR S/TR/EXT 7.00 1.00<br />

12037 INTMD WND REPAIR S/TR/EXT 8.14 1.00<br />

12041 INTMD WND REPAIR N-HF/GENIT 4.03 1.00<br />

12042 INTMD WND REPAIR N-HG/GENIT 4.72 1.00<br />

12044 INTMD WND REPAIR N-HG/GENIT 5.20 1.00<br />

12045 INTMD WND REPAIR N-HG/GENIT 6.23 1.00<br />

12046 INTMD WND REPAIR N-HG/GENIT 7.32 1.00<br />

12047 INTMD WND REPAIR N-HG/GENIT 8.11 1.00<br />

12051 INTMD WND REPAIR FACE/MM 4.38 1.00<br />

12052 INTMD WND REPAIR FACE/MM 4.98 1.00<br />

12053 INTMD WND REPAIR FACE/MM 5.20 1.00<br />

12054 INTMD WND REPAIR, FACE/MM 5.61 1.00<br />

12055 INTMD WND REPAIR FACE/MM 7.00 1.00<br />

12056 INTMD WND REPAIR FACE/MM 8.66 1.00<br />

12057 INTMD WND REPAIR FACE/MM 9.87 1.00<br />

13100 REPAIR OF WOUND OR LESION 5.79 1.00<br />

13101 REPAIR OF WOUND OR LESION 7.02 1.00<br />

13102 REPAIR WOUND/LESION ADD-ON 1.92 1.00<br />

13120 REPAIR OF WOUND OR LESION 6.04 1.00<br />

13121 REPAIR OF WOUND OR LESION 7.83 1.00<br />

13122 REPAIR WOUND/LESION ADD-ON 2.19 1.00<br />

13131 REPAIR OF WOUND OR LESION 6.84 1.00<br />

13132 REPAIR OF WOUND OR LESION 11.36 1.00<br />

13133 REPAIR WOUND/LESION ADD-ON 3.37 1.00<br />

13150 REPAIR OF WOUND OR LESION 6.90 1.00<br />

13151 REPAIR OF WOUND OR LESION 7.95 1.00<br />

13152 REPAIR OF WOUND OR LESION 10.72 1.00<br />

13153 REPAIR WOUND/LESION ADD-ON 3.70 1.00<br />

13160 LATE CLOSURE OF WOUND 20.47 1.00<br />

14000 SKIN TISSUE REARRANGEMENT 13.18 1.00<br />

14001 SKIN TISSUE REARRANGEMENT 17.70 1.00<br />

14020 SKIN TISSUE REARRANGEMENT 15.01 1.00<br />

14021 SKIN TISSUE REARRANGEMENT 20.46 1.00<br />

14040 SKIN TISSUE REARRANGEMENT 16.16 1.00<br />

14041 SKIN TISSUE REARRANGEMENT 22.41 1.00<br />

14060 SKIN TISSUE REARRANGEMENT 17.06 1.00<br />

14061 SKIN TISSUE REARRANGEMENT 24.27 1.00<br />

14300 SKIN TISSUE REARRANGEMENT 23.73 1.00<br />

14350 SKIN TISSUE REARRANGEMENT 19.18 1.00

---

15002 WOUND PREP, TRK/ARM/LEG 5.83 1.00<br />

15003 WOUND PREP, ADDL 100 CM 1.17 1.00<br />

15004 WOUND PREP, F/N/HF/G 7.22 1.00<br />

15005 WND PREP, F/N/HF/G, ADDL CM 2.35 1.00<br />

15040 HARVEST CULTURED SKIN GRAFT 3.33 1.00<br />

15050 SKIN PINCH GRAFT 11.00 1.00<br />

15100 SKIN SPLT GRFT, TRNK/ARM/LEG 18.27 1.00<br />

15101 SKIN SPLT GRFT T/A/L, ADD-ON 2.97 1.00<br />

15110 EPIDRM AUTOGRFT TRNK/ARM/LEG 18.87 1.00<br />

15111 EPIDRM AUTOGRFT T/A/L ADD-ON 2.81 1.00<br />

15115 EPIDRM A-GRFT FACE/NCK/HF/G 19.39 1.00<br />

15116 EPIDRM A-GRFT F/N/HF/G ADDL 3.82 1.00<br />

15120 SKN SPLT A-GRFT FAC/NCK/HF/G 19.74 1.00<br />

15121 SKN SPLT A-GRFT F/N/HF/G ADD 4.60 1.00<br />

15130 <strong>DE</strong>RM AUTOGRAFT, TRNK/ARM/LEG 14.34 1.00<br />

15131 <strong>DE</strong>RM AUTOGRAFT T/A/L ADD-ON 2.27 1.00<br />

15135 <strong>DE</strong>RM AUTOGRAFT FACE/NCK/HF/G 19.73 1.00<br />

15136 <strong>DE</strong>RM AUTOGRAFT, F/N/HF/G ADD 2.29 1.00<br />

15150 CULT EPI<strong>DE</strong>RM GRFT T/ARM/LEG 16.54 1.00<br />

15151 CULT EPI<strong>DE</strong>RM GRFT T/A/L ADDL 3.04 1.00<br />

15152 CULT EPI<strong>DE</strong>RM GRAFT T/A/L +% 3.80 1.00<br />

15155 CULT EPI<strong>DE</strong>RM GRAFT, F/N/HF/G 17.74 1.00<br />

15156 CULT EPIDRM GRFT F/N/HFG ADD 4.20 1.00<br />

15157 CULT EPI<strong>DE</strong>RM GRFT F/N/HFG +% 4.58 1.00<br />

15170 ACELL GRAFT TRUNK/ARMS/LEGS 9.02 1.00<br />

15171 ACELL GRAFT T/ARM/LEG ADD-ON 2.28 1.00<br />

15175 ACELLULAR GRAFT, F/N/HF/G 12.38 1.00<br />

15176 ACELL GRAFT, F/N/HF/G ADD-ON 3.63 1.00<br />

15200 SKIN FULL GRAFT, TRUNK 16.23 1.00<br />

15201 SKIN FULL GRAFT TRUNK ADD-ON 2.05 1.00<br />

15220 SKIN FULL GRAFT SCLP/ARM/LEG 15.48 1.00<br />

15221 SKIN FULL GRAFT ADD-ON 1.88 1.00<br />

15240 SKIN FULL GRFT FACE/GENIT/HF 19.50 1.00<br />

15241 SKIN FULL GRAFT ADD-ON 2.95 1.00<br />

15260 SKIN FULL GRAFT EEN & LIPS 21.04 1.00<br />

15261 SKIN FULL GRAFT ADD-ON 3.72 1.00<br />

15300 APPLY SKINALLOGRFT, T/ARM/LG 7.33 1.00<br />

15301 APPLY SKNALLOGRFT T/A/L ADDL 1.50 1.00<br />

15320 APPLY SKIN ALLOGRFT F/N/HF/G 8.39 1.00<br />

15321 APLY SKNALLOGRFT F/N/HFG ADD 2.26 1.00<br />

15330 APLY ACELL ALOGRFT T/ARM/LEG 6.66 1.00<br />

15331 APLY ACELL GRFT T/A/L ADD-ON 1.52 1.00<br />

15335 APPLY ACELL GRAFT, F/N/HF/G 7.28 1.00<br />

15336 APLY ACELL GRFT F/N/HF/G ADD 2.17 1.00<br />

15340 APPLY CULT SKIN SUBSTITUTE 6.87 1.00<br />

15341 APPLY CULT SKIN SUB ADD-ON 0.73 1.00<br />

15360 APPLY CULT <strong>DE</strong>RM SUB, T/A/L 7.67 1.00<br />

15361 APLY CULT <strong>DE</strong>RM SUB T/A/L ADD 1.68 1.00<br />

15365 APPLY CULT <strong>DE</strong>RM SUB F/N/HF/G 7.82 1.00<br />

15366 APPLY CULT <strong>DE</strong>RM F/HF/G ADD 2.15 1.00

---

15400 APPLY SKIN XENOGRAFT, T/A/L 8.74 1.00<br />

15401 APPLY SKN XENOGRFT T/A/L ADD 1.53 1.00<br />

15420 APPLY SKIN XGRAFT, F/N/HF/G 9.39 1.00<br />

15421 APPLY SKN XGRFT F/N/HF/G ADD 2.26 1.00<br />

15430 APPLY ACELLULAR XENOGRAFT 12.93 1.00<br />

15570 FORM SKIN PEDICLE FLAP 17.86 1.00<br />

15572 FORM SKIN PEDICLE FLAP 17.70 1.00<br />

15574 FORM SKIN PEDICLE FLAP 19.14 1.00<br />

15576 FORM SKIN PEDICLE FLAP 16.81 1.00<br />

15600 SKIN GRAFT 5.13 1.00<br />

15610 SKIN GRAFT 6.05 1.00<br />

15620 SKIN GRAFT 7.86 1.00<br />

15630 SKIN GRAFT 8.52 1.00<br />

15650 TRANSFER SKIN PEDICLE FLAP 9.36 1.00<br />

15731 FOREHEAD FLAP W/VASC PEDICLE 24.74 1.00<br />

15732 MUSCLE-SKIN GRAFT, HEAD/NECK 33.36 1.00<br />

15734 MUSCLE-SKIN GRAFT, TRUNK 34.36 1.00<br />

15736 MUSCLE-SKIN GRAFT, ARM 29.79 1.00<br />

15738 MUSCLE-SKIN GRAFT, LEG 32.54 1.00<br />

15740 ISLAND PEDICLE FLAP GRAFT 21.04 1.00<br />

15750 NEUROVASCULAR PEDICLE GRAFT 23.10 1.00<br />

15756 FREE MYO/SKIN FLAP MICROVASC 60.93 1.00<br />

15757 FREE SKIN FLAP, MICROVASC 60.59 1.00<br />

15758 FREE FASCIAL FLAP, MICROVASC 60.52 1.00<br />

15760 COMPOSITE SKIN GRAFT 17.69 1.00<br />

15770 <strong>DE</strong>RMA-FAT-FASCIA GRAFT 16.44 1.00<br />

15775 HAIR TRANSPLANT PUNCH GRAFTS 5.73 1.00<br />

15776 HAIR TRANSPLANT PUNCH GRAFTS 8.72 1.00<br />

15780 ABRASION TREATMENT OF SKIN 16.56 1.00<br />

15781 ABRASION TREATMENT OF SKIN 10.76 1.00<br />

15782 ABRASION TREATMENT OF SKIN 10.46 1.00<br />

15783 ABRASION TREATMENT OF SKIN 9.19 1.00<br />

15786 ABRASION, LESION, SINGLE 3.44 1.00<br />

15787 ABRASION, LESIONS, ADD-ON 0.49 1.00<br />

15819 PLASTIC SURGERY, NECK 18.35 1.00<br />

15820 REVISION OF LOWER EYELID 11.87 1.00<br />

15821 REVISION OF LOWER EYELID 12.61 1.00<br />

15822 REVISION OF UPPER EYELID 9.17 1.00<br />

15823 REVISION OF UPPER EYELID 14.89 1.00<br />

15830 EXC SKIN ABD 29.65 1.00<br />

15832 EXCISE EXCESSIVE SKIN TISSUE 22.62 1.00<br />

15833 EXCISE EXCESSIVE SKIN TISSUE 21.05 1.00<br />

15834 EXCISE EXCESSIVE SKIN TISSUE 21.51 1.00<br />

15835 EXCISE EXCESSIVE SKIN TISSUE 22.09 1.00<br />

15836 EXCISE EXCESSIVE SKIN TISSUE 18.56 1.00<br />

15837 EXCISE EXCESSIVE SKIN TISSUE 17.13 1.00<br />

15838 EXCISE EXCESSIVE SKIN TISSUE 14.41 1.00<br />

15839 EXCISE EXCESSIVE SKIN TISSUE 17.97 1.00<br />

15840 GRAFT FOR FACE NERVE PALSY 25.53 1.00<br />

15841 GRAFT FOR FACE NERVE PALSY 42.51 1.00

---

15842 FLAP FOR FACE NERVE PALSY 67.53 1.00<br />

15845 SKIN AND MUSCLE REPAIR, FACE 23.69 1.00<br />

15850 REMOVAL OF SUTURES 5.00 1.00<br />

15851 REMOVAL OF SUTURES 1.19 1.00<br />

15852 DRESSING CHANGE NOT FOR BURN 1.24 1.00<br />

15860 TEST FOR BLOOD FLOW IN GRAFT 2.93 1.00<br />

15920 REMOVAL OF TAIL BONE ULCER 14.64 1.00<br />

15922 REMOVAL OF TAIL BONE ULCER 18.84 1.00<br />

15931 REMOVE SACRUM PRESSURE SORE 16.84 1.00<br />

15933 REMOVE SACRUM PRESSURE SORE 20.70 1.00<br />

15934 REMOVE SACRUM PRESSURE SORE 23.21 1.00<br />

15935 REMOVE SACRUM PRESSURE SORE 27.43 1.00<br />

15936 REMOVE SACRUM PRESSURE SORE 22.63 1.00<br />

15937 REMOVE SACRUM PRESSURE SORE 26.45 1.00<br />

15940 REMOVE HIP PRESSURE SORE 17.41 1.00<br />

15941 REMOVE HIP PRESSURE SORE 22.84 1.00<br />

15944 REMOVE HIP PRESSURE SORE 22.29 1.00<br />

15945 REMOVE HIP PRESSURE SORE 24.65 1.00<br />

15946 REMOVE HIP PRESSURE SORE 41.01 1.00<br />

15950 REMOVE THIGH PRESSURE SORE 14.36 1.00<br />

15951 REMOVE THIGH PRESSURE SORE 20.50 1.00<br />

15952 REMOVE THIGH PRESSURE SORE 21.35 1.00<br />

15953 REMOVE THIGH PRESSURE SORE 23.81 1.00<br />

15956 REMOVE THIGH PRESSURE SORE 28.97 1.00<br />

15958 REMOVE THIGH PRESSURE SORE 29.55 1.00<br />

16000 INITIAL TREATMENT OF BURN(S) 1.22 1.00<br />

16020 DRESS/<strong>DE</strong>BRID P-THICK BURN, S 1.45 1.00<br />

16025 DRESS/<strong>DE</strong>BRID P-THICK BURN, M 2.95 1.00<br />

16030 DRESS/<strong>DE</strong>BRID P-THICK BURN, L 3.39 1.00<br />

16035 INCISION OF BURN SCAB, INITI 5.60 1.00<br />

16036 ESCHAROTOMY; ADDÏL INCISION 2.23 1.00<br />

17000 <strong>DE</strong>STRUCT PREMALG LESION 1.29 1.00<br />

17003 <strong>DE</strong>STRUCT PREMALG LES, 2-14 0.13 1.00<br />

17004 <strong>DE</strong>STROY PREMLG LESIONS 15+ 3.41 1.00<br />

17106 <strong>DE</strong>STRUCTION OF SKIN LESIONS 8.28 1.00<br />

17107 <strong>DE</strong>STRUCTION OF SKIN LESIONS 15.02 1.00<br />

17108 <strong>DE</strong>STRUCTION OF SKIN LESIONS 20.79 1.00<br />

17110 <strong>DE</strong>STRUCT B9 LESION, 1-14 1.51 1.00<br />

17111 <strong>DE</strong>STRUCT LESION, 15 OR MORE 1.95 1.00<br />

17250 CHEMICAL CAUTERY, TISSUE 0.92 1.00<br />

17260 <strong>DE</strong>STRUCTION OF SKIN LESIONS 1.66 1.00<br />

17261 <strong>DE</strong>STRUCTION OF SKIN LESIONS 2.19 1.00<br />

17262 <strong>DE</strong>STRUCTION OF SKIN LESIONS 2.81 1.00<br />

17263 <strong>DE</strong>STRUCTION OF SKIN LESIONS 3.11 1.00<br />

17264 <strong>DE</strong>STRUCTION OF SKIN LESIONS 3.32 1.00<br />

17266 <strong>DE</strong>STRUCTION OF SKIN LESIONS 3.85 1.00<br />

17270 <strong>DE</strong>STRUCTION OF SKIN LESIONS 2.37 1.00<br />

17271 <strong>DE</strong>STRUCTION OF SKIN LESIONS 2.67 1.00<br />

17272 <strong>DE</strong>STRUCTION OF SKIN LESIONS 3.10 1.00<br />

17273 <strong>DE</strong>STRUCTION OF SKIN LESIONS 3.50 1.00

---

17274 <strong>DE</strong>STRUCTION OF SKIN LESIONS 4.30 1.00<br />

17276 <strong>DE</strong>STRUCTION OF SKIN LESIONS 5.20 1.00<br />

17280 <strong>DE</strong>STRUCTION OF SKIN LESIONS 2.16 1.00<br />

17281 <strong>DE</strong>STRUCTION OF SKIN LESIONS 3.02 1.00<br />

17282 <strong>DE</strong>STRUCTION OF SKIN LESIONS 3.50 1.00<br />

17283 <strong>DE</strong>STRUCTION OF SKIN LESIONS 4.40 1.00<br />

17284 <strong>DE</strong>STRUCTION OF SKIN LESIONS 5.25 1.00<br />

17286 <strong>DE</strong>STRUCTION OF SKIN LESIONS 7.15 1.00<br />

17311 MOHS, 1 STAGE, H/N/HF/G 9.49 1.00<br />

17312 MOHS ADDL STAGE 5.05 1.00<br />

17313 MOHS, 1 STAGE, T/A/L 8.52 1.00<br />

17314 MOHS, ADDL STAGE, T/A/L 4.68 1.00<br />

17315 MOHS SURG, ADDL BLOCK 1.33 1.00<br />

17340 CRYOTHERAPY OF SKIN 1.18 1.00<br />

17360 SKIN PEEL THERAPY 2.44 1.00<br />

19000 DRAINAGE OF BREAST LESION 1.21 1.00<br />

19001 DRAIN BREAST LESION ADD-ON 0.60 1.00<br />

19020 INCISION OF BREAST LESION 7.05 1.00<br />

19030 INJECTION FOR BREAST X-RAY 2.14 1.00<br />

19100 BX BREAST PERCUT W/O IMAGE 1.80 1.00<br />

19101 BIOPSY OF BREAST, OPEN 5.44 1.00<br />

19102 BX BREAST PERCUT W/IMAGE 2.81 1.00<br />

19103 BX BREAST PERCUT W/<strong>DE</strong>VICE 5.20 1.00<br />

19105 CRYOSURG ABLATE FA, EACH 4.99 1.00<br />

19110 NIPPLE EXPLORATION 7.90 1.00<br />

19112 EXCISE BREAST DUCT FISTULA 7.11 1.00<br />

19120 REMOVAL OF BREAST LESION 9.78 1.00<br />

19125 EXCISION, BREAST LESION 10.86 1.00<br />

19126 EXCISION, ADDL BREAST LESION 4.18 1.00<br />

19260 REMOVAL OF CHEST WALL LESION 30.39 1.00<br />

19271 REVISION OF CHEST WALL 41.39 1.00<br />

19272 EXTENSIVE CHEST WALL SURGERY 45.77 1.00<br />

19290 PLACE NEEDLE WIRE, BREAST 1.77 1.00<br />

19291 PLACE NEEDLE WIRE, BREAST 0.88 1.00<br />

19295 PLACE BREAST CLIP, PERCUT 2.50 1.00<br />

19296 PLACE PO BREAST CATH FOR RAD 5.35 1.00<br />

19297 PLACE BREAST CATH FOR RAD 2.43 1.00<br />

19298 PLACE BREAST RAD TUBE/CATHS 8.69 1.00<br />

19301 PARTICAL MASTECTOMY 14.81 1.00<br />

19302 P-MASTECTOMY W/LN REMOVAL 21.92 1.00<br />

19303 MAST, SIMPLE, COMPLETE 22.86 1.00<br />

19304 MAST, SUBQ 13.70 1.00<br />

19305 MAST, RADICAL 27.20 1.00<br />

19306 MAST, RAD, URBAN TYPE 28.41 1.00<br />

19307 MAST, MOD RAD 28.57 1.00<br />

19316 SUSPENSION OF BREAST 19.85 1.00<br />

19318 REDUCTION OF LARGE BREAST 29.38 1.00<br />

19328 REMOVAL OF BREAST IMPLANT 12.27 1.00<br />

19330 REMOVAL OF IMPLANT MATERIAL 15.65 1.00<br />

19340 IMMEDIATE BREAST PROSTHESIS 10.34 1.00

---

19342 <strong>DE</strong>LAYED BREAST PROSTHESIS 23.17 1.00<br />

19350 BREAST RECONSTRUCTION 17.28 1.00<br />

19357 BREAST RECONSTRUCTION 39.02 1.00<br />

19361 BREAST RECONSTR W/LAT FLAP 40.72 1.00<br />

19364 BREAST RECONSTRUCTION 71.51 1.00<br />

19366 BREAST RECONSTRUCTION 35.70 1.00<br />

19367 BREAST RECONSTRUCTION 46.58 1.00<br />

19368 BREAST RECONSTRUCTION 57.63 1.00<br />

19369 BREAST RECONSTRUCTION 52.90 1.00<br />

19370 SURGERY OF BREAST CAPSULE 17.13 1.00<br />

19371 REMOVAL OF BREAST CAPSULE 19.80 1.00<br />

19380 REVISE BREAST RECONSTRUCTION 19.31 1.00<br />

19396 <strong>DE</strong>SIGN CUSTOM BREAST IMPLANT 3.61 1.00<br />

22900 REMOVE ABDOMINAL WALL LESION 10.28 1.00<br />

23000 REMOVAL OF CALCIUM <strong>DE</strong>POSITS 9.16 1.00<br />

23020 RELEASE SHOUL<strong>DE</strong>R JOINT 17.80 1.00<br />

23030 DRAIN SHOUL<strong>DE</strong>R LESION 6.66 1.00<br />

23031 DRAIN SHOUL<strong>DE</strong>R BURSA 5.69 1.00<br />

23035 DRAIN SHOUL<strong>DE</strong>R BONE LESION 17.87 1.00<br />

23040 EXPLORATORY SHOUL<strong>DE</strong>R SURGERY 18.54 1.00<br />

23044 EXPLORATORY SHOUL<strong>DE</strong>R SURGERY 14.70 1.00<br />

23065 BIOPSY SHOUL<strong>DE</strong>R TISSUES 4.16 1.00<br />

23066 BIOPSY SHOUL<strong>DE</strong>R TISSUES 8.64 1.00<br />

23075 REMOVAL OF SHOUL<strong>DE</strong>R LESION 4.50 1.00<br />

23076 REMOVAL OF SHOUL<strong>DE</strong>R LESION 14.34 1.00<br />

23077 REMOVE TUMOR OF SHOUL<strong>DE</strong>R 30.34 1.00<br />

23100 BIOPSY OF SHOUL<strong>DE</strong>R JOINT 12.46 1.00<br />

23101 SHOUL<strong>DE</strong>R JOINT SURGERY 11.53 1.00<br />

23105 REMOVE SHOUL<strong>DE</strong>R JOINT LINING 16.39 1.00<br />

23106 INCISION OF COLLARBONE JOINT 12.26 1.00<br />

23107 EXPLORE TREAT SHOUL<strong>DE</strong>R JOINT 17.07 1.00<br />

23120 PARTIAL REMOVAL, COLLAR BONE 14.43 1.00<br />

23125 REMOVAL OF COLLAR BONE 18.12 1.00<br />

23130 REMOVE SHOUL<strong>DE</strong>R BONE, PART 15.54 1.00<br />

23140 REMOVAL OF BONE LESION 13.16 1.00<br />

23145 REMOVAL OF BONE LESION 17.74 1.00<br />

23146 REMOVAL OF BONE LESION 15.83 1.00<br />

23150 REMOVAL OF HUMERUS LESION 16.70 1.00<br />

23155 REMOVAL OF HUMERUS LESION 20.32 1.00<br />

23156 REMOVAL OF HUMERUS LESION 17.33 1.00<br />

23170 REMOVE COLLAR BONE LESION 13.73 1.00<br />

23172 REMOVE SHOUL<strong>DE</strong>R BLA<strong>DE</strong> LESION 14.11 1.00<br />

23174 REMOVE HUMERUS LESION 19.32 1.00<br />

23180 REMOVE COLLAR BONE LESION 18.03 1.00<br />

23182 REMOVE SHOUL<strong>DE</strong>R BLA<strong>DE</strong> LESION 17.33 1.00<br />

23184 REMOVE HUMERUS LESION 19.51 1.00<br />

23190 PARTIAL REMOVAL OF SCAPULA 14.27 1.00<br />

23195 REMOVAL OF HEAD OF HUMERUS 19.28 1.00<br />

23200 REMOVAL OF COLLAR BONE 22.55 1.00<br />

23210 REMOVAL OF SHOUL<strong>DE</strong>R BLA<strong>DE</strong> 23.60 1.00

---

23220 PARTIAL REMOVAL OF HUMERUS 27.84 1.00<br />

23221 PARTIAL REMOVAL OF HUMERUS 32.64 1.00<br />

23222 PARTIAL REMOVAL OF HUMERUS 43.96 1.00<br />

23330 REMOVE SHOUL<strong>DE</strong>R FOREIGN BODY 3.81 1.00<br />

23331 REMOVE SHOUL<strong>DE</strong>R FOREIGN BODY 15.10 1.00<br />

23332 REMOVE SHOUL<strong>DE</strong>R FOREIGN BODY 22.91 1.00<br />

23350 INJECTION FOR SHOUL<strong>DE</strong>R X-RAY 1.40 1.00<br />

23395 MUSCLE TRANSFER,SHOUL<strong>DE</strong>R/ARM 33.27 1.00<br />

23397 MUSCLE TRANSFERS 29.83 1.00<br />

23400 FIXATION OF SHOUL<strong>DE</strong>R BLA<strong>DE</strong> 25.34 1.00<br />

23405 INCISION OF TENDON & MUSCLE 16.30 1.00<br />

23406 INCISE TENDON(S) & MUSCLE(S) 20.41 1.00<br />

23410 REPAIR ROTATOR CUFF, ACUTE 23.40 1.00<br />

23412 REPAIR ROTATOR CUFF, CHRONIC 24.90 1.00<br />

23415 RELEASE OF SHOUL<strong>DE</strong>R LIGAMENT 19.12 1.00<br />

23420 REPAIR OF SHOUL<strong>DE</strong>R 27.35 1.00<br />

23430 REPAIR BICEPS TENDON 19.23 1.00<br />

23440 REMOVE/TRANSPLANT TENDON 19.88 1.00<br />

23450 REPAIR SHOUL<strong>DE</strong>R CAPSULE 24.93 1.00<br />

23455 REPAIR SHOUL<strong>DE</strong>R CAPSULE 26.55 1.00<br />

23460 REPAIR SHOUL<strong>DE</strong>R CAPSULE 28.72 1.00<br />

23462 REPAIR SHOUL<strong>DE</strong>R CAPSULE 28.12 1.00<br />

23465 REPAIR SHOUL<strong>DE</strong>R CAPSULE 29.27 1.00<br />

23466 REPAIR SHOUL<strong>DE</strong>R CAPSULE 28.71 1.00<br />

23470 RECONSTRUCT SHOUL<strong>DE</strong>R JOINT 31.93 1.00<br />

23472 RECONSTRUCT SHOUL<strong>DE</strong>R JOINT 39.42 1.00<br />

23480 REVISION OF COLLAR BONE 21.41 1.00<br />

23485 REVISION OF COLLAR BONE 25.18 1.00<br />

23490 REINFORCE CLAVICLE 21.24 1.00<br />

23491 REINFORCE SHOUL<strong>DE</strong>R BONES 26.59 1.00<br />

23500 TREAT CLAVICLE FRACTURE 5.05 1.00<br />

23505 TREAT CLAVICLE FRACTURE 8.08 1.00<br />

23515 TREAT CLAVICLE FRACTURE 17.59 1.00<br />

23520 TREAT CLAVICLE DISLOCATION 5.34 1.00<br />

23525 TREAT CLAVICLE DISLOCATION 7.92 1.00<br />

23530 TREAT CLAVICLE DISLOCATION 14.19 1.00<br />

23532 TREAT CLAVICLE DISLOCATION 15.96 1.00<br />

23540 TREAT CLAVICLE DISLOCATION 5.12 1.00<br />

23545 TREAT CLAVICLE DISLOCATION 6.98 1.00<br />

23550 TREAT CLAVICLE DISLOCATION 14.69 1.00<br />

23552 TREAT CLAVICLE DISLOCATION 16.95 1.00<br />

23570 TREAT SHOUL<strong>DE</strong>R BLA<strong>DE</strong> FX 5.55 1.00<br />

23575 TREAT SHOUL<strong>DE</strong>R BLA<strong>DE</strong> FX 8.91 1.00<br />

23585 TREAT SCAPULA FRACTURE 23.69 1.00<br />

23600 TREAT HUMERUS FRACTURE 7.08 1.00<br />

23605 TREAT HUMERUS FRACTURE 10.63 1.00<br />

23615 TREAT HUMERUS FRACTURE 22.19 1.00<br />

23616 TREAT HUMERUS FRACTURE 34.19 1.00<br />

23620 TREAT HUMERUS FRACTURE 5.93 1.00<br />

23625 TREAT HUMERUS FRACTURE 8.76 1.00

---

23630 TREAT HUMERUS FRACTURE 18.66 1.00<br />

23650 TREAT SHOUL<strong>DE</strong>R DISLOCATION 6.53 1.00<br />

23655 TREAT SHOUL<strong>DE</strong>R DISLOCATION 9.49 1.00<br />

23660 TREAT SHOUL<strong>DE</strong>R DISLOCATION 14.88 1.00<br />

23665 TREAT DISLOCATION/FRACTURE 9.74 1.00<br />

23670 TREAT DISLOCATION/FRACTURE 20.86 1.00<br />

23675 TREAT DISLOCATION/FRACTURE 12.63 1.00<br />

23680 TREAT DISLOCATION/FRACTURE 22.92 1.00<br />

23700 FIXATION OF SHOUL<strong>DE</strong>R 5.02 1.00<br />

23800 FUSION OF SHOUL<strong>DE</strong>R JOINT 26.59 1.00<br />

23802 FUSION OF SHOUL<strong>DE</strong>R JOINT 31.58 1.00<br />

23900 AMPUTATION OF ARM & GIRDLE 34.83 1.00<br />

23920 AMPUTATION AT SHOUL<strong>DE</strong>R JOINT 28.08 1.00<br />

23921 AMPUTATION FOLLOW-UP SURGERY 11.36 1.00<br />

23930 DRAINAGE OF ARM LESION 5.54 1.00<br />

23931 DRAINAGE OF ARM BURSA 4.05 1.00<br />

23935 DRAIN ARM/ELBOW BONE LESION 12.83 1.00<br />

24000 EXPLORATORY ELBOW SURGERY 12.04 1.00<br />

24006 RELEASE ELBOW JOINT 18.30 1.00<br />

24065 BIOPSY ARM/ELBOW SOFT TISSUE 4.10 1.00<br />

24066 BIOPSY ARM/ELBOW SOFT TISSUE 10.09 1.00<br />

24075 REMOVE ARM/ELBOW LESION 7.85 1.00<br />

24076 REMOVE ARM/ELBOW LESION 12.03 1.00<br />

24077 REMOVE TUMOR OF ARM/ELBOW 20.98 1.00<br />

24100 BIOPSY ELBOW JOINT LINING 10.14 1.00<br />

24101 EXPLORE/TREAT ELBOW JOINT 12.71 1.00<br />

24102 REMOVE ELBOW JOINT LINING 15.82 1.00<br />

24105 REMOVAL OF ELBOW BURSA 8.49 1.00<br />

24110 REMOVE HUMERUS LESION 14.90 1.00<br />

24115 REMOVE/GRAFT BONE LESION 17.45 1.00<br />

24116 REMOVE/GRAFT BONE LESION 22.55 1.00<br />

24120 REMOVE ELBOW LESION 13.36 1.00<br />

24125 REMOVE/GRAFT BONE LESION 15.16 1.00<br />

24126 REMOVE/GRAFT BONE LESION 16.18 1.00<br />

24130 REMOVAL OF HEAD OF RADIUS 12.93 1.00<br />

24134 REMOVAL OF ARM BONE LESION 19.62 1.00<br />

24136 REMOVE RADIUS BONE LESION 16.17 1.00<br />

24138 REMOVE ELBOW BONE LESION 16.81 1.00<br />

24140 PARTIAL REMOVAL OF ARM BONE 18.78 1.00<br />

24145 PARTIAL REMOVAL OF RADIUS 15.80 1.00<br />

24147 PARTIAL REMOVAL OF ELBOW 16.43 1.00<br />

24149 RADICAL RESECTION OF ELBOW 29.47 1.00<br />

24150 EXTENSIVE HUMERUS SURGERY 25.28 1.00<br />

24151 EXTENSIVE HUMERUS SURGERY 29.29 1.00<br />

24152 EXTENSIVE RADIUS SURGERY 18.67 1.00<br />

24153 EXTENSIVE RADIUS SURGERY 17.69 1.00<br />

24155 REMOVAL OF ELBOW JOINT 21.81 1.00<br />

24160 REMOVE ELBOW JOINT IMPLANT 15.55 1.00<br />

24164 REMOVE RADIUS HEAD IMPLANT 12.71 1.00<br />

24200 REMOVAL OF ARM FOREIGN BODY 3.47 1.00

---

24201 REMOVAL OF ARM FOREIGN BODY 9.28 1.00<br />

24220 INJECTION FOR ELBOW X-RAY 1.84 1.00<br />

24300 MANIPULATE ELBOW W/ANESTH 9.95 1.00<br />

24301 MUSCLE/TENDON TRANSFER 19.43 1.00<br />

24305 ARM TENDON LENGTHENING 14.85 1.00<br />

24310 REVISION OF ARM TENDON 12.15 1.00<br />

24320 REPAIR OF ARM TENDON 19.76 1.00<br />

24330 REVISION OF ARM MUSCLES 18.53 1.00<br />

24331 REVISION OF ARM MUSCLES 20.43 1.00<br />

24332 TENOLYSIS, TRICEPS 15.35 1.00<br />

24340 REPAIR OF BICEPS TENDON 15.79 1.00<br />

24341 REPAIR ARM TENDON/MUSCLE 18.32 1.00<br />

24342 REPAIR OF RUPTURED TENDON 20.39 1.00<br />

24343 REPR ELBOW LAT LIGMNT W/TISS 17.99 1.00<br />

24344 RECONSTRUCT ELBOW LAT LIGMNT 28.08 1.00<br />

24345 REPR ELBW MED LIGMNT W/TISSU 17.91 1.00<br />

24346 RECONSTRUCT ELBOW MED LIGMNT 28.00 1.00<br />

24357 REPAIR ELBOW, PERC 11.34 1.00<br />

24358 REPAIR ELBOW W/<strong>DE</strong>B, OPEN 13.34 1.00<br />

24359 REPAIR ELBOW <strong>DE</strong>B/ATTCH OPEN 16.47 1.00<br />

24360 RECONSTRUCT ELBOW JOINT 23.25 1.00<br />

24361 RECONSTRUCT ELBOW JOINT 26.13 1.00<br />

24362 RECONSTRUCT ELBOW JOINT 25.68 1.00<br />

24363 REPLACE ELBOW JOINT 38.44 1.00<br />

24365 RECONSTRUCT HEAD OF RADIUS 16.51 1.00<br />

24366 RECONSTRUCT HEAD OF RADIUS 17.70 1.00<br />

24400 REVISION OF HUMERUS 21.30 1.00<br />

24410 REVISION OF HUMERUS 27.32 1.00<br />

24420 REVISION OF HUMERUS 25.29 1.00<br />

24430 REPAIR OF HUMERUS 26.78 1.00<br />

24435 REPAIR HUMERUS WITH GRAFT 27.37 1.00<br />

24470 REVISION OF ELBOW JOINT 16.98 1.00<br />

24495 <strong>DE</strong>COMPRESSION OF FOREARM 17.06 1.00<br />

24498 REINFORCE HUMERUS 22.70 1.00<br />

24500 TREAT HUMERUS FRACTURE 7.54 1.00<br />

24505 TREAT HUMERUS FRACTURE 11.28 1.00<br />

24515 TREAT HUMERUS FRACTURE 22.72 1.00<br />

24516 TREAT HUMERUS FRACTURE 22.48 1.00<br />

24530 TREAT HUMERUS FRACTURE 8.16 1.00<br />

24535 TREAT HUMERUS FRACTURE 14.38 1.00<br />

24538 TREAT HUMERUS FRACTURE 19.22 1.00<br />

24545 TREAT HUMERUS FRACTURE 23.19 1.00<br />

24546 TREAT HUMERUS FRACTURE 27.69 1.00<br />

24560 TREAT HUMERUS FRACTURE 6.62 1.00<br />

24565 TREAT HUMERUS FRACTURE 11.86 1.00<br />

24566 TREAT HUMERUS FRACTURE 17.64 1.00<br />

24575 TREAT HUMERUS FRACTURE 19.09 1.00<br />

24576 TREAT HUMERUS FRACTURE 7.11 1.00<br />

24577 TREAT HUMERUS FRACTURE 12.29 1.00<br />

24579 TREAT HUMERUS FRACTURE 21.58 1.00

---

24582 TREAT HUMERUS FRACTURE 20.02 1.00<br />

24586 TREAT ELBOW FRACTURE 28.57 1.00<br />

24587 TREAT ELBOW FRACTURE 28.35 1.00<br />

24600 TREAT ELBOW DISLOCATION 8.17 1.00<br />

24605 TREAT ELBOW DISLOCATION 11.53 1.00<br />

24615 TREAT ELBOW DISLOCATION 18.51 1.00<br />

24620 TREAT ELBOW FRACTURE 14.01 1.00<br />

24635 TREAT ELBOW FRACTURE 21.24 1.00<br />

24640 TREAT ELBOW DISLOCATION 2.15 1.00<br />

24650 TREAT RADIUS FRACTURE 5.44 1.00<br />

24655 TREAT RADIUS FRACTURE 9.78 1.00<br />

24665 TREAT RADIUS FRACTURE 16.64 1.00<br />

24666 TREAT RADIUS FRACTURE 18.87 1.00<br />

24670 TREAT ULNAR FRACTURE 6.12 1.00<br />

24675 TREAT ULNAR FRACTURE 10.37 1.00<br />

24685 TREAT ULNAR FRACTURE 16.75 1.00<br />

24800 FUSION OF ELBOW JOINT 20.72 1.00<br />

24802 FUSION/GRAFT OF ELBOW JOINT 25.77 1.00<br />

24900 AMPUTATION OF UPPER ARM 18.31 1.00<br />

24920 AMPUTATION OF UPPER ARM 18.12 1.00<br />

24925 AMPUTATION FOLLOW-UP SURGERY 13.85 1.00<br />

24930 AMPUTATION FOLLOW-UP SURGERY 19.12 1.00<br />

24931 AMPUTATE UPPER ARM & IMPLANT 20.62 1.00<br />

24935 REVISION OF AMPUTATION 27.69 1.00<br />

25000 INCISION OF TENDON SHEATH 9.42 1.00<br />

25001 INCISE FLEXOR CARPI RADIALIS 8.32 1.00<br />

25020 <strong>DE</strong>COMPRESS FOREARM 1 SPACE 15.16 1.00<br />

25023 <strong>DE</strong>COMPRESS FOREARM 1 SPACE 28.87 1.00<br />

25024 <strong>DE</strong>COMPRESS FOREARM 2 SPACES 19.26 1.00<br />

25025 <strong>DE</strong>COMPRESS FOREARM 2 SPACES 29.44 1.00<br />

25028 DRAINAGE OF FOREARM LESION 13.29 1.00<br />

25031 DRAINAGE OF FOREARM BURSA 10.52 1.00<br />

25035 TREAT FOREARM BONE LESION 18.39 1.00<br />

25040 EXPLORE/TREAT WRIST JOINT 14.91 1.00<br />

25065 BIOPSY FOREARM SOFT TISSUES 4.10 1.00<br />

25066 BIOPSY FOREARM SOFT TISSUES 10.27 1.00<br />

25075 REMOVAL FOREARM LESION SUBCU 8.93 1.00<br />

25076 REMOVAL FOREARM LESION <strong>DE</strong>EP 12.54 1.00<br />

25077 REMOVE TUMOR, FOREARM/WRIST 20.46 1.00<br />

25085 INCISION OF WRIST CAPSULE 12.27 1.00<br />

25100 BIOPSY OF WRIST JOINT 9.06 1.00<br />

25101 EXPLORE/TREAT WRIST JOINT 10.61 1.00<br />

25105 REMOVE WRIST JOINT LINING 12.97 1.00<br />

25107 REMOVE WRIST JOINT CARTILAGE 15.78 1.00<br />

25109 EXCISE TENDON FOREARM/WRIST 13.01 1.00<br />

25110 REMOVE WRIST TENDON LESION 9.92 1.00<br />

25111 REMOVE WRIST TENDON LESION 8.13 1.00<br />

25112 REREMOVE WRIST TENDON LESION 9.95 1.00<br />

25115 REMOVE WRIST/FOREARM LESION 21.89 1.00<br />

25116 REMOVE WRIST/FOREARM LESION 18.16 1.00

---

25118 EXCISE WRIST TENDON SHEATH 10.05 1.00<br />

25119 PARTIAL REMOVAL OF ULNA 13.39 1.00<br />

25120 REMOVAL OF FOREARM LESION 15.76 1.00<br />

25125 REMOVE/GRAFT FOREARM LESION 17.88 1.00<br />

25126 REMOVE/GRAFT FOREARM LESION 18.33 1.00<br />

25130 REMOVAL OF WRIST LESION 11.70 1.00<br />

25135 REMOVE & GRAFT WRIST LESION 14.55 1.00<br />

25136 REMOVE & GRAFT WRIST LESION 12.91 1.00<br />

25145 REMOVE FOREARM BONE LESION 16.08 1.00<br />

25150 PARTIAL REMOVAL OF ULNA 15.28 1.00<br />

25151 PARTIAL REMOVAL OF RADIUS 17.94 1.00<br />

25170 EXTENSIVE FOREARM SURGERY 24.38 1.00<br />

25210 REMOVAL OF WRIST BONE 12.81 1.00<br />

25215 REMOVAL OF WRIST BONES 16.61 1.00<br />

25230 PARTIAL REMOVAL OF RADIUS 11.39 1.00<br />

25240 PARTIAL REMOVAL OF ULNA 11.74 1.00<br />

25246 INJECTION FOR WRIST X-RAY 2.04 1.00<br />

25248 REMOVE FOREARM FOREIGN BODY 12.21 1.00<br />

25250 REMOVAL OF WRIST PROSTHESIS 13.36 1.00<br />

25251 REMOVAL OF WRIST PROSTHESIS 18.29 1.00<br />

25259 MANIPULATE WRIST W/ANESTHES 9.92 1.00<br />

25260 REPAIR FOREARM TENDON/MUSCLE 18.93 1.00<br />

25263 REPAIR FOREARM TENDON/MUSCLE 18.76 1.00<br />

25265 REPAIR FOREARM TENDON/MUSCLE 22.14 1.00<br />

25270 REPAIR FOREARM TENDON/MUSCLE 15.51 1.00<br />

25272 REPAIR FOREARM TENDON/MUSCLE 17.35 1.00<br />

25274 REPAIR FOREARM TENDON/MUSCLE 20.18 1.00<br />

25275 REPAIR FOREARM TENDON SHEATH 17.16 1.00<br />

25280 REVISE WRIST/FOREARM TENDON 17.46 1.00<br />

25290 INCISE WRIST/FOREARM TENDON 15.91 1.00<br />

25295 RELEASE WRIST/FOREARM TENDON 16.34 1.00<br />

25300 FUSION OF TENDONS AT WRIST 17.70 1.00<br />

25301 FUSION OF TENDONS AT WRIST 16.89 1.00<br />

25310 TRANSPLANT FOREARM TENDON 18.96 1.00<br />

25312 TRANSPLANT FOREARM TENDON 21.44 1.00<br />

25315 REVISE PALSY HAND TENDON(S) 22.90 1.00<br />

25316 REVISE PALSY HAND TENDON(S) 26.54 1.00<br />

25320 REPAIR/REVISE WRIST JOINT 24.62 1.00<br />

25332 REVISE WRIST JOINT 21.84 1.00<br />

25335 REALIGNMENT OF HAND 25.13 1.00<br />

25337 RECONSTRUCT ULNA/RADIOULNAR 22.91 1.00<br />

25350 REVISION OF RADIUS 20.60 1.00<br />

25355 REVISION OF RADIUS 22.83 1.00<br />

25360 REVISION OF ULNA 20.09 1.00<br />

25365 REVISE RADIUS & ULNA 26.85 1.00<br />

25370 REVISE RADIUS OR ULNA 28.77 1.00<br />

25375 REVISE RADIUS & ULNA 28.08 1.00<br />

25390 SHORTEN RADIUS OR ULNA 23.06 1.00<br />

25391 LENGTHEN RADIUS OR ULNA 28.98 1.00<br />

25392 SHORTEN RADIUS & ULNA 28.99 1.00

---

25393 LENGTHEN RADIUS & ULNA 32.77 1.00<br />

25394 REPAIR CARPAL BONE, SHORTEN 19.81 1.00<br />

25400 REPAIR RADIUS OR ULNA 24.22 1.00<br />

25405 REPAIR/GRAFT RADIUS OR ULNA 30.31 1.00<br />

25415 REPAIR RADIUS & ULNA 28.50 1.00<br />

25420 REPAIR/GRAFT RADIUS & ULNA 33.62 1.00<br />

25425 REPAIR/GRAFT RADIUS OR ULNA 30.61 1.00<br />

25426 REPAIR/GRAFT RADIUS & ULNA 31.74 1.00<br />

25430 VASC GRAFT INTO CARPAL BONE 18.03 1.00<br />

25431 REPAIR NONUNION CARPAL BONE 20.44 1.00<br />

25440 REPAIR/GRAFT WRIST BONE 20.34 1.00<br />

25441 RECONSTRUCT WRIST JOINT 24.29 1.00<br />

25442 RECONSTRUCT WRIST JOINT 20.71 1.00<br />

25443 RECONSTRUCT WRIST JOINT 19.89 1.00<br />

25444 RECONSTRUCT WRIST JOINT 21.24 1.00<br />

25445 RECONSTRUCT WRIST JOINT 18.66 1.00<br />

25446 WRIST REPLACEMENT 30.60 1.00<br />

25447 REPAIR WRIST JOINT(S) 20.83 1.00<br />

25449 REMOVE WRIST JOINT IMPLANT 26.84 1.00<br />

25450 REVISION OF WRIST JOINT 16.32 1.00<br />

25455 REVISION OF WRIST JOINT 19.39 1.00<br />

25490 REINFORCE RADIUS 21.20 1.00<br />

25491 REINFORCE ULNA 22.26 1.00<br />

25492 REINFORCE RADIUS AND ULNA 26.49 1.00<br />

25500 TREAT FRACTURE OF RADIUS 5.65 1.00<br />

25505 TREAT FRACTURE OF RADIUS 11.40 1.00<br />

25515 TREAT FRACTURE OF RADIUS 17.20 1.00<br />

25520 TREAT FRACTURE OF RADIUS 13.03 1.00<br />

25525 TREAT FRACTURE OF RADIUS 21.21 1.00<br />

25526 TREAT FRACTURE OF RADIUS 26.26 1.00<br />

25530 TREAT FRACTURE OF ULNA 5.41 1.00<br />

25535 TREAT FRACTURE OF ULNA 11.18 1.00<br />

25545 TREAT FRACTURE OF ULNA 16.26 1.00<br />

25560 TREAT FRACTURE RADIUS & ULNA 5.58 1.00<br />

25565 TREAT FRACTURE RADIUS & ULNA 11.82 1.00<br />

25574 TREAT FRACTURE RADIUS & ULNA 16.73 1.00<br />

25575 TREAT FRACTURE RADIUS/ULNA 22.86 1.00<br />

25600 TREAT FRACTURE RADIUS/ULNA 6.18 1.00<br />

25605 TREAT FRACTURE RADIUS/ULNA 14.20 1.00<br />

25606 TREAT FX DISTAL RADIAL 17.19 1.00<br />

25607 TREAT FX RAD EXTRA-ARTICUL 17.91 1.00<br />

25608 TREAT FX RAD INTRA-ARTICUL 20.50 1.00<br />

25609 TREAT FX RADIAL 3+ FRAG 26.16 1.00<br />

25622 TREAT WRIST BONE FRACTURE 6.32 1.00<br />

25624 TREAT WRIST BONE FRACTURE 10.30 1.00<br />

25628 TREAT WRIST BONE FRACTURE 18.22 1.00<br />

25630 TREAT WRIST BONE FRACTURE 6.49 1.00<br />

25635 TREAT WRIST BONE FRACTURE 9.33 1.00<br />

25645 TREAT WRIST BONE FRACTURE 14.61 1.00<br />

25650 TREAT WRIST BONE FRACTURE 6.88 1.00

---

25651 PIN ULNAR STYLOID FRACTURE 11.86 1.00<br />

25652 TREAT FRACTURE ULNAR STYLOID 15.71 1.00<br />

25660 TREAT WRIST DISLOCATION 9.94 1.00<br />

25670 TREAT WRIST DISLOCATION 15.67 1.00<br />

25671 PIN RADIOULNAR DISLOCATION 13.17 1.00<br />

25675 TREAT WRIST DISLOCATION 9.69 1.00<br />

25676 TREAT WRIST DISLOCATION 16.23 1.00<br />

25680 TREAT WRIST FRACTURE 11.42 1.00<br />

25685 TREAT WRIST FRACTURE 18.78 1.00<br />

25690 TREAT WRIST DISLOCATION 11.64 1.00<br />

25695 TREAT WRIST DISLOCATION 16.27 1.00<br />

25800 FUSION OF WRIST JOINT 19.47 1.00<br />

25805 FUSION/GRAFT OF WRIST JOINT 22.37 1.00<br />

25810 FUSION/GRAFT OF WRIST JOINT 22.41 1.00<br />

25820 FUSION OF HAND BONES 15.87 1.00<br />

25825 FUSE HAND BONES WITH GRAFT 19.40 1.00<br />

25830 FUSION, RADIOULNAR JNT/ULNA 24.74 1.00<br />

25900 AMPUTATION OF FOREARM 20.42 1.00<br />

25905 AMPUTATION OF FOREARM 20.07 1.00<br />

25907 AMPUTATION FOLLOW-UP SURGERY 17.85 1.00<br />

25909 AMPUTATION FOLLOW-UP SURGERY 19.95 1.00<br />

25915 AMPUTATION OF FOREARM 32.75 1.00<br />

25920 AMPUTATE HAND AT WRIST 17.49 1.00<br />

25922 AMPUTATE HAND AT WRIST 15.33 1.00<br />

25924 AMPUTATION FOLLOW-UP SURGERY 17.13 1.00<br />

25927 AMPUTATION OF HAND 20.42 1.00<br />

25929 AMPUTATION FOLLOW-UP SURGERY 14.62 1.00<br />

25931 AMPUTATION FOLLOW-UP SURGERY 18.98 1.00<br />

26010 DRAINAGE OF FINGER ABSCESS 3.31 1.00<br />

26011 DRAINAGE OF FINGER ABSCESS 4.68 1.00<br />

26020 DRAIN HAND TENDON SHEATH 10.75 1.00<br />

26025 DRAINAGE OF PALM BURSA 10.54 1.00<br />

26030 DRAINAGE OF PALM BURSA(S) 12.44 1.00<br />

26034 TREAT HAND BONE LESION 13.47 1.00<br />

26035 <strong>DE</strong>COMPRESS FINGERS/HAND 20.61 1.00<br />

26037 <strong>DE</strong>COMPRESS FINGERS/HAND 14.52 1.00<br />

26040 RELEASE PALM CONTRACTURE 7.74 1.00<br />

26045 RELEASE PALM CONTRACTURE 11.82 1.00<br />

26055 INCISE FINGER TENDON SHEATH 7.31 1.00<br />

26060 INCISION OF FINGER TENDON 6.58 1.00<br />

26070 EXPLORE/TREAT HAND JOINT 7.42 1.00<br />

26075 EXPLORE/TREAT FINGER JOINT 7.94 1.00<br />

26080 EXPLORE/TREAT FINGER JOINT 9.61 1.00<br />

26100 BIOPSY HAND JOINT LINING 8.15 1.00<br />

26105 BIOPSY FINGER JOINT LINING 8.30 1.00<br />

26110 BIOPSY FINGER JOINT LINING 7.93 1.00<br />

26115 REMOVAL HAND LESION SUBCUT 9.01 1.00<br />

26116 REMOVAL HAND LESION, <strong>DE</strong>EP 12.11 1.00<br />

26117 REMOVE TUMOR, HAND/FINGER 16.51 1.00<br />

26121 RELEASE PALM CONTRACTURE 15.23 1.00

---

26123 RELEASE PALM CONTRACTURE 20.60 1.00<br />

26125 RELEASE PALM CONTRACTURE 7.46 1.00<br />

26130 REMOVE WRIST JOINT LINING 11.54 1.00<br />

26135 REVISE FINGER JOINT, EACH 14.06 1.00<br />

26140 REVISE FINGER JOINT, EACH 12.76 1.00<br />

26145 TENDON EXCISION, PALM/FINGER 12.97 1.00<br />

26160 REMOVE TENDON SHEATH LESION 7.98 1.00<br />

26170 REMOVAL OF PALM TENDON, EACH 10.17 1.00<br />

26180 REMOVAL OF FINGER TENDON 11.08 1.00<br />

26185 REMOVE FINGER BONE 13.02 1.00<br />

26200 REMOVE HAND BONE LESION 11.40 1.00<br />

26205 REMOVE/GRAFT BONE LESION 15.39 1.00<br />

26210 REMOVAL OF FINGER LESION 11.08 1.00<br />

26215 REMOVE/GRAFT FINGER LESION 14.07 1.00<br />

26230 PARTIAL REMOVAL OF HAND BONE 12.82 1.00<br />

26235 PARTIAL REMOVAL, FINGER BONE 12.57 1.00<br />

26236 PARTIAL REMOVAL, FINGER BONE 11.13 1.00<br />

26250 EXTENSIVE HAND SURGERY 14.76 1.00<br />

26255 EXTENSIVE HAND SURGERY 23.32 1.00<br />

26260 EXTENSIVE FINGER SURGERY 13.93 1.00<br />

26261 EXTENSIVE FINGER SURGERY 16.87 1.00<br />

26262 PARTIAL REMOVAL OF FINGER 11.64 1.00<br />

26320 REMOVAL OF IMPLANT FROM HAND 8.66 1.00<br />

26340 MANIPULATE FINGER W/ANESTH 7.75 1.00<br />

26350 REPAIR FINGER/HAND TENDON 19.08 1.00<br />

26352 REPAIR/GRAFT HAND TENDON 21.60 1.00<br />

26356 REPAIR FINGER/HAND TENDON 27.48 1.00<br />

26357 REPAIR FINGER/HAND TENDON 22.98 1.00<br />

26358 REPAIR/GRAFT HAND TENDON 24.41 1.00<br />

26370 REPAIR FINGER/HAND TENDON 20.60 1.00<br />

26372 REPAIR/GRAFT HAND TENDON 23.83 1.00<br />

26373 REPAIR FINGER/HAND TENDON 22.63 1.00<br />

26390 REVISE HAND/FINGER TENDON 21.96 1.00<br />

26392 REPAIR/GRAFT HAND TENDON 25.90 1.00<br />

26410 REPAIR HAND TENDON 15.20 1.00<br />

26412 REPAIR/GRAFT HAND TENDON 18.29 1.00<br />

26415 EXCISION, HAND/FINGER TENDON 19.01 1.00<br />

26416 GRAFT HAND OR FINGER TENDON 22.06 1.00<br />

26418 REPAIR FINGER TENDON 15.24 1.00<br />

26420 REPAIR/GRAFT FINGER TENDON 19.12 1.00<br />

26426 REPAIR FINGER/HAND TENDON 16.30 1.00<br />

26428 REPAIR/GRAFT FINGER TENDON 19.94 1.00<br />

