Medicaid Fee Schedule without Mods 200801

PROC-CODE DESC MAC BEG END 

A0130 NON-EMERGENCY TRANSPORTATION: WHEEL-CHAIR VAN $25.00 19990701 99999999 

A0225 

AMB SERV NEONATAL TRANS BASE RATE EMER TRANSPORT ONE 

WAY $245.70 20030401 99999999 

A0390 ALS MILEAGE (PER MILE) $5.84 19990701 99999999 

A0425 GROUND MILEAGE, PER STATUTE MILE $1.95 20010101 99999999 

A0426 

AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY 

TRANSPORT, LEVEL 1 (ALS $245.70 20030401 99999999 

A0428 

AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY 

TRANSPORT, (BLS) $204.74 20030401 99999999 

A0431 

AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, 

ONE WAY (ROTARY WING) $2,250.00 20010101 99999999 

A4206 SYRINGE W/NEEDLE,STERILE 1CC $0.16 20030401 99999999 

A4207 SYRINGE W/NEEDLES , STERILE 2CC $0.16 20030401 99999999 

A4208 SYRINGE W/NEEDLE, STERILE 3CC $0.16 20030401 99999999 

A4209 SYRINGE W/NEEDLE STERILE 5CC OR GREATER $0.21 20030401 99999999 

A4210 NEEDLE FREE INJECTION DEVICE $0.21 20030401 99999999 

A4212 HUBER-TYPE NEEDLE, EACH $3.64 20030401 99999999 

A4213 SYRINGE STERILE 20CC OR GREATER $0.52 20030401 99999999 

A4214 STERILE SALINE OR WATER 30CC VIAL $1.41 20030401 99999999 

A4215 NEEDLES ONLY STERILE ANY SIZE $0.10 19990701 99999999 

A4216 HEMOSTATIC CELLULOSE ANY SIZE (EG. SURGICAL) $0.60 20060701 99999999 

A4217 STERILE WATER/SALINE, 500 ML $2.43 20060701 99999999 

A4218 STERILE SALINE OR WATER, METERED DOSE DISPENSER, 10 ML $0.67 20071101 99999999 

A4221 

SUPPLIES FOR MAINTENANCE OF DRUG INFUSION CATHETER, PER 

WEEK (LIST DRUG SEPARATE $24.04 19990701 99999999 

A4222 

SUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, PER CASSETTE OR 

BAG (LIST DRUG SEPARAT $47.71 19990701 99999999 

A4230 

INFUSION SET FOR EXTERNAL INSULIN PUMP, NON NEEDLE CANNULA 

TYPE $9.06 20030401 99999999 

A4231 INFUSION SET FOR EXTERNAL INSULIN PUMP, NEEDLE TYPE $3.88 20030401 99999999 

A4232 SYRINGE WITH NEEDLE FOR EXTERNAL INSULIN PUMP STERILE 3CC $2.61 20030401 99999999 

A4233 

REPLACEMENT BATTERY, ALKALINE (OTHER THAN J CELL), FOR USE 

WITH MEDICALLY NECESS $0.72 20071101 99999999 

A4234 

REPLACEMENT BATTERY, ALKALINE, J CELL, FOR USE WITH 

MEDICALLY NECESSARY HOME BLO $3.27 20071101 99999999 

A4235 

REPLACEMENT BATTERY, LITHIUM, FOR USE WITH MEDICALLY 

NECESSARY HOME BLOOD GLUCOS $2.11 20071101 99999999 

A4236 

REPLACEMENT BATTERY, SILVER OXIDE, FOR USE WITH MEDICALLY 

NECESSARY HOME BLOOD G $1.51 20071101 99999999 

A4244 ALCOHOL OR PEROXIDE, PER PINT $0.73 20030401 99999999 

A4245 ALCOHOL WIPES, PER BOX $0.01 19990701 99999999 

A4246 BETADINE OR PHISOHEX SOLUTION PER PINT $6.17 20030401 99999999 

A4247 BETADINE OR IODINE SWABS/WIPES PER BOX $5.82 20030401 99999999 

A4250 URINE TEST OR REAGENT STRIPS OR TABLETS 100 TABS OR STRIPS $0.24 20030401 99999999 

A4253 

BLOOD GLUCOSE TEST OR REGENT STRIPS FOR HOME GLUCOSE 

MONITOR $0.73 20040129 99999999 

A4254 MEDICINE DROPPER (3) PER BOX $2.80 20030401 99999999 

A4255 AFJ SLK $4.30 20060701 99999999 

A4256 NORMAL LOW AND HIGH CALIBRATOR SOLUTION/CHIPS $5.08 20060701 99999999 

A4257 

REPLACEMENT LENS SHIELD CARTRIDGE FOR USE WITH LASER SKIN 

PIERCING DEVICE, EACH $12.75 20060701 99999999 

A4258 SPRING-POWERED DEVICE FOR LANCET, EACH $18.30 20060701 99999999 

A4259 LANCETS, PER BOX $0.07 20060701 99999999 

A4263 

PERMANENT, LONG TERM, NON-DISSOLVABLE LACRIMAL DUCT 

IMPLANT, EACH $31.60 20030401 99999999 

A4265 PARAFFIN $3.39 20060701 99999999 

A4267 CONTRACEPTIVE SUPPLY, CONDOM, MALE, EACH $0.26 20030101 99999999 

A4268 CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EACH $2.50 20030101 99999999 

Hawaii Medicaid Fee Schedule without Mods 01/2008 1


A4280 

ADHESIVE SKIN SUPPORT ATTACHMENT FOR USE WITH EXTERNAL 

BREAST PROSTHESIS, EACH $4.95 20060701 99999999 

A4300 

IMPLANTABLE VASCULAR ACCESS 

PORTAL/CATH,VENOUS,ARTERIAL,PERI $3.43 20030401 99999999 

A4301 

IMPLANTABLE ACCESS TOTAL SYSTEM; CATHETER, PORT/RESERVOIR 

(VENOUS, ARTERIAL OR E $3.43 20030401 99999999 

A4305 

DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF 50 ML OR 

GREATER PER HOUR $15.95 20030401 99999999 

A4306 

DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF 5 ML OR LESS 

PER HOUR $15.95 20030401 99999999 

A4310 

INSERTION TRAY W/O DRAINAGE BAG & W/O CATH (ACCESSORIES 

ONLY $9.76 20060701 99999999 

A4311 

INSERTION TRAY/W/O DRAINAGE BAG W/INDWELLING CATH FOLEY 

TYPE $14.13 20060701 99999999 

A4312 

INSERT TRAY W/O DRAINAGE BAG W/INDWELLING CATH FOLEY 

TWOWAY $15.02 20060701 99999999 

A4313 

INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING 

CATHETER, FOLEY TYPE, THREE- $17.05 20060701 99999999 

A4314 CATHETERIZATION TRAY $17.58 20060701 99999999 

A4315 

INSER TRAY W/DRAINAGE BAG W/INDWELLING CATH FOLEY TWO 

WAY AL $20.36 20060701 99999999 

A4316 

INSERT TRAY W/DRAINAGE BAG W/INDWELLING CATH FOLEY THREE 

WAY $20.36 20060701 99999999 

A4319 STERILE WATER IRRIGATION SOLUTION, 1000 ML $6.19 20010101 99999999 

A4320 IRRIGATION TRAY FOR BLADDER IRRIG W/BULB OR PISTON SYRINGE $2.86 20060701 99999999 

A4322 IRRIGATION SYRINGE BULB OR PISTON $2.60 20060701 99999999 

A4323 STERILE SALINE IRRIG SOLUTION 1000 ML $5.28 20030401 99999999 

A4324 MALE EXTERNAL CATHETER, WITH ADHESIVE COATING, EACH $2.27 20030401 99999999 

A4325 MALE EXTERNAL CATHETER, WITH ADHESIVE STRIP, EACH $1.87 20030401 99999999 

A4326 MALE EXT CATH SPECILITY TYPE EG.INFLATABLE,FACEPLATE,EACH $9.37 20060701 99999999 

A4327 FEMALE CATH URINARY COLL DEVICE MEATAL CUP EACH $38.49 20060701 99999999 

A4328 FEMALE EXT URINARY COLL DEVICE POUCH EACH $8.75 20060701 99999999 

A4329 EXT CATH STARTER SET M/F INCL CATH URINARY COLL DEVICE BAG/P $15.70 20030401 99999999 

A4330 PERIANAL FECAL COLLECTION POUCH W/ADHESIVE $5.64 20060701 99999999 

A4331 

EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH 

CONNECTOR/ADAPTOR, FOR USE $3.30 20060701 99999999 

A4332 

LUBRICANT, INDIVIDUAL STERILE PACKET, FOR INSERTION OF 

URINARY CATHETER, EACH $0.13 20060701 99999999 

A4333 

URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN 

ATTACHMENT, EACH $2.94 20060701 99999999 

A4334 URINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACH $2.81 20060701 99999999 

A4335 INCONTINENCE SUPPLY MISCELLANEOUS $0.66 20030401 99999999 

A4338 CATH,FOLEY TFLN CTD W/30ML BAG $8.32 20060701 99999999 

A4340 INDWELLING CATH SPECIALTY TYPE EG. COUDE,MUSHROOM,WING $18.18 20060701 99999999 

A4344 INDWELLING CATH FOLEY TYPE TWO WAY ALL SILICONE $11.56 20060701 99999999 

A4346 INDWELLING CATH FOLEY TYPE THREE WAY FOR CONT IRRIGATION $12.30 20060701 99999999 

A4347 EXTERNAL CATHETER, CONDOM TYPE $1.42 20030401 99999999 

A4348 

URINARY COLLECTION AND RETENTION SYSTEM, DRAINAGE BAG 

WITH TUBE $26.55 20030401 99999999 

A4349 URINARY COLLECTION AND RETENTION SYSTEM, LEG BAG WITH TUBE $1.87 20060701 99999999 

A4351 INTERMITTENT URINARY CATHETER STRAIGHT TIP $1.20 20060701 99999999 

A4352 INTERMITTENT URINARY CATH,COUDE_(CURVED)TIP $6.43 20060701 99999999 

A4353 

CATHETER INSERTION TRAY WITH CATHETER INCLUDING TUBING 

AND DRAINAGE BAG $7.48 20060701 99999999 

A4354 

CATHETER INSERTION TRAY WITHOUT CATHETER INCLUDING 

TUBING AND DRAINAGE BAG $11.50 20060701 99999999 



A4355 3-WAY IRRIGATION SET FOR CATHETER $7.02 20060701 99999999 

A4356 

EXT URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED 

FOR $33.48 20060701 99999999 

A4357 URINARY DRAINAGE BAG $10.81 20060701 99999999 

A4358 URINARY LEG BAG $7.04 20060701 99999999 

A4359 URINARY SUSPENSORY W/O LEG BAG $30.07 20030401 99999999 

A4361 OSTOMY FACE PLATE $28.88 20060701 99999999 

A4362 OSTOMY SKIN BARRIER $3.65 20060701 99999999 

A4363 SKIN BARRIER LIQUID,POWDER,PASTE PER OZ (SPRAY,BRUSH,ECT) $1.20 20060701 99999999 

A4364 OSTOMY SKIN BOND OR CEMENT $2.33 20060701 99999999 

A4365 OSTOMY BAG, DISPOSABLE/CLOSED $12.23 20060701 99999999 

A4366 OSTOMY BAG, REUSEABLE OR DRAINABLE $0.78 20060701 99999999 

A4367 OSTOMY BELT $7.52 20060701 99999999 

A4368 STOMA WICKS $0.27 20060701 99999999 

A4369 TAIL CLOSURES $1.79 20060701 99999999 

A4370 OSTOMY SKIN BOND OR CEMENT,REMOVER $2.78 20030401 99999999 

A4371 OSTOMY SKIN BARRIER, POWDER, PER OZ $3.60 20060701 99999999 

A4372 

OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, WITH BUILT-IN 

CONVEXITY, EACH $4.52 20060701 99999999 

A4373 

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR 

ACCORDIAN), WITH BUILT-IN $6.77 20060701 99999999 

A4374 


ACCORDION), EXTENDED WEAR, $9.10 19990701 99999999 

A4375 

OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, 

EACH $18.54 20060701 99999999 

A4376 

OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, 

EACH $51.39 20060701 99999999 

A4377 

OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, 

EACH $4.63 20060701 99999999 

A4378 

OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, 

EACH $33.18 20060701 99999999 

A4379 

OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, 

EACH $16.23 20060701 99999999 

A4380 ILEOSTOMY SET $40.31 20060701 99999999 

A4381 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, EACH $4.98 20060701 99999999 

OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY 

A4382 PLASTIC, EACH $26.59 20060701 99999999 

A4383 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACH $30.47 20060701 99999999 

A4384 OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EACH $10.41 20060701 99999999 

A4385 

OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED 

WEAR, WITHOUT BUILT-IN CO $5.49 20060701 99999999 

A4386 



A4387 

OSTOMY POUCH CLOSED, WITH STANDARD WEAR BARRIER 

ATTACHED, WITH BUILT-IN CONVEXIT $4.62 20030401 99999999 

A4388 

OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER 

ATTACHED, (1 PIECE), EACH $4.71 20060701 99999999 

A4389 

OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT- 

IN CONVEXITY (1 PIECE $6.70 20060701 99999999 

A4390 ILEAL BLADDER SET $10.40 20060701 99999999 

A4391 

OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER 

ATTACHED, WITHOUT BUILT-IN CON $7.66 20060701 99999999 

A4392 

OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER 

ATTACHED, WITH BUILT-IN CONVEX $8.18 20060701 99999999 

A4393 





A4394 

OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, LIQUID, PER 

FLUID OUNCE $2.76 20060701 99999999 

A4395 

OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER 

TABLET $0.05 20060701 99999999 

A4396 OSTOMY BELT WITH PERISTOMAL HERNIA SUPPORT $40.48 20060701 99999999 

A4397 IRRIGATION SUPPLY SLEEVE $1.83 20060701 99999999 

A4398 IRRIGATION SUPPLY;BAGS $14.93 20060701 99999999 

A4399 IRRIGATION SUPPLY; CONE/CATHETER $10.31 20060701 99999999 

A4400 OSTOMY ITTIGATION SET $63.84 20060701 99999999 

A4402 OSTOMY LUBRICANT $4.00 20060701 99999999 

A4404 OSTOMY RINGS $1.83 20060701 99999999 

A4405 OSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCE $3.40 20060701 99999999 

A4406 OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCE $5.74 20060701 99999999 

A4407 

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR 


A4408 

OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, FLEXIBLE OR 


A4409 



A4410 



A4411 

OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED 

WEAR, WITH BUILT-IN CONVE $3.06 20060701 99999999 

A4412 

OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER 

WITH FLANGE (2 PIECE $1.62 20060701 99999999 

A4413 

OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER 

WITH FLANGE (2 PIECE $5.50 20060701 99999999 

A4414 


ACCORDION), WITHOUT BUILT-I $4.93 20060701 99999999 

A4415 


ACCORDION), WITHOUT BUILT-I $6.00 20060701 99999999 

A4416 

OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 

PIECE), EACH $2.75 20060701 99999999 

A4417 

OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN 

CONVEXITY, WITH FILTE $3.72 20060701 99999999 

A4418 

OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH 

FILTER (1 PIECE), EACH $1.81 20060701 99999999 

A4419 

OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH NON-LOCKING 

FLANGE, WITH FILTER (2 $1.74 20060701 99999999 

A4421 OSTOMY SUPPLY MISC $4.68 20030401 99999999 

A4422 

OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR 

USE IN OSTOMY POUCH TO $0.12 20060701 99999999 

A4423 

OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING 

FLANGE, WITH FILTER (2 PIE $1.86 20060701 99999999 

A4424 

OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH 


A4425 

OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH NON- 

LOCKING FLANGE, WITH FILTER $3.58 20060701 99999999 

A4426 

OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING 

FLANGE (2 PIECE SYSTEM) $2.73 20060701 99999999 

A4427 


FLANGE, WITH FILTER (2 $2.78 20060701 99999999 

A4428 


ATTACHED, WITH FAUCET-TYPE TAP $6.51 20060701 99999999 

A4429 

OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN 

CONVEXITY, WITH FAUC $8.25 20060701 99999999 

A4430 URETEROSTOMY SET $8.52 20060701 99999999 



A4431 

OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET- 

TYPE TAP WITH VALVE (1 $6.22 20060701 99999999 

A4432 

OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON- 

LOCKING FLANGE, WITH FAUCET-T $3.59 20060701 99999999 

A4433 

OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING 

FLANGE (2 PIECE), EACH $3.34 20060701 99999999 

A4434 


FLANGE, WITH FAUCET-TYPE $3.76 20060701 99999999 

A4450 AHDESIVE TAPE ALL SIZES $0.09 20021101 99999999 

A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES $0.36 20030401 99999999 

A4454 TAPE, ALL TYPES, ALL SIZES $0.86 19990701 99999999 

A4455 

ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER 

ADHESIVE) $1.70 20060701 99999999 

A4458 ENEMA BAG WITH TUBING, REUSABLE $1.86 20071101 99999999 

A4460 ELASTIC BANDAGE, ACE $5.41 20030401 99999999 

A4461 SURGICAL DRESSING HOLDER, NON-REUSABLE, EACH $3.29 20070101 99999999 

A4462 ABDOMINAL DRESSING HOLDER/BINDER, EACH $3.53 20030401 99999999 

A4465 NON-ELASTIC BINDER FOR EXTREMITY $8.10 20010101 99999999 

A4481 THRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE, EACH $0.53 20060701 99999999 

A4483 

MOISTURE EXCHANGER, DISPOSABLE, FOR USE WITH INVASIVE 

MECHANICAL VENTILATION $5.20 20030401 99999999 

A4490 SURGICAL STOCKINGS ABOVE KNEE LENGTH, EACH $11.44 20030401 99999999 

A4495 SURGICAL STOCKINGS THIGH LENGTH, EACH $11.44 20030401 99999999 

A4500 SURGICAL STOCKINGS BELOW KNEE LENGTH EACH $7.28 20030401 99999999 

A4510 SURGICAL STOCKINGS FULL LENGTH, EACH $11.44 20030401 99999999 

A4521 ADULT-SIZED INCONTINENCE PRODUCT, DIAPER, SMALL SIZE, EACH $0.62 20030812 99999999 

A4522 ADULT-SIZED INCONTINENCE PRODUCT, DIAPER, MEDIUM SIZE, EACH $0.66 20030812 99999999 

A4524 

ADULT-SIZED INCONTINENCE PRODUCT, DIAPER, EXTRA LARGE SIZE, 

EACH $0.69 20030812 99999999 

A4550 SURGICAL TRAYS $5.20 20030401 99999999 

A4554 DISPOSABLE UNDERPADS, ALL SIZES, (E.G., CHUX'S) $0.30 20030401 99999999 

A4556 ELECTRODES (EG.APNEA MONITOR) $10.41 20060701 99999999 

A4557 LEAD WIRES (EG.APNEA MONITOR) $15.74 20060701 99999999 

A4558 CONDUCTIVE PASTE OR GEL $6.84 20060701 99999999 

A4565 SLINGS $10.40 20030401 99999999 

A4570 SPLINT $10.40 20030401 99999999 

A4572 RIB BELT $10.40 20030401 99999999 

A4580 CAST SUPPLIES $14.56 20030401 99999999 

A4590 SPECIAL CASTING MATERIALS,HEXCELITE AND LIGHT CAST $20.80 20030401 99999999 

A4595 TENS SUPPLIES, 2 LEAD, PER MONTH $26.00 20060701 99999999 

A4604 

TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH 

POSITIVE AIRWAY PRESSURE DEV $6.68 20071101 99999999 

A4605 TRACHEAL SUCTION CATHETER, CLOSED SYSTEM, EACH $16.00 20060101 99999999 

A4606 OXYGEN PROBE FOR USE WITH OXIMETER DEVICE, REPLACEMENT $40.43 19990701 99999999 

A4608 TRANSTRACHEAL OXYGEN CATHETER, EACH $58.15 20060701 99999999 

A4609 

TRACHEAL SUCTION CATHETER, CLOSED SYSTEM, FOR LESS THAN 72 

HOURS OF USE, EACH $14.30 20030401 99999999 

A4611 

BATTERY HEAVY DUTY REPLACEMENT FOR PATIENT OWNED 

VENTILATOR $7.25 20071101 99999999 

A4612 BATTERY CABLES;REPLACEMENT FOR PATIENT OWNED VENTILATOR $8.46 20071101 99999999 

A4613 

BATTERY CHARGER;REPLACEMENT FOR PATIENT OWNED 

VENTILATOR $9.21 20071101 99999999 

A4614 PEAK EXPIRATORY FLOW RATE METER, HAND HELD $23.59 20060701 99999999 

A4615 CANULA, NASAL $2.16 20030401 99999999 

A4616 AEROSOL TUBING %PER FOOT< $9.36 20030401 99999999 

A4617 MOUTH PIECE $5.20 20030401 99999999 

A4618 IPPB SUPPLIES $7.31 20030401 99999999 



A4619 FACE TENT $1.21 20060701 99999999 

A4620 VARIABLE CONCENTRATION MASK $5.20 20030401 99999999 

A4621 TRACHEA MASK $1.39 19990701 99999999 

A4622 TRACHEOSTOMY OR LARYNGECTOMY TUBE $24.28 20030401 99999999 

A4623 TRACHEOSTOMY INNER CANNULA (REPLACEMENT ONLY) $3.50 20060701 99999999 

A4624 TRACHEAL SUCTION CATH ANY TYPE EACH $2.60 20030401 99999999 

A4625 TRACHEOSTOMY CARE OR CLEANING STARTER KIT $6.24 20060701 99999999 

A4626 TRACHEOSTOMY CLEANING BRUSH EACH $1.93 20060701 99999999 

A4627 

APACER, BAG OR RESERVOIR W/WO MASK USE W/ METERED DOSE 

INHAL $20.80 20030401 99999999 

A4628 OROPHARYNGEAL SUCTION CATHETER, EACH $2.92 20030401 99999999 

A4629 TRACHEOSTOMY CARE KIT FOR ESTABLISHED TRACHEOSTOMY $3.81 20060701 99999999 

A4630 

REPLACEMENT BATTERIES. MEDICALLY NECESSARY TENS OWNED BY 

PT. $5.20 20030401 99999999 

A4631 

REPLACE BATTERIES FOR MED. NEC. ELECTRONIC WHEEL CHAIR 

OWNED $132.36 20030401 99999999 

A4633 

REPLACEMENT BULB/LAMP FOR ULTRAVIOLET LIGHT THERAPY 

SYSTEM, EACH $41.04 20030401 99999999 

A4635 UNDERARM PAD CRUTCH REPLACEMENT EACH $1.03 20071101 99999999 

A4636 REPLACEMENT, HAND GRIP. CANE. CRUTHCH. OR WALKER, EACH $0.44 20071101 99999999 

A4637 ASDF $0.36 20071101 99999999 

A4638 

REPLACEMENT BATTERY FOR PATIENT-OWNED EAR PULSE 

GENERATOR, EACH $0.50 20071101 99999999 

A4639 REPLACEMENT PAD FOR INFRARED HEATING PAD SYSTEM, EACH $287.21 20030401 99999999 

A4640 

REPLACEMENT PAD FOR MED. NEC. ALTERNATING PRESSURE PAD 

OWNED $6.10 20071101 99999999 

A4653 PERITONEAL DIALYSIS CATHETER ANCHORING DEVICE, BELT, EACH $0.61 20030101 99999999 

A4656 NEEDLE, ANY SIZE, FOR DIALYSIS, EACH $0.10 20040101 99999999 

A4657 SYRINGE, WITH OR WITHOUT NEEDLE, FOR DIALYSIS, EACH $0.16 20030401 99999999 

A4660 

SPHYGMOMANOMETER/BLOOD PRESSURE APPARATUS W/CUFF 

STETHOSCOPE $25.00 20010101 99999999 

A4670 AUTOMATIC BLOOD PRESSURE MONITOR $15.00 20010101 99999999 

A4712 WATER,STERILE $0.21 20030401 99999999 

A4750 BLOOD TUBING ARTERIAL OR VENOUS EACH $22.50 20010101 99999999 

A4772 DEXTROSTICK OR GLUCOSE TEST STRIPS PER BOX $0.62 20030401 99999999 

A4860 DISPOSABLE CATHETER CAPS $0.87 20030401 99999999 

A4927 GLOVES,STERILE OR NON STERILE PER PAIR $0.11 20030812 99999999 

A4928 SURGICAL MASK, FOR DIALYSIS, PER 20 $5.60 20021101 99999999 

A4930 GLOVES, STERILE, PER PAIR $0.75 20031016 99999999 

A4931 ORAL THERMOMETER, REUSABLE, ANY TYPE, EACH $2.00 20071101 99999999 

A4932 RECTAL THERMOMETER, REUSABLE, ANY TYPE, EACH $2.00 20071101 99999999 

A5051 COLOSTOMY BAGS DISPOSABLE $2.07 20060701 99999999 

A5052 POUCH,CLOSED,W/O BARRIER ATTACHED 1 PIECE $1.49 20060701 99999999 

A5053 POUCH, CLOSED FOR USE ON FACEPLATE $2.14 20060701 99999999 

A5054 POUCH,CLOSED FOR USE ON BARRIER W FLANGE 2 PIECE $1.79 20060701 99999999 

A5055 STOMA CAP $1.46 20060701 99999999 

A5061 COLOSTOMY BAGS REUSABLE $3.52 20060701 99999999 

A5062 POUCH,DRAINABLE,W/O BARRIER ATTACHED 1 PIECE $2.27 20060701 99999999 

A5063 

POUCH,DRAINABLE,FOR USE ON BARRIER W/FLANGE 2 PIECE 

SYSTEM $2.70 20060701 99999999 

A5064 POUCH,DRAINABLE W/FACEPLATE ATTACHED;PLASTIC OR RUBBER $3.23 20030401 99999999 

A5071 UROSTOMY BAGS DISPOSABLE $6.01 20060701 99999999 

A5072 POUCH,URINARY;W/O BARRIER ATTACHED 1 PIECE $4.24 20060701 99999999 

A5073 POUCH/URINARY;FOR USE ON BARRIER W/FLANGE 2 PIECE $3.55 20060701 99999999 

A5074 POUCH,URINARY W/FACEPLATE ATTACHED ;PLASTIC OR RUBBER $3.23 20030401 99999999 

A5075 POUCH,URINARY,FOR USE ON FACEPLATE PLASTIC OR RUBBER $3.60 20030401 99999999 

A5081 CONTINENT DEVICE;PLUG FOR CONTINENT STOMA $3.89 20060701 99999999 

A5082 CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA $10.62 20060701 99999999 



A5093 OSTOMY ACCESSORY CONVEX INSERT $2.09 20060701 99999999 

A5102 BEDSIDE DRAINAGE BOTTLE RIGID OR EXPANDABLE $24.21 20060701 99999999 

A5105 URINARY SUSPENSORY W/LEG BAG W OR W/O TUBE $61.69 20060701 99999999 

A5112 URINARY LEG BAG; LATEX $33.44 20060701 99999999 

A5113 LEG STRAP LATEX PER SET $3.72 20060701 99999999 

A5114 LEG STRAP; FOAM OR FABRIC, PER SET $11.29 20060701 99999999 

A5119 SKIN BARRIER; WIPES, BOX PER 50 $12.56 20040801 99999999 

A5120 SKIN BARRIER, WIPES OR SWABS, EACH $0.25 20060101 99999999 

A5121 SKIN BARRIER;SOLID 6X6 OR EQUIVALENT EACH $9.11 20060701 99999999 

A5122 SKIN BARRIER;SOLID 8X8 OR EQUIVALENT EACH $15.22 20060701 99999999 

A5123 

SKIN BARRIER;W FLANGE SOLID FLEX OR ACCORIDIAN ANY SIZE 

EACH $4.46 19990701 99999999 

A5126 ADHESIVE; DISC OR FOAM PAD $1.16 20060701 99999999 

A5131 

APPLIANCE CLEANER;INCONTINENCE AND OSTOMY APPLIANCES 

PER16OZ $17.83 20060701 99999999 

A5200 

PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE 

SKIN ATTACHMENT $11.29 20060701 99999999 

A5500 

FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM 

PREPARATION AND SUPPLY $59.36 20060701 99999999 

A5501 



A5502 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT(S), PER SHOE $32.49 20030401 99999999 

A5503 

FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF- 

THE-SHELF DEPTH-INLA $27.54 20060701 99999999 

A5504 



A5505 



A5506 



A5507 A $27.54 20060701 99999999 

A5508 

FOR DIABETICS ONLY, DELUXE FEATURE OF OFF-THE-SHELF DEPTH- 

INLAY SHOE OR CUSTOM-M $25.00 20071101 99999999 

A5509 

FOR DIABETICS ONLY, DIRECT FORMED, MOLDED TO FOOT WITH 

EXTERNAL HEAT SOURCE (I.E $33.00 20040101 99999999 

A5510 

FOR DIABETICS ONLY, DIRECT FORMED, COMPRESSION MOLDED TO 

PATIENT'S FOOT WITHOUT $15.62 20020101 99999999 

A5511 

FOR DIABETICS ONLY, CUSTOM-MOLDED FROM MODEL OF PATIENT'S 

FOOT, MULTIPLE DENSITY $33.00 20040101 99999999 

A5512 

FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, 

MOLDED TO FOOT AFTER $25.26 20060701 99999999 

A5513 

FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED 

FROM MODEL OF PATIENT $37.69 20060701 99999999 

A6000 

NON-CONTACT WOUND WARMING WOUND COVER FOR USE WITH THE 

NON-CONTACT WOUND WARMING $5.00 20071101 99999999 

A6010 

COLLAGEN BASED WOUND FILLER, DRY FORM, PER GRAM OF 

COLLAGEN $30.96 20060701 99999999 

A6011 

COLLAGEN BASED WOUND FILLER, GEL/PASTE, PER GRAM OF 

COLLAGEN $2.28 20060701 99999999 

A6020 

COLLAGEN BASED WOUND DRESSING, WOUND COVER, EACH 

DRESSING $0.94 20030401 99999999 

A6021 COLLAGEN DRESSING, PAD SIZE 16 SQ. IN. OR LESS, EACH $17.88 20060701 99999999 

A6022 

COLLAGEN DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS 

THAN OR EQUAL TO 48 SQ $20.05 20060701 99999999 

A6023 COLLAGEN DRESSING, PAD SIZE MORE THAN 48 SQ. IN., EACH $190.30 20060701 99999999 

A6024 COLLAGEN DRESSING WOUND FILLER, PER 6 INCHES $5.90 20060701 99999999 

A6154 WOUND POUCH, EACH $15.37 20060701 99999999 



A6196 

ALGINATE DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, 

EACH DRESSING $7.86 20060701 99999999 

A6197 

ALGINATE DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. 

IN. BUT LESS THAN OR E $17.62 20060701 99999999 

A6198 

ALGINATE DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. 

IN., EACH DRESSING $18.00 20061101 99999999 

A6199 ALGINATE DRESSING, WOUND FILLER, PER 6 INCHES $5.66 20060701 99999999 

A6200 

COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT 

ADHESIVE BORDER, EACH D $9.50 20060701 99999999 

A6201 

COMPOSITE DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS 

THAN OR EQUAL TO 48 S $20.80 20060701 99999999 

A6202 

COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT 

ADHESIVE BORDER, EACH $34.60 20060701 99999999 

A6203 

COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE 

ADHESIVE BORDER, $3.90 20060701 99999999 

A6204 

COMPOSITE DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS 

THAN OR EQUAL TO 48 S $7.27 20060701 99999999 

A6205 

COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY 

SIZE ADHESIVE BORDER $7.12 19990701 99999999 

A6206 CONTACT LAYER, 16 SQ. IN. OR LESS, EACH DRESSING $1.57 20030401 99999999 

A6207 

CONTACT LAYER, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL 

TO 48 SQ. IN., EACH D $4.75 20060701 99999999 

A6209 

FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, 

WITHOUT ADHESIVE BORDER $7.83 20060701 99999999 

A6210 

FOAM DRESSING. WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. 

BUT LESS THAN OR EQUAL $16.82 20060701 99999999 

A6211 

FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., 

WITHOUT ADHESIVE BORD $30.61 20060701 99999999 

A6212 

FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH 

ANY SIZE ADHESIVE $10.11 20060701 99999999 

A6213 

FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. 

BUT LESS THAN OR EQUAL $10.39 20030401 99999999 

A6214 

FORM DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., 

WITH ANY SIZE ADHESIV $10.72 20060701 99999999 

A6216 

GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR 

LESS, WITHOUT ADHESI $0.08 20060701 99999999 

A6217 

GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 16 

SQ. IN. BUT LESS THAN $0.45 20030401 99999999 

A6218 

GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 48 

SQ. IN., WITHOUT ADHE $0.94 20030401 99999999 

A6219 

GAUZE, NON-IMPREGNATED, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY 

SIZE ADHESIVE BORD $0.63 20060701 99999999 

A6220 

GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 16 SQ. IN. BUT 

LESS THAN OR EQUAL TO $1.66 20060701 99999999 

A6221 

GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 48 SQ. IN., WITH 

ANY SIZE ADHESIVE BO $4.16 20030401 99999999 

A6222 

GAUZE, IMPREGNATED, OTHER THAN WATER OR NORMAL SALINE, 

PAD SIZE 16 SQ. IN. OR LE $2.22 20060701 99999999 

A6223 


PAD SIZE MORE THAN 16 SQ. $2.53 20060701 99999999 

A6224 



A6228 

GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE 16 SQ. 

IN. OR LESS, WITHOUT $3.88 20030401 99999999 

A6229 

GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE MORE 

THAT 16 SQ. IN. BUT LE $3.88 20060701 99999999 

A6230 

GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE MORE 

THAN 48 SQ. IN., WITHO $3.88 20030401 99999999 



A6231 

GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, 

PAD SIZE 16 SQ. IN. OR L $4.46 20060701 99999999 

A6232 

GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, 

PAD SIZE GREATER THAN 16 $6.57 20060701 99999999 

A6233 

GAUZE, IMPREGNATED, HYDROGEL FOR DIRECT WOUND CONTACT, 


A6234 

HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR 

LESS, WITHOUT ADHESIV $6.81 20060701 99999999 

A6235 

HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 


A6236 


SQ. IN., WITHOUT ADHES $29.16 20060701 99999999 

A6237 

HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR 

LESS, WITH ANY SIZE A $8.48 20060701 99999999 

A6238 



A6239 


SQ. IN., WITH ANY SIZE $13.12 20030401 99999999 

A6240 

HYDROCOLLOID DRESSING, WOUND FILLER, PASTE, PER FLUID 

OUNCE $12.77 20060701 99999999 

A6241 HYDROCOLLOID DRESSING, WOUND FILLER, DRY FORM, PER GRAM $2.74 20060701 99999999 

A6242 

HYDROGEL DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, 

WITHOUT ADHESIVE BO $6.50 20060701 99999999 

A6243 

HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. 


A6244 


IN., WITHOUT ADHESIVE $42.08 20060701 99999999 

A6245 

HYDROGEL DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, 

WITH ANY SIZE ADHES $7.76 20060701 99999999 

A6246 



A6247 


IN., WITH ANY SIZE ADH $25.68 20060701 99999999 

A6248 HYDROGEL DRESSING, WOUND FILLER, GEL, PER FLUID OUNCE $16.91 20060701 99999999 

A6251 

SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE 16 SQ. 

IN. OR LESS, WITHOUT $2.10 20060701 99999999 

A6252 

SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE 

THAN 16 SQ. IN. BUT LE $4.05 20060701 99999999 

A6253 


THAN 48 SQ. IN., WITHO $6.85 20060701 99999999 

A6254 

SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE 16 SQ. 

IN. OR LESS, WITH AN $1.30 20060701 99999999 

A6255 


THAN 16 SQ. IN. BUT LE $3.22 20060701 99999999 

A6256 


THAN 48 SQ. IN., WITH $6.85 20061101 99999999 

A6257 TRANSPARENT FILM, 16 SQ. IN. OR LESS, EACH DRESSING $1.63 20060701 99999999 

A6258 

TRANSPARENT FILM, MORE THAN 16 SQ. IN. BUT LESS THAN OR 

EQUAL TO 48 SQ. IN., EAC $4.48 20060701 99999999 

A6259 TRANSPARENT FILM, MORE THAN 48 SQ. IN., EACH DRESSING $8.50 20060701 99999999 

A6263 GAUZE, ELASTIC, NON-STERILE, ALL TYPES, PER LINEAR YARD $0.26 20030401 99999999 

A6264 GAUZE, NON-ELASTIC, NON-STERILE, PER LINEAR YARD $0.34 20030401 99999999 

A6265 TAPE, ALL TYPES, PER 18 SQUARE INCHES $0.13 19990701 99999999 

A6266 


ANY WIDTH, PER LINEAR YAR $2.06 20060701 99999999 

A6402 

GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, 

WITHOUT ADHESIVE B $0.13 20060701 99999999 



A6403 

GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. 

IN. LESS THAN OR EQUA $0.45 20060701 99999999 

A6404 

GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. 

IN., WITHOUT ADHESIVE $0.46 20030401 99999999 

A6405 GAUZE, ELASTIC, STERILE, ALL TYPES, PER LINEAR YARD $0.34 20030401 99999999 

A6406 GAUZE, NON-ELASTIC, STERILE, ALL TYPES, PER LINEAR YARD $0.82 20030401 99999999 

A6407 

PACKING STRIPS, NON-IMPREGNATED, UP TO 2 INCHES IN WIDTH, 

PER LINEAR YARD $1.13 20060701 99999999 

A6410 EYE PAD, STERILE, EACH $0.39 20060701 99999999 

A6411 EYE PAD, NON-STERILE, EACH $0.25 20071101 99999999 

A6412 EYE PATCH, OCCLUSIVE, EACH $0.17 20040101 99999999 

A6422 

CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON- 

STERILE, WIDTH GREATER THAN $1.17 20030101 99999999 

A6426 

CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE 

WIDTH GREATER THAN OR EQ $0.41 20040101 99999999 

A6440 

ZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, 

KNITTED/WOVEN, WIDTH GREATER THAN O $11.38 20030401 99999999 

A6441 

PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, 

WIDTH GREATER THAN OR EQUAL $0.67 20061101 99999999 

A6441 

PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, 


A6442 


STERILE, WIDTH LESS THAN THR $0.17 20061101 99999999 

A6442 


STERILE, WIDTH LESS THAN THR $0.17 20060701 99999999 

A6443 



A6443 



A6444 



A6444 



A6445 

CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, 

WIDTH LESS THAN THREE I $0.32 20061101 99999999 

A6445 


WIDTH LESS THAN THREE I $0.32 20060701 99999999 

A6446 


WIDTH GREATER THAN OR E $0.41 20061101 99999999 

A6446 



A6447 



A6447 



A6448 

LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH 

LESS THAN THREE INCHES, $1.16 20061101 99999999 

A6448 


LESS THAN THREE INCHES, $1.16 20060701 99999999 

A6449 


GREATER THAN OR EQUAL T $1.75 20061101 99999999 

A6449 



A6450 



A6451 

MODERATE COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, 

LOAD RESISTANCE OF 1.25 TO $4.00 20040101 99999999 



A6452 

HIGH COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD 

RESISTANCE GREATER THAN O $5.91 20060701 99999999 

A6453 

SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, 

WIDTH LESS THAN THREE INC $0.61 20060701 99999999 

A6454 


WIDTH GREATER THAN OR EQU $0.77 20060701 99999999 

A6455 


WIDTH GREATER THAN OR EQU $1.39 20060701 99999999 

A6456 

ZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, 

KNITTED/WOVEN, WIDTH GREATER THAN O $1.28 20060701 99999999 

A6457 

TUBULAR DRESSING WITH OR WITHOUT ELASTIC, ANY WIDTH, PER 

LINEAR YARD $1.14 20060701 99999999 

A6530 

GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, 

EACH $28.08 20060121 99999999 

A6531 


EACH $38.48 20060121 99999999 

A6532 


EACH $40.00 20060121 99999999 

A6533 

GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, 

EACH $20.80 20060121 99999999 

A6534 


EACH $26.00 20060121 99999999 

A6535 


EACH $33.28 20060121 99999999 

A6536 

GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18- 

30 MMHG, EACH $95.00 20060121 99999999 

A6537 


40 MMHG, EACH $104.00 20060121 99999999 

A6538 


50 MMHG, EACH $104.00 20060121 99999999 

A6539 

GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, 

EACH $28.08 20060121 99999999 

A6540 


EACH $28.08 20060121 99999999 

A6541 


EACH $28.08 20060121 99999999 

A6542 GRADIENT COMPRESSION STOCKING, CUSTOM MADE $28.08 20060121 99999999 

A6543 GRADIENT COMPRESSION STOCKING, LYMPHEDEMA $28.08 20060121 99999999 

A6544 GRADIENT COMPRESSION STOCKING, GARTER BELT $1.00 20060121 99999999 

A6549 GRADIENT COMPRESSION STOCKING, NOT OTHERWISE SPECIFIED $28.08 20060121 99999999 

A6550 

DRESSING SET FOR NEGATIVE PRESSURE WOUND THERAPY 

ELECTRICAL PUMP, STATIONARY OR $27.28 20060701 99999999 

A6551 

CANISTER SET FOR NEGATIVE PRESSURE WOUND THERAPY 


A7000 CANISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACH $7.70 20030401 99999999 

A7001 CANISTER, NON-DISPOSABLE, USED WITH SUCTION PUMP, EACH $30.90 20030401 99999999 

A7002 TUBING, USED WITH SUCTION PUMP, EACH $3.58 20030401 99999999 

A7003 

ADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED 

PNEUMATIC NEBULIZER, DISPOSABL $2.08 20030401 99999999 

A7004 SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLE $1.64 20030401 99999999 

A7005 

ADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED 

PNEUMATIC NEBULIZER, NON-DISPO $28.18 20030401 99999999 

A7006 

ADMINISTRATION SET, WITH SMALL VOLUME FILTERED PNEUMATIC 

NEBULIZER $13.36 20030401 99999999 

A7007 

LARGE VOLUME NEBULIZER, DISPOSABLE, UNFILLED, USED WITH 

AEROSOL COMPRESSOR $4.93 20030401 99999999 

A7010 

CORRUGATED TUBING, DISPOSABLE, USED WITH LARGE VOLUME 

NEBULIZER, 100 FEET $21.28 20030401 99999999 



CORRUGATED TUBING, NON-DISPOSABLE, USED WITH LARGE 

A7011 VOLUME NEBULIZER, 10 FEET $2.08 20030401 99999999 

A7012 WATER COLLECTION DEVICE, USED WITH LARGE VOLUME NEBULIZER $2.81 20030401 99999999 

A7013 FILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSOR $0.76 20030401 99999999 

A7014 

FILTER, NONDISPOSABLE, USED WITH AEROSOL COMPRESSOR OR 

ULTRASONIC GENERATOR $4.36 20010101 99999999 

A7015 AEROSOL MASK, USED WITH DME NEBULIZER $1.44 20030401 99999999 

A7016 

DOME AND MOUTHPIECE, USED WITH SMALL VOLUME ULTRASONIC 

NEBULIZER $11.88 20030401 99999999 

A7017 

NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE 

TYPE, NOT USED WITH OX $12.78 20010101 99999999 

A7018 WATER, DISTILLED, USED WITH LARGE VOLUME NEBULIZER, 1000 ML $0.51 20060701 99999999 

A7019 

SALINE SOLUTION, PER 10 ML, METERED DOSE DISPENSER, FOR USE 

WITH INHALATION DRUG $0.26 20030401 99999999 

A7020 

STERILE WATER OR STERILE SALINE, 1000 ML, USED WITH LARGE 

VOLUME NEBULIZER $2.10 20030401 99999999 

A7025 

HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, 

REPLACEMENT FOR USE WITH PATI $397.50 20071101 99999999 

A7026 

HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, 

REPLACEMENT FOR USE WITH PATI $28.75 20030401 99999999 

A7027 

COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS 

POSITIVE AIRWAY PRESSURE DEVIC $186.52 20080101 99999999 

A7028 

ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, 

REPLACEMENT ONLY, EACH $49.54 20080101 99999999 

A7029 

NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, 

REPLACEMENT ONLY, PAIR $20.24 20080101 99999999 

A7030 

FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, 

EACH $188.64 20030401 99999999 

A7031 FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH $69.77 20030401 99999999 

A7032 REPLACEMENT CUSHION FOR NASAL APPLICATION DEVICE, EACH $40.53 20030401 99999999 

A7033 REPLACEMENT PILLOWS FOR NASAL APPLICATION DEVICE, PAIR $28.41 20030401 99999999 

A7034 

NASAL INTERFACE (MASK OR CANNULA TYPE) USED WITH POSITIVE 

AIRWAY PRESSURE DEVICE $117.64 20030401 99999999 

A7035 HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE $41.46 20030401 99999999 

A7036 CHINSTRAP USED WITH POSITIVE AIRWAY PRESSURE DEVICE $13.94 20030401 99999999 

A7037 TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE $38.64 20030401 99999999 

A7038 

FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE 

DEVICE $3.23 20030401 99999999 

A7039 

FILTER, NON DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE 

DEVICE $13.26 20030401 99999999 

A7040 ONE WAY CHEST DRAIN VALVE $35.20 20071101 99999999 

A7041 

WATER SEAL DRAINAGE CONTAINER AND TUBING FOR USE WITH 

IMPLANTED CHEST TUBE $66.14 20071101 99999999 

A7042 IMPLANTED PLEURAL CATHETER, EACH $159.65 20071101 99999999 

A7043 

VACUUM DRAINAGE BOTTLE AND TUBING FOR USE WITH IMPLANTED 

CATHETER $27.36 20071101 99999999 

A7044 

ORAL INTERFACE USED WITH POSITIVE AIRWAY PRESSURE DEVICE, 

EACH $120.91 20030401 99999999 

A7046 

WATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY 

PRESSURE DEVICE, REPLACE $19.51 20040101 99999999 

A7501 TRACHEOSTOMA VALVE, INCLUDING DIAPHRAGM, EACH $100.18 20060701 99999999 

A7502 

REPLACEMENT DIAPHRAGM/FACEPLATE FOR TRACHEOSTOMA 

VALVE, EACH $47.61 20060701 99999999 

A7503 

FILTER HOLDER OR FILTER CAP, REUSABLE, FOR USE IN A 

TRACHEOSTOMA HEAT AND MOISTU $10.81 20060701 99999999 



A7504 

FILTER FOR USE IN A TRACHEOSTOMA HEAT AND MOISTURE 

EXCHANGE SYSTEM, EACH $0.64 20060701 99999999 

A7505 

HOUSING, REUSABLE WITHOUT ADHESIVE, FOR USE IN A HEAT AND 

MOISTURE EXCHANGE SYST $4.46 20060701 99999999 

A7506 

ADHESIVE DISC FOR USE IN A HEAT AND MOISTURE EXCHANGE 

SYSTEM AND/OR WITH TRACHEO $0.32 20060701 99999999 

A7507 

FILTER HOLDER AND INTEGRATED FILTER WITHOUT ADHESIVE, FOR 

USE IN A TRACHEOSTOMA $2.37 20060701 99999999 

A7508 

HOUSING AND INTEGRATED ADHESIVE, FOR USE IN A 

TRACHEOSTOMA HEAT AND MOISTURE EXC $2.74 20060701 99999999 

A7509 

FILTER HOLDER AND INTEGRATED FILTER HOUSING, AND ADHESIVE, 

FOR USE AS A TRACHEOS $1.41 20060701 99999999 

A7520 

TRACHEOSTOMY/LARYNGECTOMY TUBE, NON-CUFFED, 

POLYVINYLCHLORIDE (PVC), SILICONE OR $47.48 20060701 99999999 

A7521 

TRACHEOSTOMY/LARYNGECTOMY TUBE, CUFFED, 

POLYVINYLCHLORIDE (PVC), SILICONE OR EQU $47.05 20060701 99999999 

A7522 

TRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLESS STEEL OR 

EQUAL (STERILIZABLE AND REUSA $45.16 20061101 99999999 

A7522 

TRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLESS STEEL OR 

EQUAL (STERILIZABLE AND REUSA $45.16 20060701 99999999 

A7523 TRACHEOSTOMY SHOWER PROTECTOR, EACH $25.23 20071101 99999999 

A7524 TRACHEOSTOMA STENT/STUD/BUTTON, EACH $77.40 20060701 99999999 

A7525 TRACHEOSTOMY MASK, EACH $2.07 20061101 99999999 

A7525 TRACHEOSTOMY MASK, EACH $2.07 20060701 99999999 

A7526 TRACHEOSTOMY TUBE COLLAR/HOLDER, EACH $3.37 20060701 99999999 

A7527 TRACHEOSTOMY/LARYNGECTOMY TUBE PLUG/STOP, EACH $3.37 20060701 99999999 

A8000 

HELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL 

COMPONENTS AND ACCESSORIES $15.33 20070101 99999999 

A8001 

HELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL 

COMPONENTS AND ACCESSORIES $15.33 20070101 99999999 

A8002 

HELMET, PROTECTIVE, SOFT, CUSTOM FABRICATED, INCLUDES ALL 

COMPONENTS AND ACCESSO $15.33 20071101 99999999 

A8003 

HELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL 

COMPONENTS AND ACCESSO $15.33 20071101 99999999 

A9500 A $83.20 20030401 99999999 

A9502 

SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, 

TECHNETIUM TC 99M TETROF $83.20 20030401 99999999 

A9503 


TECHNETIUM TC 99M, MEDRO $31.20 20030401 99999999 

A9505 A $59.80 20030401 99999999 

A9507 


INDIUM IN 111 CAPROMAB P $1,855.00 20040101 99999999 

A9510 


TECHNETIUM TC99M DISOFEN $79.17 20010101 99999999 

A9515 


TECHNETIUM TC-99M PENTET $38.00 20030101 99999999 

A9516 

SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, I- 

123 SODIUM IODIDE CAPS $36.40 20030101 99999999 

A9517 

SUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, 

I-131 SODIUM IODIDE CAP $117.25 20030101 99999999 

A9518 

SUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, 

I-131 SODIUM IODIDE SOL $146.57 20030101 99999999 

A9519 


TECHNETIUM TC-99M MACROA $85.00 20030101 99999999 

A9521 


TECHNETIUM TC-99M EXAMET $231.44 20030101 99999999 

A9524 


IODINATED I-131 SERUM AL $17.68 20030101 99999999 



A9525 

SUPPLY OF LOW OR ISO-OSMOLAR CONTRAST MATERIAL, 10 MG OF 

IODINE $0.29 20040101 99999999 

A9526 


AMMONIA N-13, PER DOSE $20.80 20040101 99999999 

A9528 

SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC AGENT, I-131 

SODIUM IODIDE CAPSULE, PER $20.80 20040101 99999999 

A9529 


SODIUM IODIDE SOLUTION, PE $20.00 20040101 99999999 

A9530 

SUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC AGENT, I-131 

SODIUM IODIDE SOLUTION, P $20.00 20040101 99999999 

A9531 


SODIUM IODIDE, PER MICROCU $11.50 20040101 99999999 

A9535 INJECTION, METHYLENE BLUE, 1 ML $4.10 20060101 99999999 

A9542 

INDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER STUDY 

DOSE, UP TO 5 MILLICUR $2,260.00 20060101 99999999 

A9550 

TECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY 

DOSE, UP TO 25 MILLIC $14.56 20060101 99999999 

A9556 GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE $15.60 20060101 99999999 

A9558 XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES $40.00 20060101 99999999 

A9560 

TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER 

STUDY DOSE, UP TO 30 $55.00 20060101 99999999 

A9561 

TECHNETIUM TC-99M OXIDRONATE, DIAGNOSTIC, PER STUDY DOSE, 

UP TO 30 MILLICURIES $9.00 20070101 99999999 

A9564 

CHROMIC PHOSPHATE P-32 SUSPENSION, THERAPEUTIC, PER 

MILLICURIE $2,675.00 20060601 99999999 

A9565 INDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER MILLICURIE $1,500.00 20060101 99999999 

A9600 

SUPPLY OF THERAPEUTIC RADIOPHARMACEUTICAL, STRONTIUM-89 

CHLORIDE, PER MCI $892.46 20010101 99999999 

A9605 

SUPPLY OF THERAPEUTIC RADIOPHARMACEUTICAL, SAMARIUM SM 

153 LEXIDRONAMM, 50 MCI $3,485.00 20040101 99999999 

A9900 

MISCELLANEOUS SUPPLY, ACCESSORY, AND/OR SERVICE 

COMPONENT OF ANOTHER HCPCS CODE $1.25 20040101 99999999 

B4034 ENTERAL FEEDING SUPPLY KIT;SYRINGE MONTHLY $5.20 20060701 99999999 

B4035 ENTERAL FEEDING SUPPLY KIT;PUMP FED MONTHLY $10.26 20060701 99999999 

B4036 ENTERAL FEEDING SUPPLY KIT;GRAVITY FED MONTHLY $6.78 20060701 99999999 

B4081 NASOGASTIC TUBING WITH STYLET $19.17 20060701 99999999 

B4082 NASOGASTRIC TUBING WITHOUT STYLET $13.50 20060701 99999999 

B4083 STOMACH TUBE-LEVINE TYPE $2.17 20060701 99999999 

B4084 GASTROSTOMY/JEJUNOSTOMY TUBING $15.60 20030401 99999999 

B4085 GASTROSTOMY TUBE, SILICONE WITH SLIDING RING, EACH $36.40 20030401 99999999 

B4086 

GASTROSTOMY / JEJUNOSTOMY TUBE, ANY MATERIAL, ANY TYPE, 

(STANDARD OR LOW PROFILE $33.71 20040101 99999999 

B4087 

GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, ANY MATERIAL, 

ANY TYPE, EACH $38.22 20080101 99999999 

B4088 

GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANY MATERIAL, 

ANY TYPE, EACH $38.22 20080101 99999999 

B4100 FOOD THICKENER, ADMINISTERED ORALLY, PER OUNCE $5.00 20071101 99999999 

B4104 ADDITIVE FOR ENTERAL FORMULA (E.G. FIBER) $0.17 20071101 99999999 

B4149 

ENTERAL FORMULA, BLENDERIZED NATURAL FOODS WITH INTACT 

NUTRIENTS, INCLUDES $0.94 20060701 99999999 

B4150 

ENTERAL FORMULAE;CATEGORY I;SEMI-SYNTHETIC INTACT 

PROTEIN/PR $0.56 20060701 99999999 

B4151 

ENTERAL FORMULAE;CATEGORY I;NATURAL INTACT 

PROTEIN/PROTEIN $1.31 20030401 99999999 

B4152 

ENTERAL FORMULAE;CATEGORY II;INTACT PROTEIN/PROTEIN 

ISOLATES $0.49 20060701 99999999 

B4153 

ENTERAL FORMULAE;CATEGORY III;HYDROLIZED PROTEIN/AMINO 

ACIDS $1.59 20060701 99999999 



ENTERAL FORMULAE;CAT IV;DEFINED FORMULA FOR SPECIAL 

B4154 METABOLI $1.12 20060701 99999999 

B4155 ENT FORMULAE;CAT V;MODULAR COMPONENTS,100 CALORIES-1 UNIT $0.87 20060701 99999999 

B4157 

ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL 

METABOLIC NEEDS FOR $1.12 20050101 99999999 

B4158 

ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE 

WITH INTACT NUTRIENTS, $0.56 20050101 99999999 

B4159 


SOY BASED WITH INTACT $0.56 20050101 99999999 

B4160 


CALORICALLY DENSE $0.49 20050101 99999999 

B4161 

ENTERAL FORMULA, FOR PEDIATRICS, HYDROLYZED/AMINO ACIDS 

AND PEPTIDE CHAIN $1.59 20050101 99999999 

B4162 

ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS 

FOR INHERITED DISEASE $1.12 20050101 99999999 

B4164 

PARENTERAL NUTRITION SOLUTION;CARBOHYDRATES 

(DEXTROSE)HOMEMI $9.89 20060701 99999999 

B4168 PARENTERAL NUTR SOLUTION;AMINO ACID,3.5% HOMEMIX $14.41 20060701 99999999 

B4176 PARENTERAL NUTRI SOLUTIONS;AMINO ACID;7%-8.5% HOMEMIX $27.88 20060701 99999999 

B4178 

PARENTERAL NUTRITION SOLUTION;AMINO ACIDS,GREATER THAN 

8.5% $33.47 20060701 99999999 

B4180 PARENTL NUTR SOLUTIONS;CARBOHY,GREATER THAN 50% HOMEMIX $14.18 20060701 99999999 

B4185 PARENTERAL NUTRITION SOLUTION, PER 10 GRAMS LIPIDS $6.53 20060701 99999999 

B4189 

PARNTL NUTR SOLU;COMPOUNDED AMINO 

ACID/CARBOHY/W/ELECTROLYTE $145.60 20060701 99999999 

B4193 

PARNTL NUTR SOLU;COMPOUND AMINO/CARBOHY 

W/ELECTROLYTES,TRACE $197.60 20060701 99999999 

B4197 

PARENTL NUTR SOLU;COMPOUND AMINO/CARBOHY 

W/ELECTROLYTES TRAC $239.20 20060701 99999999 

B4199 

PARENTL NUTR SOLU;COMPOUND AMINO/CARBOHY/ 

W/ELECTROLYTES $280.80 20060701 99999999 

B4216 

PARENTL NUTR;ADDITIVES(VITS,TRACE 

ELEMENTS,HEPARIN,ELECTRO) $4.49 20060701 99999999 

B4220 PARENTERAL NUTR SUPPLY KIT FOR 1 MONTH PREMIX $6.76 20060701 99999999 

B4222 PARENTERAL NUTR SUPPLY KIT FOR 1 MONTH HOMEMIX $5.74 20060701 99999999 

B4224 PARENTERAL NUTR ADMIN KIT FOR 1 MONTH $20.80 20060701 99999999 

B5000 



B5100 



B9000 ENTERAL NUTRTION INFUSION PUMP - WITHOUT ALARM $79.80 20071101 99999999 

B9002 ENTERAL NUTRITION INFUSION PUMP; W/ALARM $74.80 20071101 99999999 

B9004 PARENTERAL NUTRITION INFUSION PUMP, PORTABLE $2,262.63 20030401 99999999 

B9006 PARENTERAL NUTR INFUSION PUMP;STATIONARY $2,262.63 20030401 99999999 

D0120 PERIODIC ORAL EXAMINATION $29.12 19990701 99999999 

D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED $29.12 19990701 99999999 

D0150 COMPREHENSIVE ORAL EVALUATION $29.12 19990701 99999999 

D0210 INTRAORAL COMPLETE SERIES (INCL BITEWING) $58.24 19990701 99999999 

D0220 INTRAORAL PERIAPICAL FIRST FILM $10.92 19990701 99999999 

D0230 INTRAORAL PERIAPICAL EACH ADDITIONAL FILM $6.76 19990701 99999999 

D0240 INTRAORAL-OCCLUSAL FILM $18.72 19990701 99999999 

D0250 EXTRAORAL FIRST FILM $36.40 19990701 99999999 

D0260 EXTRAORAL EACH ADDITIONAL FILM $20.80 19990701 99999999 

D0270 BITEWING SINGLE FILM $10.19 19990701 99999999 

D0272 BITEWINGS TWO FILMS $18.93 19990701 99999999 

D0273 BITEWINGS - THREE FILMS $19.11 20070101 99999999 



D0274 BITEWINGS FOUR FILMS $25.48 19990701 99999999 

D0277 VERTICAL BITEWINGS - 7 TO 8 FILMS $46.80 20000101 99999999 

D0290 POSTEROANTERIOR & LATERAL SKULL & FACIAL BONE, SURVEY FILM $67.60 19990701 99999999 

D0310 SALIOGRAPHY $67.60 19990701 99999999 

D0330 PANORAMIC FILM $47.32 19990701 99999999 

D0340 CEPHALOMETRIC FILM $62.40 19990701 99999999 

D0350 ORAL/FACIAL IMAGES (INCLUDES INTRA AND EXTRAORAL IMAGES) $26.00 20000101 99999999 

D0415 

BACTERIOLOGIC STUDIES FOR DETERMINATION OF PATHOLOGIC 

AGENTS $36.40 19990701 99999999 

D1110 PROPHYLAXIS ADULT $36.40 19990701 99999999 

D1120 PROPHYLAXIS CHILD $26.00 19990701 99999999 

D1201 TOPICAL APPLICATION OF FLUORIDE(INCL PROPHYLAXIS) CHILD $30.16 19990701 99999999 

D1203 TOPICAL APPLICATION OF FLUORIDE(EXCL PROPHYLAXIS) CHILD $4.16 19990701 99999999 

D1204 TOPICAL APPLICATION OF FLUORIDE(EXCL PROPHYLAXIS) ADULT $4.16 19990701 99999999 

D1205 

TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)- 

ADULT $40.56 19990701 99999999 

D1206 

TOPICAL FLUORIDE VARNISH; THERAPEUTIC APPLICATION FOR 

MODERATE TO HIGH CARIES RI $4.16 20070101 99999999 

D1351 SEALANT PER TOOTH $24.32 19990701 99999999 

D1510 SPACE MAINTAINER FIXED UNILATERAL $115.44 19990701 99999999 

D1515 SPACE MAINTAINER FIXED BILATERAL $149.76 19990701 99999999 

D1520 SPACE MAINTAINER REMOVABLE UNILATERAL $85.61 19990701 99999999 

D1525 SPACE MAINTAINER REMOVABLE BILATERAL $158.08 19990701 99999999 

D1550 RECEMENTATION OF SPACE MAINTAINER $31.20 19990701 99999999 

D2140 AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT $30.94 20030808 99999999 

D2140 AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT $38.53 20030808 99999999 

D2150 AMALGAM TWO SURFACES PERMANENT $40.40 20030808 99999999 

D2150 AMALGAM TWO SURFACES PERMANENT $50.02 20030808 99999999 

D2160 AMALGAM THREE SURFACES PERMANENT $48.46 20030808 99999999 

D2160 AMALGAM THREE SURFACES PERMANENT $60.63 20030808 99999999 

D2161 AMALGAM FOUR OR MORE SURFACES PERMANENT $53.56 20030808 99999999 

D2161 AMALGAM FOUR OR MORE SURFACES PERMANENT $66.90 20030808 99999999 

D2752 CROWN PORCELAIN FUSED TO NOBLE METAL $234.00 19990701 99999999 

D2792 CROWN FULL CAST NOBLE METAL $234.00 19990701 99999999 

D2910 RECEMENT INLAY $28.08 19990701 99999999 

D2920 RECEMENT CROWN $28.08 19990701 99999999 

D2930 PREFABRICATED STAINLESS STEEL CROWN PRIMARY TOOTH $74.36 19990701 99999999 

D2931 PREFABRICATED STAINLESS STEEL CROWN-PERMANENT TOOTH $80.60 19990701 99999999 

D2932 PREFABRICATED RESIN CROWN $46.80 19990701 99999999 

D2950 CROWN BUILD UP,INCLUDING ANY PINS $62.40 19990701 99999999 

D2951 PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION $15.60 19990701 99999999 

D2952 CAST POST AND CORE IN ADDITION TO CROWN $74.88 20070101 99999999 

D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN $74.88 19990701 99999999 

D2970 TEMPORARY (FRACTURED TOOTH) $46.80 19990701 99999999 

D3220 THERAPEUTIC PULPOTOMY (EXCL FINAL RESTORATION) $67.60 19990701 99999999 

D3310 ONE CANAL (EXCLUDING FINAL RESTORATION) $260.00 19990701 99999999 

D3320 TWO CANALS (EXCLUDING FINAL RESTORATION) $338.00 19990701 99999999 

D3330 THREE CANALS (EXCLUDING FINAL RESTORATION) $416.00 19990701 99999999 

D3351 

APEXIFICATION/RECALCIFICATION-INITIAL VISIT (APICAL 

CLOSURE/CALCIFIC REPAIR OF P $80.29 19990701 99999999 

D3352 

APEXIFICATION/RECALCIFICATION-INTERIM MEDICATION REPLACEM 

ENT (APICAL CLOSURE/C $36.40 19990701 99999999 

D3353 

APEXIFICATION/RECALCIFICATION-FINAL VISIT (INCLUDES 

COMPLETED ROOT CANAL THERAPY $36.40 19990701 99999999 

D3410 APICOECTOMY (PER TOOTH) FIRST ROOT $260.00 19990701 99999999 

D3421 APICOECTOMY/PERIRADICULAR SURGERY-BICUSPID (FIRST ROOT) $338.00 19990701 99999999 

D3425 APICOECTOMY/PERIRADICULAR SURGERY-MOLAR (FIRST ROOT). $416.00 19990701 99999999 



D4210 GINGIVECTOMY OR GINGIVOPLASTY PER QUADRANT $187.20 19990701 99999999 

D4211 GINGIVECTOMY OR GINGIVOPLASTY PER TOOTH $20.68 19990701 99999999 

D4240 GINGIVAL FLAP PROC, INCL ROOT PLANING PER QUADRANT $49.92 19990701 99999999 

D4260 OSSEOUS SURGERY (INCL FLAP ENTRY & CLOSURE) PER QUADRANT $450.00 19990701 99999999 

D4261 

OSSEOUS GRAFT/SINGLE SITE (INCL FLAP ENTRY,CLOSURE,AND 

DONOR $250.00 19990701 99999999 

D4341 PERIODONTAL SCALING & ROOT PLANING-PER QUADRANT $90.00 19990701 99999999 

D4342 

PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH, 

PER QUADRANT $48.00 20030101 99999999 

D5110 COMPLETE UPPER $520.00 19990701 99999999 

D5120 COMPLETE LOWER $520.00 19990701 99999999 

D5130 IMMEDIATE UPPER $416.00 19990701 99999999 

D5140 IMMEDIATE LOWER $416.00 19990701 99999999 

D5211 

UPPER PARTIAL-ACRYLIC BASE (INC ANY CONVENTIONAL 

CLASPS/REST $416.00 19990701 99999999 

D5212 

LOWER PARTIAL-ACRYLIC BASE (INC ANY CONVENTIONAL 

CLASPS/REST $416.00 19990701 99999999 

D5213 

UPPER PARTIAL-PREDOMINANTLY BASE CAST BASE W/ACRYLIC 

SADDLES $520.00 19990701 99999999 

D5214 

LOWER PARTIAL-PREDOMINANTLY BASE CAST BASE W/ACRYLIC 

SADDLES $520.00 19990701 99999999 

D5410 ADJUST COMPLETE DENTURE UPPER $41.81 19990701 99999999 

D5411 ADJUST COMPLETE DENTURE LOWER $37.44 19990701 99999999 

D5421 ADJUST PARTIAL DENTURE-UPPER $28.08 19990701 99999999 

D5422 ADJUST PARTIAL DENTURE-LOWER $26.21 19990701 99999999 

D5510 REPAIR BROKEN COMPLETE DENTURE BASE $43.68 19990701 99999999 

D5520 

REPLACE MISSING OR BROKEN TEETH-CMPLT DENTURE(EACH 

TOOTH) $49.92 19990701 99999999 

D5610 REPAIR ACRYLIC SADDLE OR BASE $45.43 19990701 99999999 

D5620 REPAIR CAST FRAMEWORK $49.92 19990701 99999999 

D5630 REPAIR OR REPLACE BROKEN CLASP $49.92 19990701 99999999 

D5640 REPLACE BROKEN TEETH-PER TOOTH $43.68 19990701 99999999 

D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $72.80 19990701 99999999 

D5660 

ADD CLASP TO EXISTING PARTIAL DENTURE TOOTH,INVOLVING 

CLASP $42.01 19990701 99999999 

D5710 REBASE COMPLETE UPPER DENTURE $135.20 19990701 99999999 

D5711 REBASE COMPLETE LOWER DENTURE $135.20 19990701 99999999 

D5720 REBASE UPPER PARTIAL DENTURE $90.95 19990701 99999999 

D5721 REBASE LOWER PARTIAL DENTURE $90.95 19990701 99999999 

D5730 RELINE UPPER COMPLETE DENTURE (CHAIRSIDE) $78.00 19990701 99999999 

D5731 RELINE LOWER COMPLETE DENTURE (CHAIRSIDE) $78.00 19990701 99999999 

D5740 RELINE UPPER PARTIAL DENTURE (CHAIRSIDE) $78.00 19990701 99999999 

D5741 RELINE LOWER PARTIAL DENTURE (CHAIRSIDE) $87.36 19990701 99999999 

D5750 RELINE UPPER COMPLETE DENTURE (LAB) $140.40 19990701 99999999 

D5751 RELINE LOWER COMPLETE DENTURE (LAB) $145.60 19990701 99999999 

D5760 RELINE UPPER PARTIAL DENTURE (LAB) $116.48 19990701 99999999 

D5761 RELINE LOWER PARTIAL DENTURE (LAB) $121.68 19990701 99999999 

D5810 TEMPORARY COMPLETE DENTURE (UPPER) $104.00 19990701 99999999 

D5811 TEMPORARY COMPLETE DENTURE (LOWER) $104.00 19990701 99999999 

D5820 TEMPORARY PARTIAL-STAYPLATE DENTURE (UPPER) $160.16 19990701 99999999 

D5821 TEMPORARY PARTIAL-STAYPLATE DENTURE (LOWER) $160.16 19990701 99999999 

D5850 TISSUE CONDITIONING -PER DENTURE UNIT $40.77 19990701 99999999 

D7210 

SURG REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF 

MUCOPER $145.60 19990701 99999999 

D7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $167.44 19990701 99999999 

D7230 REMOVAL OF IMPACTED TOOTH-PARTIALLY BODY $245.44 19990701 99999999 

D7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $302.64 19990701 99999999 



D7241 

REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY,W/UNUSUAL 

SURG $302.64 19990701 99999999 

D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS(CUTTING PROC) $99.84 19990701 99999999 

D7260 OROANTRAL FISTULA CLOSURE $99.84 19990701 99999999 

D7270 TOOTH RE-IMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY $98.80 19990701 99999999 

D7272 TOOTH TRANSPLANTATION $98.80 19990701 99999999 

D7280 

SURG EXPOSURE IMPACTED OR UNERUPTED TOOTH FOR 

ORTHODONTIC $78.00 20050102 99999999 

D7281 

SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TOOTH TO AID 

ERUP $78.00 19990701 99999999 

D7283 

PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED 

TOOTH $78.00 20050102 99999999 

D7285 BIOPSY OF ORAL TISSUE-HARD $78.00 19990701 99999999 

D7286 BIOPSY OF ORAL TISSUE -SOFT $78.00 19990701 99999999 

D7310 ALVEOLOPLASTY IN CONJUNCTION W/EXTRACTIONS-PER QUADRANT $93.60 19990701 99999999 

D7311 

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO 

THREE TEETH OR TOOTH $36.40 20050101 99999999 

D7320 

ALVEOLOPLASTY NOT IN CONJUNCTION W/EXTRACTIONS -PER 

QUADRANT $78.00 19990701 99999999 

D7321 

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO 

THREE TEETH OR TOOTH $31.20 20050101 99999999 

D7410 RADICAL EXCISION LESION DIAMETER UP TO 1.25 CM $104.00 19990701 99999999 

D7411 EXCISION OF BENIGN LESION GREATER THAN 1.25 CM $104.00 20030401 99999999 

D7413 EXCISION OF MALIGNANT LESION UP TO 1.25 CM $208.00 20030401 99999999 

D7414 EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM $260.00 20030401 99999999 

D7420 RADICAL EXCISION LESION DIAMETER OVER 1.25 CM $104.00 19990701 99999999 

D7430 EXCISION OF BENIGN TUMOR-LESION DIAMETER UP TO 1.25CM $130.00 19990701 99999999 

D7431 EXCISION OF BENIGN TUMOR-LESION DIAMETER OVER 1.25 CM $104.00 19990701 99999999 

D7440 EXCISION OF MALIGNANT TUMOR-LESION DIAMETER UP TO 1.25 CM $208.00 19990701 99999999 

D7441 EXCISION OF MALIGNANT TUMOR-LESION DIAMETER OVER 1.25 CM $260.00 19990701 99999999 

D7450 

REMOVAL OF ODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP 

TO $104.00 19990701 99999999 

D7451 

REMOVAL OF ODONTOGENIC CYST OR TUMOR-LESION DIAMETER 

1.25CM $104.00 19990701 99999999 

D7460 REMOVAL OF NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER $104.00 19990701 99999999 

D7461 

REMOVAL NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER 

OVER1.2 $130.00 19990701 99999999 

D7465 

DESTRUCTION OF LESION(S) BY PHYSICAL 

METHODS,ELECTROSURGERY $78.00 19990701 99999999 

D7471 REMOVAL OF EXOSTOSIS - PER SITE $78.00 20000101 99999999 

D7480 PARTIAL OSTECTOMY (GUTTERING OR SAUCERIZATION) $78.00 19990701 99999999 

D7510 INCISION & DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE $62.40 19990701 99999999 

D7511 

INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE - 

COMPLICATED $62.40 20050101 99999999 

D7520 INCISION & DRAINAGE OF ABCESS-EXTRAORAL SOFT TISSUE $55.33 19990701 99999999 

D7521 

INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE - 

COMPLICATED $525.90 20050101 99999999 

D7530 

REMOVAL OF FOREIGN BODY,SKIN,OR SUBCUTANEOUS AREOLAR 

TISSUE $31.20 19990701 99999999 

D7540 

REMOVAL OF REACTION PRODUCING FOREIGN 

BODIES,MUSCULOSKELETAL $208.00 19990701 99999999 

D7550 SEQUESTRECTOMY FOR OSTEOMYELITIS $182.00 19990701 99999999 

D7560 

MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR 

FOREIG $260.00 19990701 99999999 

D7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM $119.60 19990701 99999999 



D7911 SUTURE - UP TO 5 CM $182.00 19990701 99999999 

D7912 SUTURE - OVER 5 CM $208.00 19990701 99999999 

D7960 

FRENULECTOMY (FRENECTOMY OR FRENOTOMY) - SEPARATE 

PROCEDURE $75.00 19990701 99999999 

D7970 EXCISION OF HYPERPLASTIC TISSUE - PER ARCH $208.00 19990701 99999999 

D7971 EXCISION OF PERICORONAL GINGIVA $32.03 19990701 99999999 

D9110 PALLIATIVE (ER) TREATMENT OD DENTAL PAIN-MINOR PROCEDURES $59.28 19990701 99999999 

D9230 ANALGESIA $55.99 19990701 99999999 

D9241 INTRAVENOUS SEDATION/ANALGESIA - FIRST 30 MINUTES $208.00 20000101 99999999 

D9242 INTRAVENOUS SEDATION/ANALGESIA - EACH ADDITIONAL 15 MINUTES $52.00 20000101 99999999 

D9310 CONSULTATION PER SESSION $66.56 20011001 99999999 

D9440 OFFICE VISIT-AFTER REGULARLY SCHEDULED HOURS $60.00 19990701 99999999 

E0100 CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, $13.52 20030401 99999999 

E0105 

CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL 

MATERIALS, $50.04 20030401 99999999 

E0110 

CRUTCHES,FOREARM INC VARIOUS MATERIALS,ADJ OR FIXED PAIR 

CMP $84.01 20030401 99999999 

E0111 

CRUTCH FOREARM;INC VARIOUS MATERIALS,ADJ OR FIXED, 

TIP&HANDG $54.51 20030401 99999999 

E0112 

CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH 

PADS, $38.04 20030401 99999999 

E0113 

CRUTCH UNDERARM,WOOD,ADJ/FIXED, EACH, W/PAD, TIP OR 

HANDGRIP $39.13 20030401 99999999 

E0114 

CRUTCHES UNDERARM,ALUMINUM,ADJ OR 

FIXED,PAIR,W/PADS,TIPS,HAN $48.52 20030401 99999999 

E0116 CRUTCH UNDERARM,ALUMINUM,ADJ OR FIXED,W/PAD,TIP,HANDGRIP $24.25 20030401 99999999 

E0117 CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH $19.27 20071101 99999999 

E0130 WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT $82.90 20030401 99999999 

E0135 WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT $101.63 20030401 99999999 

E0140 

WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, 

ANY TYPE $36.08 20071101 99999999 

E0141 WALKER WHEELED, WITHOUT SEAT $127.71 20030401 99999999 

E0142 RIGID WALKER,WHEELED,/SEAT $128.54 20030401 99999999 

E0143 FOLDING WALKER,WHEELED,W/O SEAT $120.91 20030401 99999999 

E0144 

ENCLOSED, FRAMED FOLDING WALKER, WHEELED, WITH POSTERIOR 

SEAT $11.99 20071101 99999999 

E0145 WALKER,WHEELED,W/SEAT AND CRUTCH ATTACHMENTS $395.20 20030401 99999999 

E0146 WALKER/WHEELED/WITH SEAT $329.68 20030401 99999999 

E0147 

HEAVY DUTY/MULT BREAKING SYST/VARIABLE WHEEL RESIST 

WALKER $57.48 20071101 99999999 

E0148 

WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY 

TYPE, EACH $127.05 20030401 99999999 

E0149 

WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE, 

EACH $223.20 20030401 99999999 

E0153 PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH $8.87 20071101 99999999 

E0154 PLATFORM ATTACHMENT/WALKER/EACH $10.39 20071101 99999999 

E0155 WHEEL ATTACHMENT,RIGID PICK-UP WALKER $3.11 20071101 99999999 

E0156 SEAT ATTACHMENT/WALKER $3.12 20071101 99999999 

E0157 CRUTCH ATTACHMENT/WALKER/EACH $6.78 20071101 99999999 

E0158 LEG EXTENSIONS FOR A WALKER $3.83 20071101 99999999 

E0159 BRAKE ATTACHMENT FOR WHEELED WALKER $1.93 20071101 99999999 

E0160 SITZ TYPE BATH, PORTABLE, FITS OVER COMMODE SEAT $7.39 20071101 99999999 

E0161 

SITZ TYPE BATH/PORT/FITS OVER COMMODE SEAT/W FAUCET 

ATTACHME $1.89 20071101 99999999 

E0162 SITZ BATH CHAIR $9.95 20071101 99999999 

E0163 COMMODE CHAIR,STATIONARY,WITH FIXED ARMS $9.36 20071101 99999999 



E0164 COMMODE CHAIR,MOBILE,WITH FIXED ARMS $93.60 20030401 99999999 

E0165 COMMODE CHAIR,STATIONARY,W DETACHABLE ARMS $9.36 20071101 99999999 

E0167 PAIL OR PAN FOR USE W/COMMODE CHAIRS $13.01 20030401 99999999 

E0168 

COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY 

OR MOBILE, WITH OR WITHO $15.09 20071101 99999999 

E0170 

COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, 

ELECTRIC, ANY TYPE $188.04 20071101 99999999 

E0171 

COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON- 

ELECTRIC, ANY TYPE $34.70 20071101 99999999 

E0175 FOOT REST FOR USE WITH COMMODE CHAIR, EACH $5.81 20071101 99999999 

E0176 AIR PRESSURE PAD OR CUSHION, NONPOSITIONING $155.19 20030401 99999999 

E0177 WATER PRESSURE PAD OR CUSHION,NONPOSITIONING $155.19 20030401 99999999 

E0178 FOOT REST FOR USE W/COMMODE CHAIR EACH $155.19 20030401 99999999 

E0179 DRY PRESSURE PAD OR CUSHION, NONPOSITIONING (EGGCRATE) $52.95 20030401 99999999 

E0180 PRESSURE PAD, ALTERNATING WITH PUMP $312.00 20030401 99999999 

E0181 PRESSURE PAD,ALTERNATING W/PUMP,HEAVY DUTY $33.28 20071101 99999999 

E0182 PUMP FOR ALTERNATION PRESSURE PAD $30.12 20071101 99999999 

E0184 FLOTATION MATTRESS,DRY $10.87 20071101 99999999 

E0185 

DECUBITUS CARE PAD,FLOATATION OR GEL PAD,W/FORAM LEVEL 

PAD $36.18 20071101 99999999 

E0186 AIR $41.43 20071101 99999999 

E0187 WATER $41.43 20071101 99999999 

E0188 SYNTHETIC SHEEPSKIN PAD $3.10 20071101 99999999 

E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE $10.81 20071101 99999999 

E0191 HEEL OR ELBOW PROTECTOR EACH $0.93 20071101 99999999 

E0192 

LOW PRESSURE AND POSITIONING EQUALIZATION PAD FOR 

WHEELCHAIR $421.03 20030401 99999999 

E0194 AIR FLUIDIZED BED $3,410.32 19910101 99999999 

E0196 GEL $41.43 20071101 99999999 

E0197 AIR PRESSURE PAD FOR MATTRESS $36.18 20071101 99999999 

E0198 WATER PRESSURE PAD FOR MATTRESS $36.18 20071101 99999999 

E0199 DRY PRESSURE PAD FOR MATTRESS $8.09 20071101 99999999 

E0200 HEAT LAMP,W/O STAND INCL BULB,OR INFRARED ELEMENT $10.70 20071101 99999999 

E0202 PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETER $56.14 20071101 99999999 

E0205 HEAT LAMP,W/STAND,INCL BULB,OR INFRARED ELEMENT $125.06 20071101 99999999 

E0210 ELECTRIC HEAT PAD, STANDARD $89.64 20071101 99999999 

E0215 ELECTRIC HEAT PAD, MOIST $86.80 20071101 99999999 

E0217 WATER CIRCULATING HEAT PAD WITH PUMP $647.82 20030401 99999999 

E0218 WATER CIRCULATING COLD PAD WITH PUMP $50.00 20071101 99999999 

E0220 HOT WATER BOTTLE $9.13 20071101 99999999 

E0221 INFRARED HEATING PAD SYSTEM $2,113.46 20030401 99999999 

E0225 HYDROCOLLATOR UNIT, INCLUDES PADS $39.66 20071101 99999999 

E0230 ICE CAP OR COLLAR $8.26 20071101 99999999 

E0235 

PARAFFIN BATH UNIT,PORTABLE(SEE MED SUPPLY CODE A4265 FOR 

PA $52.75 20071101 99999999 

E0236 PUMP FOR WATER CIRCULATING PAD $92.62 20071101 99999999 

E0238 NON ELECTRIC HEAT PAD MOIST $7.85 20071101 99999999 

E0239 HYDROCOLLATOR UNIT/PORTABLE $1,692.56 20030401 99999999 

E0240 BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE $10.40 20071101 99999999 

E0241 BATH TUB WALL RAIL, EACH $2.60 20071101 99999999 

E0242 BATH TUB RAIL,FLOOR BASE $4.16 20071101 99999999 

E0243 TOILET RAIL,EACH $5.41 20071101 99999999 

E0244 RAISED TOILET SEAT $5.20 20071101 99999999 

E0245 TUB STOOL OR BENCH $10.40 20071101 99999999 

E0246 TRANSFER TUB RAIL ATTACHMENT $9.36 20071101 99999999 

E0247 

TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE 

OPENING $11.00 20071101 99999999 



E0248 

TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR 

WITHOUT COMMODE OPENING $15.00 20071101 99999999 

E0249 PAD FOR WATER CIRCULATING HEAT UNIT $15.37 20071101 99999999 

E0250 HOSPITAL BED, WITH SIDE RAILS, FIXED HEIGHT, WITH MATTRESS $94.30 20071101 99999999 

E0251 HOSP BED,W/SIDE RAILS,FIXED HGT,W/O MATTRESS $84.70 20071101 99999999 

E0255 HOSPITAL BED, WITH SIDE RAILS VARIABLE HEIGHT, HI-LO, WITH $111.42 20071101 99999999 

E0256 

HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, 

WITHOUT MATTRESS $73.62 20071101 99999999 

E0260 

HOSP BED W/SIDE RAILS,SEMI ELECT, HEAD & FOOT 

ADJ,W/MATTRESS $213.72 20071101 99999999 

E0261 

HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), 

WITH ANY TYPE SIDE RAILS $187.72 20071101 99999999 

E0265 HOSPITAL BED, TOTAL ELECTRIC WITH SIDERAILS (HEAD, FOOT AND $2,365.00 20030401 99999999 

E0271 MATTRESS, INNERSPRING $20.62 20071101 99999999 

E0272 MATTRESS,FOAM RUBBER $22.69 20071101 99999999 

E0274 OVER-BED TABLE $194.48 20030401 99999999 

E0275 BED PAN, STANDARD, METAL OR PLASTIC $18.61 20030401 99999999 

E0276 BED PAN, FRACTURE, METAL OR PLASTIC $17.02 20030401 99999999 

E0277 ALTERNATING PRESSURE MATTRESS $703.50 20071101 99999999 

E0280 BED CRADLE,ANY TYPE $4.42 20071101 99999999 

E0290 

HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH 

MATTRESS $94.30 20071101 99999999 

E0291 

HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT 

MATTRESS $84.70 20071101 99999999 

E0292 

HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH 

MATTRESS $111.42 20071101 99999999 

E0293 

HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, 

WITHOUT MATTRESS $73.26 20071101 99999999 

E0294 

HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), 

WITHOUT SIDE RAILS, WITH $210.69 20071101 99999999 

E0295 

HOSPITAL BED,SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), 

WITHOUT SIDE RAILS, WITHO $187.72 20071101 99999999 

E0300 PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED $283.86 20071101 99999999 

E0301 

HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY 

GREATER THAN 350 POUN $380.10 20071101 99999999 

E0302 

HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT 

CAPACITY GREATER THAN 60 $1,000.00 20071101 99999999 

E0303 

HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY 

GREATER THAN 350 POUN $286.65 20071101 99999999 

E0304 

HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT 

CAPACITY GREATER THAN 60 $1,155.00 20071101 99999999 

E0305 BED SIDE RAILS, HALF LENGTH $22.67 20071101 99999999 

E0310 BED SIDE RAILS,FULL LENGTH $20.57 20071101 99999999 

E0315 BED ACCESSORIES;BOARDS OR TABLES,ANY TYPE $76.00 20040501 99999999 

E0316 

SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, 

ANY TYPE $190.46 20071101 99999999 

E0325 URINAL, MALE, ANY MATERIAL $9.06 20030401 99999999 

E0326 URINAL, FEMALE, ANY MATERIAL $17.40 20030401 99999999 

E0371 

NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR 

MATTRESS, STANDARD MATTRESS LE $451.75 20071101 99999999 

E0372 

POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS 

LENGTH AND WIDTH $548.13 20071101 99999999 

E0373 NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS $581.41 20071101 99999999 

E0424 

STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; 

INCLUDES CONTENTS (PER UNIT $200.39 20050101 99999999 

E0431 

PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES 

REGULATOR, FLOWMETER, HUMIDIFIE $34.34 20060401 99999999 



E0434 

PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE 

CONTAINER, SUPPLY RESER $32.08 20050101 99999999 

E0439 

STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES USE OF 

RESERVOIR, CONTENTS (PE $200.39 20050101 99999999 

E0440 

OXYGEN SYSTEM, LIQUID, STATIONARY, INCLUDES USE OF 

RESERVOIR, $329.68 20030401 99999999 

E0441 

OXYGEN CONTENTS, GASEOUS, PER UNIT (FOR USE WITH OWNED 

GASEOUS STATIONARY SYSTEM $198.12 20060701 99999999 

E0442 

OXYGEN CONTENTS, LIQUID, PER UNIT (FOR USE WITH OWNED 

LIQUID STATIONARY SYSTEMS $198.12 20060701 99999999 

E0443 

PORTABLE OXYGEN CONTENTS, GASEOUS, PER UNIT (FOR USE ONLY 

WITH PORTABLE GASEOUS $44.36 20060701 99999999 

E0444 

PORTABLE OXYGEN CONTENTS, LIQUID, PER UNIT (FOR USE ONLY 

WITH PORTABLE LIQUID SY $44.36 20060701 99999999 

E0445 OXYGEN TENT; EXC CROUP OR PEDIATRIC TENTS $320.00 19990701 99999999 

E0452 

INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY 

PRESSURE DEVICE (CPAP $1,456.00 20030401 99999999 

E0454 

PRESSURE VENTILATOR WITH PRESSURE CONTROL, PRESSURE 

SUPPORT AND FLOW TRIGGERING $1,400.14 20030101 99999999 

E0455 OXYGEN TENT,EXCL CROUP OR PEDIATRIC TENTS $20.00 20071101 99999999 

E0457 CHEST SHELL(CUIRASS) $614.51 20030401 99999999 

E0459 CHEST WRAP $93.68 20071101 99999999 

E0460 NEGATIVE PRESSURE VENTILATOR;PORTABLE(EG.PORTA-LUNG) $704.83 20071101 99999999 

E0470 

RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, 

WITHOUT BACKUP RATE FEA $2,660.50 20040101 99999999 

E0471 


WITH BACK-UP RATE FEATU $253.77 20040101 99999999 

E0472 


WITH BACKUP RATE FEATUR $673.77 20040101 99999999 

E0483 

HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE 

GENERATOR SYSTEM, (INCLUDES HOSE $1,063.13 20030101 99999999 

E0484 

OSCILLATORY POSITIVE EXPIRATORY PRESSURE DEVICE, NON- 

ELECTRIC, ANY TYPE, EACH $36.92 20030401 99999999 

E0485 

ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY 

COLLAPSIBILITY, ADJUSTABLE OR $5.00 20071101 99999999 

E0486 

ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY 

COLLAPSIBILITY, ADJUSTABLE OR $5.00 20071101 99999999 

E0500 

IPPB W/MANUAL VALVES EXT POWER SOURCE,INCL CYLINDER 

REG,NEBU $1,134.64 20030401 99999999 

E0550 

HUMIDIFIER,DURABLE FOR EXT SUPPLEMENTAL HUMIDIFICATION 

W/IPP $143.52 20030401 99999999 

E0555 HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE $5.00 19990701 99999999 