26432 REPAIR FINGER TENDON 13.24 1.00<br />

26433 REPAIR FINGER TENDON 14.24 1.00<br />

26434 REPAIR/GRAFT FINGER TENDON 16.82 1.00<br />

26437 REALIGNMENT OF TENDONS 16.46 1.00<br />

26440 RELEASE PALM/FINGER TENDON 16.79 1.00<br />

26442 RELEASE PALM & FINGER TENDON 24.59 1.00<br />

26445 RELEASE HAND/FINGER TENDON 15.70 1.00<br />

26449 RELEASE FOREARM/HAND TENDON 20.93 1.00

---

26450 INCISION OF PALM TENDON 10.56 1.00<br />

26455 INCISION OF FINGER TENDON 10.48 1.00<br />

26460 INCISE HAND/FINGER TENDON 10.18 1.00<br />

26471 FUSION OF FINGER TENDONS 16.19 1.00<br />

26474 FUSION OF FINGER TENDONS 15.64 1.00<br />

26476 TENDON LENGTHENING 15.18 1.00<br />

26477 TENDON SHORTENING 15.34 1.00<br />

26478 LENGTHENING OF HAND TENDON 16.57 1.00<br />

26479 SHORTENING OF HAND TENDON 16.37 1.00<br />

26480 TRANSPLANT HAND TENDON 20.14 1.00<br />

26483 TRANSPLANT/GRAFT HAND TENDON 22.49 1.00<br />

26485 TRANSPLANT PALM TENDON 21.65 1.00<br />

26489 TRANSPLANT/GRAFT PALM TENDON 22.45 1.00<br />

26490 REVISE THUMB TENDON 20.55 1.00<br />

26492 TENDON TRANSFER WITH GRAFT 22.82 1.00<br />

26494 HAND TENDON/MUSCLE TRANSFER 20.93 1.00<br />

26496 REVISE THUMB TENDON 22.52 1.00<br />

26497 FINGER TENDON TRANSFER 22.61 1.00<br />

26498 FINGER TENDON TRANSFER 30.10 1.00<br />

26499 REVISION OF FINGER 21.35 1.00<br />

26500 HAND TENDON RECONSTRUCTION 16.52 1.00<br />

26502 HAND TENDON RECONSTRUCTION 18.51 1.00<br />

26508 RELEASE THUMB CONTRACTURE 16.79 1.00<br />

26510 THUMB TENDON TRANSFER 15.77 1.00<br />

26516 FUSION OF KNUCKLE JOINT 18.59 1.00<br />

26517 FUSION OF KNUCKLE JOINTS 21.63 1.00<br />

26518 FUSION OF KNUCKLE JOINTS 21.68 1.00<br />

26520 RELEASE KNUCKLE CONTRACTURE 17.55 1.00<br />

26525 RELEASE FINGER CONTRACTURE 17.64 1.00<br />

26530 REVISE KNUCKLE JOINT 13.58 1.00<br />

26531 REVISE KNUCKLE WITH IMPLANT 15.81 1.00<br />

26535 REVISE FINGER JOINT 9.93 1.00<br />

26536 REVISE/IMPLANT FINGER JOINT 16.85 1.00<br />

26540 REPAIR HAND JOINT 17.45 1.00<br />

26541 REPAIR HAND JOINT WITH GRAFT 21.23 1.00<br />

26542 REPAIR HAND JOINT WITH GRAFT 17.98 1.00<br />

26545 RECONSTRUCT FINGER JOINT 18.34 1.00<br />

26546 REPAIR NONUNION HAND 25.21 1.00<br />

26548 RECONSTRUCT FINGER JOINT 20.13 1.00<br />

26550 CONSTRUCT THUMB REPLACEMENT 40.07 1.00<br />

26551 GREAT TOE-HAND TRANSFER 81.03 1.00<br />

26553 SINGLE TRANSFER, TOE-HAND 75.38 1.00<br />

26554 DOUBLE TRANSFER, TOE-HAND 102.86 1.00<br />

26555 POSITIONAL CHANGE OF FINGER 35.53 1.00<br />

26556 TOE JOINT TRANSFER 77.71 1.00<br />

26560 REPAIR OF WEB FINGER 14.51 1.00<br />

26561 REPAIR OF WEB FINGER 23.36 1.00<br />

26562 REPAIR OF WEB FINGER 31.60 1.00<br />

26565 CORRECT METACARPAL FLAW 17.88 1.00<br />

26567 CORRECT FINGER <strong>DE</strong>FORMITY 17.96 1.00

---

26568 LENGTHEN METACARPAL/FINGER 23.71 1.00<br />

26580 REPAIR HAND <strong>DE</strong>FORMITY 33.49 1.00<br />

26587 RECONSTRUCT EXTRA FINGER 24.51 1.00<br />

26590 REPAIR FINGER <strong>DE</strong>FORMITY 34.48 1.00<br />

26591 REPAIR MUSCLES OF HAND 11.70 1.00<br />

26593 RELEASE MUSCLES OF HAND 15.63 1.00<br />

26596 EXCISION CONSTRICTING TISSUE 18.61 1.00<br />

26600 TREAT METACARPAL FRACTURE 5.85 1.00<br />

26605 TREAT METACARPAL FRACTURE 6.99 1.00<br />

26607 TREAT METACARPAL FRACTURE 11.85 1.00<br />

26608 TREAT METACARPAL FRACTURE 12.05 1.00<br />

26615 TREAT METACARPAL FRACTURE 13.43 1.00<br />

26641 TREAT THUMB DISLOCATION 7.87 1.00<br />

26645 TREAT THUMB FRACTURE 9.20 1.00<br />

26650 TREAT THUMB FRACTURE 11.92 1.00<br />

26665 TREAT THUMB FRACTURE 15.15 1.00<br />

26670 TREAT HAND DISLOCATION 7.12 1.00<br />

26675 TREAT HAND DISLOCATION 9.97 1.00<br />

26676 PIN HAND DISLOCATION 12.64 1.00<br />

26685 TREAT HAND DISLOCATION 14.06 1.00<br />

26686 TREAT HAND DISLOCATION 15.79 1.00<br />

26700 TREAT KNUCKLE DISLOCATION 6.99 1.00<br />

26705 TREAT KNUCKLE DISLOCATION 9.09 1.00<br />

26706 PIN KNUCKLE DISLOCATION 10.90 1.00<br />

26715 TREAT KNUCKLE DISLOCATION 13.54 1.00<br />

26720 TREAT FINGER FRACTURE, EACH 4.12 1.00<br />

26725 TREAT FINGER FRACTURE, EACH 7.38 1.00<br />

26727 TREAT FINGER FRACTURE, EACH 11.85 1.00<br />

26735 TREAT FINGER FRACTURE, EACH 14.05 1.00<br />

26740 TREAT FINGER FRACTURE, EACH 5.01 1.00<br />

26742 TREAT FINGER FRACTURE, EACH 8.20 1.00<br />

26746 TREAT FINGER FRACTURE, EACH 16.88 1.00<br />

26750 TREAT FINGER FRACTURE, EACH 4.10 1.00<br />

26755 TREAT FINGER FRACTURE, EACH 6.54 1.00<br />

26756 PIN FINGER FRACTURE, EACH 10.46 1.00<br />

26765 TREAT FINGER FRACTURE, EACH 11.29 1.00<br />

26770 TREAT FINGER DISLOCATION 5.82 1.00<br />

26775 TREAT FINGER DISLOCATION 8.17 1.00<br />

26776 PIN FINGER DISLOCATION 11.14 1.00<br />

26785 TREAT FINGER DISLOCATION 12.27 1.00<br />

26820 THUMB FUSION WITH GRAFT 20.74 1.00<br />

26841 FUSION OF THUMB 19.39 1.00<br />

26842 THUMB FUSION WITH GRAFT 20.89 1.00<br />

26843 FUSION OF HAND JOINT 19.28 1.00<br />

26844 FUSION/GRAFT OF HAND JOINT 21.46 1.00<br />

26850 FUSION OF KNUCKLE 18.33 1.00<br />

26852 FUSION OF KNUCKLE WITH GRAFT 20.83 1.00<br />

26860 FUSION OF FINGER JOINT 14.86 1.00<br />

26861 FUSION OF FINGER JNT, ADD-ON 2.83 1.00<br />

26862 FUSION/GRAFT OF FINGER JOINT 19.05 1.00

---

26863 FUSE/GRAFT AD<strong>DE</strong>D JOINT 6.30 1.00<br />

26910 AMPUTATE METACARPAL BONE 18.58 1.00<br />

26951 AMPUTATION OF FINGER/THUMB 15.84 1.00<br />

26952 AMPUTATION OF FINGER/THUMB 17.11 1.00<br />

33010 DRAINAGE OF HEART SAC 3.29 1.00<br />

33011 REPEAT DRAINAGE OF HEART SAC 3.36 1.00<br />

33015 INCISION OF HEART SAC 14.14 1.00<br />

33020 INCISION OF HEART SAC 23.25 1.00<br />

33025 INCISION OF HEART SAC 21.56 1.00<br />

33030 PARTIAL REMOVAL OF HEART SAC 34.44 1.00<br />

33031 PARTIAL REMOVAL OF HEART SAC 38.25 1.00<br />

33050 REMOVAL OF HEART SAC LESION 26.61 1.00<br />

33120 REMOVAL OF HEART LESION 42.11 1.00<br />

33130 REMOVAL OF HEART LESION 36.81 1.00<br />

33140 HEART REVASCULARIZE (TMR) 41.72 1.00<br />

33141 HEART TMR W/OTHER PROCEDURE 4.41 1.00<br />

33202 INSERT EPICARD ELTRD, OPEN 20.94 1.00<br />

33203 INSERT EPICARD ELTRD, ENDO 21.44 1.00<br />

33206 INSERTION OF HEART PACEMAKER 12.62 1.00<br />

33207 INSERTION OF HEART PACEMAKER 13.53 1.00<br />

33208 INSERTION OF HEART PACEMAKER 14.49 1.00<br />

33210 INSERTION OF HEART ELECTRO<strong>DE</strong> 4.94 1.00<br />

33211 INSERTION OF HEART ELECTRO<strong>DE</strong> 5.05 1.00<br />

33212 INSERTION OF PULSE GENERATOR 9.47 1.00<br />

33213 INSERTION OF PULSE GENERATOR 10.78 1.00<br />

33214 UPGRA<strong>DE</strong> OF PACEMAKER SYSTEM 13.49 1.00<br />

33215 REPOSITION PACING-<strong>DE</strong>FIB LEAD 8.59 1.00<br />

33216 INSERT LEAD PACE-<strong>DE</strong>FIB, ONE 10.54 1.00<br />

33217 INSERT LEAD PACE-<strong>DE</strong>FIB, DUAL 10.50 1.00<br />

33218 REPAIR LEAD PACE-<strong>DE</strong>FIB, ONE 10.90 1.00<br />

33220 REPAIR LEAD PACE-<strong>DE</strong>FIB, DUAL 10.95 1.00<br />

33222 REVISE POCKET, PACEMAKER 9.73 1.00<br />

33223 REVISE POCKET, PACING-<strong>DE</strong>FIB 11.68 1.00<br />

33224 INSERT PACING LEAD & CONNECT 14.03 1.00<br />

33225 L VENTRIC PACING LEAD ADD-ON 12.58 1.00<br />

33226 REPOSITION L VENTRIC LEAD 13.55 1.00<br />

33233 REMOVAL OF PACEMAKER SYSTEM 6.82 1.00<br />

33234 REMOVAL OF PACEMAKER SYSTEM 13.61 1.00<br />

33235 REMOVAL PACEMAKER ELECTRO<strong>DE</strong> 17.69 1.00<br />

33236 REMOVE ELECTRO<strong>DE</strong>/THORACOTOMY 21.24 1.00<br />

33237 REMOVE ELECTRO<strong>DE</strong>/THORACOTOMY 23.24 1.00<br />

33238 REMOVE ELECTRO<strong>DE</strong>/THORACOTOMY 25.44 1.00<br />

33240 INSERT PULSE GENERATOR 12.94 1.00<br />

33241 REMOVE PULSE GENERATOR 6.42 1.00<br />

33243 REMOVE ELTRD/THORACOTOMY 36.72 1.00<br />

33244 REMOVE ELTRD, TRANSVEN 24.00 1.00<br />

33249 ELTRD/INSERT PACE-<strong>DE</strong>FIB 25.05 1.00<br />

33250 ABLATE HEART DYSRHYTHM FOCUS 39.93 1.00<br />

33251 ABLATE HEART DYSRHYTHM FOCUS 43.72 1.00<br />

33254 ABLATE ATRIA, LMTD 36.70 1.00

---

33255 ABLATE ATRIA W/O BYPASS, EXT 44.22 1.00<br />

33256 ABLATE ATRIA W/BYPASS, EXTEN 52.84 1.00<br />

33257 ABLATE ATRIA, LMTD, ADD-ON 15.99 1.00<br />

33258 ABLATE ATRIA, X10SV, ADD-ON 18.08 1.00<br />

33259 ABLATE ATRIA W/BYPASS ADD-ON 23.72 1.00<br />

33261 ABLATE HEART DYSRHYTHM FOCUS 43.99 1.00<br />

33265 ABLATE ATRIA, LMTD, ENDO 36.70 1.00<br />

33266 ABLATE ATRIA, X10SV, ENDO 50.28 1.00<br />

33282 IMPLANT PAT-ACTIVE HT RECORD 9.06 1.00<br />

33284 REMOVE PAT-ACTIVE HT RECORD 6.63 1.00<br />

33300 REPAIR OF HEART WOUND 59.70 1.00<br />

33305 REPAIR OF HEART WOUND 97.86 1.00<br />

33310 EXPLORATORY HEART SURGERY 31.78 1.00<br />

33315 EXPLORATORY HEART SURGERY 39.95 1.00<br />

33320 REPAIR MAJOR BLOOD VESSEL(S) 28.65 1.00<br />

33321 REPAIR MAJOR VESSEL 32.70 1.00<br />

33322 REPAIR MAJOR BLOOD VESSEL(S) 37.12 1.00<br />

33330 INSERT MAJOR VESSEL GRAFT 37.88 1.00<br />

33332 INSERT MAJOR VESSEL GRAFT 37.48 1.00<br />

33335 INSERT MAJOR VESSEL GRAFT 50.99 1.00<br />

33400 REPAIR OF AORTIC VALVE 60.61 1.00<br />

33401 VALVULOPLASTY, OPEN 39.87 1.00<br />

33403 VALVULOPLASTY, W/CP BYPASS 42.36 1.00<br />

33404 PREPARE HEART-AORTA CONDUIT 48.86 1.00<br />

33405 REPLACEMENT OF AORTIC VALVE 63.23 1.00<br />

33406 REPLACEMENT OF AORTIC VALVE 76.76 1.00<br />

33410 REPLACEMENT OF AORTIC VALVE 67.53 1.00<br />

33411 REPLACEMENT OF AORTIC VALVE 87.35 1.00<br />

33412 REPLACEMENT OF AORTIC VALVE 68.48 1.00<br />

33413 REPLACEMENT OF AORTIC VALVE 88.46 1.00<br />

33414 REPAIR OF AORTIC VALVE 58.07 1.00<br />

33415 REVISION, SUBVALVULAR TISSUE 53.92 1.00<br />

33416 REVISE VENTRICLE MUSCLE 54.38 1.00<br />

33417 REPAIR OF AORTIC VALVE 45.93 1.00<br />

33420 REVISION OF MITRAL VALVE 37.02 1.00<br />

33422 REVISION OF MITRAL VALVE 46.06 1.00<br />

33425 REPAIR OF MITRAL VALVE 69.24 1.00<br />

33426 REPAIR OF MITRAL VALVE 64.63 1.00<br />

33427 REPAIR OF MITRAL VALVE 68.33 1.00<br />

33430 REPLACEMENT OF MITRAL VALVE 73.78 1.00<br />

33460 REVISION OF TRICUSPID VALVE 61.08 1.00<br />

33463 VALVULOPLASTY, TRICUSPID 77.15 1.00<br />

33464 VALVULOPLASTY, TRICUSPID 63.33 1.00<br />

33465 REPLACE TRICUSPID VALVE 70.29 1.00<br />

33468 REVISION OF TRICUSPID VALVE 51.34 1.00<br />

33470 REVISION OF PULMONARY VALVE 31.66 1.00<br />

33471 VALVOTOMY, PULMONARY VALVE 36.90 1.00<br />

33472 REVISION OF PULMONARY VALVE 36.78 1.00<br />

33474 REVISION OF PULMONARY VALVE 54.41 1.00<br />

33475 REPLACEMENT, PULMONARY VALVE 62.42 1.00

---

33476 REVISION OF HEART CHAMBER 40.00 1.00<br />

33478 REVISION OF HEART CHAMBER 43.31 1.00<br />

33496 REPAIR, PROSTH VALVE CLOT 45.77 1.00<br />

33500 REPAIR HEART VESSEL FISTULA 42.94 1.00<br />

33501 REPAIR HEART VESSEL FISTULA 29.48 1.00<br />

33502 CORONARY ARTERY CORRECTION 34.90 1.00<br />

33503 CORONARY ARTERY GRAFT 35.10 1.00<br />

33504 CORONARY ARTERY GRAFT 39.86 1.00<br />

33505 REPAIR ARTERY W/TUNNEL 54.57 1.00<br />

33506 REPAIR ARTERY, TRANSLOCATION 56.10 1.00<br />

33507 REPAIR ART, INTRAMURAL 47.78 1.00<br />

33508 ENDOSCOPIC VEIN HARVEST 0.45 1.00<br />

33510 CABG, VEIN, SINGLE 53.91 1.00<br />

33511 CABG, VEIN, TWO 58.52 1.00<br />

33512 CABG, VEIN, THREE 65.32 1.00<br />

33513 CABG, VEIN, FOUR 67.23 1.00<br />

33514 CABG, VEIN, FIVE 70.45 1.00<br />

33516 CABG, VEIN, SIX OR MORE 73.17 1.00<br />

33517 CABG, ARTERY-VEIN, SINGLE 4.96 1.00<br />

33518 CABG, ARTERY-VEIN, TWO 10.63 1.00<br />

33519 CABG, ARTERY-VEIN, THREE 14.26 1.00<br />

33521 CABG, ARTERY-VEIN, FOUR 17.38 1.00<br />

33522 CABG, ARTERY-VEIN, FIVE 19.94 1.00<br />

33523 CABG, ART-VEIN, SIX OR MORE 22.87 1.00<br />

33530 CORONARY ARTERY, BYPASS/REOP 13.44 1.00<br />

33533 CABG, ARTERIAL, SINGLE 52.72 1.00<br />

33534 CABG, ARTERIAL, TWO 60.71 1.00<br />

33535 CABG, ARTERIAL, THREE 66.89 1.00<br />

33536 CABG, ARTERIAL, FOUR OR MORE 71.58 1.00<br />

33542 REMOVAL OF HEART LESION 67.41 1.00<br />

33545 REPAIR OF HEART DAMAGE 80.04 1.00<br />

33548 RESTORE/REMO<strong>DE</strong>L, VENTRICLE 78.82 1.00<br />

33572 OPEN CORONARY ENDARTERECTOMY 6.47 1.00<br />

33600 CLOSURE OF VALVE 46.91 1.00<br />

33602 CLOSURE OF VALVE 44.81 1.00<br />

33606 ANASTOMOSIS/ARTERY-AORTA 48.58 1.00<br />

33608 REPAIR ANOMALY W/CONDUIT 49.95 1.00<br />

33610 REPAIR BY ENLARGEMENT 49.38 1.00<br />

33611 REPAIR DOUBLE VENTRICLE 53.12 1.00<br />

33612 REPAIR DOUBLE VENTRICLE 56.53 1.00<br />

33615 REPAIR, MODIFIED FONTAN 53.56 1.00<br />

33617 REPAIR SINGLE VENTRICLE 59.60 1.00<br />

33619 REPAIR SINGLE VENTRICLE 74.46 1.00<br />

33641 REPAIR HEART SEPTUM <strong>DE</strong>FECT 42.97 1.00<br />

33645 REVISION OF HEART VEINS 43.00 1.00<br />

33647 REPAIR HEART SEPTUM <strong>DE</strong>FECTS 45.94 1.00<br />

33660 REPAIR OF HEART <strong>DE</strong>FECTS 48.90 1.00<br />

33665 REPAIR OF HEART <strong>DE</strong>FECTS 51.78 1.00<br />

33670 REPAIR OF HEART CHAMBERS 55.64 1.00<br />

33675 CLOSE MULT VSD 56.58 1.00

---

33676 CLOSE MULT VSD W/RESECTION 58.37 1.00<br />

33677 CL MULT VSD W/REM PUL BAND 60.68 1.00<br />

33681 REPAIR HEART SEPTUM <strong>DE</strong>FECT 50.40 1.00<br />

33684 REPAIR HEART SEPTUM <strong>DE</strong>FECT 51.14 1.00<br />

33688 REPAIR HEART SEPTUM <strong>DE</strong>FECT 50.45 1.00<br />

33690 REINFORCE PULMONARY ARTERY 31.57 1.00<br />

33692 REPAIR OF HEART <strong>DE</strong>FECTS 52.72 1.00<br />

33694 REPAIR OF HEART <strong>DE</strong>FECTS 52.91 1.00<br />

33697 REPAIR OF HEART <strong>DE</strong>FECTS 57.49 1.00<br />

33702 REPAIR OF HEART <strong>DE</strong>FECTS 42.34 1.00<br />

33710 REPAIR OF HEART <strong>DE</strong>FECTS 47.33 1.00<br />

33720 REPAIR OF HEART <strong>DE</strong>FECT 42.46 1.00<br />

33722 REPAIR OF HEART <strong>DE</strong>FECT 42.59 1.00<br />

33724 REPAIR VENOUS ANOMALY 41.93 1.00<br />

33726 REPAIR PUL VENOUS STENOSIS 55.30 1.00<br />

33730 REPAIR HEART-VEIN <strong>DE</strong>FECT(S) 54.54 1.00<br />

33732 REPAIR HEART-VEIN <strong>DE</strong>FECT 45.51 1.00<br />

33735 REVISION OF HEART CHAMBER 33.96 1.00<br />

33736 REVISION OF HEART CHAMBER 39.21 1.00<br />

33737 REVISION OF HEART CHAMBER 35.62 1.00<br />

33750 MAJOR VESSEL SHUNT 33.04 1.00<br />

33755 MAJOR VESSEL SHUNT 34.00 1.00<br />

33762 MAJOR VESSEL SHUNT 35.01 1.00<br />

33764 MAJOR VESSEL SHUNT & GRAFT 35.04 1.00<br />

33766 MAJOR VESSEL SHUNT 37.19 1.00<br />

33767 MAJOR VESSEL SHUNT 39.08 1.00<br />

33768 CAVOPULMONARY SHUNTING 11.44 1.00<br />

33770 REPAIR GREAT VESSELS <strong>DE</strong>FECT 58.06 1.00<br />

33771 REPAIR GREAT VESSELS <strong>DE</strong>FECT 59.00 1.00<br />

33774 REPAIR GREAT VESSELS <strong>DE</strong>FECT 49.79 1.00<br />

33775 REPAIR GREAT VESSELS <strong>DE</strong>FECT 50.37 1.00<br />

33776 REPAIR GREAT VESSELS <strong>DE</strong>FECT 52.65 1.00<br />

33777 REPAIR GREAT VESSELS <strong>DE</strong>FECT 52.22 1.00<br />

33778 REPAIR GREAT VESSELS <strong>DE</strong>FECT 64.74 1.00<br />

33779 REPAIR GREAT VESSELS <strong>DE</strong>FECT 59.99 1.00<br />

33780 REPAIR GREAT VESSELS <strong>DE</strong>FECT 63.65 1.00<br />

33781 REPAIR GREAT VESSELS <strong>DE</strong>FECT 61.36 1.00<br />

33786 REPAIR ARTERIAL TRUNK 62.86 1.00<br />

33788 REVISION OF PULMONARY ARTERY 41.39 1.00<br />

33800 AORTIC SUSPENSION 27.16 1.00<br />

33802 REPAIR VESSEL <strong>DE</strong>FECT 29.10 1.00<br />

33803 REPAIR VESSEL <strong>DE</strong>FECT 31.46 1.00<br />

33813 REPAIR SEPTAL <strong>DE</strong>FECT 34.23 1.00<br />

33814 REPAIR SEPTAL <strong>DE</strong>FECT 41.79 1.00<br />

33820 REVISE MAJOR VESSEL 26.62 1.00<br />

33822 REVISE MAJOR VESSEL 27.76 1.00<br />

33824 REVISE MAJOR VESSEL 32.21 1.00<br />

33840 REMOVE AORTA CONSTRICTION 33.19 1.00<br />

33845 REMOVE AORTA CONSTRICTION 36.36 1.00<br />

33851 REMOVE AORTA CONSTRICTION 34.81 1.00

---

33852 REPAIR SEPTAL <strong>DE</strong>FECT 39.51 1.00<br />

33853 REPAIR SEPTAL <strong>DE</strong>FECT 50.37 1.00<br />

33860 ASCENDING AORTIC GRAFT 83.43 1.00<br />

33861 ASCENDING AORTIC GRAFT 67.02 1.00<br />

33863 ASCENDING AORTIC GRAFT 84.45 1.00<br />

33864 ASCENDING AORTIC GRAFT 86.84 1.00<br />

33870 TRANSVERSE AORTIC ARCH GRAFT 69.89 1.00<br />

33875 THORACIC AORTIC GRAFT 54.08 1.00<br />

33877 THORACOABDOMINAL GRAFT 93.47 1.00<br />

33880 ENDOVASC TAA REPR INCL SUBCL 49.43 1.00<br />

33881 ENDOVASC TAA REPR W/O SUBCL 42.63 1.00<br />

33883 INSERT ENDOVASC PROSTH, TAA 31.31 1.00<br />

33884 ENDOVASC PROSTH, TAA, ADD-ON 11.39 1.00<br />

33886 ENDOVASC PROSTH, <strong>DE</strong>LAYED 27.08 1.00<br />

33889 ARTERY TRANSPOSE/ENDOVAS TAA 22.68 1.00<br />

33891 CAR-CAR BP GRFT/ENDOVAS TAA 29.12 1.00<br />

33910 REMOVE LUNG ARTERY EMBOLI 44.68 1.00<br />

33915 REMOVE LUNG ARTERY EMBOLI 35.65 1.00<br />

33916 SURGERY OF GREAT VESSEL 43.06 1.00<br />

33917 REPAIR PULMONARY ARTERY 39.96 1.00<br />

33920 REPAIR PULMONARY ATRESIA 48.61 1.00<br />

33922 TRANSECT PULMONARY ARTERY 37.77 1.00<br />

33924 REMOVE PULMONARY SHUNT 8.03 1.00<br />

33925 RPR PUL ART UNIFOCAL W/O CPB 51.42 1.00<br />

33926 REPR PUL ART, UNIFOCAL W/CPB 67.15 1.00<br />

33935 TRANSPLANTATION, HEART/LUNG 96.61 1.00<br />

33945 TRANSPLANTATION OF HEART 121.24 1.00<br />

33960 EXTERNAL CIRCULATION ASSIST 27.08 1.00<br />

33961 EXTERNAL CIRCULATION ASSIST 15.09 1.00<br />

33967 INSERT IA PERCUT <strong>DE</strong>VICE 7.32 1.00<br />

33968 REMOVE AORTIC ASSIST <strong>DE</strong>VICE 0.95 1.00<br />

33970 AORTIC CIRCULATION ASSIST 9.97 1.00<br />

33971 AORTIC CIRCULATION ASSIST 19.17 1.00<br />

33973 INSERT BALLOON <strong>DE</strong>VICE 14.64 1.00<br />

33974 REMOVE INTRA-AORTIC BALLOON 24.48 1.00<br />

33975 IMPLANT VENTRICULAR <strong>DE</strong>VICE 30.33 1.00<br />

33976 IMPLANT VENTRICULAR <strong>DE</strong>VICE 33.84 1.00<br />

33977 REMOVE VENTRICULAR <strong>DE</strong>VICE 33.13 1.00<br />

33978 REMOVE VENTRICULAR <strong>DE</strong>VICE 36.91 1.00<br />

33979 INSERT INTRACORPOREAL <strong>DE</strong>VICE 67.01 1.00<br />

33980 REMOVE INTRACORPOREAL <strong>DE</strong>VICE 97.62 1.00<br />

34001 REMOVAL OF ARTERY CLOT 26.17 1.00<br />

34051 REMOVAL OF ARTERY CLOT 26.73 1.00<br />

34101 REMOVAL OF ARTERY CLOT 17.09 1.00<br />

34111 REMOVAL OF ARM ARTERY CLOT 17.07 1.00<br />

34151 REMOVAL OF ARTERY CLOT 39.50 1.00<br />

34201 REMOVAL OF ARTERY CLOT 26.81 1.00<br />

34203 REMOVAL OF LEG ARTERY CLOT 27.31 1.00<br />

34401 REMOVAL OF VEIN CLOT 39.48 1.00<br />

34421 REMOVAL OF VEIN CLOT 20.59 1.00

---

34451 REMOVAL OF VEIN CLOT 42.67 1.00<br />

34471 REMOVAL OF VEIN CLOT 28.77 1.00<br />

34490 REMOVAL OF VEIN CLOT 17.13 1.00<br />

34501 REPAIR VALVE, FEMORAL VEIN 26.55 1.00<br />

34502 RECONSTRUCT VENA CAVA 42.88 1.00<br />

34510 TRANSPOSITION OF VEIN VALVE 30.60 1.00<br />

34520 CROSS-OVER VEIN GRAFT 29.08 1.00<br />

34530 LEG VEIN FUSION 27.20 1.00<br />

34800 ENDOVAS AAA REPR W/SM TUBE 32.13 1.00<br />

34802 ENDOVAS AAA REPR W/2-P PART 35.03 1.00<br />

34803 ENDOVAS AAA REPR W/3-P PART 35.87 1.00<br />

34804 ENDOVAS AAA REPR W/1-P PART 34.95 1.00<br />

34805 ENDOVAS AAA REPR W/LONG TUBE 33.06 1.00<br />

34806 ANEURYSM PRESS SENSOR ADD-ON 2.87 1.00<br />

34808 ENDOVAS ILIAC A <strong>DE</strong>VICE ADDON 5.92 1.00<br />

34812 XPOSE FOR ENDOPROSTH, FEMORL 9.87 1.00<br />

34813 FEMORAL ENDOVAS GRAFT ADD-ON 6.82 1.00<br />

34820 XPOSE FOR ENDOPROSTH, ILIAC 14.08 1.00<br />

34825 ENDOVASC EXTEND PROSTH, INIT 19.65 1.00<br />

34826 ENDOVASC EXTEN PROSTH, ADDÏL 5.81 1.00<br />

34830 OPEN AORTIC TUBE PROSTH REPR 51.67 1.00<br />

34831 OPEN AORTOILIAC PROSTH REPR 54.25 1.00<br />

34832 OPEN AORTOFEMOR PROSTH REPR 55.92 1.00<br />

34833 XPOSE FOR ENDOPROSTH, ILIAC 17.54 1.00<br />

34834 XPOSE, ENDOPROSTH, BRACHIAL 7.98 1.00<br />

34900 ENDOVASC ILIAC REPR W/GRAFT 25.59 1.00<br />

35001 REPAIR <strong>DE</strong>FECT OF ARTERY 32.14 1.00<br />

35002 REPAIR ARTERY RUPTURE, NECK 33.73 1.00<br />

35005 REPAIR <strong>DE</strong>FECT OF ARTERY 29.64 1.00<br />

35011 REPAIR <strong>DE</strong>FECT OF ARTERY 28.19 1.00<br />

35013 REPAIR ARTERY RUPTURE, ARM 34.92 1.00<br />

35021 REPAIR <strong>DE</strong>FECT OF ARTERY 33.90 1.00<br />

35022 REPAIR ARTERY RUPTURE, CHEST 39.01 1.00<br />

35045 REPAIR <strong>DE</strong>FECT OF ARM ARTERY 27.28 1.00<br />

35081 REPAIR <strong>DE</strong>FECT OF ARTERY 48.47 1.00<br />

35082 REPAIR ARTERY RUPTURE, AORTA 61.41 1.00<br />

35091 REPAIR <strong>DE</strong>FECT OF ARTERY 52.28 1.00<br />

35092 REPAIR ARTERY RUPTURE, AORTA 73.29 1.00<br />

35102 REPAIR <strong>DE</strong>FECT OF ARTERY 52.68 1.00<br />

35103 REPAIR ARTERY RUPTURE, GROIN 63.50 1.00<br />

35111 REPAIR <strong>DE</strong>FECT OF ARTERY 39.13 1.00<br />

35112 REPAIR ARTERY RUPTURE,SPLEEN 47.54 1.00<br />

35121 REPAIR <strong>DE</strong>FECT OF ARTERY 46.88 1.00<br />

35122 REPAIR ARTERY RUPTURE, BELLY 55.17 1.00<br />

35131 REPAIR <strong>DE</strong>FECT OF ARTERY 39.78 1.00<br />

35132 REPAIR ARTERY RUPTURE, GROIN 48.08 1.00<br />

35141 REPAIR <strong>DE</strong>FECT OF ARTERY 31.66 1.00<br />

35142 REPAIR ARTERY RUPTURE, THIGH 37.70 1.00<br />

35151 REPAIR <strong>DE</strong>FECT OF ARTERY 35.67 1.00<br />

35152 REPAIR ARTERY RUPTURE, KNEE 41.39 1.00

---

35180 REPAIR BLOOD VESSEL LESION 22.61 1.00<br />

35182 REPAIR BLOOD VESSEL LESION 47.76 1.00<br />

35184 REPAIR BLOOD VESSEL LESION 28.65 1.00<br />

35188 REPAIR BLOOD VESSEL LESION 24.17 1.00<br />

35189 REPAIR BLOOD VESSEL LESION 45.18 1.00<br />

35190 REPAIR BLOOD VESSEL LESION 20.99 1.00<br />

35201 REPAIR BLOOD VESSEL LESION 26.34 1.00<br />

35206 REPAIR BLOOD VESSEL LESION 21.56 1.00<br />

35207 REPAIR BLOOD VESSEL LESION 19.33 1.00<br />

35211 REPAIR BLOOD VESSEL LESION 37.87 1.00<br />

35216 REPAIR BLOOD VESSEL LESION 50.40 1.00<br />

35221 REPAIR BLOOD VESSEL LESION 39.05 1.00<br />

35226 REPAIR BLOOD VESSEL LESION 23.86 1.00<br />

35231 REPAIR BLOOD VESSEL LESION 32.72 1.00<br />

35236 REPAIR BLOOD VESSEL LESION 27.46 1.00<br />

35241 REPAIR BLOOD VESSEL LESION 39.61 1.00<br />

35246 REPAIR BLOOD VESSEL LESION 42.78 1.00<br />

35251 REPAIR BLOOD VESSEL LESION 46.59 1.00<br />

35256 REPAIR BLOOD VESSEL LESION 28.97 1.00<br />

35261 REPAIR BLOOD VESSEL LESION 28.99 1.00<br />

35266 REPAIR BLOOD VESSEL LESION 24.09 1.00<br />

35271 REPAIR BLOOD VESSEL LESION 37.76 1.00<br />

35276 REPAIR BLOOD VESSEL LESION 39.71 1.00<br />

35281 REPAIR BLOOD VESSEL LESION 44.40 1.00<br />

35286 REPAIR BLOOD VESSEL LESION 26.59 1.00<br />

35301 RECHANNELING OF ARTERY 29.77 1.00<br />

35302 RECHANNELING OF ARTERY 31.16 1.00<br />

35303 RECHANNELING OF ARTERY 34.24 1.00<br />

35304 RECHANNELING OF ARTERY 35.64 1.00<br />

35305 RECHANNELING OF ARTERY 34.24 1.00<br />

35306 RECHANNELING OF ARTERY 12.87 1.00<br />

35311 RECHANNELING OF ARTERY 42.63 1.00<br />

35321 RECHANNELING OF ARTERY 25.34 1.00<br />

35331 RECHANNELING OF ARTERY 41.47 1.00<br />

35341 RECHANNELING OF ARTERY 39.44 1.00<br />

35351 RECHANNELING OF ARTERY 36.50 1.00<br />

35355 RECHANNELING OF ARTERY 29.67 1.00<br />

35361 RECHANNELING OF ARTERY 44.91 1.00<br />

35363 RECHANNELING OF ARTERY 48.07 1.00<br />

35371 RECHANNELING OF ARTERY 23.51 1.00<br />

35372 RECHANNELING OF ARTERY 28.22 1.00<br />

35390 REOPERATION, CAROTID ADD-ON 4.59 1.00<br />

35400 ANGIOSCOPY 4.34 1.00<br />

35450 REPAIR ARTERIAL BLOCKAGE 14.57 1.00<br />

35452 REPAIR ARTERIAL BLOCKAGE 10.17 1.00<br />

35454 REPAIR ARTERIAL BLOCKAGE 8.94 1.00<br />

35456 REPAIR ARTERIAL BLOCKAGE 10.82 1.00<br />

35458 REPAIR ARTERIAL BLOCKAGE 13.88 1.00<br />

35459 REPAIR ARTERIAL BLOCKAGE 12.74 1.00<br />

35460 REPAIR VENOUS BLOCKAGE 8.87 1.00

---

35470 REPAIR ARTERIAL BLOCKAGE 12.71 1.00<br />

35471 REPAIR ARTERIAL BLOCKAGE 15.04 1.00<br />

35472 REPAIR ARTERIAL BLOCKAGE 10.24 1.00<br />

35473 REPAIR ARTERIAL BLOCKAGE 9.00 1.00<br />

35474 REPAIR ARTERIAL BLOCKAGE 10.86 1.00<br />

35475 REPAIR ARTERIAL BLOCKAGE 13.57 1.00<br />

35476 REPAIR VENOUS BLOCKAGE 8.66 1.00<br />

35480 ATHERECTOMY, OPEN 16.38 1.00<br />

35481 ATHERECTOMY, OPEN 11.45 1.00<br />

35482 ATHERECTOMY, OPEN 9.82 1.00<br />

35483 ATHERECTOMY, OPEN 12.03 1.00<br />

35484 ATHERECTOMY, OPEN 15.03 1.00<br />

35485 ATHERECTOMY, OPEN 14.03 1.00<br />

35490 ATHERECTOMY, PERCUTANEOUS 16.71 1.00<br />

35491 ATHERECTOMY, PERCUTANEOUS 11.91 1.00<br />

35492 ATHERECTOMY, PERCUTANEOUS 10.41 1.00<br />

35493 ATHERECTOMY, PERCUTANEOUS 12.53 1.00<br />

35494 ATHERECTOMY, PERCUTANEOUS 15.82 1.00<br />

35495 ATHERECTOMY, PERCUTANEOUS 14.59 1.00<br />

35500 HARVEST VEIN FOR BYPASS 9.18 1.00<br />

35501 ARTERY BYPASS GRAFT 42.86 1.00<br />

35506 ARTERY BYPASS GRAFT 36.99 1.00<br />

35508 ARTERY BYPASS GRAFT 37.88 1.00<br />

35509 ARTERY BYPASS GRAFT 41.69 1.00<br />

35510 ARTERY BYPASS GRAFT 35.35 1.00<br />

35511 ARTERY BYPASS GRAFT 33.54 1.00<br />

35512 ARTERY BYPASS GRAFT 34.65 1.00<br />

35515 ARTERY BYPASS GRAFT 37.96 1.00<br />

35516 ARTERY BYPASS GRAFT 33.58 1.00<br />

35518 ARTERY BYPASS GRAFT 33.75 1.00<br />

35521 ARTERY BYPASS GRAFT 36.02 1.00<br />

35522 ARTERY BYPASS GRAFT 33.75 1.00<br />

35523 ARTERY BYPASS GRAFT 35.36 1.00<br />

35525 ARTERY BYPASS GRAFT 31.92 1.00<br />

35526 ARTERY BYPASS GRAFT 48.38 1.00<br />

35531 ARTERY BYPASS GRAFT 57.14 1.00<br />

35533 ARTERY BYPASS GRAFT 44.25 1.00<br />

35536 ARTERY BYPASS GRAFT 49.45 1.00<br />

35537 ARTERY BYPASS GRAFT 60.57 1.00<br />

35538 ARTERY BYPASS GRAFT 67.66 1.00<br />

35539 ARTERY BYPASS GRAFT 63.47 1.00<br />

35540 ARTERY BYPASS GRAFT 70.78 1.00<br />

35548 ARTERY BYPASS GRAFT 34.13 1.00<br />

35549 ARTERY BYPASS GRAFT 37.20 1.00<br />

35551 ARTERY BYPASS GRAFT 41.91 1.00<br />

35556 ARTERY BYPASS GRAFT 38.90 1.00<br />

35558 ARTERY BYPASS GRAFT 34.71 1.00<br />

35560 ARTERY BYPASS GRAFT 50.62 1.00<br />

35563 ARTERY BYPASS GRAFT 39.21 1.00<br />

35565 ARTERY BYPASS GRAFT 37.45 1.00

---

35566 ARTERY BYPASS GRAFT 46.67 1.00<br />

35571 ARTERY BYPASS GRAFT 38.29 1.00<br />

35572 HARVEST FEMOROPOPLITEAL VEIN 9.88 1.00<br />

35583 VEIN BYPASS GRAFT 40.19 1.00<br />

35585 VEIN BYPASS GRAFT 47.41 1.00<br />

35587 VEIN BYPASS GRAFT 39.58 1.00<br />

35600 HARVEST ART FOR CABG ADD-ON 7.24 1.00<br />

35601 ARTERY BYPASS GRAFT 40.24 1.00<br />

35606 ARTERY BYPASS GRAFT 33.22 1.00<br />

35612 ARTERY BYPASS GRAFT 25.90 1.00<br />

35616 ARTERY BYPASS GRAFT 31.56 1.00<br />

35621 ARTERY BYPASS GRAFT 31.60 1.00<br />

35623 BYPASS GRAFT, NOT VEIN 38.72 1.00<br />

35626 ARTERY BYPASS GRAFT 44.27 1.00<br />

35631 ARTERY BYPASS GRAFT 53.06 1.00<br />

35636 ARTERY BYPASS GRAFT 46.73 1.00<br />

35637 BYPASS GRAFT, WITH OTHER THAN VEIN 48.01 1.00<br />

35638 BYPASS GRAFT, WITH OTHER THAN VEIN 48.78 1.00<br />

35642 ARTERY BYPASS GRAFT 28.58 1.00<br />

35645 ARTERY BYPASS GRAFT 28.97 1.00<br />

35646 ARTERY BYPASS GRAFT 49.06 1.00<br />

35647 ARTERY BYPASS GRAFT 44.33 1.00<br />

35650 ARTERY BYPASS GRAFT 30.45 1.00<br />

35651 ARTERY BYPASS GRAFT 39.05 1.00<br />

35654 ARTERY BYPASS GRAFT 39.21 1.00<br />

35656 ARTERY BYPASS GRAFT 30.91 1.00<br />

35661 ARTERY BYPASS GRAFT 30.93 1.00<br />

35663 ARTERY BYPASS GRAFT 35.85 1.00<br />

35665 ARTERY BYPASS GRAFT 33.64 1.00<br />

35666 ARTERY BYPASS GRAFT 36.27 1.00<br />

35671 ARTERY BYPASS GRAFT 31.92 1.00<br />

35681 COMPOSITE BYPASS GRAFT 2.30 1.00<br />

35682 COMPOSITE BYPASS GRAFT 10.26 1.00<br />

35683 COMPOSITE BYPASS GRAFT 12.08 1.00<br />

35685 BYPASS GRAFT PATENCY/PATCH 5.77 1.00<br />

35686 BYPASS GRAFT/AV FIST PATENCY 4.80 1.00<br />

35691 ARTERIAL TRANSPOSITION 28.09 1.00<br />

35693 ARTERIAL TRANSPOSITION 24.78 1.00<br />

35694 ARTERIAL TRANSPOSITION 29.35 1.00<br />

35695 ARTERIAL TRANSPOSITION 30.34 1.00<br />

35697 REIMPLANT ARTERY EACH 4.29 1.00<br />

35700 REOPERATION, BYPASS GRAFT 4.41 1.00<br />

35701 EXPLORATION, CAROTID ARTERY 14.96 1.00<br />

35721 EXPLORATION, FEMORAL ARTERY 12.82 1.00<br />

35741 EXPLORATION POPLITEAL ARTERY 13.99 1.00<br />

35761 EXPLORATION OF ARTERY/VEIN 10.31 1.00<br />

35800 EXPLORE NECK VESSELS 13.24 1.00<br />

35820 EXPLORE CHEST VESSELS 48.82 1.00<br />

35840 EXPLORE ABDOMINAL VESSELS 17.26 1.00<br />

35860 EXPLORE LIMB VESSELS 11.21 1.00

---

35870 REPAIR VESSEL GRAFT <strong>DE</strong>FECT 36.25 1.00<br />

35875 REMOVAL OF CLOT IN GRAFT 16.79 1.00<br />

35876 REMOVAL OF CLOT IN GRAFT 26.87 1.00<br />

35879 REVISE GRAFT W/VEIN 26.39 1.00<br />

35881 REVISE GRAFT W/VEIN 29.35 1.00<br />

35883 REVISE GRAFT W/NONAUTO GRAFT 34.76 1.00<br />

35884 REVISE GRAFT W/VEIN 36.92 1.00<br />

35901 EXCISION, GRAFT, NECK 14.18 1.00<br />

35903 EXCISION, GRAFT, EXTREMITY 16.12 1.00<br />

35905 EXCISION, GRAFT, THORAX 49.75 1.00<br />

35907 EXCISION, GRAFT, ABDOMEN 54.59 1.00<br />

36000 PLACE NEEDLE IN VEIN 0.25 1.00<br />

36002 PSEUDOANEURYSM INJECTION TRT 3.04 1.00<br />

36005 INJECTION EXT VENOGRAPHY 1.35 1.00<br />

36010 PLACE CATHETER IN VEIN 3.42 1.00<br />

36011 PLACE CATHETER IN VEIN 4.44 1.00<br />

36012 PLACE CATHETER IN VEIN 4.97 1.00<br />

36013 PLACE CATHETER IN ARTERY 3.58 1.00<br />

36014 PLACE CATHETER IN ARTERY 4.28 1.00<br />

36015 PLACE CATHETER IN ARTERY 4.84 1.00<br />

36100 ESTABLISH ACCESS TO ARTERY 4.44 1.00<br />

36120 ESTABLISH ACCESS TO ARTERY 2.77 1.00<br />

36140 ESTABLISH ACCESS TO ARTERY 2.84 1.00<br />

36145 ARTERY TO VEIN SHUNT 2.78 1.00<br />

36160 ESTABLISH ACCESS TO AORTA 3.73 1.00<br />

36200 PLACE CATHETER IN AORTA 4.28 1.00<br />

36215 PLACE CATHETER IN ARTERY 6.69 1.00<br />

36216 PLACE CATHETER IN ARTERY 7.52 1.00<br />

36217 PLACE CATHETER IN ARTERY 9.03 1.00<br />

36218 PLACE CATHETER IN ARTERY 1.44 1.00<br />

36245 PLACE CATHETER IN ARTERY 6.88 1.00<br />

36246 PLACE CATHETER IN ARTERY 7.56 1.00<br />

36247 PLACE CATHETER IN ARTERY 9.01 1.00<br />

36248 PLACE CATHETER IN ARTERY 1.44 1.00<br />

36260 INSERTION OF INFUSION PUMP 15.87 1.00<br />

36261 REVISION OF INFUSION PUMP 9.61 1.00<br />

36262 REMOVAL OF INFUSION PUMP 7.32 1.00<br />

36400 BL DRAW < 3 YRS FEM/JUGULAR 0.50 1.00<br />

36405 BL DRAW < 3 YRS SCALP VEIN 0.42 1.00<br />

36406 BL DRAW < 3 YRS OTHER VEIN 0.24 1.00<br />

36410 NON-ROUTINE BL DRAW > 3 YRS 0.24 1.00<br />

36420 VEIN ACCESS CUTDOWN < 1 YR 1.32 1.00<br />

36425 VEIN ACCESS CUTDOWN > 1 YR 1.03 1.00<br />

36430 BLOOD TRANSFUSION SERVICE 1.03 1.00<br />

36440 BL PUSH TRANSFUSE, 2 YR OR < 1.40 1.00<br />

36450 BL EXCHANGE/TRANSFUSE, NB 3.18 1.00<br />

36455 BL EXCHANGE/TRANSFUSE NON-NB 3.42 1.00<br />

36460 TRANSFUSION SERVICE, FETAL 9.40 1.00<br />

36470 INJECTION THERAPY OF VEIN 1.90 1.00<br />

36471 INJECTION THERAPY OF VEINS 2.67 1.00

---

36475 ENDOVENOUS RF, 1ST VEIN 9.30 1.00<br />

36476 ENDOVENOUS RF, VEIN ADD-ON 4.54 1.00<br />

36478 ENDOVENOUS LASER, 1ST VEIN 9.38 1.00<br />

36479 ENDOVENOUS LASER VEIN ADDON 4.60 1.00<br />

36481 INSERTION OF CATHETER, VEIN 10.01 1.00<br />

36500 INSERTION OF CATHETER, VEIN 5.02 1.00<br />

36510 INSERTION OF CATHETER, VEIN 1.64 1.00<br />

36511 APHERESIS WBC 2.47 1.00<br />

36512 APHERESIS RBC 2.49 1.00<br />

36513 APHERESIS PLATELETS 2.55 1.00<br />

36514 APHERESIS PLASMA 2.44 1.00<br />

36515 APHERESIS, ADSORP/REINFUSE 2.39 1.00<br />

36516 APHERESIS, SELECTIVE 1.73 1.00<br />

36555 INSERT NON-TUNNEL CV CATH 3.48 1.00<br />

36556 INSERT NON-TUNNEL CV CATH 3.34 1.00<br />

36557 INSERT TUNNELED CV CATH 8.15 1.00<br />

36558 INSERT TUNNELED CV CATH 7.91 1.00<br />

36560 INSERT TUNNELED CV CATH 9.71 1.00<br />

36561 INSERT TUNNELED CV CATH 9.38 1.00<br />

36563 INSERT TUNNELED CV CATH 9.84 1.00<br />

36565 INSERT TUNNELED CV CATH 9.29 1.00<br />

36566 INSERT TUNNELED CV CATH 9.94 1.00<br />

36568 INSERT PICC CATH 2.62 1.00<br />

36569 INSERT PICC CATH 2.63 1.00<br />

36570 INSERT PICVAD CATH 8.31 1.00<br />

36571 INSERT PICVAD CATH 8.46 1.00<br />

36575 REPAIR TUNNELED CV CATH 1.12 1.00<br />

36576 REPAIR TUNNELED CV CATH 5.11 1.00<br />

36578 REPLACE TUNNELED CV CATH 5.85 1.00<br />

36580 REPLACE CVAD CATH 1.92 1.00<br />

36581 REPLACE TUNNELED CV CATH 5.47 1.00<br />

36582 REPLACE TUNNELED CV CATH 8.06 1.00<br />

36583 REPLACE TUNNELED CV CATH 8.13 1.00<br />

36584 REPLACE PICC CATH 1.97 1.00<br />

36585 REPLACE PICVAD CATH 7.58 1.00<br />

36589 REMOVAL TUNNELED CV CATH 3.82 1.00<br />

36590 REMOVAL TUNNELED CV CATH 5.42 1.00<br />

36591 DRAW BLOOD OFF VENOUS <strong>DE</strong>VICE 0.55 1.00<br />

36592 COLLECT BLOOD FROM PICC 0.68 1.00<br />

36593 <strong>DE</strong>CLOT VASCULAR <strong>DE</strong>VICE 0.97 1.00<br />

36595 MECH REMOV TUNNELED CV CATH 5.21 1.00<br />

36596 MECH REMOV TUNNELED CV CATH 1.27 1.00<br />

36597 REPOSITION VENOUS CATHETER 1.73 1.00<br />

36598 INJ W/FLUOR, EVAL CV <strong>DE</strong>VICE 2.25 1.00<br />

36600 WITHDRAWAL OF ARTERIAL BLOOD 0.42 1.00<br />

36620 INSERTION CATHETER, ARTERY 1.41 1.00<br />

36625 INSERTION CATHETER, ARTERY 2.89 1.00<br />

36640 INSERTION CATHETER, ARTERY 3.28 1.00<br />

36660 INSERTION CATHETER, ARTERY 1.96 1.00<br />

36680 INSERT NEEDLE, BONE CAVITY 1.70 1.00

---

36800 INSERTION OF CANNULA 4.35 1.00<br />

36810 INSERTION OF CANNULA 5.91 1.00<br />

36815 INSERTION OF CANNULA 4.07 1.00<br />

36818 AV FUSE, UPPR ARM, CEPHALIC 18.97 1.00<br />

36819 AV FUSE, UPPR ARM, BASILIC 22.10 1.00<br />

36820 AV FUSION/FOREARM VEIN 22.16 1.00<br />

36821 AV FUSION DIRECT ANY SITE 14.68 1.00<br />

36822 INSERTION OF CANNULA(S) 10.36 1.00<br />

36823 INSERTION OF CANNULA(S) 34.72 1.00<br />

36825 ARTERY-VEIN AUTOGRAFT 15.99 1.00<br />

36830 ARTERY-VEIN NONAUTOGRAFT 18.34 1.00<br />

36831 OPEN THROMBECT AV FISTULA 12.67 1.00<br />

36832 AV FISTULA REVISION, OPEN 16.17 1.00<br />

36833 AV FISTULA REVISION 18.26 1.00<br />

36834 REPAIR A-V ANEURYSM 16.98 1.00<br />

36835 ARTERY TO VEIN SHUNT 12.44 1.00<br />

36838 DIST REVAS LIGATION, HEMO 32.83 1.00<br />

36860 EXTERNAL CANNULA <strong>DE</strong>CLOTTING 2.77 1.00<br />

36861 CANNULA <strong>DE</strong>CLOTTING 4.14 1.00<br />

36870 PERCUT THROMBECT AV FISTULA 8.42 1.00<br />

37140 REVISION OF CIRCULATION 36.85 1.00<br />

37145 REVISION OF CIRCULATION 40.05 1.00<br />

37160 REVISION OF CIRCULATION 34.55 1.00<br />

37180 REVISION OF CIRCULATION 39.27 1.00<br />

37181 SPLICE SPLEEN/KIDNEY VEINS 41.59 1.00<br />

37182 INSERT HEPATIC SHUNT (TIPS) 24.17 1.00<br />

37183 REMOVE HEPATIC SHUNT (TIPS) 11.51 1.00<br />

37184 PRIM ART MECH THROMBECTOMY 12.50 1.00<br />

37185 PRIM ART M-THROMBECT ADD-ON 4.61 1.00<br />

37186 SEC ART M-THROMBECT ADD-ON 6.96 1.00<br />

37187 VENOUS MECH THROMBECTOMY 11.61 1.00<br />

37188 VENOUS M-THROMBECTOMY ADD-ON 8.35 1.00<br />

37195 THROMBOLYTIC THERAPY, STROKE 8.54 1.00<br />

37200 TRANSCATHETER BIOPSY 6.40 1.00<br />

37201 TRANSCATHETER THERAPY INFUSE 7.76 1.00<br />

37202 TRANSCATHETER THERAPY INFUSE 9.29 1.00<br />

37203 TRANSCATHETER RETRIEVAL 7.37 1.00<br />

37204 TRANSCATHETER OCCLUSION 25.66 1.00<br />

37205 TRANSCATH IV STENT, PERCUT 12.37 1.00<br />

37206 TRANSCATH IV STENT/PERC ADDL 5.93 1.00<br />

37207 TRANSCATH IV STENT, OPEN 12.21 1.00<br />

37208 TRANSCATH IV STENT/OPEN ADDL 5.90 1.00<br />