E0560 HUMIDIFIER, DURABLE FOR SUPPLEMENTAL HUMIDIFICATION DURING $129.17 20030401 99999999 

E0561 

HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE 

DEVICE $10.32 20040101 99999999 

E0562 

HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE 

DEVICE $28.72 20040101 99999999 

E0565 

COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT 

SELF- $75.90 20071101 99999999 

E0570 NEBULIZER, WITH COMPRESSOR E.G., DEVILBISS PULMO-AID $13.00 20071101 99999999 

E0571 

AEROSOL COMPRESSOR, BATTERY POWERED, FOR USE WITH SMALL 


E0572 

AEROSOL COMPRESSOR, ADJUSTABLE PRESSURE, LIGHT DUTY FOR 

INTERMITTENT USE $36.03 20071101 99999999 

E0574 

ULTRASONIC GENERATOR WITH SMALL VOLUME ULTRASONIC 

NEBULIZER $38.09 20071101 99999999 

E0575 NEBULIZER, SELF-CONTAINED, ULTRASONIC $13.00 20071101 99999999 



E0580 

NEBULIZER,DURABLE,GLASS OR AUTOCLAVABLE,BOTTLE TYPE,FOR 

USE $134.04 20030401 99999999 

E0585 NEBULIZER,W/COMPRESSOR AND HEATER $57.96 20071101 99999999 

E0600 SUCTION PUMP, HOME MODEL, PORTABLE $44.79 20071101 99999999 

E0601 NASAL CONTINUOUS AIRWAY PRESSURE(CPAP)DEVICE $1,182.48 20030401 99999999 

E0602 BREAST PUMP, ALL TYPES $29.52 20030401 99999999 

E0605 VAPORIZER, ROOM TYPE $75.56 20030401 99999999 

E0606 POSTURAL DRAINAGE BOARD $228.80 20030401 99999999 

E0607 HOME BLOOD GLUCOSE MONITOR $73.51 20030401 99999999 

E0608 APNEA MONITOR $239.20 20030401 99999999 

E0609 

BLOOD GLUCOSE MONITOR W/SPECIAL FEATURES(EG.VOICE SYNTH 

ECT) $504.96 20030401 99999999 

E0610 

PACEMAKER MONITOR,SELF CONT,(CHECKS BATTERY 

DEPLETION,INCL $499.30 20030401 99999999 

E0615 

PACEMAKER MONITOR,SELF CHECKS BATTERY DELPETION AND 

OTHER $486.71 20030401 99999999 

E0616 

IMPLANTABLE CARDIAC EVENT RECORDER WITH MEMORY, 

ACTIVATOR AND PROGRAMMER $500.00 20071101 99999999 

E0617 

EXTERNAL DEFIBRILLATOR WITH INTEGRATED 

ELECTROCARDIOGRAM ANALYSIS $304.05 20071101 99999999 

E0618 APNEA MONITOR, WITHOUT RECORDING FEATURE $85.00 20030401 99999999 

E0620 

SEAT LIFT CHAIR, MOTORIZED TO ASSIST PATIENT IN STANDING AND 

SITTING $0.05 20071101 99999999 

E0621 SLING OR SEAT, PATIENT LIFT, CANVAS OR NYLON $97.00 20071101 99999999 

E0625 PATIENT LIFT,KARTOP,BATHROOM OR TOILET $100.00 20071101 99999999 

E0627 

SEAT LIFT MECHANISM INCORPORATED INTO A COMBINATION LIFT- 

CHAIR MECHANISM $357.15 20071101 99999999 

E0628 

SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED 

FURNITURE-ELECTRIC $357.15 20071101 99999999 

E0629 

SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED 

FURNITURE-NON-ELECTRIC $357.15 20071101 99999999 

E0630 PATIENT LIFT,HYDRAULIC, W/SEAT OR SLING $1,303.12 20030401 99999999 

E0635 PATIENT LIFT,ELECTRIC W/SEAT OR SLING $142.55 20071101 99999999 

E0636 

MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED 

LIFT, PATIENT ACCESSIBLE $1,054.56 20071101 99999999 

E0650 PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL, $107.55 20071101 99999999 

E0651 

PNEUMATIC COMPRESSOR,SEGMENTAL HOME MODEL W/O 

CALIBRATED GRA $666.57 20030401 99999999 

E0652 

PNEUMATIC COMPRESSOR SEGMENTAL HOME MODEL W/CALIBRATED 

GRADI $6,600.54 20030401 99999999 

E0655 

PNEUMATIC APPLIANCE FOR USE W/PNEUMATIC COMPRESSOR HALF 

ARM $96.95 20030401 99999999 

E0660 

PNEUMATIC APPLIANCE FOR USE W/PNEUMATIC COMPRESSOR,FULL 

LEG $119.16 20030401 99999999 

E0665 

PNEUMATIC APPLIANCE FOR USE W PNEUMATIC COMPRESSOR,FULL 

ARM $111.44 20030401 99999999 

E0666 

PNEUMATIC APPLIANCE FOR USE W/PNEUMATIC COMPRESSOR,HALF 

LEG $94.79 20030401 99999999 

E0667 

PNEUMATIC APPLIANCE FOR USE W/SEGMENTAL PNEUMATIC 

COMPRESSOR $553.95 20030401 99999999 

E0668 

PNEUMATIC APPLIANCE FOR USE W/SEGMENTAL PNEUMATIC 

COMPRESSOR $474.25 20030401 99999999 

E0669 

SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC 

COMPRESSOR, HALF LEG $198.00 20030401 99999999 

E0671 SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG $448.57 20030401 99999999 

SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL 

E0672 ARM $348.56 20030401 99999999 



E0673 

SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF 

LEG $289.61 20030401 99999999 

E0690 ULTRAVIOLET CABINET,APPROPRIATE FOR HOME USE $2,021.35 20030401 99999999 

E0691 

ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES 

BULBS/LAMPS, TIMER AND EYE PROT $898.59 20030401 99999999 

E0692 


BULBS/LAMPS, TIMER AND EYE PROT $1,128.37 20030401 99999999 

E0693 


BULBS/LAMPS, TIMER AND EYE PROT $1,390.98 20030401 99999999 

E0694 

ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT 

CABINET, INCLUDES BU $4,427.34 20030401 99999999 

E0700 SAFETY EQUIPMENT(EG.BELT,HARNESS OR VEST) $48.10 20071101 99999999 

E0701 

HELMET WITH FACE GUARD AND SOFT INTERFACE MATERIAL, 

PREFABRICATED $153.35 20030401 99999999 

E0705 TRANSFER BOARD OR DEVICE, ANY TYPE, EACH $55.64 20071101 99999999 

E0710 RESTRAINTS, ANY TYPE (BODY, CHEST, WRIST OR ANKLE) $18.39 20071101 99999999 

E0720 TENS,TWO LEAD,LOCALIZED STIMULATION $487.78 20030401 99999999 

E0730 TENS, FOUR LEAD, LARGER AREA/MULTIPLE NERVE STIMULATION $532.82 20030401 99999999 

E0731 FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS $594.69 19990701 99999999 

E0740 REPLACEMENT BATTERY FOR TENS $522.87 20030401 99999999 

E0747 OSTEOGENESIS STIMULATOR/_(NON-INVASIVE) $243.07 20071101 99999999 

E0748 OSTEOGENIC STIMULATOR, NONINVASIVE, SPINAL APPLICATIONS $243.07 20071101 99999999 

E0749 OSTEOGENESIS STIMULATOR (SURGICALLY IMPLANTED) $235.36 20071101 99999999 

E0755 

ELECTRONIC SALIVARY REFLEX STIMULATION (INTRA-ORAL/NON- 

INVAS $100.00 20071101 99999999 

E0760 

OSTOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON- 

INVASIVE $2,912.05 20030401 99999999 

E0761 

NON-THERMAL PULSED HIGH FREQUENCY RADIOWAVES, HIGH PEAK 

POWER ELECTROMAGNETIC EN $100.00 20071101 99999999 

E0764 

FUNCTIONAL NEUROMUSCULAR STIMULATOR, TRANSCUTANEOUS 

STIMULATION OF MUSCLES OF AM $1,077.58 20060101 99999999 

E0765 

FDA APPROVED NERVE STIMULATOR, WITH REPLACEABLE 

BATTERIES, FOR TREATMENT OF NAUS $84.13 20030401 99999999 

E0769 

ELECTRICAL STIMULATION OR ELECTROMAGNETIC WOUND 

TREATMENT DEVICE, NOT OTHERWISE $84.13 20071101 99999999 

E0776 IV POLE $15.60 20071101 99999999 

E0779 

AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR 

INFUSION 8 HOURS OR GREATER $18.42 20071101 99999999 

E0780 

AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR 

INFUSION LESS THAN 8 HOURS $10.68 20071101 99999999 

E0830 AMBULATORY TRACTION DEVICE, ALL TYPES, EACH $5.00 20071101 99999999 

E0840 

TRACTION FRAME,ATTACHED TO HEADBOARD,SIMPLE CERVICAL 

TRACTIO $6.44 20071101 99999999 

E0849 

TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, 

PNEUMATIC, APPLYING $51.53 20071101 99999999 

E0850 TRACTION STAND,FREE STANDING,SIMPLE CERVICAL TRACTION $6.44 20071101 99999999 

E0855 

CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL 

STAND OR FRAME $53.38 20071101 99999999 

E0860 TRACTION EQUIPMENT, OVERDOOR, CERVICAL $4.69 20071101 99999999 

E0870 TRACTION FRAME ATT TO FOOTBOARD,SIMPLE EXTREMITY TRACTION $8.92 20071101 99999999 

E0880 TRACTION STAND;FREE STANDING,SIMPLE EXTREMITY TRACTION $9.57 20071101 99999999 

E0890 TRACTION FRAME, ATTACHED TO FOOTBOARD, SIMPLE PELVIC TRAC- $9.60 20071101 99999999 

E0900 

TRACTION STAND, FREE STANDING, SIMPLE PELVIC TRACTION, (E.G., 

BUCK'S) $16.42 20071101 99999999 

E0910 

TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH 

GRAB $19.04 20071101 99999999 



E0911 

TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY 

GREATER THAN 250 POUNDS, AT $49.85 20071101 99999999 

E0912 

TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY 

GREATER THAN 250 POUNDS, FR $114.47 20071101 99999999 

E0920 FRACTURE FRAME,ATTACHED TO BED,INCL WEIGHTS $6.44 20071101 99999999 

E0930 FRACTURE FRAME,FREE STANDING,INCLUDES WEIGHTS $13.52 20071101 99999999 

E0935 PASSIVE MOTION EXERCISE DEVICE $2.15 20071101 99999999 

E0940 TRAPEZE BAR,FREE STANDING, COMPLETE W/GRAB BAR $36.59 20071101 99999999 

E0941 GRAVITY ASSISTED TRACTION DEVICE ANY TYPE $66.29 20071101 99999999 

E0942 CERVICAL HEAD HARNESS/HALTER $2.75 20071101 99999999 

E0943 CERVICAL PILLOW $14.19 20030401 99999999 

E0944 PELVIC BELT/HARNESS/BOOT $3.57 20071101 99999999 

E0945 EXTREMITY BELT/HARNESS $4.79 20071101 99999999 

E0946 FRACTURE FRAME DUAL W/CROSS BARS,ATTACHED TO BED $497.12 20030401 99999999 

E0947 FRACTURE FRAME,ATTACHEMENTS FOR COMPLEX PELVIC TRACTION $479.17 20030401 99999999 

E0948 

FRACTURE FRAME,ATTACHMENTS FOR COMPLEX CERVICAL 

TRACTION $469.39 20030401 99999999 

E0950 TRAY $89.58 20040101 99999999 

E0951 LOOP HEEL EACH $22.34 19990701 99999999 

E0952 LOOP TOE EACH $4.11 20071101 99999999 

E0955 

WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, 

PREFABRICATED, INCLUDING FIXED MOUNTI $20.22 20071101 99999999 

E0956 

WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, 

PREFABRICATED, INCLUDING FIX $9.85 20071101 99999999 

E0957 

WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, 

PREFABRICATED, INCLUDING FIXED MOUNT $13.79 20071101 99999999 

E0958 

WHEELCHAIR ATTACHMENT TO CONVERT ANY WHEELCHAIR TO 1 

ARM DR $43.54 20071101 99999999 

E0959 

AMPUTEE ADAPTER(DEVICE USED TO COMPENSATE FOR TRANSFER 

OF $5.48 20071101 99999999 

E0960 

WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST 

STRAP, INCLUDING ANY TYPE $9.10 20071101 99999999 

E0961 BRAKE EXTENSION FOR WHEELCHAIR $2.14 20071101 99999999 

E0962 1" CUSHION ,FOR WHEELCHAIR $52.05 20030401 99999999 

E0963 2" CUSHION,FOR WHEELCHAIR $78.35 20030401 99999999 

E0964 3" CUSHION , FOR WHEELCHAIR $86.18 20030401 99999999 

E0965 4" CUSHION FOR WHEELCHAIR $97.96 20030401 99999999 

E0966 HOOK ON HEAD REST EXTENSION $8.84 20071101 99999999 

E0967 

WHEELCHAIR HAND RIMS W/8 VERTICAL RUBBER TIPPED 

PROJECTIONS $6.46 20071101 99999999 

E0968 COMMODE SEAT,WHEELCHAIR $17.49 20071101 99999999 

E0969 NARROWING DEVICE,WHEELCHAIR $16.93 20071101 99999999 

E0971 ANTI=TIPPING DEVICE WHEELCHAIRS $4.34 20071101 99999999 

E0973 

ADJ HEIGHT DETACHABLE ARMS,DESK OR FULL 

LENGTH,WHEELCHAIR $10.95 20071101 99999999 

E0974 GRADE-AID(DEVICE TO PREVENT ROLLING BACK ON AN INCLINE) W/C $5.03 20071101 99999999 

E0977 WEDGE CUSHION,WHEELCHAIR $22.63 20030401 99999999 

E0978 BELT SAFETY W/AIRPLANE BUCKLE WHEELCHAIR $4.33 20071101 99999999 

E0980 SAFETY VEST,WHEELCHAIR $2.99 20071101 99999999 

E0981 

WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT 

ONLY, EACH $3.76 20071101 99999999 

E0982 

WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT 

ONLY, EACH $4.39 20071101 99999999 

E0983 

MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT 

MANUAL WHEELCHAIR TO MOTORI $235.68 20071101 99999999 



E0984 

MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT 

MANUAL WHEELCHAIR TO MOTORI $116.69 20071101 99999999 

E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM $18.25 20071101 99999999 

E0986 

MANUAL WHEELCHAIR ACCESSORY, PUSH-RIM ACTIVATED POWER 

ASSIST, EACH $413.47 20071101 99999999 

E0990 ELEVATING LEG REST EACH $16.71 20071101 99999999 

E0992 SOLID SEAT INSERT $6.50 20071101 99999999 

E0994 ARM REST,EACH $3.30 20071101 99999999 

E0995 CALF REST,EACH $3.15 20071101 99999999 

E0997 CASTER WITH A FORK $169.31 20030401 99999999 

E0998 CASTER WITHOUT FORK $135.78 20030401 99999999 

E0999 PNEUMATIC TIRE W WHEEL $72.50 20030401 99999999 

E1001 WHEEL SINGLE $73.28 20030401 99999999 

E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY $4,364.78 20071101 99999999 

E1003 

WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE 

ONLY, WITHOUT SHEAR REDUCTIO $395.21 20071101 99999999 

E1004 

WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE 

ONLY, WITH MECHANICAL SHEAR $4,438.21 20071101 99999999 

E1005 REPLACEMENT, BATTERIES FOR MEDICALLY NECESSARY ELECTRIC $4,474.33 20071101 99999999 

E1006 

WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION 

TILT AND RECLINE, WITHOU $581.01 20071101 99999999 

E1007 


TILT AND RECLINE, WITH M $786.71 20071101 99999999 

E1008 


TILT AND RECLINE, WITH P $786.78 20071101 99999999 

E1009 

WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, 

MECHANICALLY LINKED LEG $97.22 20071101 99999999 

E1010 

WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, 

POWER LEG ELEVATION SYST $102.94 20071101 99999999 

E1011 

MODIFICATION TO PEDIATRIC WHEELCHAIR, WIDTH ADJUSTMENT 

PACKAGE (NOT TO BE DISPEN $50.00 20071101 99999999 

E1014 RECLINING BACK, ADDITION TO PEDIATRIC WHEELCHAIR $32.86 20071101 99999999 

E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH $11.46 20071101 99999999 

E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH $13.14 20071101 99999999 

E1017 

HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY 

DUTY MANUAL WHEELCHAIR, $13.14 20071101 99999999 

E1018 

HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY 

DUTY POWER WHEELCHAIR, E $13.14 20071101 99999999 

E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR $24.32 20071101 99999999 

E1028 

WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR 

REMOVABLE MOUNTING HARDWA $206.54 20071101 99999999 

E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED $36.95 20071101 99999999 

E1030 ROLLABOUT CHAIR, WITHOUT ARMS $116.53 20071101 99999999 

E1031 WHLCHR,STNDRD,DETACH DESK $54.41 20071101 99999999 

E1035 GERIATRIC CHAIR $613.20 20071101 99999999 

E1037 TRANSPORT CHAIR, PEDIATRIC SIZE $97.64 20071101 99999999 

E1038 TRANSPORT CHAIR, ADULT SIZE $40.01 20071101 99999999 

E1039 

TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT 

CAPACITY 250 POUNDS OR $40.01 20071101 99999999 

E1050 

FULLY-RECLIN W/C,FIXED FULL LENGTH ARMS,SWING AWAY DET 

ELEV $182.95 20071101 99999999 

E1060 FULLY RECLIN W/C DETACH ARMS,DESK,OR FULL LENGTH ,DET LEG $119.14 20071101 99999999 

E1065 POWER ATT(TO CONVERT W/C TO MOTORIZED WHEELCHAIR) $2,922.58 20030401 99999999 

E1070 FULLY-RECLIN W/C,DET ARMS , SWING AWAY DET FOOTREST $117.06 20071101 99999999 

E1083 HEMI/ W/C FIXED FULL LENGTH ARMS,SWING AWAY DET ELEVAT LEG $96.20 20071101 99999999 

E1084 HEMI-W/C, DET ARMS DESK OR FULL LNGTH ARMS,SWING AWAY LEG $112.84 20071101 99999999 



E1085 HEMI-W/C FIXED FULL LGNTH ARMS,SWING AWAY DET FOOT RESTS $76.96 20071101 99999999 

E1086 HEMI-W/C DET ATMS DESK OR FULL,SWING AWAY DET FOOTRESTS $96.20 20071101 99999999 

E1087 

HIGH STRENGTH LTWGT W/C,FIXED FULL ARMS,SWING AWAY DET 

ELEVA $165.56 20071101 99999999 

E1088 HIGH STRENGTH LTWGT W/C,DET ARMS DESK OR FULL,DET ELEV LEG $126.88 20071101 99999999 

E1089 

HIGH STRGTH LTWGT W/C,FIXED ARMS,SWING AWAY DET 

FOOTRESTS $139.41 20071101 99999999 

E1090 

HIGH STRENGTH LTWGT W/C,DET ARMS DESK OR FULL,DRT FOOT 

RESTS $119.08 20071101 99999999 

E1092 

WIDE HEAVY DUTY W/C,DET ARMS DESK OR FULL,SWING DET ELEV 

LEG $109.95 20071101 99999999 

E1093 WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL $177.97 20071101 99999999 

E1100 SEMI-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING $135.20 20071101 99999999 

E1110 SEMI-RECLIN W/C DET ARMS,ELEVATING LEG REST $135.20 20071101 99999999 

E1130 

STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR 

SWING $57.72 20071101 99999999 

E1140 

WHEELCHAIR,DETACH ARMS,DESK/FULL LENGTH,SWING DETACH 

FOOTRES $57.72 20071101 99999999 

E1150 

W/C,DET ARMS,_DESK OR FULL SWING AWAY DET ELEVATING 

LEGRESTS $83.20 20071101 99999999 

E1160 

WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY 

DETACHABLE $74.36 20071101 99999999 

E1161 MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE $235.92 20071101 99999999 

E1170 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY $86.55 20071101 99999999 

E1171 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, $83.08 20071101 99999999 

E1172 

AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL 

LENGTH) $126.78 20071101 99999999 

E1180 


LENGTH) $116.54 20071101 99999999 

E1190 


LENGTH) $111.51 20071101 99999999 

E1195 

HEAVY DUTY W/C,FIXED OR FULL ARMS,SWING DET ELEVAT 

LEGRESTS $147.78 20071101 99999999 

E1200 AMPUTEE W/C,FIXED FULL ARMS,SWING DETACH FOOTREST $101.83 20071101 99999999 

E1211 

MOTORIZED W/C,DET ARMS DESK OR FULL SWING,DET ELEV LEG 

REST $3,844.44 20030401 99999999 

E1220 W/C;SPECIALLY SIZED OR CONSTRUCTED,AND JUSTIFICATION $268.01 20071101 99999999 

E1221 WHEELCHAIR WITH FIXED ARM, FOOTRESTS $43.16 20071101 99999999 

E1222 WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS $74.36 20071101 99999999 

E1223 WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS $70.69 20071101 99999999 

E1224 WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS $79.82 20071101 99999999 

E1225 SEMI-RECLINING BACK FOR CUSTOMIZED WHEEL CHAIR $37.36 20071101 99999999 

E1226 FULL RECLINING BACK FOR CUSTOMIZED WHEELCHAIR $73.89 20071101 99999999 

E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR $13.34 20071101 99999999 

E1228 SPECIAL BACK HEIGHT FOR WHEELCHAIR $36.40 20071101 99999999 

E1230 

POWER OPER VEHICLE(3 WHEEL NON-HIGHWAY) INDICATE BRAND 

NAME $196.46 20071101 99999999 

E1231 

WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, 

WITH SEATING SYSTE $189.20 20071101 99999999 

E1232 

WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, 

ADJUSTABLE, WITH SEATING SYS $192.45 20071101 99999999 

E1233 

WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, 

WITHOUT SEATING SY $199.41 20071101 99999999 

E1234 

WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, 

ADJUSTABLE, WITHOUT SEATING $192.89 20071101 99999999 



E1235 

WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING 

SYSTEM $167.16 20071101 99999999 

E1236 

WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH 

SEATING SYSTEM $147.48 20071101 99999999 

E1237 

WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT 


E1238 

WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT 


E1240 

LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, (DESK OR FULL 

LENGTH) $105.04 20071101 99999999 

E1250 LTWGT W/C FIXED FULL ARMS,SWING DETACH FOOTREST $63.11 20071101 99999999 

E1260 LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL $63.11 20071101 99999999 

E1270 LTWGT W/C,FIXED FULL ARMS,SWING DETACH ELEVATING LEGRESTS $63.11 20071101 99999999 

E1280 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL $148.09 20071101 99999999 

E1285 HEAVY DUTY W/C,FIXED FULL ARMS,SWING AWAY DET FOOTREST $109.92 20071101 99999999 

E1290 

HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL 

LENGTH) SWING AWAY DETACHAB $109.92 20071101 99999999 

E1295 HEAVY DUTY W/C,FIXED FULL ARMS,ELEVATING LEGREST $131.19 20071101 99999999 

E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR $49.94 20071101 99999999 

E1297 SPECIAL WHEELCHAIR SEAT DEPTH BY UPHOLSTERY $8.92 20071101 99999999 

E1298 SPECIAL W/C SEAT DEPTH AND/OR WIDTH,BY CONSTRUCTION $43.35 20071101 99999999 

E1310 WHIRLPOOL,NON-PORTABLE (BUILT IN TYPE) $231.93 20071101 99999999 

E1340 

REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL 

EQUIPMENT REQUIRING THE SKILL O $14.00 19990701 99999999 

E1350 REPAIR OR NON-ROUTINE SERVICE (E.G., BREAKING DOWN SEALED $54.08 20030401 99999999 

E1353 REGULATOR $54.08 20030401 99999999 

E1355 STAND/RACK $34.32 20030401 99999999 

E1372 IMMERSION EXTERNAL HEATER FOR NEBULIZER $139.15 20030401 99999999 

E1390 OX $251.18 20060401 99999999 

E1391 OXYGEN CONCENTRATOR, EQUIV TO 976 CU FT $200.39 20050101 99999999 

E1392 OXYGEN CONCENTRATOR EQUIV TO 1220 CUBIC FEET $32.08 20060101 99999999 

E1405 OXYGEN & WATER VAPOR ENRICHING SYST W/HEATED DELIVERY $258.35 20071101 99999999 

E1406 OXYGEN & WATER VAPOR ENRICHING SYST W/O HEATED DELIVERY $216.50 20071101 99999999 

E1500 CENTRIFUGE, FOR DIALYSIS $5.00 20071101 99999999 

E1510 

KIDNEY DIALYSATE DELIVERY SYST,KIDNEY MACHINE,PUMP 

RECIRCULA $5.00 20071101 99999999 

E1520 HEPARIN INFUSION PUMP FOR DIALYSIS $5.00 20071101 99999999 

E1530 AIR BUBBLE DETECTOR FOR DIALYSIS $5.00 20071101 99999999 

E1540 PRESSURE ALARM FOR DIALYSIS $5.00 20071101 99999999 

E1550 BATH CONDUCTIVITY METER FOR DIALYSIS $5.00 20071101 99999999 

E1560 BLOOD LEAK DETECTOR FOR DIALYSIS $5.00 20071101 99999999 

E1570 ADJUSTABLE CHAIR, FOR ESRD PATIENTS $5.00 20071101 99999999 

E1575 TRANSDUCER PROTECTORS/FLUID BARRIERS,ANY SIZE EACH $5.00 20071101 99999999 

E1580 UNIPUNCTURE CONTROL SYSTEM FOR DIALYSIS $5.00 20071101 99999999 

E1590 HEMODIALYSIS MACHINE $5.00 20071101 99999999 

E1592 AUTOMATIC INTERMITTENT PERITIONEAL DIALYSIS SYSTEM $5.00 20071101 99999999 

E1594 CYCLER DIALYSIS MACHINE FOR PERITONEAL DIALYSIS $5.00 20071101 99999999 

E1600 DELIVERY AND/OR INSTALLATION CHRGS FOR RENAL DIALYSIS EQUIP $5.00 20071101 99999999 

E1610 REVERSE OSMOSIS WATER PURIFICATION SYSTEM $5.00 20071101 99999999 

E1615 DEIONIZER WATER PURIFICATION SYSTEM $5.00 20071101 99999999 

E1620 BLOOD PUMP FOR DIALYSIS $5.00 20071101 99999999 

E1625 WATER SOFTENING SYSTEM $5.00 20071101 99999999 

E1630 RECIPROCATING PERITONEAL DIALYSIS SYSTEM $5.00 20071101 99999999 

E1632 WEARABLE ARTIFICIAL KIDNEY $5.00 20071101 99999999 

E1634 PERITONEAL DIALYSIS CLAMPS, EACH $5.00 20071101 99999999 

E1635 COMPACT PORTABLE TRAVEL HEMODIALYZER SYSTEM $5.00 20071101 99999999 



E1638 HEATING PAD, FOR PERITONEAL DIALYSIS, ANY SIZE, EACH $5.00 20071101 99999999 

E1639 SCALE, FOR DIALYSIS, EACH $5.00 20071101 99999999 

E1700 JAW MOTION REHABILITATION SYSTEM $41.49 20071101 99999999 

E1701 

REPLACEMENT CUSHIONS FOR JAW MOTION REHABILITATION 

SYSTEM, PKG. OF 6 $11.45 20060701 99999999 

E1702 

REPLACEMENT MEASURING SCALES FOR JAW MOTION 

REHABILITATION SYSTEM, PKG. OF 200 $23.05 20060701 99999999 

E1800 DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 

E1801 

BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH ELBOW DEVICE 

WITH RANGE OF MOTION ADJU $121.43 20071101 99999999 

E1802 

DYNAMIC ADJUSTABLE FOREARM PRONATION/SUPINATION DEVICE, 

INCLUDES SOFT INTERFACE $326.80 20071101 99999999 

E1805 DYNAMIC ADJUSTABLE WRIST EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 

E1806 

BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH WRIST DEVICE 


E1810 DYNAMIC ADJUSTABLE KNEE EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 

E1811 

BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH KNEE DEVICE WITH 

RANGE OF MOTION ADJUS $126.22 20071101 99999999 

E1812 

DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE 

RESISTANCE CONTROL $85.99 20071101 99999999 

E1815 DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 

E1816 

BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH ANKLE DEVICE 


E1818 

BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH FOREARM 

PRONATION / SUPINATION DEVICE $130.90 20071101 99999999 

E1820 

SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE 

EXTENSION/FLEXION DEVICE $8.33 20071101 99999999 

E1821 

REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI- 

DIRECTIONAL STATIC PROGRESSIVE $10.51 20071101 99999999 

E1825 DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 

E1830 DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE $138.27 20071101 99999999 

E1840 

DYNAMIC ADJUSTABLE SHOULDER FLEXION / ABDUCTION / ROTATION 

DEVICE, INCLUDES SOFT $371.93 20071101 99999999 

E1841 

MULTI-DIRECTIONAL STATIC PROGRESSIVE STRETCH SHOULDER 

DEVICE, WITH RANGE OF $453.00 20071101 99999999 

E1902 

COMMUNICATION BOARD, NON-ELECTRONIC AUGMENTATIVE OR 

ALTERNATIVE COMMUNICATION DE $50.00 20071101 99999999 

E2000 

GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, 

ELECTRIC $48.77 20071101 99999999 

E2100 BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER $48.80 20071101 99999999 

E2101 

BLOOD GLUCOSE MONITOR WITH INTEGRATED LANCING/BLOOD 

SAMPLE $18.86 20071101 99999999 

E2120 

PULSE GENERATOR SYSTEM FOR TYMPANIC TREATMENT OF INNER 

EAR ENDOLYMPHATIC FLUID $283.52 20071101 99999999 

E2201 

MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, 


E2202 

MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME 

WIDTH, 24-27 INCHES $40.29 20071101 99999999 

E2203 


DEPTH, 20 TO LESS THAN 22 IN $40.71 20071101 99999999 

E2204 


DEPTH, 22 TO 25 INCHES $69.15 20071101 99999999 

E2205 

MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT 

PROJECTIONS, ANY TYPE, REPLACEMENT $3.19 20071101 99999999 

E2206 

MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, 

COMPLETE, EACH $4.00 20071101 99999999 

E2207 WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH $4.27 20071101 99999999 

E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH $11.68 20071101 99999999 



E2209 WHEELCHAIR ACCESSORY, ARM TROUGH, EACH $10.52 20071101 99999999 

E2210 

WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT 

ONLY, EACH $0.72 20071101 99999999 

E2211 

MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, 

ANY SIZE, EACH $12.56 20071101 99999999 

E2212 

MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC 

PROPULSION TIRE, ANY SIZE, EACH $0.61 20071101 99999999 

E2213 

MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC 

PROPULSION TIRE (REMOVABLE), A $3.01 20071101 99999999 

E2214 

MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY 

SIZE, EACH $4.49 20071101 99999999 

E2215 

MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER 

TIRE, ANY SIZE, EACH $0.94 20071101 99999999 

E2216 

MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, 

ANY SIZE, EACH $0.50 20071101 99999999 

E2217 

MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY 

SIZE, EACH $0.50 20071101 99999999 

E2218 

MANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY 

SIZE, EACH $0.50 20071101 99999999 

E2219 

MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, 

EACH $2.98 20071101 99999999 

E2220 

MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) 

PROPULSION TIRE, ANY SIZE, E $3.21 20071101 99999999 

E2221 


CASTER TIRE (REMOVABLE), ANY $2.49 20071101 99999999 

E2222 


CASTER TIRE WITH INTEGRATED $2.09 20071101 99999999 

E2223 

MANUAL WHEELCHAIR ACCESSORY, VALVE, ANY TYPE, 

REPLACEMENT ONLY, EACH $0.56 20071101 99999999 

E2224 

MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES 

TIRE, ANY SIZE, EACH $7.34 20071101 99999999 

E2225 

MANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, 

ANY SIZE, REPLACEMENT O $1.74 20071101 99999999 

E2226 

MANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, 


E2291 

BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED 

ATTACHING HARDWARE $50.00 20071101 99999999 

E2292 

SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED 

ATTACHING HARDWARE $50.00 20071101 99999999 

E2293 

BACK, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING 

FIXED ATTACHING $50.00 20071101 99999999 

E2294 

SEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING 

FIXED ATTACHING $50.00 20071101 99999999 

E2310 

POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION 

BETWEEN WHEELCHAIR CONTROLLER $117.02 20071101 99999999 

E2311 

POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION 

BETWEEN WHEELCHAIR CONTROLLER $236.93 20071101 99999999 

E2312 

POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL 

INTERFACE, MINI-PROPORTIONAL RE $201.67 20080101 99999999 

E2313 

POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO 

EXPANDABLE CONTROLLER, INCLUD $32.03 20080101 99999999 

E2321 

POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, 

REMOTE JOYSTICK, NONPROPORTI $158.92 20071101 99999999 

E2322 

POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, 

MULTIPLE MECHANICAL SWITCHES $141.03 20071101 99999999 

E2323 

POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE 

FOR HAND CONTROL INTERFACE $6.92 20071101 99999999 



E2324 

POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL 

INTERFACE $4.37 20071101 99999999 

E2325 

POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, 

NONPROPORTIONAL, INCLUDING A $134.70 20071101 99999999 

E2326 

POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND 

PUFF INTERFACE $34.73 20071101 99999999 

E2327 

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, 

MECHANICAL, PROPORTIONAL, IN $261.24 20071101 99999999 

E2328 

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY 

CONTROL INTERFACE, ELECTRO $495.52 20071101 99999999 

E2329 


CONTACT SWITCH MECHANISM, NO $176.61 20071101 99999999 

E2330 


PROXIMITY SWITCH MECHANISM, $342.20 20071101 99999999 

E2340 

POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME 

WIDTH, 20-23 INCHES $35.85 20071101 99999999 

E2341 


WIDTH, 24-27 INCHES $53.76 20071101 99999999 

E2342 


DEPTH, 20 OR 21 INCHES $38.08 20071101 99999999 

E2343 


DEPTH, 22-25 INCHES $60.92 20071101 99999999 

E2351 

POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO 

OPERATE SPEECH GENERATING DE $69.88 20071101 99999999 

E2360 

POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID 

BATTERY, EACH $12.20 20071101 99999999 

E2361 

POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID 

BATTERY, EACH, (E.G. GEL CELL, $13.72 20071101 99999999 

E2362 

POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD 

ACID BATTERY, EACH $9.04 20071101 99999999 

E2363 

POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID 

BATTERY, EACH (E.G. GEL CE $18.30 20071101 99999999 

E2364 

POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID 

BATTERY, EACH $12.20 20071101 99999999 

E2365 

POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, 

EACH (E.G. GEL CELL, A $11.03 20071101 99999999 

E2366 

POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE 

MODE, FOR USE WITH ONLY ONE $10.65 20071101 99999999 

E2367 

POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, 

FOR USE WITH EITHER BATT $41.91 20071101 99999999 

E2368 POWER WHEELCHAIR COMPONENT, MOTOR, REPLACEMENT ONLY $51.67 20071101 99999999 

E2369 POWER WHEELCHAIR COMPONENT, GEAR BOX, REPLACEMENT ONLY $45.00 20071101 99999999 

E2370 

POWER WHEELCHAIR COMPONENT, MOTOR AND GEAR BOX 

COMBINATION, REPLACEMENT ONLY $80.29 20071101 99999999 

E2371 

POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID 

BATTERY, (E.G. GEL CELL, A $15.08 20071101 99999999 

E2372 

POWER WHEELCHAIR ACCESSORY, GROUP 27 NON-SEALED LEAD 

ACID BATTERY, EACH $15.08 20071101 99999999 

E2373 


INTERFACE, MINI-PROPORTIONAL, C $125.83 20071101 99999999 

E2374 


INTERFACE, STANDARD REMOTE JOYS $16.92 20071101 99999999 

E2375 

POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, 

INCLUDING ALL RELATED ELE $85.65 20071101 99999999 

E2376 

POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, 

INCLUDING ALL RELATED ELECTRO $134.23 20071101 99999999 



E2377 

POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, 

INCLUDING ALL RELATED ELECTRO $48.56 20071101 99999999 

E2381 

POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, 

ANY SIZE, REPLACEMENT ON $7.47 20071101 99999999 

E2382 

POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE 

WHEEL TIRE, ANY SIZE, REPLA $2.02 20071101 99999999 

E2383 

POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE 

WHEEL TIRE (REMOVABLE), A $14.93 20071101 99999999 

E2384 

POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY 

SIZE, REPLACEMENT ONLY, E $7.94 20071101 99999999 

E2385 

POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER 

TIRE, ANY SIZE, REPLACEMEN $6.85 20071101 99999999 

E2386 

POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, 

ANY SIZE, REPLACEMENT $14.80 20071101 99999999 

E2387 

POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY 

SIZE, REPLACEMENT ONLY, $6.37 20071101 99999999 

E2388 

POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY 

SIZE, REPLACEMENT ONLY, E $5.04 20071101 99999999 

E2389 

POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, 


E2390 

POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE 

WHEEL TIRE, ANY SIZE, R $4.28 20071101 99999999 

E2391 

POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) 

CASTER TIRE (REMOVABLE), ANY $2.05 20071101 99999999 

E2392 

POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) 

CASTER TIRE WITH INTEGRATED W $5.40 20071101 99999999 

E2393 

POWER WHEELCHAIR ACCESSORY, VALVE FOR PNEUMATIC TIRE 

TUBE, ANY TYPE, REPLACEMENT $0.70 20071101 99999999 

E2394 

POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, 

ANY SIZE, REPLACEMENT ONL $7.69 20071101 99999999 

E2395 

POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, 

ANY SIZE, REPLACEMENT ON $5.46 20071101 99999999 

E2396 

POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, 


E2500 

SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE- 

RECORDED MESSAGES, LESS TH $39.11 20071101 99999999 

E2502 


RECORDED MESSAGES, GREATER $119.59 20071101 99999999 

E2504 



E2506 



E2508 

SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING 

MESSAGE FORMULATION BY S $357.67 20071101 99999999 

E2510 

SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING 

MULTIPLE METHODS OF MES $676.82 20071101 99999999 

E2511 

SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL 

COMPUTER OR PERSONAL DIGITAL AS $50.00 20071101 99999999 

E2512 ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM $50.00 20071101 99999999 

E2601 

GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 

INCHES, ANY DEPTH $6.13 20071101 99999999 

E2602 

GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR 

GREATER, ANY DEPTH $11.94 20071101 99999999 

E2603 

SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 

22 INCHES, ANY DEPTH $15.17 20071101 99999999 

E2604 

SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES 

OR GREATER, ANY DEPTH $18.83 20071101 99999999 



E2605 

POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 

INCHES, ANY DEPTH $26.93 20071101 99999999 

E2606 

POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR 

GREATER, ANY DEPTH $42.01 20071101 99999999 

E2607 

SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, 

WIDTH LESS THAN 22 $28.99 20071101 99999999 

E2608 

SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, 

WIDTH 22 INCHES OR $34.80 20071101 99999999 

E2611 

GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 

INCHES, ANY HEIGHT, $31.23 20071101 99999999 

E2612 

GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR 

GREATER, ANY HEIGHT, $42.25 20071101 99999999 

E2613 

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS 

THAN 22 INCHES, ANY $39.31 20071101 99999999 

E2614 

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 

INCHES OR GREATER, ANY $54.40 20071101 99999999 

E2615 

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, 

WIDTH LESS THAN 22 $45.24 20071101 99999999 

E2616 

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, 

WIDTH 22 INCHES OR $60.86 20071101 99999999 

E2618 

WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES 

SLING SEAT), FOR USE $15.37 20071101 99999999 

E2619 

REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK 

CUSHION, EACH $5.13 20071101 99999999 

E2620 

POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH 

LATERAL SUPPORTS, WIDTH $54.77 20071101 99999999 

E2621 

POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH 

LATERAL SUPPORTS, WIDTH $57.47 20071101 99999999 

G0001 ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S) $3.00 19990701 99999999 

G0002 

OFFICE PROCEDURE, INSERTION OF TEMPORARY INDWELLING 

CATHETER, FOLEY TYPE (SEPARA $26.29 20030401 99999999 

G0003 

PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH 

PRESYMPTOM OR POST SYMPTO $332.28 19990701 99999999 

G0004 


PRE-SYMPTOM MEMORY LOOP A $321.24 19990701 99999999 

G0005 



G0006 



G0007 


PRE-SYMPTON MEMORY LOOP A $27.92 19990701 99999999 

G0015 

POST-SYMPTOM TELEPHONIC TRANSMISSION OF 

ELECTROCARDIOGRAM RHYTHM STRIP(S) AND 24 $243.20 19990701 99999999 

G0016 

POST-SYMPTOM TELEPHONIC TRANSMISSION OF 

ELECTROCARDIOGRAM RHYTHM STRIPS(S) AND 2 $27.92 19990701 99999999 

G0025 COLLAGEN SKIN TEST KIT $9.95 19990701 99999999 

G0026 FECAL LEUKOCYTE EXAMINATION $5.90 19990701 99999999 

G0027 NASAL SMEAR FOR GRANULOCYTES $8.99 19990701 99999999 

G0050 

MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR 

BLADDER CAPACITY BY ULTRASOUND $34.16 19990701 99999999 

G0051 

DESTRUCTION BY ANY METHOD, INCLUDING LASER, WITH OR 

WITHOUT SURGICAL CURETTEMENT $37.94 19990701 99999999 

G0052 



G0053 



G0054 

BLOOD CHOLESTEROL TEST, BY CHOLESTEROL MONITORING DEVICE 

APPROVED BY FDA FOR HOM $4.47 19990701 99999999 



G0055 

GLUCOSE POST DOSE (INCLUDES GLUCOSE) DIRECT MEASUREMENT 

BY A GLUCOSE TESTING DEV $5.53 19990701 99999999 

G0056 

GLUCOSE TOLERANCE TEST (GTT), BY DIRECT MEASUREMENT BY 

GLUCOSE TESTING DEVICE AP $15.68 19990701 99999999 

G0057 

GLUCOSE TOLERANCE TEST (GTT), BY DIRECT MEASUREMENT BY A 

GLUCOSE TESTING DEVICE $4.64 19990701 99999999 

G0058 AUTOMATED MULTICHANNEL TEST; 20 CLINICAL CHEMISTRY TESTS $15.78 19990701 99999999 

G0059 AUTOMATED MULTICHANNEL TEST; 21 CLINICAL CHEMISTRY TESTS $16.27 19990701 99999999 

G0060 AUTOMATED MULTICHANNEL TEST, 22 CLINICAL CHENISTRY TESTS $16.77 19990701 99999999 

G0062 

PERIPHERAL SKELETAL BONE MINERAL DENSITY STUDIES (E.G., 

RADIUS, WRIST, HEEL). $41.19 19990701 99999999 

G0063 

CENTRAL SKELETAL BONE MINERAL DENSITY STUDIES (E.G., SPINE, 

PELVIS). $137.13 19990701 99999999 

G0064 

PHYSICIAN SUPERVISION OF A PATIENT UNDER CARE OF A HOME 

HEALTH AGENCY (PATIENT N $80.26 19990701 99999999 

G0065 

PHYSICIAN SUPERVISION OF A HOSPICE PATIENT (PATIENT NOT 

PRESENT) REQUIRING COMPL $80.26 19990701 99999999 

G0071 

INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR 

MODIFYING AND/OR SUPPORTIVE $50.43 19990701 99999999 

G0072 



G0073 



G0074 



G0075 



G0076 



G0077 

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN OFFICE OR 

OUTPATIENT FACILITY, APPR $64.06 19990701 99999999 

G0078 



G0079 

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE IN AN OFFICE OR 

OUTPATIENT FACILITY, APPRO $84.84 19990701 99999999 

G0080 



G0081 



G0082 



G0083 



G0084 



G0085 



G0086 



G0087 



G0088 



G0089 

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN INPATIENT 

HOSPITAL, PARTIAL HOSPITA $57.25 19990701 99999999 

G0090 





G0091 



G0092 



G0093 



G0094 



G0101 

CERVICAL OR VAGINAL CANCER SCREENING; PELVIC AND CLINICAL 

BREAST EXAMINATION $23.84 20060701 99999999 

G0102 PROSTATE CANCER SCREENING; DIGITAL RECTAL EXAMINATION $9.02 20060701 99999999 

G0103 

PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST 

(PSA), TOTAL $25.42 20060701 99999999 

G0104 COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY $55.97 20060701 99999999 

G0105 

COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL 

AT HIGH RISK $189.81 20060701 99999999 

G0106 

COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, 

SCREENING SIGMOIDOSCOPY, BARI $140.76 20060701 99999999 

G0107 

COLORECTAL CANCER SCREENING; FECAL-OCCULT BLOOD TEST, 1-3 

SIMULTANEOUS DETERMINA $4.49 19990701 99999999 

G0108 

DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, 

INDIVIDUAL, PER SESSION $34.21 20060701 99999999 

G0109 

DIABETES SELF-MANAGEMENT TRAINING SERVICES, GROUP 

SESSION, PER INDIVIDUAL $20.15 20060701 99999999 

G0110 NETT PULM-REHAB; EDUCATION/SKILLS TRAINING, INDIVIDUAL $46.33 20030401 99999999 

G0111 NETT PULM-REHAB; EDUCATION/SKILLS TRAINING, GROUP $14.52 20030401 99999999 

G0112 NETT PULM-REHAB; NUTRITIONAL GUIDANCE, INITIAL $91.66 20030401 99999999 

G0113 NETT PULM-REHAB; NUTRITIONAL GUIDANCE, SUBSEQUENT $65.90 20030401 99999999 

G0114 NETT PULM-REHAB; PSYCHOSOCIAL CONSULTATION $60.64 20030401 99999999 

G0115 NETT PULM-REHAB; PSYCHOLOGICAL TESTING $60.95 20030401 99999999 

G0116 NETT PULM-REHAB; PSYCHOSOCIAL COUNSELLING $55.99 20030401 99999999 

G0117 

GLAUCOMA SCREENING FOR HIGH RISK PATIENTS FURNISHED BY AN 

OPTOMETRIST OR OPHTHAL $25.39 20060701 99999999 

G0118 

GLAUCOMA SCREENING FOR HIGH RISK PATIENT FURNISHED UNDER 

THE DIRECT SUPERVISION $9.29 20060701 99999999 

G0120 

COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0105, 

SCREENING COLONOSCOPY, BARIUM $140.76 20060701 99999999 

G0121 

COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL 

NOT MEETING CRITERIA FOR $211.36 20060701 99999999 

G0123 

SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY 

REPORTING SYSTEM), COLLECTED I $28.00 20060701 99999999 

G0124 



G0125 

PET LUNG IMAGING OF SOLITARY PULMONARY MODULES, USING 

2{FLOURINE 18}FLUORO 2 DEO $2,397.11 19990701 99999999 

G0126 

PET LUNG IMAGING OF SOLITARY PULMONARY NODULES USING 2 

{FLUORINE 18} FLUORO 2 DE $2,418.09 19990701 99999999 

G0127 TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER $8.27 20060701 99999999 

G0128 

DIRECT (FACE TO FACE) WITH PATIENT SKILLED NURSING SERVICES 

OF A REGISTERED NURS $4.41 19990701 99999999 

G0130 

SINGLE ENERGY X-RAY (SEXA) ABSORPTIOMETRY BONE DENSITY 

STUDYONE OR MORE SITES $45.36 20060701 99999999 

G0131 

COMPUTERIZED TOMOGRAPHY BONE MINERAL DENSITY STUDAY, 

ONE OR MORE SITES, AXIAL SK $116.32 19990701 99999999 

G0132 

COMPUTERIZED TOMOGRAPHY BONE MATERIAL DENSITY STUDY, 

ONE OR MORE SITES APPENDICU $46.07 19980701 99999999 

G0141 

SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, 

PERFORMED BY AUTOMATED SYST $21.72 20060701 99999999 



G0143 



G0144 



G0145 



G0147 


PERFORMED BY AUTOMATED SYS $15.73 20060701 99999999 

G0148 


PERFORMED BY AUTOMATED SYST $21.00 20060701 99999999 

G0159 

PERCUTANEOUS THROMBECTOMY AND/OR REVISION, 

ARTERIOVENOUS FISTULA, AUTOGENOUS OR $689.17 20000101 99999999 

G0160 

CRYOSURGICAL ABLATION OF LOCALIZED PROSTATE CANCER, 

PRIMARY TREATMENT ONLY $895.53 19990701 99999999 

G0163 

POSTERIOR EMISSION TOMOGRAPHY (PET), WHOLE BODY, FOR 

RECURRENCE OF COLORECTAL $2,400.36 19990701 99999999 

G0164 

POSITRON EMISSION TOMOGRAPHY (PET), WHOLE BODY FOR 

RECURRENCOF MELANOMA CANCER $2,420.12 19990701 99999999 

G0165 

POSITRON EMISSION TOMOGRAPHY (PET) WHOLE BODY FOR 

RECURRENCEOF MELANOMA/MET CANC $2,400.36 19990701 99999999 

G0166 EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION $4.05 20060701 99999999 

G0167 

HYPERBARIC OXYGEN TREATMENT NOT REQUIRING PHYSICIAN 

ATTENDANCE, PER TREATMENT SE $32.32 20000101 99999999 

G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY $23.82 20060701 99999999 

G0169 

REMOVAL OF DEVITALIZED TISSUE, WITHOUT USE OF ANESTHESIA 

(CONSCIOUS SEDATION, LO $35.26 20000101 99999999 

G0170 

APPLICATION OF TISSUE CULTURED SKIN GRAFTS, INCLUDING 

BILAMINATE SKIN SUBSTITUTE $128.70 20000101 99999999 

G0171 

APPLICATION OF TISSUE CULTURED SKIN GRAFTS, INCLUDING 

BILAMINATE SKIN SUBSTITUTE $109.31 20000101 99999999 

G0179 

INTENSITY MODULATED RADIATION THERAPY (IMRT) PLANNING, 

INCLUDES DOSE VOLUME NIST $47.36 20010101 99999999 

G0180 

PHYSICIAN CERTIFICATION SERVICES FOR MEDICARE-COVERED 

SERVICES PROVIDED BY A PAR $55.63 20010101 99999999 

G0181 

PHYSICIAN SUPERVISION OF A PATIENT RECEIVING MEDICARE- 

COVERED SERVICES PROVIDED $92.25 20060701 99999999 

G0182 

PHYSICIAN SUPERVISION OF A PATIENT UNDER A MEDICARE- 

APPROVED HOSPICE (PATIENT NO $103.97 20060701 99999999 

G0184 

DESTRUCTION OF LOCALIZED LESION OF CHOROID (FOR EXAMPLE, 

CHOROIDAL NEOVASCULARIZ $29.06 20010101 99999999 

G0195 

CLINICAL EVALUATION OF SWALLOWING FUNCTION (NOT INVOLVING 

INTERPRETATION OF DYNA $88.58 20030401 99999999 

G0196 

EVALUATION OF SWALLOWING INVOLVING SWALLOWING OF RADIO- 

OPAQUE MATERIALS $88.58 20030401 99999999 

G0197 

EVALUATION OF PATIENT FOR PRESCRIPTION OF SPEECH 

GENERATING DEVICES $81.75 20030401 99999999 

G0198 

PATIENT ADAPTATION AND TRAINING FOR USE OF SPEECH 

GENERATING DEVICES $59.77 20010101 99999999 

G0199 RE-EVALUATION OF PATIENT USING SPEECH GENERATING DEVICES $61.12 20030401 99999999 

G0200 EVALUATION OF PATIENT FOR PRESCRIPTION OF VOICE PROSTHETIC $81.75 20030401 99999999 

G0201 MODIFICATION OR TRAINING IN USE OF VOICE PROSTHETIC $59.77 20010101 99999999 

G0202 

SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, 

BILATERAL, ALL VIEWS $137.84 20060701 99999999 

G0204 

DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, 

BILATERAL, ALL VIEWS $145.19 20060701 99999999 

G0205 

DIAGNOSTIC MAMMOGRAPHY, FILM PROCESSED TO PRODUCE 

DIGITAL IMAGE ANALYZED FOR POT $91.91 20030101 99999999 



G0206 

DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, 

UNILATERAL, ALL VIEWS $117.19 20060701 99999999 

G0207 

DIAGNOSTIC MAMMOGRAPHY, FILM PROCESSED TO PRODUCE 

DIGITAL IMAGE ANALYZED FOR POT $75.43 20030101 99999999 

G0236 

DIGITIZATION OF FILM RADIOGRAPHIC IMAGES WITH COMPUTER 

ANALYSIS FOR LESION DETEC $15.38 20020101 99999999 

G0237 

THERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR 

ENDURANCE OF RESPIRATORY MUSCLES, $18.91 20060701 99999999 

G0238 

THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, 

OTHER THAN DESCRIBED BY $12.74 20060701 99999999 

G0239 

THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, 

OTHER THAN SERVICES DESC $8.70 20060701 99999999 

G0240 

CRITICAL CARE SERVICE DELIVERED BY A PHYSICIAN, FACE TO FACE; 

DURING INTERFACILI $153.86 20020101 99999999 

G0241 

EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO 

G0240) $76.92 20020101 99999999 

G0245 

INITIAL PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC 

PATIENT WITH DIABETIC $33.87 20060701 99999999 

G0246 

FOLLOW-UP PHYSICIAN EVALUATION AND MANAGEMENT OF A 

DIABETIC PATIENT WITH DIABETI $17.09 20060701 99999999 

G0247 

ROUTINE FOOT CARE BY A PHYSICIAN OF A DIABETIC PATIENT WITH 

DIABETIC SENSORY NEU $20.56 20060701 99999999 

G0248 

DEMONSTRATION, AT INITIAL USE, OF HOME INR MONITORING FOR 

PATIENT WITH MECHANICA $167.67 20060701 99999999 

G0249 

PROVISION OF TEST MATERIALS AND EQUIPMENT FOR HOME INR 

MONITORING TO PATIENT WIT $100.48 20060701 99999999 

G0250 

PHYSICIAN REVIEW, INTERPRETATION AND PATIENT MANAGEMENT 

OF HOME INR TESTING FOR $7.06 20060701 99999999 

G0253 

PET IMAGING FOR BREAST CANCER, FULL AND PARTIAL-RING PET 

SCANNERS ONLY, STAGING/ $1,788.18 20030401 99999999 

G0254 

PET IMAGING FOR BREAST CANCER, FULL AND PARTIAL- RING PET 

SCANNERS ONLY, EVALUAT $1,788.18 20030401 99999999 

G0262 

SMALL INTESTINAL IMAGING; INTRALUMINAL, FROM LIGAMENT OF 

TREITZ TO THE ILEO CECA $613.55 20030401 99999999 

G0265 

CRYOPRESERVATION, FREEZING AND STORAGE OF CELLS FOR 

THERAPEUTIC USE, EACH CELL L $6.27 20030401 99999999 

G0266 

THAWING AND EXPANSION OF FROZEN CELLS FOR THERAPEUTIC 

USE, EACH ALIQUOT $6.27 20030401 99999999 

G0268 

REMOVAL OF IMPACTED CERUMEN (ONE OR BOTH EARS) BY 

PHYSICIAN ON SAME DATE OF SERV $24.13 20060701 99999999 

G0272 

NASO/ORO GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S 

SKILL AND FLUOROSCOPIC GU $12.76 20030401 99999999 

G0273 

RADIOPHARMACEUTICAL BIODISTRIBUTION, SINGLE OR MULTIPLE 

SCANS ON ONE OR MORE DAY $367.08 20030401 99999999 

G0274 

RADIOPHARMACEUTICAL THERAPY, NON-HODGKIN'S LYMPHOMA, 

INCLUDES ADMINISTRATION OF $160.89 20030401 99999999 

G0275 

RENAL ARTERY ANGIOGRAPHY (UNILATERAL OR BILATERAL) 

PERFORMED AT THE TIME OF CARD $9.80 20060701 99999999 

G0278 

ILIAC ARTERY ANGIOGRAPHY PERFORMED AT THE SAME TIME OF 

CARDIAC CATHETERIZATION, $9.80 20060701 99999999 

G0281 

ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, 

FOR CHRONIC STAGE II $9.73 20060701 99999999 

G0283 

ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS 

FOR INDICATION(S) OTHE $9.73 20060701 99999999 

G0288 

RECONSTRUCTION, COMPUTED TOMOGRAPHIC ANGIOGRAPHY OF 

AORTA FOR SURGICAL PLANNING $317.98 20060701 99999999 

G0289 

ARTHROSCOPY, KNEE, SURGICAL, FOR REMOVAL OF LOOSE BODY, 

FOREIGN BODY, DEBRIDEMEN $62.31 20060701 99999999 



G0306 

COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, WITHOUT 

PLATELET COUNT) AND AUTOMAT $6.52 20060701 99999999 

G0307 

COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC; WITHOUT 

PLATELET COUNT) $5.42 20060701 99999999 

G0319 

END STAGE RENAL DISEASE RELATED SERVICES;>20YRS;1 

PHYSICIAN VISIT PER MONTH $212.44 20050101 99999999 

G0329 

ELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS FOR 

CHRONIC STAGE III AND STAGE $2.06 20060701 99999999 

G0389 

ULTRASOUND B-SCAN AND/OR REAL TIME WITH IMAGE 

DOCUMENTATION; FOR ABDOMINAL AORTI $66.13 20070101 99999999 

G0392 

TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FOR 

MAINTENANCE OF HEMODIALYSIS $325.70 20070101 99999999 

G0393 

TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FOR 

MAINTENANCE OF HEMODIALYSIS $207.40 20070101 99999999 

J7320 YELLOW HORNET VENOM PROTEIN $201.24 20030519 99999999 

J7321 

HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA- 

ARTICULAR INJECTION, PER $102.06 20080101 99999999 

J7322 

HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR 

INJECTION, PER DOSE $178.16 20080101 99999999 

J7323 

HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR 


J7324 

HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR 


K0001 STANDARD WHEELCHAIR $65.72 20071101 99999999 

K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR $66.78 20071101 99999999 

K0003 LIGHTWEIGHT WHEELCHAIR $85.74 20071101 99999999 

K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR $189.39 20071101 99999999 

K0005 ULTRALIGHTWEIGHT WHEELCHAIR $196.33 20071101 99999999 

K0006 HEAVY DUTY WHEELCHAIR $166.41 20071101 99999999 

K0007 EXTRA HEAVY DUTY WHEELCHAIR $207.90 20071101 99999999 

K0010 STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR $3,221.92 20030401 99999999 

K0011 

STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR WITH 

PROGRAMMABLE CONTROL PAR $4,311.00 20060707 99999999 

K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR $2,402.09 20030401 99999999 

K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH $17.86 20071101 99999999 

K0016 

DETACHABLE, ADJUSTABLE HEIGHT ARMREST, COMPLETE 

ASSEMBLY, EACH $172.91 20030401 99999999 

K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH $5.03 20071101 99999999 

K0018 

DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION 

EACH $2.80 20071101 99999999 

K0019 ARM PAD, EACH $2.58 20071101 99999999 

K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR $4.58 20071101 99999999 

K0021 ANTI-TIPPING DEVICE, EACH $116.81 20030401 99999999 

K0022 REINFORCED BACK UPOSTERY $37.06 20030401 99999999 

K0023 

SOLID BACK INSERT, PLANAR BACK, SINGLE DENSITY FOAM, 

ATTACHED WITH STRAPS $261.23 20030401 99999999 

K0024 

SOLID BACK INSERT, PLANAR BACK, SINGLE DENSITY FORM, WITH 

ADJUSTABLE HOOK-ON HAR $247.87 20030401 99999999 

K0025 HOOK-ON HEADREST EXTENSION $72.86 20030401 99999999 

K0026 

BACK UPHOLSTERY FOR ULTRALIGHTWEIGHT OR HIGH STRENGTH 

LIGHTWEIGHT WHEELCHAIR $43.96 20030401 99999999 

K0027 

BACK UPHOLSTERY FOR WHEELCHAIR TYPE OTHER THAN 

ULTRALIGHTWEIGHT OR HIGH STRENGTH $43.96 20030401 99999999 

K0028 FULLY RECLINING BACK $609.22 20030401 99999999 

K0029 REINFORCED SEAT UPHOLSTERY $37.69 20030401 99999999 

K0030 SOLID SEAT INSERT, PLANAR SEAT, SINGLE DENSITY FOAM $121.85 20030401 99999999 

K0031 SAFETY BELT/PELVIC STRAP $43.36 20030401 99999999 



K0032 

SEAT UPHOLSTERY FOR ULTRALIGHTWEIGHT OR HIGH STRENGTH 

LIGHTWEIGHT WHEELCHAIR $32.39 20030401 99999999 

K0033 

SEAT UPHOLSTERY FOR WHEELCHAIR TYPE OTHER THAN 

ULTRALIGHTWEIGHT OR HIGH STRENGTH $32.39 20030401 99999999 

K0034 HEEL LOOP,EACH $33.92 20030401 99999999 

K0035 HEEL LOOP WITH ANKLE STRAP, EACH $20.21 20030401 99999999 

K0036 TOE LOOP, EACH $33.92 20030401 99999999 

K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH $12.17 20071101 99999999 

K0038 LEG STRAP, EACH $2.38 20071101 99999999 

K0039 LEG STRAP, H STYLE, EACH $5.32 20071101 99999999 

K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH $7.45 20071101 99999999 

K0041 LARGE SIZE FOOTPLATE, EACH $5.19 20071101 99999999 

K0042 STANDARD SIZE FOOTPLATE, EACH $2.72 20071101 99999999 

K0043 FOOTREST, LOWER EXTENSION TUBE, EACH $1.92 20071101 99999999 

K0044 FOOTREST, UPPER HANGER BRACKET, EACH $1.64 20071101 99999999 

K0045 FOOTREST, COMPLETE ASSEMBLY $12.17 20071101 99999999 

K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, EACH $1.92 20071101 99999999 

K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, EACH $7.52 20071101 99999999 

K0048 ELEVATING LEGREST, COMPLETE ASSEMBLY $137.80 20030401 99999999 

K0049 CALF PAD, EACH $28.88 20030401 99999999 

K0050 RATCHET ASSEMBLY $3.18 20071101 99999999 

K0051 CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACH $5.16 20071101 99999999 

K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH $9.10 20071101 99999999 

K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH $10.04 20071101 99999999 

K0054 

SEAT WIDTH OF 10", 11", 12", 15", 17", OR 20" FOR A HIGH STRENGTH, 

LIGHTWEIGHT O $84.82 20030401 99999999 

K0055 

SEAT DEPTH OF 15", 17", OR 18" FOR A HIGH STRENGTH, 

LIGHTWEIGHT OR ULTRALIGHTWEI $77.10 20030401 99999999 

K0056 

SEAT HEIGHT < 17" OR < OR EQUAL TO 21" FOR A HIGH STRENGTH, 

LIGHTWEIGHT, OR ULTR $9.36 20071101 99999999 

K0057 

SEAT WIDTH 19" OR 20" FOR HEAVY DUTY OR EXTRA HEAVY DUTY 

CHAIR $100.66 20030401 99999999 

K0058 SEAT DEPTH 17" OR 18" FOR MOTORIZED/POWER WHEELCHAIR $48.92 20030401 99999999 

K0059 PLASTIC COATED HANDRIM, EACH $25.71 20030401 99999999 

K0060 STEEL HANDRIM, EACH $22.50 20030401 99999999 

K0061 ALUMINUM HANDRIM, EACH $31.91 20030401 99999999 

K0062 HANDRIM WITH 8-10 VERTICAL OR OBLIQUE PROJECTIONS, EACH $49.44 20030401 99999999 

K0063 HANDRIM WITH 12-16 VERTICAL OR OLBIQUE PROJECTIONS, EACH $66.02 20030401 99999999 

K0064 ZERO PRESSURE TUBE (FLAT FREE INSERTS), ANY SIZE, EACH $24.64 20030401 99999999 

K0065 SPOKE PROTECTORS $4.36 20071101 99999999 

K0066 SOLID TIRE, ANY SIZE EACH $26.61 20030401 99999999 

K0067 PNEUMATIC TIRE, ANY SIZE, EACH $39.61 20030401 99999999 

K0068 PNEUMATIC TIRE TUBE, EACH $4.76 20030401 99999999 

K0069 

REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR 

MOLDED, EACH $9.84 20071101 99999999 

K0070 

REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, 

SPOKES OR MOLDED, EACH $18.02 20071101 99999999 

K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, EACH $10.77 20071101 99999999 

K0072 

FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, 

EACH $6.08 20071101 99999999 

K0073 CASTER PIN LOCK,EACH $3.29 20071101 99999999 

K0074 PNEUMATIC CASTER TIRE, ANY SIZE, EACH $37.00 20030401 99999999 

K0075 SEMI-PNEUMATIC CASTER TIRE, ANY SIZE, EACH $24.37 20030401 99999999 

K0076 SOLID CASTER TIRE, ANY SIZE, EACH $20.72 20030401 99999999 

K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH $5.78 20071101 99999999 

K0078 PNEUMATIC CASTER TIRE TUBE, EACH $7.79 20030401 99999999 

K0079 WHEEL LOCK EXTENSION, PAIR $35.19 20030401 99999999 



K0080 ANTI-ROLLBACK DEVICE, PAIR $82.91 20030401 99999999 

K0081 WHEEL LOCK ASSEMBLY, COMPLETE, EACH $32.98 20030401 99999999 

K0082 22 NF DEEP CYCLE LEAD ACID BATTERY, EACH $100.63 20030401 99999999 

K0083 22 NF GEL CELL BATTERY, EACH $113.07 20030401 99999999 

K0084 GROUP 24 DEEP CYCLE LEAD ACID BATTERY, EACH $74.56 20030401 99999999 

K0085 GROUP 24 GEL CELL BATTERY, EACH $150.78 20030401 99999999 

K0086 U-1 LEAD ACID BATTERY, EACH $100.63 20030401 99999999 

K0087 U-1 GEL CELL BATTERY, EACH $90.95 20030401 99999999 

K0088 BATTERY CHARGER, LEAD ACID OR GEL CELL $102.81 20030401 99999999 

K0089 BATTERY CHARGER, DUAL MODE $415.72 20030401 99999999 

K0090 REAR WHEEL TIRE FOR POWER WHEELCHAIR, ANY SIZE, EACH $61.76 20030401 99999999 

K0091 

REAR WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR POWER 

WHEELCHAIR, ANY SIZE, EA $16.84 20030401 99999999 

K0092 

REAR WHEEL ASSEMBLY FOR POWER WHEELCHAIR, COMPLETE 

EACH $197.08 20030401 99999999 

K0093 

REAR WHEEL, ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR 

POWER WHEELCHAIR, ANY $123.13 20030401 99999999 

K0094 WHEEL TIRE FOR POWER BASE, ANY SIZE, EACH $40.10 20030401 99999999 

K0095 

WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR EACH BASE, 

ANY SIZE, EACH $56.46 20030401 99999999 

K0096 WHEEL ASSEMBLY FOR POWER BASE, COMPLETE, EACH $226.12 20030401 99999999 

K0097 

WHEEL ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER 

BASE, ANY SIZE, EACH $49.17 20030401 99999999 

K0098 DRIVE BELT FOR POWER WHEELCHAIR $2.61 20071101 99999999 

K0099 FRONT CASTER FOR POWER WHEELCHAIR $65.58 20030401 99999999 

K0100 AMPUTEE ADAPTER, PARI $90.44 20030401 99999999 

K0102 CRUTCH AND CANE HOLDER $35.14 20030401 99999999 

K0103 TRANSFER BOARD,


K0130 FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE $49.78 20030401 99999999 

K0131 SPRING-POWERED DEVICE FOR LANCET $17.16 20030401 99999999 

K0132 

MALE EXTERNAL CATHETER WITH OR WITHOUT ADHESIVE, WITH OR 

WITHOUT ANTI-REFLUX DEV $1.14 20030401 99999999 

K0133 INTERMITTENT URINARY CATHETER, DISPOSABLE; STRAIGHT TIP $1.45 20030401 99999999 

K0134 

INTERMITTENT URINARY CATHETER, DISPOSABLE; COUDE (CURVED) 

TIP $2.91 20030401 99999999 

K0135 INTERMITTENT URINARY CATHETER, REUSABLE; STRAIGHT TIP $1.38 20030401 99999999 

K0136 

INTERMITTENT URINARY CATHETER, REUSABLE, COUDE (CURVED) 

TIP $8.16 20030401 99999999 

K0137 SKIN BARRIER; LIQUID (SPRAY, BRUSH, ETC.), PER OZ. $1.47 20030401 99999999 

K0138 SKIN BARRIER; PASTE, PER OZ. $2.78 20030401 99999999 

K0139 SKIN BARRIER; POWDER, PER OZ. $2.96 20030401 99999999 

K0148 HYDROGEL DRESSING, EACH $3.66 20030401 99999999 

K0149 HYDROCOLLOID DRESSING, EACH $5.99 20030401 99999999 

K0151 FOAM DRESSING, EACH $65.37 20030401 99999999 

K0154 WOUND POUCH, EACH $14.97 20030401 99999999 

K0163 VACUUM ERECTION SYSTEM $355.53 20030401 99999999 

K0164 OROPHARYNGEAL SUCTION CATHETER, EACH $3.53 20030401 99999999 

K0165 TRACHEOSTOMY CARE KIT FOR ESTABLISHED TRACHEOSTOMY $3.81 20030401 99999999 

K0166 METHYLPREDNISOLONE - ORAL, 4 MG $0.52 20030401 99999999 

K0167 PREDNISOLONE - ORAL, 5 MG $0.03 19990701 99999999 

K0168 

ADMINISTRATION SET, SMALL VOL NON-FILTERED,PNEUMATIC 

NEBULIZER, DISPOSABLE $2.16 20030401 99999999 

K0169 SMALL VOLUME NON-FILTERED PNEUMATIC NEBULIZER,DISPOSABLE $1.68 20030401 99999999 

K0170 

ADMINISTRATION SET, SMALL VOL, NON-FILTERED, PNEUMATIC 

NEBULIZER, NON-DISPOSABLE $29.31 20030401 99999999 

K0171 ADMINISTRATION SET, SMALL VOL FILTERED PNEUMATIC NEBULIZER $9.07 20030401 99999999 

K0172 

LARGE VOLUME NEBULIZER, DISPOSABLE UNFILLED, USED WITH 


K0173 

LARGE VOL NEBULIZER, DISPOSABLE, PREFILLED, USED WITH 


K0174 

RESERVOIR, NON-DISPOSABLE, USED W LGE VOL ULTRASONIC 

NEBULIZER $39.99 20030401 99999999 

K0175 

CORRUGATED TUBING, DISPOSABLE, USED W LGE VOL NEBULIZER 

100 FEET $22.13 20030401 99999999 

K0176 

CORRUGATED TUBING, NON-DISPOSABLE, USED W LGE VOL 

NEBULIZER,TEN FEET $2.11 20030401 99999999 

K0177 WATER COLLECTION DEVICE, USED W LARGE VOLUME NEBULIZER $2.92 20030401 99999999 

K0178 FILTER, NON-DISPOSABLE, USED W AEROSOL COMPRESSOR $0.79 20030401 99999999 

K0179 

FILTER, NON-DISPOSABLE,USED W AEROSOL COMPRESSOR OR 

ULTRASONIC GENERATOR $4.26 20030401 99999999 

K0180 AEROSOL MASK, USED WITH DME NEBULIZER $1.50 20030401 99999999 

K0181 

DOME AND MOUTHPIECE, USED W SMALL VOL ULTRASONIC 

NEBULIZER $6.88 20030401 99999999 

K0182 S $0.37 20030401 99999999 

K0183 NASAL APPLICATION DEVICE, USED WITH CPAP $68.56 20030401 99999999 

K0184 

NASAL PILLOWS/SEALS, REPLACEMENT FOR NASAL APPLICATION 

DEVICE,PAIR $22.81 20030401 99999999 

K0185 HEADGEAR, USED WITH CPAP DEVICE $37.82 20030401 99999999 

K0186 CHIN STRAP, USED WITH CPAP DEVICE $13.83 20030401 99999999 

K0187 TUBING, USED WITH CPAP $38.33 20030401 99999999 

K0188 FILTER,DISPOSABLE,USED WITH CPAP DEVICE $3.20 20030401 99999999 

K0189 FILTER, NON-DISPOSABLE, USED W CPAP DEVICE $13.16 20030401 99999999 

K0190 CANISTER, DISPOSABLE, USED WITH SUCTION PUMP $8.01 20030401 99999999 

K0191 CANISTER, NON-DISPOSABLE, USED WITH SUCTION PUMP $31.46 20030401 99999999 

K0192 TUBING, USED WITH SUCTION PUMP $3.65 20030401 99999999 



K0195 

ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL 

WHEELCHAIR BASE) $17.07 20030401 99999999 

K0196 

ALGINATE DRESSING,WOUND COVER,PAD SIZE 16 SQ IN OR LESS EA 

DRESSING $7.64 20030401 99999999 

K0197 

ALGINATE DRESSING,WOUND COVER,PAD SIZE > 16 BUT 16 BUT 48 SQ. IN.,WITH ANY SIZE 

ADHESIVE BORDER,EACH DRES $7.40 20030401 99999999 

K0206 CONTACT LAYER, 16 SQ. IN. OR LESS, EACH DRESSING $1.57 20030401 99999999 

K0207 

CONTACT LAYER,MORE THAN 16 BUT LESS THAN OR EQUAL TO 48 SQ. 

IN., EACH DRESSING $2.71 20030401 99999999 

K0208 CONTACT LAYER, MORE THAN 48 SQ. IN., EACH DRESSING $5.54 20030401 99999999 

K0209 

FOAM DRESSING,WOUND COVER,PAD SIZE 16 SQ. IN. OR LESS, WITH 

OUT ADHESIVE BORDER $7.83 20030401 99999999 

K0210 

FOAM DRESSING,WOUND COVER,PAD SIZE MORE THAN 16 BUT LESS 

THAN OR EQUAL TO 48 SQ $16.82 20030401 99999999 

K0211 

FOAM DRESSING,WOUND COVER,PAD SIZE MORE THAN 48 SQ. IN., 

W/OADHESIVE BORDER, EAC $30.61 20030401 99999999 

K0212 

FOAM DRESSING,WOUND COVER,PAD SIZE 16 SQ. IN. OR LESS,WITH 

ANY SIZE ADHESIVE $10.11 20030401 99999999 

K0214 

FOAM DRESSING,WOUND COVER,PAD SIZE > 48 SQ. IN., WITH ANY 

SZADHESIVE BORDER, EAC $10.72 20030401 99999999 

K0215 FOAM DRESSING, WOUND FILLER, PER GRAM $3.78 20030401 99999999 

K0216 

GUAZE, NON-IMPREGNATED, PAD SIZE 16 SQ. IN. OR LESS, W/O 


K0217 

GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 48 SQ. IN., W/O 


K0218 

GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 48 SQ. IN., W/O 

ADHESIVE BORDER, EAC $0.95 20030401 99999999 

K0219 

GAUZE,NON-IMPREGNATED, PAD SIZE 16 SQ.IN. OR LESS, WITH ANY 

SIZE ADHESIVE BORDER $0.44 20030401 99999999 

K0220 

GAUZE,NON-IMPREGNATED,PAD SIZE > 16 BUT 16 

48 

W/O ADHESIVE BORDER $3.78 20030401 99999999 

K0229 

GAUZE,IMPREGNATED,WATER OR NORMAL SALINE,PAD SIZE > 16 BUT 

16 SQ.IN. OR < 

W/O ADHESIVE BORDER $6.82 20030401 99999999 

K0235 

HYDROCOLLOID DRESSING,WOUND COVER,PAD SIZE > 16 BUT 16


K0240 HYDROCOLLOID DRESSING,WOUND FILLER,PASTE,PER FLUID OUNCE $12.77 20030401 99999999 

K0241 HYDROCOLLOID DRESSING,WOUND FILLER,DRY FORM, PER GRAM $2.42 20030401 99999999 

K0242 

HYDROGEL DRESSING,WOUND COVER,PAD SIZE 16 SQ.IN. OR LESS 

W/OADHESIVE BORDER, EAC $6.32 20030401 99999999 

K0243 

HYDROGEL DRESSING,WOUND COVER,PAD SIZE > 16 BUT 48 SQ.IN.,W/O 

ADHESIVE BORDER,EACH DRES $28.69 20030401 99999999 

K0245 

HYDROGEL DRESSING,WOUND COVER,PAD SIZE 16 SQ.IN. OR LESS, 

WITH ANY ADHESIVE BORD $7.55 20030401 99999999 

K0246 

HYDROGEL DRESSING,WOUND COVER,PAD SIZE > 16 BUT 48 SQ.IN., WITH 

ANYSIZE ADHESIVE BORDER $24.77 20030401 99999999 

K0248 HYDROGEL DRESSING, WOUND FILLER, GEL PER FLUID OUNCE $16.91 20030401 99999999 

K0249 HYDROGEL DRESSING, WOUND FILLER, DRY FORM, PER GRAM $0.90 20030401 99999999 

K0251 

SPECIALTY ABSORPTIVE DRESSING,WOUND COVER,PAD SIZE 16 

SQ.IN.OR LESS,W/O ADHESIVE $2.10 20030401 99999999 

K0252 

SPECIALTY ABSORPTIVE DRESSING,WOUND COVER,PAD SIZE > 16 

BUT 48 

SQ. IN.,W/O ADHESIVE BOR $6.85 20030401 99999999 

K0254 

SPECIALTY ABSORPTIVE DRESSING,WOUND COVER,PAD SIZE 16 

SQ.IN.OR LESS WITH ANY SIZ $1.27 20030401 99999999 

K0255 

SPECIALTY ABSORPTIVE DRESSING,WOUND COVER,PAD SIZE > 48 

SQ. IN.,WITH ANY SIZE AD $2.95 20030401 99999999 

K0257 TRANSPARENT FILM, 16 SQ. IN. OR LESS, EACH DRESSING $0.72 20030401 99999999 

K0258 TRANSPARENT FILM, > 16 BUT


K0407 

URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN 

ATTACHMENT $2.29 20030401 99999999 

K0408 URINARY CATHETER ANCHORING DEVICE, LEG STRAP $2.81 20030401 99999999 

K0409 STERILE WATER IRRIGATION SOLUTION, 1000 ML $6.14 20030401 99999999 

K0410 MALE EXTERNAL CATHETER, WITH ADHESIVE COATING, EACH $2.25 20030401 99999999 

K0411 MALE EXTERNAL CATHETER, WITH ADHESIVE STRIP, EACH $1.87 20030401 99999999 

K0417 

EXTERNAL INFUSION PUMP, MECHANICAL, REUSABLE, FOR SHORT 

TERM DRUG INFUSION $11.11 20030401 99999999 

K0419 POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, EACH $18.40 20030401 99999999 

K0420 POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, EACH $50.98 20030401 99999999 

K0421 POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, EACH $4.60 20030401 99999999 

K0422 POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, EACH $32.92 20030401 99999999 

K0423 POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, EACH $16.10 20030401 99999999 

K0424 POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, EACH $39.99 20030401 99999999 

K0425 POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, EACH $4.94 20030401 99999999 

K0426 POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, EACH $26.37 20030401 99999999 

K0427 POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACH $30.22 20030401 99999999 

K0428 OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EACH $10.33 20030401 99999999 

K0429 

SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, 

WITHOUT BUILT-IN CONVEXITY $5.45 20030401 99999999 

K0430 

SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), 

EXTENDED WEAR, WITHOUT $7.22 20030401 99999999 

K0431 

POUCH, CLOSED; WITH STANDARD WEAR BARRIER ATTACHED, WITH 

BUILT-IN CONVEXITY (1 P $4.32 20030401 99999999 

K0432 

POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, 

WITHOUT BUILT-IN CONVEXIT $4.67 20030401 99999999 

K0433 

POUCH, DRAINABLE, WITH STANDARD WEAR BARRIER ATTACHED, 

WITH BUILT-IN CONVEXITY ( $6.65 20030401 99999999 

K0434 

POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, 

WITH BUILT-IN CONVEXITY ( $10.32 20030401 99999999 

K0435 

POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, 

WITHOUT BUILT-IN CONVEXITY $7.60 20030401 99999999 

K0436 

POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH 

BUILT-IN CONVEXITY (1 $7.10 20030401 99999999 

K0437 

POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH 

BUILT-IN CONVEXITY (1P $9.82 20030401 99999999 

K0438 

OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, LIQUID, PER 

FLUID OUNCE $2.74 20030401 99999999 

K0439 

OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER 

TABLET $0.05 19990701 99999999 

K0440 NASAL PROSTHESIS - PROVIDED BY A NON-PHYSICIAN $2,098.90 20030401 99999999 

K0441 MIDFACIAL PROSTHESIS - PROVIDED BY A NON-PHYSICIAN $2,529.96 20030401 99999999 

K0442 ORBITAL PROSTHESIS - PROVIDED BY A NON-PHYSICIAN $2,842.64 20030401 99999999 

K0443 UPPER FACIAL PROSTHESIS - PROVIDED BY A NON-PHYSICIAN $3,183.76 20030401 99999999 

K0444 HEMI-FACIAL PROSTHESIS - PROVIDED BY A NON-PHYSICIAN $3,524.88 20030401 99999999 

K0445 AURICULAR PROSTHESIS - PROVIDED BY A NON-PHYSICIAN $2,219.20 20030401 99999999 

K0446 PARTIAL FACIAL PROSTHESIS - PROVIDED BY A NON-PHYSICIAN $2,274.12 20030401 99999999 

K0447 NASAL SEPTAL PROSTHESIS - PROVIDED BY A NON-PHYSICIAN $1,165.49 20030401 99999999 

K0449 

REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR 

COMPONENT, 15 MINUTE I $18.82 20030401 99999999 

K0452 WHEELCHAIR BEARINGS, ANY TYPE $7.01 20030401 99999999 

K0455 

INFUSION PUMP USED FOR UNINTERRUPTED ADMINISTRATION OF 

EPOPROSTENOL $339.20 20071101 99999999 

K0457 EXTRA WIDE/HEAVY DUTY COMMODE CHAIR, EACH $149.71 20030401 99999999 

K0458 HEAVY DUTY WALKER, WITHOUT WHEELS, EACH $126.04 20030401 99999999 

K0459 HEAVY DUTY WHEELED WALKER, EACH $221.41 20030401 99999999 

K0461 

POWER ADD-ON, TO CONVERT MANUAL WHEENCHAIR TO POWER 

OPERATEDVEHICLE, TILLER CON $1,286.22 20030401 99999999 



K0529 

STERILE WATER OR STERILE SALINE, 1000 ML, USED WITH LARGE 


K0530 

NEBULIZER, DURABLE, GLASS , OR AUTOCLAVABLE PLASTIC, BOTTLE 

TYPE, NOT USED WITH $127.85 20030401 99999999 

K0531 

HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE 

(PAP)DEVICE $284.32 20030401 99999999 

K0532 

RESP ASSIST DEVICE (RAD) BI-LEVEL PRESSURE CAPABILITY, W/O 

BACKUP RATE FEATURE $2,440.10 19990401 99999999 

K0539 

DRESSING SET FOR NEGATIVE PRESSURE WOUND THERAPY 


K0540 

CANISTER SET FOR NEGATIVE PRESSURE WOUND THERAPY 


K0541 

SPEECH GENERATING DEVICE, DIGITIZED SPEECH USING PRE- 

RECORDED MESSAGES, LESS THA $374.13 20030401 99999999 

K0542 


RECORDED MESSAGES, GREATER $1,446.05 20030401 99999999 

K0543 

SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING 

MESSAGE FORMULATION BY S $3,421.71 20030401 99999999 

K0544 

SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING 

MULTIPLE METHODS OF MES $6,475.12 20030401 99999999 

K0551 

RESIDUAL LIMB SUPPORT SYSTEM, SOLID BASE WITH ADJUSTABLE 

DROP HOOKS, MOUNTS TO W $384.53 20030401 99999999 

K0556 

ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, 

CUSTOM FABRICATED FROM EXIST $783.89 20030401 99999999 

K0557 



K0558 


CUSTOM FABRICATED SOCKET INS $1,035.59 20030401 99999999 

K0559 


CUSTOM FABRICATED SOCKET INS $1,035.59 20030401 99999999 

K0581 

OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 

PIECE), EACH $2.75 20030401 99999999 

K0582 

OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN 

CONVEXITY, WITH FILTE $3.72 20030401 99999999 

K0583 

OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH 


K0584 

OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE, WITH 

FILTER (2 PIECE), EAC $1.74 20030401 99999999 

K0587 

OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH 


K0588 

OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE, 

WITH FILTER (2 PIECE SY $3.58 20030401 99999999 

K0589 


FLANGE (2 PIECE SYSTEM) $2.36 20030401 99999999 

K0591 


ATTACHED, WITH FAUCET-TYPE TAP $6.51 20030401 99999999 

K0592 

OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN 

CONVEXITY, WITH FAUC $7.52 20030401 99999999 

K0593 



K0594 

OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET- 

TYPE TAP WITH VALVE (1 $5.08 20030401 99999999 

K0595 

OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE, 

WITH FAUCET-TYPE TAP WITH $3.59 20030401 99999999 

K0596 


FLANGE (2 PIECE), EACH $3.34 20030401 99999999 

K0597 


FLANGE, WITH FAUCET-TYPE $3.76 20030401 99999999 



K0601 

REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY 

PATIENT, SILVER OXIDE, 1 $1.10 20071101 99999999 

K0602 


PATIENT, SILVER OXIDE, 3 $6.36 20071101 99999999 

K0603 


PATIENT, ALKALINE, 1.5 V $0.57 20071101 99999999 

K0604 


PATIENT, LITHIUM, 3.6 VO $6.09 20071101 99999999 

K0605 


PATIENT, LITHIUM, 4.5 VO $14.60 20071101 99999999 

K0606 

AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH INTEGRATED 

ELECTROCARDIOGRAM ANALYSIS, GA $2,268.20 20071101 99999999 

K0607 

REPLACEMENT BATTERY FOR AUTOMATED EXTERNAL 

DEFIBRILLATOR, GARMENT TYPE ONLY, EAC $194.23 20071101 99999999 

K0608 

REPLACEMENT GARMENT FOR USE WITH AUTOMATED EXTERNAL 

DEFIBRILLATOR, EACH $12.14 20071101 99999999 

K0609 

REPLACEMENT ELECTRODES FOR USE WITH AUTOMATED EXTERNAL 

DEFIBRILLATOR, GARMENT TY $483.65 20060701 99999999 

K0628 

FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, 

MOLDED TO FOOT $24.22 20050101 99999999 

K0629 

FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED 

FROM MODEL OF $33.00 20050101 99999999 

K0637 

LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL 

SUPPORT, POSTERIOR $60.41 20050102 99999999 

K0669 

WHEELCHAIR ACCESSORY, SEAT OR BACK CUSHION, DOES NOT 

MEET SPECIFIC CODE $25.00 20071101 99999999 

K0733 PWR WHEELCHAIR ACC, 12-24 AMP HR BATTERY, EACH $3.04 20071101 99999999 

K0734 SKIN PROTECT WHEELCHAIR SEAT CUSHION,


K0822 

POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, 

PATIENT WEIGHT CAPACI $399.75 20071101 99999999 

K0823 

POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, 

PATIENT WEIGHT CAPACITY UP T $402.37 20071101 99999999 

K0824 

POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID 

SEAT/BACK, PATIENT WEIGHT CAPA $484.27 20071101 99999999 

K0825 

POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, 

PATIENT WEIGHT CAPACITY 30 $443.32 20071101 99999999 

K0826 

POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID 

SEAT/BACK, PATIENT WEIGHT $626.93 20071101 99999999 

K0827 

POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS 

CHAIR, PATIENT WEIGHT CAPACI $533.09 20071101 99999999 

K0828 

POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID 

SEAT/BACK, PATIENT WEIGH $690.82 20071101 99999999 

K0829 

POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS 

CHAIR, PATIENT WEIGHT 601 P $634.37 20071101 99999999 

K0830 

POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, 

SLING/SOLID SEAT/BACK, PATIEN $442.59 20061115 99999999 

K0831 

POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, 

CAPTAINS CHAIR, PATIENT WEIGH $442.59 20061115 99999999 

K0835 

POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, 

SLING/SOLID SEAT/BACK, $405.74 20071101 99999999 

K0836 


CAPTAINS CHAIR, PATIENT $420.75 20071101 99999999 

K0837 

POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER 

OPTION, SLING/SOLID SEAT/BACK $484.27 20071101 99999999 

K0838 


OPTION, CAPTAINS CHAIR, PATIE $433.23 20071101 99999999 

K0839 

POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER 

OPTION SLING/SOLID SEAT/ $626.93 20071101 99999999 

K0840 

POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER 

OPTION, SLING/SOLID SEA $807.36 20071101 99999999 

K0841 

POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER 


K0842 



K0843 

POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER 

OPTION, SLING/SOLID SEAT/BA $519.96 20071101 99999999 

K0848 

POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, 

PATIENT WEIGHT CAPACI $528.44 20071101 99999999 

K0849 

POWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, 

PATIENT WEIGHT CAPACITY UP T $508.07 20071101 99999999 

K0850 

POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SLING/SOLID 

SEAT/BACK, PATIENT WEIGHT CAPA $521.03 20071101 99999999 

K0851 

POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, 

PATIENT WEIGHT CAPACITY 30 $500.96 20071101 99999999 

K0852 

POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SLING/SOLID 

SEAT/BACK, PATIENT WEIGHT $708.26 20071101 99999999 

K0853 

POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS 

CHAIR, PATIENT WEIGHT CAPACI $727.56 20071101 99999999 

K0854 

POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID 

SEAT/BACK, PATIENT WEIGH $963.86 20071101 99999999 

K0855 

POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS 

CHAIR, PATIENT WEIGHT CAPAC $910.51 20071101 99999999 

K0856 


SLING/SOLID SEAT/BACK, $567.23 20071101 99999999 

K0857 


CAPTAINS CHAIR, PATIENT $578.60 20071101 99999999 



K0858 



K0859 



K0860 

POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER 

OPTION, SLING/SOLID SEAT $1,005.41 20071101 99999999 

K0861 



K0862 

POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER 

OPTION, SLING/SOLID SEAT/BA $703.76 20071101 99999999 

K0863 

POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE 

POWER OPTION, SLING/SOLID SE $973.41 20161115 99999999 

K0863 

POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE 

POWER OPTION, SLING/SOLID SE $1,005.41 20071101 99999999 

K0864 

POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE 

POWER OPTION, SLING/SOLID S $1,196.45 20071101 99999999 

K0899 

POWER MOBILITY DEVICE, NOT CODED BY SADMERC OR DOES NOT 

MEET CRITERIA $50.00 20071101 99999999 

L0100 CERVICAL,CRANIOSTENOSIS,HELMET MOLDED TO PATIENT MODEL $53.45 20030401 99999999 

L0110 CERVICAL,CRANIOSTENOSIS,HELMET,NON-MOLDED $96.70 20030401 99999999 

L0112 

CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, 

WITH OR WITHOUT SOFT INT $659.86 20060701 99999999 

L0120 CERVICAL,FLEXIBLE,NON-ADJUSTABLE (FOAM COLLAR) $23.71 20060701 99999999 

L0130 CERVICAL,FLEXIBLE,THERMOPLASTIC COLLAR,MOLDED TO PATIENT $123.49 20060701 99999999 

L0140 CERVICAL,SEMI-RIGID,ADJUSTABLE (PLASTIC COLLAR) $26.99 20060701 99999999 

L0150 CERVICAL,SEMI-RIGID,ADJUSTABLE MOLDED CHIN CUP,(PLASTIC COL) $67.92 20060701 99999999 

L0160 

CERVICAL,SEMI-RIGID,WIRE FRAME OCCIPITAL/MANDIBULAR 

SUPPORT $85.95 20060701 99999999 

L0170 CERVICAL,COLLAR,MOLDED TO PATIENT MODEL $412.90 20060701 99999999 

L0172 CERVICAL,COLLAR,SEMI-RIGID THERMOPLASTIC FOAM,TWO PIECE $78.38 20060701 99999999 

L0174 

CERVICAL,COLLAR,SEMI-RIGID,THERMOPLASTIC FOAM,TWO PIECE 

WITH $211.18 20060701 99999999 

L0180 

CERVICAL,MULTIPLE POST COLLAR,OCCIPITAL/MANDIBULAR 

SUPPORT $230.90 20060701 99999999 

L0190 


SUPPORT $346.13 20060701 99999999 

L0200 


SUPPORTS $403.40 20060701 99999999 

L0210 THORACIC,RIB BELT,CUSTOM FITTED $24.10 20060701 99999999 

L0220 THORACIC,RIB BELT,CUSTOM FABRICATED $39.80 20060701 99999999 

L0300 

THORACIC-LUMBAR-SACRAL-ORTHOSIS(TLSO),FLEXIBLE,CUSTOM 

FITTED $147.23 20030401 99999999 

L0310 

TLSO,FLEXIBLE,(DORSO-LUMBAR SURGICAL SUPPORT)CUSTOM 

FABRICAT $123.91 20030401 99999999 

L0315 TLSO,FLEXIBLE DORSO-LUMBAR SURGICAL SUPPORT,ELASTIC TYPE $180.00 20030401 99999999 

L0317 

TLSO,FLEXIBLE DORSO-LUMBAR SURGICAL 

SUPPORT,HYPEREXTENSION $223.70 20030401 99999999 

L0320 

TLSO,ANTERIOR-POSTERIOR CONTROL(TAYLOR TYPE)WITH APRON 

FRONT $267.17 20030401 99999999 

L0321 

TLSO, ANTERIOR-POSTERIOR CONTROL, WITH RIGID OR SEMI-RIGID 

POSTERIOR PANEL, PREF $330.52 20030401 99999999 

L0330 TLSO,ANTERIOR-POSTERIOR-LATER CONTROL,WITH APRON FRONT $326.53 20030401 99999999 

L0331 

TLSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH RIGID OR 

SEMI-RIGID POSTERIOR PAN $385.34 20030401 99999999 

L0340 

TLSO,ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL,WITH 

APRON FR $489.20 20030401 99999999 



L0350 TLSO,ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL,FLEXION $534.33 20030401 99999999 