37209 CHANGE IV CATH AT THROMB TX 3.17 1.00<br />

37210 EMBOLIZATION UTERINE FIBROID 14.88 1.00<br />

37215 TRANSCATH STENT, CCA W/EPS 30.19 1.00<br />

37216 TRANSCATH STENT, CCA W/O EPS 27.18 1.00<br />

37250 IV US FIRST VESSEL ADD-ON 3.07 1.00<br />

37251 IV US EACH ADD VESSEL ADD-ON 2.31 1.00<br />

37500 ENDOSCOPY LIGATE PERF VEINS 19.18 1.00<br />

37565 LIGATION OF NECK VEIN 18.68 1.00

---

37600 LIGATION OF NECK ARTERY 19.53 1.00<br />

37605 LIGATION OF NECK ARTERY 22.37 1.00<br />

37606 LIGATION OF NECK ARTERY 14.66 1.00<br />

37607 LIGATION OF A-V FISTULA 10.33 1.00<br />

37609 TEMPORAL ARTERY PROCEDURE 5.27 1.00<br />

37615 LIGATION OF NECK ARTERY 12.50 1.00<br />

37616 LIGATION OF CHEST ARTERY 29.23 1.00<br />

37617 LIGATION OF ABDOMEN ARTERY 35.22 1.00<br />

37618 LIGATION OF EXTREMITY ARTERY 10.11 1.00<br />

37620 REVISION OF MAJOR VEIN 17.98 1.00<br />

37650 REVISION OF MAJOR VEIN 13.88 1.00<br />

37660 REVISION OF MAJOR VEIN 33.02 1.00<br />

37700 REVISE LEG VEIN 6.88 1.00<br />

37718 LIGATE/STRIP SHORT LEG VEIN 10.96 1.00<br />

37722 LIGATE/STRIP LONG LEG VEIN 12.99 1.00<br />

37735 REMOVAL OF LEG VEINS/LESION 17.39 1.00<br />

37760 LIGATION, LEG VEINS, OPEN 17.04 1.00<br />

37765 PHLEB VEINS - EXTREM - TO 20 12.20 1.00<br />

37766 PHLEB VEINS - EXTREM 20+ 14.79 1.00<br />

37780 REVISION OF LEG VEIN 7.02 1.00<br />

37785 LIGATE/DIVI<strong>DE</strong>/EXCISE VEIN 7.06 1.00<br />

37788 REVASCULARIZATION, PENIS 36.04 1.00<br />

37790 PENILE VENOUS OCCLUSION 13.72 1.00<br />

40490 BIOPSY OF LIP 1.86 1.00<br />

40500 PARTIAL EXCISION OF LIP 9.08 1.00<br />

40510 PARTIAL EXCISION OF LIP 9.05 1.00<br />

40520 PARTIAL EXCISION OF LIP 9.20 1.00<br />

40525 RECONSTRUCT LIP WITH FLAP 14.28 1.00<br />

40527 RECONSTRUCT LIP WITH FLAP 16.92 1.00<br />

40530 PARTIAL REMOVAL OF LIP 10.42 1.00<br />

40650 REPAIR LIP 7.30 1.00<br />

40652 REPAIR LIP 9.03 1.00<br />

40654 REPAIR LIP 10.78 1.00<br />

40700 REPAIR CLEFT LIP/NASAL 23.79 1.00<br />

40701 REPAIR CLEFT LIP/NASAL 28.26 1.00<br />

40702 REPAIR CLEFT LIP/NASAL 22.35 1.00<br />

40720 REPAIR CLEFT LIP/NASAL 26.05 1.00<br />

40761 REPAIR CLEFT LIP/NASAL 27.42 1.00<br />

40799 LIP SURGERY PROCEDURE 999.99 1.00<br />

40800 DRAINAGE OF MOUTH LESION 3.15 1.00<br />

40801 DRAINAGE OF MOUTH LESION 5.54 1.00<br />

40804 REMOVAL, FOREIGN BODY, MOUTH 3.22 1.00<br />

40805 REMOVAL, FOREIGN BODY, MOUTH 5.79 1.00<br />

40806 INCISION OF LIP FOLD 0.85 1.00<br />

40808 BIOPSY OF MOUTH LESION 2.63 1.00<br />

40810 EXCISION OF MOUTH LESION 3.15 1.00<br />

40812 EXCISE/REPAIR MOUTH LESION 4.95 1.00<br />

40814 EXCISE/REPAIR MOUTH LESION 7.65 1.00<br />

40816 EXCISION OF MOUTH LESION 7.99 1.00<br />

40818 EXCISE ORAL MUCOSA FOR GRAFT 6.79 1.00

---

40819 EXCISE LIP OR CHEEK FOLD 5.84 1.00<br />

40820 TREATMENT OF MOUTH LESION 4.10 1.00<br />

40830 REPAIR MOUTH LACERATION 4.02 1.00<br />

40831 REPAIR MOUTH LACERATION 5.68 1.00<br />

40840 RECONSTRUCTION OF MOUTH 16.39 1.00<br />

40842 RECONSTRUCTION OF MOUTH 16.36 1.00<br />

40843 RECONSTRUCTION OF MOUTH 20.79 1.00<br />

40844 RECONSTRUCTION OF MOUTH 28.91 1.00<br />

40845 RECONSTRUCTION OF MOUTH 32.86 1.00<br />

41000 DRAINAGE OF MOUTH LESION 2.81 1.00<br />

41005 DRAINAGE OF MOUTH LESION 3.15 1.00<br />

41006 DRAINAGE OF MOUTH LESION 6.63 1.00<br />

41007 DRAINAGE OF MOUTH LESION 6.32 1.00<br />

41008 DRAINAGE OF MOUTH LESION 6.84 1.00<br />

41009 DRAINAGE OF MOUTH LESION 7.46 1.00<br />

41010 INCISION OF TONGUE FOLD 2.73 1.00<br />

41015 DRAINAGE OF MOUTH LESION 8.52 1.00<br />

41016 DRAINAGE OF MOUTH LESION 8.79 1.00<br />

41017 DRAINAGE OF MOUTH LESION 8.85 1.00<br />

41018 DRAINAGE OF MOUTH LESION 10.35 1.00<br />

41019 PLACE NEEDLES H&N FOR RT 12.71 1.00<br />

41100 BIOPSY OF TONGUE 2.83 1.00<br />

41105 BIOPSY OF TONGUE 2.83 1.00<br />

41108 BIOPSY OF FLOOR OF MOUTH 2.28 1.00<br />

41110 EXCISION OF TONGUE LESION 3.30 1.00<br />

41112 EXCISION OF TONGUE LESION 6.28 1.00<br />

41113 EXCISION OF TONGUE LESION 7.00 1.00<br />

41114 EXCISION OF TONGUE LESION 16.29 1.00<br />

41115 EXCISION OF TONGUE FOLD 3.73 1.00<br />

41116 EXCISION OF MOUTH LESION 5.50 1.00<br />

41120 PARTIAL REMOVAL OF TONGUE 26.53 1.00<br />

41130 PARTIAL REMOVAL OF TONGUE 32.49 1.00<br />

41135 TONGUE AND NECK SURGERY 54.27 1.00<br />

41140 REMOVAL OF TONGUE 56.22 1.00<br />

41145 TONGUE REMOVAL, NECK SURGERY 69.84 1.00<br />

41150 TONGUE, MOUTH, JAW SURGERY 55.36 1.00<br />

41153 TONGUE, MOUTH, NECK SURGERY 59.78 1.00<br />

41155 TONGUE, JAW, & NECK SURGERY 73.52 1.00<br />

41250 REPAIR TONGUE LACERATION 3.50 1.00<br />

41251 REPAIR TONGUE LACERATION 4.17 1.00<br />

41252 REPAIR TONGUE LACERATION 5.47 1.00<br />

41500 FIXATION OF TONGUE 11.53 1.00<br />

41510 TONGUE TO LIP SURGERY 10.86 1.00<br />

41520 RECONSTRUCTION, TONGUE FOLD 6.48 1.00<br />

41800 DRAINAGE OF GUM LESION 3.03 1.00<br />

41805 REMOVAL FOREIGN BODY, GUM 3.87 1.00<br />

41806 REMOVAL FOREIGN BODY,JAWBONE 6.29 1.00<br />

41820 EXCISION, GUM, EACH QUADRANT 4.00 1.00<br />

41822 EXCISION OF GUM LESION 4.52 1.00<br />

41823 EXCISION OF GUM LESION 7.97 1.00

---

41825 EXCISION OF GUM LESION 3.36 1.00<br />

41826 EXCISION OF GUM LESION 4.99 1.00<br />

41827 EXCISION OF GUM LESION 7.59 1.00<br />

41828 EXCISION OF GUM LESION 5.85 1.00<br />

41830 REMOVAL OF GUM TISSUE 7.19 1.00<br />

41872 REPAIR GUM 6.58 1.00<br />

41874 REPAIR TOOTH SOCKET 6.53 1.00<br />

42000 DRAINAGE MOUTH ROOF LESION 2.60 1.00<br />

42100 BIOPSY ROOF OF MOUTH 2.77 1.00<br />

42104 EXCISION LESION, MOUTH ROOF 3.43 1.00<br />

42106 EXCISION LESION, MOUTH ROOF 4.63 1.00<br />

42107 EXCISION LESION, MOUTH ROOF 8.74 1.00<br />

42120 REMOVE PALATE/LESION 24.25 1.00<br />

42140 EXCISION OF UVULA 3.89 1.00<br />

42145 REPAIR PALATE, PHARYNX/UVULA 17.77 1.00<br />

42160 TREATMENT MOUTH ROOF LESION 3.98 1.00<br />

42180 REPAIR PALATE 4.71 1.00<br />

42182 REPAIR PALATE 6.95 1.00<br />

42200 RECONSTRUCT CLEFT PALATE 23.10 1.00<br />

42205 RECONSTRUCT CLEFT PALATE 23.87 1.00<br />

42210 RECONSTRUCT CLEFT PALATE 27.94 1.00<br />

42215 RECONSTRUCT CLEFT PALATE 18.44 1.00<br />

42220 RECONSTRUCT CLEFT PALATE 14.80 1.00<br />

42225 RECONSTRUCT CLEFT PALATE 25.18 1.00<br />

42226 LENGTHENING OF PALATE 24.56 1.00<br />

42227 LENGTHENING OF PALATE 24.18 1.00<br />

42235 REPAIR PALATE 19.75 1.00<br />

42260 REPAIR NOSE TO LIP FISTULA 17.91 1.00<br />

42281 INSERTION, PALATE PROSTHESIS 3.90 1.00<br />

42300 DRAINAGE OF SALIVARY GLAND 3.89 1.00<br />

42305 DRAINAGE OF SALIVARY GLAND 11.10 1.00<br />

42310 DRAINAGE OF SALIVARY GLAND 3.17 1.00<br />

42320 DRAINAGE OF SALIVARY GLAND 4.57 1.00<br />

42330 REMOVAL OF SALIVARY STONE 4.21 1.00<br />

42335 REMOVAL OF SALIVARY STONE 6.64 1.00<br />

42340 REMOVAL OF SALIVARY STONE 8.77 1.00<br />

42400 BIOPSY OF SALIVARY GLAND 1.52 1.00<br />

42405 BIOPSY OF SALIVARY GLAND 5.89 1.00<br />

42408 EXCISION OF SALIVARY CYST 8.47 1.00<br />

42409 DRAINAGE OF SALIVARY CYST 5.77 1.00<br />

42410 EXCISE PAROTID GLAND/LESION 16.17 1.00<br />

42415 EXCISE PAROTID GLAND/LESION 29.17 1.00<br />

42420 EXCISE PAROTID GLAND/LESION 33.50 1.00<br />

42425 EXCISE PAROTID GLAND/LESION 22.08 1.00<br />

42426 EXCISE PAROTID GLAND/LESION 35.87 1.00<br />

42440 EXCISE SUBMAXILLARY GLAND 11.97 1.00<br />

42450 EXCISE SUBLINGUAL GLAND 9.22 1.00<br />

42500 REPAIR SALIVARY DUCT 8.77 1.00<br />

42505 REPAIR SALIVARY DUCT 11.82 1.00<br />

42507 PAROTID DUCT DIVERSION 13.09 1.00

---

42508 PAROTID DUCT DIVERSION 18.47 1.00<br />

42509 PAROTID DUCT DIVERSION 22.14 1.00<br />

42510 PAROTID DUCT DIVERSION 16.27 1.00<br />

42550 INJECTION FOR SALIVARY X-RAY 1.75 1.00<br />

42600 CLOSURE OF SALIVARY FISTULA 9.06 1.00<br />

42650 DILATION OF SALIVARY DUCT 1.52 1.00<br />

42660 DILATION OF SALIVARY DUCT 2.02 1.00<br />

42665 LIGATION OF SALIVARY DUCT 5.30 1.00<br />

42700 DRAINAGE OF TONSIL ABSCESS 3.44 1.00<br />

42720 DRAINAGE OF THROAT ABSCESS 10.23 1.00<br />

42725 DRAINAGE OF THROAT ABSCESS 20.84 1.00<br />

42800 BIOPSY OF THROAT 2.87 1.00<br />

42802 BIOPSY OF THROAT 3.55 1.00<br />

42804 BIOPSY OF UPPER NOSE/THROAT 2.98 1.00<br />

42806 BIOPSY OF UPPER NOSE/THROAT 3.50 1.00<br />

42808 EXCISE PHARYNX LESION 4.28 1.00<br />

42809 REMOVE PHARYNX FOREIGN BODY 3.31 1.00<br />

42810 EXCISION OF NECK CYST 7.23 1.00<br />

42815 EXCISION OF NECK CYST 14.18 1.00<br />

42820 REMOVE TONSILS AND A<strong>DE</strong>NOIDS 7.55 1.00<br />

42821 REMOVE TONSILS AND A<strong>DE</strong>NOIDS 7.91 1.00<br />

42825 REMOVAL OF TONSILS 6.74 1.00<br />

42826 REMOVAL OF TONSILS 6.53 1.00<br />

42830 REMOVAL OF A<strong>DE</strong>NOIDS 5.30 1.00<br />

42831 REMOVAL OF A<strong>DE</strong>NOIDS 5.72 1.00<br />

42835 REMOVAL OF A<strong>DE</strong>NOIDS 4.66 1.00<br />

42836 REMOVAL OF A<strong>DE</strong>NOIDS 6.28 1.00<br />

42842 EXTENSIVE SURGERY OF THROAT 24.25 1.00<br />

42844 EXTENSIVE SURGERY OF THROAT 34.59 1.00<br />

42845 EXTENSIVE SURGERY OF THROAT 56.52 1.00<br />

42860 EXCISION OF TONSIL TAGS 4.78 1.00<br />

42870 EXCISION OF LINGUAL TONSIL 14.52 1.00<br />

42890 PARTIAL REMOVAL OF PHARYNX 34.68 1.00<br />

42892 REVISION OF PHARYNGEAL WALLS 45.25 1.00<br />

42894 REVISION OF PHARYNGEAL WALLS 58.27 1.00<br />

42900 REPAIR THROAT WOUND 9.07 1.00<br />

42950 RECONSTRUCTION OF THROAT 20.35 1.00<br />

42953 REPAIR THROAT, ESOPHAGUS 25.77 1.00<br />

42955 SURGICAL OPENING OF THROAT 19.11 1.00<br />

42960 CONTROL THROAT BLEEDING 4.38 1.00<br />

42961 CONTROL THROAT BLEEDING 10.86 1.00<br />

42962 CONTROL THROAT BLEEDING 13.44 1.00<br />

42970 CONTROL NOSE/THROAT BLEEDING 10.03 1.00<br />

42971 CONTROL NOSE/THROAT BLEEDING 11.86 1.00<br />

42972 CONTROL NOSE/THROAT BLEEDING 13.50 1.00<br />

43020 INCISION OF ESOPHAGUS 14.01 1.00<br />

43030 THROAT MUSCLE SURGERY 13.62 1.00<br />

43045 INCISION OF ESOPHAGUS 34.30 1.00<br />

43100 EXCISION OF ESOPHAGUS LESION 16.20 1.00<br />

43101 EXCISION OF ESOPHAGUS LESION 26.84 1.00

---

43107 REMOVAL OF ESOPHAGUS 66.48 1.00<br />

43108 REMOVAL OF ESOPHAGUS 106.09 1.00<br />

43112 REMOVAL OF ESOPHAGUS 71.28 1.00<br />

43113 REMOVAL OF ESOPHAGUS 104.52 1.00<br />

43116 PARTIAL REMOVAL OF ESOPHAGUS 119.36 1.00<br />

43117 PARTIAL REMOVAL OF ESOPHAGUS 64.93 1.00<br />

43118 PARTIAL REMOVAL OF ESOPHAGUS 88.63 1.00<br />

43121 PARTIAL REMOVAL OF ESOPHAGUS 71.11 1.00<br />

43122 PARTIAL REMOVAL OF ESOPHAGUS 65.90 1.00<br />

43123 PARTIAL REMOVAL OF ESOPHAGUS 107.02 1.00<br />

43124 REMOVAL OF ESOPHAGUS 91.30 1.00<br />

43130 REMOVAL OF ESOPHAGUS POUCH 20.54 1.00<br />

43135 REMOVAL OF ESOPHAGUS POUCH 37.44 1.00<br />

43200 ESOPHAGUS ENDOSCOPY 2.74 1.00<br />

43201 ESOPH SCOPE W/SUBMUCOUS INJ 3.39 1.00<br />

43202 ESOPHAGUS ENDOSCOPY, BIOPSY 3.00 1.00<br />

43204 ESOPH SCOPE W/SCLEROSIS INJ 5.82 1.00<br />

43205 ESOPHAGUS ENDOSCOPY/LIGATION 5.85 1.00<br />

43215 ESOPHAGUS ENDOSCOPY 4.06 1.00<br />

43216 ESOPHAGUS ENDOSCOPY/LESION 3.76 1.00<br />

43217 ESOPHAGUS ENDOSCOPY 4.44 1.00<br />

43219 ESOPHAGUS ENDOSCOPY 4.49 1.00<br />

43220 ESOPH ENDOSCOPY, DILATION 3.32 1.00<br />

43226 ESOPH ENDOSCOPY, DILATION 3.69 1.00<br />

43227 ESOPH ENDOSCOPY, REPAIR 5.48 1.00<br />

43228 ESOPH ENDOSCOPY, ABLATION 5.82 1.00<br />

43231 ESOPH ENDOSCOPY W/US EXAM 4.95 1.00<br />

43232 ESOPH ENDOSCOPY W/US FN BX 6.91 1.00<br />

43234 UPPER GI ENDOSCOPY, EXAM 3.12 1.00<br />

43235 UPPR GI ENDOSCOPY, DIAGNOSIS 3.76 1.00<br />

43236 UPPR GI SCOPE W/SUBMUC INJ 4.56 1.00<br />

43237 ENDOSCOPIC US EXAM, ESOPH 6.29 1.00<br />

43238 UPPR GI ENDOSCOPY W/US FN BX 7.72 1.00<br />

43239 UPPER GI ENDOSCOPY, BIOPSY 4.46 1.00<br />

43240 ESOPH ENDOSCOPE W/DRAIN CYST 10.36 1.00<br />

43241 UPPER GI ENDOSCOPY WITH TUBE 4.05 1.00<br />

43242 UPPR GI ENDOSCOPY W/US FN BX 11.04 1.00<br />

43243 UPPER GI ENDOSCOPY & INJECT 6.97 1.00<br />

43244 UPPER GI ENDOSCOPY/LIGATION 7.72 1.00<br />

43245 UPPR GI SCOPE DILATE STRICTR 4.90 1.00<br />

43246 PLACE GASTROSTOMY TUBE 6.56 1.00<br />

43247 OPERATIVE UPPER GI ENDOSCOPY 5.23 1.00<br />

43248 UPPR GI ENDOSCOPY/GUI<strong>DE</strong> WIRE 4.92 1.00<br />

43249 ESOPH ENDOSCOPY, DILATION 4.53 1.00<br />

43250 UPPER GI ENDOSCOPY/TUMOR 4.92 1.00<br />

43251 OPERATIVE UPPER GI ENDOSCOPY 5.68 1.00<br />

43255 OPERATIVE UPPER GI ENDOSCOPY 7.37 1.00<br />

43256 UPPR GI ENDOSCOPY W/STENT 6.64 1.00<br />

43257 UPPR GI SCOPE W/THRML TXMNT 8.03 1.00<br />

43258 OPERATIVE UPPER GI ENDOSCOPY 6.95 1.00

---

43259 ENDOSCOPIC ULTRASOUND EXAM 7.88 1.00<br />

43260 ENDO CHOLANGIOPANCREATOGRAPH 9.05 1.00<br />

43261 ENDO CHOLANGIOPANCREATOGRAPH 9.52 1.00<br />

43262 ENDO CHOLANGIOPANCREATOGRAPH 11.18 1.00<br />

43263 ENDO CHOLANGIOPANCREATOGRAPH 11.02 1.00<br />

43264 ENDO CHOLANGIOPANCREATOGRAPH 13.42 1.00<br />

43265 ENDO CHOLANGIOPANCREATOGRAPH 15.07 1.00<br />

43267 ENDO CHOLANGIOPANCREATOGRAPH 11.01 1.00<br />

43268 ENDO CHOLANGIOPANCREATOGRAPH 11.31 1.00<br />

43269 ENDO CHOLANGIOPANCREATOGRAPH 12.39 1.00<br />

43271 ENDO CHOLANGIOPANCREATOGRAPH 11.17 1.00<br />

43272 ENDO CHOLANGIOPANCREATOGRAPH 11.20 1.00<br />

43280 LAPAROSCOPY, FUNDOPLASTY 27.24 1.00<br />

43300 REPAIR OF ESOPHAGUS 16.23 1.00<br />

43305 REPAIR ESOPHAGUS AND FISTULA 29.04 1.00<br />

43310 REPAIR OF ESOPHAGUS 40.23 1.00<br />

43312 REPAIR ESOPHAGUS AND FISTULA 44.33 1.00<br />

43313 ESOPHAGOPLASTY CONGENITAL 71.79 1.00<br />

43314 TRACHEO-ESOPHAGOPLASTY CONG 76.95 1.00<br />

43320 FUSE ESOPHAGUS & STOMACH 34.83 1.00<br />

43324 REVISE ESOPHAGUS & STOMACH 34.18 1.00<br />

43325 REVISE ESOPHAGUS & STOMACH 33.66 1.00<br />

43326 REVISE ESOPHAGUS & STOMACH 34.25 1.00<br />

43330 REPAIR OF ESOPHAGUS 33.01 1.00<br />

43331 REPAIR OF ESOPHAGUS 35.68 1.00<br />

43340 FUSE ESOPHAGUS & INTESTINE 34.45 1.00<br />

43341 FUSE ESOPHAGUS & INTESTINE 36.86 1.00<br />

43350 SURGICAL OPENING, ESOPHAGUS 29.33 1.00<br />

43351 SURGICAL OPENING, ESOPHAGUS 34.67 1.00<br />

43352 SURGICAL OPENING, ESOPHAGUS 27.91 1.00<br />

43360 GASTROINTESTINAL REPAIR 59.86 1.00<br />

43361 GASTROINTESTINAL REPAIR 67.52 1.00<br />

43400 LIGATE ESOPHAGUS VEINS 38.95 1.00<br />

43401 ESOPHAGUS SURGERY FOR VEINS 38.93 1.00<br />

43405 LIGATE/STAPLE ESOPHAGUS 37.52 1.00<br />

43410 REPAIR ESOPHAGUS WOUND 25.65 1.00<br />

43415 REPAIR ESOPHAGUS WOUND 44.02 1.00<br />

43420 REPAIR ESOPHAGUS OPENING 25.52 1.00<br />

43425 REPAIR ESOPHAGUS OPENING 38.16 1.00<br />

43450 DILATE ESOPHAGUS 2.30 1.00<br />

43453 DILATE ESOPHAGUS 2.49 1.00<br />

43456 DILATE ESOPHAGUS 4.04 1.00<br />

43458 DILATE ESOPHAGUS 4.74 1.00<br />

43460 PRESSURE TREATMENT ESOPHAGUS 5.72 1.00<br />

43496 FREE JEJUNUM FLAP, MICROVASC 5.00 1.00<br />

43500 SURGICAL OPENING OF STOMACH 19.29 1.00<br />

43501 SURGICAL REPAIR OF STOMACH 33.32 1.00<br />

43502 SURGICAL REPAIR OF STOMACH 37.88 1.00<br />

43510 SURGICAL OPENING OF STOMACH 24.35 1.00<br />

43520 INCISION OF PYLORIC MUSCLE 17.61 1.00

---

43600 BIOPSY OF STOMACH 2.76 1.00<br />

43605 BIOPSY OF STOMACH 20.54 1.00<br />

43610 EXCISION OF STOMACH LESION 24.29 1.00<br />

43611 EXCISION OF STOMACH LESION 30.14 1.00<br />

43620 REMOVAL OF STOMACH 49.32 1.00<br />

43621 REMOVAL OF STOMACH 55.63 1.00<br />

43622 REMOVAL OF STOMACH 56.75 1.00<br />

43631 REMOVAL OF STOMACH, PARTIAL 36.25 1.00<br />

43632 REMOVAL OF STOMACH, PARTIAL 48.22 1.00<br />

43633 REMOVAL OF STOMACH, PARTIAL 46.11 1.00<br />

43634 REMOVAL OF STOMACH, PARTIAL 50.78 1.00<br />

43635 REMOVAL OF STOMACH, PARTIAL 2.94 1.00<br />

43640 VAGOTOMY & PYLORUS REPAIR 28.99 1.00<br />

43641 VAGOTOMY & PYLORUS REPAIR 29.43 1.00<br />

43644 LAP GASTRIC BYPASS/ROUX-EN-Y 43.06 1.00<br />

43645 LAP GASTR BYPASS INCL SMLL I 46.16 1.00<br />

43651 LAPAROSCOPY, VAGUS NERVE 16.15 1.00<br />

43652 LAPAROSCOPY, VAGUS NERVE 19.17 1.00<br />

43653 LAPAROSCOPY, GASTROSTOMY 13.71 1.00<br />

43752 NASAL/OROGASTRIC W/STENT 1.09 1.00<br />

43760 CHANGE GASTROSTOMY TUBE 1.38 1.00<br />

43761 REPOSITION GASTROSTOMY TUBE 2.82 1.00<br />

43770 LAP PLACE GASTR ADJ <strong>DE</strong>VICE 27.60 1.00<br />

43771 LAP REVISE GASTR ADJ <strong>DE</strong>VICE 31.55 1.00<br />

43772 LAP RMVL GASTR ADJ <strong>DE</strong>VICE 23.76 1.00<br />

43773 LAP REPLACE GASTR ADJ <strong>DE</strong>VICE 31.55 1.00<br />

43774 LAP RMVL GASTR ADJ ALL PARTS 23.88 1.00<br />

43800 RECONSTRUCTION OF PYLORUS 23.03 1.00<br />

43810 FUSION OF STOMACH AND BOWEL 24.90 1.00<br />

43820 FUSION OF STOMACH AND BOWEL 31.68 1.00<br />

43825 FUSION OF STOMACH AND BOWEL 32.13 1.00<br />

43830 PLACE GASTROSTOMY TUBE 17.01 1.00<br />

43831 PLACE GASTROSTOMY TUBE 14.13 1.00<br />

43832 PLACE GASTROSTOMY TUBE 26.20 1.00<br />

43840 REPAIR OF STOMACH LESION 32.22 1.00<br />

43842 V-BAND GASTROPLASTY 30.62 1.00<br />

43843 GASTROPLASTY W/O V-BAND 31.34 1.00<br />

43845 GASTRIC RESTRICTIVE PROCEDURE 49.01 1.00<br />

43846 GASTRIC BYPASS FOR OBESITY 40.43 1.00<br />

43847 GASTRIC BYPASS INCL SMALL I 44.37 1.00<br />

43848 REVISION GASTROPLASTY 48.01 1.00<br />

43850 REVISE STOMACH-BOWEL FUSION 40.39 1.00<br />

43855 REVISE STOMACH-BOWEL FUSION 42.05 1.00<br />

43860 REVISE STOMACH-BOWEL FUSION 40.80 1.00<br />

43865 REVISE STOMACH-BOWEL FUSION 42.55 1.00<br />

43870 REPAIR STOMACH OPENING 17.36 1.00<br />

43880 REPAIR STOMACH-BOWEL FISTULA 39.91 1.00<br />

43886 REVISE GASTRIC PORT, OPEN 8.08 1.00<br />

43887 REMOVE GASTRIC PORT, OPEN 7.66 1.00<br />

43888 CHANGE GASTRIC PORT, OPEN 10.93 1.00

---

44005 FREEING OF BOWEL ADHESION 27.18 1.00<br />

44010 INCISION OF SMALL BOWEL 21.31 1.00<br />

44015 INSERT NEEDLE CATH BOWEL 3.75 1.00<br />

44020 EXPLORE SMALL INTESTINE 23.97 1.00<br />

44021 <strong>DE</strong>COMPRESS SMALL BOWEL 24.16 1.00<br />

44025 INCISION OF LARGE BOWEL 24.37 1.00<br />

44050 REDUCE BOWEL OBSTRUCTION 23.19 1.00<br />

44055 CORRECT MALROTATION OF BOWEL 37.05 1.00<br />

44100 BIOPSY OF BOWEL 2.99 1.00<br />

44110 EXCISE INTESTINE LESION(S) 20.88 1.00<br />

44111 EXCISION OF BOWEL LESION(S) 24.41 1.00<br />

44120 REMOVAL OF SMALL INTESTINE 30.10 1.00<br />

44121 REMOVAL OF SMALL INTESTINE 6.34 1.00<br />

44125 REMOVAL OF SMALL INTESTINE 29.34 1.00<br />

44126 ENTERECTOMY W/O TAPER, CONG 60.57 1.00<br />

44127 ENTERECTOMY W/TAPER, CONG 70.55 1.00<br />

44128 ENTERECTOMY CONG, ADD-ON 6.42 1.00<br />

44130 BOWEL TO BOWEL FUSION 30.96 1.00<br />

44133 ENTERECTOMY, LIVE DONOR 6.00 1.00<br />

44136 INTESTINE TRANSPLANT, LIVE 6.00 1.00<br />

44139 MOBILIZATION OF COLON 3.17 1.00<br />

44140 PARTIAL REMOVAL OF COLON 33.53 1.00<br />

44141 PARTIAL REMOVAL OF COLON 43.23 1.00<br />

44143 PARTIAL REMOVAL OF COLON 41.17 1.00<br />

44144 PARTIAL REMOVAL OF COLON 42.73 1.00<br />

44145 PARTIAL REMOVAL OF COLON 41.89 1.00<br />

44146 PARTIAL REMOVAL OF COLON 51.67 1.00<br />

44147 PARTIAL REMOVAL OF COLON 45.86 1.00<br />

44150 REMOVAL OF COLON 45.35 1.00<br />

44151 REMOVAL OF COLON/ILEOSTOMY 51.89 1.00<br />

44155 REMOVAL OF COLON/ILEOSTOMY 50.89 1.00<br />

44156 REMOVAL OF COLON/ILEOSTOMY 55.94 1.00<br />

44157 COLECTOMY W/ILEOANAL ANAST 56.52 1.00<br />

44158 COLECTOMY W/NEO-RECTUM POUCH 57.99 1.00<br />

44160 REMOVAL OF COLON 30.78 1.00<br />

44180 LAP, ENTEROLYSIS 23.07 1.00<br />

44186 LAP, JEJUNOSTOMY 16.26 1.00<br />

44187 LAP, ILEO/JEJUNO-STOMY 27.43 1.00<br />

44188 LAP, COLOSTOMY 30.20 1.00<br />

44202 LAP, ENTERECTOMY 34.73 1.00<br />

44203 LAP RESECT S/INTESTINE, ADDL 6.32 1.00<br />

44204 LAPARO PARTIAL COLECTOMY 38.82 1.00<br />

44205 LAP COLECTOMY PART W/ILEUM 33.94 1.00<br />

44206 LAP PART COLECTOMY W/STOMA 43.96 1.00<br />

44207 L COLECTOMY/COLOPROCTOSTOMY 46.26 1.00<br />

44208 L COLECTOMY/COLOPROCTOSTOMY 50.32 1.00<br />

44210 LAPARO TOTAL PROCTOCOLECTOMY 44.83 1.00<br />

44211 LAP COLECTOMY W/PROCTECTOMY 55.18 1.00<br />

44212 LAPARO TOTAL PROCTOCOLECTOMY 51.52 1.00<br />

44213 LAP, MOBIL SPLENIC FL ADD-ON 4.98 1.00

---

44227 LAP, CLOSE ENTEROSTOMY 41.93 1.00<br />

44300 OPEN BOWEL TO SKIN 20.77 1.00<br />

44310 ILEOSTOMY/JEJUNOSTOMY 26.03 1.00<br />

44312 REVISION OF ILEOSTOMY 14.57 1.00<br />

44314 REVISION OF ILEOSTOMY 25.03 1.00<br />

44316 <strong>DE</strong>VISE BOWEL POUCH 34.55 1.00<br />

44320 COLOSTOMY 29.64 1.00<br />

44322 COLOSTOMY WITH BIOPSIES 23.53 1.00<br />

44340 REVISION OF COLOSTOMY 14.71 1.00<br />

44345 REVISION OF COLOSTOMY 25.93 1.00<br />

44346 REVISION OF COLOSTOMY 29.06 1.00<br />

44360 SMALL BOWEL ENDOSCOPY 4.08 1.00<br />

44361 SMALL BOWEL ENDOSCOPY/BIOPSY 4.49 1.00<br />

44363 SMALL BOWEL ENDOSCOPY 5.37 1.00<br />

44364 SMALL BOWEL ENDOSCOPY 5.73 1.00<br />

44365 SMALL BOWEL ENDOSCOPY 5.10 1.00<br />

44366 SMALL BOWEL ENDOSCOPY 6.77 1.00<br />

44369 SMALL BOWEL ENDOSCOPY 6.89 1.00<br />

44370 SMALL BOWEL ENDOSCOPY/STENT 7.43 1.00<br />

44372 SMALL BOWEL ENDOSCOPY 6.68 1.00<br />

44373 SMALL BOWEL ENDOSCOPY 5.35 1.00<br />

44376 SMALL BOWEL ENDOSCOPY 7.92 1.00<br />

44377 SMALL BOWEL ENDOSCOPY/BIOPSY 8.37 1.00<br />

44378 SMALL BOWEL ENDOSCOPY 10.78 1.00<br />

44379 S BOWEL ENDOSCOPE W/STENT 11.50 1.00<br />

44380 SMALL BOWEL ENDOSCOPY 1.78 1.00<br />

44382 SMALL BOWEL ENDOSCOPY 2.12 1.00<br />

44383 ILEOSCOPY W/STENT 4.59 1.00<br />

44385 ENDOSCOPY OF BOWEL POUCH 2.79 1.00<br />

44386 ENDOSCOPY, BOWEL POUCH/BIOP 3.27 1.00<br />

44388 COLONOSCOPY 4.33 1.00<br />

44389 COLONOSCOPY WITH BIOPSY 4.82 1.00<br />

44390 COLONOSCOPY FOR FOREIGN BODY 5.84 1.00<br />

44391 COLONOSCOPY FOR BLEEDING 6.60 1.00<br />

44392 COLONOSCOPY & POLYPECTOMY 5.75 1.00<br />

44393 COLONOSCOPY, LESION REMOVAL 7.25 1.00<br />

44394 COLONOSCOPY W/SNARE 6.69 1.00<br />

44397 COLONOSCOPY W/STENT 7.07 1.00<br />

44602 SUTURE, SMALL INTESTINE 33.77 1.00<br />

44603 SUTURE, SMALL INTESTINE 38.57 1.00<br />

44604 SUTURE, LARGE INTESTINE 26.44 1.00<br />

44605 REPAIR OF BOWEL LESION 32.63 1.00<br />

44615 INTESTINAL STRICTUROPLASTY 26.76 1.00<br />

44620 REPAIR BOWEL OPENING 21.28 1.00<br />

44625 REPAIR BOWEL OPENING 25.29 1.00<br />

44626 REPAIR BOWEL OPENING 40.44 1.00<br />

44640 REPAIR BOWEL-SKIN FISTULA 35.20 1.00<br />

44650 REPAIR BOWEL FISTULA 36.57 1.00<br />

44660 REPAIR BOWEL-BLAD<strong>DE</strong>R FISTULA 35.02 1.00<br />

44661 REPAIR BOWEL-BLAD<strong>DE</strong>R FISTULA 39.56 1.00

---

44680 SURGICAL REVISION, INTESTINE 26.45 1.00<br />

44700 SUSPEND BOWEL W/PROSTHESIS 25.65 1.00<br />

44701 INTRAOP COLON LAVAGE ADD-ON 4.38 1.00<br />

44800 EXCISION OF BOWEL POUCH 18.85 1.00<br />

44820 EXCISION OF MESENTERY LESION 20.75 1.00<br />

44850 REPAIR OF MESENTERY 18.43 1.00<br />

44900 DRAIN APP ABSCESS, OPEN 18.63 1.00<br />

44901 DRAIN APP ABSCESS, PERCUT 4.74 1.00<br />

44950 APPEN<strong>DE</strong>CTOMY 16.01 1.00<br />

44955 APPEN<strong>DE</strong>CTOMY ADD-ON 2.20 1.00<br />

44960 APPEN<strong>DE</strong>CTOMY 21.39 1.00<br />

44970 LAPAROSCOPY, APPEN<strong>DE</strong>CTOMY 14.63 1.00<br />

45000 DRAINAGE OF PELVIC ABSCESS 9.99 1.00<br />

45005 DRAINAGE OF RECTAL ABSCESS 3.83 1.00<br />

45020 DRAINAGE OF RECTAL ABSCESS 12.89 1.00<br />

45100 BIOPSY OF RECTUM 6.99 1.00<br />

45108 REMOVAL OF ANORECTAL LESION 8.57 1.00<br />

45110 REMOVAL OF RECTUM 46.06 1.00<br />

45111 PARTIAL REMOVAL OF RECTUM 27.04 1.00<br />

45112 REMOVAL OF RECTUM 47.52 1.00<br />

45113 PARTIAL PROCTECTOMY 48.67 1.00<br />

45114 PARTIAL REMOVAL OF RECTUM 44.58 1.00<br />

45116 PARTIAL REMOVAL OF RECTUM 40.28 1.00<br />

45119 REMOVE RECTUM W/RESERVOIR 48.71 1.00<br />

45120 REMOVAL OF RECTUM 38.85 1.00<br />

45121 REMOVAL OF RECTUM AND COLON 42.75 1.00<br />

45123 PARTIAL PROCTECTOMY 27.46 1.00<br />

45126 PELVIC EXENTERATION 71.77 1.00<br />

45130 EXCISION OF RECTAL PROLAPSE 26.89 1.00<br />

45135 EXCISION OF RECTAL PROLAPSE 33.02 1.00<br />

45136 EXCISE ILEOANAL RESERVIOR 45.69 1.00<br />

45150 EXCISION OF RECTAL STRICTURE 9.53 1.00<br />

45160 EXCISION OF RECTAL LESION 24.39 1.00<br />

45170 EXCISION OF RECTAL LESION 19.13 1.00<br />

45190 <strong>DE</strong>STRUCTION, RECTAL TUMOR 16.49 1.00<br />

45300 PROCTOSIGMOIDOSCOPY DX 1.21 1.00<br />

45303 PROCTOSIGMOIDOSCOPY DILATE 2.04 1.00<br />

45305 PROCTOSIGMOIDOSCOPY W/BX 1.91 1.00<br />

45307 PROCTOSIGMOIDOSCOPY FB 2.40 1.00<br />

45308 PROCTOSIGMOIDOSCOPY REMOVAL 2.02 1.00<br />

45309 PROCTOSIGMOIDOSCOPY REMOVAL 2.47 1.00<br />

45315 PROCTOSIGMOIDOSCOPY REMOVAL 2.70 1.00<br />

45317 PROCTOSIGMOIDOSCOPY BLEED 2.86 1.00<br />

45320 PROCTOSIGMOIDOSCOPY ABLATE 2.69 1.00<br />

45321 PROCTOSIGMOIDOSCOPY VOLVUL 2.59 1.00<br />

45327 PROCTOSIGMOIDOSCOPY W/STENT 2.96 1.00<br />

45330 DIAGNOSTIC SIGMOIDOSCOPY 1.60 1.00<br />

45331 SIGMOIDOSCOPY AND BIOPSY 1.93 1.00<br />

45332 SIGMOIDOSCOPY W/FB REMOVAL 2.85 1.00<br />

45333 SIGMOIDOSCOPY & POLYPECTOMY 2.83 1.00

---

45334 SIGMOIDOSCOPY FOR BLEEDING 4.27 1.00<br />

45335 SIGMOIDOSCOPY W/SUBMUC INJ 2.36 1.00<br />

45337 SIGMOIDOSCOPY & <strong>DE</strong>COMPRESS 3.69 1.00<br />

45338 SIGMOIDOSCOPY W/TUMR REMOVE 3.67 1.00<br />

45339 SIGMOIDOSCOPY W/ABLATE TUMR 4.87 1.00<br />

45340 SIG W/BALLOON DILATION 2.97 1.00<br />

45341 SIGMOIDOSCOPY W/ULTRASOUND 4.06 1.00<br />

45342 SIGMOIDOSCOPY W/US GUI<strong>DE</strong> BX 6.20 1.00<br />

45345 SIGMOIDOSCOPY W/STENT 4.48 1.00<br />

45355 SURGICAL COLONOSCOPY 5.35 1.00<br />

45378 DIAGNOSTIC COLONOSCOPY 5.64 1.00<br />

45379 COLONOSCOPY W/FB REMOVAL 7.06 1.00<br />

45380 COLONOSCOPY AND BIOPSY 6.77 1.00<br />

45381 COLONOSCOPY, SUBMUCOUS INJ 6.39 1.00<br />

45382 COLONOSCOPY/CONTROL BLEEDING 8.63 1.00<br />

45383 LESION REMOVAL COLONOSCOPY 8.77 1.00<br />

45384 LESION REMOVE COLONOSCOPY 7.08 1.00<br />

45385 LESION REMOVAL COLONOSCOPY 8.03 1.00<br />

45386 COLONOSCOPY DILATE STRICTURE 6.94 1.00<br />

45387 COLONOSCOPY W/STENT 8.95 1.00<br />

45391 COLONOSCOPY W/ENDOSCOPE US 7.80 1.00<br />

45392 COLONOSCOPY W/ENDOSCOPIC FNB 9.81 1.00<br />

45395 LAP, REMOVAL OF RECTUM 49.74 1.00<br />

45397 LAP, REMOVE RECTUM W/POUCH 53.79 1.00<br />

45400 LAPAROSCOPIC PROC 28.80 1.00<br />

45402 LAP PROCTOPEXY W/SIG RESECT 38.57 1.00<br />

45500 REPAIR OF RECTUM 12.39 1.00<br />

45505 REPAIR OF RECTUM 13.51 1.00<br />

45520 TREATMENT OF RECTAL PROLAPSE 0.98 1.00<br />

45540 CORRECT RECTAL PROLAPSE 26.19 1.00<br />

45541 CORRECT RECTAL PROLAPSE 22.54 1.00<br />

45550 REPAIR RECTUM/REMOVE SIGMOID 36.38 1.00<br />

45560 REPAIR OF RECTOCELE 17.84 1.00<br />

45562 EXPLORATION/REPAIR OF RECTUM 27.21 1.00<br />

45563 EXPLORATION/REPAIR OF RECTUM 39.97 1.00<br />

45800 REPAIR RECT/BLAD<strong>DE</strong>R FISTULA 30.33 1.00<br />

45805 REPAIR FISTULA W/COLOSTOMY 34.94 1.00<br />

45820 REPAIR RECTOURETHRAL FISTULA 30.18 1.00<br />

45825 REPAIR FISTULA W/COLOSTOMY 35.97 1.00<br />

45900 REDUCTION OF RECTAL PROLAPSE 4.84 1.00<br />

45905 DILATION OF ANAL SPHINCTER 4.10 1.00<br />

45910 DILATION OF RECTAL NARROWING 4.87 1.00<br />

45915 REMOVE RECTAL OBSTRUCTION 5.52 1.00<br />

45990 SURG DX EXAM, ANORECTAL 2.73 1.00<br />

46020 PLACEMENT OF SETON 5.35 1.00<br />

46030 REMOVAL OF RECTAL MARKER 2.14 1.00<br />

46040 INCISION OF RECTAL ABSCESS 9.66 1.00<br />

46045 INCISION OF RECTAL ABSCESS 9.75 1.00<br />

46050 INCISION OF ANAL ABSCESS 2.26 1.00<br />

46060 INCISION OF RECTAL ABSCESS 10.74 1.00

---

46070 INCISION OF ANAL SEPTUM 5.19 1.00<br />

46080 INCISION OF ANAL SPHINCTER 3.93 1.00<br />

46083 INCISE EXTERNAL HEMORRHOID 2.51 1.00<br />

46200 REMOVAL OF ANAL FISSURE 7.17 1.00<br />

46210 REMOVAL OF ANAL CRYPT 6.00 1.00<br />

46211 REMOVAL OF ANAL CRYPTS 8.88 1.00<br />

46220 REMOVAL OF ANAL TAG 2.77 1.00<br />

46221 LIGATION OF HEMORRHOID(S) 4.41 1.00<br />

46230 REMOVAL OF ANAL TAGS 4.20 1.00<br />

46250 HEMORRHOI<strong>DE</strong>CTOMY 7.37 1.00<br />

46255 HEMORRHOI<strong>DE</strong>CTOMY 8.41 1.00<br />

46257 REMOVE HEMORRHOIDS & FISSURE 9.68 1.00<br />

46258 REMOVE HEMORRHOIDS & FISTULA 10.57 1.00<br />

46260 HEMORRHOI<strong>DE</strong>CTOMY 11.04 1.00<br />

46261 REMOVE HEMORRHOIDS & FISSURE 12.37 1.00<br />

46262 REMOVE HEMORRHOIDS & FISTULA 12.83 1.00<br />

46270 REMOVAL OF ANAL FISTULA 8.64 1.00<br />

46275 REMOVAL OF ANAL FISTULA 9.30 1.00<br />

46280 REMOVAL OF ANAL FISTULA 10.70 1.00<br />

46285 REMOVAL OF ANAL FISTULA 9.10 1.00<br />

46288 REPAIR ANAL FISTULA 12.64 1.00<br />

46320 REMOVAL OF HEMORRHOID CLOT 2.66 1.00<br />

46500 INJECTION INTO HEMORRHOID(S) 3.00 1.00<br />

46505 CHEMO<strong>DE</strong>NERVATION ANAL MUSC 5.39 1.00<br />

46600 DIAGNOSTIC ANOSCOPY 0.96 1.00<br />

46604 ANOSCOPY AND DILATION 1.71 1.00<br />

46606 ANOSCOPY AND BIOPSY 1.79 1.00<br />

46608 ANOSCOPY, REMOVE FOR BODY 2.07 1.00<br />

46610 ANOSCOPY, REMOVE LESION 2.03 1.00<br />

46611 ANOSCOPY 2.16 1.00<br />

46612 ANOSCOPY, REMOVE LESIONS 2.63 1.00<br />

46614 ANOSCOPY, CONTROL BLEEDING 1.88 1.00<br />

46615 ANOSCOPY 2.68 1.00<br />

46700 REPAIR OF ANAL STRICTURE 15.30 1.00<br />

46705 REPAIR OF ANAL STRICTURE 12.10 1.00<br />

46706 REPR OF ANAL FISTULA W/GLUE 4.06 1.00<br />

46710 REPR PER/VAG POUCH SNGL PROC 26.04 1.00<br />

46712 REPR PER/VAG POUCH DBL PROC 54.52 1.00<br />

46715 REP PERF ANOPER FISTU 12.12 1.00<br />

46716 REP PERF ANOPER/VESTIB FISTU 27.51 1.00<br />

46730 CONSTRUCTION OF ABSENT ANUS 44.90 1.00<br />

46735 CONSTRUCTION OF ABSENT ANUS 53.15 1.00<br />

46740 CONSTRUCTION OF ABSENT ANUS 50.10 1.00<br />

46742 REPAIR OF IMPERFORATED ANUS 58.44 1.00<br />

46744 REPAIR OF CLOACAL ANOMALY 84.50 1.00<br />

46746 REPAIR OF CLOACAL ANOMALY 95.05 1.00<br />

46748 REPAIR OF CLOACAL ANOMALY 96.63 1.00<br />

46750 REPAIR OF ANAL SPHINCTER 18.53 1.00<br />

46751 REPAIR OF ANAL SPHINCTER 15.35 1.00<br />

46753 RECONSTRUCTION OF ANUS 13.97 1.00

---

46754 REMOVAL OF SUTURE FROM ANUS 5.01 1.00<br />

46760 REPAIR OF ANAL SPHINCTER 26.37 1.00<br />

46761 REPAIR OF ANAL SPHINCTER 22.83 1.00<br />

46762 IMPLANT ARTIFICIAL SPHINCTER 22.20 1.00<br />

46900 <strong>DE</strong>STRUCTION, ANAL LESION(S) 3.37 1.00<br />

46910 <strong>DE</strong>STRUCTION, ANAL LESION(S) 3.20 1.00<br />

46916 CRYOSURGERY, ANAL LESION(S) 3.47 1.00<br />

46917 LASER SURGERY, ANAL LESIONS 3.26 1.00<br />

46922 EXCISION OF ANAL LESION(S) 3.23 1.00<br />

46924 <strong>DE</strong>STRUCTION, ANAL LESION(S) 4.47 1.00<br />

46937 CRYOTHERAPY OF RECTAL LESION 4.16 1.00<br />

46938 CRYOTHERAPY OF RECTAL LESION 8.58 1.00<br />

46940 TREATMENT OF ANAL FISSURE 3.63 1.00<br />

46942 TREATMENT OF ANAL FISSURE 3.23 1.00<br />

46945 LIGATION OF HEMORRHOIDS 5.05 1.00<br />

46946 LIGATION OF HEMORRHOIDS 5.39 1.00<br />

46947 HEMORRHOIDOPEXY BY STAPLING 9.15 1.00<br />

47000 NEEDLE BIOPSY OF LIVER 2.68 1.00<br />

47001 NEEDLE BIOPSY, LIVER ADD-ON 2.72 1.00<br />

47010 OPEN DRAINAGE, LIVER LESION 29.44 1.00<br />

47011 PERCUT DRAIN, LIVER LESION 5.17 1.00<br />

47015 INJECT/ASPIRATE LIVER CYST 28.04 1.00<br />

47100 WEDGE BIOPSY OF LIVER 20.49 1.00<br />

47120 PARTIAL REMOVAL OF LIVER 58.09 1.00<br />

47122 EXTENSIVE REMOVAL OF LIVER 86.67 1.00<br />

47125 PARTIAL REMOVAL OF LIVER 77.73 1.00<br />

47130 PARTIAL REMOVAL OF LIVER 83.57 1.00<br />

47135 TRANSPLANTATION OF LIVER 122.89 1.00<br />

47136 TRANSPLANTATION OF LIVER 104.63 1.00<br />

47300 SURGERY FOR LIVER LESION 27.49 1.00<br />

47350 REPAIR LIVER WOUND 33.77 1.00<br />

47360 REPAIR LIVER WOUND 45.97 1.00<br />

47361 REPAIR LIVER WOUND 76.30 1.00<br />

47362 REPAIR LIVER WOUND 34.93 1.00<br />

47370 LAPARO ABLATE LIVER TUMOR RF 31.14 1.00<br />

47371 LAPARO ABLATE LIVER CRYOSURG 31.30 1.00<br />

47380 OPEN ABLATE LIVER TUMOR RF 36.28 1.00<br />

47381 OPEN ABLATE LIVER TUMOR CRYO 37.03 1.00<br />

47382 PERCUT ABLATE LIVER RF 22.29 1.00<br />

47400 INCISION OF LIVER DUCT 52.54 1.00<br />

47420 INCISION OF BILE DUCT 33.21 1.00<br />

47425 INCISION OF BILE DUCT 33.55 1.00<br />

47460 INCISE BILE DUCT SPHINCTER 31.37 1.00<br />

47480 INCISION OF GALLBLAD<strong>DE</strong>R 20.82 1.00<br />

47490 INCISION OF GALLBLAD<strong>DE</strong>R 13.91 1.00<br />

47500 INJECTION FOR LIVER X-RAYS 2.75 1.00<br />

47505 INJECTION FOR LIVER X-RAYS 1.06 1.00<br />

47510 INSERT CATHETER, BILE DUCT 13.22 1.00<br />

47511 INSERT BILE DUCT DRAIN 16.42 1.00<br />

47525 CHANGE BILE DUCT CATHETER 8.63 1.00

---

47530 REVISE/REINSERT BILE TUBE 9.91 1.00<br />

47550 BILE DUCT ENDOSCOPY ADD-ON 4.32 1.00<br />

47552 BILIARY ENDOSCOPY THRU SKIN 8.88 1.00<br />

47553 BILIARY ENDOSCOPY THRU SKIN 8.87 1.00<br />

47554 BILIARY ENDOSCOPY THRU SKIN 13.33 1.00<br />

47555 BILIARY ENDOSCOPY THRU SKIN 10.61 1.00<br />

47556 BILIARY ENDOSCOPY THRU SKIN 11.99 1.00<br />

47560 LAPAROSCOPY W/CHOLANGIO 6.98 1.00<br />

47561 LAPARO W/CHOLANGIO/BIOPSY 7.58 1.00<br />

47562 LAPAROSCOPIC CHOLECYSTECTOMY 18.22 1.00<br />

47563 LAPARO CHOLECYSTECTOMY/GRAPH 18.79 1.00<br />

47564 LAPARO CHOLECYSTECTOMY/EXPLR 21.78 1.00<br />

47570 LAPARO CHOLECYSTOENTEROSTOMY 19.38 1.00<br />

47600 REMOVAL OF GALLBLAD<strong>DE</strong>R 25.83 1.00<br />

47605 REMOVAL OF GALLBLAD<strong>DE</strong>R 24.29 1.00<br />

47610 REMOVAL OF GALLBLAD<strong>DE</strong>R 31.12 1.00<br />

47612 REMOVAL OF GALLBLAD<strong>DE</strong>R 31.39 1.00<br />

47620 REMOVAL OF GALLBLAD<strong>DE</strong>R 34.07 1.00<br />

47630 REMOVE BILE DUCT STONE 15.03 1.00<br />

47700 EXPLORATION OF BILE DUCTS 25.82 1.00<br />

47701 BILE DUCT REVISION 43.36 1.00<br />

47711 EXCISION OF BILE DUCT TUMOR 38.60 1.00<br />

47712 EXCISION OF BILE DUCT TUMOR 49.56 1.00<br />

47715 EXCISION OF BILE DUCT CYST 32.43 1.00<br />

47720 FUSE GALLBLAD<strong>DE</strong>R & BOWEL 27.91 1.00<br />

47721 FUSE UPPER GI STRUCTURES 32.94 1.00<br />

47740 FUSE GALLBLAD<strong>DE</strong>R & BOWEL 31.87 1.00<br />

47741 FUSE GALLBLAD<strong>DE</strong>R & BOWEL 36.18 1.00<br />

47760 FUSE BILE DUCTS AND BOWEL 53.50 1.00<br />

47765 FUSE LIVER DUCTS & BOWEL 69.18 1.00<br />

47780 FUSE BILE DUCTS AND BOWEL 58.30 1.00<br />

47785 FUSE BILE DUCTS AND BOWEL 75.49 1.00<br />

47800 RECONSTRUCTION OF BILE DUCTS 39.03 1.00<br />

47801 PLACEMENT, BILE DUCT SUPPORT 26.92 1.00<br />

47802 FUSE LIVER DUCT & INTESTINE 37.34 1.00<br />

47900 SUTURE BILE DUCT INJURY 33.82 1.00<br />

48000 DRAINAGE OF ABDOMEN 46.48 1.00<br />

48001 PLACEMENT OF DRAIN, PANCREAS 57.57 1.00<br />

48020 REMOVAL OF PANCREATIC STONE 28.54 1.00<br />

48100 BIOPSY OF PANCREAS, OPEN 21.77 1.00<br />

48102 NEEDLE BIOPSY, PANCREAS 6.89 1.00<br />

48105 RESECT/<strong>DE</strong>BRI<strong>DE</strong> PANCREAS 70.78 1.00<br />

48120 REMOVAL OF PANCREAS LESION 27.28 1.00<br />

48140 PARTIAL REMOVAL OF PANCREAS 38.68 1.00<br />

48145 PARTIAL REMOVAL OF PANCREAS 40.13 1.00<br />

48146 PANCREATECTOMY 45.88 1.00<br />

48148 REMOVAL OF PANCREATIC DUCT 30.46 1.00<br />

48150 PARTIAL REMOVAL OF PANCREAS 77.72 1.00<br />

48152 PANCREATECTOMY 71.79 1.00<br />

48153 PANCREATECTOMY 77.65 1.00

---

48154 PANCREATECTOMY 72.18 1.00<br />

48155 REMOVAL OF PANCREAS 44.35 1.00<br />

48500 SURGERY OF PANCREATIC CYST 27.56 1.00<br />

48510 DRAIN PANCREATIC PSEUDOCYST 26.41 1.00<br />

48511 DRAIN PANCREATIC PSEUDOCYST 5.60 1.00<br />