L0360 

TLSO,ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL,FLEXION 

COMPR $534.33 20030401 99999999 

L0370 

TLSO,ANTERIOR-POSTERIOR-LATERAL-ROTARY 

CONTROL,HYPEREXTEN $278.62 20030401 99999999 

L0380 

TLSO,ANTERIOR-POSTERIOR-LATERALL-ROTARY CONTROL,WITH 

EXTEN $578.16 20030401 99999999 

L0390 TLSO, ANTERIOR-POSTERIOR-LATERAL CONTROL (BODY JACKET) $843.03 20030401 99999999 

L0391 

TLSO, ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL, WITH 

RIGID OR SEMI-RIGID POSTER $502.28 20030401 99999999 

L0400 

TLSO,ANTERIOR-POSTERIOR-LATERAL CONTROL MOLDED TO 

PATIENT $843.03 20030401 99999999 

L0410 

TLSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,TWO-PIECE 

CONSTRUCT $1,369.62 20030401 99999999 

L0420 

TLSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,WITH INTERFACE 

MATER $1,538.01 20030401 99999999 

L0430 

SPINAL ORTHOSIS, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH 

INTERFACE MATERIAL, $795.99 20060701 99999999 

L0440 TLSO,ANTERIOR-POSTERIOR-LATERAL CONTROL (BODY JACKET) $1,028.61 20030401 99999999 

L0450 

TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC 

REGION, PRODUCES INTRACAV $118.75 20060701 99999999 

L0452 

TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC 

REGION, PRODUCES INTRACAV $39.00 20071101 99999999 

L0454 

TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM 

SACROCOCCYGEAL JUNCTION TO A $163.51 20060701 99999999 

L0456 

TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, 

RIGID POSTERIOR PANEL A $468.91 20060701 99999999 

L0458 

TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, 

TWO RIGID PLASTIC SHEL $420.46 20060701 99999999 

L0460 


TWO RIGID PLASTIC SHEL $473.25 20060701 99999999 

L0462 


THREE RIGID PLASTIC SH $588.65 20060701 99999999 

L0464 


FOUR RIGID PLASTIC SHE $700.78 20060701 99999999 

L0466 

TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE 

SOFT ANTERIOR APRON W $245.42 20060701 99999999 

L0468 

TLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME AND 

FLEXIBLE SOFT ANTERIOR $280.16 20060701 99999999 

L0470 

TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE 

SOFT ANTERIOR APRON $528.08 20060701 99999999 

L0472 

TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR 

AND LATERAL FRAME EXTEND $280.28 20060701 99999999 

L0474 

TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME WITH 

FLEXIBLE SOFT APRON ANTERIOR $682.30 20030401 99999999 

L0476 

TLSO, SAGITTAL-CORONAL CONTROL, FLEXION COMPRESSION 

JACKET, TWO RIGID PLASTIC SH $1,406.97 20030401 99999999 

L0478 

TLSO, SAGITTAL-CORONAL CONTROL, FLEXION COMPRESSION 

JACKET, TWO RIGID PLASTIC SH $1,783.45 20030401 99999999 

L0480 

TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL 

WITHOUT INTERFACE LINER, $792.06 20060701 99999999 

L0482 

TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH 

INTERFACE LINER, MUL $145.78 20071101 99999999 

L0482 



L0484 

TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL 

WITHOUT INTERFACE LINER, $1,002.92 20060701 99999999 



L0486 

TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH 

INTERFACE LINER, MUL $1,129.24 20060701 99999999 

L0488 



L0490 

TLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC 

SHELL, WITH OVERLAPPING $133.37 20060701 99999999 

L0491 

TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL 

SYSTEM, TWO RIGID PLAST $362.08 20060701 99999999 

L0492 


SYSTEM, THREE RIGID PLA $4.12 20071101 99999999 

L0492 


SYSTEM, THREE RIGID PLA $246.75 20060701 99999999 

L0500 

LUMBAR-SACRAL-ORTHOSIS (LSO), FLEXIBLE, (LUMBO-SACRAL 

SURGICAL SUPPORT), $60.41 20030401 99999999 

L0510 

LSO,FLEXIBLE(LUMBO-SACRAL SURGICAL SUPPORT)CUSTOM 

FABRICATED $123.69 20030401 99999999 

L0515 LSO,FLEXIBLE,LUMBO-SACRAL SURGICAL SUPPORT ELASTIC TYPE $81.72 20030401 99999999 

L0520 LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,WITH APRON FRONT $255.29 20030401 99999999 

L0530 LSO,ANTERIOR-POSTERIOR CONTROL,WITH APRON FRONT $187.60 20030401 99999999 

L0540 LSO,LUMBAR FLEXION(WILLIAMS FLEXION TYPE) $267.76 20030401 99999999 

L0550 

LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,MOLDED TO PATIENT 

MOD $843.03 20030401 99999999 

L0560 

LSO,ANTERIOR-POSTERIOR-LATERAL CONTROL,MOLDED TO PATIENT 

MOD $1,440.34 20030401 99999999 

L0561 

LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH RIGID OR SEMI- 

RIGID POSTERIOR PANE $271.24 20030401 99999999 

L0565 LSO,ANTERIOR-POSTERIO-LATERAL CONTROL,CUSTOM FITTED $793.50 20030401 99999999 

L0600 

SACROILIAC, FLEXIBLE(SACROILIAC SURGICAL SUPPORT),CUSTOM 

FIT $77.18 20030401 99999999 

L0610 

SACROILIAC,FLEXIBLE(SACROILIAC SURGICAL SUPPORT)CUSTOM 

FABRI $77.18 20030401 99999999 

L0620 

SACROILIAC,SEMI-RIGID(GOLDTHWAITE,OSGOOD TYPES)WITH APRON 

FR $77.18 20030401 99999999 

L0621 

SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL 

SUPPORT, REDUCES MOTION AB $58.10 20060701 99999999 

L0622 

SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL 

SUPPORT, REDUCES MOTION AB $193.11 20060701 99999999 

L0623 

SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH 

RIGID OR SEMI-RIGID PA $9.68 20071101 99999999 

L0624 

SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH 

RIGID OR SEMI-RIGID PA $32.18 20071101 99999999 

L0625 

LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT, 

POSTERIOR EXTENDS FROM L-1 T $43.27 20060701 99999999 

L0626 

LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR 

PANEL(S), POSTERIOR EXTE $36.75 20060701 99999999 

L0627 

LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND 

POSTERIOR PANELS, POS $193.79 20060701 99999999 

L0628 


SUPPORT, POSTERIOR EXTEN $39.55 20060701 99999999 

L0629 


SUPPORT, POSTERIOR EXTEN $32.29 20071101 99999999 

L0630 

LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID 

POSTERIOR PANEL(S), POSTERI $76.36 20060701 99999999 

L0631 


ANTERIOR AND POSTERIOR PANE $483.98 20060701 99999999 

L0632 


ANTERIOR AND POSTERIOR PANE $84.13 20071101 99999999 



L0633 

LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH 

RIGID POSTERIOR FRAME/PAN $135.19 20060701 99999999 

L0634 


RIGID POSTERIOR FRAME/PAN $21.15 20071101 99999999 

L0635 

LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR 

FLEXION, RIGID POSTERIO $844.18 20060701 99999999 

L0636 

LUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR 

FLEXION, RIGID POSTERIO $1,070.07 20060701 99999999 

L0637 


RIGID ANTERIOR AND POSTER $624.97 20060701 99999999 

L0638 


RIGID ANTERIOR AND POSTER $621.81 20060701 99999999 

L0639 

LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID 

SHELL(S)/PANEL(S), POSTE $624.97 20060701 99999999 

L0640 

LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID 

SHELL(S)/PANEL(S), POSTE $493.33 20060701 99999999 

L0700 

CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES(CTLSO),MOLDED 

TO PT $1,343.75 20060701 99999999 

L0710 

CTLSO,ANTERIOR-POSTERIOR-LATERAL-CONTROL,MOLDED TO 

PATIENT $1,374.77 20060701 99999999 

L0810 

HALO PROCEDURE,CERVICAL HALO INCORPORATED INTO JACKET 

VEST $1,849.84 20060701 99999999 

L0820 

HALO PROCEDURE,CERVICAL HALO INCORPORATIED INTO PLASTER 

BODY $1,280.28 20060701 99999999 

L0830 

HALO PROCEDURE,CERVICAL HALO INCORPORATED INTO 

MILWAUKEE TYP $2,737.33 20060701 99999999 

L0859 

ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE 

COMPATIBLE SYSTEMS, RINGS A $528.06 20060701 99999999 

L0860 

ADDITION TO HALO PROCEDURES,MAGNETIC REASONANCE IMAGE 

CAMPAT $805.04 20030401 99999999 

L0861 

ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE 

MATERIAL $101.62 20060701 99999999 

L0900 TORSO SUPPORT,PTOSIS SUPPORT,CUSTOM FITTED $148.53 20030401 99999999 

L0910 TORSO SUPPORT,PTOSIS SUPPORT,CUSTOM FABRICATED $148.53 20030401 99999999 

L0920 TORSO SUPPORT,PENDULOUS ABDOMEN SUPPORT,CUSTOM FITTED $137.69 19990701 99999999 

L0930 

TORSO SUPPORT,PENDULOUS ABDOMEN SUPPORT,CUSTOM 

FABRICATED $148.53 20030401 99999999 

L0940 TORSO SUPPORT,POST SURGICAL SUPPORT,CUSTOM FITTED $100.93 20030401 99999999 

L0950 TORSO SUPPORT,POST SURGICAL SUPPORT,CUSTOM FABRICATED $100.93 20030401 99999999 

L0960 

TORSO SUPPORT,POST SURGICAL SUPPORT,PADS FOR POST 

SURGICAL $5.01 20071101 99999999 

L0970 TLSO,CORSET FRONT $87.05 20060701 99999999 

L0972 LSO,CORSET FRONT $77.89 20060701 99999999 

L0974 TLSO,FULL CORSET $112.25 20060701 99999999 

L0976 LSO,FULL CORSET $76.73 20060701 99999999 

L0978 AXILLARY CRUTCH EXTENSION $272.30 20060701 99999999 

L0980 PERONEAL STRAPS,PAIR $6.74 20060701 99999999 

L0982 STOCKING SUPPORTER GRIPS,SET OF FOUR (4) $8.15 20060701 99999999 

L0984 PROTECTIVE BODY SOCK, EACH $35.49 20060701 99999999 

L0986 

ADDITION TO SPINAL ORTHOSIS, RIGID OR SEMI-RIGID ABDOMINAL 

PANEL, PREFABRICATED $109.12 20030401 99999999 

L1000 CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS(CILSO)INCLUSIVE $1,596.75 20060701 99999999 

L1001 

CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, 

INFANT SIZE, PREFABRICATE $60.00 20071101 99999999 

L1005 

TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, 

INCLUDES FITTING AND ADJUST $1,508.96 20060701 99999999 



L1010 

ADDITION TO CERVICAL-THORACIC-LUMBAR-SACRAL 

ORTHOSIS(CTLSO) $35.43 20060701 99999999 

L1020 ADDDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,KYPHOSIS PAD $72.56 20060701 99999999 

L1025 

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,KYPHOSIS 

PAD,FLOATIN $73.64 20060701 99999999 

L1030 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR BOLSTER PAD $32.44 20060701 99999999 

L1040 

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR OR LUMBAR 

RIB $65.25 20060701 99999999 

L1050 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,STERNAL PAD $55.76 20060701 99999999 

L1060 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,THORACIC PAD $67.19 20060701 99999999 

L1070 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,TRAPEZIUS SLING $56.99 20060701 99999999 

L1080 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,OUTRIGGER $32.44 20060701 99999999 

L1085 

ADDITION TO CTLSO OR SCOLIOSIS 

ORTHOSIS,OUTRIGGER,BILATERAL $118.79 20060701 99999999 

L1090 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR SLING $65.95 20060701 99999999 

L1100 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,RING FLANGE,PLASTIC $105.14 20060701 99999999 

L1110 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,RING FLANGE,PLASTIC $205.91 20060701 99999999 

L1120 

ADDITION TO CTLSO,SCOLIOSIS ORTHOSIS,COVER FOR 

UPRIGHT,EACH $45.01 20060701 99999999 

L1200 

THORACIC-LUMBAR-SACRAL ORTHOSIS(TLSO),INCLUSIVE OR 

FURNISHIN $1,347.53 20060701 99999999 

L1210 ADDITION TO TLSO,(LOW PROFILE),LATERAL THORACIC EXTENSION $187.31 20060701 99999999 

L1220 ADDITION TO TLSO,(LOW PROFILE),ANTERIOR THORACIC EXTENSION $163.24 20060701 99999999 

L1230 

ADDITION TO TLSO,(LOW PROFILE)MILWAUKEE TYPE 

SUPERSTRUCTURE $276.65 20060701 99999999 

L1240 ADDITION TO TLSO,,(LOW PROFILE),LUMBAR DEROTATION PAD $58.18 20060701 99999999 

L1250 ADDITION TO TLSO,(LOW PROFILE),ANTERIOR ASIS PAD $43.94 20060701 99999999 

L1260 

ADDITION TO TLSO,(LOW PROFILE),ANTERIOR THORACIC 

DEROTATION $48.45 20060701 99999999 

L1270 ADDITION TO TLSO,(LOW PROFILE),ABDOMINAL PAD $65.37 20060701 99999999 

L1280 ADDITION TO TLSO,(LOW PROFILE),RIB GUSSET(ELASTIC)EACH $65.66 20060701 99999999 

L1290 ADDITION TO TLSO,(LOW PROFILE),LATERAL TROCHANTERIC PAD $91.99 20060701 99999999 

L1300 

OTHER SCOLIOSIS PROCEDURE,BODY JACKET MOLDED TO PATIENT 

MODE $1,184.61 20060701 99999999 

L1310 OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET $1,034.44 20060701 99999999 

L1499 UNLISTED PROCEDURE FOR SPINAL ORTHOSIS $39.00 20030401 99999999 

L1500 THORACIC-HIP-KNEE-ANKLE ORTHOSIS(THKAO),MOBILITY FRAME $1,416.27 20060701 99999999 

L1510 THKAO,STANDING FRAME $888.72 20060701 99999999 

L1520 THKAO,SWIVEL WALKER $1,900.93 20060701 99999999 

L1600 HIP ORTHOSIS (HO),ABDUCTION CONTROL OF HIP JOINTS,FLEXIBLE $79.47 20060701 99999999 

L1610 

HO,ABDUCTION CONTROL OF HIP JOINTS,FLEXIBLE,FREJKA COVER 

ONL $29.65 20060701 99999999 

L1620 HO,ABDUCTION CONTROL OF HIP JOINTS,FLEXIBLE,PAVLIK HARNESS $80.81 20060701 99999999 

L1630 HO,ABDUCTION CONTROL OF HIP JOINTS,SEMI-FLEXIBLE(VON ROSEN) $89.57 20060701 99999999 

L1640 HO,ABDUCTION CONTROL OF HIP JOINTS,STATIC,PELVIC BAND $192.89 20060701 99999999 

L1650 

HO,ABDUCTION CONTROL OF HIP 

JOINTS,STATIC,ADJUSTABLE,CUSTOM $126.12 20060701 99999999 

L1652 

HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE 

ABDUCTOR SPREADER BAR, ADULT $168.06 20060701 99999999 

L1660 

HO,ABDUCTION CONTROL OF HIP JOINTS,STATIC,PLASTIC,CUSTOM 

FIT $76.55 20060701 99999999 

L1680 HO,ABDUCTION CONTROL OF HIP JOINTS,DYNAMIC,PELVIC CONTROL $1,263.81 20060701 99999999 



L1685 

HO,ABDUCTION CONTROL OF HIP JOINT,POST-OPERATIVE HIP 

ABDUCT $1,077.14 20060701 99999999 

L1686 

HO,ABDUCTION CONTROL OF HIP JOINT,POST OPERATIVE 

HIP,CUSTOM $680.29 20060701 99999999 

L1690 

COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS 

PROVIDING ADDUCTION AN $911.67 20060701 99999999 

L1700 LEGG PERTHES ORTHOSIS,TORONTO TYPE $1,317.41 20060701 99999999 

L1710 LEGG PERTHES ORTHOSIS,NEWINGTON TYPE $1,458.77 20060701 99999999 

L1720 LEGG PERTHES ORTHOSIS,TRILATERAL,(TACHDIJAN TYPE) $1,284.26 20060701 99999999 

L1730 LEGG PERTHES ORTHOSIS,SCOTTISH RITE TYPE $947.32 20060701 99999999 

L1750 

LEGG PERTHES ORTHOSIS,LEGG PERTHES SLING (SAM BROWN 

TYPE) $97.38 20030401 99999999 

L1755 LEGG PERTHES ORTHOSIS,PATTEN BOTTOM TYPE $1,029.45 20060701 99999999 

L1800 KNEE ORTHOSIS (KO), ELASTIC WITH STAYS $39.83 20060701 99999999 

L1810 KO,ELASTIC WITH JOINTS $65.53 20060701 99999999 

L1815 KO,ELASTIC WITH CONDYLAR PADS $56.37 20060701 99999999 

L1820 KO,ELASTIC WITH CONDYLAR PADS AND JOINTS $76.34 20060701 99999999 

L1825 KO,ELASTIC KNEE CAP $22.77 20060701 99999999 

L1830 KO, IMMOBILIZER, CANVAS LONGITUDINAL $87.51 20060701 99999999 

L1831 

KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, 

PREFABRICATED, INCLUD $138.76 20060701 99999999 

L1832 

KO,ADJUSTABLE KNEE JOINTS,POSITIONAL ORTHOSIS,RIGID 

SUPPORT $342.56 20060701 99999999 

L1834 KO,WITHOUT KNEE JOINT,RIGID,MOLDED TO PATIENT MODEL $483.72 20060701 99999999 

L1836 

KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT 

INTERFACE MATERIAL, PREFAB $62.90 20060701 99999999 

L1840 

KO, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, 

CUSTOM FABRICATED $631.28 20060701 99999999 

L1843 

KO, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION 

AND EXTENSION JOINT, $42.63 20071101 99999999 

L1844 

KO, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION 

AND EXTENSION JOINT, $849.37 20060701 99999999 

L1845 KO/DBL UPRIGHT,THIGH & CALF,W/ADJ FLEX& EXT JNT,MEDIAL-LATER $403.56 20060701 99999999 

L1846 

KO,DBL UPRIGHT,THIGH&CALF,W/ADJ FLEXION&EXT JNT,MEDIAL- 

LATER $744.02 20060701 99999999 

L1847 

KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH 

INFLATABLE AIR SUPPORT $271.16 20060701 99999999 

L1850 KO/SWEDISH TYPE $222.29 20060701 99999999 

L1855 KO/MOLDED PLASTIC,THIGH & CALF SECT,W/DBL UPRIGHT KNEE JNT $98.47 20071101 99999999 

L1858 

KO,MOLDED PLASTIC,POLYCENTRIC KNEE JNT,PNEUMATIC KNEE 

PADS $8.98 20071101 99999999 

L1860 

KO,MODIFICATION OF SUPRACONDYLAR PROSTH SOCKET,MOLDED 

TO PAT $780.56 20060701 99999999 

L1870 

KO,DBL UPRIGHT,THIGH&CALF LACERS,MOLDED TO PATIENT MODEL 

W/ $68.51 20071101 99999999 

L1880 

KO,DBL UPRIGHT,NON MOLDED THIGH&CALF CUFFS/LACERS W/KNEE 

JNT $48.94 20071101 99999999 

L1885 

KO, SINGLE OR DOUBLE UPRIGHT, THIGH AND CALF, WITH 

FUNCTIONAL ACTIVE RESISTANCE $814.33 20030401 99999999 

L1900 ANKLE-FT ORTHOSIS,SPRING WIRE,DORIFLEXION ASSIST CALF BAND $146.01 20060701 99999999 

L1901 

ANKLE ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND 

ADJUSTMENT (E.G. NE $8.35 20060701 99999999 

L1902 AFO,ANKLE GAUNTLET,CUSTOM FITTED $45.66 20060701 99999999 

L1904 AFO,MOLDED ANKLE GAUNTLET,MOLDED TO PATIENT MODEL $389.39 20060701 99999999 

L1906 AFO/MULTILIGAMENTUS ANKLE SUPPORT $125.17 20060701 99999999 



L1907 

AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT 

INTERFACE/PADS, CUSTOM FABRICAT $265.28 20060701 99999999 

L1910 

AFO.POSTERIOR,SINGLE BAR,CLASP ATTACHMENT TO SHOE 

COUNTER $206.26 20060701 99999999 

L1920 

AFO,SINGLE UPRIGHT W/STATIC OR ADJ STOP(PHELPS OR 

PERLSTEIN) $157.25 20060701 99999999 

L1930 AFO/CUSTOM FITTED,PLASTIC $180.74 20060701 99999999 

L1932 

AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR 

EQUAL MATERIAL, $420.71 20060701 99999999 

L1940 AFO, MOLDED TO PATIENT MODEL, PLASTIC $334.24 20060701 99999999 

L1945 AFO,MOLDED TO PATIENT MODEL,PLASTIC,RIGID ANTERIOR TIBIAL $624.75 20060701 99999999 

L1950 AFO/SPIRAL/MOLDED TO PATIENT MODEL(IRM TYPE) PLASTIC $522.07 20060701 99999999 

L1951 

ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE 

MEDICINE TYPE), PLASTI $395.95 20060701 99999999 

L1960 

AFO, POSTERIOR SOLID ANKLE, MOLDED TO PATIENT MODEL, 

PLASTIC $383.21 20060701 99999999 

L1970 AFO/PLASTIC MOLDED TO PATIENT MODEL,W/ANKLE JOINT $361.72 20060701 99999999 

L1971 

ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE 

JOINT, PREFABRICATED, $220.98 20060701 99999999 

L1980 

AFO,SGL UPRIGHT FREE PLANTAR DORSIFLEXION,SOLID 

STIRRUP,CALF $312.57 20060701 99999999 

L1990 

AFO/DBL UPRIGHT FREE PLANTAR DORSIFLEXION,SOLID 

STIRRUP,CALF $367.42 20060701 99999999 

L2000 

KNEE-ANKLE-FOOT-ORTHOSES,SGL UPRIGHT,FREE KNEE,FREE 

ANKLE, $1,011.11 20060701 99999999 

L2005 

KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE 

UPRIGHT, STANCE $1,931.89 20060701 99999999 

L2010 

KAFO,SGL UPRIGHT,FREE ANKLE,SOLID STIRRUP,THIGH&CALF 

BANDS, $883.52 20060701 99999999 

L2020 KAFO,DBL UPRIGHT,FREE KNEE,FREE ANKLE,SOLID STIRRUP,THIGH $1,262.37 20060701 99999999 

L2030 

KAFO/DBL UPRIGHT,FREE ANKLE,SOLID STIRRUP,THIGH&CALF 

BANDS/ $764.12 20060701 99999999 

L2034 

KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH 

OR WITHOUT FREE MOT $1,016.93 20060701 99999999 

L2035 KAFO, FULL PLASTIC, STATIC, PREFABRICATED (PEDIATRIC SIZE) $88.21 20060701 99999999 

L2036 

KAFO,FULL PLASTIC,DOUBLE UPRIGHT,FREE KNEE,MOLDED TO 

PATIENT $1,088.63 20060701 99999999 

L2037 KAFO,FULL PLASTIC,SGL UPRIGHT,FREE KNEE,MOLDED TO PATIENT $1,106.81 20060701 99999999 

L2038 KAFO,FULL PLASTIC,W/O KNEE JNT,MULTI-AXIS ANKLE,MOLDED TO $761.44 20060701 99999999 

L2039 

KAFO, FULL PLASTIC, SINGLE UPRIGHT, POLY-AXIAL HINGE, MEDIAL 

LATERAL ROTATION CO $1,815.80 20030401 99999999 

L2040 

HIP-KNEE-ANKLE-FOOT ORTHOSIS TORSION CONTROL,BILAT 

ROTATION{ $79.09 20060701 99999999 

L2050 

HKAFO,TORSION CONTROL,BIL TORSION CABLES,HIP JNT,PELVIC 

BAND $402.91 20060701 99999999 

L2060 

HKAFO,TORSION CONTROL.BIL TORSION CABLES,BALL BEARING HIP 

JN $493.79 20060701 99999999 

L2070 

HKAFO,TORSION CONTROL,UNIL ROTATION STRAPS,PELVIC 

BAND/BELT $73.64 20060701 99999999 

L2080 

HKAFO,TORSION CONTROL,UNIL TORSION CABLE,HIP JNT,PELVIC 

BAND $260.29 20060701 99999999 

L2090 

HKAFO,TORSION CONTROL,UNIL TORSION CABLE,BALL BEARING HIP 

JN $349.73 20060701 99999999 

L2102 AFO,FRACTURE ORTHOSIS,TIBIAL FX CAST ORTHESIS,PLASTER TYPE $296.85 20030401 99999999 

L2104 AFO,FX ORTHOSIS,TIBIAL FX CAST ORTHESIS,SYNTHETIC TYPE CASTI $285.43 20030401 99999999 



L2106 AFO,FX ORTHOSIS,TIBIAL FX CAST ORTHOSIS,THERMOPLASTIC TYPE $577.01 20060701 99999999 

L2108 AFO,FX ORTHOSIS, TIBIAL FX CAST ORTHOSIS,MOLDED TO PATIENT $652.45 20060701 99999999 

L2112 AFO,FX ORTHOSIS,TIBIAL FX ORTHOSIS,SOFT CUSTOM FITTED $278.42 20060701 99999999 

L2114 AFO,FX ORTHOSIS,TIBIAL FX ORTHOSIS, SEMI-RIGID CUSTOM FITTED $442.48 20060701 99999999 

L2116 AFO,FX ORTHOSIS,TIBIAL FX ORTHOSIS,RIGID CUSTOM FITTED $551.26 20060701 99999999 

L2122 

KAFO FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,PLASTER TYPE 

CASTI $570.86 20030401 99999999 

L2124 

KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,SYNTHETIC TYPE 

CAS $789.21 20030401 99999999 

L2126 

KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,THERMOPLASTIC 

TYPE $715.88 20060701 99999999 

L2128 

KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,MOLDED TO 

PATIENT{ $1,095.10 20060701 99999999 

L2132 

KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,SOFT CUSTOM 

FITTED $417.55 20060701 99999999 

L2134 

KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,SEMIRIGID 

CUSTOM $655.07 20060701 99999999 

L2136 

KAFO,FX ORTHOSIS,FEMORAL FX CAST ORTHOSIS,RIGID CUSTOM 

FITTE $885.48 20060701 99999999 

L2180 

ADDITION TO LOWER EXTREMITY FX ORTHOSIS,PLASTIC SHOE 

INSERT $106.64 20060701 99999999 

L2182 

ADDITION TO LOWER EXTREMITY FX ORTHOSIS,DROP LOCK KNEE 

JOINT $51.50 20060701 99999999 

L2184 

ADDITION TO LOWER EXTREMITY FX ORTHOSIS,LTD MOTION KNEE 

JNT $46.27 20060701 99999999 

L2186 

ADDITION TO LOWER EXTREMITY FX ORTHOSIS,ADJ MOTION KNEE 

JNT $70.78 20060701 99999999 

L2188 

ADDITION TO LOWER EXTREMITY FX ORTHOSIS,QUADRILATERAL 

BRIM $45.01 20060701 99999999 

L2190 ADDITION TO LOWER EXTREMITY FX ORTHOSIS,WAIST BELT $31.73 20060701 99999999 

L2192 ADDITION TO LOWER EXTREMITY ORTHOSIS,HIP JNT,PELVIC BAND, $288.79 20060701 99999999 

L2200 ADDITIONAL TO LOWER EXTREMITY LTD ANKLE MOTION EACH JOINT $52.18 20060701 99999999 

L2210 ADDITION TO LOWER EXTREMITY,DORSIFLEXION ASSIST(PLANTAR $64.58 20060701 99999999 

L2220 

ADDITION TO LOWER EXTREMITY,DORSIFLEXION AND PLANTAR 

FLEXION $77.39 20060701 99999999 

L2230 ADDITION TO LOWER EXTREMITY,SPLIT FLAT CALIPER STIRRUPS AND $86.84 20060701 99999999 

L2232 

ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR 

TOTAL CONTACT ANKLE $7.34 20071101 99999999 

L2240 

ADDITION TO LOWER EXTREMITY,ROUND CALIPER AND PLATE 

ATTACH $86.26 20060701 99999999 

L2250 

ADDITION TO LOWER EXTREMITY,FOOT PLATE,MOLDED TO PATIENT 

MOD $382.09 20060701 99999999 

L2260 ADDITION TO LOWER EXTREMITY,REINFORCED SOLID STIRRUPS $329.86 20060701 99999999 

L2265 ADDITION TO LOWER EXTREMITY,LONG TONGUE STIRRUP $138.46 20060701 99999999 

L2270 

ADDITION TO LOWER EXTREMITY,VARUS/VALGUS CORRECTION(T) 

STRAP $51.47 20060701 99999999 

L2275 

ADDITION TO LOWER EXTREMITY, VARUS/VULGUS CORRECTION, 

PLASTIC MODIFICATION, PADD $83.43 20060701 99999999 

L2280 ADDITION TO LOWER EXTREMITY,MOLDED INNER BOOT $340.37 20060701 99999999 

L2300 ADDITION TO LOWER EXTREMITY,ABDUCTION BAR JOINTED ADJ $252.68 20060701 99999999 

L2310 ADDITION TO LOWER EXTREMITY,ABDUCTION BAR-STRAIGHT $133.97 20060701 99999999 

L2320 ADDITION TO LOWER EXTREMITY,NON-MOLDED LACER $128.11 20060701 99999999 

L2330 ADDITION TO LOWER EXTREMITY,LACER MOLDED TO PATIENT MODEL $355.37 20060701 99999999 

L2335 ADDITION TO LOWER EXTREMITY,ANTERIOR SWING BAND $182.14 20060701 99999999 



L2340 

ADDITION TO LOWER EXTREMITY,PER-TIBIAL SHELL,MOLDED TO 

PATIE $301.55 20060701 99999999 

L2350 ADDITION TO LOWER EXTREMITY,PROSTHETIC TYPE,(BK) SOCKET $995.04 20060701 99999999 

L2360 ADDITION TO LOWER EXTREMITY,EXTENDED STEEL SHANK $32.72 20060701 99999999 

L2370 ADDITION TO LOWER EXTREMITY,PATTEN BOTTOM $282.82 20060701 99999999 

L2375 ADDITION TO LOWER EXTREMITY,TORSION CONTROL,ANKLE JOINT $81.01 20060701 99999999 

L2380 ADDITION TO LOWER EXTREMITY,TORSION CONTROL,STRAIGHT KNEE $95.66 20060701 99999999 

L2385 ADDITION TO LOWER EXTREMITY,STRAIGHT KNEE JOINT,HEAVY DUTY $88.81 20060701 99999999 

L2387 

ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR 

CUSTOM FABRICATED KNEE $114.64 20060701 99999999 

L2390 ADDITION TO LOWER EXTREMITY,OFFSET KNEE JOINT,EACH JOINT $89.59 20060701 99999999 

L2395 ADDITION TO LOWER EXTREMITY,OFFSET KNEE JOINT,HEAVY DUTY $98.74 20060701 99999999 

L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE $56.84 20060701 99999999 

L2405 ADDITION TO KNEE JOINT,DROP LOCK,EACH JOINT $41.10 20060701 99999999 

L2415 ADDITION TO KNEE JOINT,CAM LOCK(SWISS,FRENCH,BAIL TYPES) $57.26 20060701 99999999 

L2425 ADDITION TO KNEE JOINT,DISC OR DIAL LOCK FOR ADJUSTABLE KNEE $67.58 20060701 99999999 

L2430 

ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND 

PROGRESSIVE KNEE EXTENSION, $67.58 20060701 99999999 

L2435 ADDITION TO KNEE JOINT,POLYCENTRIC JOINT,EACH JOINT $112.21 20030401 99999999 

L2492 ADDITION TO KNEE JOINT,LIFT LOOP FOR DROP LOCK RING $58.97 20060701 99999999 

L2500 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,GLUTEAL $221.54 20060701 99999999 

L2510 

ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT 

BEARING,QUADRILATER $475.07 20060701 99999999 

L2520 


BEARING,QUADRILATER $299.85 20060701 99999999 

L2525 

ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING,ISCHIAL 

CON $742.64 20060701 99999999 

L2526 

ADDITION TO LOWER EXTREM,THIGH/WEIGHT BEARING,ISCHIAL 

CONTAI $406.87 20060701 99999999 

L2530 


BEARING,LACER,NONMO $216.31 20060701 99999999 

L2540 


BEARING,LACER,MOLDE $354.49 20060701 99999999 

L2550 

ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,HIGH 

ROLL $239.17 20060701 99999999 

L2570 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,HIP JOINT,CLEVIS $474.60 20060701 99999999 

L2580 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,PELVIC SLING $356.24 20060701 99999999 

L2600 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,HIP JOINT,CLEVIS $207.90 20060701 99999999 

L2610 ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,HIP JNT,CLEVIS $230.82 20060701 99999999 

L2620 ADDITION TO LOWER EXTREMITY,PELVIC CNTRL,HIP JNT,HEAVY DUTY $219.42 20060701 99999999 

L2622 

ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,HIP JOINT,ADJ 

FLE $275.04 20060701 99999999 

L2624 ADDITION TO LOWER EXTREMITY,PELVIC CONT,HIP JOINT,ADJ FLEX $344.43 20060701 99999999 

L2627 ADDITION TO LOWER EXTREMITY,PELVIC CNTRL,PLASTIC,MOLDED TO $627.76 20060701 99999999 

L2628 

ADDITION TO LOWER EXTREMITY,PELVIC CONTROL,METAL 

FRAME,RECIP $837.46 20060701 99999999 

L2630 ADDITION TO LOWER EXTREMITY,PELVIC CNTRL,BAND & BELT,UNIL $180.77 20060701 99999999 

L2640 

ADDITION TO LOWER EXTREMITY,PELVIC 

CNTRL,BAND&BELT,BILATERAL $376.91 20060701 99999999 

L2650 

ADDITION TO LOWER EXTREMITY,PELVIC & THORACIC 

CNTRL,GLUTEAL $68.40 20060701 99999999 

L2660 ADDITION TO LOWER EXTREMITY,THORACIC CNTRL,THORACIC BAND $120.75 20060701 99999999 



L2670 

ADDITION TO LOWER EXTREMITY,THORACIC CNTRL,PARASPINAL 

UPRGTS $102.91 20060701 99999999 

L2680 

ADDITION TO LOWER EXTREMITY,THORACIC CONTROL,LATERAL 

SUPPORT $90.39 20060701 99999999 

L2750 

ADDITION TO LOWER EXTREMITY ORTHOSIS,PLATING CHROME OR 

NICKE $36.56 20060701 99999999 

L2755 

ADDITION TO LOWER EXTREMITY ORTHOSIS, CARBON GRAPHITE 

LAMINATION $106.78 20060701 99999999 

L2760 

ADDITION TO LOWER EXTREMITY ORTHOSIS,EXTENSION,PER 

EXTENSION $62.29 20060701 99999999 

L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR $61.43 20060701 99999999 

L2770 

ADDITION TO LOWER EXTREMITY ORTHOSIS,STAINLESS STEE-PER 

BAR $46.96 20060701 99999999 

L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS,NON-CORROSIVE FINISH $48.74 20060701 99999999 

L2785 

ADDITION TO LOWER EXTREMITY ORTHOSIS,DROP LOCK 

RETAINER,EACH $28.68 20060701 99999999 

L2795 

ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE CONTROL,FULL 

KNEE $68.92 20060701 99999999 

L2800 

ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE CONTROL,KNEE 

CAP $84.76 20060701 99999999 

L2810 

ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE 

CONTROL,CONDYLAR $68.28 20060701 99999999 

L2820 

ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR 

MOLD $102.02 20060701 99999999 

L2830 

ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR 

MOLD $85.90 20060701 99999999 

L2840 ADDDITION TO LOWER EXTREMITY ORTHOSIS,TIBIAL LENGTH SOCK $21.25 20060701 99999999 

L2850 

ADDITION TO LOWER EXTREMITY ORTHOSIS,FEMORAL LENGTH 

SOCK,FX $35.74 20060701 99999999 

L2860 

ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, 

CONCENTRIC ADJUSTABLE TORSION $267.64 20030401 99999999 

L2999 UNLISTED PROCEDURES FOR LOWER EXTREMITY ORTHOSES $29.12 20030401 99999999 

L3000 FOOT,INSERT,REMOVABLE,MOLDED TO PATIENT MODEL,"UCB" TYPE $148.10 20060701 99999999 

L3001 

FOOT,INSERT,REMOVABLE,MOLDED TO PATIENT MODEL 

SPENCO,EACH $62.35 20060701 99999999 

L3002 

FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 

PLASTAZOTE $76.14 20060701 99999999 

L3003 

FOOT,INSERT,REMOVABLE,MOLDED TO PATIENT MODEL,SILICONE 

GEL,E $82.15 20060701 99999999 

L3010 

FOOT,INSSER,REMOVABLE,MOLDED TO PATIENT 

MODEL,LONGITUDINAL $82.15 20060701 99999999 

L3020 

FOOT,INSERT,REMOVABLE,MOLDED TO PATIENT MODEL 

LONGITUDINAL $93.55 20060701 99999999 

L3030 FOOT,INSERT,REMOVABLE,FORMED TO PATIENT FOOT,EACH $35.98 20060701 99999999 

L3031 

FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY 

ORTHOSIS, HIGH STRENG $5.99 20071101 99999999 

L3040 

FOOT,ARCH 

SUPPORT,REMOVABLE,PREMOLDED,LONGITUDINAL,EACH $22.18 20060701 99999999 

L3050 FOOT,ARCH SUPPORT,REMOVABLE,PREMOLDED,METATARSAL,EACH $22.18 20060701 99999999 

L3060 

FOOT,ARCH 

SUPPORT,REMOVABLE,PREMOLDED,LONGITUDINAL/METATARSA $34.78 20060701 99999999 

L3070 

FOOT,ARCH SUPPORT,NON-REMOVABLE ATTACHED TO 

SHOE,LONGITUDINA $14.98 20060701 99999999 

L3080 


SHOE,METATARSAL $14.98 20060701 99999999 

L3090 


SHOE,LONGITUDINA $19.19 20060701 99999999 



L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT $20.38 20060701 99999999 

L3140 FOOT,ABDUCTION ROTATION BARS,ATTACHED TO SHOE $41.98 20060701 99999999 

L3150 FOOT,ABDUCTION ROTATION BARS,CLAMPED TO SHOE $38.38 20060701 99999999 

L3160 FOOT,TORQUE HEELS $3.01 20071101 99999999 

L3170 FOOT,PLASTIC HEEL STABILZER $23.99 20060701 99999999 

L3201 

ORTHOPEDIC SHOE,OXFORD WITH SUPINATOR OR 

PRONATOR,INFANT $2.00 20071101 99999999 

L3202 ORTHOPEDIC SHOE,OXFORD WITH SUPINATOR OR PRONATOR,CHILD $2.00 20071101 99999999 

L3203 

ORTHOPEDIC SHOE,OXFORD WITH SUPINATOR OR 

PRONATOR,JUNIOR $2.00 20071101 99999999 

L3204 

ORTHOPEDIC SHOE,HIGHTOP WITH SUPINATOR OR 

PRONATOR,INFANT $2.00 20071101 99999999 

L3206 ORTHOPEDIC SHOE,HIGHTOP WITH SUPINATOR OR PRONATOR,CHILD $3.00 20071101 99999999 

L3207 

ORTHOPEDIC SHOE,HIGHTOP WITH SUPINATOR OR 

PRONATOR,JUNIOR $3.00 20071101 99999999 

L3208 SURGICAL BOOT,EACH,INFANT $3.00 20071101 99999999 

L3209 SUURGICAL BOOT,EACH CHILD $3.00 20071101 99999999 

L3211 SURGICAL BOOT,EACH,JUNIOR $3.00 20071101 99999999 

L3212 BENESCH BOOT,PAIR,INFANT $6.13 20071101 99999999 

L3213 BENESCH BOOT,PAIR,CHILD $6.13 20071101 99999999 

L3214 BENESCH BOOT,PAIR,JUNIOR $6.13 20071101 99999999 

L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOES, OXFORD $5.37 20071101 99999999 

L3216 ORTHOPEDIC FOOTWEAR, LADIES SHOES, DEPTH INLAY $5.37 20071101 99999999 

L3217 ORTHOPEDIC FOOTWEAR,LADIES SHOES,HIGHTOP,DEPTH INLAY $6.84 20071101 99999999 

L3218 ORTHOPEDIC FOOTWEAR,LADIES SURGICAL BOOT,EACH $35.17 20030401 99999999 

L3219 ORTHOPEDIC FOOTWEAR, MENS SHOES, OXFORD $5.37 20071101 99999999 

L3221 ORTHOPEDIC FOOTWEAR,MENS SHOES,DEPTH INLAY $6.84 20071101 99999999 

L3222 ORTHOPEDIC FOOTWEAR,MENS SHOES,HIGHTOP,DEPTH INLAY $6.84 20071101 99999999 

L3223 ORTHOPEDIC FOOTWEAR,MENS SURGICAL BOOT,EACH $26.00 20030401 99999999 

L3224 

ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN 

INTEGRAL PART OF A BRACE ( $74.31 20060701 99999999 

L3225 

ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN 

INTEGRAL PART OF A BRACE (OR $55.34 20060701 99999999 

L3230 ORTHOPEDIC FOOTWEAR,CUSTOM SHOES,DEPTH INLAY $8.55 20071101 99999999 

L3250 ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, $8.55 20071101 99999999 

L3251 FOOT,SHOE MOLDED TO PATIENT MODEL,SILICONE SHOE,EACH $8.55 20071101 99999999 

L3252 

FOOT,SHOE MOLDED TO PATIENT MODEL,PLASTAZOTE,CUSTOM 

FABRICAT $8.55 20071101 99999999 

L3253 FOOT,MOLDED SHOE PLASTAZOTE CUSTOM FITTED,EACH $8.55 20071101 99999999 

L3254 NON-STANDARD SIZE OR WIDTH $8.55 20071101 99999999 

L3255 NON-STANDARD SIZE OR LENGTH $8.55 20071101 99999999 

L3257 ORTHOPEDIC FOOTWEAR,ADDITIONAL CHARGE FOR SPLIT SIZE $8.55 20071101 99999999 

L3260 AMBULATORY SURGICAL BOOT,EACH $2.28 20071101 99999999 

L3265 PLASTAZOTE SANDAL,EACH $2.28 20071101 99999999 

L3300 LIFT,ELEVATION,HEEL,TAPERED TO METATARSALS,PER INCH $24.58 20060701 99999999 

L3310 LIFT ELEVATION,HEEL AND SOLE,NEOPRENE,PER INCH $52.00 20060701 99999999 

L3320 LIFT,ELEVATION,HEEL AND SOLE,CORK,PER INCH $0.23 20071101 99999999 

L3330 LIFT,ELEVATION,METAL EXTENSION(SKATE) $266.82 20060701 99999999 

L3332 LIFT,ELEVATION,INSIDE SHOE,TAPERED,UP TO ONE-HALF INCH $34.78 20060701 99999999 

L3334 LIFT,ELEVATION,HEEL,PER INCH $17.99 20060701 99999999 

L3340 HEEL WEDGE,SACH $40.18 20060701 99999999 

L3350 HEEL WEDGE $10.80 20060701 99999999 

L3360 SOLE WEDGE,OUTSIDE SOLE $16.79 20060701 99999999 

L3370 SOLE WEDGE, BETWEEN SOLE $23.37 20060701 99999999 

L3380 CLUBFOOT WEDGE $23.37 20060701 99999999 

L3390 OUTFLARE WEDGE $23.37 20060701 99999999 

L3400 METATARSAL BAR WEDGE,ROCKER $19.19 20060701 99999999 

L3410 METATARSAL BAR WEDGE,BETWEEN SOLE $43.76 20060701 99999999 



L3420 FULL SOLE AND HEEL WEDGE,BETWEEN SOLE $25.78 20060701 99999999 

L3430 HEEL,COUNTER,PLASTIC REINFORCED $75.55 20060701 99999999 

L3440 HEEL,COUNTER,LEATHER REINFORCE $35.98 20060701 99999999 

L3450 HEEL,SACH CUSHION TYPE $49.76 20060701 99999999 

L3455 HEEL,NEW LEATHER,STANDARD $19.19 20060701 99999999 

L3460 HEEL,NEW RUBBER,STANDARD $16.18 20060701 99999999 

L3465 HEEL,THOMAS WITH WEDGE $27.59 20060701 99999999 

L3470 HEEL,THOMAS EXTENDED TO BALL $29.38 20060701 99999999 

L3480 HEEL,PAD AND DEPRESSION FOR SPUR $29.38 20060701 99999999 

L3485 HEEL,PAD,REMOVABLE FOR SPUR $1.95 20071101 99999999 

L3500 MISCELLANEOUS SHOE ADDITION,INSOLE,LEATHER $13.79 20060701 99999999 

L3510 MISCELLANEOUS SHOE ADDITION,INSOLE,RUBBER $13.79 20060701 99999999 

L3520 

MISCELLANEOUS SHOE ADDITION,INSOLE,FELT COVERED WITH 

LEATHER $14.98 20060701 99999999 

L3530 MISCELLANEOUS SHOE ADDITION,SOLE,HALF $14.98 20060701 99999999 

L3540 MISCELLANEOUS SHOE ADDITION,SOLE,FULL $23.99 20060701 99999999 

L3550 MISCELLANEOUS SHOE ADDITION,TOE TAP,STANDARD $4.19 20060701 99999999 

L3560 MISCELLANEOUS SHOE ADDITION,TOE TAP,HORSESHOE $10.80 20060701 99999999 

L3570 MISCELLANEOUS SHOE ADDITION,SPECIAL EXTENSION TO INSTEP $40.18 20060701 99999999 

L3580 

MISCELLANEOUS SHOE ADDITION,CONVERT INSTEP TO VELCRO 

CLOSURE $30.58 20060701 99999999 

L3590 

MISCELLANEOUS SHOE ADDITION,CONVERT FIRM SHOE COUNTER TO 

SOF $25.18 20060701 99999999 

L3595 MISCELLANEOUS SHOE ADDITION,MARCH BAR $19.78 20060701 99999999 

L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER,CALIPER $35.98 20060701 99999999 

L3610 

TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER,CALIPER 

PLA $47.36 20060701 99999999 

L3620 

TRANSFER OF AN ORTHOSIS FROME ONE SHOE TO ANOTHER,SOLID 

STIR $35.98 20060701 99999999 

L3630 

TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER,SOLID 

STIRR $47.36 20060701 99999999 

L3640 

TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER,DENNIS 

BROW $20.38 20060701 99999999 

L3649 

UNLISTED PROCEDURES FOR FOOT ORTHOPEDIC SHOES,SHOE 

MODIFICAT $36.40 20030401 99999999 

L3650 

SHOULDER ORTHOSIS,FIGURE OF "8" DESIGN ABDUCTION 

RESTRAINER $41.53 20060701 99999999 

L3651 

SHOULDER ORTHOSIS, SINGLE SHOULDER, ELASTIC, 

PREFABRICATED, INCLUDES FITTING AND $28.25 20060701 99999999 

L3652 

SHOULDER ORTHOSIS, DOUBLE SHOULDER, ELASTIC, 


L3660 

SO,FIGURE OF "8" DESIGN ABDUCTION RESTRAINER,CANVAS & 

WEBBIN $57.20 20060701 99999999 

L3670 SO,ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE) $84.70 20060701 99999999 

L3671 

SHOULDER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, 

MAY INCLUDE SOFT INTERFA $386.62 20060701 99999999 

L3672 

SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), 

THORACIC COMPONENT A $480.79 20060701 99999999 

L3673 

SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), 

THORACIC COMPONENT A $524.01 20060701 99999999 

L3675 

SO, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE, 

OR EQUAL $75.29 20060701 99999999 

L3677 

SHOULDER ORTHOSIS, HARD PLASTIC, SHOULDER STABILIZER, PRE- 

FABRICATED, INCLUDES F $13.08 20071101 99999999 

L3700 ELBOW ORTHOSES (EO),ELASTIC WITH STAYS $45.77 20060701 99999999 

L3701 

ELBOW ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING 

AND ADJUSTMENT (E.G. NE $8.74 20060701 99999999 



L3702 

ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT 

INTERFACE, STRAPS, CUSTOM FABRI $123.89 20060701 99999999 

L3710 EO,ELASTIC WITH METAL JOINTS $67.12 20060701 99999999 

L3720 EO,DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS,FREE MOTION $599.65 20060701 99999999 

L3730 

EO,DOUBLE UPRIGHT WITH FOREARM/ARM 

CUFFS,EXTENSION/FLEXION $646.73 20060701 99999999 

L3740 

EO,DOUBLE UPRIGHT WITH FOREARME/ARM CUFFS,ADJUSTABLE 

POSITIO $972.27 20060701 99999999 

L3760 

ELBOW ORTHOSIS, WITH ADJUSTABLE POSITION LOCKING JOINT(S), 

PREFABRICATED, INCLUD $214.57 20060701 99999999 

L3762 

ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, INCLUDES SOFT 

INTERFACE MATERIAL, PREFABR $46.13 20060701 99999999 

L3763 

ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY 

INCLUDE SOFT INTERFACE, ST $550.16 20060701 99999999 

L3764 

ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE 

NONTORSION JOINTS, ELASTIC BANDS $582.59 20060701 99999999 

L3765 

ELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS, 

MAY INCLUDE SOFT INTERF $550.16 20060701 99999999 

L3766 

ELBOW WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE 

NONTORSION JOINTS, ELASTI $582.59 20060701 99999999 

L3800 

WRIST-HAND-FINGER-ORTHOSES,SHORT OPPONENS,NO 

ATTACHMENTS $14.96 20071101 99999999 

L3805 WHFO,LONG OPPONENS,NO ATTACHMENT $15.55 20071101 99999999 

L3806 

WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE 

NONTORSION JOINT(S), ELASTIC BA $30.49 20071101 99999999 

L3807 

WHFO, EXTENSION ASSIST, WITH INFLATABLE PALMER AIR SUPPORT, 

WITH OR WITHOUT THUM $107.29 20060701 99999999 

L3808 

WRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY 

INCLUDE SOFT INTERFACE MAT $18.94 20071101 99999999 

L3810 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,THUMB 

ABDUCTION BAR $3.91 20071101 99999999 

L3815 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,SECOND M.P. 

ABDUCT $3.99 20071101 99999999 

L3820 WHFO,ADDITION TO SHORT AND LONG OPPENENS,I.P. EXTENSION $8.01 20071101 99999999 

L3825 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,M.P. EXTENSION 

STOP $3.99 20071101 99999999 

L3830 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,M.P. EXTENSION 

ASSI $5.70 20071101 99999999 

L3835 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,M.P. SPRING 

EXTEN $6.53 20071101 99999999 

L3840 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,SPRING SWIVEL 

THUMB $3.56 20071101 99999999 

L3845 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,THUMB I.P. 

EXTENSIO $4.15 20071101 99999999 

L3850 WHFO,ADDITION TO SHORT AND LONG OPPONENS,ACTION WRIST $7.12 20071101 99999999 

L3855 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,ADJUSTABLE M.P. 

FLE $10.44 20071101 99999999 

L3860 

WHFO,ADDITION TO SHORT AND LONG OPPONENS,ADJUSTABLE M.P. 

FLE $13.06 20071101 99999999 

L3890 

ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, 

CONCENTRIC ADJUSTABLE TORSION $26.76 20071101 99999999 

L3900 

WHFO,DYNAMIC FLEXOR HINGE,RECIPROCAL WRIST 

EXTENSION/FLEXION $763.00 20060701 99999999 

L3901 WHFO,DYNAMIC FLEXOR HINGE,RECIPROCAL WRIST,CABLE DRIVEN $941.24 20060701 99999999 

L3902 WHFO,EXTERNAL POWERED,COMPRESSED GAS $1,198.81 20030401 99999999 

L3904 WHFO,EXTERNAL POWERED,ELECTRIC $2,508.92 20060701 99999999 

L3905 

WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION 

JOINTS, ELASTIC BANDS, TURN $425.51 20060701 99999999 



L3906 WHFO,WRIST GAUNTLET,MOLDED TO PATIENT MODEL $255.64 20060701 99999999 

L3907 

WHFO,WRIST GAUNTLED WITH THUMB SPICA,MOLDED TO PATIENT 

MODEL $55.57 20071101 99999999 

L3908 

WHFO,WRIST EXTENSION CONTROL COCK-UP,CANVAS OR LEATHER 

DESIG $49.46 20060701 99999999 

L3909 

WRIST ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND 

ADJUSTMENT (E.G. NE $6.05 20060701 99999999 

L3910 WHFO,SWANSON DESIGN $25.52 20071101 99999999 

L3911 

WRIST HAND FINGER ORTHOSIS, ELASTIC, PREFABRICATED, 

INCLUDES FITTING AND ADJUSTM $10.63 20060701 99999999 

L3912 WHFO,FLEXION GLOVE WITH ELASTIC FINGER CONTROL $67.78 20060701 99999999 

L3913 

HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT 

INTERFACE, STRAPS, CUSTOM $116.21 20060701 99999999 

L3914 WHFO, WRIST EXTENSION COCK-UP $78.37 20030401 99999999 

L3915 

WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION 

JOINT(S), ELASTIC BANDS, TU $35.68 20071101 99999999 

L3916 WHFO,WRIST EXTENSION COCK-UP,WITH OUTRIGGER $8.43 20071101 99999999 

L3917 

HAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, 


L3918 WHFO,KNUCKLE BENDER $6.64 20071101 99999999 

L3919 

HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, 

STRAPS, CUSTOM FABRIC $116.21 20060701 99999999 

L3920 WHFO,KNUCKLE BENDER,WITH OUTRIGGER $7.95 20071101 99999999 

L3921 

HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION 

JOINTS, ELASTIC BANDS, TUR $137.83 20060701 99999999 

L3922 WHFO,KNUCKLE BENDER,TWO SEGMENT TO FLEX JOINTS $7.95 20071101 99999999 

L3923 

HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, 

INCLUDES FITTING AND ADJU $16.69 20060701 99999999 

L3924 WHFO,OPPENHEIMER $7.95 20071101 99999999 

L3925 

FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL 

INTERPHALANGEAL (DIP), NO $51.93 20080101 99999999 

L3926 WHFO,THOMAS SUSPENSION $7.95 20071101 99999999 

L3928 WHFO,FINGER EXTENSION,WITH CLOCK SPRING $4.27 20071101 99999999 

L3929 

HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION 

JOINT(S), TURNBUCKLES, ELA $91.24 20080101 99999999 

L3930 WHFO,FINGER EXTENSION,WITH WRIST SUPPORT $4.86 20071101 99999999 

L3931 

WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE 

NONTORSION JOINT(S), TURNBUCKLE $195.96 20080101 99999999 

L3932 WHFO,SAFETY PIN,SPRING WIRE $3.68 20071101 99999999 

L3933 

FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT 

INTERFACE, CUSTOM FABRICATED, $91.55 20060701 99999999 

L3934 WHFO,SAFETY PIN,MODIFIED $3.68 20071101 99999999 

L3935 

FINGER ORTHOSIS, NONTORSION JOINT, MAY INCLUDE SOFT 

INTERFACE, CUSTOM FABRICATED $94.79 20060701 99999999 

L3936 WHFO,PALMER $5.93 20071101 99999999 

L3938 WHFO,DORSAL WRIST $7.12 20071101 99999999 

L3940 WHFO,DORSAL WRIST,WITH OUTRIGGER ATTACHMENT $8.07 20071101 99999999 

L3942 WHFO,REVERSE KNUCKLE BENDER $7.12 20071101 99999999 

L3944 WHFO,REVERSE KNUCKLE BENDER,WITH OUTRIGGER $8.07 20071101 99999999 

L3946 WHFO,COMPOSITE ELASTIC $8.31 20071101 99999999 

L3948 WHFO,FINGER KNUCKLE BENDER $3.80 20071101 99999999 

L3950 

WHFO,COMBINATION OPPENHEIMER,WITH KNUCKLE BENDER AND 

TWO ATT $11.04 20071101 99999999 

L3952 

WHFO,COMBINATION OPPENHEIMER,WITH REVERSE KNUCKLE AND 

TWO AT $12.94 20071101 99999999 

L3954 WHFO,SPREADING HAND $6.88 20071101 99999999 

L3960 

SHOULDER-ELBOW-WRIST-HAND ORTHOSISI,ABDUCTION 

POSITIONING $503.26 20060701 99999999 



L3961 

SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, 

WITHOUT JOINTS, MAY INC $720.88 20060701 99999999 

L3962 SEHOW,ABDUCTION POSITIONING,ERBS PALSEY DESIGN $458.11 20060701 99999999 

L3963 

SEWHO,MOLDED SHOULDER,ARM,FOREARM,AND WRIST,WITH 

ARTICULATIO $913.38 20030401 99999999 

L3964 

SEWHO,MOBILE ARM SUPPORT ATTACHED TO 

WHEELCHAIR,BALANCED $74.21 20071101 99999999 

L3965 

SEWHO-RADIAL ARM SUPPORT.ATTACHED TO 


L3966 

SEWHO,MOBILE ARM SUPPORT ATTACHED TO 


L3967 

SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION 

POSITIONING (AIRPLANE DESIGN), THO $851.12 20060701 99999999 

L3968 SEWHO, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR $91.33 20071101 99999999 

L3969 

SEWHO,MOBILE ARM SUPPORT,MONOSUSPENSION ARM AND HAND 

SUPPORT $76.39 20071101 99999999 

L3970 

SEWHO,ADDITION TO MOBILE ARM AUPPORT,ELEVATIONG PROXIMAL 

ARM $29.11 20071101 99999999 

L3971 

SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, 

INCLUDES ONE OR MORE NO $807.91 20060701 99999999 

L3972 SEWHO,ADDITION TO MOBILE ARM SUPPORT,OFFSET OR LATERAL $14.27 20071101 99999999 

L3973 

SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION 

POSITIONING (AIRPLANE DESIGN), THO $851.12 20060701 99999999 

L3974 SEWHO,ADDITION TO MOBILE ARM SUPPORT,SUPINATOR $12.55 20071101 99999999 

L3975 

SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP 

DESIGN, WITHOUT JOINTS, $720.88 20060701 99999999 

L3976 

SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION 

POSITIONING (AIRPLANE DESIG $720.88 20060701 99999999 

L3977 

SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP 

DESIGN, INCLUDES ONE OR $807.91 20060701 99999999 

L3978 

SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION 

POSITIONING (AIRPLANE DESIG $851.12 20060701 99999999 

L3980 UPPER EXTREMITY FRACTURE ORTHOSIS,HUMERAL $232.34 20060701 99999999 

L3982 UPPER EXTREMITY FRACTURE ORTHOSIS,RADIUS/ULNAR $358.76 20060701 99999999 

L3984 UPPER EXTREMITY FRACTURE ORTHOSIS,WRIST $230.32 20060701 99999999 

L3985 

UPPER EXTREMITY FRACTURE ORTHOSIS,FOREARM,HAND WITH 

WRIST HI $55.37 20071101 99999999 

L3986 

UPPER EXTREMITY FRACTURE ORTHOSIS,COMBINATION OF 

HUMERAL,RAD $55.45 20071101 99999999 

L3995 

ADDITION TO UPPER EXTREMITY ORTHOSIS,SOCK,FRACTURE OR 

EQUAL $18.58 20060701 99999999 

L3999 UNLISTED PROCEDURES FOR UPPER LIMB ORTHOSIS $73.84 20030401 99999999 

L4000 REPLACE GIRDLE FOR MILWAUKEE ORTHOSIS $865.76 20060701 99999999 

L4002 

REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, 

ANY LENGTH, ANY TYPE $0.50 20071101 99999999 

L4010 REPLACE TRILATERAL SOCKET BRIM $507.05 20060701 99999999 

L4020 

REPLACE QUADRILATERAL SOCKET BRIM,MOLDED TO PATIENT 

MODLE $563.36 20060701 99999999 

L4030 REPLACE QUADRILATERAL SOCKET BRIM,CUSTOM FITTED $361.73 20060701 99999999 

L4040 REPLACE MOLDED THIGH LACER $328.73 20060701 99999999 

L4045 REPLACE NON-MOLDED THIGH LACER $290.08 20060701 99999999 

L4050 REPLACE MOLDED CALF LACER $424.41 20060701 99999999 

L4055 REPLACE NON-MOLDED CALF LACER $269.71 20060701 99999999 

L4060 REPLACE HIGH ROLL CUFF $271.14 20060701 99999999 

L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO $373.08 20060701 99999999 

L4080 REPLACE METAL BANDS KAFO,PROXIMAL THIGH $54.16 20060701 99999999 

L4090 REPLACE METAL BANDS KAFO-AFO,CALF OR DISTAL THIGH $51.49 20060701 99999999 

L4100 REPLACE LEATHER CUFF KAFO,PROXIMAL THIGH $66.96 20060701 99999999 



L4110 REPLACE LEATHER CUFF KAFO-AFO,CALF OR DISTAL THIGHT $66.12 20060701 99999999 

L4130 REPLACE PRETIBIAL SHELL $551.14 20060701 99999999 

L4205 REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES $14.00 20010101 99999999 

L4210 REPAIR OF ORTHOTIC DEVICE,REPAIR OR REPLACE MINOR PARTS $21.02 20030401 99999999 

L4310 

MULTI-POUNDS OR EQUAL ORTHOTIC PREPARATORY MANAGEMENT 

SYSTEM $255.52 20030401 99999999 

L4320 

ADDITION TO AFO,MULTI-PODUS ORTHOTIC PREPARATORY 

MANAGEMENT $86.10 20030401 99999999 

L4350 PNEUMATIC ANKLE CONTROL SPLING(AIRCAST OR EQUAL) $81.51 20060701 99999999 

L4360 PNEUMATIC WALKING SPLING(AIRCAST OR EQUAL) $157.58 20060701 99999999 

L4370 PNEUMATIC FULL LEG SPLINT(AIRCAST OR EQUAL) $85.65 20060701 99999999 

L4380 PNEUMATIC KNEE SPLINT(AIRCAST OR EQUAL) $45.25 20060701 99999999 

L4386 

NON-PNEUMATIC WALKING SPLINT, WITH OR WITHOUT JOINTS, 

PREFABRICATED, INCLUDES FI $74.75 20060701 99999999 

L4390 REPLACE SOFT INTERFACE MATERIAL, MULTI-PODUS TYPE SPLINT $118.27 20030401 99999999 

L4392 REPLACE SOFT INTERFACE MATERIAL, ANKLE CONTRACTURE SPLINT $10.91 20060701 99999999 

L4394 REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT $7.95 20060701 99999999 

L4396 ANKLE CONTRACTURE SPLINT $77.80 20060701 99999999 

L4398 FOOT DROP SPINT, RECUMBENT POSITIONING DEVICE $35.81 20060701 99999999 

L5000 PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH,TOE FILLER $302.50 20060701 99999999 

L5010 PARTIAL FOOT,MOLDED SOCKET,ANKLE HEIGHT,WITH TOE FILLER $680.89 20060701 99999999 

L5020 

PARTIAL FOOT,MOLDED SOCKET,TIBIAL TUBERCLE,HEIGHT W/TOE 

FILL $1,427.30 20060701 99999999 

L5050 ANKLE,SYMES,MOLDED SOCKET,SACH FOOT $1,363.65 20060701 99999999 

L5060 

ANKLE,SYMES,METAL FRAME,MOLDED LEATHER 

SOCKET,ARTICULATED $1,866.29 20060701 99999999 

L5100 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT $1,335.91 20060701 99999999 

L5105 

BELOW KNEE,PLASTIC SOCKET,JOINTS AND THIGH LACER,SACH 

FOOT $2,648.43 20060701 99999999 

L5150 

KNEE DISARTICULATION,MOLDED SOCKET,EXTERNAL KNEE 

JOINTS,SHIN $2,593.85 20060701 99999999 

L5160 

KNEE DISARTICULATION,MOLDED SOCKET,BENT KNEE 

CONFIGUARTION $2,938.52 20060701 99999999 

L5200 

ABOVE KNEE,MOLDED SOCKET,SINGLE AXIS CONSTANT FRICTION 

KNEE $2,021.27 20060701 99999999 

L5210 

ABOVE KNEE,SHORT PROSTHESIS,NO KNEE JOINT,WITH FOOT 

BLOCKS $1,602.44 20060701 99999999 

L5220 

ABOVE KNEE,SHORT PROSTHESIS,NO KNEE JOINT,WITH 

ARTICULATED $2,198.48 20060701 99999999 

L5230 

ABOVE KNEE,FOR PROXIMAL FOCAL DEFICIENCY,CONSTANT 

FRICTION $2,783.15 20060701 99999999 

L5250 HIP DISARTICULATION,CANADIAN TYPE;MOLDED SOCKET,HIP JOINT $4,453.97 20060701 99999999 

L5270 HIP DISARTICULATION,TILT TABLE TYPE;MOLDED SOCKET,LOCKING $4,551.59 20060701 99999999 

L5280 

HEMIPELVICTOMY,CANADIAN TYPE;MOLDED SOCKET,HIP 

JOINT,SINGLE $5,083.14 20060701 99999999 

L5300 BELOW KNEE,MOLDED SOCKET,SACH FOOT,ENDOSKELETAL SYSTEM $2,208.53 20030401 99999999 

L5301 

BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL 

SYSTEM $1,695.83 20060701 99999999 

L5310 

KNEE DISARTICULATION,MOLDED SOCKET,SACH FOOT 

ENDOSKELETAL $3,419.69 20030401 99999999 

L5311 

KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, 

EXTERNAL KNEE JOINTS, SHI $2,064.60 20060701 99999999 

L5320 

ABOVE KNEE,MOLDED SOCKET,OPEN END,SACH 

FOOT,ENDOSKELETAL SYS $3,823.39 20030401 99999999 



L5321 

ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, 

ENDOSKELETAL SYSTEM, SINGLE AXIS $2,637.25 20060701 99999999 

L5330 

HIP DISARTICULATION,CANADIAN TYPE;MOLDED 

SOCKET,ENDOSKELETAL $4,512.07 20030401 99999999 

L5331 

HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, 

ENDOSKELETAL SYSTEM, HIP JOIN $2,886.55 20060701 99999999 

L5340 

HEMIPELVECTOMY,CANADIAN TYPE;MOLDED SOCKET 

ENDOSKELETAL SYS $4,512.07 20030401 99999999 

L5341 

HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, 

ENDOSKELETAL SYSTEM, HIP JOINT, SI $5,082.35 20060701 99999999 

L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION $844.32 20060701 99999999 

L5410 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION $168.16 20060701 99999999 

L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INIT $1,056.97 20060701 99999999 

L5430 IMMEDIATE POST SURG. OR EARLY FITTING,APPLICAT. OF INIT. RIG $299.51 20060701 99999999 

L5450 IMMEDIATE POST SURG. OR EARLY FIT.,APPLIC. OF NON-WT BEARING $166.00 20060701 99999999 

L5460 

IMMEDIATE POST SURG. OR EARLY FITTING,APPLIC. NON-WT 

BEARING $190.06 20060701 99999999 

L5500 INITIAL,BELOW KNEE "PTB" TYPE SOCKET,"USMC"OR EQUAL PYLON $882.99 20060701 99999999 

L5505 INITIAL,ABOVE KNEE-KNEE DISARTICULATION,ISCHIAL LEVEL SOCKET $1,182.52 20060701 99999999 

L5510 PREPARATORY,BELOW KNEE "PTB" TYPE SOCKET, "USMC" OR EQUAL $906.99 20060701 99999999 

L5520 PREPARATORY,BELOW KNEE "PTB" TYPE SOCKET, "USMC" OR EQUAL $956.90 20060701 99999999 

L5530 PREPARATORY,BELOW KNEE "PTB" TYPE SOCKET, "USMC" OR EQUAL $1,275.68 20060701 99999999 

L5535 

PREPARATORY,BELOW KNEE PTB TYPE SOCKET, USMC OR EQUAL 

PYLON $1,396.75 20060701 99999999 

L5540 

PREPARATORY,BELOW KNEE PTB,TYPE SOCKET USMC OR EQUAL 

PYLON $1,229.29 20060701 99999999 

L5560 PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION,ISCHIAL LEVEL $1,212.13 20060701 99999999 

L5570 PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION,ISCHIAL LEVEL $1,347.61 20060701 99999999 

L5580 PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION ISCHIAL LEVEL $1,628.20 20060701 99999999 

L5585 

PREPARATORY,ABOVE KNEE DISARTICULATION,ISCHIAL LEVEL 

SOCKET $1,449.79 20060701 99999999 

L5590 

PREPARATORY,ABOVE KNEE-KNEE DISARTICULATION,LAMINATED 

SOCKET $1,723.08 20060701 99999999 

L5595 PREPARATORY,HIP DISARTICULATION-HEMIPELVECTOMY,PYLON $4,400.50 20060701 99999999 

L5600 PREPARATORY,HIP DISARTICULATION-HEMIPELVECTOMY,LAMINATED $3,959.33 20060701 99999999 

L5610 

ADDITION TO LOWER EXTREMITY,ABOVE KNEE,HYDRACADENCE 

SYSTEM $1,282.07 20060701 99999999 

L5611 

ADDITION TO LOWER EXTREMITY,ABOVE KNEE-KNEE 

DISARTICULATION $1,079.75 20060701 99999999 

L5613 

ADDITION TO LOWER EXTREMITY,ABOVE KNEE-KNEE 

DISARTICULATION $1,792.79 20060701 99999999 

L5614 

ADDITION TO LOWER EXTREMITY, ABOVE KNEE-KNEE 

DISARTICULATION, 4-BAR LINKAGE, WIT $860.88 20060701 99999999 

L5616 

ADDITION TO LOWER EXTREM.,ABOVE KNEE,UNIVERAL MULTIPLEX 

SYST $729.20 20060701 99999999 

L5617 

ADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING 

UNIT, ABOVE KNEE OR BELO $285.44 20060701 99999999 

L5618 ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES $146.17 20060701 99999999 

L5620 ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE $150.76 20060701 99999999 



L5622 

ADDITION TO LOWER EXTREMITY, TEST SOCKET,KNEE 

DISARTICULATIO $195.97 20060701 99999999 

L5624 ADDITION TO LOWER EXTREMITY, TEST SOCKER, ABOVE KNEE $220.04 20060701 99999999 

L5626 

ADDITION TO LOWER EXTREMITY, TEST SOCKET,HIP 

DISARTICULATION $281.57 20060701 99999999 

L5628 ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVICTOMY $238.33 20060701 99999999 

L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET $124.96 20060701 99999999 

L5630 

ADDITION TO LOWER EXTREMITY,SYMES TYPE,EXPANDABLE WALL 

SOCKE $289.75 20060701 99999999 

L5631 

ADDITION TO LOWER EXTREMITY,ABOVE KNEE OR KNEE 

DISARTICULATI $224.09 20060701 99999999 

L5632 

ADDITION TO LOWER EXTREMITY,SYMES TYPE,"PTB" BRIM DESIGN 

SOC $126.15 20060701 99999999 

L5634 ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING $262.99 20060701 99999999 

L5636 

ADDITION TO LOWER EXTREMITY,SYMES TYPE,MEDIAL OPENING 

SOCKET $130.64 20060701 99999999 

L5637 ADDITION TO LOWER EXTREMITY,BELOW KNEE, TOTAL CONTACT $192.43 20060701 99999999 

L5638 ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKET $368.90 20060701 99999999 

L5639 ADDITION TO LOWER EXTREMITY,BELOW KNEE,WOOD SOCKET $985.39 20060701 99999999 

L5640 

ADDITION TO LOWER EXTREMITY,KNEE DISARTICULATION,LEATH. 

SOCK $410.71 20060701 99999999 

L5642 ADDITION TO LOWER EXTREMITY,ABOVE KNEE,LEATHER SOCKET $256.45 20060701 99999999 

L5643 ADDITION TO LOWER EXTREMITY,HIP DISARTICULATION,FLEXIBLE $796.52 20060701 99999999 

L5644 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET $278.32 20060701 99999999 

L5645 

ADDITION TO LOWER EXTREMITY,BELOW KNEE,FLEXIBLE INNER 

SOCKET $493.31 20060701 99999999 

L5646 

ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR CUSHION 

SOCKET $227.42 20060701 99999999 

L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKET $624.62 20060701 99999999 

L5648 ADDITION TO LOWER EXTREMITY,ABOVE KNEE,AIR CUSHION SOCKET $214.66 20060701 99999999 

L5649 

ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M- 

L $997.82 20060701 99999999 

L5650 ADDITIIONS TO LOWER EXTREMITY,TOTAL CONTACT,ABOVE KNEE $345.92 20060701 99999999 

L5651 

ADDITION TO LOWER EXTREMITY, ABOVE KNEE,FLEXIBLE INNER 

SOCK $543.77 20060701 99999999 

L5652 ADDITION TO LOWER EXTREMITY,SUCTION SUSPENSION,ABOVE KNEE $110.48 20060701 99999999 

L5653 

ADDITION TO LOWER EXTREMITY,KNEE 

DISARTICULATION,EXPANDABLE $330.47 20060701 99999999 

L5654 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,SYMES $206.97 20060701 99999999 

L5655 ADDITION TO LOWER EXTREMITY,SOCKET,INSERT,BELOW KNEE $181.15 20060701 99999999 

L5656 

ADDITION TO LOWER EXTREMITY,SOCKET INSERT,KNEE 


L5658 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,ABOVE KNEE $185.86 20060701 99999999 

L5660 

ADDITION TO LOWER EXTREMITY,SOCKET INSERT,SYMES,SILICONE 

GEL $338.41 20030401 99999999 

L5661 

ADDITION TO LOWER EXTREMITY,SOCKET INSERT,MULTI-DUROMETER 

SY $398.15 20060701 99999999 

L5662 

ADDITION TO LOWER EXTREMITY,SOCKET INSERT,BELOW 

KNEE,SILICON $338.41 20030401 99999999 

L5663 

ADDITION TO LOWER EXTREMITY,SOCKET INSERT,KNEE 


L5664 

ADDITION TO LOWER EXTREMITY,SOCKET INSERT,ABOVE 

KNEE,SILICON $409.65 20030401 99999999 

L5665 ADDITION TO LOWER EXTREMITY,SOCKET INSERT,MULTI-DUROMETER $412.36 20060701 99999999 



L5666 ADDITION TO LOWER EXTREMITY,BELOW KNEE,CUFF SUSPENSION $52.10 20060701 99999999 

L5667 

ADDITION TO LOWER EXTREMITY, BELOW KNEE, SOCKET INSERT, 

SUCTION SUSPENSION, WITH $1,446.63 20030401 99999999 

L5668 

ADDITION TO LOWER EXTREMITY,BELOW KNEE,MOLDED DISTAL 

CUSHION $73.26 20060701 99999999 

L5669 

ADDITION TO LOWER EXTREMITY, BELOW KNEE, SOCKET INSERT, 

SUCTION SUSPENSION WITHO $927.20 20030401 99999999 

L5670 

ADDITION TO LOWER EXTREMITY,BELOW KNEE,MOLDED 

SUPRACONDYLAR $195.23 20060701 99999999 

L5671 

ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE 

SUSPENSION LOCKING MECHANIS $382.21 20060701 99999999 

L5672 

ADDITION TO LOWER EXTREMITY,BELOW KNEE,REMOVABLE MEDIAL 

BRIM $156.15 20060701 99999999 

L5673 



L5674 ADDITION TO LOWER EXTREMITY,BELOW KNEE,LATEX SLEEVE $73.43 20030401 99999999 

L5675 

ADDITION TO LOWER EXTREMITY, BELOW KNEE, LATEX SLEEVE 

SUSPEN $106.64 20030401 99999999 

L5676 

ADDITIONS TO LOWER EXTREMITY, BELOW KNEE,KNEE 

JOINTS,SINGLE $259.25 20060701 99999999 

L5677 

ADDITIONS TO LOWER EXTREMITY,BELOW KNEE 

JOINTS,POLYCENTRIC $426.59 20060701 99999999 

L5678 ADDITIONS TO LOWER EXTREMITY,BELOW KNEE,JOINT COVERS,PAIR $42.22 20060701 99999999 

L5679 



L5680 

ADDITION TO LOWER EXTREMITY,BELOW KNEE,THIGH 

LACER,NONMOLDED $154.37 20060701 99999999 

L5681 


CUSTOM FABRICATED SOCKET INS $621.35 20060701 99999999 

L5682 

ADDITION TO LOWER EXTREMITY,BELOW KNEE,THIGH 

LACER,GLUTEAL $490.16 20060701 99999999 

L5683 


CUSTOM FABRICATED SOCKET INS $621.35 20060701 99999999 

L5684 ADDITION TO LOWER EXTREMITY,BELOW KNEE,FORK STRAP $55.14 20060701 99999999 

L5685 

ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, 

SUSPENSION/SEALING SLEEVE, $60.50 20060701 99999999 

L5686 

ADDITION TO LOWER EXTREMITY,BELOW KNEE,BACK CHECK(EXT. 

CONT) $32.13 20060701 99999999 

L5688 ADDITION TO LOWER EXTREMITY,BELOW KNEE,WAIST BELT,WEBBING $56.23 20060701 99999999 

L5690 

ADDITION TO LOWER EXTREMITY,BELOW KNEE,WAIST BELT,PADDED 

& L $68.65 20060701 99999999 

L5692 

ADDITION TO LOWER EXTREMITY,ABOVE KNEE,PELVIC CONTROL 

BELT $115.36 20060701 99999999 

L5694 

ADDITION TO LOWER EXTREMITY,ABOVE KNEE,PELVIC CONTROL 

BELT $147.77 20060701 99999999 

L5695 

ADDITION TO LOWER EXTREMITY,ABOVE KNEE,PELVIC 

CONTROL,SLEEVE $109.08 20060701 99999999 

L5696 


DISARTICULAT $143.37 20060701 99999999 

L5697 



L5698 

ADDITION TO LOWER EXTREMITY,ABOVE KNEE 

DISARTICULATION,SILES $70.70 20060701 99999999 

L5699 ALL LOWER EXTREMITY PROSTHESES,SHOULDER HARNESS $223.78 20060701 99999999 

L5700 

ALL LOWER EXTREMITY PROSTHESES,FOOT,EXTERNAL KEEL,SACH 

FOOT $1,514.74 20060701 99999999 



L5701 ALL LOWER EXTREMITY PROSTHESES,SAFE FOOT $2,050.79 20060701 99999999 

L5702 

ALL LOWER EXTREMITY PROSTHESES,FOOT,SINGLE AXIS 

ANKLE/FOOT $3,138.63 20060701 99999999 

L5703 ALL LOWER EXTREMITY PROSTHESES,ENERGY STORING FOOT $1,226.65 20060701 99999999 

L5704 ALL LOWER EXTREMITY PROSTHESES,FOOT,MULTIAXIAL ANKLE/FOOT $444.89 20060701 99999999 

L5705 ALL LOWER EXTREMITY PROSTHESES,FLEX FOOT SYSTEM $497.59 20060701 99999999 

L5706 

ALL EXOSKELETAL LOVER EXTREMITY PROSTHESES,AXIAL ROTATION 

UN $491.78 20060701 99999999 

L5707 

ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES,AXIAL 

ROTATION $656.73 20060701 99999999 

L5710 

ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL 

LOC $329.38 20060701 99999999 

L5711 

ADDITION EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL 

LOC $387.04 20060701 99999999 

L5712 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FRICTION $382.69 20060701 99999999 

L5714 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,VARIABLE $246.06 20060701 99999999 

ADDITION,EXOSKELETAL KNEE-SHIN 

L5716 SYSTEM,POLYCENTRIC,MECHANICAL $600.34 20060701 99999999 

L5718 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC,FRICTION $647.06 20060701 99999999 

L5722 

ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE 

AXIS,PNEUMATIC $560.77 20060701 99999999 

L5724 

ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID 

SWIN $994.34 20060701 99999999 

L5726 ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,EXTERNAL $1,014.29 20060701 99999999 

L5728 

ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID 

SWIN $1,845.55 20060701 99999999 

L5780 

ADDITION,EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE 


L5781 

ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL 

LIMB VOLUME MANAGEMENT $1,890.05 20060701 99999999 

L5782 

ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL 

LIMB VOLUME MANAGEMENT $1,992.54 20060701 99999999 

L5785 

ADDITION,EXOSKELETAL SYSTEM,BELOW KNEE,ULTRA-LIGHT 

MATERIAL $285.22 20060701 99999999 

L5790 

ADDITION,EXOSKELETAL SYSTEM,ABOVE KNEE,ULTRA-LIGHT 

MATERIAL $458.34 20060701 99999999 

L5795 ADDITION,EXOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA-LIGHT $591.40 20060701 99999999 

L5810 

ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL 

LO $443.88 20060701 99999999 

L5811 

ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,MANUAL 

LO $649.18 20060701 99999999 

L5812 ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FRICTION $496.29 20060701 99999999 

L5814 HAFHASOIF JO $1,894.69 20060701 99999999 

L5816 

ADDITION,ENDOSKELETAL KNEE-SHIN 

SYSTEM,POLYCENTRIC,MECHANICA $795.29 20060701 99999999 

L5818 

ADDITION,ENDOSKELETAL KNEE-SHIN 

SYSTEM,POLYCENTRIC,FRICTION $801.31 20060701 99999999 

L5822 

ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE 


L5824 

ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID 

SWI $1,385.18 20060701 99999999 



L5826 

ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, 

HYDRAULIC SWING PHASE CONT $1,593.19 20060701 99999999 

L5828 

ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS,FLUID 

SWI $1,948.24 20060701 99999999 

L5830 

ADDITION,ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE 

AXIS,PNEUMATIC $1,652.94 20060701 99999999 

L5840 

ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, MULTIAXIAL, 

PNEUMATIC SWING PHASE CONTR $1,891.71 20060701 99999999 

L5845 

ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION 

FEATURE, ADJUSTABLE $846.67 20060701 99999999 

L5846 

ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, MICROPROCESSOR 

CONTROL FEATURE, SWING $4,274.02 20030401 99999999 

L5847 

ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR 

CONTROL FEATURE, STANCE $12,193.31 20030401 99999999 

L5848 

ADDITION TO ENDOSKELETAL, KNEE-SHIN SYSTEM, HYDRAULIC 

STANCE EXTENSION, DAMPENIN $507.96 20060701 99999999 

L5850 

ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE OR HIP 

DISARTICULAT $61.12 20060701 99999999 

L5855 

ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, 

MECHANICAL HIP EXTENSION ASS $182.36 20060701 99999999 

L5910 ADDITION,ENDOSKELETAL SYSTEM,BELOW KNEE,ALIGNABLE SYSTEM $159.58 20060701 99999999 

L5920 

ADDITION,ENDOSKELETAL SYSTEM,ABOVE KNEE OR HIP 

DISARTICULAT $257.22 20060701 99999999 

L5925 

ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE 

DISARTICULATION OR HIP DISARTICU $221.45 20060701 99999999 

L5930 

ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL 

FRAME $1,717.16 20060701 99999999 

L5940 

ADDITION,ENDOSKELETAL SYSTEM,BELOW KNEE,ULTRA-LIGHT 

MATERIAL $275.36 20060701 99999999 

L5950 

ADDITION,ENDOSKELETA SYSTEM,ABOVE KNEE,ULTRA-LIGHT 

MATERIAL $394.82 20060701 99999999 

L5960 

ADDITION,ENDOSKELETAL SYSTEM,HIP DISARTICULATION,ULTRA- 

LIGHT $477.00 20060701 99999999 

L5962 

ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, FLEXIBLE 

PROCTECTIVE OUTER SURFACE CO $350.06 20060701 99999999 

L5964 

ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, FLEXIBLE 

PROTECTIVE OUTER SURFACE COV $550.92 20060701 99999999 

L5966 

ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE 

PROTECTIVE OUTER SU $708.19 20060701 99999999 

L5968 

ALL LOWER EXTREMITY PROSTHESIS, ANKLE, MULTIAXIAL SHOCK 

ABSORBING SYSTEM $1,716.58 20060701 99999999 

L5970 

ALL LOWER EXTREMITY PROSTHESES,FOOT,EXTERNAL KEEL,SACH 

FOOT $137.00 20060701 99999999 

L5971 

ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL 

(SACH) FOOT, REPLACEMEN $137.00 20060701 99999999 

L5972 

ALL LOWER EXTREMITY PROSTHESES,FLEXIBLE KEEL 

FOOT(SAFE,STEN) $288.47 20060701 99999999 

L5974 ALL LOWER EXTREMITY PROTHESES,FOOT,SINGLE AXIS ANKLE/FOOT $208.31 20060701 99999999 

L5975 

ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS 

ANKLE AND FLEXIBLE KEEL $218.99 20060701 99999999 

L5976 ALL LOWER EXTREMITY PROSTHESES,ENERGY STORING FOOT $472.48 20060701 99999999 

L5978 

ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL 

ANKLE/FOOT (GREISSINGER $256.36 20060701 99999999 

L5979 

ALL LOWER EXTREMITY PROSTHESES, MULTIAXIAL ANKLE/FOOT, 

DYNAMIC RESPONSE $1,325.96 20060701 99999999 

L5980 ALL LOWER EXTREMITY PROSTHESES,FLEX FOOT SYSTEM $2,281.74 20060701 99999999 



L5981 

ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR 

EQUAL $1,567.68 20060701 99999999 

L5982 

ALL EXOSKELETAL LOWER EXTREMITY PROSTHESES,AXIAL 

ROTATION $422.15 20060701 99999999 

L5984 

ALL ENDOSKELETAL LOWER EXTREMITY,PROSTHESES,AXIAL 

ROTATION $461.35 20060701 99999999 

L5985 

ALL ENDOSKELETAL LOWER EXTREMITY PROTHESES, DYNAMIC 

PROSTHETIC PYLON $144.06 20060701 99999999 

L5986 ALL LOWER EXTREMITY PROSTHESES,MULTI-AXIAL ROTATION UNIT $540.53 20060701 99999999 

L5987 

ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH 

VERTICAL LOADING PYLON $540.65 20071101 99999999 

L5988 

ALL LOWER EXTREMITY PROSTHESIS, COMBINATION VERTICAL 

SHOCK AND MULTIAXIAL ROTATI $943.67 20060701 99999999 

L5989 

ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL 

SYSTEM, PYLON WITH INTEGRAT $2,438.65 20030401 99999999 

L5990 

ADDITION TO LOWER EXTREMITY PROSTHESIS, USER ADJUSTABLE 

HEEL HEIGHT $148.97 20071101 99999999 

L5993 

ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY 

FEATURE, FOOT ONLY, (FOR PATI $50.00 20071101 99999999 

L5994 


FEATURE, KNEE ONLY, (FOR PATI $50.00 20071101 99999999 

L5995 


FEATURE (FOR PATIENT WEIGHT > $50.00 20071101 99999999 

L6000 PARTIAL HAND,ROBIN-AIDS,THUMB REMAINING (OR EQUAL) $1,156.04 20060701 99999999 

L6010 PARTIAL HAND,ROBIN-AIDS,LITTLE AND/OR RING FINGER REMAINING $1,308.42 20060701 99999999 

L6020 PARTIAL HAND,ROBIN-AIDS,NO FINGER REMAINING (OR EQUAL) $1,198.14 20060701 99999999 

L6025 

TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION 

PROSTHESIS, EXTERNAL POWE $3,780.13 20060701 99999999 

L6050 WRIST DISARTICULATION,MOLDED SOCKET,FLEXIBLE ELBOW HINGES $1,545.88 20030401 99999999 

L6055 

WRIST DISARTICULATION,MOLDED SOCKET WITH EXPANDABLE 

INTERFAC $2,357.53 20030401 99999999 

L6100 

BELOW ELBOW,MOLDED SOCKET,FLEXIBLE ELBOW HINGE,TRICEPS 

PAD $1,087.80 20060701 99999999 

L6110 

BELOW ELBOW,MOLDED SOCKET,(MUENSTER OR NORTHWESTERN 

SUSPEN.) $1,462.83 20060701 99999999 

L6120 

BELOW ELBOW,MOLDED DOUBLE WALL SPLIT SOCKET,STEP-UP 

HINGES $1,643.53 20060701 99999999 

L6130 

BELOW ELBOW,MOLDED DOUBLE WALL SPLIT SOCKET,STUMP 

ACTIVATED $2,193.93 20060701 99999999 

L6200 

ELBOW DISARTICULATION,MOLDED SOCKET,OUTSIDE LOCKING 

HINGE $2,157.85 20030401 99999999 

L6205 

ELBOW DISARTICULATION,MOLDED SOCKET,OUTSIDE LOCKING 

HINGE $3,255.65 20030401 99999999 

L6250 

ABOVE ELBOW,MOLDED DOUBLE WALL SOCKET,INTERNAL LOCKING 

ELBOW $2,077.22 20060701 99999999 

L6300 

SHOULDER DISARTICULATION,MOLDED SOCKET,SHOULDER 

BULKHEAD $2,711.83 20060701 99999999 

L6310 

SHOULDER DISARTICULATION,PASSIVE RESTORATION(COMPLETE 

PROST) $2,186.69 20060701 99999999 

L6320 

SHOULDER DISARTICULATION,PASSIVE RESTORATION(SHOULDER 

CAP) $1,855.29 20030401 99999999 

L6350 INTERSCAPULAR THORACIC,MOLDED SOCKET,SHOULDER BULKHEAD $3,425.17 20060701 99999999 

L6360 

INTERSCAPULAR THORACIC,PASSIVE RESTORATION(COMPLETE 

PROSTH) $2,933.03 20060701 99999999 

L6370 

INTERSCAPULAR THORACIC,PASSIVE RESTORATION(SHOULDER CAP 

ONL) $1,537.57 20060701 99999999 



L6380 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INIT $699.76 20060701 99999999 

L6382 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INIT $875.01 20060701 99999999 

L6384 

IMMEDIATE POST SURGICAL OR EARLY FITTING,SHOULDER 

DISARTICUL $1,143.18 20060701 99999999 

L6386 

IMMEDIATE POST SURGICAL OR EARLY FITTING,EACH ADDITIONAL 

CAS $277.55 20060701 99999999 

L6388 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF RIGI $278.47 20060701 99999999 

BELOW ELBOW,MOLDED SOCKET,ENDOSKELETAL 

L6400 SYSTEM,INCLUDING SOFT $1,665.84 20060701 99999999 

L6450 ELBOW DISARTICULATION,MOLDED SOCKET,ENDOSKELETAL SYSTEM $1,955.43 20060701 99999999 

L6500 

ABOVE ELBOW,MOLDED SOCKET,ENDOSKELETAL SYSTEM,INCLUDING 

SOFT $1,777.67 20060701 99999999 

L6550 

SHOULDER DISARTICULATION,MOLDED SOCKET,ENDOSKELETAL 

SYSTEM $2,929.10 20060701 99999999 

L6570 

INTERSCAPULAR THORACIC,MOLDED SOCKET,ENDOSKELETAL 

SYSTEM $3,393.71 20060701 99999999 

L6580 

PREPARATORY,WRIST DISARTICULATION OR BELOW ELBOW,SINGLE 

WALL $950.62 20060701 99999999 

L6582 

PREPARATORY,WRIST DISARTICULATION OR BELOW ELBOW,DIRECT 

FORM $723.67 20060701 99999999 

L6584 

PREPARATORY,ELBOW DISARTICULATION OR ABOVE ELBOW,MOLD. 