48520 FUSE PANCREAS CYST AND BOWEL 26.89 1.00<br />

48540 FUSE PANCREAS CYST AND BOWEL 32.42 1.00<br />

48545 PANCREATORRHAPHY 32.68 1.00<br />

48547 DUO<strong>DE</strong>NAL EXCLUSION 44.05 1.00<br />

48548 FUSE PANCREAS AND BOWEL 41.26 1.00<br />

48554 TRANSPL ALLOGRAFT PANCREAS 60.62 1.00<br />

48556 REMOVAL, ALLOGRAFT PANCREAS 29.97 1.00<br />

49000 EXPLORATION OF ABDOMEN 19.25 1.00<br />

49002 REOPENING OF ABDOMEN 24.62 1.00<br />

49010 EXPLORATION BEHIND ABDOMEN 23.54 1.00<br />

49020 DRAIN ABDOMINAL ABSCESS 39.35 1.00<br />

49021 DRAIN ABDOMINAL ABSCESS 4.73 1.00<br />

49040 DRAIN, OPEN, ABDOM ABSCESS 24.58 1.00<br />

49041 DRAIN, PERCUT, ABDOM ABSCESS 5.60 1.00<br />

49060 DRAIN, OPEN, RETROP ABSCESS 27.51 1.00<br />

49061 DRAIN, PERCUT, RETROPER ABSC 5.18 1.00<br />

49062 DRAIN TO PERITONEAL CAVITY 18.78 1.00<br />

49080 PUNCTURE, PERITONEAL CAVITY 1.90 1.00<br />

49081 REMOVAL OF ABDOMINAL FLUID 1.80 1.00<br />

49180 BIOPSY, ABDOMINAL MASS 2.42 1.00<br />

49203 EXC ABD TUM 5 CM OR LESS 29.93 1.00<br />

49204 EXC ABD TUM OVER 5 CM 38.21 1.00<br />

49205 EXC ABD TUM OVER 10 CM 43.75 1.00<br />

49215 EXCISE SACRAL SPINE TUMOR 55.41 1.00<br />

49220 MULTIPLE SURGERY, ABDOMEN 24.13 1.00<br />

49250 EXCISION OF UMBILICUS 14.31 1.00<br />

49255 REMOVAL OF OMENTUM 19.46 1.00<br />

49320 DIAG LAPARO SEPARATE PROC 8.28 1.00<br />

49321 LAPAROSCOPY, BIOPSY 8.69 1.00<br />

49322 LAPAROSCOPY, ASPIRATION 9.48 1.00<br />

49323 LAPARO DRAIN LYMPHOCELE 15.92 1.00<br />

49324 LAP INSERTION PERM IP CATH 9.79 1.00<br />

49325 LAP REVISION PERM IP CATH 10.54 1.00<br />

49326 LAP W/OMENTOPEXY ADD-ON 4.86 1.00<br />

49400 AIR INJECTION INTO ABDOMEN 2.65 1.00<br />

49402 REMOVE FOREIGN BODY, ADBOMEN 21.14 1.00<br />

49419 INSRT ABDOM CATH FOR CHEMOTX 11.34 1.00<br />

49420 INSERT ABDOM DRAIN, TEMP 3.56 1.00<br />

49421 INSERT ABDOM DRAIN, PERM 9.75 1.00<br />

49422 REMOVE PERM CANNULA/CATHETER 9.84 1.00<br />

49423 EXCHANGE DRAINAGE CATHETER 2.09 1.00<br />

49424 ASSESS CYST, CONTRAST INJECT 1.10 1.00<br />

49425 INSERT ABDOMEN-VENOUS DRAIN 19.11 1.00<br />

49426 REVISE ABDOMEN-VENOUS SHUNT 16.27 1.00<br />

49427 INJECTION, ABDOMINAL SHUNT 1.27 1.00

---

49428 LIGATION OF SHUNT 11.05 1.00<br />

49429 REMOVAL OF SHUNT 11.64 1.00<br />

49435 INSERT SUBQ EXTEN TO IP CATH 3.15 1.00<br />

49436 EMBED<strong>DE</strong>D IP CATH EXIT-SITE 4.63 1.00<br />

49440 PLACE GASTROSTOMY TUBE PERC 6.48 1.00<br />

49441 PLACE DUOD/JEJ TUBE PERC 7.07 1.00<br />

49442 PLACE CECOSTOMY TUBE PERC 5.87 1.00<br />

49446 CHANGE G-TUBE TO G-J PERC 4.64 1.00<br />

49450 REPLACE G/C TUBE PERC 1.88 1.00<br />

49451 REPLACE DUOD/JEJ TUBE PERC 2.59 1.00<br />

49452 REPLACE G-J TUBE PERC 4.04 1.00<br />

49460 FIX G/COLON TUBE W/<strong>DE</strong>VICE 1.32 1.00<br />

49465 FLUORO EXAM OF G/COLON TUBE 0.87 1.00<br />

49491 RPR HERN PREEMIE REDUC 18.65 1.00<br />

49492 RPR ING HERN PREMIE, BLOCKED 23.30 1.00<br />

49495 RPR ING HERNIA BABY, REDUC 9.90 1.00<br />

49496 RPR ING HERNIA BABY, BLOCKED 14.75 1.00<br />

49500 RPR ING HERNIA, INIT, REDUCE 9.85 1.00<br />

49501 RPR ING HERNIA, INIT BLOCKED 14.63 1.00<br />

49505 PRP I/HERN INIT REDUC >5 YR 12.72 1.00<br />

49507 PRP I/HERN INIT BLOCK >5 YR 15.69 1.00<br />

49520 REREPAIR ING HERNIA, REDUCE 15.59 1.00<br />

49521 REREPAIR ING HERNIA, BLOCKED 19.06 1.00<br />

49525 REPAIR ING HERNIA, SLIDING 14.08 1.00<br />

49540 REPAIR LUMBAR HERNIA 16.69 1.00<br />

49550 RPR REM HERNIA, INIT, REDUCE 14.17 1.00<br />

49553 RPR FEM HERNIA, INIT BLOCKED 15.49 1.00<br />

49555 REREPAIR FEM HERNIA, REDUCE 14.74 1.00<br />

49557 REREPAIR FEM HERNIA, BLOCKED 17.92 1.00<br />

49560 RPR VENTRAL HERN INIT, REDUC 18.37 1.00<br />

49561 RPR VENTRAL HERN INIT, BLOCK 23.12 1.00<br />

49565 REREPAIR VENTRL HERN, REDUCE 18.96 1.00<br />

49566 REREPAIR VENTRL HERN, BLOCK 23.35 1.00<br />

49568 HERNIA REPAIR W/MESH 6.97 1.00<br />

49570 RPR EPIGASTRIC HERN, REDUCE 9.99 1.00<br />

49572 RPR EPIGASTRIC HERN, BLOCKED 12.31 1.00<br />

49580 RPR UMBIL HERN, REDUC < 5 YR 7.70 1.00<br />

49582 RPR UMBIL HERN, BLOCK < 5 YR 11.51 1.00<br />

49585 RPR UMBIL HERN, REDUC > 5 YR 10.73 1.00<br />

49587 RPR UMBIL HERN, BLOCK > 5 YR 12.75 1.00<br />

49590 REPAIR SPIGELIAN HERNIA 14.03 1.00<br />

49600 REPAIR UMBILICAL LESION 18.14 1.00<br />

49605 REPAIR UMBILICAL LESION 124.29 1.00<br />

49606 REPAIR UMBILICAL LESION 28.61 1.00<br />

49610 REPAIR UMBILICAL LESION 17.14 1.00<br />

49611 REPAIR UMBILICAL LESION 15.63 1.00<br />

49650 LAP ING HERNIA REPAIR INIT 10.50 1.00<br />

49651 LAP ING HERNIA REPAIR RECUR 13.56 1.00<br />

49900 REPAIR OF ABDOMINAL WALL 20.14 1.00<br />

49904 OMENTAL FLAP, EXTRA-ABDOM 38.41 1.00

---

49905 OMENTAL FLAP, INTRA-ABDOM 9.28 1.00<br />

49906 FREE OMENTAL FLAP, MICROVASC 4.00 1.00<br />

50010 EXPLORATION OF KIDNEY 19.04 1.00<br />

50020 RENAL ABSCESS, OPEN DRAIN 27.34 1.00<br />

50021 RENAL ABSCESS, PERCUT DRAIN 4.73 1.00<br />

50040 DRAINAGE OF KIDNEY 25.33 1.00<br />

50045 EXPLORATION OF KIDNEY 25.28 1.00<br />

50060 REMOVAL OF KIDNEY STONE 31.49 1.00<br />

50065 INCISION OF KIDNEY 32.56 1.00<br />

50070 INCISION OF KIDNEY 32.91 1.00<br />

50075 REMOVAL OF KIDNEY STONE 40.42 1.00<br />

50080 REMOVAL OF KIDNEY STONE 24.07 1.00<br />

50081 REMOVAL OF KIDNEY STONE 35.33 1.00<br />

50100 REVISE KIDNEY BLOOD VESSELS 26.52 1.00<br />

50120 EXPLORATION OF KIDNEY 26.21 1.00<br />

50125 EXPLORE AND DRAIN KIDNEY 27.44 1.00<br />

50130 REMOVAL OF KIDNEY STONE 28.50 1.00<br />

50135 EXPLORATION OF KIDNEY 31.01 1.00<br />

50200 BIOPSY OF KIDNEY 4.03 1.00<br />

50205 BIOPSY OF KIDNEY 18.75 1.00<br />

50220 REMOVE KIDNEY, OPEN 28.26 1.00<br />

50225 REMOVAL KIDNEY OPEN, COMPLEX 32.81 1.00<br />

50230 REMOVAL KIDNEY OPEN, RADICAL 35.34 1.00<br />

50234 REMOVAL OF KIDNEY & URETER 35.93 1.00<br />

50236 REMOVAL OF KIDNEY & URETER 40.59 1.00<br />

50240 PARTIAL REMOVAL OF KIDNEY 36.37 1.00<br />

50250 CRYOABLATE RENAL MASS OPEN 33.78 1.00<br />

50280 REMOVAL OF KIDNEY LESION 26.01 1.00<br />

50290 REMOVAL OF KIDNEY LESION 24.51 1.00<br />

50320 REMOVE KIDNEY, LIVING DONOR 36.12 1.00<br />

50340 REMOVAL OF KIDNEY 22.66 1.00<br />

50360 TRANSPLANTATION OF KIDNEY 61.35 1.00<br />

50365 TRANSPLANTATION OF KIDNEY 68.92 1.00<br />

50370 REMOVE TRANSPLANTED KIDNEY 28.53 1.00<br />

50380 REIMPLANTATION OF KIDNEY 46.29 1.00<br />

50382 CHANGE URETER STENT, PERCUT 7.80 1.00<br />

50384 REMOVE URETER STENT, PERCUT 7.09 1.00<br />

50385 CHANGE STENT VIA TRANSURETH 6.76 1.00<br />

50386 REMOVE STENT VIA TRANSURETH 5.11 1.00<br />

50387 CHANGE EXT/INT URETER STENT 2.82 1.00<br />

50389 REMOVE RENAL TUBE W/FLUORO 1.56 1.00<br />

50390 DRAINAGE OF KIDNEY LESION 2.75 1.00<br />

50391 INSTLL RX AGNT INTO RNAL TUB 2.77 1.00<br />

50392 INSERT KIDNEY DRAIN 5.09 1.00<br />

50393 INSERT URETERAL TUBE 6.20 1.00<br />

50394 INJECTION FOR KIDNEY X-RAY 1.43 1.00<br />

50395 CREATE PASSAGE TO KIDNEY 5.11 1.00<br />

50396 MEASURE KIDNEY PRESSURE 3.30 1.00<br />

50398 CHANGE KIDNEY TUBE 2.07 1.00<br />

50400 REVISION OF KIDNEY/URETER 31.91 1.00

---

50405 REVISION OF KIDNEY/URETER 38.44 1.00<br />

50500 REPAIR OF KIDNEY WOUND 31.63 1.00<br />

50520 CLOSE KIDNEY-SKIN FISTULA 28.56 1.00<br />

50525 REPAIR RENAL-ABDOMEN FISTULA 36.45 1.00<br />

50526 REPAIR RENAL-ABDOMEN FISTULA 37.11 1.00<br />

50540 REVISION OF HORSESHOE KIDNEY 31.78 1.00<br />

50541 LAPARO ABLATE RENAL CYST 25.48 1.00<br />

50542 LAPARO ABLATE RENAL MASS 32.23 1.00<br />

50543 LAPARO PARTIAL NEPHRECTOMY 41.14 1.00<br />

50544 LAPAROSCOPY, PYELOPLASTY 34.83 1.00<br />

50545 LAPARO RADICAL NEPHRECTOMY 37.31 1.00<br />

50546 LAPAROSCOPIC NEPHRECTOMY 33.09 1.00<br />

50547 LAPARO REMOVAL DONOR KIDNEY 40.80 1.00<br />

50548 LAPARO REMOVE W/URETER 37.64 1.00<br />

50551 KIDNEY ENDOSCOPY 8.30 1.00<br />

50553 KIDNEY ENDOSCOPY 8.77 1.00<br />

50555 KIDNEY ENDOSCOPY & BIOPSY 9.65 1.00<br />

50557 KIDNEY ENDOSCOPY & TREATMENT 9.76 1.00<br />

50561 KIDNEY ENDOSCOPY & TREATMENT 11.15 1.00<br />

50562 RENAL SCOPE W/TUMOR RESECT 16.47 1.00<br />

50570 KIDNEY ENDOSCOPY 13.89 1.00<br />

50572 KIDNEY ENDOSCOPY 15.09 1.00<br />

50574 KIDNEY ENDOSCOPY & BIOPSY 16.04 1.00<br />

50575 KIDNEY ENDOSCOPY 20.24 1.00<br />

50576 KIDNEY ENDOSCOPY & TREATMENT 15.97 1.00<br />

50580 KIDNEY ENDOSCOPY & TREATMENT 17.20 1.00<br />

50590 FRAGMENTING OF KIDNEY STONE 15.41 1.00<br />

50592 PERC RF ABLATE RENAL TUMOR 10.19 1.00<br />

50593 PERC CRYO ABLATE RENAL TUM 13.11 1.00<br />

50600 EXPLORATION OF URETER 25.76 1.00<br />

50605 INSERT URETERAL SUPPORT 25.42 1.00<br />

50610 REMOVAL OF URETER STONE 26.52 1.00<br />

50620 REMOVAL OF URETER STONE 24.98 1.00<br />

50630 REMOVAL OF URETER STONE 24.41 1.00<br />

50650 REMOVAL OF URETER 28.49 1.00<br />

50660 REMOVAL OF URETER 31.59 1.00<br />

50684 INJECTION FOR URETER X-RAY 1.36 1.00<br />

50686 MEASURE URETER PRESSURE 2.44 1.00<br />

50688 CHANGE OF URETER TUBE/STENT 2.26 1.00<br />

50690 INJECTION FOR URETER X-RAY 1.96 1.00<br />

50700 REVISION OF URETER 25.75 1.00<br />

50715 RELEASE OF URETER 31.27 1.00<br />

50722 RELEASE OF URETER 27.25 1.00<br />

50725 RELEASE/REVISE URETER 30.00 1.00<br />

50727 REVISE URETER 13.78 1.00<br />

50728 REVISE URETER 19.15 1.00<br />

50740 FUSION OF URETER & KIDNEY 30.24 1.00<br />

50750 FUSION OF URETER & KIDNEY 31.98 1.00<br />

50760 FUSION OF URETERS 30.25 1.00<br />

50770 SPLICING OF URETERS 31.95 1.00

---

50780 REIMPLANT URETER IN BLAD<strong>DE</strong>R 30.16 1.00<br />

50782 REIMPLANT URETER IN BLAD<strong>DE</strong>R 30.45 1.00<br />

50783 REIMPLANT URETER IN BLAD<strong>DE</strong>R 31.68 1.00<br />

50785 REIMPLANT URETER IN BLAD<strong>DE</strong>R 33.27 1.00<br />

50800 IMPLANT URETER IN BOWEL 25.24 1.00<br />

50810 FUSION OF URETER & BOWEL 34.53 1.00<br />

50815 URINE SHUNT TO INTESTINE 33.55 1.00<br />

50820 CONSTRUCT BOWEL BLAD<strong>DE</strong>R 36.04 1.00<br />

50825 CONSTRUCT BOWEL BLAD<strong>DE</strong>R 45.58 1.00<br />

50830 REVISE URINE FLOW 49.85 1.00<br />

50840 REPLACE URETER BY BOWEL 33.84 1.00<br />

50845 APPENDICO-VESICOSTOMY 34.26 1.00<br />

50860 TRANSPLANT URETER TO SKIN 26.14 1.00<br />

50900 REPAIR OF URETER 23.09 1.00<br />

50920 CLOSURE URETER/SKIN FISTULA 24.21 1.00<br />

50930 CLOSURE URETER/BOWEL FISTULA 30.05 1.00<br />

50940 RELEASE OF URETER 24.13 1.00<br />

50945 LAPAROSCOPY URETEROLITHOTOMY 27.39 1.00<br />

50947 LAPARO NEW URETER/BLAD<strong>DE</strong>R 38.79 1.00<br />

50948 LAPARO NEW URETER/BLAD<strong>DE</strong>R 35.34 1.00<br />

50951 ENDOSCOPY OF URETER 8.65 1.00<br />

50953 ENDOSCOPY OF URETER 9.45 1.00<br />

50955 URETER ENDOSCOPY & BIOPSY 10.29 1.00<br />

50957 URETER ENDOSCOPY & TREATMENT 10.02 1.00<br />

50961 URETER ENDOSCOPY & TREATMENT 8.94 1.00<br />

50970 URETER ENDOSCOPY 10.50 1.00<br />

50972 URETER ENDOSCOPY & CATHETER 10.13 1.00<br />

50974 URETER ENDOSCOPY & BIOPSY 13.24 1.00<br />

50976 URETER ENDOSCOPY & TREATMENT 13.15 1.00<br />

50980 URETER ENDOSCOPY & TREATMENT 10.07 1.00<br />

51020 INCISE & TREAT BLAD<strong>DE</strong>R 12.65 1.00<br />

51030 INCISE & TREAT BLAD<strong>DE</strong>R 12.69 1.00<br />

51040 INCISE & DRAIN BLAD<strong>DE</strong>R 7.97 1.00<br />

51045 INCISE BLAD<strong>DE</strong>R/DRAIN URETER 12.74 1.00<br />

51050 REMOVAL OF BLAD<strong>DE</strong>R STONE 12.84 1.00<br />

51060 REMOVAL OF URETER STONE 15.90 1.00<br />

51065 REMOVE URETER CALCULUS 15.75 1.00<br />

51080 DRAINAGE OF BLAD<strong>DE</strong>R ABSCESS 11.11 1.00<br />

51100 DRAIN BLAD<strong>DE</strong>R BY NEEDLE 1.10 1.00<br />

51101 DRAIN BLAD<strong>DE</strong>R BY TROCAR/CATH 1.46 1.00<br />

51102 DRAIN BL W/CATH INSERTION 6.92 1.00<br />

51500 REMOVAL OF BLAD<strong>DE</strong>R CYST 17.33 1.00<br />

51520 REMOVAL OF BLAD<strong>DE</strong>R LESION 16.26 1.00<br />

51525 REMOVAL OF BLAD<strong>DE</strong>R LESION 23.58 1.00<br />

51530 REMOVAL OF BLAD<strong>DE</strong>R LESION 21.20 1.00<br />

51535 REPAIR OF URETER LESION 21.74 1.00<br />

51550 PARTIAL REMOVAL OF BLAD<strong>DE</strong>R 26.13 1.00<br />

51555 PARTIAL REMOVAL OF BLAD<strong>DE</strong>R 34.74 1.00<br />

51565 REVISE BLAD<strong>DE</strong>R & URETER(S) 35.67 1.00<br />

51570 REMOVAL OF BLAD<strong>DE</strong>R 40.65 1.00

---

51575 REMOVAL OF BLAD<strong>DE</strong>R & NO<strong>DE</strong>S 50.41 1.00<br />

51580 REMOVE BLAD<strong>DE</strong>R/REVISE TRACT 52.43 1.00<br />

51585 REMOVAL OF BLAD<strong>DE</strong>R & NO<strong>DE</strong>S 58.38 1.00<br />

51590 REMOVE BLAD<strong>DE</strong>R/REVISE TRACT 53.36 1.00<br />

51595 REMOVE BLAD<strong>DE</strong>R/REVISE TRACT 60.57 1.00<br />

51596 REMOVE BLAD<strong>DE</strong>R/CREATE POUCH 65.00 1.00<br />

51597 REMOVAL OF PELVIC STRUCTURES 62.94 1.00<br />

51600 INJECTION FOR BLAD<strong>DE</strong>R X-RAY 1.25 1.00<br />

51605 PREPARATION FOR BLAD<strong>DE</strong>R XRAY 1.07 1.00<br />

51610 INJECTION FOR BLAD<strong>DE</strong>R X-RAY 1.77 1.00<br />

51700 IRRIGATION OF BLAD<strong>DE</strong>R 1.25 1.00<br />

51701 INSERT BLAD<strong>DE</strong>R CATHETER 0.76 1.00<br />

51702 INSERT TEMP BLAD<strong>DE</strong>R CATH 0.83 1.00<br />

51703 INSERT BLAD<strong>DE</strong>R CATH, COMPLEX 2.25 1.00<br />

51705 CHANGE OF BLAD<strong>DE</strong>R TUBE 1.83 1.00<br />

51710 CHANGE OF BLAD<strong>DE</strong>R TUBE 2.58 1.00<br />

51715 ENDOSCOPIC INJECTION/IMPLANT 5.56 1.00<br />

51720 TREATMENT OF BLAD<strong>DE</strong>R LESION 2.35 1.00<br />

51725 SIMPLE CYSTOMETROGRAM 6.58 1.00<br />

51726 COMPLEX CYSTOMETROGRAM 9.20 1.00<br />

51736 URINE FLOW MEASUREMENT 1.43 1.00<br />

51741 ELECTRO-UROFLOWMETRY, FIRST 2.28 1.00<br />

51772 URETHRA PRESSURE PROFILE 7.13 1.00<br />

51784 ANAL/URINARY MUSCLE STUDY 5.74 1.00<br />

51785 ANAL/URINARY MUSCLE STUDY 6.18 1.00<br />

51792 URINARY REFLEX STUDY 6.82 1.00<br />

51795 URINE VOIDING PRESSURE STUDY 8.75 1.00<br />

51797 INTRAABDOMINAL PRESSURE TEST 5.08 1.00<br />

51798 US URINE CAPACITY MEASURE 0.55 1.00<br />

51800 REVISION OF BLAD<strong>DE</strong>R/URETHRA 28.70 1.00<br />

51820 REVISION OF URINARY TRACT 30.18 1.00<br />

51840 ATTACH BLAD<strong>DE</strong>R/URETHRA 18.00 1.00<br />

51841 ATTACH BLAD<strong>DE</strong>R/URETHRA 21.46 1.00<br />

51845 REPAIR BLAD<strong>DE</strong>R NECK 16.17 1.00<br />

51860 REPAIR OF BLAD<strong>DE</strong>R WOUND 19.90 1.00<br />

51865 REPAIR OF BLAD<strong>DE</strong>R WOUND 24.42 1.00<br />

51880 REPAIR OF BLAD<strong>DE</strong>R OPENING 12.87 1.00<br />

51900 REPAIR BLAD<strong>DE</strong>R/VAGINA LESION 22.71 1.00<br />

51920 CLOSE BLAD<strong>DE</strong>R-UTERUS FISTULA 21.28 1.00<br />

51925 HYSTERECTOMY/BLAD<strong>DE</strong>R REPAIR 29.90 1.00<br />

51940 CORRECTION OF BLAD<strong>DE</strong>R <strong>DE</strong>FECT 44.54 1.00<br />

51960 REVISION OF BLAD<strong>DE</strong>R & BOWEL 38.10 1.00<br />

51980 CONSTRUCT BLAD<strong>DE</strong>R OPENING 19.52 1.00<br />

51990 LAPARO URETHRAL SUSPENSION 20.69 1.00<br />

51992 LAPARO SLING OPERATION 22.54 1.00<br />

52000 CYSTOSCOPY 3.40 1.00<br />

52001 CYSTOSCOPY, REMOVAL OF CLOTS 8.05 1.00<br />

52005 CYSTOSCOPY & URETER CATHETER 3.67 1.00<br />

52007 CYSTOSCOPY AND BIOPSY 4.62 1.00<br />

52010 CYSTOSCOPY & DUCT CATHETER 4.61 1.00

---

52204 CYSTOSCOPY W/BIOPSY(S) 3.90 1.00<br />

52214 CYSTOSCOPY AND TREATMENT 5.54 1.00<br />

52224 CYSTOSCOPY AND TREATMENT 4.74 1.00<br />

52234 CYSTOSCOPY AND TREATMENT 6.91 1.00<br />

52235 CYSTOSCOPY AND TREATMENT 8.12 1.00<br />

52240 CYSTOSCOPY AND TREATMENT 14.22 1.00<br />

52250 CYSTOSCOPY AND RADIOTRACER 6.78 1.00<br />

52260 CYSTOSCOPY AND TREATMENT 5.86 1.00<br />

52265 CYSTOSCOPY AND TREATMENT 4.45 1.00<br />

52270 CYSTOSCOPY & REVISE URETHRA 5.09 1.00<br />

52275 CYSTOSCOPY & REVISE URETHRA 6.98 1.00<br />

52276 CYSTOSCOPY AND TREATMENT 7.45 1.00<br />

52277 CYSTOSCOPY AND TREATMENT 9.16 1.00<br />

52281 CYSTOSCOPY AND TREATMENT 4.31 1.00<br />

52282 CYSTOSCOPY, IMPLANT STENT 9.44 1.00<br />

52283 CYSTOSCOPY AND TREATMENT 5.61 1.00<br />

52285 CYSTOSCOPY AND TREATMENT 5.44 1.00<br />

52290 CYSTOSCOPY AND TREATMENT 6.85 1.00<br />

52300 CYSTOSCOPY AND TREATMENT 7.91 1.00<br />

52301 CYSTOSCOPY AND TREATMENT 8.29 1.00<br />

52305 CYSTOSCOPY AND TREATMENT 7.85 1.00<br />

52310 CYSTOSCOPY AND TREATMENT 4.24 1.00<br />

52315 CYSTOSCOPY AND TREATMENT 7.72 1.00<br />

52317 REMOVE BLAD<strong>DE</strong>R STONE 9.47 1.00<br />

52318 REMOVE BLAD<strong>DE</strong>R STONE 13.40 1.00<br />

52320 CYSTOSCOPY AND TREATMENT 6.94 1.00<br />

52325 CYSTOSCOPY, STONE REMOVAL 9.04 1.00<br />

52327 CYSTOSCOPY, INJECT MATERIAL 7.48 1.00<br />

52330 CYSTOSCOPY AND TREATMENT 7.44 1.00<br />

52332 CYSTOSCOPY AND TREATMENT 4.09 1.00<br />

52334 CREATE PASSAGE TO KIDNEY 7.20 1.00<br />

52341 CYSTO W/URETER STRICTURE TX 9.17 1.00<br />

52342 CYSTO W/UP STRICTURE TX 9.87 1.00<br />

52343 CYSTO W/RENAL STRICTURE TX 10.86 1.00<br />

52344 CYSTO/URETERO, STRICTURE TX 11.71 1.00<br />

52345 CYSTO/URETERO W/UP STRICTURE 12.42 1.00<br />

52346 CYSTOURETERO W/RENAL STRICT 13.89 1.00<br />

52351 CYSTOURETERO & OR PYELOSCOPE 8.81 1.00<br />

52352 CYSTOURETERO W/STONE REMOVE 10.34 1.00<br />

52353 CYSTOURETERO W/LITHOTRIPSY 11.91 1.00<br />

52354 CYSTOURETERO W/BIOPSY 11.01 1.00<br />

52355 CYSTOURETERO W/EXCISE TUMOR 13.13 1.00<br />

52400 CYSTOURETERO W/CONGEN REPR 15.30 1.00<br />

52402 CYSTOURETHRO CUT EJACUL DUCT 7.59 1.00<br />

52450 INCISION OF PROSTATE 12.75 1.00<br />

52500 REVISION OF BLAD<strong>DE</strong>R NECK 15.04 1.00<br />

52601 PROSTATECTOMY (TURP) 22.76 1.00<br />

52630 REMOVE PROSTATE REGROWTH 12.15 1.00<br />

52640 RELIEVE BLAD<strong>DE</strong>R CONTRACTURE 11.05 1.00<br />

52647 LASER SURGERY OF PROSTATE 17.59 1.00

---

52648 LASER SURGERY OF PROSTATE 18.79 1.00<br />

52649 PROSTATE LASER ENUCLEATION 27.59 1.00<br />

52700 DRAINAGE OF PROSTATE ABSCESS 11.91 1.00<br />

53000 INCISION OF URETHRA 4.12 1.00<br />

53010 INCISION OF URETHRA 7.96 1.00<br />

53020 INCISION OF URETHRA 2.71 1.00<br />

53025 INCISION OF URETHRA 1.87 1.00<br />

53040 DRAINAGE OF URETHRA ABSCESS 10.86 1.00<br />

53060 DRAINAGE OF URETHRA ABSCESS 4.38 1.00<br />

53080 DRAINAGE OF URINARY LEAKAGE 12.80 1.00<br />

53085 DRAINAGE OF URINARY LEAKAGE 17.88 1.00<br />

53200 BIOPSY OF URETHRA 3.93 1.00<br />

53210 REMOVAL OF URETHRA 21.28 1.00<br />

53215 REMOVAL OF URETHRA 25.70 1.00<br />

53220 TREATMENT OF URETHRA LESION 12.37 1.00<br />

53230 REMOVAL OF URETHRA LESION 16.58 1.00<br />

53235 REMOVAL OF URETHRA LESION 17.49 1.00<br />

53240 SURGERY FOR URETHRA POUCH 11.70 1.00<br />

53250 REMOVAL OF URETHRA GLAND 10.75 1.00<br />

53260 TREATMENT OF URETHRA LESION 4.88 1.00<br />

53265 TREATMENT OF URETHRA LESION 5.08 1.00<br />

53270 REMOVAL OF URETHRA GLAND 5.10 1.00<br />

53275 REPAIR OF URETHRA <strong>DE</strong>FECT 7.37 1.00<br />

53400 REVISE URETHRA, STAGE 1 22.06 1.00<br />

53405 REVISE URETHRA, STAGE 2 24.11 1.00<br />

53410 RECONSTRUCTION OF URETHRA 27.05 1.00<br />

53415 RECONSTRUCTION OF URETHRA 30.93 1.00<br />

53420 RECONSTRUCT URETHRA, STAGE 1 22.70 1.00<br />

53425 RECONSTRUCT URETHRA, STAGE 2 26.01 1.00<br />

53430 RECONSTRUCTION OF URETHRA 26.35 1.00<br />

53431 RECONSTRUCT URETHRA/BLAD<strong>DE</strong>R 31.96 1.00<br />

53440 MALE SLING PROCEDURE 23.88 1.00<br />

53442 REMOVE/REVISE MALE SLING 21.01 1.00<br />

53444 INSERT TAN<strong>DE</strong>M CUFF 21.95 1.00<br />

53445 INSERT URO/VES NCK SPHINCTER 24.12 1.00<br />

53446 REMOVE URO SPHINCTER 17.72 1.00<br />

53447 REMOVE/REPLACE UR SPHINCTER 22.50 1.00<br />

53448 REMOV/REPLC UR SPHINCTR COMP 35.45 1.00<br />

53449 REPAIR URO SPHINCTER 16.77 1.00<br />

53450 REVISION OF URETHRA 11.12 1.00<br />

53460 REVISION OF URETHRA 12.52 1.00<br />

53500 URETHRLYS, TRANSVAG W/ SCOPE 20.58 1.00<br />

53502 REPAIR OF URETHRA INJURY 13.32 1.00<br />

53505 REPAIR OF URETHRA INJURY 13.32 1.00<br />

53510 REPAIR OF URETHRA INJURY 17.57 1.00<br />

53515 REPAIR OF URETHRA INJURY 22.09 1.00<br />

53520 REPAIR OF URETHRA <strong>DE</strong>FECT 15.30 1.00<br />

53600 DILATE URETHRA STRICTURE 1.80 1.00<br />

53601 DILATE URETHRA STRICTURE 1.49 1.00<br />

53605 DILATE URETHRA STRICTURE 1.83 1.00

---

53620 DILATE URETHRA STRICTURE 2.44 1.00<br />

53621 DILATE URETHRA STRICTURE 2.03 1.00<br />

53660 DILATION OF URETHRA 1.14 1.00<br />

53661 DILATION OF URETHRA 1.12 1.00<br />

53665 DILATION OF URETHRA 1.08 1.00<br />

53850 PROSTATIC MICROWAVE THERMOTX 15.55 1.00<br />

53852 PROSTATIC RF THERMOTX 16.89 1.00<br />

54440 REPAIR OF PENIS 3.00 1.00<br />

54660 REVISION OF TESTIS 999.99 1.00<br />

58999 GENITAL SURGERY PROCEDURE 999.99 1.00<br />

61000 REMOVE CRANIAL CAVITY FLUID 2.80 1.00<br />

61001 REMOVE CRANIAL CAVITY FLUID 2.72 1.00<br />

61020 REMOVE BRAIN CAVITY FLUID 3.33 1.00<br />

61026 INJECTION INTO BRAIN CANAL 3.36 1.00<br />

61050 REMOVE BRAIN CANAL FLUID 2.83 1.00<br />

61055 INJECTION INTO BRAIN CANAL 3.64 1.00<br />

61070 BRAIN CANAL SHUNT PROCEDURE 2.14 1.00<br />

61105 TWIST DRILL HOLE 11.14 1.00<br />

61107 DRILL SKULL FOR IMPLANTATION 8.46 1.00<br />

61108 DRILL SKULL FOR DRAINAGE 21.90 1.00<br />

61120 BURR HOLE FOR PUNCTURE 18.01 1.00<br />

61140 PIERCE SKULL FOR BIOPSY 31.37 1.00<br />

61150 PIERCE SKULL FOR DRAINAGE 33.65 1.00<br />

61151 PIERCE SKULL FOR DRAINAGE 24.55 1.00<br />

61154 PIERCE SKULL & REMOVE CLOT 31.29 1.00<br />

61156 PIERCE SKULL FOR DRAINAGE 31.38 1.00<br />

61210 PIERCE SKULL, IMPLANT <strong>DE</strong>VICE 9.86 1.00<br />

61215 INSERT BRAIN-FLUID <strong>DE</strong>VICE 11.75 1.00<br />

61250 PIERCE SKULL & EXPLORE 21.30 1.00<br />

61253 PIERCE SKULL & EXPLORE 23.64 1.00<br />

61304 OPEN SKULL FOR EXPLORATION 41.63 1.00<br />

61305 OPEN SKULL FOR EXPLORATION 49.74 1.00<br />

61312 OPEN SKULL FOR DRAINAGE 51.57 1.00<br />

61313 OPEN SKULL FOR DRAINAGE 49.48 1.00<br />

61314 OPEN SKULL FOR DRAINAGE 45.65 1.00<br />

61315 OPEN SKULL FOR DRAINAGE 52.45 1.00<br />

61316 IMPLT CRAN BONE FLAP TO ABDO 2.30 1.00<br />

61320 OPEN SKULL FOR DRAINAGE 48.44 1.00<br />

61321 OPEN SKULL FOR DRAINAGE 53.64 1.00<br />

61322 <strong>DE</strong>COMPRESSIVE CRANIOTOMY 58.29 1.00<br />

61323 <strong>DE</strong>COMPRESSIVE LOBECTOMY 59.66 1.00<br />

61330 <strong>DE</strong>COMPRESS EYE SOCKET 40.12 1.00<br />

61332 EXPLORE/BIOPSY EYE SOCKET 47.61 1.00<br />

61333 EXPLORE ORBIT/REMOVE LESION 47.33 1.00<br />

61334 EXPLORE ORBIT/REMOVE OBJECT 31.08 1.00<br />

61340 SUBTEMPORAL <strong>DE</strong>COMPRESSION 36.25 1.00<br />

61343 INCISE SKULL (PRESS RELIEF) 55.74 1.00<br />

61345 RELIEVE CRANIAL PRESSURE 51.27 1.00<br />

61440 INCISE SKULL FOR SURGERY 50.15 1.00<br />

61450 INCISE SKULL FOR SURGERY 47.56 1.00

---

61458 INCISE SKULL FOR BRAIN WOUND 50.94 1.00<br />

61460 INCISE SKULL FOR SURGERY 51.65 1.00<br />

61470 INCISE SKULL FOR SURGERY 47.38 1.00<br />

61480 INCISE SKULL FOR SURGERY 46.39 1.00<br />

61490 INCISE SKULL FOR SURGERY 48.32 1.00<br />

61500 REMOVAL OF SKULL LESION 33.91 1.00<br />

61501 REMOVE INFECTED SKULL BONE 28.77 1.00<br />

61510 REMOVAL OF BRAIN LESION 54.81 1.00<br />

61512 REMOVE BRAIN LINING LESION 65.15 1.00<br />

61514 REMOVAL OF BRAIN ABSCESS 48.07 1.00<br />

61516 REMOVAL OF BRAIN LESION 46.96 1.00<br />

61517 IMPLT BRAIN CHEMOTX ADD-ON 2.31 1.00<br />

61518 REMOVAL OF BRAIN LESION 70.05 1.00<br />

61519 REMOVE BRAIN LINING LESION 75.57 1.00<br />

61520 REMOVAL OF BRAIN LESION 96.25 1.00<br />

61521 REMOVAL OF BRAIN LESION 81.42 1.00<br />

61522 REMOVAL OF BRAIN ABSCESS 55.13 1.00<br />

61524 REMOVAL OF BRAIN LESION 52.61 1.00<br />

61526 REMOVAL OF BRAIN LESION 86.99 1.00<br />

61530 REMOVAL OF BRAIN LESION 73.86 1.00<br />

61531 IMPLANT BRAIN ELECTRO<strong>DE</strong>S 29.87 1.00<br />

61533 IMPLANT BRAIN ELECTRO<strong>DE</strong>S 38.14 1.00<br />

61534 REMOVAL OF BRAIN LESION 40.93 1.00<br />

61535 REMOVE BRAIN ELECTRO<strong>DE</strong>S 24.20 1.00<br />

61536 REMOVAL OF BRAIN LESION 65.97 1.00<br />

61537 REMOVAL OF BRAIN TISSUE 59.18 1.00<br />

61538 REMOVAL OF BRAIN TISSUE 63.13 1.00<br />

61539 REMOVAL OF BRAIN TISSUE 59.77 1.00<br />

61540 REMOVAL OF BRAIN TISSUE 56.40 1.00<br />

61541 INCISION OF BRAIN TISSUE 53.56 1.00<br />

61542 REMOVAL OF BRAIN TISSUE 58.37 1.00<br />

61543 REMOVAL OF BRAIN TISSUE 53.87 1.00<br />

61544 REMOVE & TREAT BRAIN LESION 47.29 1.00<br />

61545 EXCISION OF BRAIN TUMOR 80.39 1.00<br />

61546 REMOVAL OF PITUITARY GLAND 58.10 1.00<br />

61548 REMOVAL OF PITUITARY GLAND 38.90 1.00<br />

61550 RELEASE OF SKULL SEAMS 22.71 1.00<br />

61552 RELEASE OF SKULL SEAMS 31.97 1.00<br />

61556 INCISE SKULL/SUTURES 40.98 1.00<br />

61557 INCISE SKULL/SUTURES 42.59 1.00<br />

61558 EXCISION OF SKULL/SUTURES 42.16 1.00<br />

61559 EXCISION OF SKULL/SUTURES 61.18 1.00<br />

61563 EXCISION OF SKULL TUMOR 47.69 1.00<br />

61564 EXCISION OF SKULL TUMOR 61.47 1.00<br />

61566 REMOVAL OF BRAIN TISSUE 56.47 1.00<br />

61567 INCISION OF BRAIN TISSUE 63.26 1.00<br />

61570 REMOVE FOREIGN BODY, BRAIN 46.23 1.00<br />

61571 INCISE SKULL FOR BRAIN WOUND 49.97 1.00<br />

61575 SKULL BASE/BRAINSTEM SURGERY 59.64 1.00<br />

61576 SKULL BASE/BRAINSTEM SURGERY 92.11 1.00

---

61580 CRANIOFACIAL APPROACH, SKULL 61.93 1.00<br />

61581 CRANIOFACIAL APPROACH, SKULL 68.45 1.00<br />

61582 CRANIOFACIAL APPROACH, SKULL 71.04 1.00<br />

61583 CRANIOFACIAL APPROACH, SKULL 73.13 1.00<br />

61584 ORBITOCRANIAL APPROACH/SKULL 71.08 1.00<br />

61585 ORBITOCRANIAL APPROACH/SKULL 75.31 1.00<br />

61586 RESECT NASOPHARYNX, SKULL 54.27 1.00<br />

61590 INFRATEMPORAL APPROACH/SKULL 78.91 1.00<br />

61591 INFRATEMPORAL APPROACH/SKULL 79.60 1.00<br />

61592 ORBITOCRANIAL APPROACH/SKULL 79.71 1.00<br />

61595 TRANSTEMPORAL APPROACH/SKULL 59.30 1.00<br />

61596 TRANSCOCHLEAR APPROACH/SKULL 65.41 1.00<br />

61597 TRANSCONDYLAR APPROACH/SKULL 72.71 1.00<br />

61598 TRANSPETROSAL APPROACH/SKULL 64.81 1.00<br />

61600 RESECT/EXCISE CRANIAL LESION 53.40 1.00<br />

61601 RESECT/EXCISE CRANIAL LESION 59.11 1.00<br />

61605 RESECT/EXCISE CRANIAL LESION 55.98 1.00<br />

61606 RESECT/EXCISE CRANIAL LESION 75.38 1.00<br />

61607 RESECT/EXCISE CRANIAL LESION 70.12 1.00<br />

61608 RESECT/EXCISE CRANIAL LESION 82.66 1.00<br />

61609 TRANSECT ARTERY, SINUS 16.49 1.00<br />

61610 TRANSECT ARTERY, SINUS 49.42 1.00<br />

61611 TRANSECT ARTERY, SINUS 12.06 1.00<br />

61612 TRANSECT ARTERY, SINUS 42.01 1.00<br />

61613 REMOVE ANEURYSM, SINUS 80.21 1.00<br />

61615 RESECT/EXCISE LESION, SKULL 62.38 1.00<br />

61616 RESECT/EXCISE LESION, SKULL 82.82 1.00<br />

61618 REPAIR DURA 32.74 1.00<br />

61619 REPAIR DURA 37.92 1.00<br />

61623 ENDOVASC TEMPORY VESSEL OCCL 14.90 1.00<br />

61624 TRANSCATH OCCLUSION, CNS 29.17 1.00<br />

61626 TRANSCATH OCCLUSION, NON-CNS 23.59 1.00<br />

61630 INTRACRANIAL ANGIOPLASTY 33.56 1.00<br />

61635 INTRACRAN ANGIOPLSTY W/STENT 36.74 1.00<br />

61640 DILATE IC VASOSPASM, INIT 15.86 1.00<br />

61641 DILATE IC VASOSPASM ADD-ON 5.58 1.00<br />

61642 DILATE IC VASOSPASM ADD-ON 11.15 1.00<br />

61680 INTRACRANIAL VESSEL SURGERY 57.44 1.00<br />

61682 INTRACRANIAL VESSEL SURGERY 109.10 1.00<br />

61684 INTRACRANIAL VESSEL SURGERY 72.99 1.00<br />

61686 INTRACRANIAL VESSEL SURGERY 116.64 1.00<br />

61690 INTRACRANIAL VESSEL SURGERY 54.75 1.00<br />

61692 INTRACRANIAL VESSEL SURGERY 93.78 1.00<br />

61697 BRAIN ANEURYSM REPR, COMPLX 104.40 1.00<br />

61698 BRAIN ANEURYSM REPR, COMPLX 110.64 1.00<br />

61700 BRAIN ANEURYSM REPR, SIMPLE 89.38 1.00<br />

61702 INNER SKULL VESSEL SURGERY 97.43 1.00<br />

61703 CLAMP NECK ARTERY 33.03 1.00<br />

61705 REVISE CIRCULATION TO HEAD 65.63 1.00<br />

61708 REVISE CIRCULATION TO HEAD 54.60 1.00

---

61710 REVISE CIRCULATION TO HEAD 49.43 1.00<br />

61711 FUSION OF SKULL ARTERIES 66.73 1.00<br />

61720 INCISE SKULL/BRAIN SURGERY 29.24 1.00<br />

61735 INCISE SKULL/BRAIN SURGERY 35.62 1.00<br />

61750 INCISE SKULL/BRAIN BIOPSY 35.24 1.00<br />

61751 BRAIN BIOPSY W/CT/MR GUI<strong>DE</strong> 34.30 1.00<br />

61760 IMPLANT BRAIN ELECTRO<strong>DE</strong>S 38.05 1.00<br />

61770 INCISE SKULL FOR TREATMENT 37.72 1.00<br />

61790 TREAT TRIGEMINAL NERVE 21.13 1.00<br />

61791 TREAT TRIGEMINAL TRACT 27.28 1.00<br />

61795 BRAIN SURGERY USING COMPUTER 6.55 1.00<br />

61850 IMPLANT NEUROELECTRO<strong>DE</strong>S 24.26 1.00<br />

61860 IMPLANT NEUROELECTRO<strong>DE</strong>S 38.94 1.00<br />

61863 IMPLANT NEUROELECTRO<strong>DE</strong> 38.09 1.00<br />

61864 IMPLANT NEUROELECTR<strong>DE</strong>, ADDL 11.90 1.00<br />

61867 IMPLANT NEUROELECTRO<strong>DE</strong> 55.51 1.00<br />

61868 IMPLANT NEUROELECTR<strong>DE</strong>, ADDÏL 16.82 1.00<br />

61870 IMPLANT NEUROELECTRO<strong>DE</strong>S 29.81 1.00<br />

61875 IMPLANT NEUROELECTRO<strong>DE</strong>S 26.26 1.00<br />

61880 REVISE/REMOVE NEUROELECTRO<strong>DE</strong> 13.40 1.00<br />

61885 INSRT/REDO NEUROSTIM 1 ARRAY 15.15 1.00<br />

61886 IMPLANT NEUROSTIM ARRAYS 19.14 1.00<br />

61888 REVISE/REMOVE NEURORECEIVER 10.10 1.00<br />

62000 TREAT SKULL FRACTURE 21.46 1.00<br />

62005 TREAT SKULL FRACTURE 30.60 1.00<br />

62010 TREATMENT OF HEAD INJURY 38.20 1.00<br />

62100 REPAIR BRAIN FLUID LEAKAGE 40.68 1.00<br />

62115 REDUCTION OF SKULL <strong>DE</strong>FECT 40.99 1.00<br />

62116 REDUCTION OF SKULL <strong>DE</strong>FECT 44.37 1.00<br />

62117 REDUCTION OF SKULL <strong>DE</strong>FECT 46.85 1.00<br />

62120 REPAIR SKULL CAVITY LESION 45.30 1.00<br />

62121 INCISE SKULL REPAIR 41.95 1.00<br />

62140 REPAIR OF SKULL <strong>DE</strong>FECT 26.40 1.00<br />

62141 REPAIR OF SKULL <strong>DE</strong>FECT 28.92 1.00<br />

62142 REMOVE SKULL PLATE/FLAP 21.85 1.00<br />

62143 REPLACE SKULL PLATE/FLAP 25.81 1.00<br />

62145 REPAIR OF SKULL & BRAIN 35.07 1.00<br />

62146 REPAIR OF SKULL WITH GRAFT 30.38 1.00<br />

62147 REPAIR OF SKULL WITH GRAFT 36.04 1.00<br />

62148 RETR BONE FLAP TO FIX SKULL 3.28 1.00<br />

62160 NEUROENDOSCOPY ADD-ON 5.09 1.00<br />

62161 DISSECT BRAIN W/SCOPE 38.42 1.00<br />

62162 REMOVE COLLOID CYST W/SCOPE 47.33 1.00<br />

62163 NEUROENDOSCOPY W/FB REMOVAL 30.00 1.00<br />

62164 REMOVE BRAIN TUMOR W/SCOPE 50.09 1.00<br />

62165 REMOVE PITUIT TUMOR W/SCOPE 38.69 1.00<br />

62180 ESTABLISH BRAIN CAVITY SHUNT 39.76 1.00<br />

62190 ESTABLISH BRAIN CAVITY SHUNT 22.10 1.00<br />

62192 ESTABLISH BRAIN CAVITY SHUNT 24.09 1.00<br />

62194 REPLACE/IRRIGATE CATHETER 9.39 1.00

---

62200 ESTABLISH BRAIN CAVITY SHUNT 34.61 1.00<br />

62201 BRAIN CAVITY SHUNT W/SCOPE 29.47 1.00<br />

62220 ESTABLISH BRAIN CAVITY SHUNT 25.65 1.00<br />

62223 ESTABLISH BRAIN CAVITY SHUNT 25.84 1.00<br />

62225 REPLACE/IRRIGATE CATHETER 12.29 1.00<br />

62230 REPLACE/REVISE BRAIN SHUNT 20.91 1.00<br />

62252 CSF SHUNT REPROGRAM 2.57 1.00<br />

62256 REMOVE BRAIN CAVITY SHUNT 14.32 1.00<br />

62258 REPLACE BRAIN CAVITY SHUNT 28.29 1.00<br />

62263 EPIDURAL LYSIS MULT SESSIONS 9.91 1.00<br />

62264 EPIDURAL LYSIS ON SINGLE DAY 6.02 1.00<br />

62268 DRAIN SPINAL CORD CYST 7.14 1.00<br />

62269 NEEDLE BIOPSY, SPINAL CORD 7.11 1.00<br />

62270 SPINAL FLUID TAP, DIAGNOSTIC 2.02 1.00<br />

62272 DRAIN CEREBRO SPINAL FLUID 2.19 1.00<br />

62273 INJECT EPIDURAL PATCH 2.92 1.00<br />

62280 TREAT SPINAL CORD LESION 4.01 1.00<br />

62281 TREAT SPINAL CORD LESION 3.81 1.00<br />

62282 TREAT SPINAL CANAL LESION 3.52 1.00<br />

62284 INJECTION FOR MYELOGRAM 2.37 1.00<br />

62287 PERCUTANEOUS DISKECTOMY 14.39 1.00<br />

62290 INJECT FOR SPINE DISK X-RAY 4.49 1.00<br />

62291 INJECT FOR SPINE DISK X-RAY 4.32 1.00<br />

62292 INJECTION INTO DISK LESION 13.63 1.00<br />

62294 INJECTION INTO SPINAL ARTERY 20.05 1.00<br />

62310 INJECT SPINE C/T 2.63 1.00<br />

62311 INJECT SPINE L/S (CD) 2.19 1.00<br />

62318 INJECT SPINE W/CATH, C/T 2.70 1.00<br />

62319 INJECT SPINE W/CATH L/S (CD) 2.50 1.00<br />

62350 IMPLANT SPINAL CANAL CATH 13.02 1.00<br />

62351 IMPLANT SPINAL CANAL CATH 21.18 1.00<br />

62355 REMOVE SPINAL CANAL CATHETER 10.65 1.00<br />

62360 INSERT SPINE INFUSION <strong>DE</strong>VICE 6.95 1.00<br />

62361 IMPLANT SPINE INFUSION PUMP 11.38 1.00<br />

62362 IMPLANT SPINE INFUSION PUMP 14.27 1.00<br />

62365 REMOVE SPINE INFUSION <strong>DE</strong>VICE 11.08 1.00<br />

62367 ANALYZE SPINE INFUSION PUMP 0.62 1.00<br />

62368 ANALYZE SPINE INFUSION PUMP 0.98 1.00<br />

63001 REMOVAL OF SPINAL LAMINA 30.92 1.00<br />

63003 REMOVAL OF SPINAL LAMINA 31.17 1.00<br />

63005 REMOVAL OF SPINAL LAMINA 29.49 1.00<br />

63011 REMOVAL OF SPINAL LAMINA 27.80 1.00<br />

63012 REMOVAL OF SPINAL LAMINA 30.16 1.00<br />

63015 REMOVAL OF SPINAL LAMINA 37.32 1.00<br />

63016 REMOVAL OF SPINAL LAMINA 38.21 1.00<br />

63017 REMOVAL OF SPINAL LAMINA 31.19 1.00<br />

63020 NECK SPINE DISK SURGERY 29.55 1.00<br />

63030 LOW BACK DISK SURGERY 24.55 1.00<br />

63035 SPINAL DISK SURGERY ADD-ON 5.33 1.00<br />

63040 LAMINOTOMY, SINGLE CERVICAL 36.13 1.00

---

63042 LAMINOTOMY, SINGLE LUMBAR 33.84 1.00<br />

63045 REMOVAL OF SPINAL LAMINA 32.16 1.00<br />

63046 REMOVAL OF SPINAL LAMINA 30.67 1.00<br />

63047 REMOVAL OF SPINAL LAMINA 28.08 1.00<br />

63048 REMOVE SPINAL LAMINA ADD-ON 5.68 1.00<br />

63050 CERVICAL LAMINOPLASTY 38.38 1.00<br />

63051 C-LAMINOPLASTY W/GRAFT/PLATE 43.33 1.00<br />

63055 <strong>DE</strong>COMPRESS SPINAL CORD 41.51 1.00<br />

63056 <strong>DE</strong>COMPRESS SPINAL CORD 38.47 1.00<br />

63057 <strong>DE</strong>COMPRESS SPINE CORD ADD-ON 8.78 1.00<br />

63064 <strong>DE</strong>COMPRESS SPINAL CORD 45.62 1.00<br />

63066 <strong>DE</strong>COMPRESS SPINE CORD ADD-ON 5.38 1.00<br />

63075 NECK SPINE DISK SURGERY 35.65 1.00<br />

63076 NECK SPINE DISK SURGERY 6.79 1.00<br />

63077 SPINE DISK SURGERY, THORAX 38.68 1.00<br />

63078 SPINE DISK SURGERY, THORAX 5.37 1.00<br />

63081 REMOVAL OF VERTEBRAL BODY 45.44 1.00<br />

63082 REMOVE VERTEBRAL BODY ADD-ON 7.32 1.00<br />

63085 REMOVAL OF VERTEBRAL BODY 48.34 1.00<br />

63086 REMOVE VERTEBRAL BODY ADD-ON 5.16 1.00<br />

63087 REMOVAL OF VERTEBRAL BODY 61.66 1.00<br />

63088 REMOVE VERTEBRAL BODY ADD-ON 7.02 1.00<br />

63090 REMOVAL OF VERTEBRAL BODY 50.22 1.00<br />

63091 REMOVE VERTEBRAL BODY ADD-ON 4.81 1.00<br />

63101 REMOVAL OF VERTEBRAL BODY 57.79 1.00<br />

63102 REMOVAL OF VERTEBRAL BODY 57.69 1.00<br />

63103 REMOVE VERTEBRAL BODY ADD-ON 7.63 1.00<br />

63170 INCISE SPINAL CORD TRACT(S) 38.10 1.00<br />

63172 DRAINAGE OF SPINAL CYST 35.01 1.00<br />

63173 DRAINAGE OF SPINAL CYST 43.07 1.00<br />

63180 REVISE SPINAL CORD LIGAMENTS 35.33 1.00<br />

63182 REVISE SPINAL CORD LIGAMENTS 37.08 1.00<br />

63185 INCISE SPINAL COLUMN/NERVES 28.11 1.00<br />

63190 INCISE SPINAL COLUMN/NERVES 31.88 1.00<br />

63191 INCISE SPINAL COLUMN/NERVES 32.44 1.00<br />

63194 INCISE SPINAL COLUMN & CORD 36.70 1.00<br />

63195 INCISE SPINAL COLUMN & CORD 37.99 1.00<br />

63196 INCISE SPINAL COLUMN & CORD 44.51 1.00<br />

63197 INCISE SPINAL COLUMN & CORD 39.17 1.00<br />