TO PT $1,168.16 20060701 99999999 

L6586 

PREPARATORY,ELBOW DISARTICULATION OR ABOVE ELBOW,DIRECT 

FORM $984.65 20060701 99999999 

L6588 

PREPARATORY,SHOULDER DISARTICULATION OR INTERSCAPULAR 

THORAC $1,676.66 20060701 99999999 

L6590 PREPARATORY,SHOULDER DISARTICULATION OR INTERSCAPULAR $1,476.86 20060701 99999999 

L6600 UPPER EXTREMITY ADDITIONS,POLYCENTRIC HINGE, PAIR $160.89 20060701 99999999 

L6605 UPPER EXTREMITY ADDITIONS,SINGLE PIVOT HINGE, PAIR $167.08 20060701 99999999 

L6610 UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIR $139.61 20060701 99999999 

L6611 

ADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, 

ADDITIONAL SWITCH, ANY $30.42 20071101 99999999 

L6615 UPPER EXTREMITY ADDITION, DISCONNECT LOCKING WRIST UNIT $92.45 20060701 99999999 

L6616 UPPER EXTREMITY ADDITION,ADDITIONAL DISCONNECT INSERT $32.32 20060701 99999999 

L6620 UPPER EXTREMITY ADDITION, FLEXION-FRICTION WRIST UNIT $201.97 20060701 99999999 

L6621 

UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION 

WRIST WITH OR WITHOUT FRI $169.03 20071101 99999999 

L6623 UPPER EXTREMITY ADDITION,SPRING ASSISTED ROTATIONAL WRIST $286.18 20060701 99999999 

L6624 

UPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION 

WRIST UNIT $278.32 20071101 99999999 

L6625 

UPPER EXTREMITY ADDITION,ROTATION WRIST UNIT WITH CABLE 

LOCK $466.88 20060701 99999999 

L6628 UPPER EXTREMITY ADDITION, QUICK DISCONNECT HOOK ADAPTER $197.62 20060701 99999999 

L6629 

UPPER EXTREMITY ADDITION,QUICK DISCONNECT LAMINATION 

COLLAR $91.58 20060701 99999999 

L6630 UPPER EXTREMITY ADDITION, STAINLESS STEEL, ANY WRIST $100.96 20060701 99999999 

L6632 UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE,EACH $28.52 20060701 99999999 

L6635 UPPER EXTREMITY ADDITION, LIFT ASSIST FOR ELBOW $129.00 20060701 99999999 

L6637 UPPER EXTEMITY ADDITION, NUDGE CONTROL ELBOW LOCK $223.18 20060701 99999999 

L6638 

UPPER EXTREMITY ADDITION TO PROSTHESIS, ELECTRIC LOCKING 

FEATURE, ONLY FOR USE W $1,181.29 20060701 99999999 

L6639 UPPER EXTREMITY ADDITION, HEAVY DUTY FEATURE, ANY ELBOW $112.71 20071101 99999999 

L6640 UPPER EXTREMITY ADDITIONS, SHOULDER ABDUCTION JOINT, PAIR $141.79 20060701 99999999 

L6641 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY TYPE $104.81 20060701 99999999 

L6642 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER,LEVER TYPE $135.46 20060701 99999999 

L6645 UPPER EXTREMITY ADDITION,SHOULDER FLEXION-ABDUCTION JOINT $234.20 20060701 99999999 



L6646 

UPPER EXTREMITY ADDITION, SHOULDER JOINT, MULTIPOSITIONAL 

LOCKING, FLEXION, ADJU $1,489.87 20060701 99999999 

L6647 

UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, BODY 

POWERED ACTUATOR $245.27 20060701 99999999 

L6648 

UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, 

EXTERNAL POWERED ACTUATOR $1,536.59 20060701 99999999 

L6650 UPPER EXTREMITY ADDITION,SHOULDER UNIVERSAL JOINT, EACH $244.49 20060701 99999999 

L6655 UPPER EXTREMITY ADDITION, STANDARD CONTROL CABLE, EXTRA $61.39 20060701 99999999 

L6660 UPPER EXTREMITY ADDITION,HEAVY DUTY CONTROL CABLE $82.19 20060701 99999999 

L6665 UPPER EXTREMITY ADDITION,TEFLON, OR EQUAL, CABLE LINING $25.27 20060701 99999999 

L6670 UPPER EXTREMITY ADDITION, HOOK TO HAND, CABLE ADAPTER $46.87 20060701 99999999 

L6672 

UPPER EXTREMITY ADDITION,HARNESS,CHEST OR 

SHOULDER,SADDLE TY $129.51 20060701 99999999 

L6675 UPPER EXTREMITY ADDITION,HARNESS,FIGURE OF "8" EIGHT TYPE $79.86 20060701 99999999 

L6676 

UPPER EXTREMITY ADDITION,HARNESS,FIGURE OF "8",FOR DUAL 

CONT $97.18 20060701 99999999 

L6677 

UPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, 

SIMULTANEOUS OPERATION OF TER $21.92 20071101 99999999 

L6680 

UPPER EXTREMIITY ADDITION,TEST SOCKET,WRIST 


L6682 

UPPER EXTREMITY ADDITION,TEST SOCKET ELBOW 


L6684 

UPPER EXTREMITY ADDITION,TEST SOCKET,ELBOW 


L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET $43.32 20071101 99999999 

L6687 

UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,BELOW ELBOW 

OR WR $306.29 20060701 99999999 

L6688 UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,ABOVE ELBOW $336.58 20060701 99999999 

L6689 

UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,SHOULDER 

DISARTIC $375.71 20060701 99999999 

L6690 UPPER EXTREMITY ADDITION,FRAME TYPE SOCKET,INTERSCAPULAR $438.70 20060701 99999999 

L6691 UPPER EXTREMITY ADDITION, REMOVABLE INSERT, EACH $241.43 20060701 99999999 

L6692 UPPER EXTREMITY ADDITION,SILICONE GEL INSERT OR EQUAL, EACH $419.09 20060701 99999999 

L6693 

UPPER EXTREMITY ADDITION, EXTERNAL LOCKING ELBOW, FOREARM 

COUNTERBALANCE $1,341.08 20060701 99999999 

L6694 

ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW 

ELBOW/ABOVE ELBOW, CUSTOM $470.33 20060701 99999999 

L6695 



L6696 



L6697 



L6698 


ELBOW/ABOVE ELBOW, LOCK $382.21 20060701 99999999 

L6700 TERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #3 $494.36 20030401 99999999 

L6703 TERMINAL DEVICE, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZE $29.81 20071101 99999999 

L6704 

TERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY 

MATERIAL, ANY SIZE $653.14 20070101 99999999 

L6705 TERMINAL DEVICE,HOOK,DORRANCE,OR EQUAL,MODEL #5 $279.72 20030401 99999999 

L6706 

TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY 

MATERIAL, ANY SIZE, LI $38.91 20071101 99999999 

L6707 

TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY 

MATERIAL, ANY SIZE, LI $143.43 20071101 99999999 

L6708 

TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY 


L6709 

TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY 




L6710 TERMINAL DEVICE,HOOK,FORRANCE,OR EQUAL,MODEL #5X $310.99 20030401 99999999 

L6715 TERMINAL DEVICE,HOOK,DORRANCE,OR EQUAL,MODEL #5XA $306.54 20030401 99999999 



L6730 TERMINAL DEVICE,HOOK,DORRANCE,OR EQUAL,MODEL #7LO $661.06 20030401 99999999 


L6740 TERMINAL DEVICE,HOOK,DORRANCE,OR EQUAL,MODEL #8X $381.33 20030401 99999999 


L6750 TERMINAL DEVICE,HOOK,DORRANCE,OR EQUAL,MODEL #10P $266.65 20030401 99999999 


L6765 TERMINAL DEVICE,HOOK,DORRANCE,OR EQUAL,MODEL #12P $353.93 20030401 99999999 


L6775 TERMINAL DEVICE, HOOK, DORRANCE, OR EQUAL, MODEL #555 $383.24 20030401 99999999 

L6780 TERMINAL DEVICE,HOOK,DORRANCE,OR EQUAL,MODEL #SS555 $441.84 20030401 99999999 

L6790 TERMINAL DEVICE,HOOK-ACCU HOOK,OR EQUAL $279.73 20030401 99999999 

L6795 TERMINAL DEVICE,HOOK-2 LOAD,OR EQUAL $1,084.64 20030401 99999999 

L6800 TERMINAL DEVICE,HOOK-APRL VC,OR EQUAL $1,084.64 20030401 99999999 

L6805 TERMINAL DEVICE,MODIFIER WRIST FLEXION UNIT $218.03 20060701 99999999 

L6806 TERMINAL DEVICE,HOOK,TRS GRIP,VC $1,027.55 20030401 99999999 

L6807 TERMINAL DEVICE, HOOK, TRS ADEPT, CHILD, VC $909.33 20030401 99999999 

L6808 TERMINAL DEVICE,HOOK,IRS ADEPT,INFANT,VC $813.90 20030401 99999999 

L6809 TERMINAL DEVICE,HOOK,TRS SUPER SPORT,PASSIVE $280.65 20030401 99999999 

L6810 TERMINAL DEVICE,PINCHER TOOL,OTTO BOCK OR EQUAL $111.41 20060701 99999999 

L6825 TERMINAL DEVICE,HAND,DORRANCE,VO $970.47 20030401 99999999 

L6830 TERMINAL DEVICE,HAND,APRL,VC $1,027.55 20030401 99999999 

L6835 TERMINAL DEVICE,HAND,SIERRA,VO $913.38 20030401 99999999 

L6840 TERMINAL DEVICE, HAND, BECKER IMPERIAL $799.21 20030401 99999999 

L6845 TERMINAL DEVICE,HAND,BECKER LOCK GRIP $627.94 20030401 99999999 

L6850 TERMINAL DEVICE,HAND,BECKER PLYLITE $627.94 20030401 99999999 

L6855 TERMINAL DEVICE,HAND,ROBIN-AIDS,VO $627.94 20030401 99999999 

L6860 TERMINAL DEVICE,HAND,ROBIN-AIDS,VO SOFT $542.31 20030401 99999999 

L6865 TERMINAL DEVICE,HAND,PASSIVE HAND $265.46 20030401 99999999 

L6867 TERMINAL DEVICE,HAND,DETROIT INFANT HAND (MECHANICAL) $785.84 20030401 99999999 

L6868 TERMINAL DEVICE,HAND,PASSIVE INFANT HAND,(STEEPER,HOSMER) $188.60 20030401 99999999 

L6870 TERMINAL DEVICE,HAND,CHILD MITT $221.54 20030401 99999999 

L6872 TERMINAL DEVICE,HAND,NYU CHILD HAND $729.72 20030401 99999999 

L6873 

TERMINAL DEVICE,HAND,MECHANICAL INFANT HAND,STEEPER OR 

EQUAL $228.34 20030401 99999999 

L6875 TERMINAL DEVICE,HAND,BOCK,VC $765.34 20030401 99999999 

L6880 TERMINAL DEVICE,HAND,BOCK,VO $448.34 20030401 99999999 

L6881 

AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB PROSTHETIC 

TERMINAL DEVICE $1,931.19 20060701 99999999 

L6882 

MICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB 

PROSTHETIC TERMINAL DEVIC $1,464.89 20060701 99999999 

L6883 

REPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, 

MOLDED TO PATIENT MODEL, $876.46 20060701 99999999 

L6884 

REPLACEMENT SOCKET, ABOVE ELBOW DISARTICULATION, MOLDED 

TO PATIENT MODEL, FOR US $1,835.12 20060701 99999999 

L6885 

REPLACEMENT SOCKET, SHOULDER 

DISARTICULATION/INTERSCAPULAR THORACIC, MOLDED TO P $2,933.03 20060701 99999999 

L6890 TERMINAL DEVICE,GLOVE FOR ABOVE HANDS,PRODUCTION GLOVE $115.99 20060701 99999999 

L6895 TERMINAL DEVICE,GLOVE FOR ABOVE HANDS,CUSTOM GLOVE $273.75 20060701 99999999 

L6900 

HAND RESTORATION,PARTICAL HAND,WITH GLOVE,THUMB OR ONE 

FINGE $1,053.77 20060701 99999999 

L6905 

HAND RESTORATION,PARTICAL HAND,WITH GLOVE,MULT. FINGERS 

REMA $1,132.34 20060701 99999999 

L6910 

HAND RESTORATION(CASTS,SHADING & MEASURMENTS 

INCL)PARTIAL HA $1,010.26 20060701 99999999 



L6915 HAND RESTORATION,REPLACEMENT GLOVE FOR ABOVE $429.50 20060701 99999999 

L6920 

WRIST DISARTICULATION,EXTERNAL POWER,SELF-SUSPENDED 

INNERSOC $3,879.54 20060701 99999999 

L6925 

WRIST DISARTICULATION,MYOELECTRONIC CONTROL OF TERMINAL 

DEVI $4,421.80 20060701 99999999 

L6930 

BELOW ELBOW,EXTERNAL POWER,SWITCH CONTROL OF TERMINAL 

DEVICE $3,590.40 20060701 99999999 

L6935 

BELOW ELBOW,EXTERNAL POWER,MYOELECTRONIC CONTROL OF 

TERMINAL $4,158.00 20060701 99999999 

L6940 ELBOW DISARTICULATION,SWITCH CONTROL OT TERMINAL DEVICE $4,560.01 20060701 99999999 

L6945 

ELBOW DISARTICULATION,MYOELECTRONIC CONTROL OF TERMINAL 

DEVI $5,248.23 20060701 99999999 

L6950 

ABOVE ELBOW,EXTERNAL POWER,MOLDED INNER SOCKET,SWITCH 

CONTRO $5,083.82 20060701 99999999 

L6955 

ABOVE ELBOW,EXTERNAL POWER,MOLDED INNER 

SOCKET,MYOELECTRONIC $6,075.04 20060701 99999999 

L6960 SHOULDER DISARTICULATION,EXTERNAL POWER,SWITCH CONTROL $6,625.82 20060701 99999999 

L6965 

SHOULDER DISARTICULATION,EXTERNAL POWER,MYOELECTRONIC 

CONTRO $7,696.48 20060701 99999999 

L6970 INTERSCAPULAR-THORACIC,EXTERNAL POWER,SWITCH CONTROL $8,161.18 20060701 99999999 

L6975 

INTERSCAPULAR-THORACIC,EXTERNAL POWER,MYOELECTRONIC 

CONTROL $9,584.89 20060701 99999999 

L7007 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT $293.44 20071101 99999999 

L7008 

ELECTRIC HAND, SWITCH OR MYOELECTRIC, CONTROLLED, 

PEDIATRIC $528.43 20071101 99999999 

L7009 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT $295.80 20071101 99999999 

L7010 

ELECTRONIC HAND,OTTO BOCK,STEEPER OR EQUAL,SWITCH 

CONTROLLED $2,357.53 20030401 99999999 

L7015 

ELECTRONIC HAND,SYSTEM TEKNIK,VARIETY VILLAGE OR 

EQUAL,SWITC $4,153.75 20030401 99999999 

L7020 ELECTRONIC GREIFER,OTTO BOCK OR EQUAL,SWITCH CONTROLLED $2,469.80 20030401 99999999 

L7025 

ELECTRONIC HAND,OTTO BOCK OR EQUAL,MYOELECTRONICALLY 

CONTROL $2,256.50 20030401 99999999 

L7030 

ELECTRONIC HAND,SYSTEM TEKNIK,VARIETY VILLAGE OR 

EQUAL,MYOEL $4,153.75 20030401 99999999 

L7035 

ELECTRONIC GREIFER,OTTO BOCK OR EQUAL,MYOELECTRONICALLY 

CONT $2,319.97 20030401 99999999 

L7040 PREHENSILE ACTUATOR,HOSMER OR EQUAL,SWITCH CONTROLLED $1,479.73 20060701 99999999 

L7045 

ELECTRONIC HOOK,CHILD,MICHIGAN OR EQUAL,SWITCH 

CONTROLLED $701.30 20060701 99999999 

L7160 ELECTRONIC ELBOW,BOSTON OR EQUAL,SWITCH CONTROLLED $11,226.35 20030401 99999999 

L7165 

ELECTRONIC ELBOW,BOSTON EQUAL,MYOELECTRONICALLY 

CONTROLLED $13,247.09 20030401 99999999 

L7170 ELECTRONIC ELBOW,HOSMER OR EQUAL,SWITCH CONTROLLED $2,969.58 20060701 99999999 

L7180 

ELECTRONIC ELBOW,UTAH OR EQUAL,MYOELECTRONICALLY 

CONTROLLED $18,827.33 20060701 99999999 

L7181 

ELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL 

OF ELBOW AND TERMINAL $18,927.16 20060701 99999999 

L7185 

ELECTRONIC ELBOW,ADOLESCENT,VARIETY VILLAGE OR 

EQUAL,SWITCH $3,110.95 20060701 99999999 

L7186 

ELECTRONIC ELBOW,CHILD,VARIETY VILLAGE OR EQUAL,SWITCH 

CONTR $4,383.56 20060701 99999999 

L7190 

ELECTRONIC ELBOW,ADOLESCENT,VARIETY VILLAGE OR 

EQUAL,MYOELEC $4,090.73 20060701 99999999 

L7191 

ELECTRONIC ELBOW,CHILD,VARIETY VILLAGE OR 

EQUAL,MYOELECTRONI $4,312.67 20060701 99999999 

L7260 ELECTRONIC WRIST ROTATOR,OTTO BOCK OR EQUAL $1,309.03 20060701 99999999 

L7261 ELECTRONIC WRIST ROTATOR,FOR UTAH ARM $2,376.98 20060701 99999999 



L7266 SERVO CONTROL,STEEPER OR EQUAL $513.76 20060701 99999999 

L7272 ANALOGUE CONTROL,UNB OR EQUAL $1,098.94 20060701 99999999 

L7274 PROPORTIONAL CONTROL,12 VOLT,UTAH OR EQUAL $3,437.72 20060701 99999999 

L7360 SIX VOLT BATTERY,OTTO BOCK OR EQUAL,EACH $128.38 20060701 99999999 

L7362 BATTERY CHARGER,SIX VOLT,OTTO BOCK OR EQUAL $134.84 20060701 99999999 

L7364 TWELVE VOLT BATTERY,UTAH OR EQUAL,EACH $247.06 20060701 99999999 

L7366 BATTERY CHARGER,TWELVE VOLT,UTAH OR EQUAL $323.22 20060701 99999999 

L7367 LITHIUM ION BATTERY, REPLACEMENT $183.91 20060701 99999999 

L7368 LITHIUM ION BATTERY CHARGER $238.40 20060701 99999999 

L7400 

ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST 

DISARTICULATION, ULTRA $144.77 20060701 99999999 

L7401 

ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW 

DISARTICULATION, ULTRALIGHT $162.07 20060701 99999999 

L7402 

ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER 

DISARTICULATION/INTERSCAPULAR T $175.03 20060701 99999999 

L7403 

ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST 

DISARTICULATION, ACRYL $173.96 20060701 99999999 

L7404 

ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW 

DISARTICULATION, ACRYLIC MAT $262.55 20060701 99999999 

L7405 

ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER 

DISARTICULATION/INTERSCAPULAR T $343.38 20060701 99999999 

L7500 

REPAIR OF PROSTHETIC DEVICE,HOURLY RATE(EXCLUDES V3014 

REP) $56.00 20071101 99999999 

L7510 REPAIR PROSTHETIC DEVICE,REPAIR OR REPLACE MINOR PARTS $7.80 20030401 99999999 

L7520 REPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES $14.00 20060101 99999999 

L7900 VACUUM ERECTION SYSTEM $410.44 20030401 99999999 

L8000 BREAST PROSTHESIS,MASTECTOMY BRA $34.21 20060701 99999999 

L8001 

BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED 

BREAST PROSTHESIS FORM, UNILA $98.74 20060701 99999999 

L8002 

BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED 

BREAST PROSTHESIS FORM, BILAT $129.88 20060701 99999999 

L8010 BREAST PROSTHESIS,MASTECTOMY SLEEVE $35.30 20071101 99999999 

L8015 

EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY 

FORM, POST MASTECTOMY $46.35 20060701 99999999 

L8020 BREAST PROSTHESIS,MASTECTOMY FORM $175.95 20060701 99999999 

L8030 BREAST PROSTHESIS,SILICONE OR EQUAL $229.69 20060701 99999999 

L8035 

CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO 

PATIENT MODEL $1,730.61 20060701 99999999 

L8040 NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,269.52 20060701 99999999 

L8041 MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,530.25 20060701 99999999 

L8042 ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,865.62 20060701 99999999 

L8043 UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $3,209.50 20060701 99999999 

L8044 HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $3,553.37 20060701 99999999 

L8045 AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,237.14 20060701 99999999 

L8046 PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $2,292.50 20060701 99999999 

L8047 NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN $1,174.90 20060701 99999999 

L8049 

REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR 

COMPONENT, 15 MINUTE I $18.82 20030401 99999999 

L8100 ELASTIC SUPPORT, ELASTIC STOCKING, BELOW KNEE, MEDIUM $28.08 20030401 99999999 

L8110 

ELASTIC SUPPORT,ELASTIC STOCKING,BELOW KNEE,HEAVY WEIGHT 

EAC $38.48 20030401 99999999 

L8130 

ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,MEDIUM WEIGHT 

EA $20.80 20030401 99999999 

L8140 

ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,HEAVY 

WEIGHT,EAC $26.00 20030401 99999999 

L8150 

ELASTIC SUPPORT,ELASTIC STOCKING,ABOVE KNEE,SURGICAL 

WEIGHT $33.28 20030401 99999999 



L8170 ELASTIC SUPPORT,ELASTIC STOCKING,FULL LENGTH,HEAVY WEIGHT $104.00 20030401 99999999 

L8210 ELASTIC SUPPORT,ELASTIC STOCKING,CUSTOM MADE $131.36 20030401 99999999 

L8239 ELASTIC SUPPORT, NOT OTHERWISE SPECIFIED $17.77 20030401 99999999 

L8300 TRUSS,SINGLE WITH STANDARD PAD $102.55 20060701 99999999 

L8310 TRUSS,DOUBLE WITH STANDARD PADS $110.27 20060701 99999999 

L8320 TRUSS,ADDITION TO STANDARD PAD,WATER PAD $41.59 20060701 99999999 

L8330 TRUSS,ADDITION TO STANDARD PAD,SCROTAL PAD $38.87 20060701 99999999 

L8400 PROSTHETIC SHEATH,BELOW KNEE,EACH $12.32 20060701 99999999 

L8410 PROSTHETIC SHEATH,ABOVE KNEE,EACH $14.19 20060701 99999999 

L8415 PROSTHETIC SHEATH,UPPER LIMB,EACH $12.64 20060701 99999999 

L8417 

PROSTHETIC SHEATH/SOCK, INCLUDING A GEL CUSHION LAYER, 

BELOW KNEE OR ABOVE KNEE, $38.37 20060701 99999999 

L8420 PROSTHETIC SOCK, WOOL, BELOW KNEE, EACH $13.85 20060701 99999999 

L8430 PROSTHETIC SOCK,WOOL,ABOVE KNEE,EACH $14.65 20060701 99999999 

L8435 PROSTHETIC SOCK,WOOL,UPPER LIMB, EACH $13.85 20060701 99999999 

L8440 PROSTHETIC SHRINKER,BELOW KNEE,EACH $38.87 20060701 99999999 

L8460 PROSTHETIC SHRINKER,ABOVE KNEE,EACH $72.55 20060701 99999999 

L8465 PROSTHETIC SHRINKER,UPPER LIMB, EACH $22.03 20060701 99999999 

L8470 STUMP SOCK,SINGLE PLU,FITTING,BELOW KNEE,EACH $4.73 20060701 99999999 

L8480 STUMP SOCK,SINGLE PLY,FITTING,ABOVE KNEE,EACH $5.54 20060701 99999999 

L8485 STUMP SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH $6.88 20060701 99999999 

L8490 

ADDITION TO PROSTHETIC SHEATH/SOCK, AIR SEAL SUCTION 

RETENTION SYSTEM $99.66 19990701 99999999 

L8499 

UNLISTED PROCEDURE FOR MISCELLANEOUS PROSTHETIC 

SERVICES $38.93 20030401 99999999 

L8500 ARTIFICIAL LARYNX,ANY TYPE $442.19 20060701 99999999 

L8501 TRACHEOSTOMY SPEAKING VALVE $69.71 20060701 99999999 

L8505 

ARTIFICIAL LARYNX REPLACEMENT BATTERY / ACCESSORY, ANY 

TYPE $2.00 20071101 99999999 

L8507 

TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, PATIENT INSERTED, 

ANY TYPE, EACH $19.79 20060701 99999999 

L8509 

TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, INSERTED BY A 

LICENSED HEALTH CARE PROVIDER $51.59 20060701 99999999 

L8510 VOICE AMPLIFIER $119.36 20060701 99999999 

L8511 

INSERT FOR INDWELLING TRACHEOESOPHAGEAL PROSTHESIS, WITH 

OR WITHOUT VALVE, REPLA $34.36 20060701 99999999 

L8512 

GELATIN CAPSULES OR EQUIVALENT, FOR USE WITH 

TRACHEOESOPHAGEAL VOICE PROSTHESIS, $1.59 20060701 99999999 

L8513 

CLEANING DEVICE USED WITH TRACHEOESOPHAGEAL VOICE 

PROSTHESIS, PIPET, BRUSH, OR E $2.45 20060701 99999999 

L8514 

TRACHEOESOPHAGEAL PUNCTURE DILATOR, REPLACEMENT ONLY, 

EACH $44.54 20060701 99999999 

L8515 

GELATIN CAPSULE, APPLICATION DEVICE FOR USE WITH 

TRACHEOESOPHAGEAL VOICE $51.83 20060701 99999999 

L8600 IMPLANTABLE BREAST PROSTHESIS, SILICONE OR EQUAL $47.00 20071101 99999999 

L8603 

COLLAGEN IMPLANT, URINARY TRACT, PER 2.5 CC SYRINGE, 

INCLUDES SHIPPING AND NECES $322.40 20030401 99999999 

L8609 ARTIFICIAL CORNEA $440.82 20071101 99999999 

L8610 OCULAR $44.09 20071101 99999999 

L8612 AQUEOUS SHUNT $45.77 20071101 99999999 

L8613 OSSICULA $19.35 20071101 99999999 

L8614 COCHLEAR DEVICE/SYSTEM $1,308.33 20071101 99999999 

L8615 TEMPOROMANDIBULAR JOINT $30.51 20071101 99999999 

L8616 MAXILLA $71.07 20071101 99999999 

L8617 MANDIBLE $62.07 20071101 99999999 

L8618 PALATE $17.74 20071101 99999999 



L8619 

COCHLEAR IMPLANT EXTERNAL SPEECH PROCESSOR, 

REPLACEMENT $561.58 20071101 99999999 

L8621 DISTAL HUMERUS $0.47 20071101 99999999 

L8622 PROXIMAL ULNA/RADIUS $0.25 20071101 99999999 

L8623 DISTAL ULNA $48.63 20071101 99999999 

L8624 DISTAL RADIUS $121.22 20071101 99999999 

L8630 METACARPOPHALANGEAL JOINT $281.81 20071101 99999999 

L8631 

METACARPAL PHALANGEAL JOINT REPLACEMENT, TWO OR MORE 

PIECES, METAL (E.G., STAINL $1,653.92 20071101 99999999 

L8641 METATARSAL JOINT $292.79 20071101 99999999 

L8642 HALLUX IMPLANT $237.49 20071101 99999999 

L8658 INTERPHALANGEAL JOINT $255.29 20071101 99999999 

L8659 

INTERPHALANGEAL FINGER JOINT REPLACEMENT, 2 OR MORE 

PIECES, METAL (E.G., STAINLE $1,450.65 20071101 99999999 

L8670 VASCULAR GRAFT MATERIAL, SYNTHETIC $419.05 20071101 99999999 

L8680 BILIARY STENT, ENDOPROSTHESIS (PERMANENT) $349.23 20071101 99999999 

L8681 

PATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE 

PROGRAMMABLE NEUROSTIMULA $92.36 20071101 99999999 

L8682 IMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVER $4,532.45 20071101 99999999 

L8683 

RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH 

IMPLANTABLE NEUROSTIMULATOR R $3,989.59 20071101 99999999 

L8684 

RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH 

IMPLANTABLE SACRAL ROOT NEURO $569.58 20071101 99999999 

L8685 

IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE 

ARRAY, RECHARGEABLE, INCLUDE $9,941.84 20071101 99999999 

L8686 

IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE 

ARRAY, NON-RECHARGEABLE, INC $6,343.69 20071101 99999999 

L8687 

IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, 

RECHARGEABLE, INCLUDES $12,938.31 20071101 99999999 

L8688 

IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, 

NON-RECHARGEABLE, INCLU $8,255.68 20071101 99999999 

L8689 

EXTERNAL RECHARGING SYSTEM FOR IMPLANTED 

NEUROSTIMULATOR, REPLACEMENT ONLY $1,416.44 20071101 99999999 

L8690 

AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND 

EXTERNAL COMPONENTS $3,515.70 20071101 99999999 

L8691 

AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND 

PROCESSOR, REPLACEMENT $1,970.66 20071101 99999999 

L8695 

EXTERNAL RECHARGING SYSTEM FOR BATTERY (EXTERNAL) FOR 

USE WITH IMPLANTABLE NEURO $12.53 20071101 99999999 

M0005 OFFICE VISITS WITH TWO OR MORE MODALITIES TO THE SAME AREA $21.84 19990701 99999999 

M0007 OFFICE VISIT INCLUDING COMBINATION OF ANY MODALITY(S) AND $13.90 19990701 99999999 

M0008 OFFICE VISIT INCLUDING COMBINATION OF ANY MODALITY(S) AND $9.20 19990701 99999999 

M0064 

BRIEF OFFICE VISIT FOR THE SOLE PURPOSE OF MONITORING OR 

CHANGING DRUG PRESCRIPT $18.84 20060701 99999999 

M0101 CUTTING OR REMOVAL OF CORNS,CALLUSES PREVENTIVE $18.80 19990701 99999999 

M0302 ASSESSMENT OF CARDIAC OUTPUT BY ELECTRICAL BIOIMPEDANCE $34.41 19990701 99999999 

M0585 ACHILLES REFLEX RESPONSE,ELECTRICAL RECORDING (ART) $16.80 19990701 99999999 

M0590 

MONITORING ECG,EEG,OR PRESSURE IN INTRATHORACTIC OR 

OTHER CR $92.40 19990701 99999999 

M0601 PSYCHOLOGICAL TESTING, WITH WRITTEN REPOR,PER HOUR $56.20 19990701 99999999 

M0702 BRIEF,OSTEO MANIP THERAPY NOT IP UP TO 2 BODY REGIONS $25.20 19990701 99999999 

M0704 LTD OSTEO MANIP THERAPY NOT IP UP TO 4 BODY REGIONS $25.90 19990701 99999999 

M0706 INTERM OSTEO MANIP THERAPY,NOT IP,UP TO 6 BODY REGIONS $87.50 19990701 99999999 

M0708 EXT OSTEO MANIP THERAPY,NOT IP, UP TO 8 BODY REGIONS $44.98 19990701 99999999 

M0710 COMPR OSTEO MANIP THERAPY,NOT IP, UP TO 10 BODY REGIONS $120.94 19990701 99999999 

M0722 BRIEF IP HOSP OMT UP TO 2 BODY REGIONS $36.53 19990701 99999999 

M0724 LTD IP HOSP OMT UP TO 4 BODY REGIONS $51.62 19990701 99999999 

M0726 INTERM IP HOSP OMT (UP TO SIX BODY REGIONS $99.60 19990701 99999999 



M0728 EXT IP HOSP OMT (UP TO 8 BODY REGIONS) $45.84 19990701 99999999 

M0730 COMPR IP HOSP OMT (UP TO 10 BODY REGIONS) $57.64 19990701 99999999 

M0900 

EXC, REVISION OR REMOVAL OF A-V SHUNT ANASTOMOSIS W/WO 

GRAFT $281.16 19990701 99999999 

M0945 

OUTPATIENT DIALYSIS RELATED PHYSIIANS' SERVICES EITHER 

PROVIDED BY THE PHYSICIA $5.22 19990701 99999999 

P2038 

MUCOPROTEIN, BLOOD (SEROMUCOID) (MEDICAL NECESSITY 

PROCEDURE) $6.95 20060701 99999999 

P3000 

SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO 

THREE SMEARS, BY TECHNI $14.60 20060701 99999999 

P3001 

SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO 

THREE SMEARS, REQUIRING $13.75 20060701 99999999 

P7001 CULTURE, BACTERIAL, URINE; QUANTITATIVE, SENSITIVITY STUDY $21.60 19990701 99999999 

P9010 BLOOD(WHOLE), FOR TRANSFUSION, PER UNIT $94.00 19990701 99999999 

P9017 PLASMA, SINGLE DONOR, FRESH FROZEN, EACH UNIT $59.50 19990701 99999999 

P9019 PLATELET CONCENTRATE, EACH UNIT $59.50 19990701 99999999 

P9021 RED BLOOD CELLS, EACH UNIT $94.00 19990701 99999999 

P9022 WASHED RED BLOOD CELLS, EACH UNIT $145.00 19990701 99999999 

P9034 PLATELETS, PHERESIS, EACH UNIT $575.00 20010101 99999999 

P9035 PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT $580.00 20010101 99999999 

P9604 

TRAVEL ALLOWANCE 1 WAY IN CONNECT. WITH 

MEDI.NECES.LAB.SPEC. $2.76 19990701 99999999 

P9605 ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN (S), $5.10 19990701 99999999 

P9610 CATHERIZATION FOR COLLECTION OF SPECIMEN (S), $5.10 19990701 99999999 

P9612 

CATHETERIZATION FOR COLLECTION OF SPECIMEN, SINGLE PATIENT, 

ALL PLACES OF SERVIC $3.00 20060701 99999999 

P9615 CATHERIZATION FOR COLLECTION OF SPECIMEN (S) (MULT.PATIENTS) $3.00 20060701 99999999 

Q0035 CARDIOKYMOGRAPHY $24.94 20060701 99999999 

Q0068 

EXTRACORPOREAL PLASMAPHERESIS: IMMUNOADSORPTION WITH 

STAPHYLOCOCCAL PROTEIN A CO $103.16 19990701 99999999 

Q0069 

MAGNETIC RESONANCE (EG., PROTON) IMAGING, BRAIN (INCLUDING 

BRAIN STEM); WITHOUT $802.47 19990701 99999999 

Q0081 

INFUSION THERAPY, USING OTHER THAN CHEMOTHERAPEUTIC 

DRUGS, PER VISIT $30.00 19920101 99999999 

Q0083 

CHEMOTHERAPY ADMINISTRATION BY OTHER THAN INFUSION 

TECHNIQUE ONLY (EG SUBCUTANEO $5.00 19920101 99999999 

Q0084 

CHEMOTHERAPY ADMINISTRATION BY INFUSION TECHNIQUE ONLY, 

PER VISIT $48.31 19920101 99999999 

Q0085 

CHEMOTHERAPY ADMINISTRATION BY BOTH INFUSION TECHNIQUE 

AND OTHER TECHIQUE(S) (EG $48.31 19920101 99999999 

Q0091 

SCREENING PAPANICOLAOU SMEAR; OBTAINING, PREPARING AND 

CONVEYANCE OF CERVICAL OR $19.67 20030401 99999999 

Q0092 SET-UP PORTABLE X-RAY EQUIPMENT $8.27 20060701 99999999 

Q0098 

GLUCOSE, BLOOD; BY GLUCOSE MONITOR'G DEVCE CLR'D BY THE 

FDA SPCFCLLY 4 HOME USE $4.91 19990701 99999999 

Q0100 

URINALYSIS BY DIP STICK OR TABLET FOR BILIRUBIN, GLUCOSE, 

HEMOGLOBIN, KETONE $3.97 19990701 99999999 

Q0101 MICROHUMATOCRIT, SPUN $3.67 19990701 99999999 

Q0102 SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED $5.51 19990701 99999999 

Q0103 PHYSICAL THERAPY EVALUATION, INITIAL $47.77 19990701 99999999 

Q0104 PHYSICAL THERAPY RE-EVALUATION, PERIODIC $17.47 19990701 99999999 

Q0109 OCCUPATIONAL THERAPY EVALUATION, INITIAL $49.20 19990701 99999999 

Q0110 OCCUPATION THERAPY RE-EVALUATION, PERIODIC $17.47 19990701 99999999 

Q0111 

WET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, CERVICAL OR 

SKIN SPECIMENS $5.90 20060701 99999999 

Q0112 ALL POTASSIUM HYDROXIDE (KOH) PREPARATIONS $5.90 20060701 99999999 

Q0113 PINWORM EXAMINATIONS $7.47 20060701 99999999 



Q0114 FERN TEST $9.88 20060701 99999999 

Q0115 

POST-COITAL DIRECT, QUALITATIVE EXAMINATIONS OF VAGINAL OR 

CERVICAL MUCOUS $13.68 20060701 99999999 

Q0117 



Q0128 ETOPOSIDE; ORAL, 50 MG $18.22 19990701 99999999 

Q3004 


XENON XE 133, PER 10 MCI $40.00 20040101 99999999 

Q3008 


INDIUM 111-IN PENTETREOT $1,500.00 20040101 99999999 

Q3009 


TECHNETIUM TC99M OXIDRON $1.47 20010101 99999999 

Q3010 


TECHNETIUM TC99M - LABEL $55.00 20040101 99999999 

Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE $20.00 20020101 99999999 

Q3020 

ALS VEHICLE USED, NON-EMERGENCY TRANSPORT, NO ALS LEVEL 

SERVICE FURNISHED $102.38 20031016 99999999 

Q4005 CAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), PLASTER $6.50 20020101 99999999 

Q4006 CAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), FIBERGLASS $20.00 20020101 99999999 

Q4008 

CAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), 

FIBERGLASS $10.36 20020101 99999999 

Q4009 CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), PLASTER $6.14 20020101 99999999 

Q4010 CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), FIBERGLASS $14.20 20020101 99999999 

Q4012 

CAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), 

FIBERGLASS $6.92 20020101 99999999 

Q4014 

CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND 

HAND), ADULT (11 YEARS $18.88 20020101 99999999 

Q4016 

CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND 

HAND), PEDIATRIC (0-10 $9.44 20020101 99999999 

Q4017 CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), PLASTER $6.47 20020101 99999999 

Q4018 

CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), 

FIBERGLASS $10.32 20020101 99999999 

Q4020 

CAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), 

FIBERGLASS $5.16 20020101 99999999 

Q4021 CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), PLASTER $4.79 20020101 99999999 

Q4022 

CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), 

FIBERGLASS $8.64 20020101 99999999 

Q4024 

CAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), 

FIBERGLASS $3.11 20030101 99999999 

Q4028 

CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0-10 

YEARS), FIBERGLASS $24.00 20020101 99999999 

Q4030 CAST SUPPLIES, LONG LEG CAST, ADULT (11 YEARS +), FIBERGLASS $38.92 20030101 99999999 

Q4031 CAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), PLASTER $10.27 20020101 99999999 

Q4037 CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), PLASTER $11.69 20020101 99999999 

Q4038 CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), FIBERGLASS $20.00 20020101 99999999 

CAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), 

Q4040 FIBERGLASS $14.20 20020101 99999999 

Q4045 CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), PLASTER $5.94 20030101 99999999 

CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), 

Q4046 FIBERGLASS $13.27 20020101 99999999 



Q4047 

CAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), 

PLASTER $4.12 20020101 99999999 

Q4049 FINGER SPLINT, STATIC $1.50 20020101 99999999 

Q9949 

LOW OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE 

CONCENTRATION, PER ML $0.36 20060101 99999999 

Q9950 


CONCENTRATION, PER ML $0.23 20060101 99999999 

Q9965 


CONCENTRATION, PER ML $1.81 20080101 99999999 

Q9966 



Q9967 



R0070 

TRANS OF PORTABLE XRAY EQ AND PERSONNEL TO HOME OR NH 

PER TR $67.71 19990701 99999999 

R0075 

TRANS OF PORTABLE XRAY EQ AND PERSONNEL TO HOME OR NH 

PER TR $28.68 19990701 99999999 

S9999 SALES TAX $0.01 20000101 99999999 

T1005 RESPITE CARE SERVICES, UP TO 15 MINUTES $78.70 20020101 99999999 

T1013 SIGN LANGUAGE OR ORAL INTERPRETER SERVICES $9.36 20030401 99999999 

T1016 CASE MANAGEMENT, EACH 15 MINUTES $336.00 20031001 99999999 

T1017 TARGETED CASE MANAGEMENT, EACH 15 MINUTES $28.00 20030101 99999999 

T1021 HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PER VISIT $20.00 20031001 99999999 

T1030 NURSING CARE, IN THE HOME, BY REGISTERED NURSE, PER DIEM $50.00 20031001 99999999 

T1999 

MISCELLANEOUS THERAPEUTIC ITEMS AND SUPPLIES, RETAIL 

PURCHASES, NOT OTHERWISE CL $31.47 20031116 99999999 

T4521 

ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, 

SMALL, EACH $0.62 20050101 99999999 

T4522 


MEDIUM, EACH $0.66 20050101 99999999 

T4524 


EXTRA LARGE, EACH $0.69 20050101 99999999 

T4541 INCONTINENCE PRODUCT, DISPOSABLE UNDERPAD, LARGE, EACH $0.30 20050101 99999999 

V2020 FRAMES, PURCHASES $20.12 20060701 99999999 

V2025 DELUXE FRAME $55.00 19920101 99999999 

V2100 SPHERE SINGLE VISION PLANO TO PLUS OR MINUS 4.00 PER LENS $25.27 20060701 99999999 

V2101 SPHERE SNGL VISION PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D $28.63 20060701 99999999 

V2102 SPHERE SGL VISION PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D $36.18 20060701 99999999 

V2103 

SPHEROCYLINDER SGL VISION PLANO TO PLUS OR MINUS 4.00D 

SPHER $25.15 20060701 99999999 

V2104 

SPHEROCYLINDER SGL VISION PLANO TO PLUS OR MINUS 4.00D 

SPHER $24.82 20060701 99999999 

V2105 SPHEROCYL SGL VISION PLANO TO + OR - 4.00D 4.25 TO 6.00D CYL $25.15 20060701 99999999 

V2106 SPHEROCYL SGL VISION PLANO + OR - 4.00D SPHERE 6.00D PER LEN $29.15 20060701 99999999 

V2107 SPHEROCYL SGL VISION + OR - 4.25 TO + OR - 7.00,.12 TO 2.00D $30.54 20060701 99999999 

V2108 SPHEROCYL SGL VISION + OR - PER LENS $28.79 20060701 99999999 






V2114 SPHEROCYL SGL VISION OVER + OR - PER LENS $32.17 20060701 99999999 

V2115 LENTICULAR (MYODISC) PER LENS SINGLE VISION $83.47 20060701 99999999 

V2116 LENTICULAR LENS NONASPHERIC PER LENS SINGLE VISION $83.47 20030401 99999999 

V2117 LENTICULAR ASPHERIC PER LENS SINGLE VISION $83.47 20030401 99999999 

V2118 ANISEIKONIC LENS SINGLE VISION $90.89 20060701 99999999 

V2121 LENTICULAR LENS, PER LENS, SINGLE $69.31 20060701 99999999 



V2199 NOT OTHERWISE CLASSIFIED SINGLE VISION LENS $52.00 20030401 99999999 

V2200 SPHERE BIFOCAL PLANO TO + OR - 4.00D PER LENS $41.45 20060701 99999999 

V2201 SPHERE BIFOCAL + OR - 4.12 TO + OR - 7.00D PER LENS $44.26 20060701 99999999 

V2202 SPHERE BIFOCAL + OR - 7.12 TO + OR - 20.00D PER LENS $39.81 20060701 99999999 

V2203 SPHEROCYL BIFOCAL PLANO TO + OR - 4.00D,.12 TO 2.00D PER LEN $38.50 20060701 99999999 

V2204 SPHEROCYL BIFOCAL PLANO TO + OR - 4.00D, 2.12 TO 4.00D PER L $40.16 20060701 99999999 

V2205 SPHEROCYL BIFOCAL + OR - 4.00D, 4.25 TO 6.00D CYL PER LENS $39.67 20060701 99999999 

V2206 SPHEROCYL BIFOCAL + OR - 4.00D, OVER 6.00D CYL PER LENS $42.13 20060701 99999999 

V2207 SPHEROCYL BIFOCAL + OR - 4.25 TO + OR - 7.00D,.12 TO 2.00D $40.04 20060701 99999999 

V2208 SPHEROCYL BIFOCAL + OR - 4.25 TO +OR- 7.00D,2.12 TO 4.00D $41.12 20060701 99999999 

V2209 SPHEROCYL BIF + OR - 4.25 TO +OR-7.00D,4.25 TO 6.00D PER LEN $41.62 20060701 99999999 

V2210 SPHEROCYL BIF +OR- 4.25 TO +OR- 7.00D,OVER 6.00D PER LENS $40.92 20060701 99999999 

V2211 SPHEROCYL BIF +OR-7.25 TO +OR- 12.00D,25 TO 2.25D PER LENS $51.73 20060701 99999999 

V2212 SPHEROCYL BIF +OR- 7.25 TO +OR- 12.00D,2.25 TO 4.00D PER LEN $48.08 20060701 99999999 

V2213 SPHEROCYL BIF +OR- 7.25 TO +OR- 12.00D,4.15 TO 6.00D PER LEN $46.31 20060701 99999999 

V2214 SPHEROCYL BIF SPHERE OVER +OR- 12.00D PER LENS $51.22 20060701 99999999 

V2215 LENTICULAR (MYODISC) PER LENS BIFOCAL $129.14 20060701 99999999 

V2216 LENTICULAR NONASPHERIC PER LENS BIFOCAL $51.07 20030401 99999999 

V2217 LENTICULAR ASPHERIC LENS BIFOCAL $66.85 20030401 99999999 

V2218 ANISEIKONIC PER LENS BIFOCAL $102.85 20060701 99999999 

V2219 BIFOCAL SEG WIDTH OVER 28MM $17.78 20060701 99999999 

V2220 BIFOCAL ADD OVER 3.25D $21.58 20060701 99999999 

V2221 LENTICULAR LENS, PER LENS, BIFOCAL $88.64 20060701 99999999 

V2300 SPHERE TRIF PLANO TO +OR- 4.00D PER LENS $50.16 20060701 99999999 

V2301 SPHERE TRIF +OR- 4.12 TO +OR- 7.00D PER LENS $50.16 20060701 99999999 

V2302 SPHERE TRIF +OR- 7.12 TO +OR- 20.00,PER LENS $50.16 20060701 99999999 

V2303 SPHEROCYL TRI PLANO TO+OR-4.00D, .12-2.00D CYL PER LENS $54.15 20060701 99999999 

V2304 SPHEROCYL TRIF PLANO TO +OR- 4.00D, 2.25-4.00D CYL PER LENS $58.46 20060701 99999999 

V2305 SPHEROCYL TRI PLANO TO +OR- 4.00D, 4.25 TO 6.00 CYL PER LENS $58.46 20060701 99999999 

V2306 SPHEROCYL TRIF PLANO TO+OR- 4.00D, OVER 6.00D CYL PER LENS $58.46 20060701 99999999 

V2307 SPHEROCYL TRIF +OR- 4.25 TO +OR- 7.00D, .12 TO 2.00D PER LEN $58.46 20060701 99999999 

V2308 SPHEROCYL TRIF +OR- 4.25 TO +OR-7.00D, 2.12 TO 4.00D PER LEN $58.46 20060701 99999999 

V2309 SPHEROCYL TRIF +OR- 4.25 RO +OR- 7.00D, 4.25 TO 6.00 PER LEN $58.46 20060701 99999999 

V2310 SPHEROCYL TRIF +OR- 4.25 TO +OR- 7.00D, OVER 6.00D PER LENS $58.46 20060701 99999999 

V2311 SPHEROCYL TRIF +OR- 7.25 TO +OR- 12.00D, .25 TO 2.25D PER LE $60.03 20060701 99999999 

V2312 SPHEROCYL TRIF +OR- 7.25 TO +OR- 12.00D, 2.25 TO 4.00D PER L $76.48 20060701 99999999 

V2313 SPHEROCYL TRIF +OR- 7.25 TO +OR- 12.00D, 4.25 TO 6.00D PER L $83.87 20060701 99999999 

V2314 SPHEROCYL TRIF SPHERE OVER +OR- 12.00D, PER LENS $69.16 20060701 99999999 

V2315 LENTICULAR (MYODISC) PER LENS TRIFOCAL $87.56 20060701 99999999 

V2316 LENTICULAR NONASPHERIC PER LENS TRIFOCAL $72.88 20030401 99999999 

V2317 LENTICULAR ASPHERIC LENS TRIFOCAL $75.78 20030401 99999999 

V2318 ANISEIKONIC LENS TRIFOCAL $174.82 20060701 99999999 

V2319 TRIFOCAL SEG WIDTH OVER 28MM $20.10 20060701 99999999 

V2320 TRIFOCAL ADD OVER 3.25D $9.11 20060701 99999999 

V2321 LENTICULAR LENS, PER LENS, TRIFOCAL $138.47 20060701 99999999 

V2410 VARIABLE ASPHERICITY LENS SGL VISION FULL FIELD GLASS OR PLA $74.27 20060701 99999999 

V2430 VARIABLE ASPHERICITY LENS BIF FULL FIELD GLASS OR PLASTIC $99.02 20060701 99999999 

V2500 CONTACT LENS PMMA SPHERICAL PER LENS $76.22 20060701 99999999 

V2501 CONTACT LENS PMMA TORIC OR PRISM BALLAST PER LENS $110.05 20060701 99999999 

V2502 CONTACT LENS PMMA BIFOCAL PER LENS $110.05 20030401 99999999 

V2503 CONTACT LENS PMMA COLOR VISION DEFICIENCY PER LENS $116.75 20060701 99999999 

V2510 CONTACT LENS GAS PERMEABLE SPHERICAL PER LENS $97.91 20060701 99999999 

V2511 CONTACT LENS GAS PERMEABLE TORIC PRISM BALLAST PER LENS $123.49 20060701 99999999 

V2512 CONTACT LENS GAS PERMEABLE BIFOCAL PER LENS $129.99 20030401 99999999 

V2513 CONTACT LENS GAS PERMEABLE EXTENDED WEAR PER LENS $129.99 20060701 99999999 

V2520 CONTACT LENS HYDROPHILIC SPHERICAL PER LENS $83.88 20060701 99999999 

V2521 CONTACT LENS HYDROPHILIC TORIC OR PRISM BALLAST PER LENS $118.74 20060701 99999999 



V2522 CONTACT LENS HYDROPHILLIC BIFOCAL PER LENS $118.74 20030401 99999999 

V2523 CONTACT LENS HYDROPHILIC EXTENDED WEAR PER LENS $121.60 20060701 99999999 

V2530 CONTACT LENS SCLERAL PER LENS (FOR MODIFICATION SEE 92325) $104.88 20060701 99999999 

V2531 

CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR 

CONTACT LENS MODIFICATION, S $426.92 20060701 99999999 

V2599 NOT OTHERWISE CLASSIFIED CONTACT LENS $59.80 20030401 99999999 

V2615 

TELESCOPIC & OTHER COMPOUND LENS SYSTEM INC DISTANCE 

VISION $542.88 20030401 99999999 

V2623 PROSTHETIC EYE PLASTIC CUSTOM $1,216.99 20060701 99999999 

V2624 POLISHING/RESURFACING OF OCULAR PROSTHESIS $28.01 20060701 99999999 

V2625 ENLARGEMENT OF OCULAR PROSTHESIS $331.46 20060701 99999999 

V2626 REDUCTION OF OCULAR PROSTHESIS $210.88 20060701 99999999 

V2627 SCLERAL COVER SHELL $999.32 20060701 99999999 

V2628 FABRICATION AND FITTING OF OCULAR CONFORMER $221.68 20060701 99999999 

V2629 NOT OTHERWISE CLASSIFIED PROSTHETIC EYE $364.00 20030401 99999999 

V2630 ANTERIOR CHAMBER INTRAOCULAR LENS $197.46 20030401 99999999 

V2632 POSTERIOR CHAMBER INTRAOCULAR LENS $311.40 20030401 99999999 

V2700 BALANCE LENS PER LENS $39.13 20060701 99999999 

V2710 SLAB OFF PRISM, GLASS OR PLASTIC. PER LENS $69.85 20030401 99999999 

V2715 PRISM PER LENS $15.66 20060701 99999999 

V2718 PRESSON LENS FRESNELL PRISM PER LENS $58.77 20030401 99999999 

V2730 SPECIAL BASE CURVE GLASS OR PLASTIC PER LENS $22.69 20060701 99999999 

V2740 TINT,PLASTIC,ROSE 1 OR 2 PER LENS $9.36 20030401 99999999 

V2741 TINT,PLASTIC,OTHER THAN ROSE 1-2 PER LENS $8.11 20030401 99999999 

V2742 TINT,GLASS ROSE 1 OR 2,PER LENS $5.74 20030401 99999999 

V2743 TINT,GLASS OTHER THAN ROSE 1 OR 2 PER LENS $6.91 20030401 99999999 

V2744 TINT,PHOTOCHROMATIC,PER LENS $8.54 20060701 99999999 

V2745 

ADDITION TO LENS, TINT, ANY COLOR, SOLID, GRADIENT OR EQUAL, 

EXCLUDES PHOTOCHROA $5.38 20060701 99999999 

V2750 ANTI REFLECTIVE COATING, PER LENS $20.63 20060701 99999999 

V2755 U-V LENS, PER LENS $9.15 20060701 99999999 

V2756 EYE GLASS CASE $1.56 20040101 99999999 

V2760 SCRATCH RESISTANT COATING, PER LENS $14.38 20060701 99999999 

V2762 POLARIZATION, ANY LENS MATERIAL, PER LENS $28.15 20060701 99999999 

V2770 OCCLUDER LENS, PER LENS $20.54 20060701 99999999 

V2780 OVERSIZE LENS, PER LENS $10.98 20060701 99999999 

V2782 

LENS, INDEX 1.54 TO 1.65 PLASTIC OR 1.60 TO 1.79 GLASS, EXCLUDES 

POLYCARBONATE, $30.41 20060701 99999999 

V2783 

LENS, INDEX GREATER THAN OR EQUAL TO 1.66 PLASTIC OR 

GREATER THAN OR EQUAL TO 1. $34.28 20060701 99999999 

V2784 LENS, POLYCARBONATE OR EQUAL, ANY INDEX, PER LENS $30.00 20060701 99999999 

V2799 NOT OTHERWISE CLASSIFIED $1.56 20050101 99999999 

V5010 ASSESSMENT FOR HEARING AID $52.00 20030401 99999999 

V5011 FITTING/ORIENTATION/CHECKING OF HEARING AID $24.30 20030401 99999999 

V5014 REPAIR/MODIFICATION OF A HEARING AID $142.05 20030401 99999999 

V5030 HEARING AID MONAURAL BODY WORN AIR CONDUCTION $442.00 20030401 99999999 

V5060 HEARING AID,MONAURAL,BEHIND THE EAR $312.00 20030401 99999999 

V5247 

HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, BTE 

(BEHIND THE EAR) $312.00 20030401 99999999 

V5260 HEARING AID, DIGITAL, BINAURAL, ITE $338.80 20050103 99999999 

V5264 EAR MOLD/INSERT, NOT DISPOSABLE, ANY TYPE $30.00 20020101 99999999 

V5266 BATTERY FOR USE IN HEARING DEVICE $1.25 19950701 99999999 

V5267 HEARING AID SUPPLIES / ACCESSORIES $4.48 20050103 99999999 

V5275 EAR IMPRESSION, EACH $20.00 20021101 99999999 

W0110 ADMINISTRATION OF INJECTION, INCLUDING COST OF THE DRUG $4.00 19990701 99999999 

W0371 ALL INCLUSIVE DAILY VAC THERAPY $104.00 20030401 99999999 

W0372 ALL INCLUSIVE VAC THERAPY AND SUPPORT, SURFACE $121.68 20030401 99999999 



W0428 

AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON EMERGENCY, 

PEDIATRIC TRANSPORT TEAM $102.38 20030401 99999999 

W0430 

OUT OF STATE AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, 

TRANSPORT ONE-WAY $24,960.00 20030401 99999999 

W0552 

SKILLED NURSING SERVICES BY RN FOR EPSDT SERVICES IN THE 

HOME $50.00 19990701 99999999 

W0553 

SKILLED NURSING SERVICES BY LPN FOR EPSDT SERVICES IN THE 

HOME $31.20 20030401 99999999 

W0554 

SKILLED NURSING SERVICES BY RN FOR EPSDT SERVICES IN THE 

HOME;MULTIPLE PATIENTS $70.00 20030714 99999999 

W0572 

PERSONAL CARE SERVICES BY A NURSE AIDE FOR EPSDT SERVICES 

INTHE HOME $20.00 19990701 99999999 

W0608 MEDICAID NEGOTIATED APNEA MONITOR (HOME USE ONLY) $208.00 20030401 99999999 

W1402 SNF/ICF OXYGEN CONCENTRATION $171.60 20030401 99999999 

W4206 INSULIN SYRINGE FOR HOME USE ONLY, EACH $0.21 20030401 99999999 

W4335 DIAPERS, ADULT SMALL/ALL CHILDRENS, EACH $0.62 20030401 99999999 

W4336 DIAPERS, ADULT EXTRA LARGE, EACH $0.69 20030401 99999999 

W4554 UNDER PADS, SMALL, EACH $0.17 20030401 99999999 

W4627 

WAIVER CASE MANAGEMENT,COMPREHENSIVE,ALL INCLUSIVE,PER 

MONTH $564.82 19990701 99999999 

W4631 

HABILITAION;RESIDENTIAL HAB/INDEP.LIVING SKILLS 

DEVELOPMENT;EACH 15 MIN. $4.50 19990701 99999999 

W4633 WAIVER SERVICE ASSESSMENT/POC DEVELOPMENT;INITIAL;EACH $135.00 19990701 99999999 

W4635 HABILITATION SUPPORTED EMPLOYMENT,EACH 15 MINUTES $4.50 19990701 99999999 

W4654 

ADULT RESIDENTIAL CARE/COMM SUPP LIVING,ASSISTED LIVING;PER 

DAY $42.38 19990701 99999999 

W4676 RESIDENTIAL/SUPPORTED LIVING;ROOM AND BOARD $22.58 19990701 99999999 

W4927 STERILE GLOVES, PER PAIR $0.75 20030401 99999999 

W4928 GLOVES, NON-STERILE, NON-LATEX; PER PAIR $0.27 20030401 99999999 

W5942 PRENATAL AND POSTPARTUM CARE ONLY (COMPREHENSIVE CARE) $416.00 20030401 99999999 

W5951 

CESAREAN SECTION DELIVERY ONLY (INCL. IN-HOSPITAL POST- 

PARTUM VISITS) $1,000.00 19990701 99999999 

W7890 

DIAG RADIOPHARMACEUTICAL FLUORODEOXYGLUCOSE (FDG) FOR 

PET (POSITRON EMM TOMOGRA $600.00 19990701 99999999 

W8390 HIV-1 DRUG RESISTANCE TESTING; GENOTYPING $420.00 19990701 99999999 

W9000 

MEDICAL CLINIC VISIT (ONLY DOH-TYPE CLINICS FOR NON-PHYSICIAN 

SERVICES) $10.40 20030401 99999999 

W9070 

EMERGENCY RESPONDER SYSTEM FOR USE IN HOME; MONTHLY 

RATE $31.47 19990701 99999999 

W9100 VISION SCREENING $12.48 20030401 99999999 

W9200 METHADONE TREATMENT (EXCLUDES COUNSELING) $5.72 20030401 99999999 

W9204 

PSYCHIATRIC CLINIC GROUP THERAPY BY NON-PHYSICIAN/NON- 

PSYCHOLOGIST (DOH ONLY) $15.00 19990701 99999999 

W9205 PSYCHIATRIC CLINIC VISIT (DOH CLINICS ONLY) $15.00 19940801 99999999 

W9206 DHS 1271 EVALUATION $93.60 19990701 99999999 

W9213 

TANF MENTAL/MEDICAL DISABILITY DETERINATION PERFORMED BY 

QUEST $77.00 19990701 99999999 

W9775 INITIAL EVALUATION REPORT $55.02 20030401 99999999 

W9776 RE-EVALUATION BY REPORT $48.05 20030401 99999999 

W9778 

INITIAL PEDIATRIC REHABILITATIVE EVALUATION FOR CHILD < 21 IN 

SUBACUTE LOC $104.00 20030401 99999999 

W9779 

PEDIATRIC REHABILITATIVE INTERVENTION FOR CHILD < 21 IN 

SUBACUTE LEVEL OF CARE $72.80 20030401 99999999 

W9780 

1270 GENERAL ASSISTANCE/AID TO THE DISABLED REVIEW 

COMMITTEEDISABILITY EVALUATIO $94.86 20030401 99999999 

W9781 

1270 GENERAL ASSISTANCE/AID TO DISABLES REVIEW COMMITTEE 

EVALUATION; COMPLEX $156.00 20030401 99999999 



W9801 

QUEST PSYCHIATRIC EVALUATION FOR THE DETERMINATION OF SMI, 

1HOUR $104.00 20030401 99999999 

W9802 

QUEST PSYCHIATRIC EVALUATION FOR DETERMINATION OF SMI, 2 

HOURS $208.00 20030401 99999999 

W9803 

QUEST PSYCHIATRIC EVALUATION FOR THE DETERMINATION OF SMI, 

3HOURS $312.00 20030401 99999999 

W9880 

CASE MGMT, INPATIENT HOSPITAL FOR VENT DEPENDENT/TRACH 

CHILDPRIOR TO INITIAL $1,260.00 20030401 99999999 

W9881 CASE MGMT FOR VENT DEPENDENT/TRACH CHILD LIVING AT HOME $840.00 20030401 99999999 

W9882 

CASE MGMT FOR NON-VENT DEPENDENT/NON-TRACH CHILD WITH 

SIGNIFICANT MEDICAL $336.00 20030401 99999999 

W9883 CASE MANAGEMENT FOR CHILD WITH SIGNIFICANT MEDICAL NEEDS $84.00 20030401 99999999 

W9884 

ADDITIONAL OR UNUSUAL CASE MGMT SERVICES TO ADDRESS 

CHANGINGMEDICAL NEEDS, UNIT $28.00 20030401 99999999 

W9890 CASE ASSESSMENT $9.75 19990701 99999999 

W9891 CASE PLANNING $9.75 19990701 99999999 

W9892 ONGOING MONITORING AND SERVICE COORDINATION $9.75 19990701 99999999 

W9900 ALL INCLUSINVE FAMILY PLANNING SERVICE $48.16 19990701 99999999 

W9970 

SPECIALTY MOLDED UPPER EXTREMITY SPLINT FOR CHILD < 21 IN 


W9971 

SPECIALTY MOLDED LOWER EXTREMITY SPLINT FOR CHILD < 21 IN 


Z9020 TAX $0.01 19990701 99999999 

Z9060 

QUEST ENABLING SERVICE, LANGUAGE TRANSLATION, PER 15 

MINUTES $9.36 20030401 99999999 

Z9415 NOSE PADS $8.32 20030401 99999999 

Z9416 EYEGLASSES CASE $1.56 20030401 99999999 

00100 

ANESTHESIA FOR PROCEDURES ON INTEGUMENTARY SYSTEM OF 

HEAD AND/ OR SALIVARY GLAND $22.80 19990701 99999999 

00102 



00103 



00104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY $22.80 19990701 99999999 

00120 PERIODIC ORAL EXAMINATION $22.80 19990701 99999999 

00124 

ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER 

EAR INCLUDING BIOPSY; O $22.80 19990701 99999999 

00126 

ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER 

EAR INCLUDING BIOPSY; T $22.80 19990701 99999999 

00140 ANESTHESIA FOR PROCEDURES ON EYE; NOT OTHERWISE SPECIFIED $22.80 19990701 99999999 

00142 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY $22.80 19990701 99999999 

00144 ANESTHESIA FOR PROCEDURES ON EYE; CORNEAL TRANSPLANT $22.80 19990701 99999999 

00145 ANESTHESIA FOR PROCEDURES ON EYE; VITRECTOMY $22.80 19990701 99999999 

00147 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY $22.80 19990701 99999999 

00148 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY $22.80 19990701 99999999 

00160 

ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY 

SINUSES; NOT OTHERWISE SPECIFIED $22.80 19990701 99999999 

00162 


SINUSES; RADICAL SURGERY $22.80 19990701 99999999 

00164 


SINUSES; BIOPSY, SOFT TISSUE $22.80 19990701 99999999 

00170 

ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; 

NOT OTHERWISE SPECIFIED $22.80 19990701 99999999 

00172 


REPAIR OF CLEFT PALATE $22.80 19990701 99999999 

00174 


EXCISION OF RETROPHARYNGE $22.80 19990701 99999999 



00176 


RADICAL SURGERY $22.80 19990701 99999999 

00190 

ANESTHESIA FOR PROCEDURES ON FACIAL BONES; NOT OTHERWISE 

SPECIFIED $22.80 19990701 99999999 

00192 

ANESTHESIA FOR PROCEDURES ON FACIAL BONES; RADICAL 

SURGERY (INCLUDING PROGNATHIS $22.80 19990701 99999999 

00210 INTRAORAL COMPLETE SERIES (INCLUDING BITEWINGS) $22.80 19990701 99999999 

00212 ANESTHESIA FOR INTRACRANIAL PROCEDURES; SUBDURAL TAPS $22.80 19990701 99999999 

00214 ANESTHESIA FOR INTRACRANIAL PROCEDURES; BURR HOLES $22.80 19990701 99999999 

00215 

ANESTHESIA FOR INTRACRANIAL PROCEDURES; ELEVATION OF 

DEPRESSED SKULL FRACTURE, E $22.80 19990701 99999999 

00216 

ANESTHESIA FOR INTRACRANIAL PROCEDURES; VASCULAR 

PROCEDURES $22.80 19990701 99999999 

00218 

ANESTHESIA FOR INTRACRANIAL PROCEDURES; PROCEDURES IN 

SITTING POSITION $22.80 19990701 99999999 

00220 INTRAORAL PERIAPICAL SINGLE 1ST FILM $22.80 19990701 99999999 

00222 

ANESTHESIA FOR INTRACRANIAL PROCEDURES; 

ELECTROCOAGULATION OF INTRACRANIAL NERVE $22.80 19990701 99999999 

00300 

ANESTHESIA FOR ALL PROCEDURES ON INTEGUMENTARY SYSTEM 

OF NECK, INCLUDING SUBCUTA $22.80 20030401 99999999 

00320 TEMPOROMANDIBULAR JOINT ARTHROGRAM INCL INJECTION $22.80 19990701 99999999 

00322 

ANESTHESIA FOR ALL PROCEDURES ON ESOPHAGUS, THYROID, 

LARYNX, TRACHEA AND LYMPHAT $22.80 19990701 99999999 

00326 

ANESTHESIA FOR ALL PROCEDURES ON THE LARYNX AND TRACHEA 

IN CHILDREN LESS THAN 1 $22.80 20030401 99999999 

00350 

ANESTHESIA FOR PROCEDURES ON MAJOR VESSELS OF NECK; NOT 

OTHERWISE SPECIFIED $22.80 19990701 99999999 

00352 

ANESTHESIA FOR PROCEDURES ON MAJOR VESSELS OF NECK; 

SIMPLE LIGATION $22.80 19990701 99999999 

00400 

ANESTHESIA FOR PROCEDURES ON ANTERIOR INTEGUMENTARY 

SYSTEM OF CHEST, INCLUDING S $22.80 19990701 99999999 

00402 URINALYSIS $22.80 19990701 99999999 

00404 HEMATOCRIT $22.80 19990701 99999999 

00406 


SYSTEM OF CHEST, INCLUDING S $22.80 19990701 99999999 

00410 BACTROLOGIC STDES FOR DTRMNTION OF PATHOLOGIC STDE $22.80 19990701 99999999 

00420 CARIES SUSCEPABILITY TESTS $22.80 19990701 99999999 

00450 HISTOPATHOLOGIC EXAMINATION $22.80 19990701 99999999 

00452 

ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA; 

RADICAL SURGERY $22.80 19990701 99999999 

00454 

ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA; BIOPSY 

OF CLAVICLE $22.80 19990701 99999999 

00470 DIAGNOSTIC COSTS $22.80 19990701 99999999 

00472 

ANESTHESIA FOR PARTIAL RIB RESECTION; THORACOPLASTY (ANY 

TYPE) $22.80 19990701 99999999 

00474 

ANESTHESIA FOR PARTIAL RIB RESECTION; RADICAL PROCEDURES 

(EG, PECTUS EXCAVATUM) $22.80 19990701 99999999 

00500 ANESTHESIA FOR ALL PROCEDURES ON ESOPHAGUS $22.80 19990701 99999999 

00520 

ANESTHESIA FOR CLOSED CHEST PROCEDURES (INCLUDING 

ESOPHAGOSCOPY, BRONCHOSCOPY, T $22.80 19990701 99999999 

00522 



00524 



00528 



00529 

ANESTHESIA FOR CLOSED CHEST PROCEDURES; MEDIASTINOSCOPY 

AND DIAGNOSTIC THORACOSC $22.80 20040101 99999999 



00530 ANESTHESIA FOR TRANSVENOUS PACEMAKER INSERTION $22.80 19990701 99999999 

00532 ANESTHESIA FOR ACCESS TO CENTRAL VENOUS CIRCULATION $22.80 19990701 99999999 

00534 

ANESTHESIA FOR TRANSVENOUS INSERTION OR REPLACEMENT OF 

CARDIOVERTER/ DEFIBRILLAT $22.80 19990701 99999999 

00537 

ANESTHESIA FOR CARDIAC ELECTROPHYSIOLOGIC PROCEDURES 

INCLUDING RADIOFREQUENCY AB $22.80 20010101 99999999 

00539 ANESTHESIA FOR TRACHEOBRONCHIAL RECONSTRUCTION $22.80 20030401 99999999 

00540 

ANESTHESIA FOR THORACOTOMY PROCEDURES INVOLVING LUNGS, 

PLEURA, DIAPHRAGM, AND ME $22.80 19990701 99999999 

00541 



00542 



00544 



00546 



00548 



00550 ANESTHESIA FOR STERNAL DEBRIDEMENT $22.80 20010101 99999999 

00560 

ANESTHESIA FOR PROCEDURES ON HEART, PERICARDIUM, AND 

GREAT VESSELS OF CHEST; WIT $22.80 19990701 99999999 

00561 

ANESTHESIA FOR PROCEDURES ON HEART, PERICARDIAL SAC, AND 

GREAT VESSELS OF $22.80 20050101 99999999 

00562 



00563 



00566 

ANESTHESIA FOR DIRECT CORONARY ARTERY BYPASS GRAFTING 

WITHOUT PUMP OXYGENATOR $22.80 20010101 99999999 

00580 ANESTHESIA FOR HEART TRANSPLANT OR HEART/LUNG TRANSPLANT $22.80 19990701 99999999 

00600 

ANESTHESIA FOR PROCEDURES ON CERVICAL SPINE AND CORD; NOT 


00604 

ANESTHESIA FOR PROCEDURES ON CERVICAL SPINE AND CORD; 

POSTERIOR CERVICAL LAMINEC $22.80 19990701 99999999 

00620 

ANESTHESIA FOR PROCEDURES ON THORACIC SPINE AND CORD; 


00622 

ANESTHESIA FOR PROCEDURES ON THORACIC SPINE AND CORD; 

THORACOLUMBAR SYMPATHECTOM $22.80 19990701 99999999 

00630 

ANESTHESIA FOR PROCEDURES IN LUMBAR REGION; NOT 


00632 

ANESTHESIA FOR PROCEDURES IN LUMBAR REGION; LUMBAR 

SYMPATHECTOMY $22.80 19990701 99999999 

00634 

ANESTHESIA FOR PROCEDURES IN LUMBAR REGION; 

CHEMONUCLEOLYSIS $22.80 19990701 99999999 

00635 

ANESTHESIA FOR PROCEDURES IN LUMBAR REGION; DIAGNOSTIC OR 

THERAPEUTIC LUMBAR PUN $22.80 20010101 99999999 

00640 

ANESTHESIA FOR MANIPULATION OF THE SPINE OR FOR CLOSED 

PROCEDURES ON THE CERVICA $22.80 20030401 99999999 

00670 

ANESTHESIA FOR EXTENSIVE SPINE AND SPINAL CORD PROCEDURES 

(EG, HARRINGTON ROD TE $22.80 19990701 99999999 

00700 

ANESTHESIA FOR PROCEDURES ON UPPER ANTERIOR ABDOMINAL 

WALL; NOT OTHERWISE SPECIF $22.80 19990701 99999999 

00702 

ANESTHESIA FOR PROCEDURES ON UPPER ANTERIOR ABDOMINAL 

WALL; PERCUTANEOUS LIVER B $22.80 19990701 99999999 

0073T 

COMPENSATOR-BASED BEAM MODULATION TREATMENT DELIVERY 

OF INVERSE PLANNED $458.86 20060701 99999999 



00730 

ANESTHESIA FOR PROCEDURES ON UPPER POSTERIOR ABDOMINAL 

WALL $22.80 19990701 99999999 

00740 

ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC 

PROCEDURES $22.80 19990701 99999999 

00750 

ANESTHESIA FOR HERNIA REPAIRS IN UPPER ABDOMEN; NOT 


00752 

ANESTHESIA FOR HERNIA REPAIRS IN UPPER ABDOMEN; LUMBAR 

AND VENTRAL (INCISIONAL) $22.80 19990701 99999999 

00754 

ANESTHESIA FOR HERNIA REPAIRS IN UPPER ABDOMEN; 

OMPHALOCELE $22.80 19990701 99999999 

00756 

ANESTHESIA FOR HERNIA REPAIRS IN UPPER ABDOMEN; 

TRANSABDOMINAL REPAIR OF DIAPHRA $22.80 19990701 99999999 

00770 

ANESTHESIA FOR ALL PROCEDURES ON MAJOR ABDOMINAL BLOOD 

VESSELS $22.80 19990701 99999999 

00790 

ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN UPPER 

ABDOMEN INCLUDING LAPAROSCOPY $22.80 19990701 99999999 

00792 



00794 



00796 



00797 



00800 

ANESTHESIA FOR PROCEDURES ON LOWER ANTERIOR ABDOMINAL 

WALL; NOT OTHERWISE SPECIF $22.80 19990701 99999999 

00802 

ANESTHESIA FOR PROCEDURES ON LOWER ANTERIOR ABDOMINAL 

WALL; PANNICULECTOMY $22.80 19990701 99999999 

00810 ANESTHESIA FOR INTESTINAL ENDOSCOPIC PROCEDURES $22.80 19990701 99999999 

00820 

ANESTHESIA FOR PROCEDURES ON LOWER POSTERIOR ABDOMINAL 

WALL $22.80 19990701 99999999 

00830 

ANESTHESIA FOR HERNIA REPAIRS IN LOWER ABDOMEN; NOT 


00832 

ANESTHESIA FOR HERNIA REPAIRS IN LOWER ABDOMEN; VENTRAL 

AND INCISIONAL HERNIAS $22.80 19990701 99999999 

00834 

ANESTHESIA FOR HERNIA REPAIRS IN THE LOWER ABDOMEN NOT 

OTHERWISE SPECIFIED, UNDE $22.80 20030401 99999999 

00836 

ANESTHESIA FOR HERNIA REPAIRS IN THE LOWER ABDOMEN NOT 

OTHERWISE SPECIFIED, INFA $22.80 20030401 99999999 

00840 

ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN LOWER 


00842 



00844 



00846 



00848 



00850 



00851 



00855 



00857 

CONTINUOUS EPIDURAL ANALGESIA, FOR LABOR AND CESAREAN 

SECTION $22.80 19990701 99999999 



00860 

ANESTHESIA FOR EXTRAPERITONEAL PROCEDURES IN LOWER 

ABDOMEN, INCLUDING URINARY TR $22.80 19990701 99999999 

00862 



00864 



00865 



00866 



00868 



00869 



00870 



00872 

ANESTHESIA FOR LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE; 

WITH WATER BATH $22.80 19990701 99999999 

00873 

ANESTHESIA FOR LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE; 

WITHOUT WATER BATH $22.80 19990701 99999999 

00880 

ANESTHESIA FOR PROCEDURES ON MAJOR LOWER ABDOMINAL 

VESSELS; NOT OTHERWISE SPECIF $22.80 19990701 99999999 

00882 


VESSELS; INFERIOR VENA CAVA L $22.80 19990701 99999999 

00884 


VESSELS; TRANSVENOUS UMBRELLA $22.80 19990701 99999999 

00900 

ANESTHESIA FOR PROCEDURES ON PERINEAL INTEGUMENTARY 

SYSTEM (INCLUDING BIOPSY OF $22.80 19990701 99999999 

00902 



00904 



00906 



00908 



00910 

ANESTHESIA FOR TRANSURETHRAL PROCEDURES (INCLUDING 

URETHROCYSTOSCOPY); NOT OTHER $22.80 19990701 99999999 

00912 


URETHROCYSTOSCOPY); TRANSURET $22.80 19990701 99999999 

00914 


URETHROCYSTOSCOPY); TRANSURET $22.80 19990701 99999999 

00916 


URETHROCYSTOSCOPY); POST-TRAN $22.80 19990701 99999999 

00918 


URETHROCYSTOSCOPY); WITH FRAG $22.80 19990701 99999999 

00920 

ANESTHESIA FOR PROCEDURES ON MALE EXTERNAL GENITALIA; NOT 


00921 

ANESTHESIA FOR PROCEDURES ON MALE GENITALIA (INCLUDING 

OPEN URETHRAL PROCEDURES) $22.80 20030401 99999999 

00922 

ANESTHESIA FOR PROCEDURES ON MALE EXTERNAL GENITALIA; 

SEMINAL VESICLES $22.80 19990701 99999999 

00924 


UNDESCENDED TESTIS, UNILAT $22.80 19990701 99999999 

00926 


RADICAL ORCHIECTOMY, INGUI $22.80 19990701 99999999 

00928 


RADICAL ORCHIECTOMY, ABDOM $22.80 19990701 99999999 



00930 


ORCHIOPEXY, UNILATERAL OR $22.80 19990701 99999999 

00932 


COMPLETE AMPUTATION OF PEN $22.80 19990701 99999999 

00934 


RADICAL AMPUTATION OF PENI $22.80 19990701 99999999 

00936 


RADICAL AMPUTATION OF PENI $22.80 19990701 99999999 

00938 


INSERTION OF PENILE PROSTH $22.80 19990701 99999999 

00940 

ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING BIOPSY OF 

LABIA, VAGINA, CERVIX OR $22.80 19990701 99999999 

00942 



00944 



00946 



00948 



00950 



00952 



00955 

CONTINUOUS EPIDURAL ANALGESIA, FOR LABOR AND VAGINAL 

DELIVERY $22.80 19990701 99999999 

01000 


SYSTEM OF PELVIS (ANTERIOR T $22.80 19990701 99999999 

01110 PROPHYLAXIS, ADULT $22.80 19990701 99999999 

01112 

ANESTHESIA FOR BONE MARROW ASPIRATION AND/OR BIOPSY, 

ANTERIOR OR POSTERIOR ILIAC $22.80 20010101 99999999 

01120 PROPHYLAXIS-CHILD $22.80 19990701 99999999 

01130 ANESTHESIA FOR BODY CAST APPLICATION OR REVISION $22.80 19990701 99999999 

01140 

ANESTHESIA FOR INTERPELVIABDOMINAL (HINDQUARTER) 

AMPUTATION $22.80 19990701 99999999 

01150 

ANESTHESIA FOR RADICAL PROCEDURES FOR TUMOR OF PELVIS, 

EXCEPT HINDQUARTER AMPUTA $22.80 19990701 99999999 

01160 

ANESTHESIA FOR CLOSED PROCEDURES INVOLVING SYMPHYSIS 

PUBIS OR SACROILIAC JOINT $22.80 19990701 99999999 

01170 

ANESTHESIA FOR OPEN PROCEDURES INVOLVING SYMPHYSIS PUBIS 

OR SACROILIAC JOINT $22.80 19990701 99999999 

01173 

ANESTHESIA FOR OPEN REPAIR OF FRACTURE DISRUPTION OF 

PELVIS OR COLUMN FRACTURE $22.80 20040101 99999999 

01180 ANESTHESIA FOR OBTURATOR NEURECTOMY; EXTRAPELVIC $22.80 19990701 99999999 

01190 ANESTHESIA FOR OBTURATOR NEURECTOMY; INTRAPELVIC $22.80 19990701 99999999 

01200 ANESTHESIA FOR ALL CLOSED PROCEDURES INVOLVING HIP JOINT $22.80 19990701 99999999 

01202 TOPICL APPLCTN FLUORIDE (INCL PROPHYLAXIS) ADULT $22.80 19990701 99999999 

01210 TOPICAL APP SODIUM FLUORIDE $22.80 19990701 99999999 

01212 

ANESTHESIA FOR OPEN PROCEDURES INVOLVING HIP JOINT; HIP 


01214 

ANESTHESIA FOR OPEN PROCEDURES INVOLVING HIP JOINT; TOTAL 

HIP REPLACEMENT OR REV $22.80 19990701 99999999 

01215 

ANESTHESIA FOR OPEN PROCEDURES INVOLVING HIP JOINT; 

REVISION OF TOTAL HIP ARTHRO $22.80 20010101 99999999 

01220 TOPICAL AYGS STANNOUS FLRIDE- TREATMNT (EXCLDING P $22.80 19990701 99999999 

01230 TOPICAL APP ACID FLRIDE PHSPHATE ONE TRM (EX-PROHY $22.80 19990701 99999999 

01232 

ANESTHESIA FOR OPEN PROCEDURES INVOLVING UPPER 2/3 OF 

FEMUR; AMPUTATION $22.80 19990701 99999999 



01234 

ANESTHESIA FOR OPEN PROCEDURES INVOLVING UPPER 2/3 OF 

FEMUR; RADICAL RESECTION $22.80 19990701 99999999 

01240 


OF UPPER LEG $22.80 19990701 99999999 

01250 

ANESTHESIA FOR ALL PROCEDURES ON NERVES, MUSCLES, 

TENDONS, FASCIA, AND BURSAE OF $22.80 19990701 99999999 

01260 

ANESTHESIA FOR ALL PROCEDURES INVOLVING VEINS OF UPPER 

LEG, INCLUDING EXPLORATIO $22.80 19990701 99999999 

01270 

ANESTHESIA FOR PROCEDURES INVOLVING ARTERIES OF UPPER 

LEG, INCLUDING BYPASS GRAF $22.80 19990701 99999999 

01272 



01274 



01300 


OF KNEE AND/OR POPLITEAL A $22.80 19990701 99999999 

01320 



01340 TRAINING IN PREVENTIVE DENTAL CARE $22.80 19990701 99999999 

01360 ANESTHESIA FOR ALL OPEN PROCEDURES ON LOWER 1/3 OF FEMUR $22.80 19990701 99999999 

01380 ANESTHESIA FOR ALL CLOSED PROCEDURES ON KNEE JOINT $22.80 19990701 99999999 

01382 001STHESIA FOR ARTHROSCOPIC PROCEDURES OF KNEE JOINT $22.80 19990701 99999999 

01390 

ANESTHESIA FOR ALL CLOSED PROCEDURES ON UPPER ENDS OF 

TIBIA, FIBULA, AND/OR PATE $22.80 19990701 99999999 

01392 

ANESTHESIA FOR ALL OPEN PROCEDURES ON UPPER ENDS OF TIBIA, 

FIBULA, AND/OR PATELL $22.80 19990701 99999999 

01400 

ANESTHESIA FOR OPEN PROCEDURES ON KNEE JOINT; NOT 


01402 

ANESTHESIA FOR OPEN PROCEDURES ON KNEE JOINT; TOTAL KNEE 

REPLACEMENT $22.80 19990701 99999999 

01404 

ANESTHESIA FOR OPEN PROCEDURES ON KNEE JOINT; 