63198 INCISE SPINAL COLUMN & CORD 44.88 1.00<br />

63199 INCISE SPINAL COLUMN & CORD 44.88 1.00<br />

63200 RELEASE OF SPINAL CORD 37.98 1.00<br />

63250 REVISE SPINAL CORD VESSELS 73.19 1.00<br />

63251 REVISE SPINAL CORD VESSELS 77.00 1.00<br />

63252 REVISE SPINAL CORD VESSELS 76.71 1.00<br />

63265 EXCISE INTRASPINAL LESION 42.02 1.00<br />

63266 EXCISE INTRASPINAL LESION 43.29 1.00<br />

63267 EXCISE INTRASPINAL LESION 34.80 1.00<br />

63268 EXCISE INTRASPINAL LESION 34.40 1.00<br />

63270 EXCISE INTRASPINAL LESION 51.92 1.00

---

63271 EXCISE INTRASPINAL LESION 52.16 1.00<br />

63272 EXCISE INTRASPINAL LESION 48.06 1.00<br />

63273 EXCISE INTRASPINAL LESION 46.31 1.00<br />

63275 BIOPSY/EXCISE SPINAL TUMOR 45.31 1.00<br />

63276 BIOPSY/EXCISE SPINAL TUMOR 45.01 1.00<br />

63277 BIOPSY/EXCISE SPINAL TUMOR 39.61 1.00<br />

63278 BIOPSY/EXCISE SPINAL TUMOR 38.71 1.00<br />

63280 BIOPSY/EXCISE SPINAL TUMOR 53.53 1.00<br />

63281 BIOPSY/EXCISE SPINAL TUMOR 53.05 1.00<br />

63282 BIOPSY/EXCISE SPINAL TUMOR 49.95 1.00<br />

63283 BIOPSY/EXCISE SPINAL TUMOR 47.56 1.00<br />

63285 BIOPSY/EXCISE SPINAL TUMOR 66.13 1.00<br />

63286 BIOPSY/EXCISE SPINAL TUMOR 66.02 1.00<br />

63287 BIOPSY/EXCISE SPINAL TUMOR 69.37 1.00<br />

63290 BIOPSY/EXCISE SPINAL TUMOR 69.66 1.00<br />

63295 REPAIR OF LAMINECTOMY <strong>DE</strong>FECT 8.33 1.00<br />

63300 REMOVAL OF VERTEBRAL BODY 46.71 1.00<br />

63301 REMOVAL OF VERTEBRAL BODY 51.71 1.00<br />

63302 REMOVAL OF VERTEBRAL BODY 51.37 1.00<br />

63303 REMOVAL OF VERTEBRAL BODY 54.07 1.00<br />

63304 REMOVAL OF VERTEBRAL BODY 57.56 1.00<br />

63305 REMOVAL OF VERTEBRAL BODY 59.34 1.00<br />

63306 REMOVAL OF VERTEBRAL BODY 60.97 1.00<br />

63307 REMOVAL OF VERTEBRAL BODY 55.10 1.00<br />

63308 REMOVE VERTEBRAL BODY ADD-ON 8.81 1.00<br />

63600 REMOVE SPINAL CORD LESION 21.26 1.00<br />

63610 STIMULATION OF SPINAL CORD 11.45 1.00<br />

63615 REMOVE LESION OF SPINAL CORD 28.97 1.00<br />

63650 IMPLANT NEUROELECTRO<strong>DE</strong>S 11.15 1.00<br />

63655 IMPLANT NEUROELECTRO<strong>DE</strong>S 21.13 1.00<br />

63660 REVISE/REMOVE NEUROELECTRO<strong>DE</strong> 11.17 1.00<br />

63685 INSRT/REDO SPINE N GENERATOR 12.82 1.00<br />

63688 REVISE/REMOVE NEURORECEIVER 10.53 1.00<br />

63700 REPAIR OF SPINAL HERNIATION 30.98 1.00<br />

63702 REPAIR OF SPINAL HERNIATION 33.90 1.00<br />

63704 REPAIR OF SPINAL HERNIATION 39.10 1.00<br />

63706 REPAIR OF SPINAL HERNIATION 45.34 1.00<br />

63707 REPAIR SPINAL FLUID LEAKAGE 22.81 1.00<br />

63709 REPAIR SPINAL FLUID LEAKAGE 27.81 1.00<br />

63710 GRAFT REPAIR OF SPINE <strong>DE</strong>FECT 27.80 1.00<br />

63740 INSTALL SPINAL SHUNT 23.25 1.00<br />

63741 INSTALL SPINAL SHUNT 15.52 1.00<br />

63744 REVISION OF SPINAL SHUNT 16.27 1.00<br />

63746 REMOVAL OF SPINAL SHUNT 13.51 1.00<br />

64400 N BLOCK INJ, TRIGEMINAL 1.62 1.00<br />

64402 N BLOCK INJ, FACIAL 1.89 1.00<br />

64405 N BLOCK INJ, OCCIPITAL 1.88 1.00<br />

64408 N BLOCK INJ, VAGUS 2.29 1.00<br />

64410 N BLOCK INJ, PHRENIC 2.03 1.00<br />

64412 N BLOCK INJ, SPINAL ACCESSOR 1.77 1.00

---

64413 N BLOCK INJ, CERVICAL PLEXUS 1.97 1.00<br />

64415 N BLOCK INJ, BRACHIAL PLEXUS 1.95 1.00<br />

64416 N BLOCK CONT INFUSE, B PLEX 4.79 1.00<br />

64417 N BLOCK INJ, AXILLARY 1.95 1.00<br />

64418 N BLOCK INJ, SUPRASCAPULAR 1.87 1.00<br />

64420 N BLOCK INJ, INTERCOST, SNG 1.69 1.00<br />

64421 N BLOCK INJ, INTERCOST, MLT 2.31 1.00<br />

64425 N BLOCK INJ, ILIO-ING/HYPOGI 2.41 1.00<br />

64430 N BLOCK INJ, PU<strong>DE</strong>NDAL 2.22 1.00<br />

64435 N BLOCK INJ, PARACERVICAL 2.23 1.00<br />

64445 N BLOCK INJ, SCIATIC, SNG 2.08 1.00<br />

64446 N BLK INJ, SCIATIC, CONT INF 4.55 1.00<br />

64447 N BLOCK INJ FEM, SINGLE 1.89 1.00<br />

64448 N BLOCK INJ FEM, CONT INF 4.14 1.00<br />

64449 N BLOCK INJ, LUMBAR PLEXUS 4.08 1.00<br />

64450 N BLOCK, OTHER PERIPHERAL 1.88 1.00<br />

64470 INJ PARAVERTEBRAL C/T 2.66 1.00<br />

64472 INJ PARAVERTEBRAL C/T ADD-ON 1.70 1.00<br />

64475 INJ PARAVERTEBRAL L/S 2.11 1.00<br />

64476 INJ PARAVERTEBRAL L/S ADD-ON 1.28 1.00<br />

64479 INJ FORAMEN EPIDURAL C/T 3.17 1.00<br />

64480 INJ FORAMEN EPIDURAL ADD-ON 2.07 1.00<br />

64483 INJ FORAMEN EPIDURAL L/S 2.80 1.00<br />

64484 INJ FORAMEN EPIDURAL ADD-ON 1.76 1.00<br />

64505 N BLOCK, SPENOPALATINE GANGL 2.16 1.00<br />

64508 N BLOCK, CAROTID SINUS S/P 1.84 1.00<br />

64510 N BLOCK, STELLATE GANGLION 1.76 1.00<br />

64517 N BLOCK INJ, HYPOGAS PLXS 3.09 1.00<br />

64520 N BLOCK, LUMBAR/THORACIC 1.96 1.00<br />

64530 N BLOCK INJ, CELIAC PELUS 2.33 1.00<br />

64550 APPLY NEUROSTIMULATOR 0.24 1.00<br />

64553 IMPLANT NEUROELECTRO<strong>DE</strong>S 4.16 1.00<br />

64555 IMPLANT NEUROELECTRO<strong>DE</strong>S 3.82 1.00<br />

64560 IMPLANT NEUROELECTRO<strong>DE</strong>S 3.87 1.00<br />

64561 IMPLANT NEUROELECTRO<strong>DE</strong>S 10.85 1.00<br />

64565 IMPLANT NEUROELECTRO<strong>DE</strong>S 3.19 1.00<br />

64573 IMPLANT NEUROELECTRO<strong>DE</strong>S 14.96 1.00<br />

64575 IMPLANT NEUROELECTRO<strong>DE</strong>S 7.35 1.00<br />

64577 IMPLANT NEUROELECTRO<strong>DE</strong>S 9.71 1.00<br />

64580 IMPLANT NEUROELECTRO<strong>DE</strong>S 7.63 1.00<br />

64581 IMPLANT NEUROELECTRO<strong>DE</strong>S 21.19 1.00<br />

64585 REVISE/REMOVE NEUROELECTRO<strong>DE</strong> 4.49 1.00<br />

64590 INSRT/REDO PN/GASTR STIMUL 4.98 1.00<br />

64595 REVISE/RMV PN/GASTR STIMUL 3.99 1.00<br />

64600 INJECTION TREATMENT OF NERVE 5.44 1.00<br />

64605 INJECTION TREATMENT OF NERVE 8.64 1.00<br />

64610 INJECTION TREATMENT OF NERVE 12.32 1.00<br />

64612 <strong>DE</strong>STROY NERVE, FACE MUSCLE 3.42 1.00<br />

64613 <strong>DE</strong>STROY NERVE, NECK MUSCLE 3.27 1.00<br />

64614 <strong>DE</strong>STROY NERVE, EXTREM MUSC 3.61 1.00

---

64620 INJECTION TREATMENT OF NERVE 4.28 1.00<br />

64622 <strong>DE</strong>STR PARAVERTEBRL NERVE L/S 4.51 1.00<br />

64623 <strong>DE</strong>STR PARAVERTEBRAL N ADD-ON 1.27 1.00<br />

64626 <strong>DE</strong>STR PARAVERTEBRL NERVE C/T 5.94 1.00<br />

64627 <strong>DE</strong>STR PARAVERTEBRAL N ADD-ON 1.49 1.00<br />

64630 INJECTION TREATMENT OF NERVE 4.86 1.00<br />

64640 INJECTION TREATMENT OF NERVE 4.70 1.00<br />

64650 CHEMO<strong>DE</strong>NERV ECCRINE GLANDS 0.99 1.00<br />

64653 CHEMO<strong>DE</strong>NERV ECCRINE GLANDS 1.25 1.00<br />

64680 INJECTION TREATMENT OF NERVE 4.13 1.00<br />

64681 INJECTION TREATMENT OF NERVE 5.73 1.00<br />

64702 REVISE FINGER/TOE NERVE 11.24 1.00<br />

64704 REVISE HAND/FOOT NERVE 8.52 1.00<br />

64708 REVISE ARM/LEG NERVE 11.71 1.00<br />

64712 REVISION OF SCIATIC NERVE 13.60 1.00<br />

64713 REVISION OF ARM NERVE(S) 19.08 1.00<br />

64714 REVISE LOW BACK NERVE(S) 15.92 1.00<br />

64716 REVISION OF CRANIAL NERVE 13.21 1.00<br />

64718 REVISE ULNAR NERVE AT ELBOW 14.21 1.00<br />

64719 REVISE ULNAR NERVE AT WRIST 9.99 1.00<br />

64721 CARPAL TUNNEL SURGERY 10.58 1.00<br />

64722 RELIEVE PRESSURE ON NERVE(S) 8.24 1.00<br />

64726 RELEASE FOOT/TOE NERVE 7.55 1.00<br />

64727 INTERNAL NERVE REVISION 4.92 1.00<br />

64732 INCISION OF BROW NERVE 9.37 1.00<br />

64734 INCISION OF CHEEK NERVE 10.58 1.00<br />

64736 INCISION OF CHIN NERVE 9.52 1.00<br />

64738 INCISION OF JAW NERVE 11.97 1.00<br />

64740 INCISION OF TONGUE NERVE 11.86 1.00<br />

64742 INCISION OF FACIAL NERVE 11.97 1.00<br />

64744 INCISE NERVE, BACK OF HEAD 10.71 1.00<br />

64746 INCISE DIAPHRAGM NERVE 11.46 1.00<br />

64752 INCISION OF VAGUS NERVE 12.56 1.00<br />

64760 INCISION OF VAGUS NERVE 11.92 1.00<br />

64761 INCISION OF PELVIS NERVE 11.39 1.00<br />

64763 INCISE HIP/THIGH NERVE 12.95 1.00<br />

64766 INCISE HIP/THIGH NERVE 15.39 1.00<br />

64771 SEVER CRANIAL NERVE 14.85 1.00<br />

64772 INCISION OF SPINAL NERVE 14.16 1.00<br />

64774 REMOVE SKIN NERVE LESION 10.37 1.00<br />

64776 REMOVE DIGIT NERVE LESION 9.98 1.00<br />

64778 DIGIT NERVE SURGERY ADD-ON 4.92 1.00<br />

64782 REMOVE LIMB NERVE LESION 11.62 1.00<br />

64783 LIMB NERVE SURGERY ADD-ON 5.82 1.00<br />

64784 REMOVE NERVE LESION 18.37 1.00<br />

64786 REMOVE SCIATIC NERVE LESION 27.87 1.00<br />

64787 IMPLANT NERVE END 6.75 1.00<br />

64788 REMOVE SKIN NERVE LESION 9.63 1.00<br />

64790 REMOVAL OF NERVE LESION 21.17 1.00<br />

64792 REMOVAL OF NERVE LESION 26.77 1.00

---

64795 BIOPSY OF NERVE 5.02 1.00<br />

64802 REMOVE SYMPATHETIC NERVES 15.85 1.00<br />

64804 REMOVE SYMPATHETIC NERVES 24.50 1.00<br />

64809 REMOVE SYMPATHETIC NERVES 22.51 1.00<br />

64818 REMOVE SYMPATHETIC NERVES 17.37 1.00<br />

64820 REMOVE SYMPATHETIC NERVES 19.16 1.00<br />

64821 REMOVE SYMPATHETIC NERVES 17.37 1.00<br />

64822 REMOVE SYMPATHETIC NERVES 17.32 1.00<br />

64823 REMOVE SYMPATHETIC NERVES 19.67 1.00<br />

64831 REPAIR OF DIGIT NERVE 18.49 1.00<br />

64832 REPAIR NERVE ADD-ON 9.12 1.00<br />

64834 REPAIR OF HAND OR FOOT NERVE 19.02 1.00<br />

64835 REPAIR OF HAND OR FOOT NERVE 20.64 1.00<br />

64836 REPAIR OF HAND OR FOOT NERVE 20.65 1.00<br />

64837 REPAIR NERVE ADD-ON 10.12 1.00<br />

64840 REPAIR OF LEG NERVE 23.13 1.00<br />

64856 REPAIR/TRANSPOSE NERVE 25.91 1.00<br />

64857 REPAIR ARM/LEG NERVE 27.11 1.00<br />

64858 REPAIR SCIATIC NERVE 31.20 1.00<br />

64859 NERVE SURGERY 6.89 1.00<br />

64861 REPAIR OF ARM NERVES 35.72 1.00<br />

64862 REPAIR OF LOW BACK NERVES 36.29 1.00<br />

64864 REPAIR OF FACIAL NERVE 22.69 1.00<br />

64865 REPAIR OF FACIAL NERVE 29.99 1.00<br />

64866 FUSION OF FACIAL/OTHER NERVE 30.89 1.00<br />

64868 FUSION OF FACIAL/OTHER NERVE 26.84 1.00<br />

64870 FUSION OF FACIAL/OTHER NERVE 26.65 1.00<br />

64872 SUBSEQUENT REPAIR OF NERVE 3.21 1.00<br />

64874 REPAIR & REVISE NERVE ADD-ON 4.79 1.00<br />

64876 REPAIR NERVE/SHORTEN BONE 5.43 1.00<br />

64885 NERVE GRAFT, HEAD OR NECK 29.41 1.00<br />

64886 NERVE GRAFT, HEAD OR NECK 34.77 1.00<br />

64890 NERVE GRAFT, HAND OR FOOT 27.90 1.00<br />

64891 NERVE GRAFT, HAND OR FOOT 27.47 1.00<br />

64892 NERVE GRAFT, ARM OR LEG 27.09 1.00<br />

64893 NERVE GRAFT, ARM OR LEG 29.11 1.00<br />

64895 NERVE GRAFT, HAND OR FOOT 33.19 1.00<br />

64896 NERVE GRAFT, HAND OR FOOT 36.31 1.00<br />

64897 NERVE GRAFT, ARM OR LEG 32.40 1.00<br />

64898 NERVE GRAFT, ARM OR LEG 35.23 1.00<br />

64901 NERVE GRAFT ADD-ON 16.02 1.00<br />

64902 NERVE GRAFT ADD-ON 18.67 1.00<br />

64905 NERVE PEDICLE TRANSFER 24.74 1.00<br />

64907 NERVE PEDICLE TRANSFER 32.51 1.00<br />

64910 NERVE REPAIR W/ALLOGRAFT 17.61 1.00<br />

64911 NEURORRAPHY W/VEIN AUTOGRAFT 21.44 1.00<br />

65091 REVISE EYE 14.99 1.00<br />

65093 REVISE EYE WITH IMPLANT 15.03 1.00<br />

65101 REMOVAL OF EYE 17.20 1.00<br />

65103 REMOVE EYE/INSERT IMPLANT 17.94 1.00

---

65105 REMOVE EYE/ATTACH IMPLANT 19.74 1.00<br />

65110 REMOVAL OF EYE 28.78 1.00<br />

65112 REMOVE EYE/REVISE SOCKET 34.20 1.00<br />

65114 REMOVE EYE/REVISE SOCKET 35.30 1.00<br />

65125 REVISE OCULAR IMPLANT 6.75 1.00<br />

65130 INSERT OCULAR IMPLANT 16.99 1.00<br />

65135 INSERT OCULAR IMPLANT 17.29 1.00<br />

65140 ATTACH OCULAR IMPLANT 18.76 1.00<br />

65150 REVISE OCULAR IMPLANT 13.76 1.00<br />

65155 REINSERT OCULAR IMPLANT 20.00 1.00<br />

65175 REMOVAL OF OCULAR IMPLANT 15.29 1.00<br />

65205 REMOVE FOREIGN BODY FROM EYE 1.04 1.00<br />

65210 REMOVE FOREIGN BODY FROM EYE 1.26 1.00<br />

65220 REMOVE FOREIGN BODY FROM EYE 1.04 1.00<br />

65222 REMOVE FOREIGN BODY FROM EYE 1.37 1.00<br />

65235 REMOVE FOREIGN BODY FROM EYE 15.91 1.00<br />

65260 REMOVE FOREIGN BODY FROM EYE 22.06 1.00<br />

65265 REMOVE FOREIGN BODY FROM EYE 24.79 1.00<br />

65270 REPAIR OF EYE WOUND 3.30 1.00<br />

65272 REPAIR OF EYE WOUND 7.90 1.00<br />

65273 REPAIR OF EYE WOUND 8.72 1.00<br />

65275 REPAIR OF EYE WOUND 10.32 1.00<br />

65280 REPAIR OF EYE WOUND 15.28 1.00<br />

65285 REPAIR OF EYE WOUND 23.87 1.00<br />

65286 REPAIR OF EYE WOUND 11.22 1.00<br />

65290 REPAIR OF EYE SOCKET WOUND 11.25 1.00<br />

65400 REMOVAL OF EYE LESION 13.55 1.00<br />

65410 BIOPSY OF CORNEA 2.45 1.00<br />

65420 REMOVAL OF EYE LESION 8.65 1.00<br />

65426 REMOVAL OF EYE LESION 10.89 1.00<br />

65430 CORNEAL SMEAR 2.46 1.00<br />

65435 CURETTE/TREAT CORNEA 1.64 1.00<br />

65436 CURETTE/TREAT CORNEA 8.48 1.00<br />

65450 TREATMENT OF CORNEAL LESION 7.28 1.00<br />

65600 REVISION OF CORNEA 7.61 1.00<br />

65710 CORNEAL TRANSPLANT 25.37 1.00<br />

65730 CORNEAL TRANSPLANT 28.18 1.00<br />

65750 CORNEAL TRANSPLANT 28.63 1.00<br />

65755 CORNEAL TRANSPLANT 28.46 1.00<br />

65767 CORNEAL TISSUE TRANSPLANT 5.00 1.00<br />

65770 REVISE CORNEA WITH IMPLANT 32.71 1.00<br />

65771 RADIAL KERATOTOMY 999.99 1.00<br />

65772 CORRECTION OF ASTIGMATISM 9.19 1.00<br />

65775 CORRECTION OF ASTIGMATISM 12.64 1.00<br />

65780 OCULAR RECONST, TRANSPLANT 20.48 1.00<br />

65781 OCULAR RECONST, TRANSPLANT 30.91 1.00<br />

65782 OCULAR RECONST, TRANSPLANT 26.69 1.00<br />

65800 DRAINAGE OF EYE 3.10 1.00<br />

65805 DRAINAGE OF EYE 3.11 1.00<br />

65810 DRAINAGE OF EYE 10.59 1.00

---

65815 DRAINAGE OF EYE 10.79 1.00<br />

65820 RELIEVE INNER EYE PRESSURE 17.40 1.00<br />

65850 INCISION OF EYE 19.64 1.00<br />

65855 LASER SURGERY OF EYE 6.95 1.00<br />

65860 INCISE INNER EYE ADHESIONS 6.03 1.00<br />

65865 INCISE INNER EYE ADHESIONS 11.10 1.00<br />

65870 INCISE INNER EYE ADHESIONS 13.58 1.00<br />

65875 INCISE INNER EYE ADHESIONS 14.39 1.00<br />

65880 INCISE INNER EYE ADHESIONS 15.18 1.00<br />

65900 REMOVE EYE LESION 22.38 1.00<br />

65920 REMOVE IMPLANT OF EYE 17.97 1.00<br />

65930 REMOVE BLOOD CLOT FROM EYE 14.91 1.00<br />

66020 INJECTION TREATMENT OF EYE 3.05 1.00<br />

66030 INJECTION TREATMENT OF EYE 2.54 1.00<br />

66130 REMOVE EYE LESION 13.36 1.00<br />

66150 GLAUCOMA SURGERY 19.75 1.00<br />

66155 GLAUCOMA SURGERY 19.66 1.00<br />

66160 GLAUCOMA SURGERY 22.37 1.00<br />

66165 GLAUCOMA SURGERY 19.30 1.00<br />

66170 GLAUCOMA SURGERY 27.06 1.00<br />

66172 INCISION OF EYE 33.92 1.00<br />

66180 IMPLANT EYE SHUNT 26.96 1.00<br />

66185 REVISE EYE SHUNT 16.96 1.00<br />

66220 REPAIR EYE LESION 16.51 1.00<br />

66225 REPAIR/GRAFT EYE LESION 21.36 1.00<br />

66250 FOLLOW-UP SURGERY OF EYE 12.59 1.00<br />

66500 INCISION OF IRIS 8.22 1.00<br />

66505 INCISION OF IRIS 8.98 1.00<br />

66600 REMOVE IRIS AND LESION 18.56 1.00<br />

66605 REMOVAL OF IRIS 24.50 1.00<br />

66625 REMOVAL OF IRIS 9.92 1.00<br />

66630 REMOVAL OF IRIS 12.94 1.00<br />

66635 REMOVAL OF IRIS 13.06 1.00<br />

66680 REPAIR IRIS & CILIARY BODY 11.68 1.00<br />

66700 <strong>DE</strong>STRUCTION, CILIARY BODY 9.06 1.00<br />

66710 CILIARY TRANSSLERAL THERAPY 9.01 1.00<br />

66711 CILIARY ENDOSCOPIC ABLATION 14.38 1.00<br />

66720 <strong>DE</strong>STRUCTION, CILIARY BODY 9.64 1.00<br />

66740 <strong>DE</strong>STRUCTION, CILIARY BODY 9.08 1.00<br />

66761 REVISION OF IRIS 9.32 1.00<br />

66762 REVISION OF IRIS 9.66 1.00<br />

66770 REMOVAL OF INNER EYE LESION 10.93 1.00<br />

66820 INCISION, SECONDARY CATARACT 9.34 1.00<br />

66821 AFTER CATARACT LASER SURGERY 6.95 1.00<br />

66825 REPOSITION INTRAOCULAR LENS 17.64 1.00<br />

66830 REMOVAL OF LENS LESION 16.29 1.00<br />

66840 REMOVAL OF LENS MATERIAL 15.95 1.00<br />

66850 REMOVAL OF LENS MATERIAL 18.12 1.00<br />

66852 REMOVAL OF LENS MATERIAL 19.41 1.00<br />

66920 EXTRACTION OF LENS 17.34 1.00

---

66930 EXTRACTION OF LENS 19.67 1.00<br />

66940 EXTRACTION OF LENS 17.87 1.00<br />

66982 CATARACT SURGERY, COMPLEX 24.87 1.00<br />

66983 CATARACT SURG W/IOL, 1 STAGE 16.65 1.00<br />

66984 CATARACT SURG W/IOL, 1 STAGE 17.68 1.00<br />

66985 INSERT LENS PROSTHESIS 17.38 1.00<br />

66986 EXCHANGE LENS PROSTHESIS 21.48 1.00<br />

66990 OPHTHALMIC ENDOSCOPE ADD-ON 2.19 1.00<br />

67005 PARTIAL REMOVAL OF EYE FLUID 10.77 1.00<br />

67010 PARTIAL REMOVAL OF EYE FLUID 12.49 1.00<br />

67015 RELEASE OF EYE FLUID 13.42 1.00<br />

67025 REPLACE EYE FLUID 14.32 1.00<br />

67027 IMPLANT EYE DRUG SYSTEM 19.65 1.00<br />

67028 INJECTION EYE DRUG 3.99 1.00<br />

67030 INCISE INNER EYE STRANDS 11.88 1.00<br />

67031 LASER SURGERY, EYE STRANDS 8.05 1.00<br />

67036 REMOVAL OF INNER EYE FLUID 22.26 1.00<br />

67039 LASER TREATMENT OF RETINA 28.54 1.00<br />

67040 LASER TREATMENT OF RETINA 32.92 1.00<br />

67041 VIT FOR MACULAR PUCKER 30.23 1.00<br />

67042 VIT FOR MACULAR HOLE 34.62 1.00<br />

67043 VIT FOR MEMBRANE DISSECT 36.33 1.00<br />

67101 REPAIR <strong>DE</strong>TACHED RETINA 15.32 1.00<br />

67105 REPAIR <strong>DE</strong>TACHED RETINA 14.69 1.00<br />

67107 REPAIR <strong>DE</strong>TACHED RETINA 27.91 1.00<br />

67108 REPAIR <strong>DE</strong>TACHED RETINA 37.19 1.00<br />

67110 REPAIR <strong>DE</strong>TACHED RETINA 17.64 1.00<br />

67112 REREPAIR <strong>DE</strong>TACHED RETINA 30.61 1.00<br />

67113 REPAIR RETINAL <strong>DE</strong>TACH, CPLX 39.88 1.00<br />

67115 RELEASE ENCIRCLING MATERIAL 11.18 1.00<br />

67120 REMOVE EYE IMPLANT MATERIAL 12.62 1.00<br />

67121 REMOVE EYE IMPLANT MATERIAL 20.77 1.00<br />

67141 TREATMENT OF RETINA 11.02 1.00<br />

67145 TREATMENT OF RETINA 11.26 1.00<br />

67208 TREATMENT OF RETINAL LESION 13.19 1.00<br />

67210 TREATMENT OF RETINAL LESION 15.45 1.00<br />

67218 TREATMENT OF RETINAL LESION 32.53 1.00<br />

67220 TREATMENT OF CHOROID LESION 23.43 1.00<br />

67221 OCULAR PHOTODYNAMIC THER 5.24 1.00<br />

67225 EYE PHOTODYNAMIC THER ADD-ON 0.68 1.00<br />

67227 TREATMENT OF RETINAL LESION 13.05 1.00<br />

67228 TREATMENT OF RETINAL LESION 23.67 1.00<br />

67229 TR RETINAL LES PRETERM INF 26.23 1.00<br />

67250 REINFORCE EYE WALL 18.35 1.00<br />

67255 REINFORCE/GRAFT EYE WALL 19.57 1.00<br />

67311 REVISE EYE MUSCLE 13.72 1.00<br />

67312 REVISE TWO EYE MUSCLES 16.38 1.00<br />

67314 REVISE EYE MUSCLE 15.33 1.00<br />

67316 REVISE TWO EYE MUSCLES 18.43 1.00<br />

67318 REVISE EYE MUSCLE(S) 16.05 1.00

---

67320 REVISE EYE MUSCLE(S) ADD-ON 7.56 1.00<br />

67331 EYE SURGERY FOLLOW-UP ADD-ON 7.16 1.00<br />

67332 REREVISE EYE MUSCLES ADD-ON 7.79 1.00<br />

67334 REVISE EYE MUSCLE W/SUTURE 7.05 1.00<br />

67335 EYE SUTURE DURING SURGERY 3.62 1.00<br />

67340 REVISE EYE MUSCLE ADD-ON 8.42 1.00<br />

67343 RELEASE EYE TISSUE 14.95 1.00<br />

67345 <strong>DE</strong>STROY NERVE OF EYE MUSCLE 5.00 1.00<br />

67346 BIOPSY, EYE MUSCLE 4.77 1.00<br />

67400 EXPLORE/BIOPSY EYE SOCKET 21.87 1.00<br />

67405 EXPLORE/DRAIN EYE SOCKET 18.50 1.00<br />

67412 EXPLORE/TREAT EYE SOCKET 20.38 1.00<br />

67413 EXPLORE/TREAT EYE SOCKET 20.33 1.00<br />

67414 EXPLR/<strong>DE</strong>COMPRESS EYE SOCKET 30.27 1.00<br />

67415 ASPIRATION, ORBITAL CONTENTS 2.54 1.00<br />

67420 EXPLORE/TREAT EYE SOCKET 38.59 1.00<br />

67430 EXPLORE/TREAT EYE SOCKET 29.23 1.00<br />

67440 EXPLORE/DRAIN EYE SOCKET 28.33 1.00<br />

67445 EXPLR/<strong>DE</strong>COMPRESS EYE SOCKET 32.89 1.00<br />

67450 EXPLORE/BIOPSY EYE SOCKET 29.29 1.00<br />

67500 INJECT/TREAT EYE SOCKET 1.86 1.00<br />

67505 INJECT/TREAT EYE SOCKET 1.73 1.00<br />

67515 INJECT/TREAT EYE SOCKET 1.93 1.00<br />

67550 INSERT EYE SOCKET IMPLANT 22.81 1.00<br />

67560 REVISE EYE SOCKET IMPLANT 23.11 1.00<br />

67570 <strong>DE</strong>COMPRESS OPTIC NERVE 27.19 1.00<br />

67700 DRAINAGE OF EYELID ABSCESS 2.66 1.00<br />

67710 INCISION OF EYELID 2.23 1.00<br />

67715 INCISION OF EYELID FOLD 2.52 1.00<br />

67800 REMOVE EYELID LESION 2.43 1.00<br />

67801 REMOVE EYELID LESIONS 3.15 1.00<br />

67805 REMOVE EYELID LESIONS 3.88 1.00<br />

67808 REMOVE EYELID LESION(S) 8.35 1.00<br />

67810 BIOPSY OF EYELID 2.22 1.00<br />

67820 REVISE EYELASHES 1.28 1.00<br />

67825 REVISE EYELASHES 2.80 1.00<br />

67830 REVISE EYELASHES 3.21 1.00<br />

67835 REVISE EYELASHES 10.26 1.00<br />

67840 REMOVE EYELID LESION 3.71 1.00<br />

67850 TREAT EYELID LESION 3.24 1.00<br />

67875 CLOSURE OF EYELID BY SUTURE 2.31 1.00<br />

67880 REVISION OF EYELID 8.35 1.00<br />

67882 REVISION OF EYELID 10.75 1.00<br />

67900 REPAIR BROW <strong>DE</strong>FECT 12.00 1.00<br />

67901 REPAIR EYELID <strong>DE</strong>FECT 13.36 1.00<br />

67902 REPAIR EYELID <strong>DE</strong>FECT 16.18 1.00<br />

67903 REPAIR EYELID <strong>DE</strong>FECT 11.82 1.00<br />

67904 REPAIR EYELID <strong>DE</strong>FECT 13.54 1.00<br />

67906 REPAIR EYELID <strong>DE</strong>FECT 12.05 1.00<br />

67908 REPAIR EYELID <strong>DE</strong>FECT 10.21 1.00

---

67909 REVISE EYELID <strong>DE</strong>FECT 10.33 1.00<br />

67911 REVISE EYELID <strong>DE</strong>FECT 12.60 1.00<br />

67912 CORRECTION EYELID W/IMPLANT 11.65 1.00<br />

67914 REPAIR EYELID <strong>DE</strong>FECT 6.75 1.00<br />

67915 REPAIR EYELID <strong>DE</strong>FECT 5.99 1.00<br />

67916 REPAIR EYELID <strong>DE</strong>FECT 10.10 1.00<br />

67917 REPAIR EYELID <strong>DE</strong>FECT 11.18 1.00<br />

67921 REPAIR EYELID <strong>DE</strong>FECT 6.32 1.00<br />

67922 REPAIR EYELID <strong>DE</strong>FECT 5.78 1.00<br />

67923 REPAIR EYELID <strong>DE</strong>FECT 10.89 1.00<br />

67924 REPAIR EYELID <strong>DE</strong>FECT 10.51 1.00<br />

67930 REPAIR EYELID WOUND 5.79 1.00<br />

67935 REPAIR EYELID WOUND 10.66 1.00<br />

67938 REMOVE EYELID FOREIGN BODY 2.65 1.00<br />

67950 REVISION OF EYELID 11.04 1.00<br />

67961 REVISION OF EYELID 10.75 1.00<br />

67966 REVISION OF EYELID 14.86 1.00<br />

67971 RECONSTRUCTION OF EYELID 17.13 1.00<br />

67973 RECONSTRUCTION OF EYELID 22.23 1.00<br />

67974 RECONSTRUCTION OF EYELID 22.14 1.00<br />

67975 RECONSTRUCTION OF EYELID 16.16 1.00<br />

68020 INCISE/DRAIN EYELID LINING 2.58 1.00<br />

68040 TREATMENT OF EYELID LESIONS 1.28 1.00<br />

68100 BIOPSY OF EYELID LINING 2.32 1.00<br />

68110 REMOVE EYELID LINING LESION 3.44 1.00<br />

68115 REMOVE EYELID LINING LESION 4.30 1.00<br />

68130 REMOVE EYELID LINING LESION 9.54 1.00<br />

68135 REMOVE EYELID LINING LESION 3.51 1.00<br />

68200 TREAT EYELID BY INJECTION 0.82 1.00<br />

68320 REVISE/GRAFT EYELID LINING 12.13 1.00<br />

68325 REVISE/GRAFT EYELID LINING 15.19 1.00<br />

68326 REVISE/GRAFT EYELID LINING 14.74 1.00<br />

68328 REVISE/GRAFT EYELID LINING 16.63 1.00<br />

68330 REVISE EYELID LINING 10.45 1.00<br />

68335 REVISE/GRAFT EYELID LINING 14.77 1.00<br />

68340 SEPARATE EYELID ADHESIONS 9.03 1.00<br />

68360 REVISE EYELID LINING 9.33 1.00<br />

68362 REVISE EYELID LINING 14.96 1.00<br />

68371 HARVEST EYE TISSUE, ALOGRAFT 9.80 1.00<br />

68400 INCISE/DRAIN TEAR GLAND 3.31 1.00<br />

68420 INCISE/DRAIN TEAR SAC 4.19 1.00<br />

68440 INCISE TEAR DUCT OPENING 2.24 1.00<br />

68500 REMOVAL OF TEAR GLAND 22.67 1.00<br />

68505 PARTIAL REMOVAL, TEAR GLAND 22.75 1.00<br />

68510 BIOPSY OF TEAR GLAND 6.89 1.00<br />

68520 REMOVAL OF TEAR SAC 15.91 1.00<br />

68525 BIOPSY OF TEAR SAC 6.44 1.00<br />

68530 CLEARANCE OF TEAR DUCT 6.21 1.00<br />

68540 REMOVE TEAR GLAND LESION 21.39 1.00<br />

68550 REMOVE TEAR GLAND LESION 26.18 1.00

---

68700 REPAIR TEAR DUCTS 13.76 1.00<br />

68705 REVISE TEAR DUCT OPENING 3.87 1.00<br />

68720 CREATE TEAR SAC DRAIN 17.59 1.00<br />

68745 CREATE TEAR DUCT DRAIN 17.64 1.00<br />

68750 CREATE TEAR DUCT DRAIN 18.15 1.00<br />

68760 CLOSE TEAR DUCT OPENING 3.38 1.00<br />

68761 CLOSE TEAR DUCT OPENING 2.72 1.00<br />

68770 CLOSE TEAR SYSTEM FISTULA 12.91 1.00<br />

68801 DILATE TEAR DUCT OPENING 2.46 1.00<br />

68810 PROBE NASOLACRIMAL DUCT 5.41 1.00<br />

68811 PROBE NASOLACRIMAL DUCT 4.79 1.00<br />

68815 PROBE NASOLACRIMAL DUCT 6.03 1.00<br />

68816 PROBE NL DUCT W/BALLOON 5.67 1.00<br />

68840 EXPLORE/IRRIGATE TEAR DUCTS 2.53 1.00<br />

68850 INJECTION FOR TEAR SAC X-RAY 1.48 1.00<br />

70010 CONTRAST X-RAY OF BRAIN 5.23 1.00<br />

70015 CONTRAST X-RAY OF BRAIN 3.68 1.00<br />

70030 X-RAY EYE FOR FOREIGN BODY 0.74 1.00<br />

70100 X-RAY EXAM OF JAW 0.82 1.00<br />

70110 X-RAY EXAM OF JAW 1.05 1.00<br />

70120 X-RAY EXAM OF MASTOIDS 0.92 1.00<br />

70130 X-RAY EXAM OF MASTOIDS 1.43 1.00<br />

70134 X-RAY EXAM OF MIDDLE EAR 1.28 1.00<br />

70140 X-RAY EXAM OF FACIAL BONES 0.86 1.00<br />

70150 X-RAY EXAM OF FACIAL BONES 1.17 1.00<br />

70160 X-RAY EXAM OF NASAL BONES 0.84 1.00<br />

70170 X-RAY EXAM OF TEAR DUCT 1.42 1.00<br />

70190 X-RAY EXAM OF EYE SOCKETS 0.97 1.00<br />

70200 X-RAY EXAM OF EYE SOCKETS 1.21 1.00<br />

70210 X-RAY EXAM OF SINUSES 0.84 1.00<br />

70220 X-RAY EXAM OF SINUSES 1.11 1.00<br />

70240 X-RAY EXAM, PITUITARY SADDLE 0.76 1.00<br />

70250 X-RAY EXAM OF SKULL 0.98 1.00<br />

70260 X-RAY EXAM OF SKULL 1.36 1.00<br />

70300 X-RAY EXAM OF TEETH 0.40 1.00<br />

70310 X-RAY EXAM OF TEETH 0.84 1.00<br />

70320 FULL MOUTH X-RAY OF TEETH 1.25 1.00<br />

70328 X-RAY EXAM OF JAW JOINT 0.80 1.00<br />

70330 X-RAY EXAM OF JAW JOINTS 1.26 1.00<br />

70332 X-RAY EXAM OF JAW JOINT 2.56 1.00<br />

70336 MAGNETIC IMAGE, JAW JOINT 14.08 1.00<br />

70350 X-RAY HEAD FOR ORTHODONTIA 0.59 1.00<br />

70355 PANORAMIC X-RAY OF JAWS 0.72 1.00<br />

70360 X-RAY EXAM OF NECK 0.72 1.00<br />

70370 THROAT X-RAY & FLUOROSCOPY 1.93 1.00<br />

70371 SPEECH EVALUATION, COMPLEX 2.93 1.00<br />

70373 CONTRAST X-RAY OF LARYNX 2.33 1.00<br />

70380 X-RAY EXAM OF SALIVARY GLAND 1.00 1.00<br />

70390 X-RAY EXAM OF SALIVARY DUCT 2.64 1.00<br />

70450 CT HEAD/BRAIN W/O DYE 6.10 1.00

---

70460 CT HEAD/BRAIN W/DYE 7.76 1.00<br />

70470 CT HEAD/BRAIN W/O & W/DYE 9.41 1.00<br />

70480 CT ORBIT/EAR/FOSSA W/O DYE 8.40 1.00<br />

70481 CT ORBIT/EAR/FOSSA W/DYE 9.79 1.00<br />

70482 CT ORBIT/EAR/FOSSA W/O&W/DYE 11.36 1.00<br />

70486 CT MAXILLOFACIAL W/O DYE 7.38 1.00<br />

70487 CT MAXILLOFACIAL W/DYE 8.89 1.00<br />

70488 CT MAXILLOFACIAL W/O & W/DYE 10.82 1.00<br />

70490 CT SOFT TISSUE NECK W/O DYE 7.41 1.00<br />

70491 CT SOFT TISSUE NECK W/DYE 8.82 1.00<br />

70492 CT SFT TSUE NCK W/O & W/DYE 10.67 1.00<br />

70496 CT ANGIOGRAPHY, HEAD 16.55 1.00<br />

70498 CT ANGIOGRAPHY, NECK 16.62 1.00<br />

70540 MRI ORBIT/FACE/NECK W/O DYE 14.71 1.00<br />

70542 MRI ORBIT/FACE/NECK W/DYE 16.80 1.00<br />

70543 MRI ORBT/FAC/NCK W/O & W/DYE 25.27 1.00<br />

70544 MR ANGIOGRAPHY HEAD W/O DYE 15.57 1.00<br />

70545 MR ANGIOGRAPHY HEAD W/DYE 15.51 1.00<br />

70546 MR ANGIOGRAPH HEAD W/O&W/DYE 26.00 1.00<br />

70547 MR ANGIOGRAPHY NECK W/O DYE 15.53 1.00<br />

70548 MR ANGIOGRAPHY NECK W/DYE 15.97 1.00<br />

70549 MR ANGIOGRAPH NECK W/O&W/DYE 26.00 1.00<br />

70551 MRI BRAIN W/O DYE 15.21 1.00<br />

70552 MRI BRAIN W/DYE 17.38 1.00<br />

70553 MRI BRAIN W/O & W/DYE 25.65 1.00<br />

70554 FMRI BRAIN BY TECH 18.45 1.00<br />

71010 CHEST X-RAY 0.69 1.00<br />

71015 CHEST X-RAY 0.82 1.00<br />

71020 CHEST X-RAY 0.90 1.00<br />

71021 CHEST X-RAY 1.10 1.00<br />

71022 CHEST X-RAY 1.23 1.00<br />

71023 CHEST X-RAY AND FLUOROSCOPY 1.67 1.00<br />

71030 CHEST X-RAY 1.27 1.00<br />

71034 CHEST X-RAY AND FLUOROSCOPY 2.41 1.00<br />

71035 CHEST X-RAY 0.89 1.00<br />

71040 CONTRAST X-RAY OF BRONCHI 2.54 1.00<br />

71060 CONTRAST X-RAY OF BRONCHI 3.68 1.00<br />

71100 X-RAY EXAM OF RIBS 0.90 1.00<br />

71101 X-RAY EXAM OF RIBS/CHEST 1.08 1.00<br />

71110 X-RAY EXAM OF RIBS 1.15 1.00<br />

71111 X-RAY EXAM OF RIBS/CHEST 1.42 1.00<br />

71120 X-RAY EXAM OF BREASTBONE 0.93 1.00<br />

71130 X-RAY EXAM OF BREASTBONE 1.03 1.00<br />

71250 CT THORAX W/O DYE 7.89 1.00<br />

71260 CT THORAX W/DYE 9.40 1.00<br />

71270 CT THORAX W/O & W/DYE 11.58 1.00<br />

71275 CT ANGIOGRAPHY, CHEST 14.79 1.00<br />

71550 MRI CHEST W/O DYE 16.00 1.00<br />

71551 MRI CHEST W/DYE 18.30 1.00<br />

71552 MRI CHEST W/O & W/DYE 27.14 1.00

---

71555 MRI ANGIO CHEST W OR W/O DYE 16.04 1.00<br />

72010 X-RAY EXAM OF SPINE 1.83 1.00<br />

72020 X-RAY EXAM OF SPINE 0.65 1.00<br />

72040 X-RAY EXAM OF NECK SPINE 0.99 1.00<br />

72050 X-RAY EXAM OF NECK SPINE 1.41 1.00<br />

72052 X-RAY EXAM OF NECK SPINE 1.76 1.00<br />

72069 X-RAY EXAM OF TRUNK SPINE 0.91 1.00<br />

72070 X-RAY EXAM OF THORACIC SPINE 0.95 1.00<br />

72072 X-RAY EXAM OF THORACIC SPINE 1.06 1.00<br />

72074 X-RAY EXAM OF THORACIC SPINE 1.25 1.00<br />

72080 X-RAY EXAM OF TRUNK SPINE 0.98 1.00<br />

72090 X-RAY EXAM OF TRUNK SPINE 1.22 1.00<br />

72100 X-RAY EXAM OF LOWER SPINE 1.04 1.00<br />

72110 X-RAY EXAM OF LOWER SPINE 1.45 1.00<br />

72114 X-RAY EXAM OF LOWER SPINE 1.87 1.00<br />

72120 X-RAY EXAM OF LOWER SPINE 1.30 1.00<br />

72125 CT NECK SPINE W/O DYE 7.90 1.00<br />

72126 CT NECK SPINE W/DYE 9.37 1.00<br />

72127 CT NECK SPINE W/O & W/DYE 11.45 1.00<br />

72128 CT CHEST SPINE W/O DYE 7.89 1.00<br />

72129 CT CHEST SPINE W/DYE 9.38 1.00<br />

72130 CT CHEST SPINE W/O & W/DYE 11.42 1.00<br />

72131 CT LUMBAR SPINE W/O DYE 7.88 1.00<br />

72132 CT LUMBAR SPINE W/DYE 9.36 1.00<br />

72133 CT LUMBAR SPINE W/O & W/DYE 11.44 1.00<br />

72141 MRI NECK SPINE W/O DYE 14.36 1.00<br />

72142 MRI NECK SPINE W/DYE 17.56 1.00<br />

72146 MRI CHEST SPINE W/O DYE 15.04 1.00<br />

72147 MRI CHEST SPINE W/DYE 16.54 1.00<br />

72148 MRI LUMBAR SPINE W/O DYE 14.87 1.00<br />

72149 MRI LUMBAR SPINE W/DYE 17.35 1.00<br />

72156 MRI NECK SPINE W/O & W/DYE 25.76 1.00<br />

72157 MRI CHEST SPINE W/O & W/DYE 24.97 1.00<br />

72158 MRI LUMBAR SPINE W/O & W/DYE 25.46 1.00<br />

72159 MR ANGIO SPINE W/O&W/DYE 16.34 1.00<br />

72170 X-RAY EXAM OF PELVIS 0.74 1.00<br />

72190 X-RAY EXAM OF PELVIS 1.05 1.00<br />

72191 CT ANGIOGRAPH PELV W/O&W/DYE 14.27 1.00<br />

72192 CT PELVIS W/O DYE 7.60 1.00<br />

72193 CT PELVIS W/DYE 8.96 1.00<br />

72194 CT PELVIS W/O & W/DYE 11.21 1.00<br />

72195 MRI PELVIS W/O DYE 15.03 1.00<br />

72196 MRI PELVIS W/DYE 17.11 1.00<br />

72197 MRI PELVIS W/O & W/DYE 25.58 1.00<br />

72198 MR ANGIO PELVIS W/O & W/DYE 15.91 1.00<br />

72200 X-RAY EXAM SACROILIAC JOINTS 0.79 1.00<br />

72202 X-RAY EXAM SACROILIAC JOINTS 0.95 1.00<br />

72220 X-RAY EXAM OF TAILBONE 0.83 1.00<br />

72240 CONTRAST X-RAY OF NECK SPINE 5.00 1.00<br />

72255 CONTRAST X-RAY, THORAX SPINE 4.60 1.00

---

72265 CONTRAST X-RAY, LOWER SPINE 4.52 1.00<br />

72270 CONTRAST X-RAY, SPINE 6.99 1.00<br />

72275 EPIDUROGRAPHY 3.04 1.00<br />

72285 X-RAY C/T SPINE DISK 6.75 1.00<br />

72295 X-RAY OF LOWER SPINE DISK 6.09 1.00<br />

73000 X-RAY EXAM OF COLLAR BONE 0.75 1.00<br />

73010 X-RAY EXAM OF SHOUL<strong>DE</strong>R BLA<strong>DE</strong> 0.78 1.00<br />

73020 X-RAY EXAM OF SHOUL<strong>DE</strong>R 0.66 1.00<br />

73030 X-RAY EXAM OF SHOUL<strong>DE</strong>R 0.83 1.00<br />

73040 CONTRAST X-RAY OF SHOUL<strong>DE</strong>R 2.95 1.00<br />

73050 X-RAY EXAM OF SHOUL<strong>DE</strong>RS 0.98 1.00<br />

73060 X-RAY EXAM OF HUMERUS 0.82 1.00<br />

73070 X-RAY EXAM OF ELBOW 0.74 1.00<br />

73080 X-RAY EXAM OF ELBOW 0.91 1.00<br />

73085 CONTRAST X-RAY OF ELBOW 2.75 1.00<br />

73090 X-RAY EXAM OF FOREARM 0.75 1.00<br />

73092 X-RAY EXAM OF ARM, INFANT 0.75 1.00<br />

73100 X-RAY EXAM OF WRIST 0.76 1.00<br />

73110 X-RAY EXAM OF WRIST 0.88 1.00<br />

73115 CONTRAST X-RAY OF WRIST 2.70 1.00<br />

73120 X-RAY EXAM OF HAND 0.74 1.00<br />

73130 X-RAY EXAM OF HAND 0.83 1.00<br />

73140 X-RAY EXAM OF FINGER(S) 0.73 1.00<br />

73200 CT UPPER EXTREMITY W/O DYE 7.25 1.00<br />

73201 CT UPPER EXTREMITY W/DYE 8.62 1.00<br />

73202 CT UPPR EXTREMITY W/O&W/DYE 10.85 1.00<br />

73206 CT ANGIO UPR EXTRM W/O&W/DYE 13.52 1.00<br />

73218 MRI UPPER EXTREMITY W/O DYE 14.95 1.00<br />

73219 MRI UPPER EXTREMITY W/DYE 16.86 1.00<br />

73220 MRI UPPR EXTREMITY W/O&W/DYE 25.42 1.00<br />

73221 MRI JOINT UPR EXTREM W/O DYE 14.40 1.00<br />

73222 MRI JOINT UPR EXTREM W/DYE 16.31 1.00<br />

73223 MRI JOINT UPR EXTR W/O&W/DYE 24.68 1.00<br />

73225 MR ANGIO UPR EXTR W/O&W/DYE 15.58 1.00<br />

73500 X-RAY EXAM OF HIP 0.71 1.00<br />

73510 X-RAY EXAM OF HIP 0.97 1.00<br />

73520 X-RAY EXAM OF HIPS 1.08 1.00<br />

73525 CONTRAST X-RAY OF HIP 2.75 1.00<br />

73530 X-RAY EXAM OF HIP 0.94 1.00<br />

73540 X-RAY EXAM OF PELVIS & HIPS 0.97 1.00<br />

73542 X-RAY EXAM, SACROILIAC JOINT 2.44 1.00<br />

73550 X-RAY EXAM OF THIGH 0.81 1.00<br />

73560 X-RAY EXAM OF KNEE, 1 OR 2 0.78 1.00<br />

73562 X-RAY EXAM OF KNEE, 3 0.91 1.00<br />

73564 X-RAY EXAM, KNEE, 4 OR MORE 1.04 1.00<br />

73565 X-RAY EXAM OF KNEES 0.80 1.00<br />

73580 CONTRAST X-RAY OF KNEE JOINT 3.39 1.00<br />

73590 X-RAY EXAM OF LOWER LEG 0.76 1.00<br />

73592 X-RAY EXAM OF LEG, INFANT 0.75 1.00<br />

73600 X-RAY EXAM OF ANKLE 0.74 1.00

---

73610 X-RAY EXAM OF ANKLE 0.83 1.00<br />

73615 CONTRAST X-RAY OF ANKLE 2.83 1.00<br />

73620 X-RAY EXAM OF FOOT 0.73 1.00<br />

73630 X-RAY EXAM OF FOOT 0.83 1.00<br />

73650 X-RAY EXAM OF HEEL 0.72 1.00<br />

73660 X-RAY EXAM OF TOE(S) 0.71 1.00<br />

73700 CT LOWER EXTREMITY W/O DYE 7.25 1.00<br />

73701 CT LOWER EXTREMITY W/DYE 8.66 1.00<br />

73702 CT LWR EXTREMITY W/O&W/DYE 10.94 1.00<br />

73706 CT ANGIO LWR EXTR W/O&W/DYE 14.34 1.00<br />

73718 MRI LOWER EXTREMITY W/O DYE 14.76 1.00<br />

73719 MRI LOWER EXTREMITY W/DYE 16.86 1.00<br />

73720 MRI LWR EXTREMITY W/O&W/DYE 25.38 1.00<br />

73721 MRI JNT OF LWR EXTRE W/O DYE 14.56 1.00<br />

73722 MRI JOINT OF LWR EXTR W/DYE 16.40 1.00<br />

73723 MRI JOINT LWR EXTR W/O&W/DYE 24.68 1.00<br />

73725 MR ANG LWR EXT W OR W/O DYE 15.96 1.00<br />

74000 X-RAY EXAM OF ABDOMEN 0.73 1.00<br />

74010 X-RAY EXAM OF ABDOMEN 1.00 1.00<br />

74020 X-RAY EXAM OF ABDOMEN 1.08 1.00<br />

74022 X-RAY EXAM SERIES, ABDOMEN 1.29 1.00<br />

74150 CT ABDOMEN W/O DYE 7.61 1.00<br />

74160 CT ABDOMEN W/DYE 9.74 1.00<br />

74170 CT ABDOMEN W/O & W/DYE 12.46 1.00<br />

74175 CT ANGIO ABDOM W/O & W/DYE 14.83 1.00<br />

74181 MRI ABDOMEN W/O DYE 14.04 1.00<br />

74182 MRI ABDOMEN W/DYE 18.07 1.00<br />

74183 MRI ABDOMEN W/O & W/DYE 25.59 1.00<br />

74185 MRI ANGIO, ABDOM W ORW/O DYE 15.91 1.00<br />

74190 X-RAY EXAM OF PERITONEUM 2.04 1.00<br />

74210 CONTRST X-RAY EXAM OF THROAT 1.98 1.00<br />

74220 CONTRAST X-RAY, ESOPHAGUS 2.22 1.00<br />

74230 CINE/VID X-RAY, THROAT/ESOPH 2.34 1.00<br />

74240 X-RAY EXAM, UPPER GI TRACT 2.80 1.00<br />

74241 X-RAY EXAM, UPPER GI TRACT 2.94 1.00<br />

74245 X-RAY EXAM, UPPER GI TRACT 4.40 1.00<br />

74246 CONTRST X-RAY UPPR GI TRACT 3.16 1.00<br />

74247 CONTRST X-RAY UPPR GI TRACT 3.40 1.00<br />

74249 CONTRST X-RAY UPPR GI TRACT 4.70 1.00<br />

74250 X-RAY EXAM OF SMALL BOWEL 2.53 1.00<br />

74251 X-RAY EXAM OF SMALL BOWEL 6.57 1.00<br />

74260 X-RAY EXAM OF SMALL BOWEL 5.58 1.00<br />

74270 CONTRAST X-RAY EXAM OF COLON 3.59 1.00<br />

74280 CONTRAST X-RAY EXAM OF COLON 4.91 1.00<br />

74283 CONTRAST X-RAY EXAM OF COLON 5.60 1.00<br />

74290 CONTRAST X-RAY, GALLBLAD<strong>DE</strong>R 1.59 1.00<br />

74291 CONTRAST X-RAYS, GALLBLAD<strong>DE</strong>R 1.25 1.00<br />

74305 X-RAY BILE DUCTS/PANCREAS 1.41 1.00<br />

74320 CONTRAST X-RAY OF BILE DUCTS 3.46 1.00<br />

74327 X-RAY BILE STONE REMOVAL 3.32 1.00

---

74340 X-RAY GUI<strong>DE</strong> FOR GI TUBE 3.51 1.00<br />

74355 X-RAY GUI<strong>DE</strong>, INTESTINAL TUBE 3.81 1.00<br />

74360 X-RAY GUI<strong>DE</strong>, GI DILATION 4.08 1.00<br />

74400 CONTRST X-RAY, URINARY TRACT 2.84 1.00<br />

74410 CONTRST X-RAY, URINARY TRACT 3.02 1.00<br />

74415 CONTRST X-RAY, URINARY TRACT 3.41 1.00<br />

74420 CONTRST X-RAY, URINARY TRACT 3.27 1.00<br />

74425 CONTRST X-RAY, URINARY TRACT 1.88 1.00<br />

74430 CONTRAST X-RAY, BLAD<strong>DE</strong>R 1.96 1.00<br />

74440 X-RAY, MALE GENITAL TRACT 2.14 1.00<br />

74445 X-RAY EXAM OF PENIS 2.77 1.00<br />

74450 X-RAY, URETHRA/BLAD<strong>DE</strong>R 2.00 1.00<br />

74455 X-RAY, URETHRA/BLAD<strong>DE</strong>R 2.39 1.00<br />

74470 X-RAY EXAM OF KIDNEY LESION 2.06 1.00<br />

74475 X-RAY CONTROL, CATH INSERT 3.97 1.00<br />

74480 X-RAY CONTROL, CATH INSERT 3.97 1.00<br />

74485 X-RAY GUI<strong>DE</strong>, GU DILATION 3.54 1.00<br />

74710 X-RAY MEASUREMENT OF PELVIS 1.32 1.00<br />

74740 X-RAY, FEMALE GENITAL TRACT 2.07 1.00<br />

74775 X-RAY EXAM OF PERINEUM 2.40 1.00<br />

75557 CARDIAC MRI FOR MORPH 14.59 1.00<br />

75558 CARDIAC MRI FLOW/VELOCITY 16.06 1.00<br />

75559 CARDIAC MRI W/STRESS IMG 21.18 1.00<br />

75560 CARDIAC MRI FLOW/VEL/STRESS 20.84 1.00<br />

75561 CARDIAC MRI FOR MORPH W/DYE 19.65 1.00<br />

75562 CARD MRI FLOW/VEL W/DYE 20.66 1.00<br />

75563 CARD MRI W/STRESS IMG & DYE 24.30 1.00<br />

75564 HT MRI W/FLO/VEL/STRS & DYE 24.29 1.00<br />

75600 CONTRAST X-RAY EXAM OF AORTA 10.78 1.00<br />

75605 CONTRAST X-RAY EXAM OF AORTA 10.12 1.00<br />

75625 CONTRAST X-RAY EXAM OF AORTA 10.02 1.00<br />

75630 X-RAY AORTA, LEG ARTERIES 11.35 1.00<br />

75635 CT ANGIO ABDOMINAL ARTERIES 17.72 1.00<br />

75650 ARTERY X-RAYS, HEAD & NECK 10.52 1.00<br />

75658 ARTERY X-RAYS, ARM 10.44 1.00<br />

75660 ARTERY X-RAYS, HEAD & NECK 10.49 1.00<br />

75662 ARTERY X-RAYS, HEAD & NECK 11.48 1.00<br />

75665 ARTERY X-RAYS, HEAD & NECK 10.63 1.00<br />

75671 ARTERY X-RAYS, HEAD & NECK 11.51 1.00<br />

75676 ARTERY X-RAYS, NECK 10.49 1.00<br />

75680 ARTERY X-RAYS, NECK 11.26 1.00<br />

75685 ARTERY X-RAYS, SPINE 10.49 1.00<br />

75705 ARTERY X-RAYS, SPINE 11.71 1.00<br />

75710 ARTERY X-RAYS, ARM/LEG 10.34 1.00<br />

75716 ARTERY X-RAYS, ARMS/LEGS 11.01 1.00<br />

75722 ARTERY X-RAYS, KIDNEY 10.27 1.00<br />

75724 ARTERY X-RAYS, KIDNEYS 11.34 1.00<br />

75726 ARTERY X-RAYS, ABDOMEN 10.21 1.00<br />

75731 ARTERY X-RAYS, ADRENAL GLAND 10.39 1.00<br />

75733 ARTERY X-RAYS, ADRENALS 11.28 1.00

---

75736 ARTERY X-RAYS, PELVIS 10.29 1.00<br />

75741 ARTERY X-RAYS, LUNG 10.13 1.00<br />

75743 ARTERY X-RAYS, LUNGS 10.74 1.00<br />

75746 ARTERY X-RAYS, LUNG 10.10 1.00<br />

75756 ARTERY X-RAYS, CHEST 10.53 1.00<br />

75774 ARTERY X-RAY, EACH VESSEL 8.65 1.00<br />

75790 VISUALIZE A-V SHUNT 4.55 1.00<br />

75801 LYMPH VESSEL X-RAY, ARM/LEG 6.88 1.00<br />

75803 LYMPH VESSEL X-RAY,ARMS/LEGS 7.32 1.00<br />

75805 LYMPH VESSEL X-RAY, TRUNK 7.58 1.00<br />

75809 NONVASCULAR SHUNT, X-RAY 2.08 1.00<br />

75810 VEIN X-RAY, SPLEEN/LIVER 14.85 1.00<br />

75820 VEIN X-RAY, ARM/LEG 2.88 1.00<br />

75822 VEIN X-RAY, ARMS/LEGS 3.69 1.00<br />

75825 VEIN X-RAY, TRUNK 9.82 1.00<br />

75827 VEIN X-RAY, CHEST 9.81 1.00<br />

75831 VEIN X-RAY, KIDNEY 9.86 1.00<br />

75833 VEIN X-RAY, KIDNEYS 10.62 1.00<br />

75840 VEIN X-RAY, ADRENAL GLAND 9.84 1.00<br />

75842 VEIN X-RAY, ADRENAL GLANDS 10.63 1.00<br />

75860 VEIN X-RAY, NECK 10.03 1.00<br />

75870 VEIN X-RAY, SKULL 9.99 1.00<br />

75872 VEIN X-RAY, SKULL 10.45 1.00<br />

75880 VEIN X-RAY, EYE SOCKET 2.99 1.00<br />

75885 VEIN X-RAY, LIVER 10.28 1.00<br />

75887 VEIN X-RAY, LIVER 10.40 1.00<br />

75889 VEIN X-RAY, LIVER 9.87 1.00<br />

75891 VEIN X-RAY, LIVER 9.86 1.00<br />

75893 VENOUS SAMPLING BY CATHETER 9.04 1.00<br />

75894 X-RAYS, TRANSCATH THERAPY 27.29 1.00<br />

75896 X-RAYS, TRANSCATH THERAPY 23.96 1.00<br />

75898 FOLLOW-UP ANGIOGRAPHY 3.38 1.00<br />

75901 REMOVE CVA <strong>DE</strong>VICE OBSTRUCT 4.15 1.00<br />

75902 REMOVE CVA LUMEN OBSTRUCT 2.77 1.00<br />

75940 X-RAY PLACEMENT, VEIN FILTER 14.05 1.00<br />

75945 INTRAVASCULAR US 5.39 1.00<br />

75960 TRANSCATH IV STENT RS&I 10.59 1.00<br />

75961 RETRIEVAL, BROKEN CATHETER 13.26 1.00<br />

75962 REPAIR ARTERIAL BLOCKAGE 11.12 1.00<br />

75964 REPAIR ARTERY BLOCKAGE, EACH 6.25 1.00<br />

75966 REPAIR ARTERIAL BLOCKAGE 12.39 1.00<br />

75968 REPAIR ARTERY BLOCKAGE, EACH 6.27 1.00<br />

75970 VASCULAR BIOPSY 13.32 1.00<br />

75978 REPAIR VENOUS BLOCKAGE 10.99 1.00<br />

75980 CONTRAST XRAY EXAM BILE DUCT 7.69 1.00<br />

75984 XRAY CONTROL CATHETER CHANGE 3.10 1.00<br />

75989 ABSCESS DRAINAGE UN<strong>DE</strong>R X-RAY 4.31 1.00<br />

75992 ATHERECTOMY, X-RAY EXAM 17.38 1.00<br />

76000 FLUOROSCOPE EXAMINATION 2.31 1.00<br />

76010 X-RAY, NOSE TO RECTUM 0.77 1.00

---

76080 X-RAY EXAM OF FISTULA 1.78 1.00<br />

76098 X-RAY EXAM, BREAST SPECIMEN 0.58 1.00<br />

76100 X-RAY EXAM OF BODY SECTION 3.18 1.00<br />

76101 COMPLEX BODY SECTION X-RAY 4.23 1.00<br />

76102 COMPLEX BODY SECTION X-RAYS 5.50 1.00<br />

76120 CINE/VI<strong>DE</strong>O X-RAYS 1.99 1.00<br />

76125 CINE/VI<strong>DE</strong>O X-RAYS ADD-ON 1.20 1.00<br />

76150 X-RAY EXAM, DRY PROCESS 0.57 1.00<br />

76376 3D REN<strong>DE</strong>R W/O POSTPROCESS 2.75 1.00<br />

76377 3D REN<strong>DE</strong>RING W/POSTPROCESS 3.72 1.00<br />

76380 CAT SCAN FOLLOW-UP STUDY 5.47 1.00<br />

76390 MR SPECTROSCOPY 12.52 1.00<br />

77261 RADIATION THERAPY PLANNING 1.95 1.00<br />

77262 RADIATION THERAPY PLANNING 2.94 1.00<br />

77263 RADIATION THERAPY PLANNING 4.37 1.00<br />

77280 SET RADIATION THERAPY FIELD 4.99 1.00<br />

77285 SET RADIATION THERAPY FIELD 8.37 1.00<br />

77290 SET RADIATION THERAPY FIELD 12.21 1.00<br />

77295 SET RADIATION THERAPY FIELD 24.70 1.00<br />

77300 RADIATION THERAPY DOSE PLAN 2.08 1.00<br />

77301 RADIOTHERAPY DOSE PLAN, IMRT 53.86 1.00<br />

77305 TELETX ISODOSE PLAN SIMPLE 2.35 1.00<br />

77310 TELETX ISODOSE PLAN INTERMED 3.19 1.00<br />

77315 TELETX ISODOSE PLAN COMPLEX 4.40 1.00<br />

77321 SPECIAL TELETX PORT PLAN 4.14 1.00<br />

77326 BRACHYTX ISODOSE CALC SIMP 3.93 1.00<br />

77327 BRACHYTX ISODOSE CALC INTERM 5.65 1.00<br />

77328 BRACHYTX ISODOSE PLAN COMPL 7.89 1.00<br />

77331 SPECIAL RADIATION DOSIMETRY 1.72 1.00<br />

77332 RADIATION TREATMENT AID(S) 2.17 1.00<br />

77333 RADIATION TREATMENT AID(S) 2.33 1.00<br />

77334 RADIATION TREATMENT AID(S) 4.65 1.00<br />

77336 RADIATION PHYSICS CONSULT 2.22 1.00<br />

77370 RADIATION PHYSICS CONSULT 3.45 1.00<br />

77371 SRS, MULTISOURCE 30.24 1.00<br />

77372 SRS, LINEAR BASED 22.96 1.00<br />

77373 SBRT <strong>DE</strong>LIVERY 42.80 1.00<br />

77401 RADIATION TREATMENT <strong>DE</strong>LIVERY 1.23 1.00<br />

77402 RADIATION TREATMENT <strong>DE</strong>LIVERY 3.17 1.00<br />

77403 RADIATION TREATMENT <strong>DE</strong>LIVERY 2.88 1.00<br />

77404 RADIATION TREATMENT <strong>DE</strong>LIVERY 3.10 1.00<br />

77406 RADIATION TREATMENT <strong>DE</strong>LIVERY 3.12 1.00<br />

77407 RADIATION TREATMENT <strong>DE</strong>LIVERY 4.06 1.00<br />

77408 RADIATION TREATMENT <strong>DE</strong>LIVERY 3.76 1.00<br />

77409 RADIATION TREATMENT <strong>DE</strong>LIVERY 4.05 1.00<br />

77411 RADIATION TREATMENT <strong>DE</strong>LIVERY 4.04 1.00<br />

77412 RADIATION TREATMENT <strong>DE</strong>LIVERY 4.69 1.00<br />

77413 RADIATION TREATMENT <strong>DE</strong>LIVERY 4.73 1.00<br />

77414 RADIATION TREATMENT <strong>DE</strong>LIVERY 5.16 1.00<br />

77416 RADIATION TREATMENT <strong>DE</strong>LIVERY 5.16 1.00

---

77417 RADIOLOGY PORT FILM(S) 0.52 1.00<br />

77418 RADIATION TX <strong>DE</strong>LIVERY, IMRT 15.73 1.00<br />

77421 STEREOSCOPIC X-RAY GUIDANCE 3.44 1.00<br />

77422 NEUTRON BEAM TX, SIMPLE 3.66 1.00<br />

77423 NEUTRON BEAM TX, COMPLEX 4.99 1.00<br />

77427 RADIATION TX MANAGEMENT, X5 5.09 1.00<br />

77431 RADIATION THERAPY MANAGEMENT 2.63 1.00<br />

77432 STEREOTACTIC RADIATION TRMT 11.08 1.00<br />

77435 SBRT MANAGEMENT 18.43 1.00<br />

77470 SPECIAL RADIATION TREATMENT 9.67 1.00<br />

77620 HYPERTHERMIA TREATMENT 8.96 1.00<br />

77750 INFUSE RADIOACTIVE MATERIALS 8.99 1.00<br />

77761 APPLY INTRCAV RADIAT SIMPLE 9.12 1.00<br />

77762 APPLY INTRCAV RADIAT INTERM 12.75 1.00<br />

77763 APPLY INTRCAV RADIAT COMPL 18.05 1.00<br />

77776 APPLY INTERSTIT RADIAT SIMPL 10.54 1.00<br />

77777 APPLY INTERSTIT RADIAT INTER 15.36 1.00<br />

77778 APPLY INTERSTIT RADIAT COMPL 22.08 1.00<br />

77789 APPLY SURFACE RADIATION 2.64 1.00<br />

77790 RADIATION HANDLING 2.27 1.00<br />

78000 THYROID, SINGLE UPTAKE 1.70 1.00<br />

78001 THYROID, MULTIPLE UPTAKES 2.19 1.00<br />

78003 THYROID SUPPRESS/STIMUL 1.90 1.00<br />

78006 THYROID IMAGING WITH UPTAKE 5.02 1.00<br />

78007 THYROID IMAGE, MULT UPTAKES 3.56 1.00<br />

78010 THYROID IMAGING 3.59 1.00<br />

78011 THYROID IMAGING WITH FLOW 4.15 1.00<br />

78015 THYROID MET IMAGING 4.92 1.00<br />

78016 THYROID MET IMAGING/STUDIES 7.18 1.00<br />

78018 THYROID MET IMAGING, BODY 8.02 1.00<br />

78020 THYROID MET UPTAKE 2.42 1.00<br />

78070 PARATHYROID NUCLEAR IMAGING 4.99 1.00<br />

78075 ADRENAL NUCLEAR IMAGING 9.71 1.00<br />

78102 BONE MARROW IMAGING, LTD 3.90 1.00<br />

78103 BONE MARROW IMAGING, MULT 5.39 1.00<br />

78104 BONE MARROW IMAGING, BODY 6.34 1.00<br />

78110 PLASMA VOLUME, SINGLE 1.84 1.00<br />

78111 PLASMA VOLUME, MULTIPLE 2.77 1.00<br />

78120 RED CELL MASS, SINGLE 2.31 1.00<br />

78121 RED CELL MASS, MULTIPLE 3.09 1.00<br />

78130 RED CELL SURVIVAL STUDY 4.06 1.00<br />

78135 RED CELL SURVIVAL KINETICS 7.81 1.00<br />

78140 RED CELL SEQUESTRATION 4.39 1.00<br />

78185 SPLEEN IMAGING 4.40 1.00<br />

78190 KINETICS, STUDY OF PLATELET SURVIV 8.71 1.00<br />

78191 PLATELET SURVIVAL 6.54 1.00<br />

78195 LYMPH SYSTEM IMAGING 8.06 1.00<br />

78201 LIVER IMAGING 4.15 1.00<br />

78202 LIVER IMAGING WITH FLOW 4.87 1.00<br />

78205 LIVER IMAGING (3D) 6.76 1.00

---

78206 LIVER IMAGE (3D) WITH FLOW 8.53 1.00<br />

78215 LIVER AND SPLEEN IMAGING 4.62 1.00<br />

78216 LIVER & SPLEEN IMAGE/FLOW 4.03 1.00<br />

78220 LIVER FUNCTION STUDY 4.18 1.00<br />

78223 HEPATOBILIARY IMAGING 7.30 1.00<br />

78230 SALIVARY GLAND IMAGING 3.85 1.00<br />

78231 SERIAL SALIVARY IMAGING 3.78 1.00<br />

78232 SALIVARY GLAND FUNCTION EXAM 3.91 1.00<br />

78258 ESOPHAGEAL MOTILITY STUDY 5.24 1.00<br />

78261 GASTRIC MUCOSA IMAGING 6.11 1.00<br />

78262 GASTROESOPHAGEAL REFLUX EXAM 6.15 1.00<br />

78264 GASTRIC EMPTYING STUDY 6.81 1.00<br />

78270 VIT B-12 ABSORPTION EXAM 2.09 1.00<br />

78271 VIT B-12 ABSRP EXAM, INT FAC 2.11 1.00<br />

78272 VIT B-12 ABSORP, COMBINED 2.65 1.00<br />

78278 ACUTE GI BLOOD LOSS IMAGING 8.19 1.00<br />

78282 GI PROTEIN LOSS EXAM 0.53 1.00<br />

78290 MECKELÏS DIVERT EXAM 6.78 1.00<br />

78291 LEVEEN/SHUNT PATENCY EXAM 5.84 1.00<br />

78300 BONE IMAGING, LIMITED AREA 4.25 1.00<br />

78305 BONE IMAGING, MULTIPLE AREAS 5.77 1.00<br />

78306 BONE IMAGING, WHOLE BODY 6.44 1.00<br />

78315 BONE IMAGING, 3 PHASE 8.17 1.00<br />

78320 BONE IMAGING (3D) 7.21 1.00<br />

78350 BONE MINERAL, SINGLE PHOTON 0.95 1.00<br />

78351 BONE MINERAL, DUAL PHOTON 0.40 1.00<br />

78414 NON-IMAGING HEART FUNCTION 0.64 1.00<br />

78428 CARDIAC SHUNT IMAGING 4.84 1.00<br />

78445 VASCULAR FLOW IMAGING 3.88 1.00<br />

78456 ACUTE VENOUS THROMBUS IMAGE 7.90 1.00<br />

78457 VENOUS THROMBOSIS IMAGING 4.73 1.00<br />

78458 VEN THROMBOSIS IMAGES, BILAT 5.58 1.00<br />

78459 HEART MUSCLE IMAGING (PET) 8.16 1.00<br />

78460 HEART MUSCLE BLOOD, SINGLE 4.68 1.00<br />

78461 HEART MUSCLE BLOOD, MULTIPLE 6.14 1.00<br />

78464 HEART IMAGE (3D), SINGLE 8.16 1.00<br />

78465 HEART IMAGE (3D), MULTIPLE 14.01 1.00<br />

78466 HEART INFARCT IMAGE 4.58 1.00<br />

78468 HEART INFARCT IMAGE (EF) 5.92 1.00<br />

78469 HEART INFARCT IMAGE (3D) 7.15 1.00<br />

78472 GATED HEART, PLANAR, SINGLE 7.26 1.00<br />

78473 GATED HEART, MULTIPLE 10.22 1.00<br />

78478 HEART WALL MOTION ADD-ON 1.92 1.00<br />

78480 HEART FUNCTION ADD-ON 1.66 1.00<br />

78481 HEART FIRST PASS, SINGLE 6.62 1.00<br />

78483 HEART FIRST PASS, MULTIPLE 9.57 1.00<br />

78494 HEART IMAGE, SPECT 8.40 1.00<br />

78496 HEART FIRST PASS ADD-ON 4.88 1.00<br />

78580 LUNG PERFUSION IMAGING 5.36 1.00<br />

78584 LUNG V/Q IMAGE SINGLE BREATH 4.48 1.00

---

78585 LUNG V/Q IMAGING 8.76 1.00<br />

78586 AEROSOL LUNG IMAGE, SINGLE 4.00 1.00<br />

78587 AEROSOL LUNG IMAGE, MULTIPLE 4.86 1.00<br />

78588 PERFUSION LUNG IMAGE 7.43 1.00<br />

78591 VENT IMAGE, 1 BREATH, 1 PROJ 4.14 1.00<br />

78593 VENT IMAGE, 1 PROJ, GAS 4.90 1.00<br />

78594 VENT IMAGE, MULT PROJ, GAS 6.03 1.00<br />

78596 LUNG DIFFERENTIAL FUNCTION 9.78 1.00<br />

78600 BRAIN IMAGE < 4 VIEWS 4.31 1.00<br />

78601 BRAIN IMAGE W/FLOW < 4 VIEWS 5.18 1.00<br />

78605 BRAIN IMAGE 4+ VIEWS 4.95 1.00<br />

78606 BRAIN IMAGE W/FLOW 4 + VIEWS 7.19 1.00<br />

78607 BRAIN IMAGING (3D) 9.44 1.00<br />

78610 BRAIN FLOW IMAGING ONLY 4.65 1.00<br />

78630 CEREBROSPINAL FLUID SCAN 7.94 1.00<br />

78635 CSF VENTRICULOGRAPHY 6.56 1.00<br />

78645 CSF SHUNT EVALUATION 6.82 1.00<br />

78647 CEREBROSPINAL FLUID SCAN 8.63 1.00<br />

78650 CSF LEAKAGE IMAGING 7.59 1.00<br />

78660 NUCLEAR EXAM OF TEAR FLOW 3.95 1.00<br />

78700 KIDNEY IMAGING, MORPHOL 4.43 1.00<br />

78701 KIDNEY IMAGING WITH FLOW 5.25 1.00<br />

78707 K FLOW/FUNCT IMAGE W/O DRUG 6.37 1.00<br />

78708 K FLOW/FUNCT IMAGE W/DRUG 5.67 1.00<br />

78709 K FLOW/FUNCT IMAGE, MULTIPLE 8.61 1.00<br />

78710 KIDNEY IMAGING (3D) 6.71 1.00<br />

78725 KIDNEY FUNCTION STUDY 2.65 1.00<br />

78730 URINARY BLAD<strong>DE</strong>R RETENTION 2.03 1.00<br />

78740 URETERAL REFLUX STUDY 4.70 1.00<br />

78761 TESTICULAR IMAGING W/FLOW 5.15 1.00<br />

78800 TUMOR IMAGING, LIMITED AREA 4.87 1.00<br />

78801 TUMOR IMAGING, MULT AREAS 6.33 1.00<br />

78802 TUMOR IMAGING, WHOLE BODY 8.18 1.00<br />

78803 TUMOR IMAGING (3D) 9.23 1.00<br />

78804 TUMOR IMAGING, WHOLE BODY 14.55 1.00<br />

78805 ABSCESS IMAGING, LTD AREA 4.88 1.00<br />

78806 ABSCESS IMAGING, WHOLE BODY 8.79 1.00<br />

78807 NUCLEAR LOCALIZATION/ABSCESS 9.21 1.00<br />

79005 NUCLEAR RX, ORAL ADMIN 4.56 1.00<br />

79101 NUCLEAR RX, IV ADMIN 4.91 1.00<br />

79200 NUCLEAR RX, INTRACAV ADMIN 4.99 1.00<br />

79300 NUCLR RX, INTERSTIT COLLOID 2.28 1.00<br />

79403 HEMATOPOIETIC NUCLEAR TX 6.53 1.00<br />

79440 NUCLEAR RX, INTRA-ARTICULAR 4.80 1.00<br />

80048 METABOLIC PANEL TOTAL CA 1.00 1.00<br />

80051 ELECTROLYTE PANEL 1.00 1.00<br />

80053 COMPREHEN METABOLIC PANEL 1.00 1.00<br />

80061 LIPID PANEL 1.00 1.00<br />

80069 RENAL FUNCTION PANEL 1.00 1.00<br />

80076 HEPATIC FUNCTION PANEL 1.00 1.00

---

90801 PSY DX INTERVIEW 3.62 1.00<br />

90802 INTAC PSY DX INTERVIEW 3.91 1.00<br />

90804 PSYTX, OFFICE, 20-30 MIN 1.54 1.00<br />

90805 PSYTX, OFF, 20-30 MIN W/E&M 1.73 1.00<br />

90806 PSYTX, OFF, 45-50 MIN 2.36 1.00<br />

90807 PSYTX, OFF, 45-50 MIN W/E&M 2.56 1.00<br />

90808 PSYTX, OFFICE, 75-80 MIN 3.55 1.00<br />

90809 PSYTX, OFF, 75-80, W/E&M 3.74 1.00<br />

90810 INTAC PSYTX, OFF, 20-30 MIN 1.69 1.00<br />

90811 INTAC PSYTX, 20-30, W/E&M 1.88 1.00<br />

90812 INTAC PSYTX, OFF, 45-50 MIN 2.50 1.00<br />

90813 INTAC PSYTX, 45-50 MIN W/E&M 2.70 1.00<br />

90814 INTAC PSYTX, OFF, 75-80 MIN 3.71 1.00<br />

90815 INTAC PSYTX, 75-80 W/E&M 3.87 1.00<br />

90816 PSYTX, HOSP, 20-30 MIN 1.67 1.00<br />

90817 PSYTX, HOSP, 20-30 MIN W/E&M 1.84 1.00<br />

90818 PSYTX, HOSP, 45-50 MIN 2.49 1.00<br />

90819 PSYTX, HOSP, 45-50 MIN W/E&M 2.66 1.00<br />

90821 PSYTX, HOSP, 75-80 MIN 3.69 1.00<br />

90822 PSYTX, HOSP, 75-80 MIN W/E&M 3.86 1.00<br />

90823 INTAC PSYTX, HOSP, 20-30 MIN 1.80 1.00<br />

90824 INTAC PSYTX, HSP 20-30 W/E&M 1.99 1.00<br />

90826 INTAC PSYTX, HOSP, 45-50 MIN 2.65 1.00<br />

90827 INTAC PSYTX, HSP 45-50 W/E&M 2.79 1.00<br />

90828 INTAC PSYTX, HOSP, 75-80 MIN 3.84 1.00<br />

90829 INTAC PSYTX, HSP 75-80 W/E&M 3.98 1.00<br />

90845 PSYCHOANALYSIS 2.26 1.00<br />

90846 FAMILY PSYTX W/O PATIENT 2.41 1.00<br />

90847 FAMILY PSYTX W/PATIENT 2.89 1.00<br />

90849 MULTIPLE FAMILY GROUP PSYTX 0.83 1.00<br />

90853 GROUP PSYCHOTHERAPY 0.81 1.00<br />

90857 INTAC GROUP PSYTX 0.87 1.00<br />

90862 MEDICATION MANAGEMENT 1.26 1.00<br />

90870 ELECTROCONVULSIVE THERAPY 2.41 1.00<br />

90885 PSY EVALUATION OF RECORDS 1.29 1.00<br />

90911 BIOFEEDBACK PERI/URO/RECTAL 1.25 1.00<br />

90935 HEMODIALYSIS, ONE EVALUATION 1.86 1.00<br />

90937 HEMODIALYSIS, REPEATED EVAL 3.05 1.00<br />

90945 DIALYSIS, ONE EVALUATION 1.94 1.00<br />

90947 DIALYSIS, REPEATED EVAL 3.12 1.00<br />

90997 HEMOPERFUSION 2.48 1.00<br />

91000 ESOPHAGEAL INTUBATION 2.00 1.00<br />

91010 ESOPHAGUS MOTILITY STUDY 5.41 1.00<br />

91011 ESOPHAGUS MOTILITY STUDY 6.93 1.00<br />

91012 ESOPHAGUS MOTILITY STUDY 7.19 1.00<br />

91020 GASTRIC MOTILITY STUDIES 6.24 1.00<br />

91022 DUO<strong>DE</strong>NAL MOTILITY STUDY 5.33 1.00<br />

91030 ACID PERFUSION OF ESOPHAGUS 3.64 1.00<br />

91034 GASTROESOPHAGEAL REFLUX TEST 5.78 1.00<br />

91035 G-ESOPH REFLX TST W/ELECTROD 12.81 1.00

---

91037 ESOPH IMPED FUNCTION TEST 4.29 1.00<br />

91038 ESOPH IMPED FUNCT TEST > 1H 3.74 1.00<br />

91040 ESOPH BALLOON DISTENSION TST 10.52 1.00<br />

91052 GASTRIC ANALYSIS TEST 3.52 1.00<br />

91055 GASTRIC INTUBATION FOR SMEAR 3.77 1.00<br />

91065 BREATH HYDROGEN TEST 1.63 1.00<br />

91105 GASTRIC INTUBATION TREATMENT 0.48 1.00<br />

91110 GI TRACT CAPSULE ENDOSCOPY 25.22 1.00<br />

91111 ESOPHAGEAL CAPSULE ENDOSCOPY 19.89 1.00<br />

91120 RECTAL SENSATION TEST 11.02 1.00<br />

91122 ANAL PRESSURE RECORD 6.68 1.00<br />

91132 ELECTROGASTROGRAPHY 0.76 1.00<br />

91133 ELECTROGASTROGRAPHY W/TEST 0.97 1.00<br />

92502 EAR AND THROAT EXAMINATION 2.57 1.00<br />

92504 EAR MICROSCOPY EXAMINATION 0.26 1.00<br />

92506 SPEECH/HEARING EVALUATION 1.23 1.00<br />

92507 SPEECH/HEARING THERAPY 0.73 1.00<br />

92508 SPEECH/HEARING THERAPY 0.38 1.00<br />

92511 NASOPHARYNGOSCOPY 1.59 1.00<br />

92512 NASAL FUNCTION STUDIES 0.75 1.00<br />

92516 FACIAL NERVE FUNCTION TEST 0.62 1.00<br />

92520 LARYNGEAL FUNCTION STUDIES 1.09 1.00<br />

92526 ORAL FUNCTION THERAPY 0.75 1.00<br />

92541 SPONTANEOUS NYSTAGMUS TEST 1.53 1.00<br />

92542 POSITIONAL NYSTAGMUS TEST 1.58 1.00<br />

92543 CALORIC VESTIBULAR TEST 0.73 1.00<br />

92544 OPTOKINETIC NYSTAGMUS TEST 1.26 1.00<br />

92545 OSCILLATING TRACKING TEST 1.16 1.00<br />

92546 SINUSOIDAL ROTATIONAL TEST 2.22 1.00<br />

92547 SUPPLEMENTAL ELECTRICAL TEST 0.15 1.00<br />

92548 POSTUROGRAPHY 2.63 1.00<br />

92551 PURE TONE HEARING TEST, AIR 0.26 1.00<br />

92552 PURE TONE AUDIOMETRY, AIR 0.56 1.00<br />

92553 AUDIOMETRY, AIR & BONE 0.77 1.00<br />

92555 SPEECH THRESHOLD AUDIOMETRY 0.44 1.00<br />

92556 SPEECH AUDIOMETRY, COMPLETE 0.60 1.00<br />

92557 COMPREHENSIVE HEARING TEST 1.41 1.00<br />

92561 BEKESY AUDIOMETRY, DIAGNOSIS 0.77 1.00<br />

92562 LOUDNESS BALANCE TEST 0.55 1.00<br />

92563 TONE <strong>DE</strong>CAY HEARING TEST 0.50 1.00<br />

92564 SISI HEARING TEST 0.52 1.00<br />

92565 STENGER TEST, PURE TONE 0.37 1.00<br />

92567 TYMPANOMETRY 0.55 1.00<br />

92568 ACOUSTIC REFL THRESHOLD TST 0.57 1.00<br />

92569 ACOUSTIC REFLEX <strong>DE</strong>CAY TEST 0.48 1.00<br />

92571 FILTERED SPEECH HEARING TEST 0.45 1.00<br />

92572 STAGGERED SPONDAIC WORD TEST 0.35 1.00<br />

92575 SENSORINEURAL ACUITY TEST 0.75 1.00<br />

92576 SYNTHETIC SENTENCE TEST 0.56 1.00<br />

92577 STENGER TEST, SPEECH 0.56 1.00

---

92579 VISUAL AUDIOMETRY (VRA) 1.24 1.00<br />

92582 CONDITIONING PLAY AUDIOMETRY 1.01 1.00<br />

92583 SELECT PICTURE AUDIOMETRY 0.89 1.00<br />

92584 ELECTROCOCHLEOGRAPHY 2.13 1.00<br />

92585 AUDITOR EVOKE POTENT, COMPRE 2.75 1.00<br />

92586 AUDITOR EVOKE POTENT, LIMIT 1.78 1.00<br />

92587 EVOKED AUDITORY TEST 1.26 1.00<br />

92588 EVOKED AUDITORY TEST 1.88 1.00<br />

92950 HEART/LUNG RESUSCITATION CPR 4.94 1.00<br />

92960 CARDIOVERSION ELECTRIC, EXT 3.63 1.00<br />

92970 CARDIOASSIST, INTERNAL 4.93 1.00<br />

92971 CARDIOASSIST, EXTERNAL 2.80 1.00<br />

92973 PERCUT CORONARY THROMBECTOMY 5.03 1.00<br />

92974 CATH PLACE, CARDIO BRACHYTX 4.61 1.00<br />

92975 DISSOLVE CLOT, HEART VESSEL 11.07 1.00<br />

92977 DISSOLVE CLOT, HEART VESSEL 5.35 1.00<br />

92980 INSERT INTRACORONARY STENT 22.94 1.00<br />

92981 INSERT INTRACORONARY STENT 6.38 1.00<br />

92982 CORONARY ARTERY DILATION 17.01 1.00<br />

92984 CORONARY ARTERY DILATION 4.55 1.00<br />

92986 REVISION OF AORTIC VALVE 37.80 1.00<br />

92987 REVISION OF MITRAL VALVE 39.16 1.00<br />

92990 REVISION OF PULMONARY VALVE 29.89 1.00<br />

92995 CORONARY ATHERECTOMY 18.71 1.00<br />

92996 CORONARY ATHERECTOMY ADD-ON 4.87 1.00<br />

92997 PUL ART BALLOON REPR, PERCUT 17.60 1.00<br />

92998 PUL ART BALLOON REPR, PERCUT 8.87 1.00<br />

93000 ELECTROCARDIOGRAM, COMPLETE 0.62 1.00<br />

93005 ELECTROCARDIOGRAM, TRACING 0.38 1.00<br />

93010 ELECTROCARDIOGRAM REPORT 0.24 1.00<br />

93015 CARDIOVASCULAR STRESS TEST 2.83 1.00<br />

93017 CARDIOVASCULAR STRESS TEST 1.72 1.00<br />

93018 CARDIOVASCULAR STRESS TEST 0.44 1.00<br />

93024 CARDIAC DRUG STRESS TEST 3.27 1.00<br />

93025 MICROVOLT T-WAVE ASSESS 6.66 1.00<br />

93040 RHYTHM ECG WITH REPORT 0.38 1.00<br />

93041 RHYTHM ECG, TRACING 0.16 1.00<br />

93042 RHYTHM ECG, REPORT 0.22 1.00<br />

93224 ECG MONITOR/REPORT, 24 HRS 3.73 1.00<br />

93225 ECG MONITOR/RECORD, 24 HRS 1.13 1.00<br />

93226 ECG MONITOR/REPORT, 24 HRS 1.83 1.00<br />

93227 ECG MONITOR/REVIEW, 24 HRS 0.77 1.00<br />

93230 ECG MONITOR/REPORT, 24 HRS 3.88 1.00<br />

93231 ECG MONITOR/RECORD, 24 HRS 1.23 1.00<br />

93232 ECG MONITOR/REPORT, 24 HRS 1.90 1.00<br />

93233 ECG MONITOR/REVIEW, 24 HRS 0.75 1.00<br />

93235 ECG MONITOR/REPORT, 24 HRS 3.40 1.00<br />

93236 ECG MONITOR/REPORT, 24 HRS 2.77 1.00<br />

93237 ECG MONITOR/REVIEW, 24 HRS 0.66 1.00<br />

93268 ECG RECORD/REVIEW 7.41 1.00

---

93270 ECG RECORDING 0.84 1.00<br />

93271 ECG/MONITORING AND ANALYSIS 5.83 1.00<br />

93272 ECG/REVIEW, INTERPRET ONLY 0.74 1.00<br />

93278 ECG/SIGNAL-AVERAGED 1.30 1.00<br />

93303 ECHO TRANSTHORACIC 5.98 1.00<br />

93304 ECHO TRANSTHORACIC 3.57 1.00<br />

93307 TTE W/O DOPPLER, COMPLETE 5.15 1.00<br />

93308 TTE, F-UP OR LMTD 3.06 1.00<br />

93312 ECHO TRANSESOPHAGEAL 8.55 1.00<br />

93313 ECHO TRANSESOPHAGEAL 1.18 1.00<br />

93314 ECHO TRANSESOPHAGEAL 7.31 1.00<br />

93315 ECHO TRANSESOPHAGEAL 4.03 1.00<br />

93316 ECHO TRANSESOPHAGEAL 1.25 1.00<br />

93317 ECHO TRANSESOPHAGEAL 2.52 1.00<br />

93318 ECHO TRANSESOPHAGEAL INTRAOP 3.01 1.00<br />

93320 DOPPLER ECHO EXAM, HEART 2.28 1.00<br />

93321 DOPPLER ECHO EXAM, HEART 1.13 1.00<br />

93325 DOPPLER COLOR FLOW ADD-ON 2.09 1.00<br />

93350 STRESS TTE ONLY 5.37 1.00<br />

93501 RIGHT HEART CATHETERIZATION 22.68 1.00<br />

93503 INSERT/PLACE HEART CATHETER 3.11 1.00<br />

93505 BIOPSY OF HEART LINING 17.12 1.00<br />

93508 CATH PLACEMENT, ANGIOGRAPHY 26.80 1.00<br />

93510 LEFT HEART CATHETERIZATION 40.58 1.00<br />

93526 RT & LT HEART CATHETERS 52.48 1.00<br />

93539 INJECTION, CARDIAC CATH 0.60 1.00<br />

93540 INJECTION, CARDIAC CATH 0.64 1.00<br />

93541 INJECTION FOR LUNG ANGIOGRAM 0.43 1.00<br />

93542 INJECTION FOR HEART X-RAYS 0.43 1.00<br />

93543 INJECTION FOR HEART X-RAYS 0.43 1.00<br />

93544 INJECTION FOR AORTOGRAPHY 0.38 1.00<br />

93545 INJECT FOR CORONARY X-RAYS 0.60 1.00<br />

93555 IMAGING, CARDIAC CATH 4.77 1.00<br />

93556 IMAGING, CARDIAC CATH 6.92 1.00<br />

93580 TRANSCATH CLOSURE OF ASD 27.62 1.00<br />

93581 TRANSCATH CLOSURE OF VSD 36.59 1.00<br />

93613 ELECTROPHYS MAP 3D, ADD-ON 10.71 1.00<br />

93620 ELECTROPHYSIOLOGY EVALUATION 17.83 1.00<br />

93621 ELECTROPHYSIOLOGY EVALUATION 3.21 1.00<br />

93622 ELECTROPHYSIOLOGY EVALUATION 4.71 1.00<br />

93623 STIMULATION, PACING HEART 4.35 1.00<br />

93650 ABLATE HEART DYSRHYTHM FOCUS 16.34 1.00<br />

93651 ABLATE HEART DYSRHYTHM FOCUS 24.79 1.00<br />

93652 ABLATE HEART DYSRHYTHM FOCUS 27.00 1.00<br />

93660 TILT TABLE EVALUATION 4.68 1.00<br />

93662 INTRACARDIAC ECG (ICE) 4.18 1.00<br />

93701 BIOIMPEDANCE, THORACIC 1.03 1.00<br />

93720 TOTAL BODY PLETHYSMOGRAPHY 1.21 1.00<br />

93721 PLETHYSMOGRAPHY TRACING 0.98 1.00<br />

93722 PLETHYSMOGRAPHY REPORT 0.23 1.00

---

93724 ANALYZE PACEMAKER SYSTEM 9.82 1.00<br />

93770 MEASURE VENOUS PRESSURE 0.23 1.00<br />

93784 AMBULATORY BP MONITORING 1.88 1.00<br />

93786 AMBULATORY BP RECORDING 0.87 1.00<br />

93788 AMBULATORY BP ANALYSIS 0.49 1.00<br />

93790 REVIEW/REPORT BP RECORDING 0.52 1.00<br />

93797 CARDIAC REHAB 0.27 1.00<br />

93798 CARDIAC REHAB/MONITOR 0.41 1.00<br />

93875 EXTRACRANIAL STUDY 2.78 1.00<br />

93880 EXTRACRANIAL STUDY 6.84 1.00<br />

93882 EXTRACRANIAL STUDY 4.48 1.00<br />

93886 INTRACRANIAL STUDY 8.27 1.00<br />

93888 INTRACRANIAL STUDY 5.51 1.00<br />

93890 TRANSCRANIAL DOPPLER STUDY OF THE 7.13 1.00<br />

93892 TCD, EMBOLI <strong>DE</strong>TECT W/O INJ 7.60 1.00<br />

93893 TCD, EMBOLI <strong>DE</strong>TECT W/INJ 7.61 1.00<br />

93922 EXTREMITY STUDY 3.30 1.00<br />

93923 EXTREMITY STUDY 5.06 1.00<br />

93924 EXTREMITY STUDY 6.16 1.00<br />

93925 LOWER EXTREMITY STUDY 8.37 1.00<br />

93926 LOWER EXTREMITY STUDY 5.26 1.00<br />

93930 UPPER EXTREMITY STUDY 6.67 1.00<br />

93931 UPPER EXTREMITY STUDY 4.41 1.00<br />

93965 EXTREMITY STUDY 3.39 1.00<br />

93970 EXTREMITY STUDY 6.87 1.00<br />

93971 EXTREMITY STUDY 4.58 1.00<br />

93975 VASCULAR STUDY 10.40 1.00<br />

93976 VASCULAR STUDY 6.01 1.00<br />

93978 VASCULAR STUDY 6.36 1.00<br />

93979 VASCULAR STUDY 4.40 1.00<br />

93980 PENILE VASCULAR STUDY 4.83 1.00<br />

93981 PENILE VASCULAR STUDY 3.63 1.00<br />

93982 ANEURYSM PRESSURE SENS STUDY 1.11 1.00<br />

93990 DOPPLER FLOW TESTING 5.12 1.00<br />

94010 BREATHING CAPACITY TEST 0.91 1.00<br />

94014 PATIENT RECOR<strong>DE</strong>D SPIROMETRY 1.33 1.00<br />

94015 PATIENT RECOR<strong>DE</strong>D SPIROMETRY 0.64 1.00<br />

94016 REVIEW PATIENT SPIROMETRY 0.69 1.00<br />

94060 EVALUATION OF WHEEZING 1.57 1.00<br />

94070 EVALUATION OF WHEEZING 1.63 1.00<br />

94150 VITAL CAPACITY TEST 0.56 1.00<br />

94200 LUNG FUNCTION TEST (MBC/MVV) 0.61 1.00<br />

94240 RESIDUAL LUNG CAPACITY 1.06 1.00<br />

94250 EXPIRED GAS COLLECTION 0.71 1.00<br />

94260 THORACIC GAS VOLUME 0.84 1.00<br />

94350 LUNG NITROGEN WASHOUT CURVE 1.00 1.00<br />

94360 MEASURE AIRFLOW RESISTANCE 1.15 1.00<br />

94370 BREATH AIRWAY CLOSING VOLUME 0.95 1.00<br />

94375 RESPIRATORY FLOW VOLUME LOOP 1.00 1.00<br />

94400 CO2 BREATHING RESPONSE CURVE 1.43 1.00

---

94450 HYPOXIA RESPONSE CURVE 1.36 1.00<br />

94452 HAST W/REPORT 1.49 1.00<br />

94453 HAST W/OXYGEN TITRATE 2.04 1.00<br />

94610 SURFACTANT ADMIN THRU TUBE 1.76 1.00<br />

94620 PULMONARY STRESS TEST/SIMPLE 2.41 1.00<br />

94621 PULM STRESS TEST/COMPLEX 4.27 1.00<br />

94640 AIRWAY INHALATION TREATMENT 0.36 1.00<br />

94644 CBT, 1ST HOUR 0.98 1.00<br />

94645 CBT, EACH ADDL HOUR 0.37 1.00<br />

94664 EVALUATE PT USE OF INHALER 0.40 1.00<br />

94680 EXHALED AIR ANALYSIS, O2 1.79 1.00<br />

94681 EXHALED AIR ANALYSIS, O2/CO2 2.12 1.00<br />

94690 EXHALED AIR ANALYSIS 1.64 1.00<br />

94720 MONOXI<strong>DE</strong> DIFFUSING CAPACITY 1.41 1.00<br />

94725 MEMBRANE DIFFUSION CAPACITY 2.33 1.00<br />

94750 PULMONARY COMPLIANCE STUDY 1.83 1.00<br />

94760 MEASURE BLOOD OXYGEN LEVEL 0.07 1.00<br />

94761 MEASURE BLOOD OXYGEN LEVEL 0.15 1.00<br />

94762 MEASURE BLOOD OXYGEN LEVEL 0.76 1.00<br />

94770 EXHALED CARBON DIOXI<strong>DE</strong> TEST 1.01 1.00<br />

95805 MULTIPLE SLEEP LATENCY TEST 14.45 1.00<br />

95807 SLEEP STUDY, ATTEN<strong>DE</strong>D 14.24 1.00<br />

95808 POLYSOMNOGRAPHY, 1-3 17.68 1.00<br />

95810 POLYSOMNOGRAPHY, 4 OR MORE 21.71 1.00<br />

95811 POLYSOMNOGRAPHY W/CPAP 23.85 1.00<br />

95812 EEG, 41-60 MINUTES 6.22 1.00<br />

95813 EEG, OVER 1 HOUR 7.70 1.00<br />

95816 EEG, AWAKE AND DROWSY 5.73 1.00<br />

95819 EEG, AWAKE AND ASLEEP 5.80 1.00<br />

95822 EEG, COMA OR SLEEP ONLY 6.33 1.00<br />

95824 EEG, CEREBRAL <strong>DE</strong>ATH ONLY 1.04 1.00<br />

95827 EEG, ALL NIGHT RECORDING 8.39 1.00<br />

95829 SURGERY ELECTROCORTICOGRAM 34.60 1.00<br />

95831 LIMB MUSCLE TESTING, MANUAL 0.40 1.00<br />

95832 HAND MUSCLE TESTING, MANUAL 0.42 1.00<br />

95833 BODY MUSCLE TESTING, MANUAL 0.67 1.00<br />

95834 BODY MUSCLE TESTING, MANUAL 0.86 1.00<br />

95852 RANGE OF MOTION MEASUREMENTS 0.16 1.00<br />

95857 TENSILON TEST 0.74 1.00<br />

95860 MUSCLE TEST, ONE LIMB 2.32 1.00<br />

95861 MUSCLE TEST, 2 LIMBS 3.20 1.00<br />

95863 MUSCLE TEST, 3 LIMBS 3.84 1.00<br />

95864 MUSCLE TEST, 4 LIMBS 4.60 1.00<br />

95865 MUSCLE TEST, LARYNX 3.10 1.00<br />

95866 MUSCLE TEST, HEMIDIAPHRAGM 2.38 1.00<br />

95867 MUSCLE TEST CRAN NERV UNILAT 1.90 1.00<br />

95868 MUSCLE TEST CRAN NERVE BILAT 2.63 1.00<br />

95869 MUSCLE TEST, THOR PARASPINAL 1.11 1.00<br />

95870 MUSCLE TEST, NONPARASPINAL 1.09 1.00<br />

95873 GUI<strong>DE</strong> NERV <strong>DE</strong>STR, ELEC STIM 1.10 1.00

---

95874 GUI<strong>DE</strong> NERV <strong>DE</strong>STR, NEEDLE EMG 1.08 1.00<br />

95875 LIMB EXERCISE TEST 2.67 1.00<br />

95900 MOTOR NERVE CONDUCTION TEST 1.55 1.00<br />

95903 MOTOR NERVE CONDUCTION TEST 1.75 1.00<br />

95904 SENSE NERVE CONDUCTION TEST 1.35 1.00<br />

95920 INTRAOP NERVE TEST ADD-ON 4.33 1.00<br />

95921 AUTONOMIC NERV FUNCTION TEST 1.90 1.00<br />

95922 AUTONOMIC NERV FUNCTION TEST 2.22 1.00<br />

95923 AUTONOMIC NERV FUNCTION TEST 3.11 1.00<br />

95925 SOMATOSENSORY TESTING 2.74 1.00<br />

95926 SOMATOSENSORY TESTING 2.70 1.00<br />

95927 SOMATOSENSORY TESTING 2.79 1.00<br />

95928 C MOTOR EVOKED, UPPR LIMBS 5.07 1.00<br />

95929 C MOTOR EVOKED, LWR LIMBS 5.33 1.00<br />

95930 VISUAL EVOKED POTENTIAL TEST 2.83 1.00<br />

95933 BLINK REFLEX TEST 1.76 1.00<br />

95934 H-REFLEX TEST 1.19 1.00<br />

95936 H-REFLEX TEST 1.12 1.00<br />

95937 NEUROMUSCULAR JUNCTION TEST 1.51 1.00<br />

95950 AMBULATORY EEG MONITORING 6.45 1.00<br />

95951 EEG MONITORING/VI<strong>DE</strong>ORECORD 8.43 1.00<br />

95953 EEG MONITORING/COMPUTER 11.33 1.00<br />

95956 EEG MONITORING, CABLE/RADIO 19.53 1.00<br />

95957 EEG DIGITAL ANALYSIS 6.41 1.00<br />

95961 ELECTRO<strong>DE</strong> STIMULATION, BRAIN 6.36 1.00<br />

95962 ELECTRO<strong>DE</strong> STIM, BRAIN ADD-ON 6.05 1.00<br />

95965 MEG, SPONTANEOUS 11.36 1.00<br />

95966 MEG, EVOKED, SINGLE 5.63 1.00<br />

95967 MEG, EVOKED, EACH ADDÏL 4.74 1.00<br />

95970 ANALYZE NEUROSTIM, NO PROG 0.61 1.00<br />

95971 ANALYZE NEUROSTIM, SIMPLE 1.05 1.00<br />

95972 ANALYZE NEUROSTIM, COMPLEX 2.10 1.00<br />

95973 ANALYZE NEUROSTIM, COMPLEX 1.27 1.00<br />

95974 CRANIAL NEUROSTIM, COMPLEX 4.20 1.00<br />

95975 CRANIAL NEUROSTIM, COMPLEX 2.42 1.00<br />

95978 ANALYZE NEUROSTIM BRAIN/1H 4.84 1.00<br />

95979 ANALYZ NEUROSTIM BRAIN ADDON 2.30 1.00<br />

95980 IO ANAL GAST N-STIM INIT 1.12 1.00<br />

95981 IO ANAL GAST N-STIM SUBSQ 0.44 1.00<br />

95982 IO GA N-STIM SUBSQ W/REPROG 0.88 1.00<br />

95990 SPIN/BRAIN PUMP REFIL & MAIN 1.62 1.00<br />

95991 SPIN/BRAIN PUMP REFIL & MAIN 1.00 1.00<br />

97001 PT EVALUATION 1.95 1.00<br />

97002 PT RE-EVALUATION 1.04 1.00<br />

97003 OT EVALUATION 2.08 1.00<br />

97004 OT RE-EVALUATION 1.23 1.00<br />

97010 HOT OR COLD PACKS THERAPY 0.13 1.00<br />

97012 MECHANICAL TRACTION THERAPY 0.40 1.00<br />

97014 ELECTRIC STIMULATION THERAPY 0.37 1.00<br />

97016 VASOPNEUMATIC <strong>DE</strong>VICE THERAPY 0.40 1.00

---

97018 PARAFFIN BATH THERAPY 0.20 1.00<br />

97022 WHIRLPOOL THERAPY 0.45 1.00<br />

97024 DIATHERMY EG, MICROWAVE 0.14 1.00<br />

97026 INFRARED THERAPY 0.13 1.00<br />

97028 ULTRAVIOLET THERAPY 0.17 1.00<br />

97032 ELECTRICAL STIMULATION 0.44 1.00<br />

97033 ELECTRIC CURRENT THERAPY 0.63 1.00<br />

97034 CONTRAST BATH THERAPY 0.39 1.00<br />

97035 ULTRASOUND THERAPY 0.32 1.00<br />

97036 HYDROTHERAPY 0.67 1.00<br />

97039 PHYSICAL THERAPY TREATMENT 0.31 1.00<br />

97110 THERAPEUTIC EXERCISES 0.76 1.00<br />

97112 NEUROMUSCULAR REEDUCATION 0.79 1.00<br />

97113 AQUATIC THERAPY/EXERCISES 0.91 1.00<br />

97116 GAIT TRAINING THERAPY 0.67 1.00<br />

97124 MASSAGE THERAPY 0.61 1.00<br />

97139 PHYSICAL MEDICINE PROCEDURE 0.42 1.00<br />

97140 MANUAL THERAPY 0.71 1.00<br />

97150 GROUP THERAPEUTIC PROCEDURES 0.48 1.00<br />

97530 THERAPEUTIC ACTIVITIES 0.80 1.00<br />

97532 COGNITIVE SKILLS <strong>DE</strong>VELOPMENT 0.66 1.00<br />

97533 SENSORY INTEGRATION 0.70 1.00<br />

97535 SELF CARE MNGMENT TRAINING 0.81 1.00<br />

97537 COMMUNITY/WORK REINTEGRATION 0.73 1.00<br />

97542 WHEELCHAIR MNGMENT TRAINING 0.74 1.00<br />

97597 ACTIVE WOUND CARE/20 CM OR < 1.02 1.00<br />

97598 ACTIVE WOUND CARE > 20 CM 1.33 1.00<br />

97605 NEG PRESS WOUND TX, < 50 CM 0.74 1.00<br />

97606 NEG PRESS WOUND TX, > 50 CM 0.81 1.00<br />

97750 PHYSICAL PERFORMANCE TEST 0.79 1.00<br />

97755 ASSISTIVE TECHNOLOGY ASSESS 0.92 1.00<br />

97760 ORTHOTIC MGMT AND TRAINING 0.86 1.00<br />

97761 PROSTHETIC TRAINING 0.77 1.00<br />

97762 C/O FOR ORTHOTIC/PROSTH USE 0.85 1.00<br />

99288 DIRECT ADVANCED LIFE SUPPORT 999.99 1.00<br />

99291 CRITICAL CARE, FIRST HOUR 5.90 1.00<br />

99292 CRITICAL CARE, ADDÏL 30 MIN 2.96 1.00<br />

99304 NURSING FACILITY CARE, INIT 2.19 1.00<br />

99305 NURSING FACILITY CARE, INIT 3.05 1.00<br />

99306 NURSING FACILITY CARE, INIT 3.92 1.00<br />

99307 NURSING FAC CARE, SUBSEQ 1.08 1.00<br />

99308 NURSING FAC CARE, SUBSEQ 1.66 1.00<br />

99309 NURSING FAC CARE, SUBSEQ 2.22 1.00<br />

99310 NURSING FAC CARE, SUBSEQ 3.25 1.00<br />

99318 ANNUAL NURSING FAC ASSESSMNT 2.29 1.00<br />

99341 HOME VISIT, NEW PATIENT 1.51 1.00<br />

99342 HOME VISIT, NEW PATIENT 2.21 1.00<br />

99343 HOME VISIT, NEW PATIENT 3.51 1.00<br />

99344 HOME VISIT, NEW PATIENT 4.60 1.00<br />

99345 HOME VISIT, NEW PATIENT 5.54 1.00

---

99347 HOME VISIT, EST PATIENT 1.45 1.00<br />

99348 HOME VISIT, EST PATIENT 2.19 1.00<br />

99349 HOME VISIT, EST PATIENT 3.20 1.00<br />

99350 HOME VISIT, EST PATIENT 4.48 1.00<br />

99354 PROLONGED SERVICE, OFFICE 2.43 1.00<br />

99355 PROLONGED SERVICE, OFFICE 2.38 1.00<br />

99356 PROLONGED SERVICE, INPATIENT 2.34 1.00<br />

99357 PROLONGED SERVICE, INPATIENT 2.35 1.00<br />

99360 PHYSICIAN STANDBY SERVICES 1.53 1.00<br />

99381 INIT PM E/M, NEW PAT, INF 1.60 1.00<br />

99382 INIT PM E/M, NEW PAT 1-4 YRS 1.83 1.00<br />

99383 PREV VISIT, NEW, AGE 5-11 1.83 1.00<br />

99384 PREV VISIT, NEW, AGE 12-17 2.06 1.00<br />

99385 PREV VISIT, NEW, AGE 18-39 2.06 1.00<br />

99386 PREV VISIT, NEW, AGE 40-64 2.53 1.00<br />

99387 INIT PM E/M, NEW PAT 65+ YRS 2.76 1.00<br />

99391 PER PM REEVAL, EST PAT, INF 1.37 1.00<br />

99392 PREV VISIT, EST, AGE 1-4 1.60 1.00<br />

99393 PREV VISIT, EST, AGE 5-11 1.60 1.00<br />

99394 PREV VISIT, EST, AGE 12-17 1.83 1.00<br />

99395 PREV VISIT, EST, AGE 18-39 1.83 1.00<br />

99396 PREV VISIT, EST, AGE 40-64 2.06 1.00<br />

99397 PER PM REEVAL EST PAT 65+ YR 2.30 1.00<br />

99477 INIT DAY HOSP NEONATE CARE 9.30 1.00

---

Fee Schedule Modifiers<br />

Procedure Code Procedure Code Modifier 1 Pricing Action Code Modifier Price<br />