DISARTICULATION AT KNEE $22.80 19990701 99999999 

01420 

ANESTHESIA FOR ALL CAST APPLICATIONS, REMOVAL, OR REPAIR 

INVOLVING KNEE JOINT $22.80 19990701 99999999 

01430 

ANESTHESIA FOR PROCEDURES ON VEINS OF KNEE AND POPLITEAL 

AREA; NOT OTHERWISE SPE $22.80 19990701 99999999 

01432 

ANESTHESIA FOR PROCEDURES ON VEINS OF KNEE AND POPLITEAL 

AREA; ARTERIOVENOUS FIS $22.80 19990701 99999999 

01440 

ANESTHESIA FOR PROCEDURES ON ARTERIES OF KNEE AND 

POPLITEAL AREA; NOT OTHERWISE $22.80 19990701 99999999 

01442 


POPLITEAL AREA; POPLITEAL THRO $22.80 19990701 99999999 

01444 


POPLITEAL AREA; POPLITEAL EXCI $22.80 19990701 99999999 

0146T 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY OF CORONARY ARTERIES 

(INCLUDING NATIVE AND ANOM $530.39 20060101 99999999 

01460 


OF LOWER LEG, ANKLE, AND F $22.80 19990701 99999999 

01462 

ANESTHESIA FOR ALL CLOSED PROCEDURES ON LOWER LEG, ANKLE, 

AND FOOT $22.80 19990701 99999999 

01464 ANESTHESIA FOR ARTHROSCOPIC PROCEDURES OF ANKLE JOINT $22.80 19990701 99999999 

01470 

ANESTHESIA FOR PROCEDURES ON NERVES, MUSCLES, TENDONS, 

AND FASCIA OF LOWER LEG, $22.80 19990701 99999999 

01472 



01474 





01480 

ANESTHESIA FOR OPEN PROCEDURES ON BONES OF LOWER LEG, 

ANKLE, AND FOOT; NOT OTHER $22.80 19990701 99999999 

01482 


ANKLE, AND FOOT; RADICAL R $22.80 19990701 99999999 

01484 


ANKLE, AND FOOT; OSTEOTOMY $22.80 19990701 99999999 

01486 


ANKLE, AND FOOT; TOTAL ANK $22.80 19990701 99999999 

01490 

ANESTHESIA FOR LOWER LEG CAST APPLICATION, REMOVAL, OR 

REPAIR $22.80 19990701 99999999 

01500 

ANESTHESIA FOR PROCEDURES ON ARTERIES OF LOWER LEG, 

INCLUDING BYPASS GRAFT; NOT $22.80 19990701 99999999 

01502 

ANESTHESIA FOR PROCEDURES ON ARTERIES OF LOWER LEG, 

INCLUDING BYPASS GRAFT; EMBO $22.80 19990701 99999999 

01520 SPACE MAINTAINER,REMOVABLE,UNILATERAL $22.80 19990701 99999999 

01522 

ANESTHESIA FOR PROCEDURES ON VEINS OF LOWER LEG; VENOUS 

THROMBECTOMY, DIRECT OR $22.80 19990701 99999999 

01600 


OF SHOULDER AND AXILLA $22.80 19990701 99999999 

01610 



01620 

ANESTHESIA FOR ALL CLOSED PROCEDURES ON HUMERAL HEAD 

AND NECK, STERNOCLAVICULAR $22.80 19990701 99999999 

01622 

ANESTHESIA FOR ARTHROSCOPIC PROCEDURES OF SHOULDER 

JOINT $22.80 19990701 99999999 

01630 

ANESTHESIA FOR OPEN PROCEDURES ON HUMERAL HEAD AND 

NECK, STERNOCLAVICULAR JOINT, $22.80 19990701 99999999 

01632 



01634 



01636 



01638 



01650 

ANESTHESIA FOR PROCEDURES ON ARTERIES OF SHOULDER AND 

AXILLA; NOT OTHERWISE SPEC $22.80 19990701 99999999 

01652 


AXILLA; AXILLARY-BRACHIAL $22.80 19990701 99999999 

01654 


AXILLA; BYPASS GRAFT $22.80 19990701 99999999 

01656 


AXILLA; AXILLARY-FEMORAL B $22.80 19990701 99999999 

01670 

ANESTHESIA FOR ALL PROCEDURES ON VEINS OF SHOULDER AND 

AXILLA $22.80 19990701 99999999 

01680 

ANESTHESIA FOR SHOULDER CAST APPLICATION, REMOVAL OR 

REPAIR; NOT OTHERWISE SPECI $22.80 19990701 99999999 

01682 

ANESTHESIA FOR SHOULDER CAST APPLICATION, REMOVAL OR 

REPAIR; SHOULDER SPICA $22.80 19990701 99999999 

01700 


OF UPPER ARM AND ELBOW $22.80 19990701 99999999 

01710 


FASCIA, AND BURSAE OF UPP $22.80 19990701 99999999 

01712 



01714 





01716 



01730 

ANESTHESIA FOR ALL CLOSED PROCEDURES ON HUMERUS AND 

ELBOW $22.80 19990701 99999999 

01732 ANESTHESIA FOR ARTHROSCOPIC PROCEDURES OF ELBOW JOINT $22.80 19990701 99999999 

01740 

ANESTHESIA FOR OPEN PROCEDURES ON HUMERUS AND ELBOW; 


01742 


OSTEOTOMY OF HUMERUS $22.80 19990701 99999999 

01744 


REPAIR OF NONUNION OR MALUN $22.80 19990701 99999999 

01756 


RADICAL PROCEDURES $22.80 19990701 99999999 

01758 


EXCISION OF CYST OR TUMOR O $22.80 19990701 99999999 

01760 


TOTAL ELBOW REPLACEMENT $22.80 19990701 99999999 

01770 

ANESTHESIA FOR PROCEDURES ON ARTERIES OF UPPER ARM AND 

ELBOW; NOT OTHERWISE SPEC $22.80 19990701 99999999 

01772 

ANESTHESIA FOR PROCEDURES ON ARTERIES OF UPPER ARM AND 

ELBOW; EMBOLECTOMY $22.80 19990701 99999999 

01780 

ANESTHESIA FOR PROCEDURES ON VEINS OF UPPER ARM AND 

ELBOW; NOT OTHERWISE SPECIFI $22.80 19990701 99999999 

01782 

ANESTHESIA FOR PROCEDURES ON VEINS OF UPPER ARM AND 

ELBOW; PHLEBORRHAPHY $22.80 19990701 99999999 

01784 

ANESTHESIA FOR REPAIR OF ARTERIO-VENOUS (A-V) FISTULA, 

CONGENITAL OR ACQUIRED $22.80 19990701 99999999 

01800 


OF FOREARM, WRIST, AND HAN $22.80 19990701 99999999 

01810 



01820 

ANESTHESIA FOR ALL CLOSED PROCEDURES ON RADIUS, ULNA, 

WRIST, OR HAND BONES $22.80 19990701 99999999 

01829 

ANESTHESIA FOR DIAGNOSTIC ARTHROSCOPIC PROCEDURES ON 

THE WRIST $22.80 20030401 99999999 

01830 

ANESTHESIA FOR OPEN PROCEDURES ON RADIUS, ULNA, WRIST, OR 

HAND BONES; NOT OTHERW $22.80 19990701 99999999 

01832 

ANESTHESIA FOR OPEN PROCEDURES ON RADIUS, ULNA, WRIST, OR 

HAND BONES; TOTAL WRIS $22.80 19990701 99999999 

01840 

ANESTHESIA FOR PROCEDURES ON ARTERIES OF FOREARM, WRIST, 

AND HAND; NOT OTHERWISE $22.80 19990701 99999999 

01842 

ANESTHESIA FOR PROCEDURES ON ARTERIES OF FOREARM, WRIST, 

AND HAND; EMBOLECTOMY $22.80 19990701 99999999 

01844 

ANESTHESIA FOR VASCULAR SHUNT, OR SHUNT REVISION, ANY TYPE 

(EG, DIALYSIS) $22.80 19990701 99999999 

01850 

ANESTHESIA FOR PROCEDURES ON VEINS OF FOREARM, WRIST, AND 

HAND; NOT OTHERWISE SP $22.80 19990701 99999999 

01852 

ANESTHESIA FOR PROCEDURES ON VEINS OF FOREARM, WRIST, AND 

HAND; PHLEBORRHAPHY $22.80 19990701 99999999 

01860 

ANESTHESIA FOR FOREARM, WRIST, OR HAND CAST APPLICATION, 

REMOVAL, OR REPAIR $22.80 19990701 99999999 

01900 

ANESTHESIA FOR INJECTION PROCEDURE FOR 

HYSTEROSALPINGOGRAPHY $22.80 19990701 99999999 

01902 ANESTHESIA FOR BURR HOLE(S) FOR VENTRICULOGRAPHY $22.80 19990701 99999999 

01904 

ANESTHESIA FOR INJECTION PROCEDURE FOR 

PNEUMOENCEPHALOGRAPHY $22.80 19990701 99999999 

01905 ANESTHESIA FOR MYELOGRAPHY, DISKOGRAPHY, VERTEBROPLASTY $22.80 20020101 99999999 



01906 

ANESTHESIA FOR INJECTION PROCEDURE FOR MYELOGRAPHY; 

LUMBAR $22.80 19990701 99999999 

01908 


CERVICAL $22.80 19990701 99999999 

01910 


POSTERIOR FOSSA $22.80 19990701 99999999 

01912 

ANESTHESIA FOR INJECTION PROCEDURE FOR DISKOGRAPHY; 

LUMBAR $22.80 19990701 99999999 

01914 

ANESTHESIA FOR INJECTION PROCEDURE FOR DISKOGRAPHY; 

CERVICAL $22.80 19990701 99999999 

01916 

ANESTHESIA FOR ARTERIOGRAMS, NEEDLE; CAROTID, OR 

VERTEBRAL $22.80 19990701 99999999 

01918 

ANESTHESIA FOR ARTERIOGRAMS, NEEDLE; RETROGRADE, 

BRACHIAL OR FEMORAL $22.80 19990701 99999999 

01920 

ANESTHESIA FOR CARDIAC CATHETERIZATION INCLUDING 

CORONARY ARTERIOGRAPHY AND VENT $22.80 19990701 99999999 

01921 ANESTHESIA FOR ANGIOPLASTY $22.80 19990701 99999999 

01922 ANESTHESIA FOR NON-INVASIVE IMAGING OR RADIATION THERAPY $22.80 19990701 99999999 

01924 

ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC 

PROCEDURES INVOLVING THE AR $22.80 20020101 99999999 

01925 



01926 



01930 


PROCEDURES INVOLVING THE VE $22.80 20020101 99999999 

01931 



01932 



01933 



01935 

ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON 

THE SPINE AND SPINAL CORD $22.80 20080101 99999999 

01936 

ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED PROCEDURES ON 

THE SPINE AND SPINAL CORD $22.80 20080101 99999999 

01951 

ANESTHESIA FOR SECOND AND THIRD DEGREE BURN EXCISION OR 

DEBRIDEMENT WITH OR WITH $22.80 20010101 99999999 

01952 



01953 



01960 ANESTHESIA FOR; VAGINAL DELIVERY ONLY $22.80 20020101 99999999 

01961 ANESTHESIA FOR; CESAREAN DELIVERY ONLY $22.80 20020101 99999999 

01962 ANESTHESIA FOR; URGENT HYSTERECTOMY FOLLOWING DELIVERY $22.80 20020101 99999999 

01963 

ANESTHESIA FOR; CESAREAN HYSTERECTOMY WITHOUT ANY LABOR 

ANALGESIA/ANESTHESIA CAR $22.80 20020101 99999999 

01964 ANESTHESIA FOR; ABORTION PROCEDURES $22.80 20020101 99999999 

01965 ANESTHESIA FOR INCOMPLETE OR MISSED ABORTION PROCEDURES $22.80 20060101 99999999 

01966 ANESTHESIA FOR INDUCED ABORTION PROCEDURES $22.80 20060101 99999999 

01968 

CESAREAN DELIVERY FOLLOWING NEURAXIAL LABOR 

ANALGESIA/ANESTHESIA (LIST SEPARATEL $22.80 20020101 99999999 

01969 

CESAREAN HYSTERECTOMY FOLLOWING NEURAXIAL LABOR 

ANALGESIA/ ANESTHESIA (LIST SEPA $22.80 20020101 99999999 

01990 

PHYSIOLOGICAL SUPPORT FOR HARVESTING OF ORGAN(S) FROM 

BRAIN-DEAD PATIENT $22.80 19990701 99999999 

01991 

ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS 

AND INJECTIONS (WHEN BLOCK $22.80 20030401 99999999 



01992 

ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS 

AND INJECTIONS (WHEN BLOCK $22.80 20030401 99999999 

01995 

REGIONAL IV ADMINISTRATION OF LOCAL ANESTHETIC AGENT 

(UPPER OR LOWER EXTREMITY) $22.80 19990701 99999999 

01996 

DAILY MANAGEMENT OF EPIDURAL OR SUBARACHNOID DRUG 

ADMINISTRATION $27.32 19990701 99999999 

01999 UNLISTED ANESTHESIA PROCEDURE(S) $22.80 20020101 99999999 

10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE $65.06 20060701 99999999 

10022 FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE $66.30 20060701 99999999 

10040 ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF $47.83 20060701 99999999 

10060 

INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, 

SUPPURATIVE $52.42 20060701 99999999 

10061 

INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, 

SUPPURATIVE $97.47 20060701 99999999 

10080 INCISION AND DRAINAGE OF PILONIDAL CYST $56.78 20060701 99999999 

10081 INCISION AND DRAINAGE OF PILONIDAL CYST $103.48 20060701 99999999 

10120 

INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS 

TISSUES $54.57 20060701 99999999 

10121 

INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS 

TISSUES $112.70 20060701 99999999 

10140 INCISION AND DRAINAGE OF HEMATOMA $71.01 20060701 99999999 

10160 PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST $57.25 20060701 99999999 

10180 

INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND 

INFECTION $108.05 20060701 99999999 

11000 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN $23.96 20060701 99999999 

11001 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN $12.45 20060701 99999999 

11004 

DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND 

FASCIA FOR NECROTIZING $415.20 20060701 99999999 

11005 



11006 



11008 

REMOVAL OF PROSTHETIC MATERIAL OR MESH, ABDOMINAL WALL 

FOR NECROTIZING SOFT $211.51 20060701 99999999 

11010 

DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL 

ASSOCIATEDWITH OPEN FRACTURE $219.04 20060701 99999999 

11011 

DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOC 

WITHOPEN FX(S)/DISLOCATI $262.37 20060701 99999999 

11012 

DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOC 

WITHOPEN FRACTURE(S)/DIS $373.19 20060701 99999999 

11040 DEBRIDEMENT $20.46 20060701 99999999 

11041 DEBRIDEMENT $33.06 20060701 99999999 

11042 DEBRIDEMENT $44.20 20060701 99999999 

11043 DEBRIDEMENT $125.89 20060701 99999999 

11044 DEBRIDEMENT $172.73 20060701 99999999 

11055 

PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, 

CORN OR CALLUS); SINGLE L $15.03 20060701 99999999 

11056 


CORN OR CALLUS); TWO TO F $21.02 20060701 99999999 

11057 


CORN OR CALLUS); MORE THA $27.45 20060701 99999999 

11100 

BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS 

MEMBRANE $32.61 20060701 99999999 

11101 

BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS 

MEMBRANE $16.91 20060701 99999999 



11200 

EXCISION (INCLUDING SIMPLE CLOSURE OR LIGATURE 

STRANGULATION), $37.52 20060701 99999999 

11201 

EXCISION (INCLUDING SIMPLE CLOSURE OR LIGATURE 

STRANGULATION), $11.56 20060701 99999999 

11300 

SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 

TRUNK, ARMS OR LEGS; LESIO $22.28 20060701 99999999 

11301 



11302 



11303 



11305 

SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, 

NECK, HANDS, FEET, $27.37 20060701 99999999 

11306 



11307 



11308 



11310 

SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, 

EARS, EYELIDS, NOSE, $31.44 20060701 99999999 

11311 



11312 



11313 



11400 

EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED 

ELSEWHERE), $42.74 20060701 99999999 

11401 


ELSEWHERE), $56.58 20060701 99999999 

11402 


ELSEWHERE), $67.58 20060701 99999999 

11403 


ELSEWHERE), $81.11 20060701 99999999 

11404 


ELSEWHERE), $92.35 20060701 99999999 

11406 


ELSEWHERE), $132.54 20060701 99999999 

11420 


ELSEWHERE), $47.53 20060701 99999999 

11421 


ELSEWHERE), $64.22 20060701 99999999 

11422 


ELSEWHERE), $73.76 20060701 99999999 

11423 


ELSEWHERE), $91.62 20060701 99999999 

11424 


ELSEWHERE), $107.64 20060701 99999999 

11426 


ELSEWHERE), $167.69 20060701 99999999 

11440 

EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), 

FACE, $58.77 20060701 99999999 

11441 


FACE, $73.83 20060701 99999999 

11442 


FACE, $81.88 20060701 99999999 



11443 


FACE, $106.21 20060701 99999999 

11444 


FACE, $138.99 20060701 99999999 

11446 


FACE, $180.43 20060701 99999999 

11450 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, $140.23 20060701 99999999 






11600 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS $63.99 20060701 99999999 






11620 

EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, 

GENITALIA $64.34 20060701 99999999 

11621 


GENITALIA $88.59 20060701 99999999 

11622 


GENITALIA $106.25 20060701 99999999 

11623 


GENITALIA $130.14 20060701 99999999 

11624 


GENITALIA $153.29 20060701 99999999 

11626 


GENITALIA $215.24 20060701 99999999 

11640 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS $74.58 20060701 99999999 






11719 TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER $6.02 20060701 99999999 

11720 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) ONE TO FIVE $13.91 20060701 99999999 

11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S) SIX OR MORE $23.32 20060701 99999999 

11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE $42.41 20060701 99999999 

11732 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE $21.92 20060701 99999999 

11740 EVACUATION OF SUBUNGUAL HEMATOMA $18.02 20060701 99999999 

11750 

EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE, (EG, 

INGROWN $90.97 20060701 99999999 

11752 

EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE, (EG, 

INGROWN $143.17 20060701 99999999 

11755 

BIOPSY OF NAIL UNIT, ANY METHOD (EG, PLATE, BED, MATRIX, 

HYPONYCHIUM, PROXIMAL A $62.05 20060701 99999999 

11760 RECONSTRUCTION OF NAIL BED $85.15 20060701 99999999 

11762 RECONSTRUCTION OF NAIL BED $131.96 20060701 99999999 

11765 

WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR INGROWN 

TOENAIL) $36.42 20060701 99999999 

11770 EXCISION OF PILONIDAL CYST OR SINUS $139.88 20060701 99999999 



11900 INJECTION, INTRALESIONAL $19.80 20060701 99999999 

11901 INJECTION, INTRALESIONAL $30.84 20060701 99999999 

11920 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE $78.75 20060701 99999999 





11950 SUBCUTANEOUS INJECTION OF ''FILLING'' MATERIAL (EG, SILICONE) $49.49 20060701 99999999 




11960 INSERTION OF TISSUE EXPANDER(S) $537.58 20060701 99999999 

11970 

REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT 

PROSTHESIS $408.87 20060701 99999999 

11971 REMOVAL OF TISSUE EXPANDER W/O INSERTION OF PROSTHESIS $151.08 20060701 99999999 

11975 

INSERTION OR REINSERTION, IMPLANTABLE CONTRACEPTIVE 

CAPSULES $41.56 19990701 99999999 

11976 

REMOVAL WITHOUT REINSERTION, IMPLANTABLE CONTRACEPTIVE 

CAPSULES $81.91 20060701 99999999 

11980 

SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION 

OF ESTRADIOL AND/OR TESTO $59.48 20060701 99999999 

11981 INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $82.56 20060701 99999999 

11982 REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $99.44 20060701 99999999 

11983 

REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG 

DELIVERY IMPLANT $160.16 20060701 99999999 

12001 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, $70.95 20060701 99999999 






12011 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, $75.59 20060701 99999999 







12020 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE $118.68 20060701 99999999 

12021 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE $82.03 20060701 99999999 

12031 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR $84.41 20060701 99999999 






12041 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR $92.51 20060701 99999999 






12051 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, $98.88 20060701 99999999 









13100 REPAIR, COMPLEX, TRUNK $134.38 20060701 99999999 

13101 REPAIR, COMPLEX, TRUNK $162.04 20060701 99999999 

13102 

REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST 

SEPARATELY IN ADDITIO $52.41 20060701 99999999 

13120 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS $139.51 20060701 99999999 

13121 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS $179.03 20060701 99999999 

13122 

REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 

CM OR LESS (LIST SE $60.73 20060701 99999999 

13131 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, $159.07 20060701 99999999 

13132 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, $252.72 20060701 99999999 

13133 

REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, 

AXILLAE, GENITALIA, HANDS $92.13 20060701 99999999 

13150 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS $176.14 20060701 99999999 



13153 

REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH 

ADDITIONAL 5 CM OR LESS ( $100.38 20060701 99999999 

13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, $456.31 20060701 99999999 

13300 REPAIR, UNUSUAL, COMPLICATED, OVER 7.5 CM, ANY AREA $278.20 19990701 99999999 

14000 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK $283.54 20060701 99999999 

14001 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK $407.78 20060701 99999999 

14020 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, $345.56 20060701 99999999 

14021 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, $491.98 20060701 99999999 

14040 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, $373.29 20060701 99999999 

14041 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, $503.33 20060701 99999999 

14060 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, $469.81 20060701 99999999 

14061 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, $562.06 20060701 99999999 

14300 

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE THAN 30 

SQ CM, $646.26 20060701 99999999 

14350 

FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF 

RECIPIENT SITE $468.19 20060701 99999999 

15000 EXCISIONAL PREPARATION OR CREATION OF RECIPIENT SITE BY $187.57 19990701 99999999 

15001 

SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY 

EXCISION OF OPEN WOUNDS, B $43.86 19990701 99999999 

15002 



15003 



15004 



15005 



15040 

HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ 

CM OR LESS $87.56 20060701 99999999 

15050 PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL $237.75 20060701 99999999 

15100 SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/OR FEET $429.21 20060701 99999999 

15101 SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/OR FEET $88.76 20060701 99999999 

15110 

EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 

LESS, OR ONE PERCENT $465.83 20060701 99999999 

15111 

EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 

SQ CM, OR EACH ADDIT $74.58 20060701 99999999 

15115 

EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, 

EARS, ORBITS, GENITALIA, $480.32 20060701 99999999 

15116 

EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, 

EARS, ORBITS, GENITALIA, $101.82 20060701 99999999 

15120 SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, $483.63 20060701 99999999 



15121 SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, $146.33 20060701 99999999 

15130 

DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 

LESS, OR ONE PERCENT OF $376.74 20060701 99999999 

15131 

DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ 

CM, OR EACH ADDITION $60.44 20060701 99999999 

15135 

DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, 

ORBITS, GENITALIA, HA $521.45 20060701 99999999 

15136 

DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, 

ORBITS, GENITALIA, HA $61.08 20060701 99999999 

15150 

TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; 

FIRST 25 SQ CM OR LESS $414.81 20060701 99999999 

15151 


ADDITIONAL 1 SQ CM TO 75 $80.49 20060701 99999999 

15152 


EACH ADDITIONAL 100 SQ C $100.51 20060701 99999999 

15155 

TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, 

MOUTH, NECK, EARS, OR $446.71 20060701 99999999 

15156 



15157 



15170 

ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 

SQ CM OR LESS, OR ONE $205.07 20060701 99999999 

15171 

ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; EACH 

ADDITIONAL 100 SQ CM, OR E $60.74 20060701 99999999 

15175 

ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, 

NECK, EARS, ORBITS, G $307.59 20060701 99999999 

15176 

ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, 

NECK, EARS, ORBITS, G $96.08 20060701 99999999 

15200 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE $382.18 20060701 99999999 






15260 

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF 

DONOR $676.17 20060701 99999999 

15261 

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF 

DONOR $122.51 20060701 99999999 

15300 

ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, 

LEGS; FIRST 100 SQ CM O $174.50 20060701 99999999 

15301 

ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, 

LEGS; EACH ADDITIONAL 1 $39.54 20060701 99999999 

15320 

ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, 

EYELIDS, MOUTH, NECK, E $202.83 20060701 99999999 

15321 

ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, 

EYELIDS, MOUTH, NECK, E $59.03 20060701 99999999 

15330 

ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ 

CM OR LESS, OR ONE P $174.22 20060701 99999999 

15331 

ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH 

ADDITIONAL 100 SQ CM, OR EAC $39.54 20060701 99999999 

15335 

ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, 

NECK, EARS, ORBITS, GEN $194.60 20060701 99999999 

15336 

ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, 

NECK, EARS, ORBITS, GEN $56.48 20060701 99999999 

15340 

TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; FIRST 25 SQ CM 

OR LESS $180.64 20060701 99999999 



15341 

TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; EACH ADDITIONAL 

25 SQ CM $19.57 20060701 99999999 

15342 

APPLICATION OF BILAMINATE SKIN SUBSTITUTE/NEODERMIS; 25 SQ 

CM $63.77 20041001 99999999 

15343 

APPLICATION OF BILAMINATE SKIN SUBSTITUTE/NEODERMIS; EACH 

ADDITIONAL 25 SQ CM (L $13.92 20030401 99999999 

15350 APPLICATION OF ALLOGRAFT (HOMOGRAFT), SKIN $212.91 20030401 99999999 

15351 

APPLICATION OF ALLOGRAFT, SKIN; EACH ADDITIONAL 100 SQ CM 

(LIST SEPARATELY IN AD $41.67 19990701 99999999 

15360 

TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE; TRUNK, ARMS, 

LEGS; FIRST 100 SQ CM $194.15 20060701 99999999 

15361 

TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE; EACH 

ADDITIONAL 100 SQ CM, OR EACH $45.05 20060701 99999999 

15365 

TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, 

EYELIDS, MOUTH, NECK, $204.97 20060701 99999999 

15366 

TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, 

EYELIDS, MOUTH, NECK, $56.67 20060701 99999999 

15400 APPLICATION OF XENOGRAFT (HETEROGRAFT), SKIN $201.29 20060701 99999999 

15401 1 $41.67 20060701 99999999 

15420 

XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, 

FACE, SCALP, EYELIDS, MOUT $231.97 20060701 99999999 

15421 

XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, 

FACE, SCALP, EYELIDS, MOUT $59.87 20060701 99999999 

15430 

ACELLULAR XENOGRAFT IMPLANT; FIRST 100 SQ CM OR LESS, OR 

ONE PERCENT OF BODY ARE $346.25 20060701 99999999 

15570 

FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 

TRANSFER; TRUNK $447.63 20060701 99999999 

15572 


TRANSFER; SCALP, ARMS, OR $435.42 20060701 99999999 

15574 


TRANSFER; FOREHEAD, CHEEKS $471.48 20060701 99999999 

15576 


TRANSFER; EYELIDS, NOSE, E $393.68 20060701 99999999 

15580 

PRIMARY ATTACHMENT OF OPEN OR TUBED PEDICLE FLAP TO 

RECIPIENT $403.57 19990701 99999999 

15600 

INTERMEDIATE ''DELAY'' OF ANY FLAP, PRIMARY ''DELAY'' OF SMALL 

FLAP, $126.11 20060701 99999999 

15610 


FLAP, $150.11 20060701 99999999 

15620 


FLAP, $185.18 20060701 99999999 

15625 


FLAP, $102.37 19990701 99999999 

15630 


FLAP, $204.34 20060701 99999999 

15650 TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG, ABDOMEN TO $239.36 20060701 99999999 

15731 

FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, 

AXIAL PATTERN FLAP, PAR $614.89 20070101 99999999 

15732 

MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP HEAD OR 

NECK $723.46 20070101 99999999 

15732 

MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP HEAD OR 

NECK $752.66 20060701 99999999 

15734 MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP TRUNK $1,167.22 20060701 99999999 

15736 

MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP UPPER 

EXTREMITY $903.23 20060701 99999999 

15738 

MUSCLE MYOCUTANEOUS OR FASCIOCUTANEOUS FLAP LOWER 

EXTREMITY $904.33 20060701 99999999 



15740 GRAFT $566.13 20060701 99999999 

15750 GRAFT $656.13 20060701 99999999 

15756 

FREE MUSCLE FLAP WITH/WITHOUT SKIN GRAFT WITH 

MICROVASCULAR ANASTOMOSIS $2,178.00 20060701 99999999 

15757 FREE SKIN FLAP WITH MICROVASCULAR ANASTOMOSIS $1,857.70 20060701 99999999 

15758 FREE FASCIAL FLAP WITH MICROVASCULAR ANASTOMOSIS $1,852.23 20060701 99999999 

15760 GRAFT $464.80 20060701 99999999 

15770 GRAFT $435.90 20060701 99999999 

15775 PUNCH GRAFT FOR HAIR TRANSPLANT $187.41 20030401 99999999 

15776 PUNCH GRAFT FOR HAIR TRANSPLANT $262.26 20030401 99999999 

15780 DERMABRASION $387.47 20060701 99999999 

15781 DERMABRASION $252.70 20060701 99999999 

15782 DERMABRASION $270.65 20060701 99999999 

15783 DERMABRASION SUPERFICIAL ANY SITE(EG TATTOO REMOVAL) $208.75 20060701 99999999 

15786 ABRASION $81.74 20060701 99999999 

15787 ABRASION $14.18 20060701 99999999 

15788 CHEMICAL PEEL, FACIAL; EPIDERMAL $127.82 20060701 99999999 

15789 CHEMICAL PEEL, FACIAL; DERMAL $237.35 20060701 99999999 

15792 CHEMICAL PEEL, NONFACIAL; EPIDERMAL $157.54 20060701 99999999 

15793 CHEMICAL PEEL, NONFACIAL; DERMAL $199.60 20060701 99999999 

15810 SALABRASION $259.01 19990701 99999999 

15811 SALABRASION $281.82 19990701 99999999 

15819 CERVICOPLASTY $502.17 20060701 99999999 

15820 BLEPHAROPLASTY, LOWER EYELID $330.78 20060701 99999999 

15821 BLEPHAROPLASTY, LOWER EYELID $362.61 20060701 99999999 

15822 BLEPHAROPLASTY, UPPER EYELID $292.82 20060701 99999999 

15823 BLEPHAROPLASTY, UPPER EYELID $432.04 20060701 99999999 

15830 

EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES 

LIPECTOMY); ABDOMEN, $766.11 20070101 99999999 

15831 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING $633.41 19990701 99999999 









15840 GRAFT FOR FACIAL NERVE PARALYSIS $770.34 20060701 99999999 

15841 GRAFT FOR FACIAL NERVE PARALYSIS $1,189.02 20060701 99999999 

15842 GRAFT FOR FACIAL NERVE PARALYSIS $1,977.93 20060701 99999999 

15845 GRAFT FOR FACIAL NERVE PARALYSIS $724.64 20060701 99999999 

15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), $31.93 20060701 99999999 

15852 DRESSING CHANGE (FOR OTHER THAN BURNS) UNDER ANESTHESIA $33.43 20060701 99999999 

15860 INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST $92.57 20060701 99999999 

15920 EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY $361.18 20060701 99999999 

15922 EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY $492.19 20060701 99999999 

15931 EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE $401.71 20060701 99999999 

15933 EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE $549.95 20060701 99999999 



15934 

EXCISION, SACRAL PRESSURE ULCER, WITH LOCAL OR REGIONAL 

SKIN $617.36 20060701 99999999 

15935 

EXCISION, SACRAL PRESSURE ULCER, WITH LOCAL OR REGIONAL 

SKIN $759.23 20060701 99999999 

15936 EXCISION, SACRAL PRESSURE ULCER, WITH OTHER FLAP CLOSURE $663.09 20060701 99999999 

15937 EXCISION, SACRAL PRESSURE ULCER, WITH OTHER FLAP CLOSURE $788.36 20060701 99999999 

15940 EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE $418.63 20060701 99999999 

15941 EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE $588.18 20060701 99999999 

15944 EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR REGIONAL $613.04 20060701 99999999 

15945 EXCISION, ISCHIAL PRESSURE ULCER, WITH LOCAL OR REGIONAL $694.45 20060701 99999999 

15946 EXCISION, ISCHIAL PRESSURE ULCER, WITH OSTECTOMY, WITH $1,113.06 20060701 99999999 

15950 

EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY 

SUTURE $347.78 20060701 99999999 

15951 

EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY 

SUTURE $558.81 20060701 99999999 

15952 

EXCISION, TROCHANTERIC PRESSURE ULCER, WITH LOCAL 

ROTATION $558.50 20060701 99999999 

15953 

EXCISION, TROCHANTERIC PRESSURE ULCER, WITH LOCAL 

ROTATION $648.71 20060701 99999999 

15956 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH MUSCLE OR $894.46 20060701 99999999 

15958 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH MUSCLE OR $892.28 20060701 99999999 

16000 

INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN 

LOCAL $32.04 20060701 99999999 

16010 DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT $32.76 20030401 99999999 





16035 ESCHAROTOMY $209.68 20060701 99999999 

16036 

ESCHAROTOMY; EACH ADDITIONAL INCISION (LIST SEPARATELY IN 

ADDITION TO CODE FOR P $59.53 20060701 99999999 

17000 



17003 



17004 



17106 

DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS 

(EG, LASER TECHNIQUE); L $195.41 20060701 99999999 

17107 DESTRUCT. OF CUTANEOUS VASC. PROLIFERATIVE LESIONS 10.0-50.0 $361.72 20060701 99999999 

DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS 

17108 (EG, LASER TECHNIQUE); O $635.22 20060701 99999999 

17110 DESTRUCTION BY ANY METHOD OF FLAT (PLANE, JUVENILE) WARTS $33.45 20060701 99999999 

17111 

DESTRUCTION BY ANY METHOD OF FLAT WARTS, MOLLUSCUM 

CONTAGIOSUM, OR MILIA; 15 OR $42.40 20060701 99999999 

17250 CHEMICAL CAUTERIZATION OF A WOUND $21.11 20060701 99999999 

17260 

DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR 

LEGS; LESION DIAMETER $41.16 20060701 99999999 

17261 



17262 



17263 



17264 





17266 



17270 

DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, 

HANDS, FEET, GENITALIA; $57.13 20060701 99999999 

17271 



17272 



17273 



17274 



17276 



17280 

DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, 

EYELIDS, NOSE, LIPS, MUCO $54.49 20060701 99999999 

17281 



17282 



17283 



17284 



17286 



17304 CHEMOSURGERY (MOHS' TECHNIQUE) $298.50 20030401 99999999 





17311 

MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL 

GROSS TUMOR, SURGICAL EXCI $247.08 20070101 99999999 

17312 



17313 



17314 



17315 



17340 CRYOTHERAPY (CO2 SLUSH, LIQUID N2) $27.80 20060701 99999999 

17360 CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE PASTE, ACID) $55.75 20060701 99999999 

17999 

UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND 

SUBCUTANEOUS TISSUE $329.32 19990701 99999999 

19000 PUNCTURE ASPIRATION OF CYST OF BREAST $31.03 20060701 99999999 

19001 PUNCTURE ASPIRATION OF CYST OF BREAST $15.86 20060701 99999999 

19020 MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP $176.39 20060701 99999999 

19030 INJECTION PROCEDURE ONLY FOR MAMMARY DUCTOGRAM OR $56.73 20060701 99999999 

19100 BIOPSY OF BREAST $47.22 20060701 99999999 

19101 BIOPSY OF BREAST $168.35 20060701 99999999 

19102 

BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, USING IMAGING 

GUIDANCE $105.45 20060701 99999999 

19103 

BIOPSY OF BREAST; PERCUTANEOUS, AUTOMATED VACUUM 

ASSISTED OR ROTATING BIOPSY DEV $193.12 20060701 99999999 

19105 

ABLATION, CRYOSURGICAL, OF FIBROADENOMA, INCLUDING 

ULTRASOUND GUIDANCE, EACH FIB $124.31 20070101 99999999 



19110 NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY $231.29 20060701 99999999 

19112 EXCISION OF LACTIFEROUS DUCT FISTULA $190.18 20060701 99999999 

19120 

EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR 

MALIGNANT TUMOR $263.34 20060701 99999999 

19125 

EXCISION OF BREAST LESION IDENTIFIED BY PRE-OPERATIVE 

PLACEMENT OF RADIOLOGICAL $280.86 20060701 99999999 

19126 

EXCISION OF BREAST LESION IDENTIFIED BY PRE-OPERATIVE 

PLACEMENT OF RADIOLOGICAL $126.42 20060701 99999999 

19140 

MASTECTOMY FOR GYNECOMASTIA THROUGH CIRCUMAREOLAR OR 

OTHER INCISION $276.48 20030401 99999999 

19160 MASTECTOMY, PARTIAL $310.90 19990701 99999999 

19162 MASTECTOMY, PARTIAL $672.89 19990701 99999999 

19180 MASTECTOMY, SIMPLE, COMPLETE $440.52 19990701 99999999 

19182 MASTECTOMY, SUBCUTANEOUS $402.68 19990701 99999999 

19200 MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, $760.17 19990701 99999999 

19220 MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY $772.58 19990701 99999999 

19240 

MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH 

NODES $759.76 19990701 99999999 

19260 EXCISION OF CHEST WALL TUMOR INCLUDING RIBS $695.15 20060701 99999999 

19271 EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC $1,001.14 20060701 99999999 

19272 EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC $1,066.32 20060701 99999999 

19290 

PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, 

BREAST; $47.76 20060701 99999999 

19291 

PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, 

BREAST; EACH ADDITIONAL LESI $24.19 20060701 99999999 

19295 

IMAGE GUIDED PLACEMENT, METALLIC LOCALIZATION CLIP, 

PERCUTANEOUS, DURING BREAST $75.00 20060701 99999999 

19296 

PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER 

INTO THE BREAST FOR $128.15 20060701 99999999 

19297 

PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER 

INTO THE BREAST FOR $70.21 20060701 99999999 

19298 

PLACEMENT OF RADIOTHERAPY AFTERLOADING BRACHYTHERAPY 

CATHETERS (MULTIPLE TUBE $246.79 20060701 99999999 

19300 MAMMOPLASTY,REDUC,REPOSITION,ONE STAGE,UNILTRL $242.52 20070101 99999999 

19301 MAMMOPLASTY,RED,REPOSTON,1 STAGE;BILAT $263.45 20070101 99999999 

19302 

MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, 

QUADRANTECTOMY, SEGMENTECTOMY); $556.02 20070101 99999999 

19303 MAMMOPLSTY; REDUCE,REPOSITION,TWO STAGE UNILATERAL $563.27 20070101 99999999 

19304 MAMMOPLSTY,RED,REPOSITION; TWO STAGE; BILAT $350.60 20070101 99999999 

19305 

MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY 

LYMPH NODES $690.04 20070101 99999999 

19306 

MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY 

AND INTERNAL MAMMARY L $717.28 20070101 99999999 

19307 

MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH 

NODES, WITH OR WITHOUT PE $721.02 20070101 99999999 

19316 MASTOPEXY $617.47 20060701 99999999 

19318 REDUCTION MAMMAPLASTY $844.14 20060701 99999999 

19324 MAMMAPLASTY, AUGMENTATION $279.65 20060701 99999999 

19325 MAMMAPLASTY, AUGMENTATION $418.34 20060701 99999999 

19328 REMOVAL OF INTACT MAMMARY IMPLANT $292.70 20060701 99999999 

19330 REMOVAL OF MAMMARY IMPLANT MATERIAL $361.70 20060701 99999999 

19340 

IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING 

MASTOPEXY, $351.48 20060701 99999999 

19342 

DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING 

MASTOPEXY, $620.86 20060701 99999999 

19350 NIPPLE/AREOLA RECONSTRUCTION $475.32 20060701 99999999 

19355 CORRECTION OF INVERTED NIPPLES $371.15 20060701 99999999 



19357 

BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE 

EXPANDER, INCLUDING SUB $926.80 20060701 99999999 

19361 

BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITH OR 

WITHOUT PROSTHETIC IMP $1,075.08 20060701 99999999 

19364 BREAST RECONSTRUCTION WITH FREE FLAP $1,838.78 20060701 99999999 

19366 BREAST RECONSTRUCTION WITH OTHER TECHNIQUE $1,071.43 20060701 99999999 

19367 

BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS 

MYOCUTANEOUS FLAP (TRAM), $1,315.42 20060701 99999999 

19368 



19369 



19370 OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST $424.59 20060701 99999999 

19371 PERIPROSTHETIC CAPSULECTOMY, BREAST $506.66 20060701 99999999 

19380 REVISION OF RECONSTRUCTED BREAST $502.19 20060701 99999999 

19396 PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT $107.16 20060701 99999999 

19499 UNLISTED PROCEDURE, BREAST $127.70 19990701 99999999 

20000 

INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO 

OSTEOMYELITIS) $96.95 20060701 99999999 

20005 

INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO 

OSTEOMYELITIS) $161.70 20060701 99999999 

20100 

EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); 

NECK $448.20 20060701 99999999 

20101 


CHEST $167.73 20060701 99999999 

20102 


ABDOMEN/FLANK/BACK $175.84 20060701 99999999 

20103 


EXTREMITY $258.18 20060701 99999999 

20150 

EXCISION OF EPIPHYSEAL BAR WITH/WITHOUT AUTOGENOUS SOFT 

TISSUE GRAFT OBTAINED TH $661.36 20060701 99999999 

20200 BIOPSY, MUSCLE $83.98 20060701 99999999 

20205 BIOPSY, MUSCLE $132.94 20060701 99999999 

20206 BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE $52.62 20060701 99999999 

20220 BIOPSY, BONE, TROCAR OR NEEDLE $84.38 20060701 99999999 

20225 BIOPSY, BONE, TROCAR OR NEEDLE $102.23 20060701 99999999 

20240 BIOPSY, EXCISIONAL $146.49 20060701 99999999 

20245 BIOPSY, EXCISIONAL $367.87 20060701 99999999 

20250 BIOPSY, VERTEBRAL BODY, OPEN $289.23 20060701 99999999 

20251 BIOPSY, VERTEBRAL BODY, OPEN $253.09 20060701 99999999 

20500 INJECTION OF SINUS TRACT $68.94 20060701 99999999 

20501 INJECTION OF SINUS TRACT $39.54 20060701 99999999 

20520 REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH $134.78 20060701 99999999 

20525 REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH $155.47 20060701 99999999 

20526 

INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, 

CORTICOSTEROID), CARPAL TUNNEL $46.50 20060701 99999999 

20550 INJECTION, TENDON SHEATH, LIGAMENT, TRIGGER POINTS $39.27 20060701 99999999 

20551 INJECTION; TENDON ORIGIN/INSERTION $43.41 20060701 99999999 

20552 

INJECTION; SINGLE OR MULTIPLE TRIGGER POINT(S), ONE OR TWO 

MUSCLE GROUP(S) $35.03 20060701 99999999 

20553 

INJECTION; SINGLE OR MULTIPLE TRIGGER POINT(S), THREE OR 

MORE MUSCLE GROUPS $39.29 20060701 99999999 

20555 

PLACEMENT OF NEEDLES OR CATHETERS INTO MUSCLE AND/OR 

SOFT TISSUE FOR SUBSEQUENT $165.01 20080101 99999999 

20600 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION $40.93 20060701 99999999 





20612 

ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY 

LOCATION $28.14 20060701 99999999 

20615 ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST $130.44 20060701 99999999 

20650 

INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL 

TRACTION, $138.73 20060701 99999999 

20660 

APPLICATION OF CRANIAL TONGS, CALIPER, OR STEREOTACTIC 

FRAME, $158.66 20060701 99999999 

20661 APPLICATION OF HALO, INCLUDING REMOVAL $308.58 20060701 99999999 



20664 

APPLICATION OF HALO, INCLUDING REMOVAL, CRANIAL, 6 OR MORE 

PINS PLACED, FOR THIN $432.00 20060701 99999999 

20665 REMOVAL OF TONGS OR HALO APPLIED BY ANOTHER PHYSICIAN $79.91 20060701 99999999 

20670 REMOVAL OF IMPLANT $137.06 20060701 99999999 

20680 REMOVAL OF IMPLANT $217.12 20060701 99999999 

20690 APPLICATION OF EXTERNAL FIXATION SYSTEM (EG, $192.28 20060701 99999999 

20692 APPLICATION OF A MULTIPLANE(PINS OR WIRES IN MORE THAN 1 PLA $330.69 20060701 99999999 

20693 

ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYS. REQ. 

ANESTH $368.18 20060701 99999999 

20694 DELETE $275.57 20060701 99999999 

20802 

REPLANTATION, ARM (INCLUDES SURGICAL NECK OF HUMERUS 

THROUGH $2,043.68 20060701 99999999 

20805 REPLANTATION, FOREARM (INCLUDES RADIUS AND ULNA TO RADIAL $2,519.44 20060701 99999999 

20808 

REPLANTATION, HAND (INCLUDES HAND THROUGH 

METACARPOPHALANGEAL JOINTS) $2,601.18 20060701 99999999 

20816 REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES $1,745.57 20060701 99999999 

20822 REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES DISTAL TIP TO $1,638.74 20060701 99999999 

20824 REPLANTATION, THUMB (INCLUDES CARPOMETACARPAL JOINT TO $1,715.63 20060701 99999999 

20827 REPLANTATION, THUMB (INCLUDES DISTAL TIP TO MP JOINT) $1,593.29 20060701 99999999 

20838 REPLANTATION, FOOT $1,959.62 20060701 99999999 

20900 BONE GRAFT, ANY DONOR AREA $288.13 20060701 99999999 

20902 BONE GRAFT, ANY DONOR AREA $424.70 20060701 99999999 

20910 CARTILAGE GRAFT $424.70 20060701 99999999 

20912 CARTILAGE GRAFT $304.21 20060701 99999999 

20920 FASCIA LATA GRAFT $239.98 20060701 99999999 

20922 FASCIA LATA GRAFT $286.84 20060701 99999999 

20924 TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, $315.82 20060701 99999999 

20926 TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS, ETC) $293.90 20060701 99999999 

20930 ALLOGRAFT FOR SPINE SURGERY ONLY; MORSELIZED $138.47 19990701 99999999 

20931 ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL $99.70 20060701 99999999 

20936 

AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE 

GRAFT); LOCAL (EG, RIB $138.47 19990701 99999999 

20937 


GRAFT); MORSELIZED (TH $150.25 20060701 99999999 

20938 


GRAFT); STRUCTURAL, BI $164.43 20060701 99999999 

20950 MONITORING OF INTERSTITIAL FLUID PRESSURE (EG, WICK $80.39 20060701 99999999 

20955 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS $2,007.53 20060701 99999999 

20956 

BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS FIBULA ILIAC 

CREST $1,650.31 20060701 99999999 

20957 

BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS FIBULA 

METATARSAL $1,817.07 20060701 99999999 

20962 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS $1,687.16 20060701 99999999 

20969 

FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR 

ANASTOMOSIS $2,211.44 20060701 99999999 



20970 


ANASTOMOSIS $2,100.99 20060701 99999999 

20972 


ANASTOMOSIS $1,783.10 20060701 99999999 

20973 


ANASTOMOSIS $2,184.25 20060701 99999999 

20974 ELECTRICAL STIMULATION TO AID BONE HEALING $31.84 20060701 99999999 

20975 ELECTRICAL STIMULATION TO AID BONE HEALING $118.29 20060701 99999999 

20979 

LOW INTENSITY ULTRASOUND STIMULATION TO AID BONE HEALING, 

NONINVASIVE (NONOPERAT $24.40 20060701 99999999 

20982 

ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS) 

RADIOFREQUENCY, PERCUT $300.94 20060701 99999999 

20985 

COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR 

MUSCULOSKELETAL PROCEDURES $75.09 20080101 99999999 

21010 ARTHROTOMY, TEMPOROMANDIBULAR JOINT $487.32 20060701 99999999 

21015 DELETE $260.21 20060701 99999999 

21025 EXCISION OF BONE MANDIBLE $490.41 20060701 99999999 

21026 EXCISION OF BONE FACIAL BONE(S) $281.68 20060701 99999999 

21029 REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BONE $426.77 20060701 99999999 

21030 

EXCISION OF BENIGN TUMOR OR CYST OF FACIAL BONE OTHER THAN 

MANDIBLE $239.75 20060701 99999999 

21031 EXCISION OF TORUS MANDIBULARIS $174.47 20060701 99999999 

21032 EXCISION OF MAXILLARY TORUS PALATINUS $189.08 20060701 99999999 

21034 EXCISION OF MALIGNANT TUMOR OF FACIAL BONE OTHER $721.00 20060701 99999999 

21040 EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE $231.92 20060701 99999999 

21044 EXCISION OF MALIGNANT TUMOR OF MANDIBLE $528.41 20060701 99999999 

21045 EXCISION OF MALIGNANT TUMOR OF MANDIBLE $709.72 20060701 99999999 

21046 

EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING 

INTRA-ORAL OSTEOTOMY (EG $675.79 20060701 99999999 

21047 

EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING 

EXTRA-ORAL OSTEOTOMY AND $822.74 20060701 99999999 

21048 

EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING 

INTRA-ORAL OSTEOTOMY (EG, $695.25 20060701 99999999 

21049 

EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING 

EXTRA-ORAL OSTEOTOMY AND $781.92 20060701 99999999 

21050 

CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE 

PROCEDURE) $511.64 20060701 99999999 

21060 

MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR 

JOINT $476.44 20060701 99999999 

21070 CORONOIDECTOMY (SEPARATE PROCEDURE) $390.13 20060701 99999999 

21073 

MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), 

THERAPEUTIC, REQUIRING AN ANES $119.94 20080101 99999999 

21076 

IMPRESSION AND CUSTOM PREPARATION; SURGICAL OBTURATOR 

PROSTHESIS $667.43 20060701 99999999 

21077 IMPRESSION AND CUSTOM PREPARATION; ORBITAL PROSTHESIS $1,678.96 20060701 99999999 

21079 

IMPRESSION & CUSTOM PREPARATION:INTERIM OBTURATOR 

PROSTHESIS $1,129.20 20060701 99999999 

21080 

IMPRESSION & CUSTOM PREPARATION:DEFINITIVE OBTURATOR 

PROSTHE $1,285.36 20060701 99999999 

21081 

IMPRESSION & CUSTOM PREPARATION:MANDIBULAR RESECTION 

PROSTHE $1,161.63 20060701 99999999 

21082 

IMPRESSION & CUSTOM PREPARATION:PALATAL AUGMENTATION 

PROSTHE $1,023.73 20060701 99999999 

21083 IMPRESSION& CUSTOM PREPARATION:PALATAL LIFT PROSTHESIS $988.24 20060701 99999999 

21084 IMPRESSION & CUSTOM PREPARATION:SPEECH AID PROSTHESIS $1,137.00 20060701 99999999 

21085 IMPRESSION & CUSTOM PREPARATION:ORAL SURGICAL SPLINT $519.71 20060701 99999999 

21086 IMPRESSION & CUSTOM PREPARATION:AURICULAR PROSTHESIS $1,261.58 20060701 99999999 

21087 IMPRESSION & CUSTOM PREPARATION:NASAL PROSTHESIS $1,232.79 20060701 99999999 



21100 APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACIAL $222.39 20060701 99999999 

21110 APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS $343.63 20060701 99999999 

21116 

INJECTION PROCEDURE FOR TEMPOROMANDIBULAR JOINT 

ARTHROGRAPHY $27.94 20060701 99999999 

21120 

GENIOPLASTY:AUGMENTATION(AUTOGRAFT,ALLOGRAFT,PROSTHETI 

C MAT) $313.07 20060701 99999999 

21121 GENIOPLASTY:SLIDING OSTEOTOMY,SINGLE PIECE $388.79 20060701 99999999 

21122 GENIOPLASTY:SLIDING OSTEOTOMIES,2 OR MORE OSTEOTOMIES $432.20 20060701 99999999 

21123 

GENIOPLASTY:SLIDING,AUGMENTATION W/INTERPOSITIONAL BONE 

GRFT $553.63 20060701 99999999 

21125 

AUGMENTATION,MANDIBULAR BODY OR ANGLE:PROSTHETIC 

MATERIAL $467.29 20060701 99999999 

21127 

AUGMENTATION,MANDIBULAR BODY OR ANGLE:W/BONE GRAFT 

ONLAY $520.80 20060701 99999999 

21137 REDUCTION FOREHEAD:CONTOURING ONLY $443.98 20060701 99999999 

21138 

REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF 

PROSTHETIC MATERIAL OR BONE GR $551.27 20060701 99999999 

21139 

REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR 

FRONTAL SINUS WALL $642.92 20060701 99999999 

21141 

RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT 

MOVEMENT IN ANY DIRECTIO $818.93 20060701 99999999 

21142 

RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT 

MOVEMENT IN ANY DIRECTION, $918.27 20060701 99999999 

21143 

RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, 

SEGMENT MOVEMENT IN ANY $856.76 20060701 99999999 

21145 

RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, ANY 

DIRECTION, REQUIRING BONE GR $858.81 20060701 99999999 

21146 

RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, ANY 

DIRECTION, REQUIRING BONE GRAF $917.08 20060701 99999999 

21147 

RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, 

ANY DIRECTION, REQUIRING $1,046.58 20060701 99999999 

21150 

RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, 

TREACHER-COLLINS SYND $1,183.44 20060701 99999999 

21151 

RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING 

BONE GRAFTS (INCLUDE $1,269.19 20060701 99999999 

21154 

RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, 

REQUIRING BONE GRAF $1,327.25 20060701 99999999 

21155 

RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, 

REQUIRING BONE GRAF $1,512.19 20060701 99999999 

21159 

RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) 

WITH FOREHEAD ADVANC $2,110.76 20060701 99999999 

21160 

RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) 

WITH FOREHEAD ADVANC $2,192.46 20060701 99999999 

21172 

RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER 

FOREHEAD, ADVANCEMENT OR A $1,244.06 20060701 99999999 

21175 

RECONSTRUCTION, BIFRONTAL, SUPERIOR-LATERAL ORBITAL RIMS 

AND LOWER FOREHEAD, ADV $1,553.85 20060701 99999999 

21179 

RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR 

SUPRAORBITAL RIMS; WITH GR $916.68 20060701 99999999 

21180 

RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR 

SUPRAORBITAL RIMS; WITH AU $1,238.28 20060701 99999999 

21181 

REMOVAL BY CONTOURING OF BENIGN TUMOR OF CRANIAL BONES 

(EG, FIBROUS DYSPLASIA), $438.98 20060701 99999999 

21182 

RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, 

NASOETHMOID COMPLEX FOLLOWING I $1,535.08 20060701 99999999 

21183 





21184 



21188 

RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT 

TYPE) AND BONE GRAFTS (IN $1,088.47 20060701 99999999 

21193 

RECONSTRUCTION OF MANDIBULAR RAMUS, HORIZONTAL, VERTICAL, 

''C'', OR ''L'' OSTEOT $752.38 20060701 99999999 

21194 

RECONSTRUCTION OF MANDIBULAR RAMUS, HORIZONTAL, VERTICAL, 

''C'', OR ''L'' OSTEOT $837.82 20060701 99999999 

21195 

RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT; 

WITHOUT INTERNAL RIGID FIXAT $798.52 20060701 99999999 

21196 

RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT; WITH 

INTERNAL RIGID FIXATION $957.49 20060701 99999999 

21198 OSTEOTOMY, MANDIBLE, SEGMENTAL $671.17 20060701 99999999 

21199 

OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS 

ADVANCEMENT $761.00 20060701 99999999 

21206 

OSTEOTOMY (EG, FOR PROGNATHISM, MICROGNATHISM, 

APERTOGNATHISM OR $713.15 20060701 99999999 

21208 OSTEOPLASTY, FACIAL BONES $495.92 20060701 99999999 

21209 OSTEOPLASTY, FACIAL BONES $374.08 20060701 99999999 

21210 GRAFT, BONE $543.34 20060701 99999999 

21215 GRAFT, BONE $564.66 20060701 99999999 

21230 GRAFT $472.74 20060701 99999999 

21235 GRAFT $326.87 20060701 99999999 

21240 

ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT 

AUTOGRAFT $735.48 20060701 99999999 

21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT $684.79 20060701 99999999 

21243 

ARTHROPLASTY TEMPOROMANDIBULAR JNT W/PROSTHETIC JNT 

REPLACEM $975.12 20060701 99999999 

21244 

RECONSTRUCT OF MANDIBLE EXTRAORAL W/TRANSOSTEAL BONE 

PLATE $608.90 20060701 99999999 

21245 

RECONSTRUCT OF MANDIBLE OR MAXILLA SUBPERIOSTEAL IMPLANT 

PAR $541.81 20060701 99999999 

21246 

RECONSTRUCT MANDIBLE OR MAXILLA SUBPERIOSTEAL IMPLNT 

CMPLT $538.20 20060701 99999999 

21247 

RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND 

CARTILAGE AUTOGRAFTS (INCLUDE $1,226.97 20060701 99999999 

21248 RECONST MANDIBLE OR MAXILLA ENDOSTEAL IMPLANT PARTIAL $581.28 20060701 99999999 

21249 RECONSTRUCT MANDIBLE/MAXILLA ENDOSTEAL IMPLANT COMPLETE $820.61 20060701 99999999 

21255 

RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH 

BONE AND CARTILAGE (INCL $844.56 20060701 99999999 

21256 

RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRANIAL) 

AND WITH BONE GRAFTS (IN $849.64 20060701 99999999 

21260 

PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH 

BONE GRAFTS $853.11 20060701 99999999 

21261 


BONE GRAFTS $1,394.56 20060701 99999999 

21263 


BONE GRAFTS $1,227.52 20060701 99999999 

21267 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, $963.10 20060701 99999999 

21268 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, $1,136.98 20060701 99999999 

21270 MALAR AUGMENTATION, BONE OR ALLOPLASTIC MATERIAL $430.07 20060701 99999999 

21275 SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRUCTION $486.52 20060701 99999999 

21280 MEDIAL CANTHOPLASTY $295.27 20060701 99999999 

21282 LATERAL CANTHOPEXY $237.19 20060701 99999999 

21295 REDUCTION OF MASSETER MUSCLE (EG, TREATMENT OF BENIGN $102.04 20060701 99999999 

21296 REDUCTION OF MASSETER MUSCLE (EG, TREATMENT OF BENIGN $227.37 20060701 99999999 



21310 TREATMENT OF CLOSED OR OPEN NASAL FRACTURE WITHOUT $29.01 20060701 99999999 

21315 MANIPULATIVE TREATMENT, NASAL BONE FRACTURE $84.80 20060701 99999999 

21320 MANIPULATIVE TREATMENT, NASAL BONE FRACTURE $144.28 20060701 99999999 

21325 OPEN TREATMENT OF NASAL FRACTURE $309.83 20060701 99999999 



21336 

OPEN TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT 

STABILIZATION $384.02 20060701 99999999 

21337 TREATMENT OF CLOSED NASAL SEPTAL FRACTURE $197.82 20060701 99999999 

21338 OPEN TREATMENT OF NASOETHMOID FRACTURE $517.51 20060701 99999999 

21339 OPEN TREATMENT OF NASOETHMOID FRACTURE $554.27 20060701 99999999 

21340 

TREATMENT OF CLOSED OR OPEN NASOETHMOID COMPLEX 

FRACTURE, $479.29 20060701 99999999 

21343 

OPEN TX OF CLOSED OR OPEN DEPRESSED FRONTAL SINUS 

FRACTURE $911.42 20060701 99999999 

21344 

OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR 

INVOLVING POSTERIOR WALL) FRONT $920.66 20060701 99999999 

21345 TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II $384.62 20060701 99999999 

21346 

OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE 

(LEFORT $592.85 20060701 99999999 

21347 


(LEFORT $726.54 20060701 99999999 

21348 


(LEFORT II TYPE); WITH BONE GRA $707.26 20060701 99999999 

21355 

MANIPULATIVE TREATMENT OF CLOSED OR OPEN FRACTURE OF 

MALAR AREA, $180.28 20060701 99999999 

21356 

OPEN TREATMENT OF DEPRESSED ZYGOMATIC ARCH FRACTURE (EG, 

GILLES APPROACH) $218.17 20060701 99999999 

21360 

OPEN TREATMENT OF CLOSED OR OPEN DEPRESSED MALAR 

FRACTURE, $347.32 20060701 99999999 

21365 

OPEN TREATMENT OF CLOSED OR OPEN COMPLICATED, (EG, 

MULTIPLE $797.25 20060701 99999999 

21366 

OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR 

INVOLVING CRANIAL NERVE FORAMIN $737.68 20060701 99999999 

21385 OPEN TREATMENT OF ORBITAL FLOOR ''BLOWOUT'' FRACTURE $525.73 20060701 99999999 





21400 TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT'' $82.22 20060701 99999999 

21401 TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT'' $169.83 20060701 99999999 

21406 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT'' $377.59 20060701 99999999 

21407 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT'' $645.46 20060701 99999999 

21408 

OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT ''BLOWOUT''; 

WITH BONE GRAFTING (INC $533.74 20060701 99999999 

21421 

TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (LEFORT I 

TYPE) $340.95 20060701 99999999 

21422 

TREATMENT OF PALATAL OR ALVEOLAR RIDGE FRACTURES (LEFORT I 

TYPE) $463.51 20060701 99999999 

21423 

OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I 

TYPE); COMPLICATED (CO $574.91 20060701 99999999 

21431 TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) USING $414.87 20060701 99999999 

21432 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) $479.69 20060701 99999999 

21433 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) $1,267.63 20060701 99999999 



21435 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) $751.37 20060701 99999999 

21436 

OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); 

COMPLICATED, MULTIP $1,157.62 20060701 99999999 

21440 

MANIPULATIVE TREATMENT OF ALVEOLAR RIDGE FRACTURE 

(SEPARATE PROCEDURE) $224.74 20060701 99999999 

21445 

OPEN TREATMENT OF ALVEOLAR RIDGE FRACTURE (SEPARATE 

PROCEDURE) $348.86 20060701 99999999 

21450 TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE $247.93 20060701 99999999 

21451 TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE $335.23 20060701 99999999 

21452 TREATMENT OF OPEN MANDIBULAR FRACTURE $166.87 20060701 99999999 

21453 TREATMENT OF OPEN MANDIBULAR FRACTURE $411.66 20060701 99999999 

21454 

OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE 

WITH $347.39 20060701 99999999 

21461 OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE $523.31 20060701 99999999 

21462 OPEN TREATMENT OF CLOSED OR OPEN MANDIBULAR FRACTURE $717.68 20060701 99999999 

21465 OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE $547.58 20060701 99999999 

21470 OPEN TREATMENT OF COMPLICATED CLOSED OR OPEN MANDIBULAR $1,014.18 20060701 99999999 

UNCOMPLICATED TREATMENT OF TEMPOROMANDIBULAR 

21480 DISLOCATION, $54.73 20060701 99999999 

21485 COMPLICATED MANIPULATIVE TREATMENT OF TEMPOROMANDIBULAR $294.25 20060701 99999999 

21490 OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION $551.78 20060701 99999999 

21494 TREATMENT OF CLOSED OR OPEN HYOID FRACTURE $296.09 19990701 99999999 

21495 OPEN TREATMENT OF CLOSED OR OPEN HYOID FRACTURE $351.38 20060701 99999999 

21497 INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE $290.59 20060701 99999999 

21501 

INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT 

TISSUES $202.17 20060701 99999999 

21502 

INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT 

TISSUES $322.86 20060701 99999999 

21510 INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR $288.98 20060701 99999999 

21550 BIOPSY, SOFT TISSUE OF NECK OR THORAX $106.18 20060701 99999999 

21555 EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX $190.68 20060701 99999999 

21556 EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX $275.32 20060701 99999999 

21557 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), $358.00 20060701 99999999 

21600 EXCISION OF RIB, PARTIAL $320.49 20060701 99999999 

21610 COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE) $613.84 20060701 99999999 

21615 EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET $513.99 20060701 99999999 

21616 EXCISION FIRST AND/OR CERVICAL RIB FOR OUTLET $511.63 20060701 99999999 

21620 OSTECTOMY OF STERNUM, PARTIAL $324.09 20060701 99999999 

21627 STERNAL DEBRIDEMENT $523.07 20060701 99999999 

21630 RADICAL RESECTION OF STERNUM $743.29 20060701 99999999 

21632 RADICAL RESECTION OF STERNUM $743.48 20060701 99999999 

21685 HYOID MYOTOMY AND SUSPENSION $658.65 20060701 99999999 

21700 DIVISION OF SCALENUS ANTICUS $367.96 20060701 99999999 

21705 DIVISION OF SCALENUS ANTICUS $474.43 20060701 99999999 

21720 DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, $208.52 20060701 99999999 

21725 DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, $319.45 20060701 99999999 

21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM $635.27 20060701 99999999 

21750 

CLOSURE OF STERNOTOMY SEPARATION WITH OR WITHOUT 

DEBRIDEMENT (SEPARATE PROCEDURE $654.42 20060701 99999999 

21800 TREATMENT OF RIB FRACTURE $57.43 20060701 99999999 



21820 TREATMENT OF STERNUM FRACTURE $76.88 20060701 99999999 

21825 TREATMENT OF STERNUM FRACTURE $351.23 20060701 99999999 

21899 UNLISTED PROCEDURE, NECK OR THORAX $307.00 19990701 99999999 



21920 BIOPSY, SOFT TISSUE OF BACK OR FLANK $86.76 20060701 99999999 

21925 BIOPSY, SOFT TISSUE OF BACK OR FLANK $195.40 20060701 99999999 

21930 EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK $231.00 20060701 99999999 

21935 RADICAL RESECTION OF TUMOR SOFT TISSUE BACK OR FLANK $808.50 20060701 99999999 

22010 

INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), 

POSTERIOR SPINE; CERV $566.96 20060701 99999999 

22015 

INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), 

POSTERIOR SPINE; LUMB $562.07 20060701 99999999 

22100 PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS $451.60 20060701 99999999 



22103 

PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, 

SPINOUS PROCESS, LAMINA O $106.06 20060701 99999999 

22110 PARTIAL EXCISION OF VERTEBRAE (EG, FOR OSTEOMYELITIS) $573.05 20060701 99999999 



22116 

PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY 

LESION, WITHOUT DECOMPRES $105.89 20060701 99999999 

22206 OSTEOTOMY OF SPINE FOR CORRECTION FIXED DEFORMITY, $1,170.28 20080101 99999999 

22207 OSTEOTOMY OF SPINE FOR CORRECTION FIXED DEFORMITY, $1,156.13 20080101 99999999 

22208 

OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL 

APPROACH, THREE COLUMNS, ONE VER $291.29 20080101 99999999 

22210 

OSTEOTOMY SPINE POSTERIOR APPRCH CORRECTION OF 

DEFORMITY SGL $1,032.69 20060701 99999999 

22212 

OSTEOTOMY SPINE POSTERIOR APPRCH CORRECTION OF 

DEFORMITY SGL $850.29 20060701 99999999 

22214 

OSTEOTOMY SPINE POST APPRCH CORRECTION OF DEFORMITY 

SINGLE $864.80 20060701 99999999 

22216 

OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL 

APPROACH, ONE VERTEBRAL SEGMENT; $275.22 20060701 99999999 

22220 

OSTEOTOMY SPINE ANTERIOR APPRCH CORRECTION OF DEFORMITY 

SNGL $924.80 20060701 99999999 

22222 

OSTEOTOMY SPINE ANTERIOR FOR CORRECTION OF DEFORM SINGLE 

SEG $847.97 20060701 99999999 

22224 

OSTEOTOMY SPINE ANTERIOR CORRECTION OF DEFORMITY 

SINGLE_SEGM $927.37 20060701 99999999 

22226 

OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR 

APPROACH, SINGLE VERTEBRAL SE $273.23 20060701 99999999 

22305 CLOSED TREATMENT OF VERTEBRAL PROCESS FRACTURE(S) $102.70 20060701 99999999 

22310 CLOSED TREATMENT OF VERTEBRAL BODY FRACTURE(S), $128.36 20060701 99999999 

22315 

CLOSED TREATMENT OF VERTEBRAL FRACTURE AND/OR 

DISLOCATION, $483.91 20060701 99999999 

22318 

OPEN TREATMENT AND/OR REDUCTION OF ODONTOID FRACTURE(S) 

AND OR DISLOCATION(S) (I $1,091.30 20060701 99999999 

22319 

OPEN TREATMENT AND/OR REDUCTION OF ODONTOID FRACTURE(S) 

AND OR DISLOCATION(S) (I $1,237.44 20060701 99999999 

22325 OPEN TREATMENT OF VERTEBRAL FRACTURE AND/OR $893.94 20060701 99999999 

22326 OPEN TREATMENT OF VERTEBRAL FRACTURE AND/OR $1,097.16 20060701 99999999 

22327 OPEN TREATMENT OF VERTEBRAL FRACTURE AND/OR $1,067.08 20060701 99999999 

22328 

OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) 

AND/OR DISLOCATION(S), $205.32 20060701 99999999 

22505 MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY REGION $73.03 20060701 99999999 

22520 

PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, 

UNILATERAL OR BILATERAL INJECTI $511.92 20060701 99999999 

22521 



22522 





22523 

PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY 

CREATION (FRACTURE REDUCTI $423.06 20060701 99999999 

22524 



22525 



22526 

PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, 

UNILATERAL OR BILATERAL IN $231.20 20070101 99999999 

22527 

PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, 

UNILATERAL OR BILATERAL IN $105.56 20070101 99999999 

22532 

ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING 

MINIMAL DISKECTOMY TO PR $1,192.02 20060701 99999999 

22533 


MINIMAL DISKECTOMY TO PR $1,112.39 20060701 99999999 

22534 


MINIMAL DISKECTOMY TO PR $278.81 20060701 99999999 

22548 ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, $1,091.23 20060701 99999999 

22554 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE $1,114.60 20060701 99999999 



22585 ARTHRODESIS, ANTERIOR OR ANTEROLATERAL, EACH ADDITIONAL $303.46 20060701 99999999 

22590 

ARTHODESIS POSTERIOR TECH CRANIOCERVICAL W/BONE GRFT 

INTFIX $1,071.61 20060701 99999999 

22595 ARTHRODESIS POST TECH C1/C2 W/BONE GRFT AND/OR INT FIX $1,009.66 20060701 99999999 

22600 

ARTHRODESIS, POSTERIOR TECHNIQUE, CERVICAL BELOW C2 

SEGMENT, $981.00 20060701 99999999 

22610 

ARTHRODESIS POSTERIOR/POSTEROLATERAL TECH W/LOCAL BONE 

OR $854.36 20060701 99999999 

22612 ARTHRODESIS POSTERIOR/POSTEROLATERAL TECH W/LOCAL BONE $1,200.94 20060701 99999999 

22614 

ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, 

SINGLE LEVEL; EACH ADDITIONA $339.12 20060701 99999999 

22630 

ARTHODESIS POSTERIOR INTERBODY TECH W/LOCAL BONE OR 

ALLOGRAF $1,179.48 20060701 99999999 

22632 

ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, SINGLE 

INTERSPACE; EACH ADDITIONAL I $283.26 20060701 99999999 

22800 

ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR 

WITHOUT $952.06 20060701 99999999 

22802 


WITHOUT $1,694.86 20060701 99999999 

22804 


WITHOUT CAST; 13 OR MORE V $1,891.39 20060701 99999999 

22808 

ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR 

WITHOUT CAST; 2 TO 3 VERTEB $1,101.95 20060701 99999999 

22810 

ARTHRODESIS ANTERIOR FOR SPINAL DEFORMITY W/WO CAST 

W/BONEGR $1,500.89 20060701 99999999 

22812 

ARTHRODESIS ANTERIOR FOR SPINAL DEFORMITY W/WO CAST 

W/BONEGR $1,350.45 20060701 99999999 

22818 

KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND 

RESECTION OF VERTEBRAL SEGMENT $1,571.43 20060701 99999999 

22819 

KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND 

RESECTION OF VERTEBRAL SEGMENT $1,709.99 20060701 99999999 

22830 EXPLORATION OF SPINAL FUSION $795.01 20060701 99999999 

22840 POSTERIOR INSTRUMENTATION $792.17 20060701 99999999 

22841 INTERNAL SPINAL FIXATION BY WIRING OF SPINOUS PROCESSES $88.50 19990701 99999999 

22842 POSTERIOR INSTRUMENTATION $592.14 20060701 99999999 

22843 

POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, 

DUAL RODS WITH MULTIP $652.96 20060701 99999999 



22844 

POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, 

DUAL RODS WITH MULTIP $814.53 20060701 99999999 

22845 ANTERIOR INSTRUMENTATION $582.00 20060701 99999999 

22846 ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS $789.08 20060701 99999999 

22847 ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS $582.00 20060701 99999999 

22848 

PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF 

INSTRUMENTATION TO PELVIC BONY STRU $341.73 20060701 99999999 

22849 REINSERTION OF SPINAL FIXATION DEVICE $949.61 20060701 99999999 

22850 REMOVAL OF POSTERIOR NONSEGMENTAL INSTRUMENTATION $564.49 20060701 99999999 

22851 

APPLICATION OF PROSTHETIC DEVICE (EG, METAL CAGES, 

METHYLMETHACRYLATE) TO VERTEB $386.73 20060701 99999999 

22852 REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION $412.09 20060701 99999999 

22855 REMOVAL OF ANTERIOR INSTRUMENTATION $653.94 20060701 99999999 

22857 

TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR 

APPROACH, INCLUDING DISCECTO $979.88 20070101 99999999 

22862 

REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY 

(ARTIFICIAL DISC) ANTE $1,186.93 20070101 99999999 

22865 

REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), 

ANTERIOR APPROACH, LUMBAR, $1,156.20 20070101 99999999 

22899 UNLISTED PROCEDURE, SPINE $555.11 19990701 99999999 

22900 EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL (EG, DESMOID) $284.50 20060701 99999999 

22999 UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM $757.48 19990701 99999999 

23000 REMOVAL OF SUBDELTOID (OR INTRATENDINOUS) $286.62 20060701 99999999 

23020 CAPSULAR CONTRACTURE RELEASE (SEVER TYPE $522.78 20060701 99999999 

23030 INCISION AND DRAINAGE, SHOULDER AREA $193.66 20060701 99999999 

23031 INCISION AND DRAINAGE, SHOULDER AREA $139.95 20060701 99999999 

23035 INCISION, DEEP, WITH OPENING OF CORTEX (EG, FOR $572.05 20060701 99999999 

23040 

ARTHROTOMY, GLENOHUMERAL JOINT, FOR INFECTION, WITH 

EXPLORATION, $586.22 20060701 99999999 

23044 

ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, 

FOR $462.90 20060701 99999999 

23065 BIOPSY, SOFT TISSUE OF SHOULDER AREA $96.44 20060701 99999999 

23066 BIOPSY, SOFT TISSUE OF SHOULDER AREA $223.29 20060701 99999999 

23075 EXCISION, TUMOR, SHOULDER AREA $140.08 20060701 99999999 

23076 EXCISION, TUMOR, SHOULDER AREA $392.82 20060701 99999999 

23077 RADICAL RESECTION OF TUMOR SOFT TISSUE OF SHOULDER AREA $782.09 20060701 99999999 

23100 ARTHROTOMY FOR BIOPSY, GLENOHUMERAL JOINT $403.26 20060701 99999999 

23101 ARTHROTOMY FOR BIOPSY OR FOR EXCISION OF TORN $382.25 20060701 99999999 

23105 ARTHROTOMY FOR SYNOVECTOMY $531.68 20060701 99999999 

23106 ARTHROTOMY FOR SYNOVECTOMY $378.73 20060701 99999999 

23107 

ARTHROTOMY GLENOHUMERAL JNT W/JNT EXPLORATION W/WO 

REMOVAL $556.10 20060701 99999999 

23120 CLAVICULECTOMY $418.42 20060701 99999999 

23125 CLAVICULECTOMY $561.47 20060701 99999999 

23130 ACROMIONECTOMY, PARTIAL OR TOTAL $470.30 20060701 99999999 

23140 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN $385.18 20060701 99999999 






23170 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), $419.39 20060701 99999999 



23180 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR $527.54 20060701 99999999 



23190 OSTECTOMY OF SCAPULA, PARTIAL (EG, SUPERIOR MEDIAL ANGLE) $425.52 20060701 99999999 



23195 RESECTION HUMERAL HEAD $585.00 20060701 99999999 

23200 RADICAL RESECTION FOR TUMOR $709.94 20060701 99999999 


23220 RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS $846.35 20060701 99999999 

23221 RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS $1,011.11 20060701 99999999 

23222 RADICAL RESECTION FOR TUMOR, PROXIMAL HUMERUS $1,230.57 20060701 99999999 

23330 REMOVAL OF FOREIGN BODY, SHOULDER $107.78 20060701 99999999 



23350 INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY $40.41 20060701 99999999 

23395 MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF $875.65 20060701 99999999 

23397 MUSCLE TRANSFER, ANY TYPE FOR PARALYSIS OF $905.41 20060701 99999999 

23400 SCAPULOPEXY (EG, SPRENGEL'S DEFORMITY OR FOR PARALYSIS) $773.34 20060701 99999999 

23405 TENOMYOTOMY, SHOULDER AREA $520.33 20060701 99999999 

23406 TENOMYOTOMY, SHOULDER AREA $632.89 20060701 99999999 

23410 

REPAIR OF RUPTURED SUPRASPINATUS TENDON (ROTATOR CUFF) 

OR $724.68 20060701 99999999 

23412 

REPAIR OF RUPTURED SUPRASPINATUS TENDON (ROTATOR CUFF) 

OR $798.21 20060701 99999999 

23415 

CORACOACROMIAL LIGAMENT RELEASE, WITH OR WITHOUT 

ACROMIOPLASTY, $516.86 20060701 99999999 

23420 REPAIR OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION, $831.01 20060701 99999999 

23430 TENODESIS FOR RUPTURE OF LONG TENDON OF BICEPS $572.01 20060701 99999999 

23440 RESECTION OR TRANSPLANTATION OF LONG TENDON OF $584.81 20060701 99999999 

23450 CAPSULORRHAPHY FOR RECURRENT DISLOCATION, $784.31 20060701 99999999 





23466 CAPSULORRHAPHY FOR RECURRENT DISLOCATION WITH ANY TYPE $866.09 20060701 99999999 

23470 

ARTHROPLASTY WITH PROXIMAL HUMERAL IMPLANT (EG, NEER TYPE 

OPERATION) $997.25 20060701 99999999 

23472 ARTHROPLASTY WITH GLENOID AND PROXIMAL HUMERAL $1,020.01 20060701 99999999 

23480 OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION $594.94 20060701 99999999 

23485 OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION $763.58 20060701 99999999 

23490 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) $670.04 20060701 99999999 


23500 TREATMENT OF CLOSED CLAVICULAR FRACTURE $121.75 20060701 99999999 

23505 TREATMENT OF CLOSED CLAVICULAR FRACTURE $203.37 20060701 99999999 

23515 OPEN TREATMENT OF CLOSED OR OPEN CLAVICULAR $446.71 20060701 99999999 

23520 TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION $125.02 20060701 99999999 

23525 TREATMENT OF CLOSED STERNOCLAVICULAR DISLOCATION $190.19 20060701 99999999 

23530 OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR $426.74 20060701 99999999 

23532 OPEN TREATMENT OF CLOSED OR OPEN STERNOCLAVICULAR $461.39 20060701 99999999 

23540 TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION $124.45 20060701 99999999 

23545 TREATMENT OF CLOSED ACROMIOCLAVICULAR DISLOCATION $175.57 20060701 99999999 

23550 OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR $457.08 20060701 99999999 

23552 OPEN TREATMENT OF CLOSED OR OPEN ACROMIOCLAVICULAR $487.63 20060701 99999999 

23570 TREATMENT OF CLOSED SCAPULAR FRACTURE $130.77 20060701 99999999 

23575 TREATMENT OF CLOSED SCAPULAR FRACTURE $223.47 20060701 99999999 

23585 OPEN TREATMENT OF CLOSED OR OPEN SCAPULAR FRACTURE $524.26 20060701 99999999 

23600 TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICAL $183.80 20060701 99999999 

23605 TREATMENT OF CLOSED HUMERAL (SURGICAL OR ANATOMICAL $312.16 20060701 99999999 

23615 OPEN TREATMENT OF CLOSED OR OPEN HUMERAL (SURGICAL $586.36 20060701 99999999 

23616 

OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR 

ANATOMICAL NECK) FRACTURE, WITH $1,225.92 20060701 99999999 



23620 TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE $138.66 20060701 99999999 

23625 TREATMENT OF CLOSED GREATER TUBEROSITY FRACTURE $253.74 20060701 99999999 

23630 OPEN TREATMENT OF CLOSED OR OPEN GREATER TUBEROSITY $464.22 20060701 99999999 

23650 TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH $180.50 20060701 99999999 


23660 OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCATION $464.21 20060701 99999999 


23670 OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCATION, $494.23 20060701 99999999 

23675 TREATMENT OF CLOSED SHOULDER DISLOCATION, WITH SURGICAL $333.81 20060701 99999999 

23680 OPEN TREATMENT OF CLOSED OR OPEN SHOULDER DISLOCATION, $614.28 20060701 99999999 

23700 MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING $153.92 20060701 99999999 

23800 ARTHRODESIS, SHOULDER JOINT $876.10 20060701 99999999 

23802 ARTHRODESIS, SHOULDER JOINT $878.67 20060701 99999999 

23900 INTERTHORACOSCAPULAR AMPUTATION (FOREQUARTER) $998.77 20060701 99999999 

23920 DISARTICULATION OF SHOULDER $841.12 20060701 99999999 

23921 DISARTICULATION OF SHOULDER $322.61 20060701 99999999 

23929 UNLISTED PROCEDURE, SHOULDER $313.82 19990701 99999999 

23930 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA $166.04 20060701 99999999 

23931 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA $104.39 20060701 99999999 


24000 

ARTHROTOMY, ELBOW, FOR INFECTION, WITH EXPLORATION, 

DRAINAGE OR $357.63 20060701 99999999 

24006 

ARTHROTOMY OF THE ELBOW, WITH CAPSULAR EXCISION FOR 

CAPSULAR RELEASE (SEPARATE P $511.08 20060701 99999999 

24065 BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA $107.39 20060701 99999999 

24066 BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA $286.56 20060701 99999999 

24075 EXCISION, TUMOR, UPPER ARM OR ELBOW AREA $225.58 20060701 99999999 

24076 EXCISION, TUMOR, UPPER ARM OR ELBOW AREA $340.26 20060701 99999999 

24077 

RAD RESECT OF TUMOR SOFT TISSUE OF UPPER ARM OR ELBOW 

AREA $685.30 20060701 99999999 

24100 ARTHROTOMY, ELBOW $304.37 20060701 99999999 



24105 EXCISION, OLECRANON BURSA $235.26 20060701 99999999 







24130 EXCISION, RADIAL HEAD $387.54 20060701 99999999 




24140 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION OR $631.84 20060701 99999999 



24149 

RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC 

BONE, ELBOW, WITH CON $789.53 20060701 99999999 

24150 RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS $823.48 20060701 99999999 

24151 RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS $895.14 20060701 99999999 

24152 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK $532.44 20060701 99999999 

24153 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK $603.00 20060701 99999999 

24155 RESECTION OF ELBOW JOINT (ARTHRECTOMY) $657.94 20060701 99999999 

24160 IMPLANT REMOVAL $413.36 20060701 99999999 

24164 IMPLANT REMOVAL $365.18 20060701 99999999 

24200 REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA $96.60 20060701 99999999 

24201 REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA $273.94 20060701 99999999 



24220 INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY $50.57 20060701 99999999 

24300 MANIPULATION, ELBOW, UNDER ANESTHESIA $268.70 20060701 99999999 

24301 

MUSCLE OR TENDON TRANSFER, ANY TYPE, UPPER ARM OR ELBOW, 

SINGLE $559.90 20060701 99999999 

24305 TENDON LENGTHENING, UPPER ARM OR ELBOW, SINGLE, EACH $369.55 20060701 99999999 

24310 TENOTOMY, OPEN, ELBOW TO SHOULDER, SINGLE, EACH $329.10 20060701 99999999 

24320 TENOPLASTY, WITH MUSCLE TRANSFER, WITH OR WITHOUT $611.83 20060701 99999999 

24330 FLEXOR-PLASTY, ELBOW, (EG, STEINDLER TYPE ADVANCEMENT) $545.74 20060701 99999999 

24331 FLEXOR-PLASTY, ELBOW, (EG, STEINDLER TYPE ADVANCEMENT) $598.45 20060701 99999999 

24332 TENOLYSIS, TRICEPS $363.93 20060701 99999999 

24340 TENODESIS FOR RUPTURE OF BICEPS TENDON AT ELBOW $450.93 20060701 99999999 

24341 

REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON 

ORMUSCLE, PRIMARY OR $453.94 20060701 99999999 

24342 REINSERTION OF RUPTURED BICEPS TENDON, DISTAL, $614.56 20060701 99999999 

24343 

REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL 

TISSUE $482.80 20060701 99999999 

24344 

RECONSTRUCTION LATERAL COLLATERAL LIGAMENT, ELBOW, WITH 

TENDON GRAFT (INCLUDES H $724.62 20060701 99999999 

24345 REPAIR MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE $482.80 20060701 99999999 

24346 

RECONSTRUCTION MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH 

TENDON GRAFT (INCLUDES HA $724.62 20060701 99999999 

24350 FASCIOTOMY, LATERAL OR MEDIAL (EG, ''TENNIS ELBOW'' $305.14 19990701 99999999 





24357 

TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, 

TENNIS ELBOW, GOLFER'S EL $228.19 20080101 99999999 

24358 



24359 



24360 ARTHROPLASTY, ELBOW $729.27 20060701 99999999 



24363 ARTHROPLASTY, ELBOW $1,077.13 20060701 99999999 

24365 ARTHROPLASTY, RADIAL HEAD $483.37 20060701 99999999 

24366 ARTHROPLASTY, RADIAL HEAD $552.25 20060701 99999999 

24400 OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTERNAL FIXATION $641.55 20060701 99999999 

24410 MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON $854.41 20060701 99999999 

24420 

OSTEOPLASTY, HUMERUS (EG, SHORTENING OR LENGTHENING) 

(EXCLUDING 64876) $822.54 20060701 99999999 

24430 REPAIR OF NONUNION OR MALUNION, HUMERUS $786.24 20060701 99999999 

24435 REPAIR OF NONUNION OR MALUNION, HUMERUS $820.73 20060701 99999999 

24470 HEMIEPIPHYSEAL ARREST (EG, FOR CUBITUS VARUS $500.70 20060701 99999999 

24495 DECOMPRESSION FASCIOTOMY, FOREARM, WITH BRACHIAL $481.02 20060701 99999999 


24500 TREATMENT OF CLOSED HUMERAL SHAFT FRACTURE $182.00 20060701 99999999 

24505 TREATMENT OF CLOSED HUMERAL SHAFT FRACTURE $319.62 20060701 99999999 

24515 OPEN TREATMENT OF CLOSED OR OPEN HUMERAL SHAFT $657.83 20060701 99999999 

24516 

OPEN TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION 

OF INTRAMEDULLARY IMPLA $665.38 20060701 99999999 

24530 

TREATMENT OF CLOSED HUMERAL SUPRACONDYLAR OR 

TRANSCONDYLAR $213.78 20060701 99999999 

24535 





24538 



24545 

OPEN TREATMENT OF CLOSED OR OPEN HUMERAL SUPRACONDYLAR 

OR $612.66 20060701 99999999 

24546 

OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR 

TRANSCONDYLAR FRACTURE, WITH OR WITHO $815.91 20060701 99999999 

24560 TREATMENT OF CLOSED HUMERAL EPICONDYLAR FRACTURE, MEDIAL $160.55 20060701 99999999 

24565 TREATMENT OF CLOSED HUMERAL EPICONDYLAR FRACTURE, MEDIAL $300.33 20060701 99999999 

24566 

PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR 

FRACTURE, MEDIAL OR LATERA $456.90 20060701 99999999 

24575 OPEN TREATMENT OF CLOSED OR OPEN HUMERAL EPICONDYLAR $559.48 20060701 99999999 

24576 TREATMENT OF CLOSED HUMERAL CONDYLAR FRACTURE, MEDIAL $167.70 20060701 99999999 

24577 TREATMENT OF CLOSED HUMERAL CONDYLAR FRACTURE, MEDIAL $320.54 20060701 99999999 

24579 

OPEN TREATMENT OF CLOSED OR OPEN HUMERAL CONDYLAR 

FRACTURE, $619.22 20060701 99999999 

24582 

PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR 

FRACTURE, MEDIAL OR LATERAL, $500.93 20060701 99999999 

24586 OPEN TREATMENT OF CLOSED OR OPEN COMMINUTED ELBOW $847.62 20060701 99999999 

24587 OPEN TREATMENT OF CLOSED OR OPEN COMMINUTED ELBOW $823.20 20060701 99999999 

24600 TREATMENT OF CLOSED ELBOW DISLOCATION $225.39 20060701 99999999 

24605 TREATMENT OF CLOSED ELBOW DISLOCATION $275.73 20060701 99999999 

24615 OPEN TREATMENT OF CLOSED OR OPEN ELBOW DISLOCATION $540.99 20060701 99999999 

24620 TREATMENT OF CLOSED MONTEGGIA TYPE OF FRACTURE $358.42 20060701 99999999 

24635 OPEN TREATMENT OF CLOSED OR OPEN MONTEGGIA TYPE $869.22 20060701 99999999 

24640 TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, $76.75 20060701 99999999 

24650 TREATMENT OF CLOSED RADIAL HEAD OR NECK FRACTURE $125.45 20060701 99999999 

24655 TREATMENT OF CLOSED RADIAL HEAD OR NECK FRACTURE $250.88 20060701 99999999 

24665 OPEN TREATMENT OF CLOSED OR OPEN RADIAL HEAD OR $486.33 20060701 99999999 

24666 OPEN TREATMENT OF CLOSED OR OPEN RADIAL HEAD OR $588.99 20060701 99999999 

24670 TREATMENT OF CLOSED ULNAR FRACTURE, PROXIMAL $149.15 20060701 99999999 

24675 TREATMENT OF CLOSED ULNAR FRACTURE, PROXIMAL $272.48 20060701 99999999 

24685 OPEN TREATMENT OF CLOSED OR OPEN ULNAR FRACTURE $532.27 20060701 99999999 

24800 ARTHRODESIS, ELBOW JOINT $635.88 20060701 99999999 

24802 ARTHRODESIS, ELBOW JOINT $762.00 20060701 99999999 

24900 AMPUTATION, ARM THROUGH HUMERUS $555.59 20060701 99999999 





24935 STUMP ELONGATION, UPPER EXTREMITY $855.46 20060701 99999999 

25000 TENDON SHEATH INCISION $261.08 20060701 99999999 

25001 

INCISION, FLEXOR TENDON SHEATH, WRIST (EG, FLEXOR CARPI 

RADIALIS) $223.58 20060701 99999999 

25020 

DECOMPRESSION FASCIOTOMY, WRIST, FLEXOR AND/OR EXTENSOR 

COMPARTMENT $394.24 20060701 99999999 

25023 

DECOMPRESSION FASCIOTOMY, WRIST, FLEXOR AND/OR EXTENSOR 

COMPARTMENT $711.07 20060701 99999999 

25024 

DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR 

AND EXTENSOR COMPARTMENT; $512.29 20060701 99999999 

25025 

DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR 

AND EXTENSOR COMPARTMENT; $824.32 20060701 99999999 

25028 INCISION AND DRAINAGE, FOREARM AND/OR WRIST $341.13 20060701 99999999 

25031 INCISION AND DRAINAGE, FOREARM AND/OR WRIST $306.43 20060701 99999999 


25040 

ARTHROTOMY, RADIOCARPAL OR MEDIOCARPAL JOINT, FOR 

INFECTION, $424.25 20060701 99999999 



25065 BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST $105.70 20060701 99999999 

25066 BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST $284.65 20060701 99999999 

25075 EXCISION, TUMOR, FOREARM AND/OR WRIST AREA $244.54 20060701 99999999 

25076 EXCISION, TUMOR, FOREARM AND/OR WRIST AREA $367.43 20060701 99999999 

25077 

RAD RESECT TUMOR SOFT TISSUE OF FOREARM AND/OR WRIST 

AREA $625.15 20060701 99999999 

25085 CAPSULOTOMY, WRIST (EG, FOR CONTRACTURE) $368.29 20060701 99999999 

25100 ARTHROTOMY, WRIST JOINT $276.33 20060701 99999999 



25107 ARTHROTOMY, DISTAL RADIOULNAR JOINT FOR REPAIR $416.79 20060701 99999999 

25110 EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST $279.23 20060701 99999999 

25111 EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR) $233.71 20060701 99999999 

25112 EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR) $287.86 20060701 99999999 

25115 RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR $586.69 20060701 99999999 

25116 RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR $532.50 20060701 99999999 

25118 SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, $306.17 20060701 99999999 

25119 SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, $429.29 20060701 99999999 










25170 RADICAL RESECTION FOR TUMOR, RADIUS OR ULNA $708.27 20060701 99999999 

25210 CARPECTOMY $364.86 20060701 99999999 

25215 CARPECTOMY $535.76 20060701 99999999 

25230 RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE) $347.40 20060701 99999999 

25240 EXCISION DISTAL ULNA (DARRACH TYPE PROCEDURE) $373.26 20060701 99999999 

25246 INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY $54.32 20060701 99999999 

25248 

EXPLORATION FOR REMOVAL OF DEEP FOREIGN BODY, FOREARM OR 

WRIST $346.07 20060701 99999999 

25250 REMOVAL OF WRIST PROSTHESIS $400.62 20060701 99999999 

25251 REMOVAL OF WRIST PROSTHESIS $608.87 20060701 99999999 

25259 MANIPULATION, WRIST, UNDER ANESTHESIA $265.48 20060701 99999999 

25260 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST $536.92 20060701 99999999 



25270 REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST $458.83 20060701 99999999 

25272 REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST $504.96 20060701 99999999 

25274 REPAIR, TENDON OR MUSCLE, EXTENSOR, SECONDARY, $580.23 20060701 99999999 

25275 

REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, 

WITH FREE GRAFT (INCLUDES $465.60 20060701 99999999 

25280 LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR $504.49 20060701 99999999 

25290 

TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM 

AND/OR $515.27 20060701 99999999 

25295 

TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR 

WRIST, $475.60 20060701 99999999 

25300 TENODESIS AT WRIST $524.10 20060701 99999999 

25301 TENODESIS AT WRIST $490.42 20060701 99999999 

25310 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR $568.66 20060701 99999999 

25312 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR $633.82 20060701 99999999 

25315 

FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY, FOREARM AND/OR 

WRIST $655.28 20060701 99999999 



25316 

FLEXOR ORIGIN SLIDE FOR CEREBRAL PALSY, FOREARM AND/OR 

WRIST $785.38 20060701 99999999 

25320 CAPSULORRHAPHY OR RECONSTRUCTION, CAPSULECTOMY, $616.58 20060701 99999999 

25332 ARTHROPLASTY, WRIST $661.80 20060701 99999999 

25335 CENTRALIZATION OF WRIST ON ULNA (EG, RADIAL CLUB HAND) $755.72 20060701 99999999 

25337 

RECONSTRUCTION FOR STABILIZATION OF UNSTABLE DISTAL ULNA 

OR DISTAL RADIOULNAR JO $614.19 20060701 99999999 

25350 OSTEOTOMY, RADIUS $598.80 20060701 99999999 

25355 OSTEOTOMY, RADIUS $662.90 20060701 99999999 

25360 OSTEOTOMY $570.63 20060701 99999999 

25365 OSTEOTOMY $793.95 20060701 99999999 

25370 MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY $787.42 20060701 99999999 

25375 MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY $836.25 20060701 99999999 

25390 OSTEOPLASTY, RADIUS OR ULNA $681.93 20060701 99999999 

25391 OSTEOPLASTY, RADIUS OR ULNA $881.02 20060701 99999999 

25392 OSTEOPLASTY, RADIUS AND ULNA $840.02 20060701 99999999 

25393 OSTEOPLASTY, RADIUS AND ULNA $956.62 20060701 99999999 

25394 OSTEOPLASTY, CARPAL BONE, SHORTENING $542.20 20060701 99999999 

25400 REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA $727.99 20060701 99999999 

25405 REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA $904.54 20060701 99999999 

25415 REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA $878.30 20060701 99999999 

25420 REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA $1,011.65 20060701 99999999 

25425 REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT $921.76 20060701 99999999 

25426 REPAIR OF DEFECT WITH AUTOGENOUS BONE GRAFT $907.78 20060701 99999999 

25430 

INSERTION OF VASCULAR PEDICLE INTO CARPAL BONE (EG, HARII 

PROCEDURE) $481.62 20060701 99999999 

25431 

REPAIR OF NONUNION OF CARPAL BONE (EXCLUDING CARPAL 

SCAPHOID (NAVICULAR)) (INCLU $485.39 20060701 99999999 

25440 REPAIR OF NONUNION, SCAPHOID (NAVICULAR) BONE, $602.71 20060701 99999999 

25441 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT $741.65 20060701 99999999 





25446 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT $1,001.79 20060701 99999999 

25447 

INTERPOSITION ARTHROPLASTY, INTERCARPAL OR 

CARPOMETACARPAL JOINTS $617.52 20060701 99999999 

25449 

REVISION OF ARTHROPLASTY, INCLUDING REMOVAL OF IMPLANT, 

WRIST JOINT $761.68 20060701 99999999 

25450 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING $528.40 20060701 99999999 





25500 TREATMENT OF CLOSED RADIAL SHAFT FRACTURE $131.07 20060701 99999999 

25505 TREATMENT OF CLOSED RADIAL SHAFT FRACTURE $289.18 20060701 99999999 

25515 OPEN TREATMENT OF CLOSED OR OPEN RADIAL SHAFT $531.35 20060701 99999999 

25520 

CLOSED TREATMENT OF RADIAL SHAFT FRACTURE, WITH 

DISLOCATION OF DISTAL RADIOULNAR $366.03 20060701 99999999 

25525 

OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTERNAL 

AND/ OR EXTERNAL FIXATION $710.36 20060701 99999999 

25526 

OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTERNAL 

AND/ OR EXTERNAL FIXATION $844.86 20060701 99999999 

25530 TREATMENT OF CLOSED ULNAR SHAFT FRACTURE $126.45 20060701 99999999 

25535 TREATMENT OF CLOSED ULNAR SHAFT FRACTURE $288.08 20060701 99999999 



25545 OPEN TREATMENT OF CLOSED OR OPEN ULNAR SHAFT $520.50 20060701 99999999 

25560 TREATMENT OF CLOSED RADIAL AND ULNAR SHAFT $148.88 20060701 99999999 

25565 TREATMENT OF CLOSED RADIAL AND ULNAR SHAFT $322.44 20060701 99999999 

25574 

OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH 

INTERNAL OR EXTERNAL FI $452.28 20060701 99999999 

25575 OPEN TREATMENT OF CLOSED OR OPEN RADIAL AND $632.66 20060701 99999999 

25600 TREATMENT OF CLOSED DISTAL RADIAL FRACTURE $143.02 20060701 99999999 

25605 TREATMENT OF CLOSED DISTAL RADIAL FRACTURE $320.44 20060701 99999999 

25606 

PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE 

OR EPIPHYSEAL SEPARATIO $468.98 20070101 99999999 

25607 

OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE 


25608 

OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE 


25609 

OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE 


25611 TREATMENT OF CLOSED, COMPLEX, DISTAL RADIAL $458.12 19990701 99999999 

25620 OPEN TREATMENT OF CLOSED OR OPEN DISTAL RADIAL $497.81 19990701 99999999 

25622 TREATMENT OF CLOSED CARPAL SCAPHOID (NAVICULAR) FRACTURE $145.67 20060701 99999999 

25624 TREATMENT OF CLOSED CARPAL SCAPHOID (NAVICULAR) FRACTURE $245.45 20060701 99999999 

25628 OPEN TREATMENT OF CLOSED OR OPEN CARPAL SCAPHOID $495.84 20060701 99999999 

25630 TREATMENT OF CLOSED CARPAL BONE FRACTURE (EXCLUDING $148.52 20060701 99999999 

25635 TREATMENT OF CLOSED CARPAL BONE FRACTURE (EXCLUDING $225.68 20060701 99999999 

25645 OPEN TREATMENT OF CLOSED OR OPEN CARPAL BONE $442.87 20060701 99999999 

25650 TREATMENT OF CLOSED ULNAR STYLOID FRACTURE $158.22 20060701 99999999 

25651 PERCUTANEOUS SKELETAL FIXATION OF ULNAR STYLOID FRACTURE $283.75 20060701 99999999 

25652 OPEN TREATMENT OF ULNAR STYLOID FRACTURE $420.71 20060701 99999999 

25660 TREATMENT OF CLOSED RADIOCARPAL OR INTERCARPAL $242.09 20060701 99999999 

25670 OPEN TREATMENT OF CLOSED OR OPEN RADIOCARPAL $474.74 20060701 99999999 

25671 

PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIOULNAR 

DISLOCATION $348.57 20060701 99999999 

25675 TREATMENT OF CLOSED DISTAL RADIOULNAR DISLOCATION $247.58 20060701 99999999 

25676 OPEN TREATMENT OF CLOSED OR OPEN DISTAL RADIOULNAR $481.38 20060701 99999999 

25680 TREATMENT OF CLOSED TRANS-SCAPHOPERILUNAR TYPE $301.28 20060701 99999999 

25685 OPEN TREATMENT OF CLOSED OR OPEN TRANS-SCAPHOPERILUNAR $575.41 20060701 99999999 

25690 TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION $336.86 20060701 99999999 

25695 OPEN TREATMENT OF LUNATE DISLOCATION $491.10 20060701 99999999 

25800 ARTHRODESIS, WRIST JOINT (INCLUDING RADIOCARPAL AND/OR $612.50 20060701 99999999 



25820 INTERCARPAL FUSION $481.56 20060701 99999999 

25825 INTERCARPAL FUSION $583.69 20060701 99999999 

25830 

DISTAL RADIOULNAR JOINT ARTHRODESIS AND SEGMENTAL 

RESECTION OF ULNA (EG, SAUVE-K $647.03 20060701 99999999 

25900 AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA $567.81 20060701 99999999 




25915 KRUKENBERG PROCEDURE $985.32 20060701 99999999 

25920 DISARTICULATION THROUGH WRIST $498.49 20060701 99999999 



25927 TRANSMETACARPAL AMPUTATION $539.95 20060701 99999999 





26010 DRAINAGE OF FINGER ABSCESS $96.86 20060701 99999999 

26011 DRAINAGE OF FINGER ABSCESS $165.44 20060701 99999999 

26020 DRAINAGE OF TENDON SHEATH, ONE DIGIT AND/OR PALM $350.06 20060701 99999999 

26025 DRAINAGE OF PALMAR BURSA $368.91 20060701 99999999 

26030 DRAINAGE OF PALMAR BURSA $431.70 20060701 99999999 


26035 DECOMPRESSION FINGERS AND/OR HAND, INJECTION $573.05 20060701 99999999 

26037 DECOMPRESSIVE FASCIOTOMY HAND (EXCLUDES 26035) $477.49 20060701 99999999 

26040 FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE $290.99 20060701 99999999 

26045 FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE $409.48 20060701 99999999 

26055 TENDON SHEATH INCISION FOR TRIGGER FINGER $224.70 20060701 99999999 

26060 TENOTOMY, SUBCUTANEOUS, SINGLE, EACH DIGIT $195.30 20060701 99999999 

26070 

ARTHROTOMY, FOR INFECTION, WITH EXPLORATION, DRAINAGE OR 

REMOVAL $283.34 20060701 99999999 

26075 


REMOVAL $303.01 20060701 99999999 

26080 


REMOVAL $331.00 20060701 99999999 

26100 ARTHROTOMY FOR SYNOVIAL BIOPSY $262.16 20060701 99999999 



26115 EXCISION, TUMOR OR VASCULAR MALFORMATION, HAND OR FINGER $241.72 20060701 99999999 

26116 EXCISION, TUMOR OR VASCULAR MALFORMATION, HAND OR FINGER $388.42 20060701 99999999 

26117 RAD RESECT TUMOR SOFT TISSUE OF HAND OR FINGER $524.01 20060701 99999999 

26121 

FASCIECTOMY PALMAR W/WO Z-PLASTY OTHER LOCAL TISSUE 

REARRANG $549.18 20060701 99999999 

26123 

FASCIECTOMY PALMAR W/WO ZPLASTY OTHER LOCAL TISSUE 

REARRANGE $628.70 20060701 99999999 

26125 

FASCIECTOMY PALMAR W/WO ZPLASTY OTHER LOCAL TISSUE 

REARRANGE $216.88 20060701 99999999 

26130 SYNOVECTOMY, CARPOMETACARPAL JOINT $427.06 20060701 99999999 

26135 SYNOVECTOMY, METACARPOPHALANGEAL JOINT INCLUDING $490.87 20060701 99999999 

26140 SYNOVECTOMY, PROXIMAL INTERPHALANGEAL JOINT, $446.31 20060701 99999999 

26145 SYNOVECTOMY TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), $460.12 20060701 99999999 

26160 EXCISION OF LESION OF TENDON SHEATH OR CAPSULE $224.40 20060701 99999999 

26170 EXCISION OF TENDON, PALM, FLEXOR, SINGLE $295.69 20060701 99999999 

26180 EXCISION OF TENDON, FINGER, FLEXOR (SEPARATE PROCEDURE) $331.31 20060701 99999999 

26185 SESAMOIDECTOMY, THUMB OR FINGER(SEPARATE PROCEDURE) $333.52 20060701 99999999 



26210 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR $385.52 20060701 99999999 

26215 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR $479.70 20060701 99999999 

26230 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, $418.28 20060701 99999999 



26250 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPAL $535.59 20060701 99999999 

26255 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPAL $771.10 20060701 99999999 

26260 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL $498.39 20060701 99999999 

26261 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL $616.33 20060701 99999999 

26262 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, DISTAL $420.67 20060701 99999999 

26320 REMOVAL OF IMPLANT FROM FINGER OR HAND $330.21 20060701 99999999 

26340 MANIPULATION, FINGER JOINT, UNDER ANESTHESIA, EACH JOINT $204.62 20060701 99999999 

26350 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, NOT $523.67 20060701 99999999 

26352 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, NOT $596.10 20060701 99999999 

26356 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN $671.53 20060701 99999999 



26357 

FLEXOR TENDON REPAIR OR ADVANCE SINGLE SECONDARY EACH 

TENDON $616.15 20060701 99999999 

26358 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN $655.37 20060701 99999999 

26370 PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTACT $565.35 20060701 99999999 



26390 FLEXOR TENDON EXCISION, IMPLANTATION OF PLASTIC TUBE $605.92 20060701 99999999 

26392 REMOVAL OF TUBE OR ROD AND INSERTION OF FLEXOR TENDON $756.22 20060701 99999999 

26410 EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, $421.25 20060701 99999999 

26412 EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, $497.86 20060701 99999999 

26415 

EXTENSOR TENDON EXCISION OMPLANTATION OF PLASTIC TUBE OR 

ROD $554.26 20060701 99999999 

26416 

REMOVAL TUBE OR ROD AND INSERT OF EXTENSOR TENDON GRAFT 

HAND $764.02 20060701 99999999 

26418 EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE, $421.33 20060701 99999999 

26420 EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE, $536.27 20060701 99999999 

26426 EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, $491.06 20060701 99999999 

26428 EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, $535.51 20060701 99999999 

26432 EXTENSOR TENDON REPAIR, DISTAL INSERTION (''MALLET FINGER''), $363.23 20060701 99999999 

26433 EXTENSOR TENDON REPAIR, DISTAL INSERTION ('MALLET FINGER'), $390.41 20060701 99999999 

26434 EXTENSOR TENDON REPAIR, DISTAL INSERTION ('MALLET FINGER'), $448.15 20060701 99999999 

26437 EXTENSOR TENDON REALIGNMENT, HAND $442.01 20060701 99999999 

26440 TENOLYSIS, SIMPLE, FLEXOR TENDON $468.42 20060701 99999999 

26442 TENOLYSIS, SIMPLE, FLEXOR TENDON $612.02 20060701 99999999 

26445 TENOLYSIS, EXTENSOR TENDON, DORSUM OF HAND OR FINGER $443.05 20060701 99999999 

26449 TENOLYSIS, COMPLEX, EXTENSOR TENDON, DORSUM OF HAND OR $578.67 20060701 99999999 

26450 TENOTOMY, FLEXOR, SINGLE, PALM, OPEN, EACH $280.05 20060701 99999999 

26455 TENOTOMY, FLEXOR, SINGLE, FINGER, OPEN, EACH $277.92 20060701 99999999 

26460 TENOTOMY, EXTENSOR, HAND OR FINGER, SINGLE, OPEN, EACH $269.72 20060701 99999999 

26471 TENODESIS $431.43 20060701 99999999 

26474 TENODESIS $423.67 20060701 99999999 

26476 TENDON LENGTHENING, EXTENSOR, HAND OR FINGER, SINGLE, EACH $409.39 20060701 99999999 

26477 TENDON SHORTENING, EXTENSOR, HAND OR FINGER, SINGLE, EACH $412.36 20060701 99999999 

26478 TENDON LENGTHENING FLEXOR HAND OR FINGER SINGLE EACH $448.55 20060701 99999999 

26479 TENDON SHORTENING FLEXOR HAND OR FINGER SINGLE EACH $440.47 20060701 99999999 

26480 TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL $552.17 20060701 99999999 

26483 TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL $653.26 20060701 99999999 

26485 TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, $589.51 20060701 99999999 

26489 TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, $546.35 20060701 99999999 

26490 OPPONENS PLASTY $568.97 20060701 99999999 




26497 TENDON TRANSFER TO RESTORE INTRINSIC FUNCTION $617.72 20060701 99999999 

26498 TENDON TRANSFER TO RESTORE INTRINSIC FUNCTION $856.37 20060701 99999999 

26499 CORRECTION CLAW FINGER, OTHER METHODS $613.40 20060701 99999999 

26500 TENDON PULLEY RECONSTRUCTION $442.10 20060701 99999999 

26502 TENDON PULLEY RECONSTRUCTION $487.90 20060701 99999999 

26504 

TENDON PULLEY RECONSTRUCTION W/TENDON PROSTHESIS (SEP 

PROC) $498.62 19990701 99999999 

26508 THENAR MUSCLE RELEASE FOR THUMB CONTRACTURE $450.76 20060701 99999999 

26510 CROSS INTRINSIC TRANSFER $425.47 20060701 99999999 

26516 CAPSULODESIS FOR M-P JOINT STABILIZATION $493.15 20060701 99999999 



26520 CAPSULECTOMY OR CAPSULOTOMY FOR CONTRACTURE $487.34 20060701 99999999 

26525 CAPSULECTOMY OR CAPSULOTOMY FOR CONTRACTURE $490.24 20060701 99999999 



26530 ARTHROPLASTY, METACARPOPHALANGEAL JOINT $521.48 20060701 99999999 

26531 ARTHROPLASTY, METACARPOPHALANGEAL JOINT $590.49 20060701 99999999 

26535 ARTHROPLASTY INTERPHALANGEAL JOINT $359.11 20060701 99999999 

26536 ARTHROPLASTY INTERPHALANGEAL JOINT $510.83 20060701 99999999 

26540 

PRIMARY REPAIR OF COLLATERAL LIGAMENT, 

METACARPOPHALANGEAL JOINT $479.17 20060701 99999999 

26541 



26542 



26545 

RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGEAL 

JOINT, SINGLE, $484.45 20060701 99999999 

26546 

REPAIR NON-UNION, METACARPAL OR PHALANX, (INCLUDES 

OBTAININGBONE GRAFT WITH OR $610.51 20060701 99999999 

26548 REPAIR&RECONSTR FINGER VOLAR PLATE INTERPHALANGEAL JOINT $530.74 20060701 99999999 

26550 POLLICIZATION OF A DIGIT $1,202.06 20060701 99999999 

26551 

TOE-TO-HAND TRANSFER WITH MICROVASCULAR ANASTOMOSIS; 

GREAT TOE "WRAP AROUND" WIT $2,507.36 20060701 99999999 

26553 

TOE-TO-HAND TRANSFER WITH MICROVASCLULAR ANASTOMOSIS 

GREAT TOE WRAP-AROUND WITH $2,485.72 20060701 99999999 

26554 

TOE-TO-HAND TRANSFER WITH MICROVASCULAR ANASTOMOSIS: 

GREAT TOE "WRAP-AROUND" WIT $2,923.25 20060701 99999999 

26555 POSITIONAL CHANGE OF OTHER FINGER $1,019.30 20060701 99999999 

26556 FREE TOE JOINT TRANSFER WITH MICROVASCULAR ANASTOMOSIS $2,577.84 20060701 99999999 

26560 REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE $386.51 20060701 99999999 



26565 OSTEOTOMY FOR CORRECTION OF DEFORMITY $480.59 20060701 99999999 

26567 OSTEOTOMY FOR CORRECTION OF DEFORMITY $477.19 20060701 99999999 

26568 OSTEOPLASTY FOR LENGTHENING OF METACARPAL OR PHALANX $661.27 20060701 99999999 

26580 REPAIR CLEFT HAND $1,025.86 20060701 99999999 

26585 REPAIR BIFID DIGIT $794.94 19990701 99999999 

26587 

RECONSTRUCTION OF SUPERNUMERARY DIGIT SOFT TISSUE AND 

BONE $581.87 20060701 99999999 

26590 REPAIR MACRODACTYLIA $1,041.77 20060701 99999999 

26591 REPAIR, INTRINSIC MUSCLES OF HAND (SPECIFY) $326.78 20060701 99999999 

26593 RELEASE, INTRINSIC MUSCLES OF HAND (SPECIFY) $417.23 20060701 99999999 

26596 EXCISION OF CONSTRICTING RING OF FINGER, $524.30 20060701 99999999 

26597 

RELEASE OF SCAR CONTRACTURE, FLEXOR OR EXTENSOR, WITH 

SKIN $632.30 19990701 99999999 

26600 TREATMENT OF CLOSED METACARPAL FRACTURE, SINGLE $117.44 20060701 99999999 



26608 

PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, 

EACH BONE $322.88 20060701 99999999 

26615 OPEN TREATMENT OF CLOSED OR OPEN METACARPAL $339.62 20060701 99999999 

26641 TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, $199.66 20060701 99999999 

26645 TREATMENT OF CLOSED CARPOMETACARPAL FRACTURE $235.74 20060701 99999999 

26650 TREATMENT OF CLOSED CARPOMETACARPAL FRACTURE $346.20 20060701 99999999 

26665 OPEN TREATMENT OF CLOSED OR OPEN CARPOMETACARPAL $449.09 20060701 99999999 

26670 TREATMENT OF CLOSED CARPOMETACARPAL DISLOCATION, $187.91 20060701 99999999 





26700 TREATMENT OF CLOSED METACARPOPHALANGEAL DISLOCATION, $162.97 20060701 99999999 





26715 OPEN TREATMENT OF CLOSED OR OPEN METACARPOPHALANGEAL $341.06 20060701 99999999 

26720 TREATMENT OF CLOSED PHALANGEAL SHAFT FRACTURE, $94.34 20060701 99999999 

26725 TREATMENT OF CLOSED PHALANGEAL SHAFT FRACTURE, $174.41 20060701 99999999 

26727 TREATMENT OF UNSTABLE PHALANGEAL SHAFT FRACTURE, $303.06 20060701 99999999 

26735 

OPEN TREATMENT OF CLOSED OR OPEN PHALANGEAL SHAFT 

FRACTURE, $344.51 20060701 99999999 

26740 TREATMENT OF CLOSED ARTICULAR FRACTURE, INVOLVING $118.43 20060701 99999999 

26742 TREATMENT OF CLOSED ARTICULAR FRACTURE, INVOLVING $214.01 20060701 99999999 

26746 OPEN TREATMENT OF CLOSED OR OPEN ARTICULAR FRACTURE, $356.56 20060701 99999999 

26750 TREATMENT OF CLOSED DISTAL PHALANGEAL FRACTURE, $94.28 20060701 99999999 



26765 OPEN TREATMENT OF CLOSED OR OPEN DISTAL PHALANGEAL $259.30 20060701 99999999 

26770 TREATMENT OF CLOSED INTERPHALANGEAL JOINT $136.33 20060701 99999999 



26785 OPEN TREATMENT OF CLOSED OR OPEN INTERPHALANGEAL $266.22 20060701 99999999 

26820 FUSION IN OPPOSITION, THUMB, WITH AUTOGENOUS $560.16 20060701 99999999 

26841 ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH $519.41 20060701 99999999 

26842 ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH $593.06 20060701 99999999 

26843 ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, $525.26 20060701 99999999 

26844 ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, $572.40 20060701 99999999 

26850 ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR $487.55 20060701 99999999 

26852 ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR $541.94 20060701 99999999 

26860 ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR $403.67 20060701 99999999 




26910 AMPUTATION, METACARPAL, WITH FINGER OR THUMB $487.40 20060701 99999999 

26951 AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, $374.75 20060701 99999999 

26952 AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, $456.57 20060701 99999999 

26990 INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA $470.25 20060701 99999999 

26991 INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA $345.22 20060701 99999999 


27000 TENOTOMY, ADDUCTOR OF HIP, SUBCUTANEOUS, CLOSED $293.74 20060701 99999999 

27001 TENOTOMY, ADDUCTOR OF HIP, SUBCUTANEOUS, OPEN $352.01 20060701 99999999 

27003 TENOTOMY, ADDUCTOR, SUBCUTANEOUS, OPEN, $454.23 20060701 99999999 

27005 TENOTOMY, ILIOPSOAS, OPEN (SEPARATE PROCEDURE) $476.20 20060701 99999999 

27006 TENOTOMY, ABDUCTORS OF HIP, OPEN (SEPARATE PROCEDURE) $505.24 20060701 99999999 

27025 OBER-YOUNT FASCIOTOMY, COMBINED WITH SPICA CAST, $573.77 20060701 99999999 

27030 ARTHROTOMY, HIP, FOR INFECTION, WITH DRAINAGE $742.10 20060701 99999999 

27033 ARTHROTOMY, HIP, FOR EXPLORATION OR REMOVAL OF $758.16 20060701 99999999 

27035 HIP JOINT DENERVATION, INTRAPELVIC OR EXTRAPELVIC $910.10 20060701 99999999 

27036 

CAPSULECTOMY OR CAPSULOTOMY OF HIP, WITH OR WITHOUT 

EXCISIONOF HETEROTOPIC BONE $762.45 20060701 99999999 

27040 BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA $142.78 20060701 99999999 

27041 BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA $442.25 20060701 99999999 

27047 EXCISION, TUMOR, PELVIS AND HIP AREA $346.22 20060701 99999999 

27048 EXCISION, TUMOR, PELVIS AND HIP AREA $363.96 20060701 99999999 

27049 RAD RESECT OF TUMOR SOFT TISSUE OF PELVIS AND HIP AREA $748.98 20060701 99999999 

27050 ARTHROTOMY, FOR BIOPSY $294.49 20060701 99999999 

27052 ARTHROTOMY, FOR BIOPSY $407.97 20060701 99999999 

27054 ARTHROTOMY FOR SYNOVECTOMY, HIP JOINT $550.94 20060701 99999999 

27060 EXCISION $317.92 20060701 99999999 

27062 EXCISION $323.83 20060701 99999999 

27065 EXCISION OF BONE CYST OR BENIGN TUMOR $381.13 20060701 99999999 





27070 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) $678.32 20060701 99999999 

27071 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) $725.12 20060701 99999999 

27075 RADICAL RESECTION FOR TUMOR OR INFECTION $1,387.84 20060701 99999999 



27078 RADICAL RESECTION FOR TUMOR OR INFECTION $750.93 20060701 99999999 

27079 RADICAL RESECTION FOR TUMOR OR INFECTION $753.72 20060701 99999999 

27080 COCCYGECTOMY, PRIMARY $367.40 20060701 99999999 

27086 REMOVAL OF FOREIGN BODY, PELVIS OR HIP $108.17 20060701 99999999 

27087 REMOVAL OF FOREIGN BODY, PELVIS OR HIP $430.06 20060701 99999999 

27090 REMOVAL OF HIP PROSTHESIS $633.82 20060701 99999999 

27091 REMOVAL OF HIP PROSTHESIS $1,224.30 20060701 99999999 

27093 INJECTION PROCEDURE FOR HIP ARTHROGRAPHY $57.11 20060701 99999999 

27095 INJECTION PROCEDURE FOR HIP ARTHROGRAPHY $65.12 20060701 99999999 

27096 

INJECTION PROCEDURE FOR SACROILIAC JOINT, ARTHROGRAPHY 

AND/OR ANESTHETIC/STEROID $42.43 20060701 99999999 

27097 HAMSTRING RECESSION, PROXIMAL $515.06 20060701 99999999 

27098 ADDUCTOR TRANSFER TO ISCHIUM $517.41 20060701 99999999 

27100 TRANSFER EXTERNAL OBLIQUE MUSCLE TO GREATER $639.14 20060701 99999999 

27105 TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES $605.99 20060701 99999999 

27110 TRANSFER ILIOPSOAS $760.26 20060701 99999999 

27111 TRANSFER ILIOPSOAS $712.11 20060701 99999999 

27120 ACETABULOPLASTY $1,037.48 20060701 99999999 

27122 ACETABULOPLASTY $914.04 20060701 99999999 

27125 HEMIARTHROPLASTY OF HIP (PARTIAL HIP REPLACEMENT) $891.37 20060701 99999999 

27130 ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL $1,385.91 20060701 99999999 

27132 

CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP 

REPLACEMENT $1,380.47 20060701 99999999 

27134 REVISION OF TOTAL HIP ARTHROPLASTY $1,668.92 20060701 99999999 



27140 OSTEOTOMY AND TRANSFER OF GREATER TROCHANTER $826.65 20060701 99999999 

27146 OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE $918.92 20060701 99999999 

27147 OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE $1,123.29 20060701 99999999 



27158 OSTEOTOMY, PELVIS, BILATERAL FOR CONGENITAL MALFORMATION $1,016.80 20060701 99999999 

27161 OSTEOTOMY, FEMORAL NECK (SEPARATE PROCEDURE) $930.77 20060701 99999999 

27165 

OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCHANTERIC 

INCLUDING $1,015.63 20060701 99999999 

27170 BONE GRAFT FOR NONUNION, FEMORAL HEAD, NECK, $941.75 20060701 99999999 

27175 TREATMENT OF SLIPPED FEMORAL EPIPHYSIS $388.67 20060701 99999999 

27176 TREATMENT OF SLIPPED FEMORAL EPIPHYSIS $660.06 20060701 99999999 

27177 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS $807.96 20060701 99999999 




27185 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, $443.51 20060701 99999999 


27193 

CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, 

DIASTASIS OR SUBLUXATION; $276.94 20060701 99999999 

27194 

CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, 

DIASTASIS OR SUBLUXATION; $454.55 20060701 99999999 

27200 TREATMENT OF CLOSED COCCYGEAL FRACTURE $102.21 20060701 99999999 

27202 OPEN TREATMENT OF CLOSED OR OPEN COCCYGEAL FRACTURE $607.12 20060701 99999999 



27215 

OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR 

ILIAC WING FRACTURE(S) $621.37 20060701 99999999 

27216 

PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC RING 

FRACTURE AND/OR DISLOCAT $685.24 20060701 99999999 

27217 

OPEN TREATMENT OF ANTERIOR RING FRACTURE AND/OR 

DISLOCATION WITH INTERNAL FIXATI $833.13 20060701 99999999 

27218 

OPEN TREATMENT OF POSTERIOR RING FRACTURE AND/OR 

DISLOCATION WITH INTERNAL FIXAT $1,002.93 20060701 99999999 

27220 TREATMENT OF CLOSED ACETABULUM (HIP SOCKET) $331.50 20060701 99999999 

27222 TREATMENT OF CLOSED ACETABULUM (HIP SOCKET) $619.62 20060701 99999999 

27226 

OPEN TREATMENT OF POSTERIOR OR ANTERIOR ACETABULAR WALL 

FRACTURE, WITH INTERNAL $877.37 20060701 99999999 

27227 

OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING 

ANTERIOR OR POSTERIOR (ONE) C $1,264.38 20060701 99999999 

27228 

OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING 

ANTERIOR AND POSTERIOR (TWO) $1,406.26 20060701 99999999 

27230 TREATMENT OF CLOSED FEMORAL FRACTURE, PROXIMAL $297.94 20060701 99999999 

27232 TREATMENT OF CLOSED FEMORAL FRACTURE, PROXIMAL $590.20 20060701 99999999 

27235 

TREATMENT OF CLOSED OR OPEN FEMORAL FRACTURE, PROXIMAL 

END, NECK, $732.45 20060701 99999999 

27236 OPEN TREATMENT OF CLOSED OR OPEN FEMORAL FRACTURE, $921.32 20060701 99999999 

27238 TREATMENT OF CLOSED INTERTROCHANTERIC, $326.78 20060701 99999999 

27240 TREATMENT OF CLOSED INTERTROCHANTERIC, $670.30 20060701 99999999 

27244 OPEN TREATMENT OF CLOSED OR OPEN INTERTROCHANTERIC, $923.47 20060701 99999999 

27245 

OPEN TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC OR 

SUBTROCHANTERIC FEMORAL $1,087.13 20060701 99999999 

27246 TREATMENT OF CLOSED GREATER TROCHANTERIC FRACTURE, $280.32 20060701 99999999 

27248 OPEN TREATMENT OF CLOSED OR OPEN GREATER TROCHANTERIC $637.47 20060701 99999999 

27250 TREATMENT OF CLOSED HIP DISLOCATION, TRAUMATIC $340.91 20060701 99999999 

27252 TREATMENT OF CLOSED HIP DISLOCATION, TRAUMATIC $490.44 20060701 99999999 

27253 OPEN TREATMENT OF CLOSED OR OPEN HIP DISLOCATION, $752.59 20060701 99999999 

27254 OPEN TREATMENT OF CLOSED OR OPEN HIP DISLOCATION, $947.13 20060701 99999999 

27256 TREATMENT OF CONGENITAL HIP DISLOCATION, BY ABDUCTION, $217.99 20060701 99999999 

27257 TREATMENT OF CONGENITAL HIP DISLOCATION, BY ABDUCTION, $293.81 20060701 99999999 

27258 OPEN TREATMENT OF CONGENITAL HIP DISLOCATION $875.74 20060701 99999999 

27259 OPEN TREATMENT OF CONGENITAL HIP DISLOCATION $1,159.68 20060701 99999999 

27265 TX OF ATRAUMATIC HIP DISLOCATION HIP W/O ANESTHESIA $285.28 20060701 99999999 

27266 TREATMENT OF ATRAUMATIC HIP DISLOCATION (EG, POST-TOTAL $393.81 20060701 99999999 

27267 

CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; 

WITHOUT MANIPULATION $212.29 20080101 99999999 

27268 

CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; 

WITH MANIPULATION $259.73 20080101 99999999 

27269 

OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD, 

INCLUDES INTERNAL FIXATI $610.72 20080101 99999999 

27275 MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA $143.41 20060701 99999999 

27280 ARTHRODESIS, SACROILIAC JOINT (INCLUDING $762.16 20060701 99999999 

27282 ARTHRODESIS, SYMPHYSIS PUBIS (INCLUDING OBTAINING GRAFT) $641.31 20060701 99999999 

27284 ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT) $980.16 20060701 99999999 

27286 ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT) $991.88 20060701 99999999 

27290 INTERPELVIABDOMINAL AMPUTATION (HIND QUARTER AMPUTATION) $1,341.88 20060701 99999999 

27295 DISARTICULATION OF HIP $1,027.02 20060701 99999999 

27299 UNLISTED PROCEDURE, PELVIS OR HIP JOINT $324.74 19990701 99999999 

27301 INCISION AND DRAINAGE OF DEEP ABSCESS, INFECTED $414.94 20060701 99999999 


27305 FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN $360.89 20060701 99999999 

27306 TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR $268.34 20060701 99999999 

27307 TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR $325.17 20060701 99999999 



27310 

ARTHROTOMY, KNEE, FOR INFECTION, WITH EXPLORATION, 

DRAINAGE OR $570.59 20060701 99999999 

27315 NEURECTOMY, HAMSTRING MUSCLE $365.83 19990701 99999999 

27320 NEURECTOMY, POPLITEAL (GASTROCNEMIUS) $335.71 19990701 99999999 

27323 BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA $118.71 20060701 99999999 

27324 BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA $280.09 20060701 99999999 

27325 NEURECTOMY, HAMSTRING MUSCLE $342.85 20070101 99999999 

27326 NEURECTOMY, POPLITEAL (GASTROCNEMIUS) $325.80 20070101 99999999 

27327 EXCISION, TUMOR, THIGH OR KNEE AREA $253.66 20060701 99999999 

27328 EXCISION, TUMOR, THIGH OR KNEE AREA $325.92 20060701 99999999 

27329 RAD RESECT TUMOR SOFT TISSUE OF THIGH OR KNEE AREA $807.96 20060701 99999999 

27330 ARTHROTOMY, KNEE $321.34 20060701 99999999 

27331 ARTHROTOMY, KNEE $382.16 20060701 99999999 

27332 ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR $511.96 20060701 99999999 

27333 ARTHROTOMY, KNEE, FOR EXCISION OF SEMILUNAR $457.35 20060701 99999999 

27334 ARTHROTOMY, KNEE, FOR SYNOVECTOMY $547.79 20060701 99999999 

27335 ARTHROTOMY, KNEE, FOR SYNOVECTOMY $624.93 20060701 99999999 

27340 EXCISION, PREPATELLAR BURSA $263.93 20060701 99999999 

27345 EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (BAKER'S CYST) $368.19 20060701 99999999 

27347 

EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, 

GANGLION), KNEE $287.11 20060701 99999999 

27350 PATELLECTOMY OR HEMIPATELLECTOMY $512.38 20060701 99999999 





27360 

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 

DIAPHYSECTOMY) $693.17 20060701 99999999 

27365 RADICAL RESECTION FOR TUMOR, FEMUR OR KNEE, BONE $917.75 20060701 99999999 

27370 INJECTION PROCEDURE FOR KNEE ARTHROGRAPHY $40.61 20060701 99999999 

27372 REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA $294.66 20060701 99999999 

27380 SUTURE OF INFRAPATELLAR TENDON $455.54 20060701 99999999 

27381 SUTURE OF INFRAPATELLAR TENDON $632.64 20060701 99999999 

27385 SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE $491.29 20060701 99999999 

27386 SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE $657.08 20060701 99999999 

27390 TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP $329.08 20060701 99999999 



27393 LENGTHENING OF HAMSTRING TENDON $395.65 20060701 99999999 



27396 TRANSPLANT, HAMSTRING TENDON TO PATELLA $482.95 20060701 99999999 

27397 TRANSPLANT, HAMSTRING TENDON TO PATELLA $638.99 20060701 99999999 

27400 TENDON OR MUSCLE TRANSFER, HAMSTRINGS TO FEMUR $540.19 20060701 99999999 

27403 ARTHROTOMY WITH OPEN MENISCUS REPAIR $515.53 20060701 99999999 

27405 REPAIR, PRIMARY, TORN $549.03 20060701 99999999 



27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE $1,180.50 20060701 99999999 

27415 SUTR RPP LIG W/WO MNSCTMY W/PES ANSRNS TRNSFR/FSCL $982.40 20060701 99999999 

27416 ADVNCMT PES ANSERINUS SLOCUM TYPE PROC (SEP PROC) $481.35 20080101 99999999 

27418 

ANTERIOR TIBIAL TUBERCLE PLASTY FOR CHONDROMALACIA 

PATELLAE $668.21 20060701 99999999 

27420 RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA $602.86 20060701 99999999 



27425 LATERAL RETINACULAR RELEASE (ANY METHOD) $344.95 20060701 99999999 



27427 LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE $580.51 20060701 99999999 



27430 QUADRICEPS PLASTY (BENNETT OR THOMPSON TYPE) $573.52 20060701 99999999 

27435 CAPSULOTOMY, KNEE, POSTERIOR CAPSULAR RELEASE $527.24 20060701 99999999 

27437 ARTHROPLASTY, PATELLA $534.30 20060701 99999999 

27438 ARTHROPLASTY, PATELLA $692.99 20060701 99999999 

27440 ARTHROPLASTY, KNEE, TIBIAL PLATEAU $639.55 20060701 99999999 

27441 ARTHROPLASTY, KNEE, TIBIAL PLATEAU $609.60 20060701 99999999 

27442 ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLATEAUS $726.15 20060701 99999999 

27443 ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLATEAUS $674.68 20060701 99999999 

27445 

ARTHROPLASTY, KNEE, CONSTRAINED PROSTHESIS (EG, WALLDIUS 

TYPE) $1,049.75 20060701 99999999 

27446 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU $960.00 20060701 99999999 

27447 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU $1,492.58 20060701 99999999 

27448 OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR $690.14 20060701 99999999 

27450 OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR $852.53 20060701 99999999 

27454 OSTEOTOMY, MULTIPLE, FEMORAL SHAFT, WITH REALIGNMENT $983.71 20060701 99999999 

27455 OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR $750.00 20060701 99999999 

27457 OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR $782.81 20060701 99999999 

27465 OSTEOPLASTY, FEMUR $811.59 20060701 99999999 

27466 OSTEOPLASTY, FEMUR $931.62 20060701 99999999 

27468 OSTEOPLASTY, FEMUR $1,039.36 20060701 99999999 

27470 REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO $975.79 20060701 99999999 

27472 REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO $1,082.92 20060701 99999999 




27485 ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR PROXIMAL $516.30 20060701 99999999 

27486 REVISION OF TOTAL KNEE ARTHROPLASTY $1,149.06 20060701 99999999 

27487 REVISION OF TOTAL KNEE ARTHROPLASTY $1,483.24 20060701 99999999 

27488 REMOVAL OF KNEE PROSTHESIS, INCLUDING 'TOTAL KNEE' $932.68 20060701 99999999 


27496 

DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE 

COMPARTMENT (FLEXOR OR EXTENSOR $365.40 20060701 99999999 

27497 

DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE 

COMPARTMENT (FLEXOR OR EXTENSOR $422.68 20060701 99999999 

27498 

DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE 

COMPARTMENTS; $452.58 20060701 99999999 

27499 

DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE 

COMPARTMENTS; WITH DEBRIDE $504.67 20060701 99999999 

27500 TREATMENT OF CLOSED FEMORAL SHAFT FRACTURE (INCLUDING $361.95 20060701 99999999 

27501 

CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR 

FEMORAL FRACTURE WITH OR WITH $375.61 20060701 99999999 

27502 TREATMENT OF CLOSED FEMORAL SHAFT FRACTURE (INCLUDING $586.07 20060701 99999999 

27503 

CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR 

FEMORAL FRACTURE WITH OR WITH $587.63 20060701 99999999 

27506 OPEN TREATMENT OF CLOSED OR OPEN FEMORAL SHAFT $982.50 20060701 99999999 

27507 

OPEN TREATMENT OF FEMORAL SHAFT FRACTURE WITH 

PLATE/SCREWS, WITH OR WITHOUT CERC $842.51 20060701 99999999 

27508 TREATMENT OF CLOSED FEMORAL FRACTURE, DISTAL END, $316.30 20060701 99999999 

27509 

PERCUTANEOUS SKELETAL FIXATION OF SUPRACONDYLAR OR 

TRANSCONDYLAR FEMORAL FRACTUR $417.25 20060701 99999999 

27510 TREATMENT OF CLOSED FEMORAL FRACTURE, DISTAL END, $484.58 20060701 99999999 

27511 

OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR 

TRANSCONDYLAR FRACTURE WITHOUT INTERC $833.16 20060701 99999999 



27513 

OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR 

TRANSCONDYLAR FRACTURE WITH INTERCOND $1,008.97 20060701 99999999 

27514 OPEN TREATMENT OF CLOSED OR OPEN FEMORAL FRACTURE, $973.63 20060701 99999999 

27516 TREATMENT OF CLOSED DISTAL FEMORAL EPIPHYSEAL SEPARATION $381.15 20060701 99999999 

27517 TREATMENT OF CLOSED DISTAL FEMORAL EPIPHYSEAL SEPARATION $495.63 20060701 99999999 

27519 OPEN TREATMENT OF CLOSED OR OPEN DISTAL $846.67 20060701 99999999 

27520 

TREATMENT OF CLOSED PATELLAR FRACTURE, WITHOUT 

MANIPULATION $161.38 20060701 99999999 

27524 OPEN TREATMENT OF CLOSED OR OPEN PATELLAR FRACTURE, $589.94 20060701 99999999 

27530 TREATMENT OF CLOSED TIBIAL FRACTURE, PROXIMAL (PLATEAU) $227.14 20060701 99999999 

27532 TREATMENT OF CLOSED TIBIAL FRACTURE, PROXIMAL (PLATEAU) $390.49 20060701 99999999 

27535 

OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); 

UNICONDYLAR, WITH OR WITH $698.67 20060701 99999999 

27536 OPEN TREATMENT OF CLOSED OR OPEN TIBIAL FRACTURE, $822.41 20060701 99999999 

27538 TREATMENT OF CLOSED INTERCONDYLAR SPINE(S) $274.74 20060701 99999999 

27540 OPEN TREATMENT OF CLOSED OR OPEN INTERCONDYLAR $711.79 20060701 99999999 

27550 TREATMENT OF CLOSED KNEE DISLOCATION $290.62 20060701 99999999 

27552 TREATMENT OF CLOSED KNEE DISLOCATION $395.00 20060701 99999999 

27556 OPEN TREATMENT OF CLOSED OR OPEN KNEE DISLOCATION, $830.62 20060701 99999999 

27557 OPEN TREATMENT OF CLOSED OR OPEN KNEE DISLOCATION, $956.30 20060701 99999999 

27558 

OPEN TREATMENT OF KNEE DISLOCATION, WITH OR WITHOUT 

INTERNAL OR EXTERNAL FIXATIO $986.12 20060701 99999999 

27560 TREATMENT OF CLOSED PATELLAR DISLOCATION $190.64 20060701 99999999 

27562 TREATMENT OF CLOSED PATELLAR DISLOCATION $332.45 20060701 99999999 

27566 OPEN TREATMENT OF CLOSED OR OPEN PATELLAR $674.98 20060701 99999999 

27570 MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA $120.79 20060701 99999999 

27580 FUSION OF KNEE, ANY TECHNIQUE $1,059.00 20060701 99999999 

27590 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL $684.13 20060701 99999999 





27598 DISARTICULATION AT KNEE $633.72 20060701 99999999 

27600 FASCIOTOMY, LEG, FOR CLOSED SPACE DECOMPRESSION $337.14 20060701 99999999 



27603 INCISION AND DRAINAGE, LEG OR ANKLE $320.62 20060701 99999999 

27604 INCISION AND DRAINAGE, LEG OR ANKLE $246.35 20060701 99999999 

27605 TENOTOMY, ACHILLES TENDON, SUBCUTANEOUS (SEPARATE $156.77 20060701 99999999 

27606 TENOTOMY, ACHILLES TENDON, SUBCUTANEOUS (SEPARATE $224.58 20060701 99999999 


27610 

ARTHROTOMY, ANKLE, FOR INFECTION, WITH EXPLORATION, 

DRAINAGE OR $505.00 20060701 99999999 

27612 ARTHROTOMY, ANKLE, POSTERIOR CAPSULAR RELEASE, $456.94 20060701 99999999 

27613 BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA $107.14 20060701 99999999 

27614 BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA $297.78 20060701 99999999 

27615 RAD RESECT TUMOR SOFT TISSUE OF LEG OR ANKLE AREA $715.15 20060701 99999999 

27618 EXCISION, TUMOR, LEG OR ANKLE AREA $270.11 20060701 99999999 

27619 EXCISION, TUMOR, LEG OR ANKLE AREA $433.53 20060701 99999999 

27620 ARTHROTOMY, ANKLE, WITH JOINT EXPLORATION, WITH OR $383.36 20060701 99999999 

27625 ARTHROTOMY, ANKLE, FOR SYNOVECTOMY $518.66 20060701 99999999 

27626 ARTHROTOMY, ANKLE, FOR SYNOVECTOMY $562.80 20060701 99999999 

27630 EXCISION OF LESION OF TENDON SHEATH OR CAPSULE $281.06 20060701 99999999 

27635 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, $510.59 20060701 99999999 







27645 RESECTION FOR TUMOR, RADICAL $844.88 20060701 99999999 



27648 INJECTION PROCEDURE FOR ANKLE ARTHROGRAPHY $39.92 20060701 99999999 

27650 

REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES 

TENDON $563.24 20060701 99999999 

27652 

REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES 

TENDON $606.10 20060701 99999999 

27654 REPAIR, SECONDARY, RUPTURED ACHILLES TENDON, $609.96 20060701 99999999 

27656 REPAIR, FASCIAL DEFECT OF LEG $281.61 20060701 99999999 

27658 REPAIR OR SUTURE OF FLEXOR TENDON OF LEG $329.70 20060701 99999999 

27659 REPAIR OR SUTURE OF FLEXOR TENDON OF LEG $422.47 20060701 99999999 

27664 REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG $307.34 20060701 99999999 

27665 REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG $365.90 20060701 99999999 

27675 REPAIR FOR DISLOCATING PERONEAL TENDONS $425.80 20060701 99999999 

27676 REPAIR FOR DISLOCATING PERONEAL TENDONS $494.61 20060701 99999999 

27680 TENOLYSIS, INCLUDING TIBIA, FIBULA AND ANKLE FLEXOR $339.55 20060701 99999999 

27681 TENOLYSIS, INCLUDING TIBIA, FIBULA AND ANKLE FLEXOR $411.71 20060701 99999999 

27685 LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE $365.66 20060701 99999999 

27686 LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE $459.37 20060701 99999999 

27687 GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE) $383.46 20060701 99999999 

27690 TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE $489.33 20060701 99999999 



27695 SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMENT, $430.99 20060701 99999999 

27696 SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMENT, $492.11 20060701 99999999 

27698 SUTURE, SECONDARY REPAIR, TORN, RUPTURED OR SEVERED $573.94 20060701 99999999 

27700 ARTHROPLASTY, ANKLE $542.19 20060701 99999999 



27704 REMOVAL OF ANKLE IMPLANT $443.11 20060701 99999999 

27705 OSTEOTOMY $640.92 20060701 99999999 

27707 OSTEOTOMY $318.71 20060701 99999999 

27709 OSTEOTOMY $628.29 20060701 99999999 

27712 OSTEOTOMY $791.47 20060701 99999999 

27715 OSTEOPLASTY, TIBIA AND FIBULA, LENGTHENING $831.90 20060701 99999999 

27720 REPAIR OF NONUNION OR MALUNION, TIBIA $897.06 20060701 99999999 




27726 

REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL 

FIXATION $455.21 20080101 99999999 

27727 REPAIR OF CONGENITAL PSEUDARTHROSIS, TIBIA $756.14 20060701 99999999 







27750 TREATMENT OF CLOSED TIBIAL SHAFT FRACTURE $205.49 20060701 99999999 

27752 TREATMENT OF CLOSED TIBIAL SHAFT FRACTURE $341.45 20060701 99999999 

27756 OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT $464.49 20060701 99999999 

27758 OPEN TREATMENT OF CLOSED OR OPEN TIBIAL SHAFT $726.16 20060701 99999999 

27759 

OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT 

FIBULAR FRACTURE) BY IN $819.11 20060701 99999999 



27760 TREATMENT OF CLOSED DISTAL TIBIAL FRACTURE $168.46 20060701 99999999 

27762 TREATMENT OF CLOSED DISTAL TIBIAL FRACTURE $288.36 20060701 99999999 

27766 OPEN TREATMENT OF CLOSED OR OPEN DISTAL TIBIAL $492.00 20060701 99999999 

27767 

CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; 

WITHOUT MANIPULATION $133.50 20080101 99999999 

27768 

CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITH 

MANIPULATION $201.54 20080101 99999999 

27769 

OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES 

INTERNAL FIXATION, WHEN $342.85 20080101 99999999 

27780 TREATMENT OF CLOSED PROXIMAL FIBULA OR SHAFT $149.36 20060701 99999999 

27781 TREATMENT OF CLOSED PROXIMAL FIBULA OR SHAFT $248.39 20060701 99999999 

27784 OPEN TREATMENT OF CLOSED OR OPEN PROXIMAL FIBULA $416.55 20060701 99999999 

27786 TREATMENT OF CLOSED DISTAL FIBULAR FRACTURE $157.64 20060701 99999999 

27788 TREATMENT OF CLOSED DISTAL FIBULAR FRACTURE $232.65 20060701 99999999 

27792 OPEN TREATMENT OF CLOSED OR OPEN DISTAL FIBULAR $458.47 20060701 99999999 

27808 TREATMENT OF CLOSED BIMALLEOLAR ANKLE FRACTURE, $190.58 20060701 99999999 

27810 TREATMENT OF CLOSED BIMALLEOLAR ANKLE FRACTURE, $313.58 20060701 99999999 

27814 OPEN TREATMENT OF CLOSED OR OPEN BIMALLEOLAR $629.86 20060701 99999999 

27816 TREATMENT OF CLOSED TRIMALLEOLAR ANKLE FRACTURE $199.34 20060701 99999999 

27818 TREATMENT OF CLOSED TRIMALLEOLAR ANKLE FRACTURE $343.72 20060701 99999999 

27822 OPEN TREATMENT OF CLOSED OR OPEN TRIMALLEOLAR $903.66 20060701 99999999 

27823 OPEN TREATMENT OF CLOSED OR OPEN TRIMALLEOLAR $1,027.55 20060701 99999999 

27824 

CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR 

PORTION OF DISTAL TIBIA $198.09 20060701 99999999 

27825 

CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR 

PORTION OF DISTAL TIBIA $378.23 20060701 99999999 

27826 

OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR 

SURFACE/ PORTION OF DISTA $734.66 20060701 99999999 

27827 


SURFACE/ PORTION OF DISTA $1,129.61 20060701 99999999 

27828 


SURFACE/ PORTION OF DISTA $1,265.82 20060701 99999999 

27829 

OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) 

DISRUPTION, WITH OR WI $517.10 20060701 99999999 

27830 TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT $218.73 20060701 99999999 

27831 TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT $269.07 20060701 99999999 

27832 OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT $401.47 20060701 99999999 

27840 TREATMENT OF ANKLE DISLOCATION $242.22 20060701 99999999 

27842 TREATMENT OF ANKLE DISLOCATION $289.47 20060701 99999999 

27846 OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION $568.00 20060701 99999999 

27848 OPEN TREATMENT OF CLOSED OR OPEN ANKLE DISLOCATION $881.98 20060701 99999999 

27860 MANIPULATION OF ANKLE UNDER GENERAL ANESTHESIA $136.89 20060701 99999999 

27870 ARTHRODESIS, ANKLE, ANY METHOD $823.12 20060701 99999999 

27871 ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL OR DISTAL $547.56 20060701 99999999 

27880 AMPUTATION LEG, THROUGH TIBIA AND FIBULA $654.00 20060701 99999999 





27888 AMPUTATION, ANKLE, THROUGH MALLEOLI OF TIBIA AND $592.29 20060701 99999999 

27889 ANKLE DISARTICULATION $567.48 20060701 99999999 

27892 

DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL 

COMPARTMENTS ONLY, WITH D $384.82 20060701 99999999 

27893 

DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR COMPARTMENT(S) 

ONLY, WITH DEBRIDEMENT O $370.71 20060701 99999999 

27894 

DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, 

AND POSTERIOR COMPARTMEN $506.24 20060701 99999999 

28001 INCISION AND DRAINAGE, INFECTED BURSA, FOOT $123.13 20060701 99999999 



28002 DEEP DISSECTION BELOW FASCIA, FOR DEEP INFECTION OF FOOT, $227.84 20060701 99999999 

28003 DEEP DISSECTION BELOW FASCIA, FOR DEEP INFECTION OF FOOT, $402.52 20060701 99999999 


28008 FASCIOTOMY, PLANTAR AND/OR TOE, SUBCUTANEOUS $250.24 20060701 99999999 

28010 TENOTOMY, SUBCUTANEOUS, TOE $171.50 20060701 99999999 

28011 TENOTOMY, SUBCUTANEOUS, TOE $220.76 20060701 99999999 

28020 ARTHROTOMY, WITH EXPLORATION, DRAINAGE OR REMOVAL $301.48 20060701 99999999 



28030 NEURECTOMY OF INTRINSIC MUSCULATURE OF FOOT $288.69 19990701 99999999 

28035 

TARSAL TUNNEL RELEASE (POSTERIOR TIBIAL NERVE 

DECOMPRESSION) $312.26 20060701 99999999 

28043 EXCISION, TUMOR, FOOT $193.49 20060701 99999999 

28045 EXCISION, TUMOR, FOOT $274.19 20060701 99999999 

28046 RAD RESECT TUMOR SOFT TISSUE FOOT (EG MALIG NEOPLASM) $518.60 20060701 99999999 




28055 NEURECTOMY, INTRINSIC MUSCULATURE OF FOOT $271.10 20070101 99999999 

28060 FASCIECTOMY, EXCISION OF PLANTAR FASCIA $302.77 20060701 99999999 

28062 FASCIECTOMY, EXCISION OF PLANTAR FASCIA $384.31 20060701 99999999 

28070 SYNOVECTOMY $299.10 20060701 99999999 

28072 SYNOVECTOMY $275.51 20060701 99999999 

28080 EXCISION OF INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH $237.64 20060701 99999999 

28086 SYNOVECTOMY, TENDON SHEATH, FOOT $296.63 20060701 99999999 

28088 SYNOVECTOMY, TENDON SHEATH, FOOT $258.49 20060701 99999999 

28090 EXCISION OF LESION OF TENDON OR FIBROUS SHEATH OR $245.38 20060701 99999999 

28092 EXCISION OF LESION OF TENDON OR FIBROUS SHEATH OR $212.58 20060701 99999999 








28110 OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL $262.02 20060701 99999999 

28111 OSTECTOMY, COMPLETE EXCISION $324.19 20060701 99999999 




28116 OSTECTOMY, EXCISION OF TARSAL COALITION $400.10 20060701 99999999 

28118 OSTECTOMY, CALCANEUS $357.86 20060701 99999999 

28119 OSTECTOMY, CALCANEUS $321.08 20060701 99999999 




28126 CONDYLECTOMY, PHALANGEAL BASE, SINGLE TOE, EACH $217.46 20060701 99999999 

28130 TALECTOMY (ASTRAGALECTOMY) $471.12 20060701 99999999 

28140 METATARSECTOMY $381.57 20060701 99999999 

28150 PHALANGECTOMY OF TOE, SINGLE, EACH $259.42 20060701 99999999 

28153 RESECTION, HEAD OF PHALANX, TOE $204.31 20060701 99999999 

28160 HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISION, $229.00 20060701 99999999 




28190 REMOVAL OF FOREIGN BODY, FOOT $105.05 20060701 99999999 





28200 REPAIR OR SUTURE OF TENDON, FOOT, FLEXOR, SINGLE $296.79 20060701 99999999 

28202 REPAIR OR SUTURE OF TENDON, FOOT, FLEXOR, SINGLE $381.33 20060701 99999999 

28208 REPAIR OR SUTURE OF TENDON, FOOT, EXTENSOR, SINGLE $244.71 20060701 99999999 

28210 REPAIR OR SUTURE OF TENDON, FOOT, EXTENSOR, SINGLE $362.63 20060701 99999999 

28220 TENOLYSIS, FLEXOR, FOOT $236.50 20060701 99999999 

28222 TENOLYSIS, FLEXOR, FOOT $302.55 20060701 99999999 

28225 TENOLYSIS, EXTENSOR, FOOT $213.60 20060701 99999999 

28226 TENOLYSIS, EXTENSOR, FOOT $264.38 20060701 99999999 

28230 TENOTOMY, OPEN, FLEXOR $225.06 20060701 99999999 

28232 TENOTOMY, OPEN, FLEXOR $189.97 20060701 99999999 

28234 TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE $179.52 20060701 99999999 

28238 ADVANCEMENT OF POSTERIOR TIBIAL TENDON WITH $440.12 20060701 99999999 

28240 

TENOTOMY LENGTHENING, OR RELEASE, ABDUCTOR HALLUCIS 

MUSCLE $238.46 20060701 99999999 

28250 DIVISION OF PLANTAR FASCIA AND MUSCLE (''STEINDLER $336.59 20060701 99999999 

28260 CAPSULOTOMY, MIDFOOT $395.28 20060701 99999999 



28264 CAPSULOTOMY, MIDTARSAL (HEYMAN TYPE PROCEDURE) $590.51 20060701 99999999 

28270 CAPSULOTOMY FOR CONTRACTURE $245.55 20060701 99999999 

28272 CAPSULOTOMY FOR CONTRACTURE $190.84 20060701 99999999 

28280 WEBBING OPERATION (CREATE SYNDACTYLISM OF TOES) $275.10 20060701 99999999 

28285 HAMMERTOE OPERATION $285.98 20060701 99999999 

28286 HAMMERTOE OPERATION $268.04 20060701 99999999 

28288 OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, $299.55 20060701 99999999 

28289 

HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT 

AND CAPSULAR RELEASE OF $325.22 20060701 99999999 

28290 

HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT 

SESAMOIDECTOMY $363.19 20060701 99999999 

28292 



28293 



28294 



28296 



28297 



28298 



28299 



28300 OSTEOTOMY $513.63 20030401 99999999 

28302 OSTEOTOMY $554.04 20060701 99999999 

28304 

OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS OR 

TALUS $475.77 20060701 99999999 

28305 

OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS OR 

TALUS $609.06 20060701 99999999 

28306 

OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, WITH OR 

WITHOUT $326.41 20060701 99999999 

28307 

OSTEOTOMY METATARSAL BASE OR SHAFT SINGLE W/WO 

LENGTHENING $394.86 20060701 99999999 

28308 

OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, WITH OR 

WITHOUT $313.26 20060701 99999999 

28309 OSTEOTOMY, METATARSALS, MULTIPLE, FOR CAVUS FOOT $622.16 20060701 99999999 

28310 OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL $308.71 20060701 99999999 

28312 OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL $298.91 20060701 99999999 



28313 

RECONSTR ANGULAR DEFORMITY OF TOE SOFT TISSUE 

PROCEDURES ONL $297.81 20060701 99999999 

28315 SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE) $279.30 20060701 99999999 

28320 REPAIR OF NONUNION OR MALUNION $540.94 20060701 99999999 

28322 REPAIR OF NONUNION OR MALUNION $427.95 20060701 99999999 

28340 RECONSTR TOE MACRODACTYLY SOFT TISSUE RESECTION $391.32 20060701 99999999 

28341 RECONSTR TOE MACRODACTYLY REQUIRING BONE RESECTION $458.70 20060701 99999999 

28344 RECONSTRUCTION TOE(S) POLYDACTYLY $261.97 20060701 99999999 

28345 

RECONSTRUCTION TOE(S) SYNDACTYLY W/WO SKIN GRFTS EACH 

WEB $355.87 20060701 99999999 

28360 RECONSTRUCTION CLEFT FOOT $775.12 20060701 99999999 

28400 TREATMENT OF CLOSED CALCANEAL FRACTURE $147.87 20060701 99999999 



28415 OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL $1,170.94 20060701 99999999 

28420 OPEN TREATMENT OF CLOSED OR OPEN CALCANEAL $1,224.82 20060701 99999999 

28430 TREATMENT OF CLOSED TALUS FRACTURE $138.29 20060701 99999999 



28445 OPEN TREATMENT OF CLOSED OR OPEN TALUS FRACTURE, $682.83 20060701 99999999 

28446 

OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING 

GRAFT[S]) $592.04 20080101 99999999 

28450 TREATMENT OF CLOSED TARSAL BONE FRACTURE (EXCEPT $126.55 20060701 99999999 



28465 OPEN TREATMENT OF CLOSED OR OPEN TARSAL BONE $560.72 20060701 99999999 

28470 TREATMENT OF CLOSED METATARSAL FRACTURE $119.51 20060701 99999999 

28475 TREATMENT OF CLOSED METATARSAL FRACTURE $164.82 20060701 99999999 

28476 

TREATMENT OF CLOSED METATARSAL FX; WITH MANIPULATION & 

PERCU $239.80 20060701 99999999 

28485 OPEN TREATMENT OF CLOSED OR OPEN METATARSAL $475.03 20060701 99999999 

28490 TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX $68.89 20060701 99999999 

28495 TREATMENT OF CLOSED FRACTURE GREAT TOE, PHALANX $92.04 20060701 99999999 

28496 

TX CLOSED FRACT GREAT TOE PHALANX/PHALANGES 

W/MANIP&PINNING $169.37 20060701 99999999 

28505 OPEN TREATMENT OF CLOSED OR OPEN FRACTURE GREAT $357.43 20060701 99999999 

28510 TREATMENT OF CLOSED FRACTURE, PHALANX OR PHALANGES, $66.80 20060701 99999999 

28515 TREATMENT OF CLOSED FRACTURE, PHALANX OR PHALANGES, $84.64 20060701 99999999 

28525 OPEN TREATMENT OF CLOSED OR OPEN FRACTURE, PHALANX $318.49 20060701 99999999 

28530 TX OF CLOSED SESAMOID FRACTURE $73.25 20060701 99999999 

28531 

OPEN TREATMENT OF SESAMOID FRACTURE, WITH OR WITHOUT 

INTERNAL FIXATION $205.28 20060701 99999999 

28540 TREATMENT OF CLOSED TARSAL BONE DISLOCATION $133.23 20060701 99999999 

28545 TREATMENT OF CLOSED TARSAL BONE DISLOCATION $148.27 20060701 99999999 

28546 TREATMENT OF CLOSED TARSAL BONE DISLOCATION, WITH $212.74 20060701 99999999 

28555 OPEN TREATMENT OF CLOSED OR OPEN TARSAL BONE $428.52 20060701 99999999 

28570 TREATMENT OF CLOSED TALOTARSAL JOINT DISLOCATION $113.31 20060701 99999999 

28575 TREATMENT OF CLOSED TALOTARSAL JOINT DISLOCATION $200.22 20060701 99999999 

28576 

PERCUTANEOUS SKELETAL FIXATION OF TALOTARSAL JOINT 

DISLOCATION, WITH MANIPULATIO $247.88 20060701 99999999 

28585 OPEN TREATMENT OF CLOSED OR OPEN TALOTARSAL JOINT $527.77 20060701 99999999 

28600 TREATMENT OF CLOSED TARSOMETATARSAL JOINT DISLOCATION $116.12 20060701 99999999 

28605 TREATMENT OF CLOSED TARSOMETATARSAL JOINT DISLOCATION $176.08 20060701 99999999 

28606 TREATMENT OF CLOSED TARSOMETATARSAL JOINT $294.30 20060701 99999999 

28615 OPEN TREATMENT OF CLOSED OR OPEN TARSOMETATARSAL $664.60 20060701 99999999 

28630 TREATMENT OF CLOSED METATARSOPHALANGEAL JOINT $93.46 20060701 99999999 

28635 TREATMENT OF CLOSED METATARSOPHALANGEAL JOINT $123.57 20060701 99999999 



28636 

PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANGEAL 

JOINT DISLOCATION, WITH MA $164.24 20060701 99999999 

28645 OPEN TREATMENT OF CLOSED OR OPEN METATARSOPHALANGEAL $294.40 20060701 99999999 



28666 

PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT 

DISLOCATION, WITH MANIPU $157.29 20060701 99999999 

28675 OPEN TREATMENT OF CLOSED OR OPEN INTERPHALANGEAL $282.19 20060701 99999999 

28705 PANTALAR ARTHRODESIS $876.66 20060701 99999999 

28715 TRIPLE ARTHRODESIS $763.86 20060701 99999999 

28725 SUBTALAR ARTHRODESIS $656.13 20060701 99999999 

28730 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, $611.05 20060701 99999999 

28735 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, $622.71 20060701 99999999 

28737 ARTHRODESIS, MIDTARSAL NAVICULAR-CUNEIFORM, WITH $566.52 20060701 99999999 

28740 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT $440.04 20060701 99999999 

28750 ARTHRODESIS, GREAT TOE $421.73 20060701 99999999 

28755 ARTHRODESIS, GREAT TOE $281.15 20060701 99999999 

28760 ARTHRODESIS, GREAT TOE, INTERPHALANGEAL JOINT, $413.65 20060701 99999999 

28800 AMPUTATION, FOOT $473.32 20060701 99999999 

28805 AMPUTATION, FOOT $472.02 20060701 99999999 

28810 AMPUTATION, METATARSAL, WITH TOE, SINGLE $350.32 20060701 99999999 

28820 AMPUTATION, TOE $264.00 20060701 99999999 

28825 AMPUTATION, TOE $230.80 20060701 99999999 

28890 

EXTRACORPOREAL SHOCK WAVE, HIGH ENERGY, PERFORMED BY A 

PHYSICIAN, REQUIRING ANES $151.10 20060701 99999999 

29000 APPLICATION OF HALO TYPE BODY CAST (SEE 20661-20663 $117.02 20060701 99999999 

29010 APPLICATION OF RISSER JACKET, LOCALIZER, BODY $116.56 20060701 99999999 

29015 APPLICATION OF RISSER JACKET, LOCALIZER, BODY $102.79 20060701 99999999 

29020 APPLICATION OF TURNBUCKLE JACKET, BODY $88.93 20060701 99999999 

29025 APPLICATION OF TURNBUCKLE JACKET, BODY $109.84 20060701 99999999 

29035 APPLICATION OF BODY CAST, SHOULDER TO HIPS $85.46 20060701 99999999 




29049 APPLICATION $36.09 20060701 99999999 

29055 APPLICATION $85.66 20060701 99999999 

29058 APPLICATION $56.82 20060701 99999999 

29065 APPLICATION $41.56 20060701 99999999 

29075 APPLICATION $37.14 20060701 99999999 

29085 APPLICATION $38.35 20060701 99999999 

29086 APPLICATION, CAST; FINGER (EG, CONTRACTURE) $41.36 20060701 99999999 

29105 APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) $34.95 20060701 99999999 

29125 APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) $24.61 20060701 99999999 

29126 APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND) $30.49 20060701 99999999 

29130 APPLICATION OF FINGER SPLINT $18.15 20060701 99999999 

29131 APPLICATION OF FINGER SPLINT $22.28 20060701 99999999 

29200 STRAPPING $24.17 20060701 99999999 

29220 STRAPPING $25.58 20060701 99999999 

29240 STRAPPING $27.92 20060701 99999999 

29260 STRAPPING $21.56 20060701 99999999 

29280 STRAPPING $20.29 20060701 99999999 

29305 APPLICATION OF HIP SPICA CAST $107.65 20060701 99999999 

29325 APPLICATION OF HIP SPICA CAST $118.53 20060701 99999999 

29345 APPLICATION OF LONG LEG CAST (THIGH TO TOES) $63.14 20060701 99999999 

29355 APPLICATION OF LONG LEG CAST (THIGH TO TOES) $67.99 20060701 99999999 

29358 APPLICATION OF LONG LEG CAST BRACE $66.41 20060701 99999999 

29365 APPLICATION OF CYLINDER CAST (THIGH TO ANKLE) $54.61 20060701 99999999 

29405 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) $40.13 20060701 99999999 



29425 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES) $44.99 20060701 99999999 

29435 APPLICATION OF PATELLAR TENDON BEARING (PTB) CAST $54.10 20060701 99999999 

29440 ADDING WALKER TO PREVIOUSLY APPLIED CAST $22.43 20060701 99999999 

29445 APPLICATION OF RIGID TOTAL CONTACT LEG CAST $91.09 20060701 99999999 

29450 APPLICATION OF CLUBFOOT CAST WITH MOLDING OR $79.98 20060701 99999999 

29505 APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) $33.01 20060701 99999999 

29515 APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) $29.94 20060701 99999999 

29520 STRAPPING $24.76 20060701 99999999 

29530 STRAPPING $24.67 20060701 99999999 

29540 STRAPPING $20.58 20060701 99999999 

29550 STRAPPING $18.91 20060701 99999999 

29580 STRAPPING $23.14 20060701 99999999 

29590 DENIS-BROWNE SPLINT STRAPPING $27.80 20060701 99999999 

29700 REMOVAL OR BIVALVING $22.74 20060701 99999999 




29720 REPAIR OF SPICA, BODY CAST OR JACKET $27.58 20060701 99999999 

29730 WINDOWING OF CAST $28.61 20060701 99999999 

29740 WEDGING OF CAST (EXCEPT CLUBFOOT CASTS) $42.21 20060701 99999999 

29750 WEDGING OF CLUBFOOT CAST $49.33 20060701 99999999 

29800 

ARTHROSCOPY,TEMPOROMANDIBULAR JOINT,DIAG,WITH OR W/OUT 

SYNOV $364.88 20060701 99999999 

29804 ARTHROSCOPY,TEMPOROMANDIBULAR JOINT,SURGICAL $511.05 20060701 99999999 

29805 

ARTHROSCOPY, SHOULDER, DIAGNOSTIC, WITH OR WITHOUT 

SYNOVIAL BIOPSY (SEPARATE PRO $296.67 20060701 99999999 

29806 ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY $749.02 20060701 99999999 

29807 ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION $728.89 20060701 99999999 

29815 

ARTHROSCOPY, SHOULDER, DIAGNOSTIC, WITH OR WITHOUT 

SYNOVIAL BIOPSY $354.79 19990701 99999999 

29819 ARTHROSCOPY, SHOULDER, SURGICAL $493.91 20060701 99999999 





29824 

ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY 

INCLUDING DISTAL ARTICULA $458.72 20060701 99999999 


29826 

ARTHROSCOPY SHOULDER SURG DECOMPRESSION OF 

SUBACROMIAL SPACE $575.82 20060701 99999999 

29827 ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR $790.52 20060701 99999999 

29828 ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS $456.26 20080101 99999999 

29830 ARTHROSCOPY, ELBOW, DIAGNOSTIC, WITH OR WITHOUT $339.28 20060701 99999999 

29834 ARTHROSCOPY, ELBOW, SURGICAL $376.86 20060701 99999999 





29840 

ARTHROSCOPY WRIST DIAG W/WO SYNOVIAL BIOP (SEP 

PROCEDURE) $322.26 20060701 99999999 

29843 ARTHROSCOPY WRIST SURG FOR INFECTION/LAVAGE AND DRAINAGE $378.05 20060701 99999999 

29844 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY PARTIAL $398.38 20060701 99999999 

29845 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY COMPLETE $452.04 20060701 99999999 

29846 

ARTHROSCOPY WRIST SURG EXC TRIANGULAR FIBROCARTILAGE JNT 

DEB $469.88 20060701 99999999 

29847 ARTHROSCOPY WRIST SURG INT FIX FOR FX OR INSTABILITY $483.68 20060701 99999999 



29848 

ARTHROSCOPY, WRIST, SURGICAL; WITH RELEASE OF TRANSVERSE 

CARPAL LIGAMENT $329.23 20060701 99999999 

29850 

ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR 

SPINE(S) AND/OR TUBEROSITY FRA $488.43 20060701 99999999 

29851 

ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR 

SPINE(S) AND/OR TUBEROSITY FRA $733.38 20060701 99999999 

29855 

ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, 

PROXIMAL (PLATEAU); UNICOND $655.16 20060701 99999999 

29856 

ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, 

PROXIMAL (PLATEAU); BICONDY $794.44 20060701 99999999 

29860 

ARTHROSCOPY, HIP, DIAGNOSTIC WITH OR WITHOUT SYNOVIAL 

BIOPSY (SEPARATE PROCEDURE $422.32 20060701 99999999 

29861 

ARTHROSCOPY, HIP, SURGICAL; WITH REMOVAL OF LOOSE BODY OR 

FOREIGN BODY $549.15 20060701 99999999 

29862 

ARTHROSCOPY, HIP, SURGICAL; WITH DEBRIDEMENT/SHAVING OF 

ARTICULAR CARTILAGE (CHO $588.73 20060701 99999999 

29863 ARTHROSCOPY, HIP, SURGICAL; WITH SYNOVECTOMY $570.02 20060701 99999999 

29866 

ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL AUTOGRAFT(S) 

(EG, MOSAICPLASTY) $777.30 20060701 99999999 

29867 

ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT 

(EG, MOSAICPLASTY) $927.86 20060701 99999999 

29868 

ARTHROSCOPY, KNEE, SURGICAL; MENISCAL TRANSPLANTATION 

(INCLUDES ARTHROTOMY FOR $1,251.04 20060701 99999999 

29870 

ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL 

BIOPSY $298.03 20060701 99999999 

29871 ARTHROSCOPY, KNEE, SURGICAL $411.39 20060701 99999999 

29873 ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL RELEASE $369.85 20060701 99999999 









29883 ARTHROSCOPY KNEE SURG W/MENISCUS REPAIR (MEDIAL&LATERAL) $578.53 20060701 99999999 


29885 

ARTHROSCOPY KNEE SURG DRILLING FOR OSTEOCHONDRITIS 

DISSECANS $539.35 20060701 99999999 



29888 ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/ $842.13 20060701 99999999 

29889 ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT REPAIR $806.54 20060701 99999999 

29891 

ARTHROSCOPY, ANKLE, SURGICAL; EXCISION OF OSTEOCHONDRAL 

DEFECT OF TALUS AND/OR T $517.99 20060701 99999999 

29892 

ARTHROSCOPICALLY AIDED REPAIR OF LARGE OSTEOCHONDRITIS 

DISSECANS LESION, TALAR D $542.76 20060701 99999999 

29893 ENDOSCOPIC PLANTAR FASCIOTOMY $306.63 20060701 99999999 

29894 ARTHROSCOPY, ANKLE, SURGICAL $450.22 20060701 99999999 




29899 

ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 

SURGICAL; WITH ANKLE ART $725.35 20060701 99999999 



29900 

ARTHROSCOPY, METACARPOPHALANGEAL JOINT, DIAGNOSTIC, 

INCLUDES SYNOVIAL BIOPSY $328.10 20060701 99999999 

29901 

ARTHROSCOPY, METACARPOPHALANGEAL JOINT, SURGICAL; WITH 

DEBRIDEMENT $360.87 20060701 99999999 

29902 

ARTHROSCOPY, METACARPOPHALANGEAL JOINT, SURGICAL; WITH 

REDUCTION OF DISPLACED UL $386.80 20060701 99999999 

29904 

ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH REMOVAL OF 

LOOSE BODY OR FOREIGN BOD $308.47 20080101 99999999 

29905 ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SYNOVECTOMY $333.14 20080101 99999999 

29906 ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT $350.92 20080101 99999999 

29907 

ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SUBTALAR 

ARTHRODESIS $427.07 20080101 99999999 

30000 DRAINAGE ABSCESS OR HEMATOMA, NASAL, INTERNAL APPROACH $69.98 20060701 99999999 

30020 DRAINAGE ABSCESS OR HEMATOMA, NASAL SEPTUM $72.00 20060701 99999999 

30100 BIOPSY, INTRANASAL $43.47 20060701 99999999 

30110 EXCISION, NASAL POLYP(S), SIMPLE $79.46 20060701 99999999 

30115 EXCISION, NASAL POLYP(S), EXTENSIVE $252.65 20060701 99999999 

30117 EXCISION, INTRANASAL LESION $194.16 20060701 99999999 

30118 EXCISION, INTRANASAL LESION $528.83 20060701 99999999 

30120 

EXCISION OR SURGICAL PLANING OF SKIN OF NOSE FOR 

RHINOPHYMA $326.47 20060701 99999999 

30124 EXCISION DERMOID CYST, NOSE $166.84 20060701 99999999 

30125 EXCISION DERMOID CYST, NOSE $386.63 20060701 99999999 

30130 EXCISION TURBINATE, PARTIAL OR COMPLETE $224.38 20060701 99999999 

30140 SUBMUCOUS RESECTION TURBINATE, PARTIAL OR COMPLETE $241.40 20060701 99999999 

30150 RHINECTOMY $510.57 20060701 99999999 

30160 RHINECTOMY $569.04 20060701 99999999 

30200 INJECTION INTO TURBINATE(S), THERAPEUTIC $37.61 20060701 99999999 

30210 DISPLACEMENT THERAPY (PROETZ TYPE) $59.41 20060701 99999999 

30220 INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON) $76.03 20060701 99999999 

30300 REMOVAL FOREIGN BODY, INTRANASAL $73.73 20060701 99999999 



30400 RHINOPLASTY, PRIMARY $635.65 20060701 99999999 



30430 RHINOPLASTY, SECONDARY $584.26 20060701 99999999 

30435 RHINOPLASTY, SECONDARY $779.68 20060701 99999999 

30450 RHINOPLASTY, SECONDARY $1,015.67 20060701 99999999 

30460 

RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL 

CLEFT LIP AND/OR PALATE, $553.36 20060701 99999999 

30462 

RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL 

CLEFT LIP AND/OR PALATE, $1,050.40 20060701 99999999 

30465 

REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, 

LATERAL NASAL WALL R $604.20 20060701 99999999 

30520 

SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT 

CARTILAGE $347.70 20060701 99999999 

30540 REPAIR CHOANAL ATRESIA $424.00 20060701 99999999 

30545 REPAIR CHOANAL ATRESIA $634.64 20060701 99999999 

30560 LYSIS INTRANASAL SYNECHIA $84.67 20060701 99999999 

30580 REPAIR FISTULA $365.78 20060701 99999999 

30600 REPAIR FISTULA $298.07 20060701 99999999 

30620 

RECONSTRUCTION, FUNCTIONAL, INTERNAL NOSE (SEPTAL OR 

OTHER $370.39 20060701 99999999 

30630 REPAIR NASAL SEPTAL PERFORATIONS $404.60 20060701 99999999 



30801 

CAUTERIZATION AND/OR ABLATION, MUCOSA OF TURBINATES, 

UNILATERAL OR BILATERAL, AN $75.30 20060701 99999999 

30802 

CAUTERIZATION AND/OR ABLATION, MUCOSA OF TURBINATES, 

UNILATERAL OR BILATERAL, AN $110.57 20060701 99999999 

30901 

CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE 

(CAUTERIZATION) $44.33 20060701 99999999 

30903 

CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX 

(CAUTERIZATION WITH LOCAL $65.99 20060701 99999999 

30905 

CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR 

NASAL $98.64 20060701 99999999 

30906 

CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR 

NASAL $107.34 20060701 99999999 

30915 LIGATION ARTERIES $384.00 20060701 99999999 

30920 LIGATION ARTERIES $559.08 20060701 99999999 

30930 FRACTURE NASAL TURBINATE(S), THERAPEUTIC $74.71 20060701 99999999 

31000 LAVAGE BY CANNULATION $63.28 20060701 99999999 

31002 LAVAGE BY CANNULATION $128.48 20060701 99999999 

31020 SINUSOTOMY, MAXILLARY (ANTROTOMY) $203.83 20060701 99999999 



31040 PTERYGOMAXILLARY FOSSA SURGERY, ANY APPROACH $497.21 20060701 99999999 

31050 SINUSOTOMY, SPHENOID, WITH OR WITHOUT BIOPSY $318.37 20060701 99999999 

31051 

SINUSOTOMY SPHENOID W/WO BIOP W/MUCOSAL STRIPPING OR 

REMOVAL $425.74 20060701 99999999 

31070 SINUSOTOMY FRONTAL $267.60 20060701 99999999 








31090 SINUSOTOMY COMBINED, THREE OR MORE SINUSES $571.27 20060701 99999999 

31200 ETHMOIDECTOMY $352.05 20060701 99999999 



31225 MAXILLECTOMY $1,090.57 20060701 99999999 

31230 MAXILLECTOMY $1,235.15 20060701 99999999 

31231 

NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL 


31233 

NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY 

SINUSOSCOPY (VIA INFERIOR MEATU $104.79 20060701 99999999 

31235 

NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH SPHENOID 

SINUSOSCOPY (VIA PUNCTURE OF SPH $118.58 20060701 99999999 

31237 

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY 

OR DEBRIDEMENT (SEPARA $137.94 20060701 99999999 

31238 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF EPISTAXIS $151.74 20060701 99999999 

31239 

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH 

DACRYOCYSTORHINOSTOMY $504.10 20060701 99999999 

31240 

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA 

RESECTION $144.92 20060701 99999999 

31254 NASAL ENDOSCOPY SURG W/ETHMOIDECTOMY PARTIAL $259.80 20060701 99999999 

31255 

NASAL ENDOSCOPY SURG W/ETHMOIDECTOMY ANTER & POSTER 

TOTAL $389.35 20060701 99999999 

31256 NASAL ENDOSCOPY SURGICAL W/MAXILLARY ANTROSTOMY $184.03 20060701 99999999 

31267 

MAXILLARY SINUS ENDOSCOPY SURG W/REMOVAL MUCOUS 

MEMBRANE $292.23 20060701 99999999 



31276 

NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL SINUS 

EXPLORATION, WITH OR WITHOUT $442.35 20060701 99999999 

31287 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; $219.33 20060701 99999999 

31288 

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH 

REMOVAL OF TISSUE FROM $256.10 20060701 99999999 

31290 

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF 

CEREBROSPINAL FLUID LEAK; ETHMOI $944.19 20060701 99999999 

31291 

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF 

CEREBROSPINAL FLUID LEAK; SPHENO $1,000.15 20060701 99999999 

31292 

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MEDIAL OR INFERIOR 

ORBITAL WALL DECOMPRESS $796.88 20060701 99999999 

31293 

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MEDIAL ORBITAL WALL 

AND INFERIOR ORBITAL W $868.03 20060701 99999999 

31294 

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH OPTIC NERVE 

DECOMPRESSION $1,021.29 20060701 99999999 

31300 LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE) $842.27 20060701 99999999 

31320 LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE) $389.30 20060701 99999999 

31360 LARYNGECTOMY $1,064.35 20060701 99999999 

31365 LARYNGECTOMY $1,457.92 20060701 99999999 

31367 LARYNGECTOMY $1,239.76 20060701 99999999 

31368 LARYNGECTOMY $1,612.33 20060701 99999999 

31370 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY) $1,226.14 20060701 99999999 




31390 PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION $1,634.76 20060701 99999999 

31395 PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION $1,916.47 20060701 99999999 

31400 ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTERNAL APPROACH $631.97 20060701 99999999 

31420 EPIGLOTTIDECTOMY $632.40 20060701 99999999 

31500 INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE $93.64 20060701 99999999 

31502 

TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF 

FISTULA TR $32.14 20060701 99999999 

31505 LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE) $30.26 20060701 99999999 





31515 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY $81.56 20060701 99999999 