11975 26 5 113.32<br />

11977 26 5 206.80<br />

11980 26 5 96.40<br />

11981 26 5 124.43<br />

11983 26 5 215.64<br />

51725 26 3 75.22<br />

51725 TC 3 173.90<br />

51726 26 3 85.60<br />

51726 TC 3 265.48<br />

51736 26 3 30.93<br />

51736 TC 3 21.54<br />

51741 26 3 57.30<br />

51741 TC 3 24.99<br />

51772 26 3 80.76<br />

51772 TC 3 189.15<br />

51784 26 3 76.39<br />

51784 TC 3 139.67<br />

51785 26 3 76.09<br />

51785 TC 3 157.38<br />

51792 26 3 55.16<br />

51792 TC 3 205.29<br />

51795 26 3 76.39<br />

51795 TC 3 257.51<br />

51797 26 3 46.64<br />

51797 TC 3 147.05<br />

58300 26 5 78.35<br />

59020 26 3 35.72<br />

59020 TC 3 30.50<br />

59025 26 3 29.03<br />

59025 TC 3 14.76<br />

62252 26 3 43.24<br />

62252 TC 3 51.74<br />

70010 26 3 57.65<br />

70010 TC 3 139.10<br />

70015 26 3 58.93<br />

70015 TC 3 77.91<br />

70030 26 3 8.43<br />

70030 TC 3 19.48<br />

70100 26 3 8.82<br />

70100 TC 3 22.23<br />

70110 26 3 11.91<br />

70110 TC 3 27.54<br />

70120 26 3 8.82<br />

70120 TC 3 25.97<br />

70130 26 3 16.47<br />

70130 TC 3 37.28<br />

70134 26 3 16.47

---

70134 TC 3 31.38<br />

70140 26 3 9.20<br />

70140 TC 3 23.22<br />

70150 26 3 12.30<br />

70150 TC 3 31.77<br />

70160 26 3 8.43<br />

70160 TC 3 23.41<br />

70170 26 3 14.24<br />

70170 TC 3 41.38<br />

70190 26 3 9.98<br />

70190 TC 3 26.36<br />

70200 26 3 13.46<br />

70200 TC 3 32.17<br />

70210 26 3 8.04<br />

70210 TC 3 23.61<br />

70220 26 3 11.91<br />

70220 TC 3 29.81<br />

70240 26 3 9.20<br />

70240 TC 3 19.48<br />

70250 26 3 11.14<br />

70250 TC 3 25.58<br />

70260 26 3 16.47<br />

70260 TC 3 34.43<br />

70300 26 3 5.34<br />

70300 TC 3 9.64<br />

70310 26 3 8.05<br />

70310 TC 3 23.80<br />

70320 26 3 10.76<br />

70320 TC 3 36.50<br />

70328 26 3 8.82<br />

70328 TC 3 21.44<br />

70330 26 3 11.53<br />

70330 TC 3 36.10<br />

70332 26 3 26.16<br />

70332 TC 3 70.44<br />

70336 26 3 71.80<br />

70336 TC 3 317.54<br />

70350 26 3 8.43<br />

70350 TC 3 13.58<br />

70355 26 3 9.98<br />

70355 TC 3 16.92<br />

70360 26 3 8.43<br />

70360 TC 3 18.69<br />

70370 26 3 15.01<br />

70370 TC 3 58.33<br />

70371 26 3 40.30<br />

70371 TC 3 68.86<br />

70373 26 3 20.72<br />

70373 TC 3 67.39<br />

70380 26 3 8.43

---

70380 TC 3 29.51<br />

70390 26 3 18.41<br />

70390 TC 3 81.94<br />

70450 26 3 41.47<br />

70450 TC 3 191.13<br />

70460 26 3 55.33<br />

70460 TC 3 240.61<br />

70470 26 3 61.82<br />

70470 TC 3 297.37<br />

70480 26 3 62.21<br />

70480 TC 3 196.44<br />

70481 26 3 67.24<br />

70481 TC 3 284.09<br />

70482 26 3 70.34<br />

70482 TC 3 333.08<br />

70486 26 3 54.94<br />

70486 TC 3 196.15<br />

70487 26 3 63.38<br />

70487 TC 3 275.63<br />

70488 26 3 68.79<br />

70488 TC 3 332.88<br />

70490 26 3 62.60<br />

70490 TC 3 195.75<br />

70491 26 3 67.24<br />

70491 TC 3 268.94<br />

70492 26 3 70.34<br />

70492 TC 3 332.88<br />

70496 26 3 85.27<br />

70496 TC 3 336.13<br />

70498 26 3 85.67<br />

70498 TC 3 336.13<br />

70540 26 3 65.30<br />

70540 TC 3 352.25<br />

70542 26 3 78.77<br />

70542 TC 3 407.04<br />

70543 26 3 104.06<br />

70543 TC 3 537.48<br />

70544 26 3 58.43<br />

70544 TC 3 351.18<br />

70545 26 3 58.43<br />

70545 TC 3 405.67<br />

70546 26 3 87.59<br />

70546 TC 3 539.14<br />

70547 26 3 58.03<br />

70547 TC 3 351.18<br />

70548 26 3 58.43<br />

70548 TC 3 406.16<br />

70549 26 3 87.59<br />

70549 TC 3 539.14<br />

70551 26 3 71.80

---

70551 TC 3 350.59<br />

70552 26 3 86.82<br />

70552 TC 3 405.58<br />

70553 26 3 114.53<br />

70553 TC 3 534.65<br />

70554 26 3 101.73<br />

70554 TC 3 603.80<br />

70555 26 3 124.92<br />

70557 26 3 143.05<br />

70557 TC 3 218.08<br />

70558 26 3 157.58<br />

70558 TC 3 243.87<br />

70559 26 3 158.96<br />

70559 TC 3 242.22<br />

71010 26 3 8.82<br />

71010 TC 3 17.12<br />

71015 26 3 9.98<br />

71015 TC 3 20.66<br />

71020 26 3 10.37<br />

71020 TC 3 23.22<br />

71021 26 3 13.08<br />

71021 TC 3 28.23<br />

71022 26 3 14.63<br />

71022 TC 3 31.38<br />

71023 26 3 18.51<br />

71023 TC 3 44.36<br />

71030 26 3 14.63<br />

71030 TC 3 32.95<br />

71034 26 3 23.46<br />

71034 TC 3 68.07<br />

71035 26 3 8.82<br />

71035 TC 3 24.99<br />

71040 26 3 27.61<br />

71040 TC 3 68.07<br />

71060 26 3 35.75<br />

71060 TC 3 103.39<br />

71090 26 3 28.52<br />

71090 TC 3 71.79<br />

71100 26 3 10.37<br />

71100 TC 3 23.22<br />

71101 26 3 13.08<br />

71101 TC 3 27.54<br />

71110 26 3 13.08<br />

71110 TC 3 30.20<br />

71111 26 3 15.01<br />

71111 TC 3 38.37<br />

71120 26 3 9.98<br />

71120 TC 3 25.18<br />

71130 26 3 10.37<br />

71130 TC 3 28.33

---

71250 26 3 56.10<br />

71250 TC 3 195.86<br />

71260 26 3 59.98<br />

71260 TC 3 283.01<br />

71270 26 3 67.24<br />

71270 TC 3 332.39<br />

71275 26 3 93.71<br />

71275 TC 3 337.20<br />

71550 26 3 70.73<br />

71550 TC 3 352.05<br />

71551 26 3 83.72<br />

71551 TC 3 407.04<br />

71552 26 3 109.88<br />

71552 TC 3 538.75<br />

71555 26 3 88.38<br />

71555 TC 3 405.87<br />

72010 26 3 21.50<br />

72010 TC 3 45.45<br />

72020 26 3 7.27<br />

72020 TC 3 17.12<br />

72040 26 3 10.37<br />

72040 TC 3 26.76<br />

72050 26 3 14.63<br />

72050 TC 3 38.37<br />

72052 26 3 17.64<br />

72052 TC 3 48.99<br />

72069 26 3 10.76<br />

72069 TC 3 23.41<br />

72070 26 3 10.37<br />

72070 TC 3 25.18<br />

72072 26 3 10.37<br />

72072 TC 3 29.41<br />

72074 26 3 10.37<br />

72074 TC 3 36.79<br />

72080 26 3 10.37<br />

72080 TC 3 26.36<br />

72090 26 3 13.86<br />

72090 TC 3 32.27<br />

72100 26 3 10.37<br />

72100 TC 3 28.72<br />

72110 26 3 14.63<br />

72110 TC 3 39.94<br />

72114 26 3 17.64<br />

72114 TC 3 53.32<br />

72120 26 3 10.37<br />

72120 TC 3 38.76<br />

72125 26 3 56.10<br />

72125 TC 3 195.86<br />

72126 26 3 58.81<br />

72126 TC 3 283.01

---

72127 26 3 61.82<br />

72127 TC 3 332.39<br />

72128 26 3 56.10<br />

72128 TC 3 195.86<br />

72129 26 3 59.21<br />

72129 TC 3 283.01<br />

72130 26 3 61.82<br />

72130 TC 3 332.39<br />

72131 26 3 56.10<br />

72131 TC 3 195.86<br />

72132 26 3 58.81<br />

72132 TC 3 283.01<br />

72133 26 3 61.82<br />

72133 TC 3 332.39<br />

72141 26 3 77.61<br />

72141 TC 3 350.59<br />

72142 26 3 93.31<br />

72142 TC 3 405.58<br />

72146 26 3 77.61<br />

72146 TC 3 350.49<br />

72147 26 3 93.31<br />

72147 TC 3 405.19<br />

72148 26 3 71.80<br />

72148 TC 3 350.49<br />

72149 26 3 86.82<br />

72149 TC 3 405.58<br />

72156 26 3 124.51<br />

72156 TC 3 534.65<br />

72157 26 3 124.51<br />

72157 TC 3 534.36<br />

72158 26 3 114.53<br />

72158 TC 3 534.65<br />

72159 26 3 85.82<br />

72159 TC 3 540.25<br />

72170 26 3 8.43<br />

72170 TC 3 19.48<br />

72190 26 3 9.98<br />

72190 TC 3 29.51<br />

72191 26 3 88.38<br />

72191 TC 3 337.10<br />

72192 26 3 53.00<br />

72192 TC 3 195.76<br />

72193 26 3 56.49<br />

72193 TC 3 283.31<br />

72194 26 3 58.81<br />

72194 TC 3 332.59<br />

72195 26 3 70.73<br />

72195 TC 3 351.86<br />

72196 26 3 84.11<br />

72196 TC 3 406.75

---

72197 26 3 109.49<br />

72197 TC 3 537.09<br />

72198 26 3 87.59<br />

72198 TC 3 405.87<br />

72200 26 3 8.43<br />

72200 TC 3 21.44<br />

72202 26 3 9.20<br />

72202 TC 3 26.76<br />

72220 26 3 8.43<br />

72220 TC 3 22.82<br />

72240 26 3 43.79<br />

72240 TC 3 145.10<br />

72255 26 3 43.00<br />

72255 TC 3 130.44<br />

72265 26 3 39.92<br />

72265 TC 3 130.84<br />

72270 26 3 64.53<br />

72270 TC 3 199.40<br />

72275 26 3 34.85<br />

72275 TC 3 78.12<br />

72285 26 3 54.33<br />

72285 TC 3 200.00<br />

72291 26 3 65.73<br />

72292 26 3 68.33<br />

72295 26 3 40.11<br />

72295 TC 3 190.46<br />

73000 26 3 7.65<br />

73000 TC 3 20.66<br />

73010 26 3 8.43<br />

73010 TC 3 21.05<br />

73020 26 3 7.27<br />

73020 TC 3 17.51<br />

73030 26 3 8.82<br />

73030 TC 3 22.43<br />

73040 26 3 26.55<br />

73040 TC 3 85.39<br />

73050 26 3 9.98<br />

73050 TC 3 27.15<br />

73060 26 3 8.43<br />

73060 TC 3 22.43<br />

73070 26 3 7.27<br />

73070 TC 3 20.66<br />

73080 26 3 8.43<br />

73080 TC 3 25.97<br />

73085 26 3 26.55<br />

73085 TC 3 77.52<br />

73090 26 3 7.65<br />

73090 TC 3 20.66<br />

73092 26 3 7.65<br />

73092 TC 3 20.66

---

73100 26 3 7.65<br />

73100 TC 3 21.05<br />

73110 26 3 8.43<br />

73110 TC 3 24.99<br />

73115 26 3 26.16<br />

73115 TC 3 76.14<br />

73120 26 3 7.65<br />

73120 TC 3 20.26<br />

73130 26 3 8.43<br />

73130 TC 3 23.02<br />

73140 26 3 6.11<br />

73140 TC 3 21.44<br />

73200 26 3 53.00<br />

73200 TC 3 196.15<br />

73201 26 3 56.10<br />

73201 TC 3 273.17<br />

73202 26 3 58.81<br />

73202 TC 3 332.88<br />

73206 26 3 88.38<br />

73206 TC 3 336.91<br />

73218 26 3 65.30<br />

73218 TC 3 352.25<br />

73219 26 3 78.77<br />

73219 TC 3 407.04<br />

73220 26 3 104.46<br />

73220 TC 3 537.48<br />

73221 26 3 65.30<br />

73221 TC 3 352.15<br />

73222 26 3 78.77<br />

73222 TC 3 406.94<br />

73223 26 3 104.06<br />

73223 TC 3 537.38<br />

73225 26 3 82.34<br />

73225 TC 3 514.37<br />

73500 26 3 8.43<br />

73500 TC 3 18.30<br />

73510 26 3 9.98<br />

73510 TC 3 26.36<br />

73520 26 3 12.69<br />

73520 TC 3 27.94<br />

73525 26 3 26.45<br />

73525 TC 3 77.52<br />

73530 26 3 14.24<br />

73530 TC 3 22.41<br />

73540 26 3 9.98<br />

73540 TC 3 26.76<br />

73542 26 3 26.81<br />

73542 TC 3 64.53<br />

73550 26 3 8.43<br />

73550 TC 3 22.04

---

73560 26 3 8.43<br />

73560 TC 3 21.05<br />

73562 26 3 8.82<br />

73562 TC 3 25.58<br />

73564 26 3 10.37<br />

73564 TC 3 28.72<br />

73565 26 3 8.43<br />

73565 TC 3 21.84<br />

73580 26 3 26.45<br />

73580 TC 3 102.50<br />

73590 26 3 8.43<br />

73590 TC 3 20.26<br />

73592 26 3 7.65<br />

73592 TC 3 20.66<br />

73600 26 3 7.65<br />

73600 TC 3 20.26<br />

73610 26 3 8.43<br />

73610 TC 3 23.02<br />

73615 26 3 26.45<br />

73615 TC 3 80.67<br />

73620 26 3 7.65<br />

73620 TC 3 19.87<br />

73630 26 3 8.43<br />

73630 TC 3 23.02<br />

73650 26 3 7.65<br />

73650 TC 3 19.48<br />

73660 26 3 6.11<br />

73660 TC 3 20.66<br />

73700 26 3 53.00<br />

73700 TC 3 196.15<br />

73701 26 3 56.49<br />

73701 TC 3 274.35<br />

73702 26 3 59.21<br />

73702 TC 3 332.88<br />

73706 26 3 93.03<br />

73706 TC 3 337.10<br />

73718 26 3 65.30<br />

73718 TC 3 352.25<br />

73719 26 3 78.77<br />

73719 TC 3 407.04<br />

73720 26 3 104.06<br />

73720 TC 3 537.48<br />

73721 26 3 65.30<br />

73721 TC 3 352.15<br />

73722 26 3 78.77<br />

73722 TC 3 406.94<br />

73723 26 3 104.46<br />

73723 TC 3 537.38<br />

73725 26 3 88.37<br />

73725 TC 3 405.87

---

74000 26 3 8.82<br />

74000 TC 3 18.69<br />

74010 26 3 11.14<br />

74010 TC 3 26.36<br />

74020 26 3 13.08<br />

74020 TC 3 27.54<br />

74022 26 3 15.41<br />

74022 TC 3 32.95<br />

74150 26 3 58.04<br />

74150 TC 3 195.46<br />

74160 26 3 62.21<br />

74160 TC 3 283.60<br />

74170 26 3 68.02<br />

74170 TC 3 332.98<br />

74175 26 3 92.25<br />

74175 TC 3 337.20<br />

74181 26 3 71.12<br />

74181 TC 3 351.57<br />

74182 26 3 84.11<br />

74182 TC 3 406.94<br />

74183 26 3 109.49<br />

74183 TC 3 537.09<br />

74185 26 3 87.59<br />

74185 TC 3 405.87<br />

74190 26 3 23.06<br />

74190 TC 3 56.73<br />

74210 26 3 17.64<br />

74210 TC 3 57.64<br />

74220 26 3 22.67<br />

74220 TC 3 61.58<br />

74230 26 3 25.77<br />

74230 TC 3 62.66<br />

74235 26 3 58.83<br />

74235 TC 3 86.32<br />

74240 26 3 33.82<br />

74240 TC 3 71.61<br />

74241 26 3 33.43<br />

74241 TC 3 77.51<br />

74245 26 3 44.19<br />

74245 TC 3 122.27<br />

74246 26 3 33.82<br />

74246 TC 3 85.58<br />

74247 26 3 33.82<br />

74247 TC 3 89.91<br />

74249 26 3 44.19<br />

74249 TC 3 133.98<br />

74250 26 3 22.67<br />

74250 TC 3 73.28<br />

74251 26 3 33.82<br />

74251 TC 3 145.87

---

74260 26 3 24.22<br />

74260 TC 3 90.89<br />

74270 26 3 33.82<br />

74270 TC 3 90.30<br />

74280 26 3 47.67<br />

74280 TC 3 138.40<br />

74283 26 3 97.56<br />

74283 TC 3 89.81<br />

74290 26 3 15.41<br />

74290 TC 3 44.76<br />

74291 26 3 9.98<br />

74291 TC 3 37.97<br />

74300 26 O 18.66<br />

74301 26 3 9.98<br />

74301 TC 3 15.98<br />

74305 26 3 20.74<br />

74305 TC 3 34.50<br />

74320 26 3 26.55<br />

74320 TC 3 104.96<br />

74327 26 3 34.20<br />

74327 TC 3 91.39<br />

74328 26 3 34.60<br />

74328 TC 3 133.29<br />

74329 26 3 34.60<br />

74330 26 3 43.80<br />

74330 TC 3 134.64<br />

74340 26 3 26.55<br />

74340 TC 3 110.77<br />

74355 26 3 36.92<br />

74355 TC 3 112.11<br />

74360 26 3 27.34<br />

74360 TC 3 132.32<br />

74363 26 3 42.64<br />

74363 TC 3 64.02<br />

74400 26 3 23.84<br />

74400 TC 3 83.91<br />

74410 26 3 23.84<br />

74410 TC 3 90.99<br />

74415 26 3 23.84<br />

74415 TC 3 106.24<br />

74420 26 3 18.03<br />

74420 TC 3 110.01<br />

74425 26 3 18.03<br />

74425 TC 3 55.58<br />

74430 26 3 15.70<br />

74430 TC 3 58.82<br />

74440 26 3 18.41<br />

74440 TC 3 62.76<br />

74445 26 3 56.71<br />

74445 TC 3 51.76

---

74450 26 3 16.48<br />

74450 TC 3 61.86<br />

74455 26 3 16.48<br />

74455 TC 3 74.57<br />

74470 26 3 26.16<br />

74470 TC 3 54.41<br />

74475 26 3 26.55<br />

74475 TC 3 124.54<br />

74480 26 3 26.55<br />

74480 TC 3 124.54<br />

74485 26 3 26.85<br />

74485 TC 3 107.72<br />

74710 26 3 16.47<br />

74710 TC 3 32.86<br />

74740 26 3 18.41<br />

74740 TC 3 59.91<br />

74775 26 3 30.33<br />

74775 TC 3 63.59<br />

75600 26 3 25.81<br />

75600 TC 3 389.07<br />

75605 26 3 57.30<br />

75605 TC 3 327.69<br />

75625 26 3 56.02<br />

75625 TC 3 324.94<br />

75630 26 3 90.06<br />

75630 TC 3 339.10<br />

75635 26 3 117.95<br />

75635 TC 3 337.30<br />

75650 26 3 73.37<br />

75650 TC 3 325.33<br />

75658 26 3 64.45<br />

75658 TC 3 332.02<br />

75660 26 3 64.55<br />

75660 TC 3 333.99<br />

75662 26 3 83.57<br />

75662 TC 3 352.08<br />

75665 26 3 65.04<br />

75665 TC 3 338.71<br />

75671 26 3 81.50<br />

75671 TC 3 355.23<br />

75676 26 3 64.45<br />

75676 TC 3 333.99<br />

75680 26 3 81.90<br />

75680 TC 3 345.00<br />

75685 26 3 64.55<br />

75685 TC 3 333.99<br />

75705 26 3 107.68<br />

75705 TC 3 333.59<br />

75710 26 3 56.71<br />

75710 TC 3 336.74

---

75716 26 3 64.45<br />

75716 TC 3 354.45<br />

75722 26 3 57.30<br />

75722 TC 3 333.59<br />

75724 26 3 77.50<br />

75724 TC 3 353.66<br />

75726 26 3 55.33<br />

75726 TC 3 333.20<br />

75731 26 3 57.59<br />

75731 TC 3 337.92<br />

75733 26 3 67.70<br />

75733 TC 3 361.92<br />

75736 26 3 56.41<br />

75736 TC 3 335.17<br />

75741 26 3 64.16<br />

75741 TC 3 320.22<br />

75743 26 3 81.11<br />

75743 TC 3 325.33<br />

75746 26 3 55.33<br />

75746 TC 3 328.87<br />

75756 26 3 59.76<br />

75756 TC 3 341.46<br />

75774 26 3 18.03<br />

75774 TC 3 313.92<br />

75790 26 3 88.65<br />

75790 TC 3 78.69<br />

75801 26 3 39.54<br />

75801 TC 3 230.21<br />

75803 26 3 56.48<br />

75803 TC 3 229.98<br />

75805 26 3 39.44<br />

75805 TC 3 257.46<br />

75807 26 3 56.48<br />

75807 TC 3 84.80<br />

75809 26 3 22.28<br />

75809 TC 3 56.17<br />

75810 26 3 54.94<br />

75810 TC 3 526.20<br />

75820 26 3 34.99<br />

75820 TC 3 73.77<br />

75822 26 3 51.45<br />

75822 TC 3 86.56<br />

75825 26 3 55.53<br />

75825 TC 3 317.46<br />

75827 26 3 54.54<br />

75827 TC 3 318.25<br />

75831 26 3 54.84<br />

75831 TC 3 319.82<br />

75833 26 3 72.78<br />

75833 TC 3 329.66

---

75840 26 3 55.13<br />

75840 TC 3 318.64<br />

75842 26 3 72.58<br />

75842 TC 3 330.45<br />

75860 26 3 57.00<br />

75860 TC 3 324.54<br />

75870 26 3 55.72<br />

75870 TC 3 324.15<br />

75872 26 3 58.78<br />

75872 TC 3 338.31<br />

75880 26 3 34.60<br />

75880 TC 3 78.50<br />

75885 26 3 69.96<br />

75885 TC 3 319.82<br />

75887 26 3 71.14<br />

75887 TC 3 323.36<br />

75889 26 3 55.33<br />

75889 TC 3 319.82<br />

75891 26 3 55.33<br />

75891 TC 3 319.43<br />

75893 26 3 26.55<br />

75893 TC 3 319.82<br />

75894 26 3 63.96<br />

75894 TC 3 1,004.64<br />

75896 26 3 64.65<br />

75896 TC 3 873.19<br />

75898 26 3 81.12<br />

75898 TC 3 50.95<br />

75900 26 3 23.74<br />

75901 26 3 23.84<br />

75901 TC 3 128.43<br />

75902 26 3 18.80<br />

75902 TC 3 79.64<br />

75940 26 3 26.75<br />

75940 TC 3 523.35<br />

75945 26 3 20.17<br />

75945 TC 3 191.04<br />

75946 26 3 20.07<br />

75952 26 3 219.51<br />

75953 26 3 66.58<br />

75954 26 3 108.22<br />

75956 26 3 347.71<br />

75957 26 3 298.28<br />

75958 26 3 198.23<br />

75959 26 3 173.51<br />

75960 26 3 41.01<br />

75960 TC 3 363.11<br />

75961 26 3 205.61<br />

75961 TC 3 285.78<br />

75962 26 3 26.85

---

75962 TC 3 399.51<br />

75964 26 3 17.93<br />

75964 TC 3 221.64<br />

75966 26 3 66.12<br />

75966 TC 3 405.41<br />

75968 26 3 18.42<br />

75968 TC 3 222.03<br />

75970 26 3 40.70<br />

75970 TC 3 480.68<br />

75978 26 3 26.16<br />

75978 TC 3 395.18<br />

75980 26 3 70.35<br />

75980 TC 3 230.52<br />

75984 26 3 34.59<br />

75984 TC 3 81.94<br />

75989 26 3 58.04<br />

75989 TC 3 103.00<br />

75992 26 3 27.63<br />

75992 TC 3 652.90<br />

75993 26 3 18.03<br />

75994 26 3 66.03<br />

75995 26 3 64.25<br />

75996 26 3 17.64<br />

76000 26 3 8.04<br />

76000 TC 3 81.15<br />

76001 26 3 33.25<br />

76001 TC 3 112.13<br />

76010 26 3 8.82<br />

76010 TC 3 20.26<br />

76080 26 3 26.55<br />

76080 TC 3 39.94<br />

76098 26 3 7.65<br />

76098 TC 3 13.97<br />

76100 26 3 28.39<br />

76100 TC 3 75.74<br />

76101 26 3 28.00<br />

76101 TC 3 134.17<br />

76102 26 3 27.61<br />

76102 TC 3 175.29<br />

76120 26 3 18.41<br />

76120 TC 3 56.86<br />

76125 26 3 13.87<br />

76125 TC 3 33.14<br />

76376 26 3 10.28<br />

76376 TC 3 96.01<br />

76377 26 3 39.94<br />

76377 TC 3 98.48<br />

76380 26 3 47.28<br />

76380 TC 3 103.09<br />

76390 26 3 65.17

---

76390 TC 3 413.26<br />

76506 26 3 31.61<br />

76506 TC 3 62.37<br />

76510 26 3 77.26<br />

76510 TC 3 78.40<br />

76511 26 3 47.01<br />

76511 TC 3 62.27<br />

76512 26 3 47.11<br />

76512 TC 3 54.89<br />

76513 26 3 33.15<br />

76513 TC 3 58.43<br />

76514 26 3 8.83<br />

76514 TC 3 3.44<br />

76516 26 3 27.04<br />

76516 TC 3 45.35<br />

76519 26 3 27.43<br />

76519 TC 3 49.28<br />

76529 26 3 28.50<br />

76529 TC 3 43.29<br />

76536 26 3 26.54<br />

76536 TC 3 79.48<br />

76604 26 3 26.55<br />

76604 TC 3 59.91<br />

76645 26 3 26.16<br />

76645 TC 3 60.40<br />

76700 26 3 39.15<br />

76700 TC 3 96.11<br />

76705 26 3 28.78<br />

76705 TC 3 72.40<br />

76770 26 3 35.75<br />

76770 TC 3 94.53<br />

76775 26 3 28.39<br />

76775 TC 3 73.58<br />

76776 26 3 36.92<br />

76776 TC 3 104.37<br />

76800 26 3 52.18<br />

76800 TC 3 70.04<br />

76801 26 3 47.27<br />

76801 TC 3 87.35<br />

76802 26 3 40.31<br />

76802 TC 3 38.17<br />

76805 26 3 47.27<br />

76805 TC 3 97.98<br />

76810 26 3 46.89<br />

76810 TC 3 53.72<br />

76811 26 3 91.36<br />

76811 TC 3 131.54<br />

76812 26 3 85.64<br />

76812 TC 3 60.51<br />

76813 26 3 57.26

---

76813 TC 3 75.36<br />

76814 26 3 46.39<br />

76814 TC 3 37.98<br />

76815 26 3 31.10<br />

76815 TC 3 61.78<br />

76816 26 3 41.08<br />

76816 TC 3 62.37<br />

76817 26 3 35.74<br />

76817 TC 3 62.37<br />

76818 26 3 50.68<br />

76818 TC 3 72.20<br />

76819 26 3 37.30<br />

76819 TC 3 61.98<br />

76820 26 3 24.52<br />

76820 TC 3 43.29<br />

76821 26 3 34.20<br />

76821 TC 3 68.08<br />

76825 26 3 80.31<br />

76825 TC 3 98.27<br />

76826 26 3 39.62<br />

76826 TC 3 62.46<br />

76827 26 3 27.71<br />

76827 TC 3 55.09<br />

76828 26 3 27.23<br />

76828 TC 3 33.45<br />

76830 26 3 33.43<br />

76830 TC 3 82.83<br />

76831 26 3 34.20<br />

76831 TC 3 82.43<br />

76856 26 3 33.43<br />

76856 TC 3 83.22<br />

76857 26 3 18.41<br />

76857 TC 3 62.46<br />

76870 26 3 31.11<br />

76870 TC 3 84.01<br />

76872 26 3 34.11<br />

76872 TC 3 98.27<br />

76873 26 3 75.49<br />

76873 TC 3 97.68<br />

76880 26 3 28.39<br />

76880 TC 3 89.32<br />

76885 26 3 35.36<br />

76885 TC 3 62.27<br />

76886 26 3 30.33<br />

76886 TC 3 62.27<br />

76930 26 3 34.72<br />

76930 TC 3 67.09<br />

76932 26 3 35.11<br />

76932 TC 3 65.10<br />

76936 26 3 98.38

---

76936 TC 3 240.62<br />

76937 26 3 14.83<br />

76937 TC 3 20.66<br />

76940 26 3 102.52<br />

76940 TC 3 88.32<br />

76941 26 3 64.43<br />

76941 TC 3 72.07<br />

76942 26 3 32.66<br />

76942 TC 3 147.74<br />

76945 26 3 31.87<br />

76945 TC 3 67.07<br />

76946 26 3 18.02<br />

76946 TC 3 39.55<br />

76950 26 3 28.00<br />

76950 TC 3 47.71<br />

76965 26 3 65.90<br />

76965 TC 3 132.12<br />

76970 26 3 18.79<br />

76970 TC 3 59.22<br />

76975 26 3 39.93<br />

76975 TC 3 67.85<br />

76977 26 3 2.62<br />

76977 TC 3 19.58<br />

76998 26 3 59.61<br />

76998 TC 3 117.18<br />

77001 26 3 18.12<br />

77001 TC 3 79.68<br />

77002 26 3 25.37<br />

77002 TC 3 48.89<br />

77003 26 3 27.20<br />

77003 TC 3 39.84<br />

77011 26 3 58.42<br />

77011 TC 3 566.00<br />

77012 26 3 56.49<br />

77012 TC 3 212.69<br />

77013 26 3 193.99<br />

77013 TC 3 411.40<br />

77014 26 3 41.08<br />

77014 TC 3 145.59<br />

77021 26 3 73.56<br />

77021 TC 3 417.58<br />

77022 26 3 207.78<br />

77022 TC 3 532.70<br />

77031 26 3 77.42<br />

77031 TC 3 178.16<br />

77032 26 3 26.94<br />

77032 TC 3 40.63<br />

77051 26 3 3.01<br />

77051 TC 3 12.10<br />

77052 26 3 3.01

---

77052 TC 3 12.10<br />

77280 26 3 34.11<br />

77280 TC 3 156.41<br />

77285 26 3 50.28<br />

77285 TC 3 269.73<br />

77290 26 3 74.79<br />

77290 TC 3 392.78<br />

77295 26 3 219.83<br />

77295 TC 3 710.68<br />

77300 26 3 29.93<br />

77300 TC 3 47.71<br />

77301 26 3 384.82<br />

77301 TC 3 1,672.63<br />

77305 26 3 34.11<br />

77305 TC 3 53.22<br />

77310 26 3 50.28<br />

77310 TC 3 67.58<br />

77315 26 3 74.79<br />

77315 TC 3 87.55<br />

77321 26 3 46.02<br />

77321 TC 3 109.30<br />

77326 26 3 44.86<br />

77326 TC 3 102.99<br />

77327 26 3 66.75<br />

77327 TC 3 145.39<br />

77328 26 3 100.86<br />

77328 TC 3 194.68<br />

77331 26 3 41.85<br />

77331 TC 3 20.66<br />

77332 26 3 26.06<br />

77332 TC 3 55.58<br />

77333 26 3 40.30<br />

77333 TC 3 45.35<br />

77334 26 3 59.48<br />

77334 TC 3 114.41<br />

77421 26 3 18.80<br />

77421 TC 3 113.12<br />

77470 26 3 100.86<br />

77470 TC 3 261.39<br />

77620 26 3 76.77<br />

77620 TC 3 263.62<br />

77750 26 3 237.85<br />

77750 TC 3 85.87<br />

77761 26 3 181.04<br />

77761 TC 3 153.65<br />

77762 26 3 276.22<br />

77762 TC 3 189.75<br />

77763 26 3 413.59<br />

77763 TC 3 243.26<br />

77776 26 3 222.82

---

77776 TC 3 160.83<br />

77777 26 3 360.50<br />

77777 TC 3 197.33<br />

77778 26 3 540.51<br />

77778 TC 3 259.00<br />

77789 26 3 55.23<br />

77789 TC 3 41.51<br />

77790 26 3 50.28<br />

77790 TC 3 32.46<br />

78000 26 3 9.20<br />

78000 TC 3 56.07<br />

78001 26 3 12.69<br />

78001 TC 3 71.32<br />

78003 26 3 15.79<br />

78003 TC 3 56.46<br />

78006 26 3 23.44<br />

78006 TC 3 169.88<br />

78007 26 3 24.22<br />

78007 TC 3 111.55<br />

78010 26 3 18.80<br />

78010 TC 3 118.93<br />

78011 26 3 21.90<br />

78011 TC 3 133.68<br />

78015 26 3 32.66<br />

78015 TC 3 155.62<br />

78016 26 3 39.63<br />

78016 TC 3 236.28<br />

78018 26 3 42.25<br />

78018 TC 3 265.50<br />

78020 26 3 29.26<br />

78020 TC 3 61.19<br />

78070 26 3 39.92<br />

78070 TC 3 150.40<br />

78075 26 3 35.75<br />

78075 TC 3 339.07<br />

78102 26 3 26.55<br />

78102 TC 3 122.37<br />

78103 26 3 36.53<br />

78103 TC 3 169.49<br />

78104 26 3 38.86<br />

78104 TC 3 203.62<br />

78110 26 3 9.60<br />

78110 TC 3 61.18<br />

78111 26 3 10.76<br />

78111 TC 3 95.42<br />

78120 26 3 11.14<br />

78120 TC 3 77.22<br />

78121 26 3 15.41<br />

78121 TC 3 102.90<br />

78122 26 9 23.48

---

78130 26 3 29.94<br />

78130 TC 3 124.93<br />

78135 26 3 31.11<br />

78135 TC 3 269.82<br />

78140 26 3 29.94<br />

78140 TC 3 137.23<br />

78185 26 3 19.58<br />

78185 TC 3 149.81<br />

78190 26 3 51.92<br />

78190 TC 3 188.87<br />

78191 26 3 29.94<br />

78191 TC 3 220.26<br />

78195 26 3 58.72<br />

78195 TC 3 249.26<br />

78201 26 3 21.12<br />

78201 TC 3 138.40<br />

78202 26 3 24.61<br />

78202 TC 3 162.70<br />

78205 26 3 34.59<br />

78205 TC 3 224.38<br />

78206 26 3 46.90<br />

78206 TC 3 282.20<br />

78215 26 3 23.84<br />

78215 TC 3 153.65<br />

78216 26 3 27.32<br />

78216 TC 3 126.11<br />

78220 26 3 23.44<br />

78220 TC 3 136.24<br />

78223 26 3 41.09<br />

78223 TC 3 239.33<br />

78230 26 3 21.90<br />

78230 TC 3 125.81<br />

78231 26 3 24.99<br />

78231 TC 3 119.13<br />

78232 26 3 22.67<br />

78232 TC 3 126.51<br />

78258 26 3 36.15<br />

78258 TC 3 164.27<br />

78261 26 3 33.82<br />

78261 TC 3 200.48<br />

78262 26 3 32.65<br />

78262 TC 3 203.23<br />

78264 26 3 38.08<br />

78264 TC 3 223.30<br />

78270 26 3 9.98<br />

78270 TC 3 70.24<br />

78271 26 3 9.59<br />

78271 TC 3 71.42<br />

78272 26 3 12.68<br />

78272 TC 3 88.83

---

78278 26 3 48.06<br />

78278 TC 3 247.20<br />

78282 26 3 18.41<br />

78290 26 3 33.43<br />

78290 TC 3 227.81<br />

78291 26 3 42.64<br />

78291 TC 3 180.21<br />

78300 26 3 30.33<br />

78300 TC 3 132.01<br />

78305 26 3 40.31<br />

78305 TC 3 179.92<br />

78306 26 3 42.25<br />

78306 TC 3 204.02<br />

78315 26 3 49.61<br />

78315 TC 3 248.28<br />

78320 26 3 50.77<br />

78320 TC 3 223.99<br />

78350 26 3 9.97<br />

78350 TC 3 25.48<br />

78414 26 3 22.68<br />

78428 26 3 40.05<br />

78428 TC 3 144.70<br />

78445 26 3 23.84<br />

78445 TC 3 124.83<br />

78456 26 3 49.23<br />

78456 TC 3 204.31<br />

78457 26 3 36.91<br />

78457 TC 3 143.42<br />

78458 26 3 43.80<br />

78458 TC 3 168.31<br />

78459 26 3 55.46<br />

78459 TC 3 255.67<br />

78460 26 3 42.25<br />

78460 TC 3 135.65<br />

78461 26 3 60.38<br />

78461 TC 3 171.46<br />

78464 26 3 55.46<br />

78464 TC 3 255.67<br />

78465 26 3 75.15<br />

78465 TC 3 461.75<br />

78466 26 3 34.61<br />

78466 TC 3 140.27<br />

78468 26 3 40.83<br />

78468 TC 3 185.42<br />

78469 26 3 47.03<br />

78469 TC 3 226.25<br />

78472 26 3 48.86<br />

78472 TC 3 228.02<br />

78473 26 3 74.27<br />

78473 TC 3 314.98

---

78478 26 3 26.98<br />

78478 TC 3 44.66<br />

78480 26 3 17.69<br />

78480 TC 3 44.66<br />

78481 26 3 50.92<br />

78481 TC 3 201.07<br />

78483 26 3 77.12<br />

78483 TC 3 286.75<br />

78491 26 3 55.17<br />

78491 TC 3 268.45<br />

78492 26 3 55.17<br />

78492 TC 3 268.45<br />

78494 26 3 60.80<br />

78494 TC 3 259.89<br />

78496 26 3 25.40<br />

78496 TC 3 160.75<br />

78580 26 3 36.15<br />

78580 TC 3 168.60<br />

78584 26 3 48.06<br />

78584 TC 3 120.70<br />

78585 26 3 53.00<br />

78585 TC 3 282.32<br />

78586 26 3 19.18<br />

78586 TC 3 134.37<br />

78587 26 3 23.84<br />

78587 TC 3 163.09<br />

78588 26 3 53.00<br />

78588 TC 3 231.16<br />

78591 26 3 19.58<br />

78591 TC 3 139.49<br />

78593 26 3 23.44<br />

78593 TC 3 164.67<br />

78594 26 3 25.77<br />

78594 TC 3 206.08<br />

78596 26 3 60.74<br />

78596 TC 3 313.11<br />

78600 26 3 21.51<br />

78600 TC 3 144.21<br />

78601 26 3 24.61<br />

78601 TC 3 174.51<br />

78605 26 3 26.17<br />

78605 TC 3 163.88<br />

78606 26 3 30.71<br />

78606 TC 3 246.21<br />

78607 26 3 59.59<br />

78607 TC 3 301.11<br />

78608 26 3 55.17<br />

78608 TC 3 268.45<br />

78609 26 3 55.17<br />

78609 TC 3 268.45

---

78610 26 3 15.42<br />

78610 TC 3 164.66<br />

78630 26 3 33.04<br />

78630 TC 3 272.77<br />

78635 26 3 30.04<br />

78635 TC 3 223.29<br />

78645 26 3 27.32<br />

78645 TC 3 210.90<br />

78647 26 3 43.41<br />

78647 TC 3 287.73<br />

78650 26 3 29.94<br />

78650 TC 3 262.84<br />

78660 26 3 25.77<br />

78660 TC 3 125.52<br />

78700 26 3 22.29<br />

78700 TC 3 147.95<br />

78701 26 3 23.84<br />

78701 TC 3 178.05<br />

78707 26 3 46.90<br />

78707 TC 3 196.05<br />

78708 26 3 59.21<br />

78708 TC 3 154.74<br />

78709 26 3 68.41<br />

78709 TC 3 259.79<br />

78710 26 3 31.88<br />

78710 TC 3 225.17<br />

78725 26 3 18.41<br />

78725 TC 3 82.34<br />

78730 26 3 9.14<br />

78730 TC 3 68.86<br />

78740 26 3 27.62<br />

78740 TC 3 152.66<br />

78761 26 3 34.59<br />

78761 TC 3 162.41<br />

78800 26 3 32.17<br />

78800 TC 3 153.65<br />

78801 26 3 39.06<br />

78801 TC 3 203.23<br />

78802 26 3 41.86<br />

78802 TC 3 272.09<br />

78803 26 3 53.40<br />

78803 TC 3 299.93<br />

78804 26 3 51.94<br />

78804 TC 3 511.30<br />

78805 26 3 35.37<br />

78805 TC 3 150.51<br />

78806 26 3 41.86<br />

78806 TC 3 295.60<br />

78807 26 3 53.10<br />

78807 TC 3 299.54

---

78811 26 3 76.48<br />

78811 TC 3 1,383.91<br />

78812 26 3 94.68<br />

78812 TC 3 1,812.42<br />

78813 26 3 98.17<br />

78813 TC 3 1,896.02<br />

78814 26 3 107.46<br />

78814 TC 3 2,119.14<br />

78815 26 3 119.09<br />

78815 TC 3 2,382.86<br />

78816 26 3 121.80<br />

78816 TC 3 2,448.93<br />

79005 26 3 86.80<br />

79005 TC 3 80.86<br />

79101 26 3 96.52<br />

79101 TC 3 84.01<br />

79200 26 3 96.41<br />

79200 TC 3 86.77<br />

79300 26 3 79.78<br />

79403 26 3 111.46<br />

79403 TC 3 130.83<br />

79440 26 3 97.29<br />

79440 TC 3 78.50<br />

79445 26 3 117.45<br />

83020 26 3 20.56<br />

83912 26 3 5.60<br />

84165 26 3 20.56<br />

84166 26 3 19.93<br />

84181 26 3 19.79<br />

84182 26 3 20.95<br />

85390 26 3 20.17<br />

85576 26 3 20.56<br />

86255 26 3 20.56<br />

86256 26 3 20.56<br />

86320 26 3 20.56<br />

86325 26 3 20.56<br />

86327 26 3 23.62<br />

86334 26 3 20.56<br />

86335 26 3 19.02<br />

87164 26 3 19.01<br />

87207 26 3 20.95<br />

88104 26 3 31.57<br />

88104 TC 3 19.92<br />

88106 26 3 31.57<br />

88106 TC 3 14.90<br />

88107 26 3 43.25<br />

88107 TC 3 25.33<br />

88108 26 3 31.57<br />

88108 TC 3 22.24<br />

88112 26 3 66.40

---

88112 TC 3 57.41<br />

88125 26 3 14.83<br />

88125 TC 3 5.71<br />

88160 26 3 28.12<br />

88160 TC 3 27.65<br />

88161 26 3 28.12<br />

88161 TC 3 26.10<br />

88162 26 3 43.25<br />

88162 TC 3 13.74<br />

88172 26 3 33.86<br />

88172 TC 3 15.67<br />

88173 26 3 77.87<br />

88173 TC 3 45.04<br />

88182 26 3 43.63<br />

88182 TC 3 49.50<br />

88300 26 3 4.89<br />

88300 TC 3 9.57<br />

88302 26 3 7.56<br />

88302 TC 3 24.94<br />

88304 26 3 12.53<br />

88304 TC 3 30.35<br />

88305 26 3 42.27<br />

88305 TC 3 55.30<br />

88307 26 3 89.26<br />

88307 TC 3 77.54<br />

88309 26 3 128.39<br />

88309 TC 3 88.75<br />

88311 26 3 13.68<br />

88311 TC 3 3.78<br />

88312 26 3 30.42<br />

88312 TC 3 43.19<br />

88313 26 3 13.68<br />

88313 TC 3 38.17<br />

88314 26 3 25.45<br />

88314 TC 3 27.26<br />

88318 26 3 23.62<br />

88318 TC 3 23.87<br />

88319 26 3 29.65<br />

88319 TC 3 64.75<br />

88331 26 3 66.87<br />

88331 TC 3 18.97<br />

88332 26 3 33.09<br />

88332 TC 3 9.87<br />

88333 26 3 59.71<br />

88333 TC 3 30.69<br />

88334 26 3 34.67<br />

88334 TC 3 18.30<br />

88342 26 3 47.84<br />

88342 TC 3 38.47<br />

88346 26 3 48.22

---

88346 TC 3 41.95<br />

88347 26 3 47.83<br />

88347 TC 3 54.70<br />

88348 26 3 84.37<br />

88348 TC 3 304.29<br />

88349 26 3 43.25<br />

88349 TC 3 374.71<br />

88355 26 3 103.70<br />

88355 TC 3 71.36<br />

88356 26 3 167.57<br />

88356 TC 3 63.93<br />

88358 26 3 55.97<br />

88358 TC 3 7.51<br />

88360 26 3 59.52<br />

88360 TC 3 47.05<br />

88361 26 3 55.20<br />

88361 TC 3 86.34<br />

88362 26 3 120.90<br />

88362 TC 3 135.89<br />

88365 26 3 52.43<br />

88365 TC 3 70.16<br />

88367 26 3 69.42<br />

88367 TC 3 130.83<br />

88368 26 3 75.29<br />

88368 TC 3 68.23<br />

88371 26 3 19.40<br />

88372 26 3 20.95<br />

88384 26 3 67.70<br />

88384 TC 3 258.95<br />

88385 26 3 84.63<br />

88385 TC 3 250.87<br />

88386 26 3 106.44<br />

88386 TC 3 243.06<br />

89060 26 3 20.95<br />

91000 26 3 34.97<br />

91000 TC 3 39.25<br />

91010 26 3 63.41<br />

91010 TC 3 141.45<br />

91011 26 3 77.29<br />

91011 TC 3 185.90<br />

91012 26 3 75.05<br />

91012 TC 3 198.79<br />

91020 26 3 72.61<br />

91020 TC 3 163.87<br />

91022 26 3 73.01<br />

91022 TC 3 127.68<br />

91030 26 3 46.55<br />

91030 TC 3 91.08<br />

91034 26 3 49.46<br />

91034 TC 3 171.35

---

91035 26 3 80.47<br />

91035 TC 3 413.71<br />

91037 26 3 49.85<br />

91037 TC 3 112.33<br />

91038 26 3 56.83<br />

91038 TC 3 83.22<br />

91040 26 3 46.70<br />

91040 TC 3 360.59<br />

91052 26 3 40.43<br />

91052 TC 3 93.44<br />

91055 26 3 44.46<br />

91055 TC 3 98.16<br />

91065 26 3 9.98<br />

91065 TC 3 52.92<br />

91110 26 3 184.10<br />

91110 TC 3 786.98<br />

91120 26 3 47.00<br />

91120 TC 3 380.07<br />

91122 26 3 87.92<br />

91122 TC 3 163.28<br />

91132 26 3 26.96<br />

91133 26 3 34.24<br />

92060 26 3 34.31<br />

92060 TC 3 19.57<br />

92065 26 3 17.72<br />

92065 TC 3 22.72<br />

92081 26 3 17.73<br />

92081 TC 3 32.56<br />

92082 26 3 21.61<br />

92082 TC 3 43.97<br />

92083 26 3 24.71<br />

92083 TC 3 50.66<br />

92135 26 3 17.35<br />

92135 TC 3 26.26<br />

92136 26 3 27.43<br />

92136 TC 3 54.01<br />

92235 26 3 40.91<br />

92235 TC 3 84.79<br />

92240 26 3 55.94<br />

92240 TC 3 142.82<br />

92250 26 3 21.61<br />

92250 TC 3 49.48<br />

92265 26 3 38.75<br />

92265 TC 3 39.15<br />

92270 26 3 39.24<br />

92270 TC 3 45.44<br />

92275 26 3 50.50<br />

92275 TC 3 71.02<br />

92283 26 3 8.43<br />

92283 TC 3 33.74

---

92284 26 3 11.14<br />

92284 TC 3 56.56<br />

92285 26 3 10.37<br />

92285 TC 3 32.16<br />

92286 26 3 32.76<br />

92286 TC 3 91.48<br />

92541 26 3 19.97<br />

92541 TC 3 37.58<br />

92542 26 3 16.58<br />

92542 TC 3 43.48<br />

92543 26 3 5.34<br />

92543 TC 3 22.72<br />

92544 26 3 13.09<br />

92544 TC 3 34.82<br />

92545 26 3 11.54<br />

92545 TC 3 32.46<br />

92546 26 3 14.24<br />

92546 TC 3 71.41<br />

92548 26 3 25.40<br />

92548 TC 3 73.88<br />

92585 26 3 24.91<br />

92585 TC 3 78.90<br />

92587 26 3 6.50<br />

92587 TC 3 41.03<br />

92588 26 3 18.13<br />

92588 TC 3 52.63<br />

92978 26 3 96.05<br />

92978 TC 3 195.61<br />

92979 26 3 77.04<br />

93024 26 3 60.91<br />

93024 TC 3 60.20<br />

93025 26 3 39.68<br />

93025 TC 3 216.89<br />

93278 26 3 12.70<br />

93278 TC 3 35.91<br />

93303 26 3 64.75<br />

93303 TC 3 160.64<br />

93304 26 3 37.42<br />

93304 TC 3 97.49<br />

93307 26 3 47.82<br />

93307 TC 3 147.26<br />

93308 26 3 27.74<br />

93308 TC 3 88.44<br />

93312 26 3 111.69<br />

93312 TC 3 209.24<br />

93314 26 3 63.61<br />

93314 TC 3 213.96<br />

93315 26 3 142.64<br />

93317 26 3 88.36<br />

93318 26 3 105.21

---

93320 26 3 19.69<br />

93320 TC 3 66.50<br />

93321 26 3 8.06<br />

93321 TC 3 34.63<br />

93325 26 3 3.79<br />

93325 TC 3 75.85<br />

93350 26 3 77.50<br />

93350 TC 3 123.85<br />

93501 26 3 162.15<br />

93501 TC 3 704.15<br />

93505 26 3 235.03<br />

93505 TC 3 410.37<br />

93508 26 3 230.71<br />

93508 TC 3 795.10<br />

93510 26 3 242.94<br />

93510 TC 3 1,307.69<br />

93511 26 3 280.88<br />

93514 26 3 372.84<br />

93524 26 3 386.00<br />

93526 26 3 332.99<br />

93526 TC 3 1,668.44<br />

93527 26 3 402.78<br />

93528 26 3 489.74<br />

93529 26 3 267.87<br />

93530 26 3 226.18<br />

93531 26 3 440.65<br />

93532 26 3 514.68<br />

93533 26 3 357.95<br />

93555 26 3 42.78<br />

93555 TC 3 136.75<br />

93556 26 3 43.95<br />

93556 TC 3 218.50<br />

93561 26 3 23.44<br />

93562 26 3 7.26<br />

93571 26 3 95.26<br />

93572 26 3 74.48<br />

93600 26 3 114.51<br />

93602 26 3 113.63<br />

93603 26 3 113.53<br />

93609 26 3 269.50<br />

93610 26 3 161.07<br />

93612 26 3 160.58<br />

93615 26 3 50.13<br />

93616 26 3 66.88<br />

93618 26 3 230.40<br />

93619 26 3 401.95<br />

93620 26 3 630.87<br />

93621 26 3 113.45<br />

93622 26 3 166.32<br />

93623 26 3 153.72

---

93624 26 3 267.07<br />

93631 26 3 394.51<br />

93640 26 3 188.64<br />

93641 26 3 319.37<br />

93642 26 3 264.83<br />

93642 TC 3 247.31<br />

93660 26 3 99.14<br />

93660 TC 3 73.77<br />

93662 26 3 148.53<br />

93701 26 3 8.83<br />

93701 TC 3 30.59<br />

93724 26 3 253.82<br />

93724 TC 3 102.31<br />

93770 26 3 7.26<br />

93770 TC 3 0.69<br />

93875 26 3 10.37<br />

93875 TC 3 96.50<br />

93880 26 3 29.46<br />

93880 TC 3 154.35<br />

93882 26 3 19.78<br />

93882 TC 3 151.69<br />

93886 26 3 46.33<br />

93886 TC 3 154.44<br />

93888 26 3 30.92<br />

93888 TC 3 62.07<br />

93890 26 3 49.82<br />

93890 TC 3 97.49<br />

93892 26 3 56.01<br />

93892 TC 3 97.59<br />

93893 26 3 56.01<br />

93893 TC 3 97.59<br />

93922 26 3 12.21<br />

93922 TC 3 114.80<br />

93923 26 3 22.09<br />

93923 TC 3 172.15<br />

93924 26 3 25.11<br />

93924 TC 3 211.59<br />

93925 26 3 28.30<br />

93925 TC 3 154.44<br />

93926 26 3 19.00<br />

93926 TC 3 97.98<br />

93930 26 3 22.87<br />

93930 TC 3 153.86<br />

93931 26 3 15.22<br />

93931 TC 3 97.68<br />

93965 26 3 16.86<br />

93965 TC 3 113.32<br />

93970 26 3 33.53<br />

93970 TC 3 153.96<br />

93971 26 3 22.19

---

93971 TC 3 97.49<br />

93975 26 3 89.07<br />

93975 TC 3 154.44<br />

93976 26 3 58.81<br />

93976 TC 3 153.86<br />

93978 26 3 32.38<br />

93978 TC 3 153.96<br />

93979 26 3 21.81<br />

93979 TC 3 97.59<br />

93980 26 3 61.64<br />

93980 TC 3 117.47<br />

93981 26 3 21.51<br />

93981 TC 3 115.80<br />

93990 26 3 12.51<br />

93990 TC 3 97.98<br />

94010 26 3 8.04<br />

94010 TC 3 26.56<br />

94060 26 3 13.84<br />

94060 TC 3 45.45<br />

94070 26 3 27.59<br />

94070 TC 3 32.07<br />

94150 26 3 3.39<br />

94150 TC 3 18.00<br />

94200 26 3 5.33<br />

94200 TC 3 17.90<br />

94240 26 3 11.91<br />

94240 TC 3 27.84<br />

94250 26 3 5.33<br />

94250 TC 3 21.94<br />

94260 26 3 5.71<br />

94260 TC 3 25.97<br />

94350 26 3 11.91<br />

94350 TC 3 25.58<br />

94360 26 3 11.91<br />

94360 TC 3 31.28<br />

94370 26 3 11.91<br />

94370 TC 3 23.80<br />

94375 26 3 13.84<br />

94375 TC 3 23.41<br />

94400 26 3 18.69<br />

94400 TC 3 34.43<br />

94450 26 3 18.00<br />

94450 TC 3 32.85<br />

94452 26 3 14.14<br />

94452 TC 3 42.30<br />

94453 26 3 18.40<br />

94453 TC 3 59.21<br />

94620 26 3 29.53<br />

94620 TC 3 60.40<br />

94621 26 3 67.22

---

94621 TC 3 91.48<br />

94680 26 3 11.91<br />

94680 TC 3 56.46<br />

94681 26 3 9.19<br />

94681 TC 3 72.01<br />

94690 26 3 3.39<br />

94690 TC 3 60.20<br />

94720 26 3 11.91<br />

94720 TC 3 41.51<br />

94725 26 3 11.91<br />

94725 TC 3 77.12<br />

94750 26 3 10.36<br />

94750 TC 3 59.81<br />

94770 26 3 6.88<br />

94770 TC 3 31.19<br />

95805 26 3 89.40<br />

95805 TC 3 464.88<br />

95807 26 3 77.08<br />

95807 TC 3 469.21<br />

95808 26 3 125.43<br />

95808 TC 3 550.26<br />

95810 26 3 165.32<br />

95810 TC 3 663.96<br />

95811 26 3 177.61<br />

95811 TC 3 734.29<br />

95812 26 3 53.31<br />

95812 TC 3 183.84<br />

95813 26 3 84.41<br />

95813 TC 3 207.06<br />

95816 26 3 53.31<br />

95816 TC 3 164.66<br />

95819 26 3 53.31<br />

95819 TC 3 167.42<br />

95822 26 3 53.31<br />

95822 TC 3 187.98<br />

95824 26 3 36.44<br />

95827 26 3 51.83<br />

95827 TC 3 270.50<br />

95829 26 3 304.71<br />

95829 TC 3 1,018.02<br />

95860 26 3 48.77<br />

95860 TC 3 36.79<br />

95861 26 3 77.65<br />

95861 TC 3 38.76<br />

95863 26 3 92.95<br />

95863 TC 3 46.63<br />

95864 26 3 99.16<br />

95864 TC 3 68.86<br />

95865 26 3 80.29<br />

95865 TC 3 31.97

---

95866 26 3 62.92<br />

95866 TC 3 22.92<br />

95867 26 3 39.25<br />

95867 TC 3 30.69<br />

95868 26 3 58.84<br />

95868 TC 3 37.28<br />

95869 26 3 18.81<br />

95869 TC 3 22.62<br />

95870 26 3 18.81<br />

95870 TC 3 21.84<br />

95873 26 3 19.20<br />

95873 TC 3 21.84<br />

95874 26 3 19.20<br />

95874 TC 3 21.05<br />

95875 26 3 55.75<br />

95875 TC 3 42.30<br />

95900 26 3 21.13<br />

95900 TC 3 37.18<br />

95903 26 3 29.95<br />

95903 TC 3 35.21<br />

95904 26 3 17.26<br />

95904 TC 3 33.64<br />

95920 26 3 107.04<br />

95920 TC 3 49.68<br />

95921 26 3 43.01<br />

95921 TC 3 26.17<br />

95922 26 3 47.19<br />

95922 TC 3 34.43<br />

95923 26 3 44.49<br />

95923 TC 3 72.20<br />

95925 26 3 27.14<br />

95925 TC 3 76.92<br />

95926 26 3 26.85<br />

95926 TC 3 75.74<br />

95927 26 3 27.93<br />

95927 TC 3 78.10<br />

95928 26 3 73.85<br />

95928 TC 3 116.56<br />

95929 26 3 74.24<br />

95929 TC 3 126.39<br />

95930 26 3 17.64<br />

95930 TC 3 91.57<br />

95933 26 3 29.47<br />

95933 TC 3 35.61<br />

95934 26 3 25.39<br />

95934 TC 3 18.30<br />

95936 26 3 27.24<br />

95936 TC 3 13.18<br />

95937 26 3 33.36<br />

95937 TC 3 21.44

---

95950 26 3 74.43<br />

95950 TC 3 166.17<br />

95951 26 3 295.81<br />

95951 TC 3 1,404.56<br />

95953 26 3 160.75<br />

95953 TC 3 261.38<br />

95956 26 3 151.58<br />

95956 TC 3 594.23<br />

95957 26 3 97.80<br />

95957 TC 3 141.25<br />

95961 26 3 158.37<br />

95961 TC 3 70.53<br />

95962 26 3 163.69<br />

95962 TC 3 53.22<br />

95965 26 3 399.19<br />

95966 26 3 197.83<br />

95967 26 3 165.83<br />

A7017 RR 3 12.82<br />

A7017 UE 3 96.17<br />

B9000 RR 3 125.00<br />

B9000 UE 3 741.00<br />

B9002 RR 3 125.00<br />

B9002 UE 3 741.00<br />

B9004 RR 3 403.88<br />

B9004 UE 3 1,913.41<br />

B9006 RR 3 400.00<br />

B9006 UE 3 1,478.10<br />

E0100 RR 3 4.84<br />

E0100 UE 3 16.08<br />

E0105 RR 3 7.46<br />

E0105 UE 3 32.84<br />

E0110 RR 3 15.31<br />

E0110 UE 3 52.16<br />

E0111 RR 3 8.06<br />

E0111 UE 3 39.32<br />

E0112 RR 3 9.50<br />

E0112 UE 3 27.00<br />

E0113 RR 3 4.92<br />

E0113 UE 3 15.18<br />

E0114 RR 3 8.20<br />

E0114 UE 3 34.12<br />

E0116 RR 3 5.17<br />

E0116 UE 3 17.07<br />

E0130 RR 3 16.10<br />

E0130 UE 3 51.20<br />

E0135 RR 3 16.51<br />

E0135 UE 3 56.91<br />

E0141 RR 3 21.39<br />

E0141 UE 3 82.73<br />

E0143 RR 3 20.66

---

E0143 UE 3 86.08<br />

E0144 RR 3 25.91<br />

E0144 UE 3 194.21<br />

E0147 RR 3 54.98<br />

E0147 UE 3 412.45<br />

E0148 RR 3 12.17<br />

E0148 UE 3 91.15<br />

E0149 RR 3 21.35<br />

E0149 UE 3 160.14<br />

E0153 RR 3 7.49<br />

E0153 UE 3 49.77<br />

E0154 RR 3 8.19<br />

E0154 UE 3 49.77<br />

E0155 RR 3 3.68<br />

E0155 UE 3 23.01<br />

E0156 RR 3 3.23<br />

E0156 UE 3 18.99<br />

E0157 RR 3 8.60<br />

E0157 UE 3 49.97<br />

E0158 RR 3 3.39<br />

E0158 UE 3 23.24<br />

E0160 RR 3 4.14<br />

E0160 UE 3 23.70<br />

E0161 RR 3 3.41<br />

E0161 UE 3 18.80<br />

E0162 RR 3 14.62<br />

E0162 UE 3 108.10<br />

E0163 RR 3 23.37<br />

E0163 UE 3 81.36<br />

E0165 RR 3 15.32<br />

E0165 UE 3 96.45<br />

E0167 RR 3 1.21<br />

E0167 UE 3 7.58<br />

E0168 RR 3 14.50<br />

E0168 UE 3 108.28<br />

E0175 RR 3 5.39<br />

E0175 UE 3 39.64<br />

E0181 RR 3 22.47<br />

E0181 UE 3 201.60<br />

E0182 RR 3 25.05<br />

E0182 UE 3 216.38<br />

E0183 UE 9 233.34<br />

E0184 RR 3 23.50<br />

E0184 UE 3 142.86<br />

E0185 RR 3 42.99<br />

E0185 UE 3 234.85<br />

E0186 RR 3 19.42<br />

E0187 RR 3 22.21<br />

E0188 UE 3 14.04<br />

E0189 RR 3 3.63

---

E0189 UE 3 23.31<br />

E0191 RR 3 0.97<br />

E0191 UE 3 7.14<br />

E0193 RR 3 806.39<br />

E0193 UE 3 5,217.23<br />

E0194 RR 3 3,113.39<br />

E0196 RR 3 30.54<br />

E0197 RR 3 29.25<br />

E0197 UE 3 186.21<br />

E0198 RR 3 21.96<br />

E0198 UE 3 160.86<br />

E0199 RR 3 3.06<br />

E0199 UE 3 23.00<br />

E0200 RR 3 10.29<br />

E0200 UE 3 56.90<br />

E0202 RR 3 59.90<br />

E0202 UE 3 673.58<br />

E0205 RR 3 20.42<br />

E0205 UE 3 118.35<br />

E0210 RR 3 2.94<br />

E0210 UE 3 23.42<br />

E0215 RR 3 7.09<br />

E0215 UE 3 50.83<br />

E0217 RR 3 44.96<br />

E0217 UE 3 302.77<br />

E0225 RR 3 31.15<br />

E0225 UE 3 237.02<br />

E0235 RR 3 16.51<br />

E0235 UE 3 148.28<br />

E0236 RR 3 38.12<br />

E0238 RR 3 2.60<br />

E0238 UE 3 19.02<br />

E0239 RR 3 43.04<br />

E0239 UE 3 322.78<br />

E0249 RR 3 10.47<br />

E0249 UE 3 71.46<br />

E0250 RR 3 93.53<br />

E0250 UE 3 712.05<br />

E0251 RR 3 70.87<br />

E0251 UE 3 601.88<br />

E0255 RR 3 112.39<br />

E0255 UE 3 688.88<br />

E0256 RR 3 75.06<br />

E0260 RR 3 160.65<br />

E0260 UE 3 1,083.60<br />

E0261 RR 3 131.01<br />

E0265 RR 3 191.23<br />

E0265 UE 3 1,412.85<br />

E0266 RR 3 144.42<br />

E0266 UE 3 938.40

---

E0271 RR 3 22.07<br />

E0271 UE 3 165.95<br />

E0272 RR 3 20.21<br />

E0272 UE 3 139.85<br />

E0275 RR 3 1.52<br />

E0275 UE 3 10.98<br />

E0276 RR 3 1.49<br />

E0276 UE 3 10.07<br />

E0277 RR 3 642.27<br />

E0280 RR 3 3.93<br />

E0280 UE 3 26.55<br />

E0290 RR 3 71.50<br />

E0291 RR 3 51.95<br />

E0292 RR 3 74.50<br />

E0293 RR 3 68.41<br />

E0294 RR 3 124.99<br />

E0295 RR 3 121.83<br />

E0296 RR 3 157.09<br />

E0297 RR 3 114.39<br />

E0305 RR 3 17.02<br />

E0305 UE 3 104.02<br />

E0310 RR 3 21.78<br />

E0310 UE 3 140.55<br />

E0325 UE 3 6.40<br />

E0326 RR 3 1.14<br />

E0326 UE 3 7.07<br />

E0371 RR 5 415.05<br />

E0372 RR 3 503.67<br />

E0373 RR 5 576.95<br />

E0424 RR 3 230.17<br />

E0431 RR 3 36.19<br />

E0434 RR 3 36.19<br />

E0439 RR 3 230.17<br />

E0445 RR 3 195.00<br />

E0450 RR 3 850.00<br />

E0451 UE O 4,296.56<br />

E0453 RR 9 520.64<br />

E0457 RR 3 58.79<br />

E0459 RR 3 48.69<br />

E0462 RR 3 278.78<br />

E0462 UE 3 1,831.27<br />

E0480 RR 3 42.04<br />

E0480 UE 3 289.20<br />

E0484 RR 3 3.69<br />

E0484 UE 3 27.70<br />

E0500 RR 3 98.86<br />

E0550 RR 3 47.95<br />

E0550 UE 3 373.50<br />

E0560 RR 3 19.23<br />

E0560 UE 3 123.07

---

E0565 RR 3 49.61<br />

E0565 UE 3 318.83<br />

E0570 RR 3 18.88<br />

E0571 RR 5 28.12<br />

E0572 RR 5 35.76<br />

E0574 RR 5 37.81<br />

E0575 RR 3 94.83<br />

E0585 RR 3 33.55<br />

E0600 RR 3 43.80<br />

E0601 RR 3 99.59<br />

E0603 RR 3 74.28<br />

E0605 RR 3 2.94<br />

E0605 UE 3 20.82<br />

E0606 RR 3 18.66<br />

E0610 RR 3 24.00<br />

E0610 UE 3 170.69<br />

E0615 RR 3 55.97<br />

E0615 UE 3 302.46<br />

E0618 RR 3 300.00<br />

E0619 RR 3 330.00<br />

E0621 RR 3 8.85<br />

E0621 UE 3 69.23<br />

E0627 RR 3 31.64<br />

E0627 UE 3 237.27<br />

E0628 RR 3 31.64<br />

E0628 UE 3 237.27<br />

E0629 RR 3 31.64<br />

E0629 UE 3 237.27<br />

E0630 RR 3 97.47<br />

E0630 UE 3 662.78<br />

E0635 RR 3 99.50<br />

E0635 UE 3 637.65<br />

E0650 RR 3 85.01<br />

E0650 UE 3 516.77<br />

E0651 RR 3 87.87<br />

E0651 UE 3 658.99<br />

E0652 RR 3 501.26<br />

E0652 UE 3 3,759.53<br />

E0655 RR 3 12.13<br />

E0655 UE 3 65.91<br />

E0660 RR 3 15.91<br />

E0660 UE 3 104.30<br />

E0665 RR 3 13.46<br />

E0665 UE 3 83.66<br />

E0666 RR 3 13.62<br />

E0666 UE 3 84.24<br />

E0667 RR 3 30.98<br />

E0667 UE 3 232.30<br />

E0668 RR 3 35.46<br />

E0668 UE 3 269.50

---

E0669 RR 3 16.66<br />

E0669 UE 3 124.90<br />

E0720 RR 3 29.59<br />

E0730 RR 3 33.38<br />

E0730 UE 3 265.88<br />

E0744 RR 3 87.60<br />

E0744 UE 3 632.40<br />

E0745 RR 3 85.64<br />

E0745 UE 3 603.75<br />

E0746 UE O 521.09<br />

E0776 RR 3 17.84<br />

E0776 UE 3 100.76<br />

E0781 RR 3 215.39<br />

E0781 UE 3 1,335.90<br />

E0782 UE O 2,774.69<br />

E0791 RR 3 257.13<br />

E0791 UE 3 1,391.93<br />

E0840 RR 3 15.61<br />

E0840 UE 3 44.67<br />

E0850 RR 3 12.65<br />

E0850 UE 3 64.08<br />

E0855 RR 3 48.08<br />

E0855 UE 3 360.64<br />

E0860 RR 3 6.23<br />

E0860 UE 3 28.23<br />

E0870 RR 3 12.65<br />

E0870 UE 3 75.39<br />

E0880 RR 3 18.86<br />

E0880 UE 3 77.27<br />

E0890 RR 3 30.34<br />

E0890 UE 3 78.87<br />

E0900 RR 3 26.43<br />

E0900 UE 3 78.17<br />

E0910 RR 3 19.13<br />

E0910 UE 3 131.93<br />

E0920 RR 3 44.14<br />

E0920 UE 3 292.05<br />

E0930 RR 3 39.52<br />

E0930 UE 3 254.40<br />

E0935 RR 5 21.75<br />

E0940 RR 3 33.26<br />

E0940 UE 3 217.20<br />

E0941 RR 3 38.56<br />

E0941 UE 3 278.40<br />

E0942 RR 3 2.24<br />

E0942 UE 3 14.22<br />

E0944 RR 3 4.40<br />

E0944 UE 3 32.92<br />

E0945 RR 3 4.24<br />

E0945 UE 3 32.83

---

E0946 RR 3 56.60<br />

E0946 UE 3 408.08<br />

E0947 RR 3 60.17<br />

E0947 UE 3 435.14<br />

E0948 RR 3 56.10<br />

E0948 UE 3 395.78<br />

E0950 RR 3 9.96<br />

E0950 UE 3 74.59<br />

E0951 RR 3 1.81<br />

E0951 UE 3 13.52<br />

E0952 RR 3 1.81<br />

E0952 UE 3 13.52<br />

E0958 RR 3 41.74<br />

E0958 UE 3 278.25<br />

E0959 RR 3 8.50<br />

E0959 UE 3 64.02<br />

E0961 RR 3 2.78<br />

E0961 UE 3 20.86<br />

E0966 RR 3 6.19<br />

E0966 UE 3 46.45<br />

E0967 RR 3 12.65<br />

E0967 UE 3 94.83<br />

E0968 RR 3 17.15<br />

E0968 UE 3 111.15<br />

E0969 RR 3 13.99<br />

E0969 UE 3 104.89<br />

E0970 RR 3 4.11<br />

E0970 UE 3 34.56<br />

E0971 RR 3 7.14<br />

E0971 UE 3 47.17<br />

E0973 RR 3 10.47<br />

E0973 UE 3 82.50<br />

E0974 RR 3 7.95<br />

E0974 UE 3 56.69<br />

E0978 RR 3 4.26<br />

E0978 UE 3 32.12<br />

E0980 RR 3 3.15<br />

E0980 UE 3 23.59<br />

E0990 RR 3 12.65<br />

E0990 UE 3 87.77<br />

E0992 RR 3 8.85<br />

E0992 UE 3 66.38<br />

E0994 RR 3 1.52<br />

E0994 UE 3 11.37<br />

E0995 RR 3 2.54<br />

E0995 UE 3 18.99<br />

E1031 RR 3 48.32<br />

E1031 UE 3 352.50<br />

E1050 RR 3 97.43<br />

E1050 UE 3 651.53

---

E1060 RR 3 120.61<br />

E1060 UE 3 769.57<br />

E1070 RR 3 89.06<br />

E1070 UE 3 544.05<br />

E1083 RR 3 75.33<br />

E1083 UE 3 462.83<br />

E1084 RR 3 93.85<br />

E1084 UE 3 590.70<br />

E1085 RR 3 66.21<br />

E1085 UE 3 443.55<br />

E1086 RR 3 80.40<br />

E1086 UE 3 540.83<br />

E1087 RR 3 121.03<br />

E1087 UE 3 855.90<br />

E1088 RR 3 144.24<br />

E1088 UE 3 890.63<br />

E1089 RR 3 114.99<br />

E1089 UE 3 798.38<br />

E1090 RR 3 110.73<br />

E1090 UE 3 633.38<br />

E1091 RR 3 79.76<br />

E1091 UE 3 640.80<br />

E1092 RR 3 122.94<br />

E1092 UE 3 896.93<br />

E1093 RR 3 105.74<br />

E1093 UE 3 763.13<br />

E1100 RR 3 99.32<br />

E1100 UE 3 627.53<br />

E1110 RR 3 82.66<br />

E1110 UE 3 541.05<br />

E1130 RR 3 44.67<br />

E1130 UE 3 316.05<br />

E1140 RR 3 68.73<br />

E1140 UE 3 498.08<br />

E1150 RR 3 78.04<br />

E1150 UE 3 581.48<br />

E1160 RR 3 59.79<br />

E1160 UE 3 420.00<br />

E1170 RR 3 85.45<br />

E1170 UE 3 522.98<br />

E1171 RR 3 68.33<br />

E1171 UE 3 480.08<br />

E1172 RR 3 87.87<br />

E1172 UE 3 537.75<br />

E1180 RR 3 82.41<br />

E1180 UE 3 497.33<br />

E1190 RR 3 112.01<br />

E1190 UE 3 693.08<br />

E1195 RR 3 102.16<br />

E1195 UE 3 562.95

---

E1200 RR 3 73.20<br />

E1200 UE 3 447.97<br />

E1221 RR 3 45.45<br />

E1222 RR 3 64.85<br />

E1223 RR 3 70.81<br />

E1223 UE 3 477.15<br />

E1224 RR 3 77.64<br />

E1225 RR 3 43.24<br />

E1228 RR 3 22.79<br />

E1230 RR 3 194.69<br />

E1230 UE 3 1,454.64<br />

E1240 RR 3 98.55<br />

E1240 UE 3 641.18<br />

E1250 RR 3 72.71<br />

E1250 UE 3 441.68<br />

E1260 RR 3 75.79<br />

E1260 UE 3 467.33<br />

E1270 RR 3 64.19<br />

E1270 UE 3 407.63<br />

E1280 RR 3 106.74<br />

E1280 UE 3 681.23<br />

E1285 RR 3 98.07<br />

E1285 UE 3 592.05<br />

E1290 RR 3 101.77<br />

E1290 UE 3 566.33<br />

E1295 RR 3 111.11<br />

E1295 UE 3 679.95<br />

E1296 RR 3 40.61<br />

E1296 UE 3 299.87<br />

E1297 RR 3 9.44<br />

E1297 UE 3 63.79<br />

E1298 RR 3 36.55<br />

E1298 UE 3 274.02<br />

E1310 RR 3 175.72<br />

E1310 UE 3 1,540.80<br />

E1353 RR 5 308.71<br />

E1355 RR 3 4.67<br />

E1355 UE 3 35.00<br />

E1372 RR 3 22.66<br />

E1372 UE 3 115.46<br />

E1390 RR 3 230.17<br />

E1405 RR 5 263.04<br />

E1406 RR 5 248.37<br />

E2000 RR 3 50.57<br />

G0202 26 3 33.81<br />

G0202 TC 3 102.79<br />

G0204 26 3 42.24<br />

G0204 TC 3 112.23<br />

G0206 26 3 33.81<br />

G0206 TC 3 89.51

---

G0252 26 3 74.46<br />

G0252 TC 3 447.50<br />

K0001 RR 3 53.27<br />

K0001 UE 3 399.52<br />

K0002 RR 5 81.43<br />

K0003 RR 3 76.15<br />

K0004 RR 3 113.03<br />

K0005 RR 3 183.95<br />

K0005 UE 3 1,379.69<br />

K0006 RR 5 106.07<br />

K0015 RR 3 18.09<br />

K0015 UE 3 135.60<br />

K0017 RR 3 5.08<br />

K0017 UE 3 38.14<br />

K0018 RR 3 2.83<br />

K0018 UE 3 21.33<br />

K0019 RR 3 1.63<br />

K0019 UE 3 12.19<br />

K0020 RR 3 4.63<br />

K0020 UE 3 34.66<br />

K0037 RR 3 4.28<br />

K0037 UE 3 35.95<br />

K0038 RR 3 2.41<br />

K0038 UE 3 18.11<br />

K0039 RR 3 5.37<br />

K0039 UE 3 40.21<br />

K0040 RR 3 7.41<br />

K0040 UE 3 55.71<br />

K0041 RR 3 5.28<br />

K0042 RR 3 3.61<br />

K0042 UE 3 27.18<br />

K0043 RR 3 1.94<br />

K0043 UE 3 14.59<br />

K0044 RR 3 1.66<br />

K0044 UE 3 12.41<br />

K0045 RR 3 5.64<br />

K0045 UE 3 42.26<br />

K0046 RR 3 1.94<br />

K0046 UE 3 14.59<br />

K0047 RR 3 7.64<br />

K0047 UE 3 57.06<br />

K0050 RR 3 3.22<br />

K0050 UE 3 24.26<br />

K0051 RR 3 5.26<br />

K0051 UE 3 39.24<br />

K0052 RR 3 9.19<br />

K0052 UE 3 68.98<br />

K0053 RR 3 10.14<br />

K0053 UE 3 76.13<br />

K0056 RR 3 9.47

---

K0056 UE 3 70.98<br />

K0065 RR 3 4.43<br />

K0065 UE 3 33.18<br />

K0069 RR 3 9.94<br />

K0069 UE 3 74.56<br />

K0070 RR 3 15.50<br />

K0070 UE 3 136.70<br />

K0071 RR 3 10.87<br />

K0071 UE 3 81.52<br />

K0072 RR 3 6.54<br />

K0072 UE 3 49.07<br />

K0073 RR 3 3.46<br />

K0073 UE 3 25.97<br />

K0077 RR 3 5.85<br />

K0077 UE 3 43.91<br />

K0098 RR 3 2.71<br />

K0098 UE 3 20.29<br />

K0105 RR 3 9.88<br />

K0105 UE 3 74.20<br />

K0193 RR 9 107.84<br />

K0195 RR 3 21.07<br />

Q0037 RR 5 275.35