31530 

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY 

REMOVAL $183.54 20060701 99999999 

31531 

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY 

REMOVAL $201.10 20060701 99999999 

31535 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY $176.24 20060701 99999999 

31536 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY $199.06 20060701 99999999 

31540 

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR 

AND/OR STRIPPING $230.97 20060701 99999999 

31541 

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR 

AND/OR STRIPPING $245.74 20060701 99999999 

31545 

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING 

MICROSCOPE OR TELESCOPE, WITH $286.01 20060701 99999999 

31546 

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING 

MICROSCOPE OR TELESCOPE, WITH $434.40 20060701 99999999 



31560 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH ARYTENOIDECTOMY $286.93 20060701 99999999 

31561 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH ARYTENOIDECTOMY $328.97 20060701 99999999 

31570 

LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), 

THERAPEUTIC $179.59 20060701 99999999 

31571 

LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), 

THERAPEUTIC $234.90 20060701 99999999 

31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC $53.40 20060701 99999999 




31579 LARYNGOSCOPY FLEXIBLE FIBEROPTIC W/STROBOSCOPY $103.09 20060701 99999999 

31580 LARYNGOPLASTY $793.80 20060701 99999999 

31582 LARYNGOPLASTY $1,218.78 20060701 99999999 

31584 LARYNGOPLASTY $1,040.08 20060701 99999999 

31585 TREATMENT OF CLOSED LARYNGEAL FRACTURE $311.31 19990701 99999999 

31586 TREATMENT OF CLOSED LARYNGEAL FRACTURE $508.77 19990701 99999999 

31587 LARYNGOPLASTY, CRICOID SPLIT $654.43 20060701 99999999 

31588 LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (EG, FOR BURNS, $785.51 20060701 99999999 

31590 LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE $567.92 20060701 99999999 

31595 SECTION RECURRENT LARYNGEAL NERVE, THERAPEUTIC (SEPARATE $503.58 20060701 99999999 

31600 TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE) $259.24 20060701 99999999 

31601 TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE) $244.63 20060701 99999999 

31603 TRACHEOSTOMY, EMERGENCY PROCEDURE $220.41 20060701 99999999 

31605 TRACHEOSTOMY, EMERGENCY PROCEDURE $189.62 20060701 99999999 

31610 TRACHEOSTOMY, FENESTRATION PROCEDURE WITH SKIN FLAPS $515.65 20060701 99999999 

31611 

CONSTRUCTION OF TRACHEOESOPHAGEAL FISTULA AND SUBQNT 

INSERTI $405.06 20060701 99999999 

31612 TRACHEAL PUNCTURE, PERCUTANEOUS FOR ASPIRATION OF MUCUS $48.22 20060701 99999999 

31613 TRACHEOSTOMA REVISION $294.72 20060701 99999999 

31614 TRACHEOSTOMA REVISION $483.82 20060701 99999999 

31615 

TRACHEOBRONCHOSCOPY THROUGH ESTABLISHED TRACHEOSTOMY 

INCISION $106.53 20060701 99999999 

31620 

ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC 

DIAGNOSTIC OR THERAPEUTIC $57.42 20060701 99999999 

31622 BRONCHOSCOPY $142.83 20060701 99999999 

31623 BRONCHOSCOPY; WITH BRUSHING OR PROTECTED BRUSHINGS $146.59 20060701 99999999 

31624 BRONCHOSCOPY; WITH BRONCHIAL ALVEOLAR LAVAGE $146.59 20060701 99999999 

31625 BRONCHOSCOPY $182.26 20060701 99999999 

31628 BRONCHOSCOPY $192.38 20060701 99999999 

31629 BRONCHOSCOPY $170.33 20060701 99999999 

31630 BRONCHOSCOPY $197.31 20060701 99999999 

31631 BRONCHOSCOPY $215.08 20060701 99999999 

31632 

BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT 

FLUOROSCOPIC GUIDANCE; WITH TRA $54.39 20060701 99999999 

31633 


FLUOROSCOPIC GUIDANCE; WITH TRA $66.72 20060701 99999999 

31635 BRONCHOSCOPY $192.10 20060701 99999999 

31636 


FLUOROSCOPIC GUIDANCE; WITH $177.90 20060701 99999999 

31637 


FLUOROSCOPIC GUIDANCE; EACH $63.08 20060701 99999999 

31638 


FLUOROSCOPIC GUIDANCE; WITH $198.19 20060701 99999999 

31640 BRONCHOSCOPY $256.53 20060701 99999999 

31641 BRONCHOSCOPY $260.69 20060701 99999999 



31643 

BRONCHOSCOPY; WITH PLACEMENT OF CATHETER(S) FOR 

INTRACAVITARY RADIOELEMENT APPLI $177.88 20060701 99999999 

31645 BRONCHOSCOPY $169.64 20060701 99999999 

31646 BRONCHOSCOPY $138.51 20060701 99999999 

31656 BRONCHOSCOPY $109.20 20060701 99999999 

31700 CATHETERIZATION, TRANSGLOTTIC (SEPARATE PROCEDURE) $66.58 20030401 99999999 

31708 INSTILLATION OF CONTRAST MATERIAL FOR LARYNGOGRAPHY $58.26 19990701 99999999 

31710 

CATHETERIZATION FOR BRONCHOGRAPHY, WITH OR WITHOUT 

INSTILLATION $56.98 19990701 99999999 

31715 TRANSTRACHEAL INJECTION FOR BRONCHOGRAPHY $43.00 20060701 99999999 

31717 CATHETERIZATION WITH BRONCHIAL BRUSH BIOPSY $80.55 20060701 99999999 

31720 CATHETER ASPIRATION (SEPARATE PROCEDURE) $47.17 20060701 99999999 

31725 CATHETER ASPIRATION (SEPARATE PROCEDURE) $87.57 20060701 99999999 

31730 

TRANSTRACHEAL (PERCUTANEOUS) INTRODUCTION OF NEEDLE WIRE 

DILATOR/ STENT OR INDWE $136.14 20060701 99999999 

31750 TRACHEOPLASTY $760.80 20060701 99999999 

31755 TRACHEOPLASTY $1,008.25 20060701 99999999 

31760 TRACHEOPLASTY $1,046.30 20060701 99999999 

31766 CARINAL RECONSTRUCTION $1,469.78 20060701 99999999 

31770 BRONCHOPLASTY $1,164.52 20060701 99999999 

31775 BRONCHOPLASTY $1,266.99 20060701 99999999 

31780 EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS $1,020.72 20060701 99999999 

31781 EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS $1,240.35 20060701 99999999 

31785 EXCISION OF TRACHEAL TUMOR OR CARCINOMA $843.72 20060701 99999999 

31786 EXCISION OF TRACHEAL TUMOR OR CARCINOMA $1,193.33 20060701 99999999 

31800 SUTURE OF EXTERNAL TRACHEAL WOUND OR INJURY $418.12 20060701 99999999 

31805 SUTURE OF EXTERNAL TRACHEAL WOUND OR INJURY $758.25 20060701 99999999 

31820 SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA $300.69 20060701 99999999 

31825 SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA $430.82 20060701 99999999 

31830 REVISION OF TRACHEOSTOMY SCAR $301.77 20060701 99999999 

32000 THORACENTESIS, PUNCTURE OF PLEURAL CAVITY FOR ASPIRATION, $57.25 20030401 99999999 

32001 TOTAL LUNG LAVAGE (UNILATERAL) $245.30 19990701 99999999 

32002 

THORACENTESIS W/INSERTION OF TUBE W/WO WATER SEAL(SEP 

PROC) $93.44 19990701 99999999 

32005 CHEMICAL PLEURODESIS (EG, FOR RECURRENT OR PERSISTENT $92.71 19990701 99999999 

32019 

INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH 

CUFF $173.40 20050101 99999999 

32020 

TUBE THORACOSTOMY WITH OR WITHOUT WATER SEAL (EG, 

PNEUMOTHORAX, $180.76 19990701 99999999 

32035 THORACOSTOMY $533.31 20060701 99999999 

32036 THORACOSTOMY $588.97 20060701 99999999 

32095 THORACOTOMY LIMITED, FOR BIOPSY OF LUNG OR PLEURA $554.58 20060701 99999999 

32100 THORACOTOMY, MAJOR $727.19 20060701 99999999 









32200 PNEUMONOSTOMY, WITH OPEN DRAINAGE OF ABSCESS OR CYST $720.30 20060701 99999999 

32201 

PNEUMONOSTOMY; WITH PERCUTANEOUS DRAINAGE OF ABSCESS 

OR CYST $210.24 20060701 99999999 

32215 PLEURAL SCARIFICATION FOR REPEAT PNEUMOTHORAX $662.49 20060701 99999999 

32220 DECORTICATION, PULMONARY, (SEPARATE PROCEDURE) $1,082.94 20060701 99999999 

32225 DECORTICATION, PULMONARY, (SEPARATE PROCEDURE) $819.89 20060701 99999999 



32310 PLEURECTOMY $789.60 20060701 99999999 

32320 DECORTICATION AND PARIETAL PLEURECTOMY $1,151.20 20060701 99999999 

32400 BIOPSY, PLEURA $81.43 20060701 99999999 

32402 BIOPSY, PLEURA $522.86 20060701 99999999 

32405 BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS NEEDLE $97.07 20060701 99999999 

32420 PNEUMONOCENTESIS, PUNCTURE OF LUNG FOR ASPIRATION $95.42 20060701 99999999 

32421 

THORACENTESIS, PUNCTURE OF PLEURAL CAVITY FOR ASPIRATION, 

INITIAL OR SUBSEQUENT $39.92 20080101 99999999 

32422 

THORACENTESIS WITH INSERTION OF TUBE, INCLUDES WATER SEAL 

(EG, FOR PNEUMOTHORAX) $65.65 20080101 99999999 

32440 PNEUMONECTOMY, TOTAL $1,183.81 20060701 99999999 

32442 

REMOVAL OF LUNG, TOTAL PNEUMONECTOMY; WITH RESECTION OF 

SEGMENT OF TRACHEA FOLLO $1,335.44 20060701 99999999 

32445 PNEUMONECTOMY, EXTRAPLEURAL $1,342.20 20060701 99999999 

32480 LOBECTOMY, TOTAL OR SEGMENTAL $1,046.59 20060701 99999999 

32482 

REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; TWO 

LOBES (BILOBECTOMY) $1,104.21 20060701 99999999 

32484 

REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; SINGLE 

SEGMENT (SEGMENTECTOMY) $1,139.00 20060701 99999999 

32486 

REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; WITH 

CIRCUMFERENTIAL RESECTION $1,264.00 20060701 99999999 

32488 

REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; ALL 

REMAINING LUNG FOLLOWING PR $1,339.81 20060701 99999999 

32491 

EXCISION-PLICATION OF EMPHYSEMATOUS LUNG(S) (BULLOUS OR 

NON -BULLOUS FOR LUNG VO $1,143.50 20060701 99999999 

32500 WEDGE RESECTION OF LUNG, SINGLE OR MULTIPLE $874.18 20060701 99999999 

32501 

RESECTION AND REPAIR OF PORTION OF BRONCHUS 

(BRONCHOPLASTY) WHEN PERFORMED AT TI $239.01 20060701 99999999 

32503 

RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), 

INCLUDING CHEST WALL RESECT $1,277.16 20060701 99999999 

32504 

RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), 

INCLUDING CHEST WALL RESECT $1,458.81 20060701 99999999 

32520 RESECTION OF LUNG $1,248.92 19990701 99999999 



32540 EXTRAPLEURAL ENUCLEATION OF EMPYEMA (EMPYEMECTOMY) $844.83 20060701 99999999 

32550 

INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH 

CUFF $112.08 20080101 99999999 

32551 

TUBE THORACOSTOMY, INCLUDES WATER SEAL (EG, FOR ABSCESS, 

HEMOTHORAX, EMPYEMA), W $92.62 20080101 99999999 

32560 

CHEMICAL PLEURODESIS (EG, FOR RECURRENT OR PERSISTENT 

PNEUMOTHORAX) $57.74 20080101 99999999 

32601 

THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS AND 

PLEURAL SPACE, WITHOUT $292.36 20060701 99999999 

32602 

THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS AND 

PLEURAL SPACE, WITH BIO $316.68 20060701 99999999 

32603 

THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); 

PERICARDIAL SAC, WITHOUT BIOPSY $371.66 20060701 99999999 

32604 


PERICARDIAL SAC, WITH BIOPSY $420.39 20060701 99999999 

32605 


MEDIASTINAL SPACE, WITHOUT BIOPSY $351.15 20060701 99999999 

32606 


MEDIASTINAL SPACE, WITH BIOPSY $404.02 20060701 99999999 

32650 THORACOSCOPY, SURGICAL; WITH PLEURODESIS, ANY METHOD $618.26 20060701 99999999 

32651 

THORACOSCOPY, SURGICAL; WITH PARTIAL PULMONARY 

DECORTICATION $754.11 20060701 99999999 



32652 

THORACOSCOPY, SURGICAL; WITH TOTAL PULMONARY 

DECORTICATION, INCLUDING INTRAPLEUR $1,039.64 20060701 99999999 

32653 

THORACOSCOPY, SURGICAL; WITH REMOVAL OF INTRAPLEURAL 

FOREIGN BODY OR FIBRIN DEPO $739.03 20060701 99999999 

32654 

THORACOSCOPY, SURGICAL; WITH CONTROL OF TRAUMATIC 

HEMORRHAGE $706.93 20060701 99999999 

32655 

THORACOSCOPY, SURGICAL; WITH EXCISION-PLICATION OF BULLAE, 

INCLUDING ANY PLEURAL $786.30 20060701 99999999 

32656 THORACOSCOPY, SURGICAL; WITH PARIETAL PLEURECTOMY $793.67 20060701 99999999 

32657 

THORACOSCOPY, SURGICAL; WITH WEDGE RESECTION OF LUNG, 

SINGLE OR MULTIPLE $817.26 20060701 99999999 

32658 

THORACOSCOPY, SURGICAL; WITH REMOVAL OF CLOT OR FOREIGN 

BODY FROM PERICARDIAL SA $744.12 20060701 99999999 

32659 

THORACOSCOPY, SURGICAL; WITH CREATION OF PERICARDIAL 

WINDOW OR PARTIAL RESECTION $743.63 20060701 99999999 

32660 THORACOSCOPY, SURGICAL; WITH TOTAL PERICARDECTOMY $1,077.56 20060701 99999999 

32661 

THORACOSCOPY, SURGICAL; WITH EXCISION OF PERICARDIAL CYST, 

TUMOR, OR MASS $751.23 20060701 99999999 

32662 

THORACOSCOPY, SURGICAL; WITH EXCISION OF MEDIASTINAL CYST, 

TUMOR, OR MASS $942.01 20060701 99999999 

32663 

THORACOSCOPY, SURGICAL; WITH LOBECTOMY, TOTAL OR 

SEGMENTAL $1,055.84 20060701 99999999 

32664 THORACOSCOPY, SURGICAL; WITH THORACIC SYMPATHECTOMY $769.11 20060701 99999999 

32665 

THORACOSCOPY, SURGICAL; WITH ESOPHAGOMYOTOMY (HELLER 

TYPE) $877.00 20060701 99999999 

32800 REPAIR LUNG HERNIA THROUGH CHEST WALL $750.84 20060701 99999999 

32810 CLOSURE OF CHEST WALL FOLLOWING OPEN FLAP DRAINAGE FOR $695.69 20060701 99999999 

32815 OPEN CLOSURE OF MAJOR BRONCHIAL FISTULA $1,228.13 20060701 99999999 

32820 MAJOR RECONSTRUCTION, CHEST WALL (POST-TRAUMATIC) $1,190.57 20060701 99999999 

32851 LUNG TRANSPLANT, SINGLE; WITHOUT CARDIOPULMONARY BYPASS $1,977.21 20060701 99999999 

32852 LUNG TRANSPLANT, SINGLE; WITH CARDIOPULMONARY BYPASS $2,127.78 20060701 99999999 

32853 

LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); 

WITHOUT CARDIOPULMONA $2,412.20 20060701 99999999 

32854 

LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); 

WITH CARDIOPULMONARY $2,572.88 20060701 99999999 

32900 RESECTION OF RIBS, EXTRAPLEURAL, ALL STAGES $972.55 20060701 99999999 

32905 THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES) $1,060.68 20060701 99999999 

32906 THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES) $1,337.48 20060701 99999999 

32940 

PNEUMONOLYSIS, EXTRAPERIOSTEAL, INCLUDING FILLING OR 

PACKING $992.74 20060701 99999999 

32960 PNEUMOTHORAX, THERAPEUTIC, INTRAPLEURAL INJECTION OF AIR $73.82 20060701 99999999 

32997 TOTAL LUNG LAVAGE (UNILATERAL) $243.55 20060701 99999999 

32998 

ABLATION THERAPY FOR REDUCTION OR ERADICATION OF ONE OR 

MORE PULMONARY TUMOR(S) $196.01 20070101 99999999 

32999 UNLISTED PROCEDURE, LUNGS AND PLEURA $205.69 19990701 99999999 

33010 PERICARDIOCENTESIS $105.02 20060701 99999999 

33011 PERICARDIOCENTESIS $97.60 20060701 99999999 

33015 TUBE PERICARDIOSTOMY $355.09 20060701 99999999 

33020 PERICARDIOTOMY FOR REMOVAL OF CLOT OR FOREIGN $763.83 20060701 99999999 

33025 

CREATION OF PERICARDIAL WINDOW OR PARTIAL RESECTION FOR 

DRAINAGE $757.17 20060701 99999999 

33030 PARTIAL RESECTION FOR CHRONIC CONSTRICTIVE PERICARDITIS, $1,160.05 20060701 99999999 

33031 COMPLT VENTRCLR DECRTCTN W/CARDPLMNRY BYPASS $1,163.58 20060701 99999999 

33050 EXCISION OF PERICARDIAL CYST OR TUMOR $786.88 20060701 99999999 

33120 EXCISION OF INTRACARDIAC TUMOR, RESECTION WITH $1,518.25 20060701 99999999 



33130 RESECTION OF EXTERNAL CARDIAC TUMOR $1,109.81 20060701 99999999 

33140 

TRANSMYOCARDIAL LASER REVASCULARIZATION, BY THORACOTOMY 

(SEPARATE PROCEDURE) $1,000.66 20060701 99999999 

33141 

TRANSMYOCARDIAL LASER REVASCULARIZATION, BY 

THORACOTOMY; PERFORMED AT THE TIME O $185.47 20060701 99999999 

33200 INSERTION OF PERMANENT PACEMAKER WITH EPICARDIAL $759.62 19990701 99999999 

33201 INSERTION OF PERMANENT PACEMAKER WITH EPICARDIAL $687.92 19990701 99999999 

33202 

INSERTION OF EPICARDIAL ELECTRODE(S); OPEN INCISION (EG, 

THORACOTOMY, MEDIAN STE $534.75 20070101 99999999 

33203 

INSERTION OF EPICARDIAL ELECTRODE(S); ENDOSCOPIC APPROACH 

(EG, THORACOSCOPY, PER $548.53 20070101 99999999 

33206 INSERTION OF PERMANENT PACEMAKER WITH TRANSVENOUS $417.10 20060701 99999999 



33210 INSERTION OF TEMPORARY TRANSVENOUS CARDIAC ELECTRODE, $174.10 20060701 99999999 

33211 

INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS DUAL 

CHAMBER PACING ELECTRODES $178.79 20060701 99999999 

33212 

INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR 

OR AUTOMATIC $331.18 20060701 99999999 

33213 

INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR 

ONLY; DUAL CHAMBER $361.30 20060701 99999999 

33214 

UPGRADE OF IMPLANTED PACEMAKER SYSTEM, CONVERSION OF 

SINGLE CHAMBER SYSTEM TO DU $418.41 20060701 99999999 

33215 

REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS 

PACEMAKER OR PACING CARDIOVERT $227.42 20060701 99999999 

33216 INSERTION, REPLACEMENT, OR REPOSITIONING OF $329.06 20060701 99999999 

33217 

INSERTION, REPLACEMENT OR REPOSITIONING OF PERMANENT 

TRANSVENOUS ELECTRODE(S) ON $341.91 20060701 99999999 

33218 REPAIR OF PACEMAKER $315.41 20060701 99999999 

33220 REPAIR OF PACEMAKER ELECTRODE(S) ONLY; DUAL CHAMBER $318.39 20060701 99999999 

33222 

REVISION OR RELOCATION OF SKIN POCKET FOR PACEMAKER OR 

AUTO $305.76 20060701 99999999 

33223 

REVISION OR RELOCATION OF SKIN POCKET FOR IMPLANTABLE 

CARDIOVERTER-DEFIBRILLATOR $377.65 20060701 99999999 

33224 

INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR 

LEFT VENTRICULAR PACIN $363.63 20060701 99999999 

33225 

INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR 

LEFT VENTRICULAR PACIN $320.77 20060701 99999999 

33226 

REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC VENOUS 

SYSTEM (LEFT VENTRICULAR) E $350.25 20060701 99999999 

33233 REMOVAL OF PERMANENT PACEMAKER; PULSE GENERATOR ONLY $208.64 20060701 99999999 

33234 

REMOVAL OF PERMANENT PACEMAKER; AND TRANSVENOUS 

ELECTRODE(S), SINGLE LEAD SYSTEM $379.03 20060701 99999999 

33235 

REMOVAL OF PERMANENT PACEMAKER; AND TRANSVENOUS 

ELECTRODE(S), DUAL LEAD SYSTEM $440.85 20060701 99999999 

33236 

REMOVAL OF PERMANENT EPICARDIAL PACEMAKER AND 

ELECTRODES BY THORACOTOMY; SINGLE $618.86 20060701 99999999 

33237 

REMOVAL OF PERMANENT EPICARDIAL PACEMAKER AND 

ELECTRODES BY THORACOTOMY; DUAL LE $761.98 20060701 99999999 

33238 

REMOVAL OF PERMANENT TRANSVENOUS ELECTRODE(S) BY 

THORACOTOMY $792.35 20060701 99999999 

33240 

INSERTION OR REPLACEMENT OF IMPLANTABLE CARDIOVERTER- 

DEFIBRILLATOR PULSE GENERAT $416.09 20060701 99999999 

33241 

REMOVAL OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PULSE 

GENERATOR ONLY $194.54 20060701 99999999 

33242 

REPAIR OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PULSE 

GENERATOR AND/OR LEADS $335.39 19990701 99999999 



33243 


GENERATOR AND/OR LEAD SY $1,040.77 20060701 99999999 

33244 


GENERATOR AND/OR LEAD SY $704.61 20060701 99999999 

33245 IMPLANTATION OF AUTOMATIC INTERNAL $911.56 19990701 99999999 

33246 

IMPLANT OF AUTOMATIC IMPLANTABLE CARDIOVERTER- 

DEFIBRILLATOR $1,220.65 19990701 99999999 

33247 


DEFIBRILLATOR LEAD(S), BY O $552.23 19990701 99999999 

33249 


DEFIBRILLATOR LEAD(S), BY O $820.76 20060701 99999999 

33250 

OPERATIVE ABLATION SUPRAVENTRICULAR ARRHYTHMOGENIC 

FOCUS OR $1,071.50 20060701 99999999 

33251 

OPERATIVE ABLATION OF SUPRAVENTRICULAR ARRHYTHMOGENIC 

FOCUS $1,326.91 20060701 99999999 

33253 

OPERATIVE INCISIONS AND RECONSTRUCTION OF ATRIA FOR 

TREATMENT OF ATRIAL FIBRILLA $1,640.55 19990701 99999999 

33254 

OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, 

LIMITED (EG, MODIFIED MAZ $928.91 20070101 99999999 

33255 


EXTENSIVE (EG, MAZE PROCE $1,117.06 20070101 99999999 

33256 


EXTENSIVE (EG, MAZE PROCE $1,331.79 20070101 99999999 

33257 


PERFORMED AT THE TIME OF $313.67 20080101 99999999 

33258 



33259 



33261 

OPERATIVE ABLATION ARRHYTHMOGENIC FOCUS/PATHWAY 

W/CARDIOPULM $1,273.64 20060701 99999999 

33265 

ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION AND 

RECONSTRUCTION OF ATRIA, LIMI $928.91 20070101 99999999 

33266 

ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION AND 

RECONSTRUCTION OF ATRIA, EXTE $1,267.31 20070101 99999999 

33282 IMPLANTATION OF PATIENT-ACTIVATED CARDIAC EVENT RECORDER $309.84 20060701 99999999 

33284 

REMOVAL OF AN IMPLANTABLE, PATIENT-ACTIVATED CARDIAC EVENT 

RECORDER $244.35 20060701 99999999 

33300 REPAIR OF CARDIAC WOUND $1,015.32 20060701 99999999 

33305 REPAIR OF CARDIAC WOUND $1,217.30 20060701 99999999 

33310 CARDIOTOMY, EXPLORATORY (INCLUDES REMOVAL OF FOREIGN $1,012.78 20060701 99999999 

33315 CARDIOTOMY, EXPLORATORY (INCLUDES REMOVAL OF FOREIGN $1,201.63 20060701 99999999 

33320 SUTURE REPAIR OF AORTA OR GREAT VESSELS $957.41 20060701 99999999 

33321 

SUTURE REPAIR OF AORTA OR GREAT VESSELS; WITH SHUNT 

BYPASS $1,226.68 20060701 99999999 

33322 SUTURE REPAIR OF AORTA OR GREAT VESSELS $1,254.39 20060701 99999999 

33330 INSERTION OF GRAFT, AORTA OR GREAT VESSELS $1,101.77 20060701 99999999 

33332 

INSERTION OF GRAFT, AORTA OR GREAT VESSELS; WITH SHUNT 

BYPASS $1,220.51 20060701 99999999 

33335 INSERTION OF GRAFT, AORTA OR GREAT VESSELS $1,485.54 20060701 99999999 

33400 VALVULOPLASTY, AORTIC VALVE, OPEN, WITH $1,557.77 20060701 99999999 

33401 VALVULOPLASTY, AORTIC VALVE; OPEN, WITH INFLOW OCCLUSION $1,443.40 20060701 99999999 

33403 

VALVULOPLASTY, AORTIC VALVE; USING TRANSVENTRICULAR 

DILATION, WITH CARDIOPULMONA $1,536.42 20060701 99999999 

33404 CONSTRUCTION OF APICAL-AORTIC CONDUIT $1,724.64 20060701 99999999 

33405 REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS $1,772.14 20060701 99999999 



33406 

REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS; 

WITH HOMOGRAFT VALVE (FR $1,916.69 20060701 99999999 

33410 

REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS; 

WITH STENTLESS TISSUE VA $1,685.57 20060701 99999999 

33411 REPLACEMENT, AORTIC VALVE $1,929.09 20060701 99999999 

33412 REPLACEMENT, AORTIC VALVE $2,082.30 20060701 99999999 

33413 

REPLACEMENT, AORTIC VALVE; BY TRANSLOCATION OF 

AUTOLOGOUS PULMONARY VALVE WITH H $2,126.28 20060701 99999999 

33414 

REPAIR OF LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION BY 

PATCH ENLARGEMENT OF THE $1,867.92 20060701 99999999 

33415 RESECTION OR INCISION OF SUBVALVULAR TISSUE FOR $1,640.02 20060701 99999999 

33416 

VENTRICULOMYOTOMY FOR IDIOPATHIC HYPERTROPHIC SUBAORTIC 

STEN $1,730.19 20060701 99999999 

33417 AORTOPLASTY (GUSSET) FOR SUPRAVALVULAR STENOSIS $1,770.89 20060701 99999999 

33420 VALVOTOMY, MITRAL VALVE (COMMISSUROTOMY) $1,152.46 20060701 99999999 

33422 VALVOTOMY, MITRAL VALVE (COMMISSUROTOMY) $1,576.67 20060701 99999999 

33425 VALVULOPLASTY, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS $1,602.41 20060701 99999999 

33426 

VALVULOPLASTY MITRAL VALVE W/CARDIOPULMONARY BYPASS 

W/PROSTH $1,813.38 20060701 99999999 

33427 

VALVULOPLASTY MITRAL VALVE W/CARDIOPULM BYPASS RAD 

RECONSTR $1,953.84 20060701 99999999 

33430 REPLACEMENT, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS $2,030.56 20060701 99999999 

33460 VALVULOPLASTY OR VALVECTOMY, TRICUSPID VALVE, WITH $1,437.01 20060701 99999999 

33463 VALVULOPLASTY, TRICUSPID VALVE; WITHOUT RING INSERTION $1,553.28 20060701 99999999 

33464 VALVULOPLASTY, TRICUSPID VALVE; WITH RING INSERTION $1,650.52 20060701 99999999 

33465 VALVULOPLASTY OR VALVECTOMY, TRICUSPID VALVE, WITH $1,726.50 20060701 99999999 

33468 

TRICUSPID VALVE REPOSITIONING AND PLICATION FOR EBSTEIN 

ANOMALY $1,841.24 20060701 99999999 

33470 VALVOTOMY, PULMONARY VALVE (COMMISSUROTOMY) $1,123.38 20060701 99999999 




33475 REPLACEMENT, PULMONARY VALVE $1,728.81 20060701 99999999 

33476 RIGHT VENTRICULAR RESECTION FOR INFUNDIBULAR $1,468.53 20060701 99999999 

33478 OUTFLOW TRACT AUGMENTATION (GUSSET), WITH OR $1,650.24 20060701 99999999 

33496 

REPAIR OF NON-STRUCTURAL PROSTHETIC VALVE DYSFUNCTION 

WITH CARDIOPULMONARY BYPAS $1,680.98 20060701 99999999 

33500 

REPAIR CORONARY ARTERIOVENOUS OR ARTERIOCARDIC CHAMBER 

FISTU $1,536.67 20060701 99999999 

33501 

REPAIR OF CORONARY ARTERIOVENOUS OR ARTERIOCARDIAC 

CHAMBER FISTULA; WITHOUT CARD $996.55 20060701 99999999 

33502 ANOMALOUS CORONARY ARTERY $1,253.87 20060701 99999999 



33505 

REPAIR OF ANOMALOUS CORONARY ARTERY; WITH CONSTRUCTION 

OF INTRAPULMONARY ARTERY $1,567.45 20060701 99999999 

33506 

REPAIR OF ANOMALOUS CORONARY ARTERY; BY TRANSLOCATION 

FROM PULMONARY ARTERY TO A $1,587.18 20060701 99999999 

33507 

REPAIR OF ANOMALOUS (EG, INTRAMURAL) AORTIC ORIGIN OF 

CORONARY ARTERY BY UNROOFI $1,230.45 20060701 99999999 

33508 

ENDOSCOPY, SURGICAL, INCLUDING VIDEO-ASSISTED HARVEST OF 

VEIN(S) FOR CORONARY AR $12.12 20060701 99999999 

33510 

CORONARY ARTERY BYPASS, AUTOGENOUS GRAFT, (EG, 

SAPHENOUS $1,525.90 20060701 99999999 

33511 


SAPHENOUS $1,649.30 20060701 99999999 



33512 


SAPHENOUS $1,769.08 20060701 99999999 

33513 


SAPHENOUS $1,898.24 20060701 99999999 

33514 


SAPHENOUS $2,005.59 20060701 99999999 

33516 


SAPHENOUS $2,124.45 20060701 99999999 

33517 

CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND 

ARTERIAL GRAFT(S); SINGLE VEIN $137.41 20060701 99999999 

33518 


ARTERIAL GRAFT(S); TWO VENOUS $259.37 20060701 99999999 

33519 


ARTERIAL GRAFT(S); THREE VENOU $380.67 20060701 99999999 

33521 


ARTERIAL GRAFT(S); FOUR VENOUS $503.04 20060701 99999999 

33522 


ARTERIAL GRAFT(S); FIVE VENOUS $624.95 20060701 99999999 

33523 


ARTERIAL GRAFT(S); SIX OR MORE $745.59 20060701 99999999 

33530 

REOPERATION, CORONARY ARTERY BYPASS PROCEDURE, MORE 

THAN ONE MONTH AFTER ORIGINA $313.28 20060701 99999999 

33533 

CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); SINGLE 

ARTERIAL GRAFT $1,847.57 20060701 99999999 

33534 

CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); TWO 

CORONARY ARTERIAL GRAFTS $1,718.37 20060701 99999999 

33535 

CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); THREE 

CORONARY ARTERIAL GRAFTS $1,875.81 20060701 99999999 

33536 

CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); FOUR OR 

MORE CORONARY ARTERIAL $2,031.76 20060701 99999999 

33542 MYOCARDIAL RESECTION (EG, VENTRICULAR ANEURYSMECTOMY) $1,745.50 20060701 99999999 

33545 REPAIR OF POSTINFARCTION VENTRICULAR SEPTAL DEFECT, $2,095.06 20060701 99999999 

33548 

SURGICAL VENTRICULAR RESTORATION PROCEDURE, INCLUDES 

PROSTHETIC PATCH, WHEN PERF $1,622.39 20060701 99999999 

33572 

CORONARY ENDARTERECTOMY, OPEN, ANY METHOD, OF LEFT 

ANTERIOR DESCENDING, CIRCUMFL $215.55 20060701 99999999 

33600 

CLOSURE OF ATRIOVENTRICULAR VALVE (MITRAL OR TRICUSPID) BY 

SUTURE OR PATCH $1,714.17 20060701 99999999 

33602 

CLOSURE OF SEMILUNAR VALVE (AORTIC OR PULMONARY) BY 

SUTURE OR PATCH $1,655.27 20060701 99999999 

33606 

ANASTOMOSIS OF PULMONARY ARTERY TO AORTA (DAMUS-KAYE- 

STANSEL PROCEDURE) $1,832.63 20060701 99999999 

33608 

REPAIR OF COMPLEX CARDIAC ANOMALY OTHER THAN PULMONARY 

ATRESIA WITH VENTRICULAR $1,906.45 20060701 99999999 

33610 

REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, SINGLE VENTRICLE 

WITH SUBAORTIC OBSTRUC $1,863.63 20060701 99999999 

33611 

REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH 

INTRAVENTRICULAR TUNNEL REPAIR; $1,931.64 20060701 99999999 

33612 

REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH 

INTRAVENTRICULAR TUNNEL REPAIR; WIT $2,044.74 20060701 99999999 

33615 

REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, TRICUSPID ATRESIA) 

BY CLOSURE OF ATRIAL $1,973.80 20060701 99999999 

33617 

REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, SINGLE VENTRICLE) 

BY MODIFIED FONTAN PR $2,124.67 20060701 99999999 

33619 

REPAIR OF SINGLE VENTRICLE WITH AORTIC OUTFLOW 

OBSTRUCTION AND AORTIC ARCH HYPOP $2,393.57 20060701 99999999 

33641 REPAIR ATRIAL SEPTAL DEFECT, SECUNDUM $1,283.21 20060701 99999999 

33645 DIRECT OR PATCH CLOSURE, SINUS VENOSUS, WITH OR $1,525.81 20060701 99999999 



33647 

REPAIR OF ATRIAL SEPTAL DEFECT AND VENTRICULAR SEPTAL 

DEFECT, $1,769.42 20060701 99999999 

33660 PATCH CLOSURE, ENDOCARDIAL CUSHION DEFECT, WITH OR $1,588.62 20060701 99999999 

33665 PATCH CLOSURE, ENDOCARDIAL CUSHION DEFECT, WITH OR $1,750.26 20060701 99999999 

33670 REPAIR OF COMPLETE ATRIOVENTRICULAR CANAL, WITH $1,818.87 20060701 99999999 

33675 CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; $1,489.58 20070101 99999999 

33676 

CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; WITH 

PULMONARY VALVOTOMY OR INFU $1,534.13 20070101 99999999 

33677 

CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; WITH 

REMOVAL OF PULMONARY ARTERY $1,594.33 20070101 99999999 

33681 CLOSURE VENTRICULAR SEPTAL DEFECT $1,726.34 20060701 99999999 



33690 BANDING OF PULMONARY ARTERY $1,225.68 20060701 99999999 

33692 TOTAL REPAIR TETRALOGY OF FALLOT $1,820.78 20060701 99999999 

33694 TOTAL REPAIR TETRALOGY OF FALLOT $1,849.26 20060701 99999999 

33697 

COMPLETE REPAIR TETRALOGY OF FALLOT WITH PULMONARY 

ATRESIA INCLUDING CONSTRUCTIO $1,979.80 20060701 99999999 

33702 REPAIR SINUS OF VALSALVA FISTULA, WITH $1,647.23 20060701 99999999 

33710 REPAIR SINUS OF VALSALVA FISTULA, WITH $1,765.77 20060701 99999999 

33720 REPAIR SINUS OF VALSALVA ANEURYSM, WITH $1,626.27 20060701 99999999 

33722 CLOSURE OF AORTICO-LEFT VENTRICULAR TUNNEL $1,702.46 20060701 99999999 

33724 

REPAIR OF ISOLATED PARTIAL ANOMALOUS PULMONARY VENOUS 

RETURN (EG, SCIMITAR SYNDR $1,055.96 20070101 99999999 

33726 REPAIR OF PULMONARY VENOUS STENOSIS $1,390.51 20070101 99999999 

33730 COMPLETE REPAIR OF ANOMALOUS VENOUS RETURN $1,794.03 20060701 99999999 

33732 

REPAIR OF COR TRIATRIATUM OR SUPRAVALVULAR MITRAL RING BY 

RESECTION OF LEFT ATRI $1,697.63 20060701 99999999 

33735 ATRIAL SEPTECTOMY OR SEPTOSTOMY $1,246.81 20060701 99999999 

33736 

ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HEART WITH 

CARDIOPULMONARY BYPASS $1,477.64 20060701 99999999 

33737 ATRIAL SEPTECTOMY OR SEPTOSTOMY $1,289.88 20060701 99999999 

33750 SHUNT $1,209.87 20060701 99999999 

33755 SHUNT $1,183.11 20060701 99999999 

33762 SHUNT $1,222.85 20060701 99999999 

33764 SHUNT $1,224.42 20060701 99999999 

33766 SHUNT $1,372.33 20060701 99999999 

33767 

SHUNT; SUPERIOR VENA CAVA TO PULMONARY ARTERY FOR FLOW 

TO BOTH LUNGS (BIDIRECTIO $1,399.73 20060701 99999999 

33768 

ANASTOMOSIS, CAVOPULMONARY, SECOND SUPERIOR VENA CAVA 

(LIST SEPARATELY IN ADDITI $302.83 20060701 99999999 

33770 

REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES WITH 

VENTRICULAR SEPTAL DEFECT AND $1,914.82 20060701 99999999 

33771 

REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES WITH 

VENTRICULAR SEPTAL DEFECT AND $1,886.31 20060701 99999999 

33774 RPR TRANSPSTN GRT VESSLS ARTRL BAFFE PROC;W/BYPASS $1,742.27 20060701 99999999 

33775 RPR TRNSPSTN GRT VSSLS MUSTRD TYPE;W/RMVL BND $1,707.99 20060701 99999999 

33776 RPR TRNSPSTN GRT VSSLS MSTED TYPE;W/CLSR SPTL DFCT $1,832.83 20060701 99999999 

33777 

REPAIR TRANSPOSITION OF GRT ARTERIES ATRIAL BAFFLE PROC 

W/CA $1,751.14 20060701 99999999 

33778 RPR TRANS; AORTIC PULM ART RECONST $2,074.92 20060701 99999999 

33779 

REPAIR TRANSPOSITION OF GRT ARTERIES AORTIC PULMONARY 

ARTERY $2,006.94 20060701 99999999 

33780 


ARTERY $2,080.11 20060701 99999999 

33781 


ARTERY $1,970.50 20060701 99999999 



33786 TOTAL REPAIR, TRUNCUS ARTERIOSUS (RASTELLI TYPE OPERATION) $1,917.76 20060701 99999999 

33788 REPLANT PULMONARY ARTERY FOR HEMITRUNCUS $1,478.20 20060701 99999999 

33800 

AORTIC SUSPENSION (AORTOPEXY) FOR TRACHEAL 

DECOMPRESSION (EG, FOR TRACHEOMALACIA $991.04 20060701 99999999 

33802 DIVISION OF ABERRANT VESSEL (VASCULAR RING) $1,105.90 20060701 99999999 

33803 DIVISION OF ABERRANT VESSEL (VASCULAR RING) $1,128.00 20060701 99999999 

33813 

OBLITERATION AORTOPULMONARY SEPTAL DEFECT W/O 

CARDIOPULM BYP $1,252.92 20060701 99999999 

33814 OBLIT AORTOPULM SEPTAL DEFECT W/CARDIOPULM BYPASS $1,587.67 20060701 99999999 

33820 PATENT DUCTUS ARTERIOSUS $1,036.76 20060701 99999999 



33840 

EXCISION OF COARCTATION OF AORTA, WITH OR WITHOUT 

ASSOCIATED $1,282.33 20060701 99999999 

33845 


ASSOCIATED $1,382.19 20060701 99999999 

33851 


ASSOCIATED $1,350.69 20060701 99999999 

33852 

EXC COARCTATION OF AORTA W/WO ASSOCIATED PATENT DUCTUS 

ARTER $1,443.82 20060701 99999999 

33853 

REPAIR OF HYPOPLASTIC OR INTERRUPTED AORTIC ARCH USING 

AUTOGENOUS OR PROSTHETIC $1,963.33 20060701 99999999 

33860 ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, $1,964.91 20060701 99999999 

33861 

ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, WITH 

OR WITHOUT VALVE SUSPEN $1,979.23 20060701 99999999 

33863 

ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, WITH 

OR WITHOUT VALVE SUSPEN $2,049.34 20060701 99999999 

33864 

ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS WITH 

VALVE SUSPENSION, WITH C $1,647.47 20080101 99999999 

33870 TRANSVERSE ARCH GRAFT, WITH CARDIOPULMONARY BYPASS $2,349.71 20060701 99999999 

33875 DESCENDING THORACIC AORTA GRAFT, WITH OR WITHOUT BYPASS $1,851.62 20060701 99999999 

33877 

REPAIR THORACOABDOMINAL AORTIC ANEURYSM W/GRAFT W/WO 

CARDIOP $2,429.32 20060701 99999999 

33880 

ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (EG, 

ANEURYSM, PSEUDOANEURYSM, $1,275.48 20060701 99999999 

33881 

ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (EG, 

ANEURYSM, PSEUDOANEURYSM, $1,096.96 20060701 99999999 

33883 

PLACEMENT OF PROXIMAL EXTENSION PROSTHESIS FOR 

ENDOVASCULAR REPAIR OF DESCENDING $810.68 20060701 99999999 

33884 

PLACEMENT OF PROXIMAL EXTENSION PROSTHESIS FOR 

ENDOVASCULAR REPAIR OF DESCENDING $298.70 20060701 99999999 

33886 

PLACEMENT OF DISTAL EXTENSION PROSTHESIS(S) DELAYED AFTER 

ENDOVASCULAR REPAIR OF $701.04 20060701 99999999 

33889 

OPEN SUBCLAVIAN TO CAROTID ARTERY TRANSPOSITION 

PERFORMED IN CONJUNCTION WITH EN $595.15 20060701 99999999 

33891 

BYPASS GRAFT, WITH OTHER THAN VEIN, TRANSCERVICAL 

RETROPHARYNGEAL CAROTID-CAROTI $760.49 20060701 99999999 

33910 PULMONARY ARTERY EMBOLECTOMY $1,269.60 20060701 99999999 

33915 PULMONARY ARTERY EMBOLECTOMY $1,009.35 20060701 99999999 

33916 

PULM ENDARTERECTOMY W/WO EMBOLECTOMY W/CARDIOPULM 

BYPASS $1,339.99 20060701 99999999 

33917 

REPAIR OF PULMONARY ARTERY STENOSIS BY RECONSTRUCTION 

WITH PATCH OR GRAFT $1,522.81 20060701 99999999 

33918 

REPAIR OF PULMONARY ATRESIA WITH VENTRICULAR SEPTAL 

DEFECT, BY UNIFOCALIZATION O $1,512.96 19990701 99999999 

33919 


DEFECT, BY UNIFOCALIZATION O $1,849.59 19990701 99999999 



33920 


DEFECT, BY CONSTRUCTION OR R $1,907.94 20060701 99999999 

33922 

TRANSECTION OF PULMONARY ARTERY WITH CARDIOPULMONARY 

BYPASS $1,421.98 20060701 99999999 

33924 

LIGATION AND TAKEDOWN OF A SYSTEMIC-TO-PULMONARY ARTERY 

SHUNT, PERFORMED IN CONJ $266.67 20060701 99999999 

33925 

REPAIR OF PULMONARY ARTERY ARBORIZATION ANOMALIES BY 

UNIFOCALIZATION; WITHOUT CA $1,257.56 20060701 99999999 

33926 

REPAIR OF PULMONARY ARTERY ARBORIZATION ANOMALIES BY 

UNIFOCALIZATION; WITH CARDI $1,693.36 20060701 99999999 

33935 

HEART-LUNG TRANSPLANT WITH RECIPIENT CARDIECTOMY- 

PNEUMONECTOMY $3,491.81 20060701 99999999 

33945 HEART TRANSPLANT, WITH OR WITHOUT RECIPIENT CARDIECTOMY $2,463.46 20060701 99999999 

33960 PROLONGED EXTRACORPOREAL CIRCULATION FOR $761.08 20060701 99999999 

33961 

PROLONGED EXTRACORPOREAL CIRCULATION FOR 

CARDIOPULMONARY INSUFFICIENCY; EACH ADD $505.50 20060701 99999999 

33967 

INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE, 

PERCUTANEOUS $190.78 20060701 99999999 

33968 

REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE, 

PERCUTANEOUS $31.43 20060701 99999999 

33970 INTRA-AORTIC BALLOON COUNTERPULSATION $361.17 20060701 99999999 

33971 INTRA-AORTIC BALLOON COUNTERPULSATION $531.88 20060701 99999999 

33973 

INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE THROUGH 

THE ASCENDING AORTA $480.21 20060701 99999999 

33974 

REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE FROM THE 

ASCENDING AORTA, INCLUDIN $725.10 20060701 99999999 

33975 

IMPLANTATION OF VENTRICULAR ASSIST DEVICE; SINGLE VENTRICLE 

SUPPORT $1,082.61 20060701 99999999 

33976 

IMPLANTATION OF VENTRICULAR ASSIST DEVICE; BIVENTRICULAR 

SUPPORT $1,231.77 20060701 99999999 

33977 

REMOVAL OF VENTRICULAR ASSIST DEVICE; SINGLE VENTRICLE 

SUPPORT $996.64 20060701 99999999 

33978 

REMOVAL OF VENTRICULAR ASSIST DEVICE; BIVENTRICULAR 

SUPPORT $1,119.97 20060701 99999999 

33979 

INSERTION OF VENTRICULAR ASSIST DEVICE, IMPLANTABLE 

INTRACORPOREAL, SINGLE VENTR $1,553.95 20060701 99999999 

33980 

REMOVAL OF VENTRICULAR ASSIST DEVICE, IMPLANTABLE 

INTRACORPOREAL, SINGLE VENTRIC $2,078.71 20060701 99999999 

33999 UNLISTED PROCEDURE, CARDIAC SURGERY $971.74 19990701 99999999 

34001 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER $644.59 20060701 99999999 







34401 THROMBECTOMY, DIRECT OR WITH CATHETER $896.66 20060701 99999999 





34501 VALVULOPLASTY, FEMORAL VEIN $622.73 20060701 99999999 

34502 RECONSTRUCTION OF VENA CAVA, ANY METHOD $1,299.23 20060701 99999999 

34510 VENOUS VALVE TRANSPOSITION, ANY VEIN DONOR $713.05 20060701 99999999 

34520 CROSS-OVER VEIN GRAFT TO VENOUS SYSTEM $686.53 20060701 99999999 

34530 SAPHENOPOPLITEAL VEIN ANASTOMOSIS $871.62 20060701 99999999 

34800 

ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC 

ANEURYSM OR DISSECTION; USING $858.38 20060701 99999999 



34802 



34803 


ANEURYSM OR DISSECTION; $1,010.43 20060701 99999999 

34804 



34805 



34806 

TRANSCATHETER PLACEMENT OF WIRELESS PHYSIOLOGIC SENSOR 

IN ANEURYSMAL SAC DURING $53.30 20080101 99999999 

34808 

ENDOVASCULAR PLACEMENT OF ILIAC ARTERY OCCLUSION DEVICE 

(LIST SEPARATELY IN ADDI $161.96 20060701 99999999 

34812 

OPEN FEMORAL ARTERY EXPOSURE FOR DELIVERY OF AORTIC 

ENDOVASCULAR PROSTHESIS, BY $264.86 20060701 99999999 

34813 

PLACEMENT OF FEMORAL-FEMORAL PROSTHETIC GRAFT DURING 

ENDOVASCULAR AORTIC ANEURYS $188.37 20060701 99999999 

34820 

OPEN ILIAC ARTERY EXPOSURE FOR DELIVERY OF ENDOVASCULAR 

PROSTHESIS OR ILIAC OCCL $382.53 20060701 99999999 

34825 

PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR 


34826 

PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR 


34830 

OPEN REPAIR OF INFRARENAL AORTIC ANEURYSM OR DISSECTION, 

PLUS REPAIR OF ASSOCIAT $1,333.93 20060701 99999999 

34831 



34832 



34833 

OPEN ILIAC ARTERY EXPOSURE WITH CREATION OF CONDUIT FOR 

DELIVERY OF INFRARENAL A $480.59 20060701 99999999 

34834 

OPEN BRACHIAL ARTERY EXPOSURE TO ASSIST IN THE DEPLOYMENT 

OF INFRARENAL AORTIC O $225.93 20060701 99999999 

34900 

ENDOVASCULAR GRAFT REPLACEMENT FOR REPAIR OF ILIAC 

ARTERY (EG, ANEURYSM, PSEUDOA $710.75 20060701 99999999 

35001 

DIRECT REPAIR OF ANEURYSM OR EXCISION (PARTIAL OR TOTAL) 

AND $997.73 20060701 99999999 

35002 


AND $979.73 20060701 99999999 

35005 


AND $801.65 20060701 99999999 

35011 


AND $658.96 20060701 99999999 

35013 


AND $878.57 20060701 99999999 

35021 


AND $1,048.44 20060701 99999999 

35022 


AND $1,068.71 20060701 99999999 

35045 


AND $642.60 20060701 99999999 

35081 


AND $1,385.32 20060701 99999999 

35082 


AND $1,683.86 20060701 99999999 

35091 


AND $1,668.63 20060701 99999999 

35092 


AND $1,821.56 20060701 99999999 



35102 


AND $1,490.48 20060701 99999999 

35103 


AND $1,646.84 20060701 99999999 

35111 


AND $899.67 20060701 99999999 

35112 


AND $1,061.59 20060701 99999999 

35121 


AND $1,272.25 20060701 99999999 

35122 


AND $1,502.69 20060701 99999999 

35131 


AND $955.64 20060701 99999999 

35132 


AND $1,112.39 20060701 99999999 

35141 


AND $791.31 20060701 99999999 

35142 


AND $860.05 20060701 99999999 

35151 


AND $890.44 20060701 99999999 

35152 


AND $938.04 20060701 99999999 

35161 


AND $969.65 19990701 99999999 

35162 


AND $1,047.52 19990701 99999999 

35180 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA $631.32 20060701 99999999 

35182 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA $1,087.90 20060701 99999999 

35184 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA $666.43 20060701 99999999 

35188 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA $662.64 20060701 99999999 

35189 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA $1,014.35 20060701 99999999 

35190 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA $650.22 20060701 99999999 

35201 REPAIR BLOOD VESSEL, DIRECT $613.12 20060701 99999999 



35211 REPAIR BLOOD VESSEL, DIRECT $1,173.77 20060701 99999999 




35231 REPAIR BLOOD VESSEL WITH VEIN GRAFT $756.07 20060701 99999999 


35241 REPAIR BLOOD VESSEL WITH VEIN GRAFT $1,235.43 20060701 99999999 




35261 REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN $656.24 20060701 99999999 


35271 REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN $1,159.80 20060701 99999999 


35281 REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN $1,007.31 20060701 99999999 


35301 THROMBOENDARTERECTOMY, WITH OR WITHOUT PATCH GRAFT $948.13 20060701 99999999 

35302 

THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF 

PERFORMED; SUPERFICIAL FEMORAL $783.06 20070101 99999999 

35303 


PERFORMED; POPLITEAL ARTERY $859.88 20070101 99999999 



35304 


PERFORMED; TIBIOPERONEAL TRUNK $894.39 20070101 99999999 

35305 


PERFORMED; TIBIAL OR PERONEAL A $859.88 20070101 99999999 

35306 


PERFORMED; EACH ADDITIONAL TIBI $320.07 20070101 99999999 

35311 THROMBOENDARTERECTOMY, WITH OR WITHOUT PATCH GRAFT $1,281.64 20060701 99999999 











35390 

REOPERATION, CAROTID, THROMBOENDARTERECTOMY, MORE THAN 

ONE MONTH AFTER ORIGINAL $141.70 20060701 99999999 

35400 

ANGIOSCOPY (NON-CORONARY VESSELS OR GRAFTS) DURING 

THERAPEUTIC INTERVENTION (LIS $142.16 20060701 99999999 

35450 

TRANSLUMINAL ANGIOPLASTY, INTRAOPERATIVE (SEPARATE 

PROCEDURE) $551.33 20060701 99999999 

35452 


PROCEDURE) $328.35 20060701 99999999 

35454 


PROCEDURE) $334.88 20060701 99999999 

35456 


PROCEDURE) $406.43 20060701 99999999 

35458 


PROCEDURE) $516.66 20060701 99999999 

35459 

TRANSLUMINAL ANGIOPLASTY, OPEN; TIBIOPERONEAL TRUNK AND 

BRANCHES $473.36 20060701 99999999 

35460 TRANSLUMINAL ANGIOPLASTY, OPEN; VENOUS $271.37 20060701 99999999 

35470 

TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; TIBIOPERONEAL 

TRUNK AND BRANCHES $460.89 20060701 99999999 

35471 

TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; RENAL OR 

VISCERAL ARTERY $537.85 20060701 99999999 

35472 TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; AORTIC $303.22 20060701 99999999 

35473 TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; ILIAC $322.34 20060701 99999999 

35474 

TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; FEMORAL- 

POPLITEAL $391.90 20060701 99999999 

35475 TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; BRACHIOCEPHALIC $488.29 20060701 99999999 

35476 TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; VENOUS $255.57 20060701 99999999 

35480 

TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; RENAL OR 

OTHER VISCERAL ARTERY $601.35 20060701 99999999 

35481 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; AORTIC $357.89 20060701 99999999 

35482 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; ILIAC $371.40 20060701 99999999 

35483 

TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; FEMORAL- 

POPLITEAL $447.95 20060701 99999999 

35484 

TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; 

BRACHIOCEPHALIC $547.08 20060701 99999999 

35485 

TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; TIBIOPERONEAL 

TRUNK AND BRANCHES $421.74 20060701 99999999 

35490 

TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; 

RENAL OR OTHER VISCERAL ARTER $592.78 20060701 99999999 




35491 AORTIC $341.52 20060701 99999999 

35492 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; ILIAC $363.09 20060701 99999999 

35493 


FEMORAL-POPLITEAL $448.99 20060701 99999999 

35494 


BRACHIOCEPHALIC $517.39 20060701 99999999 

35495 


TIBIOPERONEAL TRUNK AND BRANC $426.15 20060701 99999999 

35500 

HARVEST OF UPPER EXTREMITY VEIN, ONE SEGMENT, FOR LOWER 

EXTREMITY BYPASS PROCEDU $247.21 20060701 99999999 

35501 BYPASS GRAFT, WITH VEIN $1,004.08 20060701 99999999 




35509 BYPASS GRAFT, WITH VEIN $982.25 20060701 99999999 

35510 BYPASS GRAFT, WITH VEIN; CAROTID-BRACHIAL $820.97 20060701 99999999 


35512 BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-BRACHIAL $952.34 20060701 99999999 





35522 BYPASS GRAFT, WITH VEIN; AXILLARY-BRACHIAL $924.60 20060701 99999999 

35523 BYPASS GRAFT, WITH VEIN; BRACHIAL-ULNAR OR -RADIAL $378.03 20080101 99999999 

35525 BYPASS GRAFT, WITH VEIN; BRACHIAL-BRACHIAL $882.43 20060701 99999999 





35537 BYPASS GRAFT, WITH VEIN; AORTOILIAC $1,510.87 20070101 99999999 

35538 BYPASS GRAFT, WITH VEIN; AORTOBI-ILIAC $1,687.18 20070101 99999999 

35539 BYPASS GRAFT, WITH VEIN; AORTOFEMORAL $1,585.78 20070101 99999999 

35540 BYPASS GRAFT, WITH VEIN; AORTOBIFEMORAL $1,766.72 20070101 99999999 













35572 

HARVEST OF FEMOROPOPLITEAL VEIN, ONE SEGMENT, FOR 

VASCULAR RECONSTRUCTION PROCED $270.51 20060701 99999999 

35582 IN-SITU VEIN BYPASS $1,383.71 19990701 99999999 




35600 

HARVEST OF UPPER EXTREMITY ARTERY, ONE SEGMENT, FOR 

CORONARY ARTERY BYPASS PROCE $199.67 20060701 99999999 

35601 BYPASS GRAFT, WITH OTHER THAN VEIN $961.32 20060701 99999999 







35623 

BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-POPLITEAL OR - 

TIBIAL $876.06 20060701 99999999 

35626 BYPASS GRAFT, WITH OTHER THAN VEIN $1,228.67 20060701 99999999 









35647 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOFEMORAL $1,143.03 20060701 99999999 










35681 BYPASS GRAFT, COMPOSITE $85.96 20060701 99999999 

35682 

BYPASS GRAFT; AUTOGENOUS COMPOSITE, TWO SEGMENTS OF 

VEINS FROM TWO LOCATIONS (LI $387.04 20060701 99999999 

35683 

BYPASS GRAFT; AUTOGENOUS COMPOSITE, THREE OR MORE 

SEGMENTS OF VEIN FROM TWO OR M $450.18 20060701 99999999 

35685 

PLACEMENT OF VEIN PATCH OR CUFF AT DISTAL ANASTOMOSIS OF 

BYPASS GRAFT, SYNTHETIC $158.10 20060701 99999999 

35686 

CREATION OF DISTAL ARTERIOVENOUS FISTULA DURING LOWER 

EXTREMITY BYPASS SURGERY ( $130.77 20060701 99999999 

35691 

TRANSPOSITION AND/OR REIMPLANTATION; VERTEBRAL TO CAROTID 

ARTERY $993.84 20060701 99999999 

35693 

TRANSPOSITION AND/OR REIMPLANTATION; VERTEBRAL TO 

SUBCLAVIAN ARTERY $721.41 20060701 99999999 

35694 

TRANSPOSITION AND/OR REIMPLANTATION; SUBCLAVIAN TO CAROTID 

ARTERY $851.46 20060701 99999999 

35695 

TRANSPOSITION AND/OR REIMPLANTATION; CAROTID TO SUBCLAVIAN 

ARTERY $851.24 20060701 99999999 

35697 

REIMPLANTATION, VISCERAL ARTERY TO INFRARENAL AORTIC 

PROSTHESIS, EACH ARTERY (LI $120.78 20060701 99999999 

35700 

REOPERATION, FEMORAL-POPLITEAL OR FEMORAL (POPLITEAL) - 

ANTERIOR TIBIAL, POSTERIO $165.56 20060701 99999999 

35701 EXPLORATION $344.74 20060701 99999999 

35721 EXPLORATION $325.09 20060701 99999999 

35741 EXPLORATION $323.72 20060701 99999999 

35761 EXPLORATION $324.09 20060701 99999999 

35800 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE OR $362.49 20060701 99999999 




35870 REPAIR OF GRAFT-ENTERIC FISTULA $998.08 20060701 99999999 

35875 THROMBECTOMY AND/OR REPAIR OF ARTERIAL OR VENOUS GRAFT $530.37 20060701 99999999 

35876 

THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; WITH REVISION 

OF ARTERIAL OR VENOUS GR $778.71 20060701 99999999 

35879 

REVISION, LOWER EXTREMITY ARTERIAL BYPASS, WITHOUT 

THROMBECTOMY, OPEN; WITH VEIN $734.33 20060701 99999999 



35881 

REVISION, LOWER EXTREMITY ARTERIAL BYPASS, WITHOUT 

THROMBECTOMY, OPEN; WITH SEGM $802.65 20060701 99999999 

35883 

REVISION, FEMORAL ANASTOMOSIS OF SYNTHETIC ARTERIAL 

BYPASS GRAFT IN GROIN, OPEN; $884.37 20070101 99999999 

35884 

REVISION, FEMORAL ANASTOMOSIS OF SYNTHETIC ARTERIAL 

BYPASS GRAFT IN GROIN, OPEN; $938.83 20070101 99999999 

35901 EXCISION OF INFECTED GRAFT; NECK $456.61 20060701 99999999 

35903 EXCISION OF INFECTED GRAFT; EXTREMITY $527.44 20060701 99999999 

35905 EXCISION OF INFECTED GRAFT; THORAX $1,127.54 20060701 99999999 

35907 EXCISION OF INFECTED GRAFT; ABDOMEN $1,246.73 20060701 99999999 

36000 INTRODUCTION OF NEEDLE OR INTRACATHETER, VEIN $7.48 20060701 99999999 

36002 

INJECTION PROCEDURES (EG, THROMBIN) FOR PERCUTANEOUS 

TREATMENT OF EXTREMITY PSEU $116.30 20060701 99999999 

36005 

INJECTION PROCEDURE FOR CONTRAST VENOGRAPHY (INCLUDING 

INTRODUCTION OF NEEDLE OR $38.41 20060701 99999999 

36010 INTRODUCTION OF CATHETER $115.98 20060701 99999999 

36011 

SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER 

BRANCH (EG, RENAL VEIN, $135.35 20060701 99999999 

36012 

SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND 

ORDER, OR MORE SELECTIVE, BR $157.51 20060701 99999999 

36013 

INTRODUCTION OF CATHETER, RIGHT HEART OR MAIN PULMONARY 

ARTERY $119.61 20060701 99999999 

36014 

SELECTIVE CATHETER PLACEMENT, LEFT OR RIGHT PULMONARY 

ARTERY $134.86 20060701 99999999 

36015 

SELECTIVE CATHETER PLACEMENT, EACH SEGMENTAL OR 

SUBSEGMENTAL PULMONARY ARTERY $157.82 20060701 99999999 

36100 INTRODUCTION OF NEEDLE OR INTRACATHETER, CAROTID OR $149.56 20060701 99999999 

36120 INTRODUCTION OF NEEDLE OR INTRACATHETER $103.31 20060701 99999999 



36160 

INTRODUCTION OF NEEDLE OR INTRACATHETER, AORTIC, 

TRANSLUMBAR $125.41 20060701 99999999 

36200 INTRODUCTION OF CATHETER, $143.67 20060701 99999999 


36216 

SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL 

SECOND ORDER THORACIC OR $225.04 20060701 99999999 

36217 

SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD 

ORDER OR MORE SELEC $271.17 20060701 99999999 

36218 

SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL 

SECOND ORDER, THIRD OR $43.98 20060701 99999999 


36246 

SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL 

SECOND ORDER ABDOMINAL, P $228.92 20060701 99999999 

36247 

SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD 

ORDER OR MORE SELEC $270.60 20060701 99999999 

36248 

SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL 

SECOND ORDER, THIRD OR $44.55 20060701 99999999 

36260 INSERTION OF IMPLANTABLE INTRA-ARTERIAL INFUSION PUMP $478.13 20060701 99999999 

36261 REVISION OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP $244.97 20060701 99999999 

36262 REMOVAL OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP $188.11 20060701 99999999 

36299 UNLISTED PROCEDURE, VASCULAR INJECTION $343.20 19990701 99999999 

36400 VENIPUNCTURE, UNDER AGE 3 YEARS $11.50 20060701 99999999 



36410 

VENIPUNCTURE, CHILD OVER AGE 3 YEARS OR ADULT, 

NECESSITATING $7.48 20060701 99999999 

36415 ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S) $3.00 20060701 99999999 

36420 VENIPUNCTURE, CUTDOWN $42.81 20060701 99999999 



36425 VENIPUNCTURE, CUTDOWN $38.50 20060701 99999999 

36430 TRANSFUSION, BLOOD OR BLOOD COMPONENTS $33.38 20060701 99999999 

36440 PUSH TRANSFUSION, BLOOD, 2 YEARS OR UNDER $49.88 20060701 99999999 

36450 EXCHANGE TRANSFUSION, BLOOD $105.23 20060701 99999999 

36455 EXCHANGE TRANSFUSION, BLOOD $120.47 20060701 99999999 

36460 TRANSFUSION, INTRAUTERINE, FETAL $304.16 20060701 99999999 

36470 INJECTION OF SCLEROSING SOLUTION $45.53 20060701 99999999 

36471 INJECTION OF SCLEROSING SOLUTION $63.59 20060701 99999999 

36475 

ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, 

EXTREMITY, INCLUSIVE OF ALL $268.80 20060701 99999999 

36476 



36478 



36479 



36481 PERCUTANEOUS PORTAL VEIN CATHETERIZATION BY ANY METHOD $316.84 20060701 99999999 

36488 

PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, 

JUGULAR, $61.36 19990701 99999999 

36489 


JUGULAR, $58.69 20030401 99999999 

36490 


JUGULAR, $79.33 19990701 99999999 

36491 


JUGULAR, $74.89 19990701 99999999 

36493 

REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS 

CATHETER UNDER FLUOROSCOPIC GU $49.56 19990701 99999999 

36500 

VENOUS CATHETERIZATION FOR SELECTIVE ORGAN BLOOD 

SAMPLING $118.46 20060701 99999999 

36510 CATHETERIZATION OF UMBILICAL VEIN FOR DIAGNOSIS OR THERAPY, $42.29 20060701 99999999 

36511 THERAPEUTIC APHERESIS; FOR WHITE BLOOD CELLS $68.11 20060701 99999999 

36512 THERAPEUTIC APHERESIS; FOR RED BLOOD CELLS $68.11 20060701 99999999 

36513 THERAPEUTIC APHERESIS; FOR PLATELETS $68.11 20060701 99999999 

36514 THERAPEUTIC APHERESIS; FOR PLASMA PHERESIS $68.11 20060701 99999999 

36515 

THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL 

IMMUNOADSORPTION AND PLASMA REINFUSIO $68.11 20060701 99999999 

36516 

THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL SELECTIVE 

ADSORPTION OR SELECTIVE FIL $68.11 20060701 99999999 

36520 THERAPEUTIC APHERESIS (PLASMA AND/OR CELL EXCHANGE) $90.71 19990701 99999999 

36521 

THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL AFFINITY 

COLUMN ADSORPTION AND PLASMA $68.31 20000101 99999999 

36522 PHOTOPHERESIS EXTRACORPOREAL $89.42 20060701 99999999 

36530 INSERTION OF IMPLANTABLE INTRAVENOUS INFUSION PUMP $315.24 19990701 99999999 

36531 REVISION OF IMPLANTABLE INTRAVENOUS INFUSION PUMP $265.19 19990701 99999999 

36532 REMOVAL OF IMPLANTABLE INTRAVENOUS INFUSION PUMP $150.00 19990701 99999999 

36533 

INSERTION OF IMPLANTABLE VENOUS ACCESS PORT, WITH OR 

WITHOUT SUBCUTANEOUS RESERV $276.54 20030401 99999999 

36534 

REVISION OF IMPLANTABLE VENOUS ACCESS PORT AND/OR 

SUBCUTANEOUS RESERVOIR $151.86 19990701 99999999 

36535 

REMOVAL OF IMPLANTABLE VENOUS ACCESS PORT AND/OR 

SUBCUTANEOUS RESERVOIR $125.70 20030401 99999999 

36536 

MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL 

(EG, FIBRIN SHEATH) FROM $143.91 20030401 99999999 

36537 

MECHANICAL REMOVAL OF INTRALUMINAL (INTRACATHETER) 

OBSTRUCTIVE MATERIAL FROM CEN $35.27 20030401 99999999 

36550 

DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR 

ACCESS DEVICE OR CATHETER $23.95 20000101 99999999 



36555 

INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL 

VENOUS CATHETER; UNDER 5 YE $83.45 20060701 99999999 

36556 

INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL 

VENOUS CATHETER; AGE 5 YEAR $79.28 20060701 99999999 

36557 

INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS 

CATHETER, WITHOUT SUBCUT $227.75 20060701 99999999 

36558 


CATHETER, WITHOUT SUBCUT $216.36 20060701 99999999 

36560 


ACCESS DEVICE, WITH SUBC $270.15 20060701 99999999 

36561 


ACCESS DEVICE, WITH SUBC $260.70 20060701 99999999 

36563 


ACCESS DEVICE WITH SUBCU $271.38 20060701 99999999 

36565 


ACCESS DEVICE, REQUIRING $260.70 20060701 99999999 

36566 


ACCESS DEVICE, REQUIRING $279.29 20060701 99999999 

36568 

INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS 

CATHETER (PICC), WITHOUT SUBCU $74.05 20060701 99999999 

36569 

INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS 

CATHETER (PICC), WITHOUT SUBCU $69.67 20060701 99999999 

36570 

INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS 

DEVICE, WITH SUBCUTANEO $235.48 20060701 99999999 

36571 

INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS 

DEVICE, WITH SUBCUTANEO $234.64 20060701 99999999 

36575 

REPAIR OF TUNNELED OR NON-TUNNELED CENTRAL VENOUS 

ACCESS CATHETER, WITHOUT SUBCU $36.89 20060701 99999999 

36576 

REPAIR OF CENTRAL VENOUS ACCESS DEVICE, WITH 

SUBCUTANEOUS PORT OR PUMP, CENTRAL $151.90 20060701 99999999 

36578 

REPLACEMENT, CATHETER ONLY, OF CENTRAL VENOUS ACCESS 

DEVICE, WITH SUBCUTANEOUS P $173.25 20060701 99999999 

36580 

REPLACEMENT, COMPLETE, OF A NON-TUNNELED CENTRALLY 

INSERTED CENTRAL VENOUS CATHE $51.12 20060701 99999999 

36581 

REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED 

CENTRAL VENOUS CATHETER, $160.76 20060701 99999999 

36582 


CENTRAL VENOUS ACCESS DE $235.88 20060701 99999999 

36583 


CENTRAL VENOUS ACCESS DE $237.52 20060701 99999999 

36584 

REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL 

VENOUS CATHETER (PICC) $52.10 20060701 99999999 

36585 

REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL 

VENOUS ACCESS DEVICE, $220.90 20060701 99999999 

36589 

REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT 

SUBCUTANEOUS PORT OR PUMP $109.12 20060701 99999999 

36590 

REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH 

SUBCUTANEOUS PORT OR PUMP $147.28 20060701 99999999 

36591 

COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY 

IMPLANTABLE VENOUS ACCESS DEVICE $12.68 20080101 99999999 

36592 

COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR 

PERIPHERAL CATHETER, V $15.71 20080101 99999999 

36593 

DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR 

ACCESS DEVICE OR CATHETER $19.39 20080101 99999999 

36595 



36596 





36597 

REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS 

CATHETER UNDER FLUOROSCOPIC GU $44.70 20060701 99999999 

36598 

CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING 

CENTRAL VENOUS ACCES $93.80 20060701 99999999 

36600 ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS $15.16 20060701 99999999 

36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR $47.24 20060701 99999999 

36625 ARTERIAL CATHETERIZATION OR CANNULATION FOR $82.56 20060701 99999999 

36640 ARTERIAL CATHETERIZATION FOR PROLONGED INFUSION THERAPY $111.18 20060701 99999999 

36660 

CATHETERIZATION, UMBILICAL ARTERY, NEWBORN, FOR DIAGNOSIS 

OR $53.88 20060701 99999999 

36680 PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION $61.78 20060701 99999999 

36800 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE $131.27 20060701 99999999 



36818 

ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC 

VEIN TRANSPOSITION $539.64 20060701 99999999 

36819 

ARTERIOVENOUS ANASTOMOSIS, OPEN; BY BASILIC VEIN 

TRANSPOSITION $614.70 20060701 99999999 


36821 ARTERIOVENOUS ANASTOMOSIS, DIRECT, ANY SITE $556.23 20060701 99999999 

36822 

INSERTION OF CANNULA(S) FOR PROLONGED EXTRACORPOREAL 

CIRCULATION $413.24 20060701 99999999 

36823 

INSERTION OF ARTERIAL AND VENOUS CANNULA(S) FOR ISOLATED 

EXTRACORPOREAL CIRCULAT $904.49 20060701 99999999 

36825 CREATION OF ARTERIOVENOUS FISTULA $560.04 20060701 99999999 

36830 CREATION OF ARTERIOVENOUS FISTULA $718.23 20060701 99999999 

36831 

THROMBECTOMY, ARTERIOVENOUS FISTULA WITHOUT REVISION, 

AUTOGENOUS OR NONAUTOGENOU $417.83 20060701 99999999 

36832 

REVIS OF ARTERIOVENOUS FISTULA W/WO THROMBECTOMY 

AUTOGENOUS $611.77 20060701 99999999 

36833 

REVISION, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, 

AUTOGENOUS OR NONAUTOGENOUS $642.67 20060701 99999999 

36834 

PLASTIC REPAIR OF ARTERIOVENOUS ANEURYSM (SEPARATE 

PROCEDURE) $483.96 20060701 99999999 

36835 INSERTION OF THOMAS SHUNT $344.20 20060701 99999999 

36838 

DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER 

EXTREMITY HEMODIALY $902.28 20060701 99999999 

36860 CANNULA DECLOTTING $109.31 20060701 99999999 

36861 CANNULA DECLOTTING $142.93 20060701 99999999 

36870 

THROMBECTOMY, PERCUTANEOUS, ARTERIOVENOUS FISTULA, 

AUTOGENOUS OR NONAUTOGENOUS G $295.12 20060701 99999999 

37140 ANASTOMOSIS $1,059.21 20060701 99999999 

37145 ANASTOMOSIS $1,108.27 20060701 99999999 

37160 ANASTOMOSIS $1,072.45 20060701 99999999 

37180 ANASTOMOSIS $1,119.18 20060701 99999999 

37181 ANASTOMOSIS $1,217.26 20060701 99999999 

37182 

INSERTION OF TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC 

SHUNT(S) (TIPS) (INCLUDES VE $671.45 20060701 99999999 

37183 

REVISION OF TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC 

SHUNT(S) (TIPS) (INCLUDES VEN $313.63 20060701 99999999 

37184 

PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL 

THROMBECTOMY, NONCORONARY, ARTERIAL $326.07 20060701 99999999 

37185 

PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL 

THROMBECTOMY, NONCORONARY, ARTERIAL $118.97 20060701 99999999 

37186 

SECONDARY PERCUTANEOUS TRANSLUMINAL THROMBECTOMY (EG, 

NONPRIMARY MECHANICAL, SNA $178.40 20060701 99999999 

37187 

PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, 

VEIN(S), INCLUDING INTRAPROCE $303.32 20060701 99999999 



37188 

PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, 

VEIN(S), INCLUDING INTRAPROCE $219.50 20060701 99999999 

37195 THROMBOLYSIS, CEREBRAL, BY INTRAVENOUS INFUSION $265.85 19990701 99999999 

37200 TRANSCATHETER BIOPSY $173.66 20060701 99999999 

37201 

TRANSCATHETER THERAPY, INFUSION FOR THROMBOLYSIS OTHER 

THAN CORONARY $263.51 20060701 99999999 

37202 

TRANSCATHETER THERAPY, INFUSION OTHER THAN FOR 

THROMBOLYSIS, ANY TYPE (EG, SPASM $288.12 20060701 99999999 

37203 

TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR 

FOREIGN BODY (EG, FRACTU $236.55 20060701 99999999 

37204 

TRANSCATHETER OCCLUSION OR EMBOLIZATION (EG, FOR TUMOR 

DESTRUCTION, TO ACHIEVE H $930.12 20060701 99999999 

37205 

TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), 

(NON-CORONARY VESSEL), PER $373.52 20060701 99999999 

37206 



37207 


(NON-CORONARY VESSEL), OPE $388.19 20060701 99999999 

37208 


(NON-CORONARY VESSEL), OPE $188.96 20060701 99999999 

37209 

EXCHANGE OF A PREVIOUSLY PLACED ARTERIAL CATHETER DURING 

THROMBOLYTIC THERAPY $97.11 20060701 99999999 

37210 

UTERINE FIBROID EMBOLIZATION (UFE, EMBOLIZATION OF THE 

UTERINE ARTERIES TO TREAT $359.02 20070101 99999999 

37215 

TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), 

CERVICAL CAROTID ARTERY, $812.13 20060701 99999999 

37216 

TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), 

CERVICAL CAROTID ARTERY, $782.55 20060701 99999999 

37250 

INTRASVASCULAR ULTRASOUND (NON-CORONARY VESSEL) DURING 

THERAPEUTIC INTERVENTION $94.03 20060701 99999999 

37251 

INTRASVASCULAR ULTRASOUND (NON-CORONARY VESSEL) DURING 

THERAPEUTIC INT EACH ADDL $71.82 20060701 99999999 

37500 PHLEBORRHAPHY, SUTURE OF MAJOR VEIN, WOUND OR INJURY $452.48 20060701 99999999 

37565 LIGATION OF INTERNAL JUGULAR VEIN $414.85 20060701 99999999 

37600 LIGATION $450.28 20060701 99999999 

37605 LIGATION $509.97 20060701 99999999 

37606 LIGATION $361.85 20060701 99999999 

37607 LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA $288.88 20060701 99999999 

37609 LIGATION OR BIOPSY, TEMPORAL ARTERY $137.46 20060701 99999999 

37615 LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE) $319.71 20060701 99999999 




37620 INTERRUPTION, PARTIAL OR COMPLETE, OF INFERIOR VENA CAVA BY $523.85 20060701 99999999 

37650 

INTERRUPTION, PARTIAL OR COMPLETE, OF FEMORAL VEIN, BY 

LIGATURE, $314.87 20060701 99999999 

37660 INTERRUPTION, PARTIAL OR COMPLETE, OF COMMON ILIAC VEIN BY $753.71 20060701 99999999 

37700 

LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT 

SAPHENOFEMORAL $217.28 20060701 99999999 

37718 LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN $289.39 20060701 99999999 

37720 

LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR 

SHORT $308.58 19990701 99999999 

37722 

LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS 

VEINS FROM SAPHENOFE $340.04 20060701 99999999 

37730 

LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG AND 

SHORT $401.95 19990701 99999999 



LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR 

37735 SHORT $541.97 20060701 99999999 

37760 LIGATION OF PERFORATORS, SUBFASCIAL, RADICAL (LINTON TYPE), $518.74 20060701 99999999 

37765 

STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; 10-20 

STAB INCISIONS $328.08 20060701 99999999 

37766 

STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; MORE 

THAN 20 INCISIONS $419.22 20060701 99999999 

37780 

LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT 

SAPHENOPOPLITEAL $191.68 20060701 99999999 

37785 LIGATION, DIVISION, AND/OR EXCISION OF SECONDARY VARICOSE $173.26 20060701 99999999 

37788 

PENILE REVASCULARIZATION, ARTERY, WITH OR WITHOUT VEIN 

GRAFT $1,056.31 20060701 99999999 

37790 PENILE VENOUS OCCLUSIVE PROCEDURE $445.13 20060701 99999999 

37799 UNLISTED PROCEDURE, VASCULAR SURGERY $475.92 19990701 99999999 

38100 SPLENECTOMY (SEPARATE PROCEDURE) $618.85 20060701 99999999 

38101 SPLENECTOMY (SEPARATE PROCEDURE) $620.36 20060701 99999999 

38102 

SPLENECTOMY; TOTAL, EN BLOC FOR EXTENSIVE DISEASE, IN 

CONJUNCTION WITH OTHER PRO $209.15 20060701 99999999 

38115 

REPAIR OF RUPTURED SPLEEN (SPLENORRHAPHY) WITH OR 

WITHOUT $645.06 20060701 99999999 

38120 LAPAROSCOPY, SURGICAL, SPLENECTOMY $701.41 20060701 99999999 

38200 INJECTION PROCEDURE FOR SPLENOPORTOGRAPHY $114.26 20060701 99999999 

38205 

BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING 

FOR TRANSPLANTATION, PER $58.87 20060701 99999999 

38206 

BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING 

FOR TRANSPLANTATION, PER $58.87 20060701 99999999 

38220 BONE MARROW ASPIRATION $58.31 20060701 99999999 

38221 BONE MARROW BIOPSY, NEEDLE OR TROCAR $73.80 20060701 99999999 

38230 BONE MARROW HARVESTING FOR TRANSPLANTATION $209.12 20060701 99999999 

38231 

BLOOD-DERIVED PERIPHERAL STEM CELL HARVESTING FOR 

TRANSPLANTATION, PER COLLECTIO $73.72 19990701 99999999 

38240 BONE MARROW TRANSPLANTATION $109.73 20060701 99999999 

38241 BONE MARROW TRANSPLANTATION AUTOLOGOUS $109.48 20060701 99999999 

38242 

BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL 

TRANSPLANTATION; ALLOGENEIC DO $67.10 20060701 99999999 

38300 DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS $102.07 20060701 99999999 

38305 DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS $265.31 20060701 99999999 

38308 

LYMPHANGIOTOMY OR OTHER OPERATIONS ON LYMPHATIC 

CHANNELS $274.83 20060701 99999999 

38380 SUTURE AND/OR LIGATION OF THORACIC DUCT $405.33 20060701 99999999 



38500 BIOPSY OR EXCISION OF LYMPH NODE(S) $147.18 20060701 99999999 






38542 DISSECTION, DEEP JUGULAR NODE(S) $327.74 20060701 99999999 

38550 

EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL, WITHOUT 

DEEP $326.23 20060701 99999999 

38555 

EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL, WITHOUT 

DEEP $715.79 20060701 99999999 

38562 

LIMITED LYMPHADENECTOMY FOR STAGING (SEPARATE 

PROCEDURE) $509.80 20060701 99999999 

38564 

LIMITED LYMPHADENECTOMY FOR STAGING (SEPARATE 

PROCEDURE) $530.25 20060701 99999999 



38570 

LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE 

SAMPLING (BIOPSY), SINGLE $442.74 20060701 99999999 

38571 

LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC 

LYMPHADENECTOMY $573.92 20060701 99999999 

38572 


LYMPHADENECTOMY AND PERI-AORT $667.67 20060701 99999999 

38700 SUPRAHYOID LYMPHADENECTOMY $567.88 20060701 99999999 

38720 CERVICAL LYMPHADENECTOMY (COMPLETE) $868.60 20060701 99999999 

38724 CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK $890.72 20060701 99999999 

38740 AXILLARY LYMPHADENECTOMY $377.81 20060701 99999999 

38745 AXILLARY LYMPHADENECTOMY $497.46 20060701 99999999 

38746 

THORACIC LYMPHADENECTOMY, REGIONAL, INCLUDING MEDIASTINAL 

AND PERITRACHEAL NODES $196.32 20060701 99999999 

38747 

ABDOMINAL LYMPHADENECTOMY, REGIONAL, INCLUDING CELIAC, 

PARA-AORTIC AND VENA CAVA $212.01 20060701 99999999 

38760 INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, $481.70 20060701 99999999 

38765 INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, IN $822.66 20060701 99999999 

38770 PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, $718.11 20060701 99999999 

38780 

RETROPERITONEAL TRANSABDOMINAL LYMPHADENECTOMY, 

EXTENSIVE, $873.58 20060701 99999999 

38790 INJECTION PROCEDURE FOR LYMPHANGIOGRAPHY $67.38 20060701 99999999 

38792 INJECTION PROCEDURE; FOR IDENTIFICATION OF SENTINEL NODE $27.71 20060701 99999999 

38794 CANNULATION, THORACIC DUCT $194.69 20060701 99999999 

38999 UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM $274.25 19990701 99999999 

39000 MEDIASTINOTOMY WITH EXPLORATION, DRAINAGE, OR REMOVAL OF $436.63 20060701 99999999 

39010 MEDIASTINOTOMY WITH EXPLORATION, DRAINAGE, OR REMOVAL OF $746.97 20060701 99999999 

39200 EXCISION OF MEDIASTINAL CYST $808.98 20060701 99999999 

39220 EXCISION OF MEDIASTINAL TUMOR $994.77 20060701 99999999 

39400 MEDIASTINOSCOPY, WITH OR WITHOUT BIOPSY $403.65 20060701 99999999 

39501 REPAIR, LACERATION OF DIAPHRAGM $695.02 20060701 99999999 

39502 

REPAIR, PARAESOPHAGEAL HIATUS HERNIA, TRANSABDOMINAL, 

WITH OR $809.24 20060701 99999999 

39503 REPAIR, NEONATAL DIAPHRAGMATIC HERNIA, INCLUDING CHEST $3,212.48 20060701 99999999 

39520 REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL) $863.86 20060701 99999999 



39540 

REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), 

TRAUMATIC $730.00 20060701 99999999 

39541 

REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), 

TRAUMATIC $756.32 20060701 99999999 

39545 IMBRICATION OF DIAPHRAGM FOR EVENTRATION $706.41 20060701 99999999 

39560 

RESECTION, DIAPHRAGM; WITH SIMPLE REPAIR (EG, PRIMARY 

SUTURE) $620.52 20060701 99999999 

39561 

RESECTION, DIAPHRAGM; WITH COMPLEX REPAIR (EG, PROSTHETIC 

MATERIAL, LOCAL MUSCLE $845.04 20060701 99999999 

40490 BIOPSY OF LIP $49.51 20060701 99999999 

40500 VERMILIONECTOMY (LIP SHAVE), WITH MUCOSAL ADVANCEMENT $273.21 20060701 99999999 

40510 EXCISION OF LIP $304.17 20060701 99999999 




40530 

RESECTION OF LIP, MORE THAN ONE-FOURTH, WITHOUT 

RECONSTRUCTION $320.85 20060701 99999999 

40650 REPAIR LIP, FULL THICKNESS $232.61 20060701 99999999 





40700 PLASTIC REPAIR OF CLEFT LIP $647.11 20060701 99999999 





40800 DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH $74.07 20060701 99999999 

40801 DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH $132.92 20060701 99999999 

40804 REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH $77.33 20060701 99999999 

40805 REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH $154.14 20060701 99999999 

40806 INCISION OF LABIAL FRENUM (FRENOTOMY) $22.01 20060701 99999999 

40808 BIOPSY, VESTIBULE OF MOUTH $61.15 20060701 99999999 

40810 

EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 

MOUTH $76.90 20060701 99999999 

40812 


MOUTH $118.76 20060701 99999999 

40814 


MOUTH $183.91 20060701 99999999 

40816 


MOUTH $192.22 20060701 99999999 

40818 EXCISION OF MUCOSA OF VESTIBULE OF MOUTH AS DONOR GRAFT $163.92 20060701 99999999 

40819 EXCISION OF FRENUM, LABIAL OR BUCCAL (FRENUMECTOMY, $138.66 20060701 99999999 

40820 DESTRUCTION OF LESION OR SCAR OF VESTIBULE OF MOUTH BY $93.14 20060701 99999999 

40830 CLOSURE OF LACERATION, VESTIBULE OF MOUTH $96.73 20060701 99999999 

40831 CLOSURE OF LACERATION, VESTIBULE OF MOUTH $138.98 20060701 99999999 

40840 VESTIBULOPLASTY $440.25 20060701 99999999 




40845 VESTIBULOPLASTY $1,029.22 20060701 99999999 

41000 

INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR 

HEMATOMA $67.51 20060701 99999999 

41005 


HEMATOMA $74.43 20060701 99999999 

41006 


HEMATOMA $160.74 20060701 99999999 

41007 


HEMATOMA $178.83 20060701 99999999 

41008 


HEMATOMA $165.52 20060701 99999999 

41009 


HEMATOMA $200.41 20060701 99999999 

41010 INCISION OF LINGUAL FRENUM (FRENOTOMY) $77.74 20060701 99999999 

41015 

EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR 

HEMATOMA $203.47 20060701 99999999 

41016 


HEMATOMA $224.28 20060701 99999999 

41017 


HEMATOMA $211.30 20060701 99999999 

41018 


HEMATOMA $263.10 20060701 99999999 

41019 

PLACEMENT OF NEEDLES, CATHETERS, OR OTHER DEVICE(S) INTO 

THE HEAD AND/OR NECK RE $244.06 20080101 99999999 

41100 BIOPSY OF TONGUE $85.88 20060701 99999999 

41105 BIOPSY OF TONGUE $80.04 20060701 99999999 

41108 BIOPSY OF FLOOR OF MOUTH $65.19 20060701 99999999 

41110 EXCISION OF LESION OF TONGUE WITHOUT CLOSURE $86.77 20060701 99999999 

41112 EXCISION OF LESION OF TONGUE WITH CLOSURE $149.08 20060701 99999999 





41115 EXCISION OF LINGUAL FRENUM (FRENECTOMY) $112.10 20060701 99999999 

41116 EXCISION, LESION OF FLOOR OF MOUTH $158.23 20060701 99999999 

41120 GLOSSECTOMY $625.19 20060701 99999999 

41130 GLOSSECTOMY $681.52 20060701 99999999 

41135 GLOSSECTOMY $1,201.85 20060701 99999999 

41140 GLOSSECTOMY $1,298.70 20060701 99999999 

41145 GLOSSECTOMY $1,545.37 20060701 99999999 

41150 GLOSSECTOMY $1,222.11 20060701 99999999 

41153 GLOSSECTOMY $1,355.23 20060701 99999999 

41155 GLOSSECTOMY $1,587.75 20060701 99999999 

41250 REPAIR OF LACERATION 2.5 CM OR LESS $96.06 20060701 99999999 

41251 REPAIR OF LACERATION 2.5 CM OR LESS $126.68 20060701 99999999 

41252 REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, OVER 2.6 CM $157.46 20060701 99999999 

41500 

FIXATION OF TONGUE, MECHANICAL, OTHER THAN SUTURE (EG, K- 

WIRE) $278.72 20060701 99999999 

41510 SUTURE OF TONGUE TO LIP FOR MICROGNATHIA (DOUGLAS TYPE $282.40 20060701 99999999 

41520 

FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, WITH Z- 

PLASTY) $166.05 20060701 99999999 

41800 

DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR 

STRUCTURES $61.25 20060701 99999999 

41805 

REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR 

STRUCTURES $86.78 20060701 99999999 

41806 

REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR 

STRUCTURES $145.00 20060701 99999999 

41822 

EXCISION OF FIBROUS TUBEROSITIES, DENTOALVEOLAR 

STRUCTURES $130.49 20060701 99999999 

41823 

EXCISION OF OSSEOUS TUBEROSITIES, DENTOALVEOLAR 

STRUCTURES $195.52 20060701 99999999 

41825 EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), $89.51 20060701 99999999 



41828 EXCISION OF HYPERPLASTIC ALVEOLAR MUCOSA, EACH SEXTANT OR $188.87 20060701 99999999 

41830 

ALVEOLECTOMY, INCLUDING CURETTAGE OF OSTEITIS OR 

SEQUESTRECTOMY $196.46 20060701 99999999 

41872 GINGIVOPLASTY $163.04 20060701 99999999 

41874 ALVEOPLASTY $178.39 20060701 99999999 

41899 UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES $35.12 19990701 99999999 

42000 DRAINAGE OF ABSCESS OF PALATE, UVULA $61.87 20060701 99999999 

42100 BIOPSY OF PALATE, UVULA $74.71 20060701 99999999 

42104 EXCISION, LESION OF PALATE, UVULA $105.79 20060701 99999999 



42120 RESECTION OF PALATE OR EXTENSIVE RESECTION OF LESION $448.33 20060701 99999999 

42140 UVULECTOMY, EXCISION OF UVULA $109.32 20060701 99999999 

42145 PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, $482.16 20060701 99999999 

42160 

DESTRUCTION OF LESION, PALATE OR UVULA (THERMAL, CRYO OR 

CHEMICAL) $102.33 20060701 99999999 

42180 REPAIR, LACERATION OF PALATE $137.66 20060701 99999999 

42182 REPAIR, LACERATION OF PALATE $209.41 20060701 99999999 

42200 

PALATOPLASTY FOR CLEFT PALATE, SOFT AND/OR HARD PALATE 

ONLY $605.76 20060701 99999999 

42205 PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF $587.14 20060701 99999999 

42210 PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF $754.39 20060701 99999999 

42215 PALATOPLASTY FOR CLEFT PALATE $495.66 20060701 99999999 





42226 LENGTHENING OF PALATE, AND PHARYNGEAL FLAP $619.03 20060701 99999999 

42227 LENGTHENING OF PALATE, WITH ISLAND FLAP $628.99 20060701 99999999 

42235 REPAIR OF ANTERIOR PALATE, INCLUDING VOMER FLAP $493.09 20060701 99999999 

42260 REPAIR OF NASOLABIAL FISTULA $446.59 20060701 99999999 

42280 MAXILLARY IMPRESSION FOR PALATAL PROSTHESIS $83.62 20060701 99999999 

42281 INSERTION OF PIN-RETAINED PALATAL PROSTHESIS $94.69 20060701 99999999 

42300 DRAINAGE OF ABSCESS $92.99 20060701 99999999 




42325 FISTULIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) $129.65 20030401 99999999 

42326 FISTULIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) $201.36 20030401 99999999 

42330 SIALOLITHOTOMY $100.70 20060701 99999999 



42400 BIOPSY OF SALIVARY GLAND $37.10 20060701 99999999 

42405 BIOPSY OF SALIVARY GLAND $151.22 20060701 99999999 

42408 EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA) $242.76 20060701 99999999 

42409 MARSUPIALIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) $173.76 20060701 99999999 

42410 EXCISION OF PAROTID TUMOR OR PAROTID GLAND $478.66 20060701 99999999 


42420 EXCISION OF PAROTID TUMOR OR PAROTID GLAND $1,013.54 20060701 99999999 


42426 EXCISION OF PAROTID TUMOR OR PAROTID GLAND $1,220.80 20060701 99999999 

42440 EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND $412.20 20060701 99999999 

42450 EXCISION OF SUBLINGUAL GLAND $255.15 20060701 99999999 

42500 PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY $265.88 20060701 99999999 

42505 PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY $363.40 20060701 99999999 

42507 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE) $337.60 20060701 99999999 




42550 INJECTION PROCEDURE FOR SIALOGRAPHY $46.93 20060701 99999999 

42600 CLOSURE SALIVARY FISTULA $276.77 20060701 99999999 

42650 DILATION SALIVARY DUCT $36.80 20060701 99999999 

42660 

DILATION AND CATHETERIZATION OF SALIVARY DUCT, WITH OR 

WITHOUT $57.06 20060701 99999999 

42665 LIGATION SALIVARY DUCT, INTRAORAL $154.98 20060701 99999999 

42700 INCISION AND DRAINAGE ABSCESS $82.33 20060701 99999999 



42800 BIOPSY $77.75 20060701 99999999 

42802 BIOPSY $94.12 20060701 99999999 

42804 BIOPSY $84.47 20060701 99999999 

42806 BIOPSY $102.65 20060701 99999999 

42808 EXCISION OF LESION OF PHARYNX $148.11 20060701 99999999 

42809 REMOVAL OF FOREIGN BODY FROM PHARYNX $89.50 20060701 99999999 

42810 EXCISION BRANCHIAL CLEFT CYST OR VESTIGE, CONFINED TO SKIN $207.30 20060701 99999999 

42815 EXCISION BRANCHIAL CLEFT CYST, VESTIGE, OR FISTULA, $433.27 20060701 99999999 

42820 TONSILLECTOMY AND ADENOIDECTOMY $217.62 20060701 99999999 

42821 TONSILLECTOMY AND ADENOIDECTOMY $245.40 20060701 99999999 

42825 TONSILLECTOMY, PRIMARY OR SECONDARY $192.63 20060701 99999999 

42826 TONSILLECTOMY, PRIMARY OR SECONDARY $208.79 20060701 99999999 

42830 ADENOIDECTOMY, PRIMARY $138.25 20060701 99999999 

42831 ADENOIDECTOMY, PRIMARY $152.17 20060701 99999999 

42835 ADENOIDECTOMY, SECONDARY $135.32 20060701 99999999 



42836 ADENOIDECTOMY, SECONDARY $186.13 20060701 99999999 

42842 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR $491.26 20060701 99999999 

42844 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR $758.93 20060701 99999999 

42845 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR $1,258.65 20060701 99999999 

42860 EXCISION OF TONSIL TAGS $134.78 20060701 99999999 

42870 EXCISION LINGUAL TONSIL (SEPARATE PROCEDURE) $348.18 20060701 99999999 

42890 LIMITED PHARYNGECTOMY $673.14 20060701 99999999 

42892 

RESECTION OF LATERAL PHARYNGEAL WALL OR PYRIFORM SINUS, 

DIRECT $819.60 20060701 99999999 

42894 

RESECTION OF PHARYNGEAL WALL REQUIRING CLOSURE WITH 

MYOCUTANEOUS FLAP $1,171.50 20060701 99999999 

42900 SUTURE PHARYNX FOR WOUND OR INJURY $276.11 20060701 99999999 

42950 

PHARYNGOPLASTY (PLASTIC OR RECONSTRUCTIVE OPERATION ON 

PHARYNX) $498.59 20060701 99999999 

42953 PHARYNGOESOPHAGEAL REPAIR $659.60 20060701 99999999 

42955 

PHARYNGOSTOMY (FISTULIZATION OF PHARYNX, EXTERNAL FOR 

FEEDING) $453.51 20060701 99999999 

42960 

CONTROL OROPHARYNGEAL HEMORRHAGE (PRIMARY OR 

SECONDARY, EG, $113.60 20060701 99999999 

42961 


SECONDARY, EG, $261.26 20060701 99999999 

42962 


SECONDARY, EG, $388.66 20060701 99999999 

42970 

CONTROL OF NASOPHARYNGEAL HEMORRHAGE (PRIMARY OR 

SECONDARY, EG, $236.80 20060701 99999999 

42971 


SECONDARY, EG, $301.31 20060701 99999999 

42972 


SECONDARY, EG, $360.24 20060701 99999999 

43020 ESOPHAGOTOMY, CERVICAL APPROACH $449.01 20060701 99999999 

43030 CRICOPHARYNGEAL MYOTOMY $463.34 20060701 99999999 

43045 ESOPHAGOTOMY, THORACIC APPROACH $1,003.59 20060701 99999999 

43100 EXCISION OF LOCAL LESION, ESOPHAGUS, WITH PRIMARY REPAIR $476.97 20060701 99999999 

43101 EXCISION OF LOCAL LESION, ESOPHAGUS, WITH PRIMARY REPAIR $794.20 20060701 99999999 

43107 

TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; 

WITH PHARYNGOGASTROSTOMY $1,487.29 20060701 99999999 

43108 

TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; 

WITH COLON INTERPOSITION $1,698.39 20060701 99999999 

43112 

TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; 

WITH PHARYNGOGASTROSTOMY OR $1,588.39 20060701 99999999 

43113 

TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; 

WITH COLON INTERPOSITION OR $1,755.32 20060701 99999999 

43116 

PARTIAL ESOPHAGECTOMY, CERVICAL, WITH FREE INTESTINAL 

GRAFT, INCLUDING MICROVASC $1,608.11 20060701 99999999 

43117 

PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, WITH 

THORACOTOMY AND SEPARATE ABDOMINA $1,582.62 20060701 99999999 

43118 


THORACOTOMY AND SEPARATE ABDOMINA $1,665.09 20060701 99999999 

43121 


THORACOTOMY ONLY, WITH OR WITHOUT $1,502.45 20060701 99999999 

43122 

PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL 

APPROACH, WITH OR WITHOUT P $1,459.71 20060701 99999999 

43123 

PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL 

APPROACH, WITH OR WITHOUT P $1,702.61 20060701 99999999 

43124 

TOTAL OR PARTIAL ESOPHAGECTOMY, WITHOUT RECONSTRUCTION 

(ANY APPROACH), WITH CERV $1,438.26 20060701 99999999 

43130 DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR $659.19 20060701 99999999 

43135 DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR $854.32 20060701 99999999 



43200 ESOPHAGOSCOPY, RIGID OR FLEXIBLE FIBEROPTIC (SPECIFY) $86.70 20060701 99999999 

43201 

ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH DIRECTED 

SUBMUCOSAL INJECTION(S), ANY SUB $95.64 20060701 99999999 



43205 

ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BAND LIGATION OF 

ESOPHAGEAL VARICES $171.61 20060701 99999999 


43216 

ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF 

TUMOR(S), POLYP(S), OR OTHER L $125.73 20060701 99999999 







43231 

ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH ENDOSCOPIC 

ULTRASOUND EXAMINATION $134.11 20060701 99999999 

43232 

ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH TRANSENDOSCOPIC 

ULTRASOUND-GUIDED INTRAMU $185.05 20060701 99999999 

43234 

UPPER GASTROINTESTINAL ENDOSCOPY, SIMPLE PRIMARY 

EXAMINATION $105.06 20060701 99999999 

43235 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, $124.03 20060701 99999999 

43236 

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 

STOMACH, AND EITHER THE DU $117.71 20060701 99999999 

43237 



43238 




43240 




43242 



43243 

UPPER GI ENDOSCOPY INCL ESOPHAGUS STOMACH AND DUODE OR 

JEJUN $237.05 20060701 99999999 

43244 






43248 



43249 



43250 





43256 



43257 


STOMACH, AND EITHER THE $225.19 20060701 99999999 


43259 





43260 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP), $299.02 20060701 99999999 

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 

43261 WITH BIOPSY, SINGLE OR MU $309.24 20060701 99999999 




ERCP W/WO BIOP AND/OR COLLECTION OF SPECIMEN FOR 

43265 DESTRUCTION $410.83 20060701 99999999 



ERCP W/WO BIOP AND OR COLL OF SPECIMEN FOR REMOVAL AND/OR 

43269 CH $313.23 20060701 99999999 



43280 

LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, 

NISSEN, TOUPET PROCEDURE $837.01 20060701 99999999 

43300 ESOPHAGOPLASTY, (PLASTIC REPAIR OR RECONSTRUCTION) $543.59 20060701 99999999 

43305 ESOPHAGOPLASTY, (PLASTIC REPAIR OR RECONSTRUCTION) $912.90 20060701 99999999 

43310 

ESOPHAGOPLASTY, (PLASTIC REPAIR OR RECONSTRUCTION) 

THORACIC APPROACH $1,307.79 20060701 99999999 

43312 

ESOPHAGOPLASTY, (PLASTIC REPAIR OR RECONSTRUCTION) 

THORACIC APPROACH $1,427.88 20060701 99999999 

43313 

ESOPHAGOPLASTY FOR CONGENITAL DEFECT, (PLASTIC REPAIR OR 

RECONSTRUCTION), THORAC $1,939.44 20060701 99999999 

43314 

ESOPHAGOPLASTY FOR CONGENITAL DEFECT, (PLASTIC REPAIR OR 

RECONSTRUCTION), THORAC $2,131.62 20060701 99999999 

43320 

ESOPHAGOGASTROSTOMY (CARDIOPLASTY) WITH OR WITHOUT 

VAGOTOMY $832.04 20060701 99999999 

43324 

ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, BELSEY IV, HILL 

PROCEDURES) $816.32 20060701 99999999 

43325 

ESOPHAGOGASTRIC FUNDOPLASTY WITH FUNDIC PATCH (THAL- 

NISSEN $804.91 20060701 99999999 

43326 

ESOPHAGOGASTRIC FUNDOPLASTY; WITH GASTROPLASTY (EG, 

COLLIS) $760.18 20060701 99999999 

43330 ESOPHAGOMYOTOMY ((HELLER TYPE) WITH OR WITHOUT $788.67 20060701 99999999 

43331 ESOPHAGOMYOTOMY ((HELLER TYPE) WITH OR WITHOUT $886.90 20060701 99999999 

43340 ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL GASTRECTOMY) $828.26 20060701 99999999 

43341 ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL GASTRECTOMY) $867.72 20060701 99999999 

43350 ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL $629.35 20060701 99999999 



43360 

GASTROINTESTINAL RECONSTRUCTION FOR PREVIOUS 

ESOPHAGECTOMY, FOR OBSTRUCTING ESOP $1,455.90 20060701 99999999 

43361 

GASTROINTESTINAL RECONSTRUCTION FOR PREVIOUS 

ESOPHAGECTOMY, FOR OBSTRUCTING ESOP $1,661.05 20060701 99999999 

43400 LIGATION, DIRECT, ESOPHAGEAL VARICES $802.37 20060701 99999999 

43401 

TRANSECTION OF ESOPHAGUS WITH REPAIR, FOR ESOPHAGEAL 

VARICES $823.13 20060701 99999999 

43405 

LIGATION OR STAPLING AT GASTROESOPHAGEAL JUNCTION FOR PRE- 

EXISTING ESOPHAGEAL PE $853.40 20060701 99999999 



43410 SUTURE OF ESOPHAGEAL WOUND OR INJURY $610.85 20060701 99999999 

43415 SUTURE OF ESOPHAGEAL WOUND OR INJURY $931.76 20060701 99999999 

43420 CLOSURE OF ESOPHAGOSTOMY OR FISTULA $544.08 20060701 99999999 

43425 CLOSURE OF ESOPHAGOSTOMY OR FISTULA $853.32 20060701 99999999 

43450 DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, $57.59 20060701 99999999 

43453 DILATION OF ESOPHAGUS, OVER GUIDE WIRE OR STRING $75.92 20060701 99999999 

43456 DILATION OF ESOPHAGUS, BY BALLOON OR STARCK DILATOR $127.46 20060701 99999999 

43458 

DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR 

LARGER) FOR ACHALASIA $128.26 20060701 99999999 

43460 

ESOPHAGOGASTRIC TAMPONADE, WITH BALLOON (SENGSTAAKEN 

TYPE) $157.85 20060701 99999999 

43499 UNLISTED PROCEDURE, ESOPHAGUS $400.67 19990701 99999999 

43500 GASTROTOMY $413.88 20060701 99999999 

43501 GASTROTOMY $715.48 20060701 99999999 

43502 

GASTROTOMY; WITH SUTURE REPAIR OF PRE-EXISTING 

ESOPHAGOGASTRIC LACERATION (EG, M $823.58 20060701 99999999 

43510 GASTROTOMY $519.21 20060701 99999999 

43520 

PYLOROMYOTOMY, CUTTING OF PYLORIC MUSCLE (FREDET- 

RAMSTEDT TYPE $385.94 20060701 99999999 

43600 BIOPSY OF STOMACH $71.98 20060701 99999999 

43605 BIOPSY OF STOMACH $436.13 20060701 99999999 

43610 EXCISION, LOCAL, OF ULCER OR TUMOR OF STOMACH $548.92 20060701 99999999 

43611 EXCISION, LOCAL; MALIGNANT TUMOR OF STOMACH $641.24 20060701 99999999 

43620 GASTRECTOMY, TOTAL $1,074.97 20060701 99999999 

43621 GASTRECTOMY, TOTAL; WITH ROUX-EN-Y RECONSTRUCTION $1,091.22 20060701 99999999 

43622 

GASTRECTOMY, TOTAL; WITH FORMATION OF INTESTINAL POUCH, 

ANY TYPE $1,140.80 20060701 99999999 

43631 GASTRECTOMY, PARTIAL, DISTAL; WITH GASTRODUODENOSTOMY $916.13 20060701 99999999 

43632 GASTRECTOMY, PARTIAL, DISTAL; WITH GASTROJEJUNOSTOMY $914.94 20060701 99999999 

43633 

GASTRECTOMY, PARTIAL, DISTAL; WITH ROUX-EN-Y 

RECONSTRUCTION $929.96 20060701 99999999 

43634 

GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL 

POUCH $1,145.89 20060701 99999999 

43635 

HEMIGASTRECTOMY OR DISTAL SUBTOTAL GASTRECTOMY 

INCLUDING PYLOROPLASTY, $89.79 20060701 99999999 

43638 

HEMIGASTRECTOMY OR PROXIMAL SUBTOTAL GASTRECTOMY, 

THORACIC OR $996.80 19990701 99999999 

43639 

GASTRECTOMY, PARTIAL, PROXIMAL, THORACIC OR ABDOMINAL 

APPROACH INCLUDING ESOPHAG $1,015.57 19990701 99999999 

43640 

VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT 

GASTROSTOMY $711.96 20060701 99999999 

43641 

VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT 

GASTROSTOMY $724.43 20060701 99999999 

43644 

LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; 

WITH GASTRIC BYPASS AND RO $1,170.43 20060701 99999999 

43645 


WITH GASTRIC BYPASS AND $1,261.31 20060701 99999999 

43651 

LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, 

TRUNCAL $451.80 20060701 99999999 

43652 


SELECTIVE OR HIGHLY SELECTIV $541.09 20060701 99999999 

43653 

LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT 

CONSTRUCTION OF GASTRIC TUBE (EG, ST $395.37 20060701 99999999 

43750 PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE $238.95 19990701 99999999 

43752 

NASO- OR ORO-GASTRIC TUBE PLACEMENT, NECESSITATING 

PHYSICIAN¦S SKILL $36.91 20060701 99999999 

43760 CHANGE OF GASTROSTOMY TUBE $48.41 20060701 99999999 



43761 

REPOSITIONING OF THE GASTRIC FEEDING TUBE THROUGH THE 

DUODENUM FOR ENTERIC NUTRI $82.53 20060701 99999999 

43770 


PLACEMENT OF ADJUSTABLE GA $686.92 20060701 99999999 

43771 


REVISION OF ADJUSTABLE GAS $789.99 20060701 99999999 

43772 


REMOVAL OF ADJUSTABLE GAST $601.85 20060701 99999999 

43773 


REMOVAL AND REPLACEMENT OF $790.19 20060701 99999999 

43774 


REMOVAL OF ADJUSTABLE GAST $604.16 20060701 99999999 

43800 PYLOROPLASTY $504.68 20060701 99999999 

43810 GASTRODUODENOSTOMY $538.68 20060701 99999999 

43820 GASTROJEJUNOSTOMY $570.69 20060701 99999999 

43825 GASTROJEJUNOSTOMY $718.95 20060701 99999999 

43830 

GASTROSTOMY, TEMPORARY (TUBE, RUBBER OR PLASTIC) 


43831 

GASTROSTOMY, TEMPORARY (TUBE, RUBBER OR PLASTIC) 


43832 

GASTROSTOMY, PERMANENT, WITH CONSTRUCTION OF GASTRIC 

TUBE $575.55 20060701 99999999 

43840 

GASTRORRHAPHY, SUTURE OF PERFORATED DUODENAL OR 

GASTRIC ULCER, $567.96 20060701 99999999 

43842 GASTROPLASTY, VERTICAL-BANDED, FOR MORBID OBESITY $812.12 20060701 99999999 

43843 

GASTROPLASTY, OTHER THAN VERTICAL-BANDED, FOR MORBID 

OBESITY $803.76 20060701 99999999 

43845 GASTRIC STAPLING FOR MORBID OBESITY $1,054.93 20060701 99999999 

43846 GASTRIC BYPASS WITH ROUX-EN-Y GASTROENTEROSTOMY $977.92 20060701 99999999 

43847 

GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR 

MORBID OBESITY; WITH SMAL $1,072.44 20060701 99999999 

43848 

REVISION OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID 

OBESITY (SEPARATE PROCEDURE $1,143.78 20060701 99999999 

43850 

REVISION OF GASTRODUODENAL ANASTOMOSIS 

(GASTRODUODENOSTOMY) WITH $902.25 20060701 99999999 

43855 

REVISION OF GASTRODUODENAL ANASTOMOSIS 

(GASTRODUODENOSTOMY) WITH $921.31 20060701 99999999 

43860 

REVISION OF GASTROJEJUNAL ANASTOMOSIS 

(GASTROJEJUNOSTOMY) WITH $908.24 20060701 99999999 

43865 

REVISION OF GASTROJEJUNAL ANASTOMOSIS 

(GASTROJEJUNOSTOMY) WITH $982.26 20060701 99999999 

43870 CLOSURE OF GASTROSTOMY, SURGICAL $377.77 20060701 99999999 

43880 CLOSURE OF GASTROCOLIC FISTULA $872.30 20060701 99999999 

43886 

GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF 

SUBCUTANEOUS PORT COMPONENT ONL $195.21 20060701 99999999 

43887 

GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF 

SUBCUTANEOUS PORT COMPONENT ONLY $189.08 20060701 99999999 

43888 

GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND 

REPLACEMENT OF SUBCUTANEOUS POR $267.86 20060701 99999999 

44005 

ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) FOR ACUTE 

BOWEL $642.14 20060701 99999999 

44010 

DUODENOTOMY, FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY 

REMOVAL $515.03 20060701 99999999 

44015 

NEEDLE CATHETER JEJUNOSTOMY FOR ENTERAL 

HYPERALIMENTATION $139.15 20060701 99999999 

44020 ENTEROTOMY, SMALL BOWEL, OTHER THAN DUODENUM $566.70 20060701 99999999 

44021 ENTEROTOMY, SMALL BOWEL, OTHER THAN DUODENUM $563.70 20060701 99999999 

44025 COLOTOMY, FOR EXPLORATION, BIOPSY(S), OR $574.86 20060701 99999999 



44050 REDUCTION OF VOLVULUS, INTUSSUSCEPTION, INTERNAL $548.52 20060701 99999999 

44055 CORRECTION OF MALROTATION BY LYSIS OF DUODENAL $775.86 20060701 99999999 

44100 BIOPSY OF INTESTINE BY CAPSULE, TUBE, PERORAL $91.02 20060701 99999999 

44110 EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE $500.46 20060701 99999999 

44111 EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE $615.84 20060701 99999999 

44120 ENTERECTOMY, RESECTION OF SMALL INTESTINE $901.47 20060701 99999999 

44121 

ENTERECTOMY, RESECTION OF SMALL INTESTINE; EACH ADDITIONAL 

RESECTION AND ANASTOM $193.63 20060701 99999999 

44125 ENTERECTOMY, RESECTION OF SMALL INTESTINE $722.71 20060701 99999999 

44126 

ENTERECTOMY, RESECTION OF SMALL INTESTINE FOR CONGENITAL 

ATRESIA, SINGLE RESECTI $1,458.50 20060701 99999999 

44127 


ATRESIA, SINGLE RESECTI $1,676.62 20060701 99999999 

44128 


ATRESIA, SINGLE RESECTI $177.56 20060701 99999999 

44130 ENTEROENTEROSTOMY, ANASTOMOSIS OF INTESTINE $596.93 20060701 99999999 

44139 

MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN 

CONJUNCTION WITH PARTIA $97.26 20060701 99999999 

44140 COLECTOMY, PARTIAL $1,036.36 20060701 99999999 

44141 COLECTOMY, PARTIAL $947.85 20060701 99999999 






44150 COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PROCTECTOMY $1,062.07 20060701 99999999 




44155 COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY $1,206.77 20060701 99999999 

44156 COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY $1,154.86 20060701 99999999 

44157 

COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH 

ILEOANAL ANASTOMOSIS, INCLUD $1,395.74 20070101 99999999 

44158 

COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH 

ILEOANAL ANASTOMOSIS, CREATI $1,431.30 20070101 99999999 

44160 

COLECTOMY WITH REMOVAL OF TERMINAL ILEUM AND 

ILEOCOLOSTOMY $789.34 20060701 99999999 

44180 

LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL 

ADHESION) (SEPARATE PR $580.32 20060701 99999999 

44186 

LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR 

DECOMPRESSION OR FEEDING) $409.43 20060701 99999999 

44187 

LAPAROSCOPY, SURGICAL; ILEOSTOMY OR JEJUNOSTOMY, NON- 

TUBE $678.17 20060701 99999999 

44188 LAPAROSCOPY, SURGICAL, COLOSTOMY OR SKIN LEVEL CECOSTOMY $742.92 20060701 99999999 

44200 

LAPAROSCOPY, SURGICAL; ENTEROLYSIS (FREEING OF INTESTINAL 


44201 

LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR 

DECOMPRESSION OR FEEDING) $426.38 20000101 99999999 

44202 

LAPAROSCOPY, SURGICAL; INTESTINAL RESECTION, WITH 

ANASTOMOSIS (INTRA OR EXTRACOR $1,015.83 20060701 99999999 

44203 

LAPAROSCOPY, SURGICAL; EACH ADDITIONAL SMALL INTESTINE 

RESECTION AND ANASTOMOSIS $172.29 20060701 99999999 

44204 

LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH 

ANASTOMOSIS $997.92 20060701 99999999 

44205 

LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH REMOVAL 

OF TERMINAL ILEUM WITH I $884.08 20060701 99999999 



44206 

LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH END 

COLOSTOMY AND CLOSURE OF DIS $1,091.61 20060701 99999999 

44207 


ANASTOMOSIS, WITH COLOPROCTOSTOM $1,193.10 20060701 99999999 

44208 


ANASTOMOSIS, WITH COLOPROCTOSTOM $1,293.11 20060701 99999999 

44210 

LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, 

WITHOUT PROCTECTOMY, WITH IL $1,145.17 20060701 99999999 

44211 

LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITH 

PROCTECTOMY, WITH ILEOA $1,422.83 20060701 99999999 

44212 

LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITH 

PROCTECTOMY, WITH ILEOS $1,329.66 20060701 99999999 

44213 

LAPAROSCOPY, SURGICAL, MOBILIZATION (TAKE-DOWN) OF SPLENIC 

FLEXURE PERFORMED IN $132.31 20060701 99999999 

44227 

LAPAROSCOPY, SURGICAL, CLOSURE OF ENTEROSTOMY, LARGE OR 

SMALL INTESTINE, WITH RE $1,042.35 20060701 99999999 

44300 

ENTEROSTOMY, OR CECOSTOMY, TUBE (EG, FOR DECOMPRESSION 

OR FEEDING) $445.37 20060701 99999999 

44310 ILEOSTOMY $609.24 20060701 99999999 

44312 REVISION OF ILEOSTOMY $300.83 20060701 99999999 

44314 REVISION OF ILEOSTOMY $571.96 20060701 99999999 

44316 CONTINENT ILEOSTOMY (KOCK PROCEDURE) $787.02 20060701 99999999 

44320 COLOSTOMY OR SKIN LEVEL CECOSTOMY $658.30 20060701 99999999 

44322 COLOSTOMY OR SKIN LEVEL CECOSTOMY $653.91 20060701 99999999 

44340 REVISION OF COLOSTOMY $302.07 20060701 99999999 



44360 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND $148.89 20060701 99999999 




44365 

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 

PORTION OF DUODENUM, NOT I $188.21 20060701 99999999 



44370 


PORTION OF DUODENUM, NOT I $180.27 20060701 99999999 

44372 

SMALL INTEST ENDOSCOPY ENTEROSCOPY BEYOND 2ND PORTION 

OF DUO $247.79 20060701 99999999 

44373 

SMALL INTEST ENDOSCOPY ENTEROSCOPY BEYOND 2ND PORTION 

DUODEN $198.18 20060701 99999999 

44376 


PORTION OF DUODENUM, INCLU $258.18 20060701 99999999 

44377 



44378 



44379 



44380 FIBEROPTIC ILEOSCOPY THROUGH STOMA $65.56 20060701 99999999 

44382 FIBEROPTIC ILEOSCOPY THROUGH STOMA $78.05 20060701 99999999 

44383 

ILEOSCOPY, THROUGH STOMA; WITH TRANSENDOSCOPIC STENT 

PLACEMENT (INCLUDES PREDILA $121.52 20060701 99999999 

44385 FIBEROPTIC EVALUATION OF SMALL INTESTINAL (KOCK) OR $94.81 20060701 99999999 

44386 FIBEROPTIC EVALUATION OF SMALL INTESTINAL (KOCK) OR $97.78 20060701 99999999 

44388 FIBEROPTIC COLONOSCOPY THROUGH COLOSTOMY $148.02 20060701 99999999 








44394 

COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), 

POLYP(S), OR OTHER LESION(S $231.57 20060701 99999999 

44397 

COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC STENT 

PLACEMENT (INCLUDES PREDIL $189.99 20060701 99999999 

44500 

INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER- 

ABBOTT) (SEPARATE PROCEDU $21.51 20060701 99999999 

44602 

SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED 

ULCER, DIVERTICULUM, WO $566.18 20060701 99999999 

44603 

SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED 

ULCER, DIVERTICULUM, WO $661.26 20060701 99999999 

44604 

SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED 

ULCER, DIVERTICULUM, WOUN $649.54 20060701 99999999 

44605 SUTURE OF INTESTINE (ENTERORRHAPHY), LARGE OR SMALL, FOR $718.40 20060701 99999999 

44615 

INTESTINAL STRICTUROPLASTY (ENTEROTOMY AND 

ENTERORRHAPHY) WITH OR WITHOUT DILATI $627.21 20060701 99999999 

44620 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE $499.01 20060701 99999999 

44625 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE $648.22 20060701 99999999 

44626 

CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH 

RESECTION AND COLORECTAL $997.19 20060701 99999999 

44640 CLOSURE OF INTESTINAL CUTANEOUS FISTULA $761.46 20060701 99999999 

44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA $793.30 20060701 99999999 

44660 CLOSURE OF ENTEROVESICAL FISTULA $737.38 20060701 99999999 

44661 CLOSURE OF ENTEROVESICAL FISTULA $859.00 20060701 99999999 

44680 INTESTINAL PLICATION (SEPARATE PROCEDURE) $668.61 20060701 99999999 

44700 

EXCLUSION OF SMALL BOWEL FROM PELVIS BY MESH OR OTHER 

PROSTHESIS, OR NATIVE TISS $712.41 20060701 99999999 

44701 

INTRAOPERATIVE COLONIC LAVAGE (LIST SEPARATELY IN ADDITION 

TO CODE FOR PRIMARY P $118.35 20060701 99999999 

44720 

BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR 

INTESTINE ALLOGRAFT PRIOR $196.81 20050101 99999999 

44721 


INTESTINE ALLOGRAFT PRIOR $285.28 20050101 99999999 

44799 UNLISTED PROCEDURE, INTESTINE $141.75 19990701 99999999 

44800 EXCISION OF MECKEL'S DIVERTICULUM (DIVERTICULECTOMY) OR $499.38 20060701 99999999 

44820 EXCISION OF LESION OF MESENTERY (SEPARATE PROCEDURE) $478.77 20060701 99999999 

44850 SUTURE OF MESENTERY (SEPARATE PROCEDURE) $449.06 20060701 99999999 

44900 

INCISION AND DRAINAGE OF APPENDICEAL ABSCESS, 

TRANSABDOMINAL $408.35 20060701 99999999 

44901 

INCISION AND DRAINAGE OF APPENDICEAL ABSCESS; 

PERCUTANEOUS $179.24 20060701 99999999 

44950 APPENDECTOMY $408.32 20060701 99999999 

44955 APPENDECTOMY $81.19 20060701 99999999 

44960 APPENDECTOMY $500.95 20060701 99999999 

44970 LAPAROSCOPY, SURGICAL, APPENDECTOMY $399.90 20060701 99999999 

45000 TRANSRECTAL DRAINAGE OF PELVIC ABSCESS $208.94 20060701 99999999 

45005 INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM $102.04 20060701 99999999 

45020 

INCISION AND DRAINAGE OF DEEP SUPRALEVATOR, PELVIRECTAL, 

OR $232.49 20060701 99999999 

45100 BIOPSY OF ANORECTAL WALL, ANAL APPROACH $208.84 20060701 99999999 

45108 ANORECTAL MYOMECTOMY $270.78 20060701 99999999 

45110 PROCTECTOMY $1,146.31 20060701 99999999 

45111 PROCTECTOMY $809.82 20060701 99999999 

45112 PROCTECTOMY, COMBINED ABDOMINOPERINEAL, PULL-THROUGH $1,207.43 20060701 99999999 

45113 

PROCTECTOMY, PARTIAL, WITH RECTAL MUCOSECTOMY, ILEOANAL 

ANASTOMOSIS, CREATION OF $1,194.29 20060701 99999999 



45114 PROCTECTOMY, PARTIAL, WITH ANASTOMOSIS $1,100.42 20060701 99999999 

45116 PROCTECTOMY, PARTIAL, WITH ANASTOMOSIS $938.33 20060701 99999999 

45119 

PROCTECTOMY, COMBINED ABDOMINOPERINEAL PULL-THROUGH 

PROCEDURE (EG, COLO-ANAL ANA $1,211.32 20060701 99999999 

45120 PROCTECTOMY, COMPLETE $1,161.24 20060701 99999999 

45121 

PROCTECTOMY CMPLT W/SUBTOTAL/TOTAL COLECTOMY W/MULT 

BIOPS $1,163.20 20060701 99999999 

45123 

PROCTECTOMY, PARTIAL, WITHOUT ANASTOMOSIS, PERINEAL 

APPROACH $720.29 20060701 99999999 

45126 

PELVIC EXENTERATION FOR COLORECTAL MALIGNANCY, WITH 

PROCTECTOMY (WITH OR WITHOUT $1,595.54 20060701 99999999 

45130 EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS $661.22 20060701 99999999 

45135 EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS $869.88 20060701 99999999 

45136 EXCISION OF ILEOANAL RESERVOIR WITH ILEOSTOMY $1,127.88 20060701 99999999 

45150 DIVISION OF STRICTURE OF RECTUM $305.78 20060701 99999999 

45160 EXCISION OF RECTAL TUMOR BY PROCTOTOMY, TRANSACRAL OR $601.34 20060701 99999999 

45170 EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH $440.73 20060701 99999999 

45190 

DESTRUCTION OF RECTAL TUMOR, ANY METHOD (EG, 

ELECTRODESICCATION) TRANSANAL APPRO $396.20 20060701 99999999 

45300 PROCTOSIGMOIDOSCOPY $24.58 20060701 99999999 




45308 

PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, 

POLYP, OR OTHER LESION $49.75 20060701 99999999 

45309 

PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, 

POLYP, OR OTHER LESION $78.87 20060701 99999999 



45320 PROCTO FOR ABLATION OF TUMOR $90.73 20060701 99999999 


45327 

PROCTOSIGMOIDOSCOPY, RIGID; WITH TRANSENDOSCOPIC STENT 

PLACEMENT (INCLUDES PREDI $71.12 20060701 99999999 

45330 SIGMOIDOSCOPY, FLEXIBLE FIBEROPTIC $41.36 20060701 99999999 





45335 

SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL 

INJECTION(S), ANY SUBSTANCE $56.81 20060701 99999999 

45337 

SIGMOIDOSCOPY FLEX FIBEROPTIC FOR DECOMPRESSION OF 

VOLVULUS $123.44 20060701 99999999 

45338 

SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), 

OR OTHER LESION(S) $124.22 20060701 99999999 

45339 

SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), 

OR OTHER LESION(S) $160.19 20060701 99999999 

45340 

SIGMOIDOSCOPY, FLEXIBLE; WITH DILATION BY BALLOON, 1 OR MORE 

STRICTURES $68.00 20060701 99999999 

45341 

SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND 

EXAMINATION $112.92 20060701 99999999 

45342 

SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND 

GUIDED INTRAMURAL OR TR $164.69 20060701 99999999 

45345 

SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC STENT 

PLACEMENT (INCLUDES PREDILAT $121.32 20060701 99999999 

45355 

COLONOSCOPY, WITH STANDARD SIGMOIDOSCOPE, 

TRANSABDOMINAL VIA $138.95 20060701 99999999 

45378 COLONOSCOPY, FIBEROPTIC, BEYOND SPLENIC FLEXURE $193.08 20060701 99999999 





45381 

COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 

DIRECTED SUBMUCOSAL INJ $166.15 20060701 99999999 



45384 


REMOVAL OF TUMOR(S), PO $244.59 20060701 99999999 


45386 COLNSPY FIBRPTC BEYND SPLNC; W/RETRGRDE LAVAGE $180.35 20060701 99999999 

45387 


TRANSENDOSCOPIC STENT P $236.04 20060701 99999999 

45391 


ENDOSCOPIC ULTRASOUND $208.29 20060701 99999999 

45392 


TRANSENDOSCOPIC $263.46 20060701 99999999 

45395 

LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMPLETE, COMBINED 

ABDOMINOPERINEAL, WITH CO $1,235.31 20060701 99999999 

45397 

LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMBINED 

ABDOMINOPERINEAL PULL-THROUGH PROCE $1,341.80 20060701 99999999 

45400 LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE) $721.42 20060701 99999999 

45402 

LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE), WITH 

SIGMOID RESECTION $975.84 20060701 99999999 

45500 PROCTOPLASTY $373.88 20060701 99999999 

45505 PROCTOPLASTY $328.78 20060701 99999999 

45520 PERIRECTAL INJECTION OF SCLEROSING SOLUTION FOR PROLAPSE $24.08 20060701 99999999 

45540 PROCTOPEXY FOR PROLAPSE $644.79 20060701 99999999 

45541 PROCTOPEXY FOR PROLAPSE $570.98 20060701 99999999 

45550 

PROCTOPEXY COMBINED WITH SIGMOID RESECTION, ABDOMINAL 

APPROACH $857.06 20060701 99999999 

45560 REPAIR OF RECTOCELE (SEPARATE PROCEDURE) $393.09 20060701 99999999 

45562 

EXPLORATION, REPAIR, AND PRESACRAL DRAINAGE FOR RECTAL 

INJURY; $582.24 20060701 99999999 

45563 

EXPLORATION, REPAIR, AND PRESACRAL DRAINAGE FOR RECTAL 

INJURY; WITH COLOSTOMY $899.35 20060701 99999999 

45800 CLOSURE OF RECTOVESICAL FISTULA $668.58 20060701 99999999 

45805 CLOSURE OF RECTOVESICAL FISTULA $813.06 20060701 99999999 

45820 CLOSURE OF RECTOURETHRAL FISTULA $676.37 20060701 99999999 

45825 CLOSURE OF RECTOURETHRAL FISTULA $788.49 20060701 99999999 

45900 REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER $103.00 20060701 99999999 

45905 DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER $93.59 20060701 99999999 

45910 DILATION OF RECTAL STRICTURE (SEPARATE PROCEDURE) $111.38 20060701 99999999 

45915 REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE $130.27 20060701 99999999 

45990 

ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, 

SPINAL, OR EPIDURAL), D $71.48 20060701 99999999 

46020 PLACEMENT OF SETON $170.66 20060701 99999999 

46030 REMOVAL OF ANAL SETON, OTHER MARKER $59.39 20060701 99999999 

46040 

INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL 

ABSCESS $218.22 20060701 99999999 

46045 INCISION AND DRAINAGE OF INTRAMURAL, INTRAMUSCULAR OR $197.76 20060701 99999999 

46050 INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL $58.09 20060701 99999999 

46060 INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL $310.30 20060701 99999999 

46070 INCISION, ANAL SEPTUM (INFANT) $141.96 20060701 99999999 

46080 SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER $132.61 20060701 99999999 

46083 INCISION OF THROMBOSED HEMORRHOID, EXTERNAL $66.73 20060701 99999999 

46200 FISSURECTOMY, WITH OR WITHOUT SPHINCTEROTOMY $189.59 20060701 99999999 

46210 CRYPTECTOMY $133.09 20060701 99999999 

46211 CRYPTECTOMY $196.66 20060701 99999999 

46220 PAPILLECTOMY OR EXCISION OF SINGLE TAG, ANUS $64.46 20060701 99999999 



46221 HEMORRHOIDECTOMY, BY SIMPLE LIGATURE (EG, RUBBER BAND) $95.01 20060701 99999999 

46230 

EXCISION OF EXTERNAL HEMORRHOID TAGS AND/OR MULTIPLE 

PAPILLAE $106.34 20060701 99999999 

46250 HEMORRHOIDECTOMY, EXTERNAL, COMPLETE $222.24 20060701 99999999 

46255 HEMORRHOIDECTOMY INTERNAL AND EXTERNAL, SIMPLE $282.52 20060701 99999999 



46260 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX $382.85 20060701 99999999 



46270 FISTULECTOMY $177.65 20060701 99999999 

46275 FISTULECTOMY $258.47 20060701 99999999 

46280 FISTULECTOMY $331.72 20060701 99999999 

46285 FISTULECTOMY $195.26 20060701 99999999 

46288 CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP $330.49 20060701 99999999 

46320 

ENUCLEATION OR EXCISION OF EXTERNAL THROMBOTIC 

HEMORRHOID $74.51 20060701 99999999 

46500 INJECTION OF SCLEROSING SOLUTION, HEMORRHOIDS $68.75 20060701 99999999 

46505 CHEMODENERVATION OF INTERNAL ANAL SPHINCTER $131.05 20060701 99999999 

46600 ANOSCOPY $20.92 20060701 99999999 

46604 ANOSCOPY $48.15 20060701 99999999 

46606 ANOSCOPY $31.12 20060701 99999999 

46608 ANOSCOPY $68.88 20060701 99999999 

46610 ANOSCOPY $59.64 20060701 99999999 

46611 

ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER 

LESION BY SNARE TECHNIQU $69.42 20060701 99999999 

46612 ANOSCOPY $103.70 20060701 99999999 

46614 ANOSCOPY $81.48 20060701 99999999 

46615 

ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER 

LESION(S) NOT AMENABLE T $104.98 20060701 99999999 

46700 ANOPLASTY, PLASTIC OPERATION FOR STRICTURE $374.95 20060701 99999999 

46705 ANOPLASTY, PLASTIC OPERATION FOR STRICTURE $333.61 20060701 99999999 

46706 REPAIR OF ANAL FISTULA WITH FIBRIN GLUE $103.78 20060701 99999999 

46710 

REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR 

VAGINAL), POUCH ADVANCEM $653.77 20060701 99999999 

46712 

REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR 

VAGINAL), POUCH ADVANCEM $1,363.74 20060701 99999999 

46715 REPAIR OF CONGENITAL ANOVAGINAL FISTULA (''CUT-BACK'' TYPE $344.51 20060701 99999999 

46716 PERINEAL TRANSPLANT OF ANOVAGINAL FISTULA $574.51 20060701 99999999 

46730 CONSTRUCTION OF ANUS FOR CONGENITAL ABSENCE $980.40 20060701 99999999 

46735 CONSTRUCTION OF ANUS FOR CONGENITAL ABSENCE $1,157.70 20060701 99999999 

46740 

CONSTRUCTION OF ANUS FOR CONGENITAL ABSENCE, WITH REPAIR 

OF $1,063.47 20060701 99999999 

46742 

REPAIR OF HIGH IMPERFORATE ANUS WITH RECTOURETHRAL OR 

RECTOVAGINAL FISTULA; COMB $1,422.06 20060701 99999999 

46744 

REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND 

URETHROPLASTY, SACROPERINE $1,851.74 20060701 99999999 

46746 


URETHROPLASTY, COMBINED AB $2,104.97 20060701 99999999 

46748 


URETHROPLASTY, COMBINED AB $2,124.89 20060701 99999999 

46750 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE $406.48 20060701 99999999 

46751 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE $402.14 20060701 99999999 

46753 GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR $325.94 20060701 99999999 

46754 REMOVAL OF THIERSCH WIRE OR SUTURE, ANAL CANAL $95.92 20060701 99999999 

46760 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT $537.59 20060701 99999999 

46761 

SPHINCTEROPLASTY ANAL FOR INCONTINENCE ADULT LEVATOR 

MUSCLE $516.01 20060701 99999999 



46762 

SPHINCTEROPLASTY ANAL FON INCONT ADULT IMPLANT ARTIFICIAL 

SP $463.49 20060701 99999999 

46900 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, $78.82 20060701 99999999 






46934 DESTRUCTION OF HEMORRHOIDS, ANY METHOD $179.26 20060701 99999999 



46937 CRYOSURGERY OF RECTAL TUMOR $140.84 20060701 99999999 

46938 CRYOSURGERY OF RECTAL TUMOR $222.99 20060701 99999999 

46940 

CURETTAGE OR CAUTERIZATION OF ANAL FISSURE, INCLUDING 

DILATION $84.74 20060701 99999999 

46942 

CURETTAGE OR CAUTERIZATION OF ANAL FISSURE, INCLUDING 

DILATION $75.84 20060701 99999999 

46945 LIGATION OF INTERNAL HEMORRHOIDS $108.16 20060701 99999999 

46946 LIGATION OF INTERNAL HEMORRHOIDS $130.00 20060701 99999999 

46947 

HEMORRHOIDOPEXY (EG, FOR PROLAPSING INTERNAL 

HEMORRHOIDS) BY STAPLING $247.07 20060701 99999999 

47000 BIOPSY OF LIVER, PERCUTANEOUS NEEDLE $84.69 20060701 99999999 

47001 

BIOPSY OF LIVER, PERCUTANEOUS NEEDLE; WHEN DONE FOR 

INDICATED PURPOSE AT TIME OF $89.45 19990701 99999999 

47010 

HEPATOTOMY FOR DRAINAGE OF ABSCESS OR CYST, ONE OR TWO 

STAGES $610.61 20060701 99999999 

47011 

HEPATOTOMY; FOR PERCUTANEOUS DRAINAGE OF ABSCESS OR 

CYST, ONE OR TWO STAGES $194.96 20060701 99999999 

47015 

LAPAROTOMY, WITH ASPIRATION AND/OR INJECTION OF HEPATIC 

PARASITIC (EG, AMOEBIC O $567.60 20060701 99999999 

47100 BIOPSY OF LIVER, WEDGE (SEPARATE PROCEDURE) $446.90 20060701 99999999 

47120 HEPATECTOMY, RESECTION OF LIVER $1,278.18 20060701 99999999 

47122 HEPATECTOMY RESECTION OF LIVER TRISEGEMENTECTOMY $1,931.95 20060701 99999999 



47134 

DONOR HEPATECTOMY, WITH PREPARATION AND MAINTENANCE OF 

ALLOGRAFT; PARTIAL, FROM $1,707.93 19990701 99999999 

47135 LIVER TRANSPLANT, WITH OR WITHOUT RECIPIENT HEPATECTOMY $3,922.56 20060701 99999999 

47136 

LIVER ALLOTRANSPLANTATION; HETEROTOPIC, PARTIAL OR WHOLE, 

FROM CADAVER OR LIVING $3,158.55 20060701 99999999 

47140 


ALLOGRAFT, FROM LIVING DO $2,268.96 20060701 99999999 

47141 



47142 



47146 


LIVER GRAFT PRIOR TO $244.53 20050101 99999999 

47147 


LIVER GRAFT PRIOR TO $285.28 20050101 99999999 

47300 MARSUPIALIZATION OF CYST OR ABSCESS OF LIVER $563.07 20060701 99999999 

47350 HEPATORRHAPHY, SUTURE OF LIVER WOUND OR INJURY $717.82 20060701 99999999 

47360 HEPATORRHAPHY, SUTURE OF LIVER WOUND OR INJURY $968.62 20060701 99999999 

47361 

MANAGEMENT OF LIVER HEMORRHAGE; EXPLORATION OF HEPATIC 

WOUND, EXTENSIVE DEBRIDEM $1,650.49 20060701 99999999 

47362 

MANAGEMENT OF LIVER HEMORRHAGE; RE-EXPLORATION OF 

HEPATIC WOUND FOR REMOVAL OF P $688.58 20060701 99999999 



47370 

LAPAROSCOPY, SURGICAL, ABLATION OF ONE OR MORE LIVER 

TUMOR(S); RADIOFREQUENCY $701.55 20060701 99999999 

47371 

LAPAROSCOPY, SURGICAL, ABLATION OF ONE OR MORE LIVER 

TUMOR(S); CRYOSURGICAL $702.71 20060701 99999999 

47380 

ABLATION, OPEN, OF ONE OR MORE LIVER TUMOR(S); 

RADIOFREQUENCY $819.09 20060701 99999999 

47381 ABLATION, OPEN, OF ONE OR MORE LIVER TUMOR(S); CRYOSURGICAL $825.52 20060701 99999999 

47382 

ABLATION, ONE OR MORE LIVER TUMOR(S), PERCUTANEOUS, 

RADIOFREQUENCY $517.98 20060701 99999999 

47400 

HEPATICOTOMY OR HEPATICOSTOMY WITH EXPLORATION, 

DRAINAGE, OR $1,137.46 20060701 99999999 

47420 

CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY WITH EXPLORATION, 

DRAINAGE, $774.41 20060701 99999999 

47425 

CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY WITH EXPLORATION, 

DRAINAGE, $812.28 20060701 99999999 

47460 TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY $816.57 20060701 99999999 

47480 

CHOLECYSTOTOMY OR CHOLECYSTOSTOMY WITH EXPLORATION, 

DRAINAGE, $485.40 20060701 99999999 

47490 PERCUTANEOUS CHOLECYSTOSTOMY $356.49 20060701 99999999 

47500 INJECTION PROCEDURE FOR PERCUTANEOUS TRANSHEPATIC $87.57 20060701 99999999 

47505 

INJECTION PROCEDURE FOR CHOLANGIOGRAPHY THROUGH AN 

EXISTING CATHETER (EG, PERCUT $38.21 20060701 99999999 

47510 INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC CATHETER $407.09 20060701 99999999 

47511 

INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC STENT FOR 

INTERNAL AND EXTERNAL BILIAR $495.50 20060701 99999999 

47525 CHANGE OF PERCUTANEOUS BILIARY DRAINAGE CATHETER $220.15 20060701 99999999 

47530 REVISION AND/OR REINSERTION OF TRANSHEPATIC T-TUBE $250.14 20060701 99999999 

47550 BILIARY ENDOSCOPY, INTRAOPERATIVE (CHOLEDOCHOSCOPY) $131.28 20060701 99999999 

47552 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT $225.50 20060701 99999999 




47556 

BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; 

FOR DILATION OF BILIA $314.28 20060701 99999999 

47560 

LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC 

CHOLANGIOGRAPHY, WITHOUT BIOPSY $217.56 20060701 99999999 

47561 

LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC 

CHOLANGIOGRAPHY WITH BIOPSY $246.65 20060701 99999999 

47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY $643.90 20060701 99999999 

47563 

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH 

CHOLANGIOGRAPHY $688.39 20060701 99999999 

47564 

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION 

OF COMMON DUCT $679.84 20060701 99999999 

47570 LAPAROSCOPY, SURGICAL; CHOLECYSTOENTEROSTOMY $612.40 20060701 99999999 

47600 CHOLECYSTECTOMY $552.72 20060701 99999999 

47605 CHOLECYSTECTOMY $744.14 20060701 99999999 

47610 CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT $738.19 20060701 99999999 



47630 

BILIARY DUCT STONE EXTRACTION, PERCUTANEOUS VIA T-TUBE 

TRACT, $356.28 20060701 99999999 

47700 EXPLORATION FOR CONGENITAL ATRESIA OF BILE DUCTS, WITHOUT $684.85 20060701 99999999 

47701 PORTOENTEROSTOMY (EG. KASAI PROCEDURE) $1,148.75 20060701 99999999 



47711 

EXCISION OF BILE DUCT TUMOR, WITH OR WITHOUT PRIMARY REPAIR 

OF BILE DUCT; EXTRAH $916.27 20060701 99999999 

47712 

EXCISION OF BILE DUCT TUMOR, WITH OR WITHOUT PRIMARY REPAIR 

OF BILE DUCT; INTRAH $1,130.34 20060701 99999999 

47715 EXCISION OF CHOLEDOCHAL CYST $733.42 20060701 99999999 

47716 ANASTOMOSIS CHOLEDOCHAL CYST W/O EXCISION $625.46 19990701 99999999 

47719 ANASTOMOSIS, CHOLEDOCHAL CYST, WITHOUT EXCISION $733.90 20070101 99999999 

47720 CHOLECYSTOENTEROSTOMY $663.65 20060701 99999999 



47741 

CHOLECYSTOENTEROSTOMY; ROUX-EN-Y WITH 

GASTROENTEROSTOMY $911.83 20060701 99999999 

47760 ANASTOMOSIS, DIRECT, OF EXTRAHEPATIC BILIARY DUCTS AND $992.35 20060701 99999999 

47765 

ANASTOMOSIS, DIRECT, OF INTRAHEPATIC DUCTS AND 

GASTROINTESTINAL TRACT $1,036.82 20060701 99999999 

47780 ANASTOMOSIS, ROUX-EN-Y, OF EXTRAHEPATIC BILIARY DUCTS AND $1,037.14 20060701 99999999 

ANASTOMOSIS, ROUX-EN-Y, OF INTRAHEPATIC BILIARY DUCTS AND 

47785 GASTROINTESTINAL TRACT $1,182.23 20060701 99999999 

47800 RECONSTRUCTION, PLASTIC, OF EXTRAHEPATIC BILIARY DUCTS WITH $945.73 20060701 99999999 

47801 PLACEMENT OF CHOLEDOCHAL STENT $575.11 20060701 99999999 

47802 U-TUBE HEPATICOENTEROSTOMY $858.76 20060701 99999999 

47900 

SUTURE OF EXTRAHEPATIC BILIARY DUCT FOR PRE-EXISTING INJURY 


48000 DRAINAGE OF ABDOMEN FOR PANCREATITIS $994.69 20060701 99999999 

48001 

PLACEMENT OF DRAINS, PERIPANCREATIC, FOR ACUTE 

PANCREATITIS; WITH CHOLECYSTOSTOM $1,245.25 20060701 99999999 

48005 

RESECTION OR DEBRIDEMENT OF PANCREAS AND PERIPANCREATIC 

TISSUE FOR ACUTE NECROTI $963.94 19990701 99999999 

48020 REMOVAL OF PANCREATIC CALCULUS $621.50 20060701 99999999 

48100 BIOPSY OF PANCREAS (SEPARATE PROCEDURE) $491.44 20060701 99999999 

48102 BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE $199.01 20060701 99999999 

48105 

RESECTION OR DEBRIDEMENT OF PANCREAS AND PERIPANCREATIC 

TISSUE FOR ACUTE NECROTI $1,776.88 20070101 99999999 

48120 EXCISION OF LESION OF PANCREAS (EG, CYST, ADENOMA) $688.88 20060701 99999999 

48140 

PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR WITHOUT 

SPLENECTOMY $981.85 20060701 99999999 

48145 

PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR WITHOUT 

SPLENECTOMY $1,057.80 20060701 99999999 

48146 

PANCREATECTOMY, DISTAL, NEAR-TOTAL WITH PRESERVATION OF 

DUODENUM (CHILD-TYPE PRO $1,165.69 20060701 99999999 

48148 EXCISION OF AMPULLA OF VATER, SIMPLE $728.35 20060701 99999999 

48150 

PANCREATECTOMY, PROXIMAL SUBTOTAL, WITH 

PANCREATICODUODENECTOMY $1,960.11 20060701 99999999 

48152 

PANCREATECTOMY, PROXIMAL SUBTOTAL WITH TOTAL 

DUODENECTOMY, PARTIAL GASTRECTOMY, $1,828.96 20060701 99999999 

48153 

PANCREATECTOMY, PROXIMAL SUBTOTAL WITH NEAR-TOTAL 

DUODENECTOMY, CHOLEDOCHOENTERO $1,958.85 20060701 99999999 

48154 

PANCREATECTOMY, PROXIMAL SUBTOTAL WITH NEAR-TOTAL 

DUODENECTOMY, CHOLEDOCHOENTERO $1,831.87 20060701 99999999 

48155 PANCREATECTOMY, TOTAL $1,192.36 20060701 99999999 

48180 

PANCREATICOJEJUNOSTOMY, SIDE-TO-SIDE ANASTOMOSIS, 

PUESTOW TYPE $1,022.56 19990701 99999999 

48400 INJECTION PROCEDURE FOR INTRAOPERATIVE PANCREATOGRAPHY $80.64 20060701 99999999 

48500 MARSUPIALIZATION OF CYST OF PANCREAS $642.05 20060701 99999999 

48510 EXTERNAL DRAINAGE PSEUDOCYST OF PANCREAS $596.13 20060701 99999999 



48511 EXTERNAL DRAINAGE, PSEUDOCYST OF PANCREAS; PERCUTANEOUS $210.36 20060701 99999999 

48520 

INTERNAL ANASTOMOSIS OF PANCREATIC CYST TO 

GASTROINTESTINAL TRACT $704.33 20060701 99999999 

48540 

INTERNAL ANASTOMOSIS OF PANCREATIC CYST TO 

GASTROINTESTINAL TRACT $858.82 20060701 99999999 

48545 PANCREATORRHAPHY FOR TRAUMA $737.98 20060701 99999999 

48547 

DUODENAL EXCLUSION WITH GASTROJEJUNOSTOMY FOR 

PANCREATIC TRAUMA $1,026.40 20060701 99999999 

48548 

PANCREATICOJEJUNOSTOMY, SIDE-TO-SIDE ANASTOMOSIS 

(PUESTOW-TYPE OPERATION) $1,036.92 20070101 99999999 

48552 

BACKBENCH RECONSTRUCTION OF CADAVER DONOR PANCREAS 

ALLOGRAFT PRIOR TO $168.75 20050101 99999999 

48554 TRANSPLANTATION OF PANCREATIC ALLOGRAFT $1,489.62 19990701 99999999 

48556 REMOVAL OF TRANSPLANTED PANCREATIC ALLOGRAFT $705.83 19990701 99999999 

48999 UNLISTED PROCEDURE, PANCREAS $400.67 19990701 99999999 

49000 

EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR 

WITHOUT $547.40 20060701 99999999 

49002 REOPENING OF RECENT LAPAROTOMY INCISION FOR EXPLORATION, $498.36 20060701 99999999 

49010 

EXPLORATION, RETROPERITONEAL AREA WITH OR WITHOUT 

BIOPSY(S) $581.10 20060701 99999999 

49020 DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, $830.85 20060701 99999999 

49021 

DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, 

EXCLUSIVE OF APPENDICEA $178.63 20060701 99999999 

49040 DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS $501.68 20060701 99999999 

49041 

DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS; 

PERCUTANEOUS $210.66 20060701 99999999 

49060 DRAINAGE OF RETROPERITONEAL ABSCESS $581.59 20060701 99999999 

49061 DRAINAGE OF RETROPERITONEAL ABSCESS; PERCUTANEOUS $194.96 20060701 99999999 

49062 

DRAINAGE OF EXTRAPERITONEAL LYMPHOCELE TO PERITONEAL 

CAVITY, OPEN $570.28 20060701 99999999 

49080 

PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL 

LAVAGE $58.74 20060701 99999999 

49081 

PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL 

LAVAGE $54.19 20060701 99999999 

49085 

REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL 

CAVITY $398.85 19990701 99999999 

49180 BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS $85.89 20060701 99999999 

49200 

EXCISION OR DESTRUCTION BY ANY METHOD OF INTRA-ABDOMINAL 

OR $527.64 19990701 99999999 

49201 

EXCISION OR DESTRUCTION BY ANY METHOD OF INTRA-ABDOMINAL 

OR $756.00 19990701 99999999 

49203 

EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, 

CYSTS OR ENDOMETRIOMAS, 1 $571.70 20080101 99999999 

49204 



49205 



49215 EXCISION OF PRESACRAL OR SACROCOCCYGEAL TUMOR $1,199.60 20060701 99999999 

49220 STAGING CELIOTOMY (LAPAROTOMY) FOR HODGKIN'S DISEASE OR $756.34 20060701 99999999 

49250 

UMBILECTOMY, OMPHALECTOMY, EXCISION OF UMBILICUS 

(SEPARATE $395.48 20060701 99999999 

49255 

OMENTECTOMY, EPIPLOECTOMY, RESECTION OF OMENTUM 

(SEPARATE $504.80 20060701 99999999 

49320 

LAPAROSCOPY, SURGICAL, ABDOMEN, PERITONEUM, AND OMENTUM; 

DIAGNOSTIC, WITH OR WIT $266.69 20060701 99999999 



49321 


WITH BIOPSY (SINGLE OR $284.44 20060701 99999999 

49322 


WITH ASPIRATION OF CAVI $295.14 20060701 99999999 

49323 


WITH DRAINAGE OF LYMPHO $452.92 20060701 99999999 

49324 

LAPAROSCOPY, SURGICAL; WITH INSERTION OF INTRAPERITONEAL 

CANNULA OR CATHETER, PE $248.28 20070101 99999999 

49325 

LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED 

INTRAPERITONEAL CANNUL $266.83 20070101 99999999 

49326 

LAPAROSCOPY, SURGICAL; WITH OMENTOPEXY (OMENTAL TACKING 

PROCEDURE) (LIST SEPARAT $120.33 20070101 99999999 

49329 

UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND 

OMENTUM $548.58 20000101 99999999 

49400 PNEUMOPERITONEUM (SEPARATE PROCEDURE) $80.29 20060701 99999999 

49402 

REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL 

CAVITY $532.43 20070101 99999999 

49419 

INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER, WITH 

SUBCUTANEOUS RESERVOIR, P $301.18 20060701 99999999 

49420 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR $103.28 20060701 99999999 

49421 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR $290.20 20060701 99999999 

49422 

REMOVAL OF PERMANENT INTRAPERITONEAL CANNULA OR 

CATHETER $297.22 20060701 99999999 

49423 

EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE 

CATHETER UNDER RADIOLOGIC $67.13 20060701 99999999 

49424 

CONTRAST INJECTION FOR ASSESSMENT OF ABSCESS OR CYST VIA 

PREVIOUSLY PLACED CATHE $34.35 20060701 99999999 

49425 PERITONEAL-VENOUS SHUNT (EG, LEVEEN SHUNT) $584.98 20060701 99999999 

49426 REVISION OF PERITONEAL-VENOUS SHUNT $461.01 20060701 99999999 

49427 

INJECTION PROCEDURE (EG, CONTRAST MEDIA) FOR EVALUATION OF 

PREVIOUSLY PLACED PER $36.89 20060701 99999999 

49428 LIGATION OF PERITONEAL-VENOUS SHUNT $252.09 20060701 99999999 

49429 REMOVAL OF PERITONEAL-VENOUS SHUNT $329.32 20060701 99999999 

49435 

INSERTION OF SUBCUTANEOUS EXTENSION TO INTRAPERITONEAL 

CANNULA OR CATHETER WITH $77.41 20070101 99999999 

49436 

DELAYED CREATION OF EXIT SITE FROM EMBEDDED SUBCUTANEOUS 

SEGMENT OF INTRAPERITON $118.49 20070101 99999999 

49440 INJ PROC FOR PELVIC PNEUMOGRAPHY $124.56 20080101 99999999 

49441 

INSERTION OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, 

PERCUTANEOUS, UNDER FLUOROSCOPIC $139.89 20080101 99999999 

49442 

INSERTION OF CECOSTOMY OR OTHER COLONIC TUBE, 

PERCUTANEOUS, UNDER FLUOROSCOPIC G $113.42 20080101 99999999 

49446 

CONVERSION OF GASTROSTOMY TUBE TO GASTRO-JEJUNOSTOMY 

TUBE, PERCUTANEOUS, UNDER F $88.90 20080101 99999999 

49450 

REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER 

COLONIC) TUBE, PERCUTANEOUS, U $35.77 20080101 99999999 

49451 

REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, 

PERCUTANEOUS, UNDER FLUOROSCOPI $49.63 20080101 99999999 

49452 

REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, 

UNDER FLUOROSCOPIC GUIDANC $77.44 20080101 99999999 

49460 

MECHANICAL REMOVAL OF OBSTRUCTIVE MATERIAL FROM 

GASTROSTOMY, DUODENOSTOMY, JEJUN $25.33 20080101 99999999 

49465 

CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF 

EXISTING GASTROSTOMY, DUODE $16.81 20080101 99999999 

49491 

REPAIR, INITIAL INGUINAL HERNIA, PRETERM INFANT (LESS THAN 37 

WEEKS GESTATION AT $476.47 20060701 99999999 

49492 

REPAIR, INITIAL INGUINAL HERNIA, PRETERM INFANT (LESS THAN 37 

WEEKS GESTATION AT $582.93 20060701 99999999 



49495 

REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 6 MONTHS, WITH OR 

WITHOUT HYDROCELECTO $310.63 20060701 99999999 

49496 

REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 6 MONTHS, WITH OR 

WITHOUT HYDROCELECTO $444.12 20060701 99999999 

49500 REPAIR INGUINAL HERNIA, UNDER AGE 5 YEARS, WITH OR WITHOUT $266.17 20060701 99999999 

49501 RPR INQNL HERNIA UNDER AGE 5 W/WO HYDRCLMY;BI $366.73 20060701 99999999 

49505 REPAIR INGUINAL HERNIA, AGE 5 OR OVER $320.63 20060701 99999999 

49507 

REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; 

INCARCERATED OR STRANGULATE $405.91 20060701 99999999 

49520 REPAIR INGUINAL HERNIA, ANY AGE $401.86 20060701 99999999 

49521 

REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR 

STRANGULATED $461.07 20060701 99999999 

49525 REPAIR INGUINAL HERNIA, ANY AGE $373.73 20060701 99999999 

49540 REPAIR LUMBAR HERNIA $425.09 20060701 99999999 

49550 REPAIR FEMORAL HERNIA, GROIN INCISION $354.10 20060701 99999999 

49553 REPAIR FEMORAL HERNIA;BILATERAL $379.37 20060701 99999999 

49555 REPAIR FEMORAL HERNIA, RECURRENT, ANY APPROACH $397.79 20060701 99999999 

49557 

REPAIR RECURRENT FEMORAL HERNIA; INCARCERATED OR 

STRANGULATED $454.61 20060701 99999999 

49560 REPAIR VENTRAL (INCISIONAL) HERNIA (SEPARATE PROCEDURE) $466.02 20060701 99999999 

49561 

REPAIR INITIAL INCISIONAL HERNIA; INCARCERATED OR 

STRANGULATED $539.91 20060701 99999999 

49565 REPAIR VENTRAL (INCISIONAL) HERNIA (SEPARATE PROCEDURE) $480.43 20060701 99999999 

49566 

REPAIR RECURRENT INCISIONAL HERNIA; INCARCERATED OR 

STRANGULATED $556.99 20060701 99999999 

49568 

IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR INCISIONAL 

HERNIA REPAIR (LIST SEPA $213.33 20060701 99999999 

49570 REPAIR EPIGASTRIC HERNIA, PROPERITONEAL FAT $264.30 20060701 99999999 

49572 

REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); 

INCARCERATED OR STRANGULATED $316.24 20060701 99999999 

49580 REPAIR UMBILICAL HERNIA $209.11 20060701 99999999 

49582 

REPAIR UMBILICAL HERNIA, UNDER AGE 5 YEARS; INCARCERATED OR 

STRANGULATED $310.03 20060701 99999999 

49585 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OVER; REDUCIBLE $285.21 20060701 99999999 

49587 

REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OVER; INCARCERATED 

OR STRANGULATED $319.84 20060701 99999999 

49590 REPAIR SPIGELIAN HERNIA $374.50 20060701 99999999 

49600 REPAIR OF OMPHALOCELE $473.64 20060701 99999999 

49605 REPAIR OF OMPHALOCELE $2,626.52 20060701 99999999 

49606 REPAIR OF OMPHALOCELE $816.81 20060701 99999999 

49610 REPAIR OF OMPHALOCELE (GROSS TYPE OPERATION) $497.88 20060701 99999999 

49611 REPAIR OF OMPHALOCELE (GROSS TYPE OPERATION) $498.46 20060701 99999999 

49650 LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA $309.04 20060701 99999999 

49651 LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA $395.21 20060701 99999999 

49900 SUTURE, SECONDARY, OF ABDOMINAL WALL FOR EVISCERATION $520.10 20060701 99999999 

49904 

OMENTAL FLAP, EXTRA-ABDOMINAL (EG, FOR RECONSTRUCTION OF 

STERNAL AND CHEST WALL $1,046.04 20060701 99999999 

49905 

OMENTAL FLAP (EG, FOR RECONSTRUCTION OF STERNAL AND CHEST 

WALL DEFECTS) (LIST SE $286.03 20060701 99999999 

49999 UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM $695.22 19990701 99999999 

50010 

RENAL EXPLORATION, NOT NECESSITATING OTHER SPECIFIC 

PROCEDURES $570.01 20060701 99999999 

50020 

DRAINAGE OF PERIRENAL OR RENAL ABSCESS (SEPARATE 

PROCEDURE) $692.83 20060701 99999999 

50021 DRAINAGE OF PERIRENAL OR RENAL ABSCESS; PERCUTANEOUS $177.90 20060701 99999999 

50040 NEPHROSTOMY, NEPHROTOMY WITH DRAINAGE $689.23 20060701 99999999 

50045 NEPHROTOMY, WITH EXPLORATION $723.63 20060701 99999999 

50060 NEPHROLITHOTOMY $886.97 20060701 99999999 





50075 NEPHROLITHOTOMY $1,170.63 20060701 99999999 

50080 PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, $764.15 20060701 99999999 

50081 PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, $1,044.82 20060701 99999999 

50100 TRANSECTION OR REPOSITIONING OF ABERRANT RENAL VESSELS $796.71 20060701 99999999 

50120 PYELOTOMY $752.77 20060701 99999999 

50125 PYELOTOMY $782.35 20060701 99999999 

50130 PYELOTOMY $831.51 20060701 99999999 

50135 PYELOTOMY $966.53 20060701 99999999 

50200 RENAL BIOPSY $129.47 20060701 99999999 

50205 RENAL BIOPSY $511.48 20060701 99999999 

50220 

NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY 

APPROACH $841.70 20060701 99999999 

50225 


APPROACH $994.91 20060701 99999999 

50230 


APPROACH $1,243.21 20060701 99999999 

50234 NEPHRECTOMY WITH TOTAL URETERECTOMY AND BLADDER CUFF $1,066.87 20060701 99999999 

50236 NEPHRECTOMY WITH TOTAL URETERECTOMY AND BLADDER CUFF $1,196.92 20060701 99999999 

50240 NEPHRECTOMY, PARTIAL $1,074.81 20060701 99999999 

50250 

ABLATION, OPEN, ONE OR MORE RENAL MASS LESION(S), 

CRYOSURGICAL, INCLUDING INTRAO $794.68 20060701 99999999 

50280 EXCISION OR UNROOFING OF CYST(S) OF KIDNEY $746.78 20060701 99999999 

50290 EXCISION OF PERINEPHRIC CYST $686.47 20060701 99999999 

50320 DONOR NEPHRECTOMY, WITH PREPARATION AND MAINTENANCE OF $1,071.86 20060701 99999999 

50327 


RENAL ALLOGRAFT PRIOR TO $156.77 20060701 99999999 

50328 



50329 



50340 RECIPIENT NEPHRECTOMY (SEPARATE PROCEDURE) $702.01 20060701 99999999 

50360 RENAL HOMOTRANSPLANTATION, IMPLANTATION OF GRAFT $1,582.57 20060701 99999999 

50365 RENAL HOMOTRANSPLANTATION, IMPLANTATION OF GRAFT $1,884.60 20060701 99999999 

50370 

REMOVAL OF TRANSPLANTED HOMOGRAFT (EG, INFARCTED OR 

REJECTED $724.90 20060701 99999999 

50380 RENAL AUTOTRANSPLANTATION, REIMPLANTATION OF KIDNEY $956.07 20060701 99999999 

50382 

REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY 

DWELLING URETERAL STEN $199.48 20060701 99999999 

50384 

REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING 

URETERAL STENT VIA PERCUTANEO $181.64 20060701 99999999 

50385 

REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY 

DWELLING URETERAL STEN $131.59 20080101 99999999 

50386 

REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING 

URETERAL STENT VIA TRANSURETH $99.88 20080101 99999999 

50387 

REMOVAL AND REPLACEMENT OF EXTERNALLY ACCESSIBLE 

TRANSNEPHRIC URETERAL STENT (EG $72.18 20060701 99999999 

50389 

REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC 

GUIDANCE (EG, WITH CONCURREN $39.82 20060701 99999999 

50390 

ASPIRATION AND/OR INJECTION OF RENAL CYST OR PELVIS BY 

NEEDLE, $90.69 20060701 99999999 

50391 

INSTILLATION(S) OF THERAPEUTIC AGENT INTO RENAL PELVIS 

AND/OR URETER THROUGH $75.81 20060701 99999999 

50392 

INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL 

PELVIS $146.77 20060701 99999999 



50393 INTRODUCTION OF URETERAL CATHETER OR STENT INTO $182.39 20060701 99999999 

50394 INJECTION PROCEDURE FOR PYELOGRAPHY (AS NEPHROSTOGRAM, $34.95 20060701 99999999 

50395 INTRODUCTION OF GUIDE INTO RENAL PELVIS AND/OR URETER $163.30 20060701 99999999 

50396 

MANOMETRIC STUDIES THROUGH NEPHROSTOMY OR PYELOSTOMY 

TUBE, OR $77.41 20060701 99999999 

50398 CHANGE OF NEPHROSTOMY OR PYELOSTOMY TUBE $55.20 20060701 99999999 

50400 

PYELOPLASTY (FOLEY Y-PYELOPLASTY), PLASTIC OPERATION ON 

RENAL $918.87 20060701 99999999 

50405 

PYELOPLASTY (FOLEY Y-PYELOPLASTY), PLASTIC OPERATION ON 

RENAL $1,151.74 20060701 99999999 

50500 NEPHRORRHAPHY, SUTURE OF KIDNEY WOUND OR INJURY $938.12 20060701 99999999 

50520 CLOSURE OF NEPHROCUTANEOUS OR PYELOCUTANEOUS FISTULA $817.28 20060701 99999999 

50525 

CLOSURE OF NEPHROVISCERAL FISTULA (EG, RENOCOLIC), 

INCLUDING $1,044.74 20060701 99999999 

50526 

CLOSURE OF NEPHROVISCERAL FISTULA (EG, RENOCOLIC), 

INCLUDING $1,029.74 20060701 99999999 

50540 

SYMPHYSIOTOMY FOR HORSESHOE KIDNEY WITH OR WITHOUT 

PYELOPLASTY $934.90 20060701 99999999 

50541 LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS $650.50 20060701 99999999 

50542 LAPAROSCOPY, SURGICAL; ABLATION OF RENAL MASS LESION(S) $806.44 20060701 99999999 

50543 LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY $1,015.39 20060701 99999999 

50544 LAPAROSCOPY, SURGICAL; PYELOPLASTY $894.84 20060701 99999999 

50545 

LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES 

REMOVAL OF GEROTA¦S FASCIA $939.60 20060701 99999999 

50546 LAPAROSCOPY, SURGICAL; NEPHRECTOMY $830.93 20060701 99999999 

50547 

LAPAROSCOPY, SURGICAL; DONOR NEPHRECTOMY FROM LIVING 

DONOR (EXCLUDING PREPARATIO $1,070.27 20060701 99999999 

50548 LAPAROSCOPICALLY ASSISTED NEPHROURETERECTOMY $973.94 20060701 99999999 

50551 

RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR 

PYELOSTOMY, $221.80 20060701 99999999 

50553 


PYELOSTOMY, $225.77 20060701 99999999 

50555 


PYELOSTOMY, $293.87 20060701 99999999 

50557 


PYELOSTOMY, $297.92 20060701 99999999 

50559 


PYELOSTOMY, $246.11 19990701 99999999 

50561 


PYELOSTOMY, $336.24 20060701 99999999 

50562 


PYELOSTOMY, WITH OR WITHOUT I $426.59 20060701 99999999 

50570 

RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH 

OR WITHOUT $339.11 20060701 99999999 

50572 


OR WITHOUT $461.96 20060701 99999999 

50574 


OR WITHOUT $482.34 20060701 99999999 

50575 


OR WITHOUT IRRIGATION, INS $629.36 20060701 99999999 

50576 


OR WITHOUT $510.44 20060701 99999999 

50578 


OR WITHOUT $445.49 19990701 99999999 

50580 


OR WITHOUT $452.31 20060701 99999999 

50590 LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE $538.30 20060701 99999999 



50592 

ABLATION, ONE OR MORE RENAL TUMOR(S), PERCUTANEOUS, 

UNILATERAL, RADIOFREQUENCY $264.93 20060701 99999999 

50593 

ABLATION, RENAL TUMOR(S), UNILATERAL, PERCUTANEOUS, 

CRYOTHERAPY $252.36 20080101 99999999 

50600 

URETEROTOMY WITH EXPLORATION OR DRAINAGE (SEPARATE 

PROCEDURE) $731.97 20060701 99999999 

50605 URETEROTOMY FOR INSERTION OF INDWELLING STENT, ALL TYPES $664.87 20060701 99999999 

50610 URETEROLITHOTOMY $773.06 20060701 99999999 



50650 URETERECTOMY, WITH BLADDER CUFF (SEPARATE PROCEDURE) $828.06 20060701 99999999 

50660 

URETERECTOMY, TOTAL, ECTOPIC URETER, COMBINATION 

ABDOMINAL, $908.47 20060701 99999999 

50684 

INJECTION PROCEDURE FOR URETEROGRAPHY OR 

URETEROPYELOGRAPHY $33.16 20060701 99999999 

50686 

MANOMETRIC STUDIES THROUGH URETEROSTOMY OR INDWELLING 

URETERAL $57.27 20060701 99999999 

50688 CHANGE OF URETEROSTOMY TUBE $60.73 20060701 99999999 

50690 

INJECTION PROCEDURE FOR VISUALIZATION OF ILIAL CONDUIT 

AND/OR $45.97 20060701 99999999 

50700 URETEROPLASTY, PLASTIC OPERATION ON URETER (EG, STRICTURE) $765.29 20060701 99999999 

50715 URETEROLYSIS, WITH OR WITHOUT REPOSITIONING OF URETER FOR $889.96 20060701 99999999 

50722 URETEROLYSIS FOR OVARIAN VEIN SYNDROME $771.44 20060701 99999999 

50725 

URETEROLYSIS FOR RETROCAVAL URETER, WITH REANASTOMOSIS 

OF $873.50 20060701 99999999 

50727 

REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE 

UROSTOMY); $410.72 20060701 99999999 

50728 

REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE 

UROSTOMY); WITH REPAIR OF FA $591.11 20060701 99999999 

50740 

URETEROPYELOSTOMY, ANASTOMOSIS OF URETER AND RENAL 

PELVIS $883.84 20060701 99999999 

50750 

URETEROCALYCOSTOMY, ANASTOMOSIS OF URETER TO RENAL 

CALYX $930.60 20060701 99999999 

50760 URETEROURETEROSTOMY $887.21 20060701 99999999 

50770 TRANSURETEROURETEROSTOMY, ANASTOMOSIS OF URETER TO $949.89 20060701 99999999 

50780 

URETERONEOCYSTOSTOMY, ANASTOMOSIS OF URETER TO 

BLADDER, $889.13 20060701 99999999 

50782 

URETERONEOCYSTOSTOMY; ANASTOMOSIS OF DUPLICATED URETER 

TO BLADDER $935.10 20060701 99999999 

50783 URETERONEOCYSTOSTOMY; WITH EXTENSIVE URETERAL TAILORING $965.55 20060701 99999999 

50785 URETERONEOCYSTOSTOMY, WITH BLADDER FLAP $989.20 20060701 99999999 

50800 

URETEROENTEROSTOMY, DIRECT ANASTOMOSIS OF URETER TO 

INTESTINE $792.79 20060701 99999999 

50810 URETEROSIGMOIDOSTOMY, WITH CREATION OF SIGMOID BLADDER $974.91 20060701 99999999 

50815 URETEROCOLON CONDUIT, INCLUDING BOWEL ANASTOMOSIS $1,059.57 20060701 99999999 

50820 URETEROILEAL CONDUIT (ILEAL BLADDER), INCLUDING BOWEL $1,110.05 20060701 99999999 

50825 CONTINENT DIVERSION INCL BOWEL ANASTOMOSIS $1,518.52 20060701 99999999 

50830 URINARY UNDIVERSION $1,458.64 20060701 99999999 

50840 

REPLACEMENT OF ALL OR PART OF URETER BY BOWEL SEGMENT, 

INCLUDING $953.06 20060701 99999999 

50845 CUTANEOUS APPENDICO-VESICOSTOMY $962.69 20060701 99999999 

50860 URETEROSTOMY, TRANSPLANTATION OF URETER TO SKIN $743.24 20060701 99999999 

50900 URETERORRHAPHY, SUTURE OF URETER (SEPARATE PROCEDURE) $667.14 20060701 99999999 

50920 CLOSURE OF URETEROCUTANEOUS FISTULA $686.08 20060701 99999999 

50930 

CLOSURE OF URETEROVISCERAL FISTULA (INCLUDING VISCERAL 

REPAIR) $878.92 20060701 99999999 



50940 DELIGATION OF URETER $708.45 20060701 99999999 

50945 LAPAROSCOPY, SURGICAL, URETEROLITHOTOMY $687.48 20060701 99999999 

50947 

LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH 

CYSTOSCOPY AND URETERAL STENT P $1,023.82 20060701 99999999 

50948 

LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT 

CYSTOSCOPY AND URETERAL STEN $935.27 20060701 99999999 

50951 

URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, 

WITH OR $221.14 20060701 99999999 

50953 


WITH OR $234.04 20060701 99999999 

50955 


WITH OR $263.92 20060701 99999999 

50957 


WITH OR $266.16 20060701 99999999 

50959 


WITH OR $200.94 19990701 99999999 

50961 


WITH OR $242.63 20060701 99999999 

50970 

URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR 

WITHOUT IRRIGATION, $323.84 20060701 99999999 

50972 



50974 



50976 



50978 



50980 



51000 ASPIRATION OF BLADDER BY NEEDLE $33.63 20030401 99999999 

51005 ASPIRATION OF BLADDER $42.26 20030401 99999999 

51010 ASPIRATION OF BLADDER $141.75 20030401 99999999 

51020 CYSTOTOMY OR CYSTOSTOMY $380.45 20060701 99999999 

51030 CYSTOTOMY OR CYSTOSTOMY $345.97 20060701 99999999 

51040 CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE $293.18 20060701 99999999 

51045 

CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT 

(SEPARATE $352.97 20060701 99999999 

51050 

CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, 

WITHOUT $430.94 20060701 99999999 

51060 TRANSVESICAL URETEROLITHOTOMY $498.15 20060701 99999999 

51065 

CYSTOTOMY, WITH STONE BASKET EXTRACTION AND/OR 

ULTRASONIC OR $452.68 20060701 99999999 

51080 DRAINAGE OF PERIVESICAL OR PREVESICAL SPACE ABSCESS $329.90 20060701 99999999 

51100 ASPIRATION OF BLADDER; BY NEEDLE $21.13 20080101 99999999 

51101 ASPIRATION OF BLADDER; BY TROCAR OR INTRACATHETER $27.79 20080101 99999999 

51102 

ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC 

CATHETER $136.10 20080101 99999999 

51500 

EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT 

UMBILICAL $494.78 20060701 99999999 

51520 CYSTOTOMY $492.96 20060701 99999999 

51525 CYSTOTOMY $684.56 20060701 99999999 

51530 CYSTOTOMY $612.79 20060701 99999999 

51535 CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE $594.46 20060701 99999999 

51550 CYSTECTOMY, PARTIAL $746.85 20060701 99999999 

51555 CYSTECTOMY, PARTIAL $960.93 20060701 99999999 

51565 CYSTECTOMY, PARTIAL, WITH REIMPLANTATION OF URETER(S) INTO $1,037.68 20060701 99999999 

51570 CYSTECTOMY, COMPLETE $1,121.73 20060701 99999999 



51575 CYSTECTOMY, COMPLETE $1,459.21 20060701 99999999 

51580 CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR $1,433.19 20060701 99999999 

51585 CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR $1,658.56 20060701 99999999 

51590 

CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR 

SIGMOID $1,558.35 20060701 99999999 

51595 

CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR 

SIGMOID $1,861.32 20060701 99999999 

51596 

CYSTECTOMY COMPL W/CONTINENT DIVERSION INCL BOWEL 

ANASTOMOSI $1,963.82 20060701 99999999 

51597 PELVIC EXENTERATION, COMPLETE, FOR VESICAL, PROSTATIC OR $1,863.15 20060701 99999999 

51600 

INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING 

URETHROCYSTOGRAPHY $32.89 20060701 99999999 

51605 

INJECTION PROCEDURE AND PLACEMENT OF CHAIN FOR CONTRAST 

AND/OR $26.01 20060701 99999999 

51610 INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY $40.43 20060701 99999999 

51700 BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION $30.96 20060701 99999999 

51701 

INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT 

CATHETERIZATION FOR R $19.82 20060701 99999999 

51702 

INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; 

SIMPLE (EG, FOLEY) $21.90 20060701 99999999 

51703 

INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; 

COMPLICATED (EG, ALTERED ANA $58.37 20060701 99999999 

51705 CHANGE OF CYSTOSTOMY TUBE $49.55 20060701 99999999 

51710 CHANGE OF CYSTOSTOMY TUBE $66.41 20060701 99999999 

51715 

ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE 

SUBMUCOSAL TISSUES OF THE URET $168.80 20060701 99999999 

51720 BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING $68.68 20060701 99999999 

51725 SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL MANOMETER) $178.89 20060701 99999999 

51726 

COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC 

EQUIPMENT) $232.33 20060701 99999999 

51736 

SIMPLE UROFLOWMETRY (UFR) (EG, STOP-WATCH FLOW RATE, 

MECHANICAL $30.09 20060701 99999999 

51741 

COMPLEX UROFLOWMETRY (EG, CALIBRATED ELECTRONIC 

EQUIPMENT) $51.59 20060701 99999999 

51772 URETHRAL PRESSURE PROFILE STUDIES (UPP) (URETHRAL CLOSURE $181.65 20060701 99999999 

51784 

ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL 

SPHINCTER, OTHER THAN NEEDLE, $138.67 20060701 99999999 

51785 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL $150.11 20060701 99999999 

51792 

STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF 

BULBOCAVERNOSUS $180.61 20060701 99999999 

51795 VOIDING PRESSURE STUDIES (VP) $223.63 20060701 99999999 

51797 VOIDING PRESSURE STUDIES (VP) $186.18 20060701 99999999 

51798 

MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR 

BLADDER CAPACITY BY ULTRASOUND $15.83 20060701 99999999 

51800 CYSTOPLASTY OR CYSTOURETHROPLASTY, PLASTIC OPERATION ON $825.34 20060701 99999999 

51820 CYSTOURETHROPLASTY WITH UNILATERAL OR BILATERAL $780.81 20060701 99999999 

51840 ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY $551.43 20060701 99999999 

51841 ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY $668.26 20060701 99999999 

51845 ABDOMINO-VAGINAL VESICAL NECK SUSPENSION, WITH OR WITHOUT $546.20 20060701 99999999 

51860 

CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR 

RUPTURE $581.94 20060701 99999999 

51865 

CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR 

RUPTURE $735.21 20060701 99999999 

51880 CLOSURE OF CYSTOSTOMY (SEPARATE PROCEDURE) $377.65 20060701 99999999 

51900 CLOSURE OF VESICOVAGINAL FISTULA, ABDOMINAL APPROACH $675.48 20060701 99999999 



51920 CLOSURE OF VESICOUTERINE FISTULA $561.93 20060701 99999999 

51925 CLOSURE OF VESICOUTERINE FISTULA $744.32 20060701 99999999 

51940 CLOSURE OF BLADDER EXSTROPHY $1,282.67 20060701 99999999 

51960 ENTEROCYSTOPLASTY, INCLUDING BOWEL ANASTOMOSIS $1,188.89 20060701 99999999 

51980 CUTANEOUS VESICOSTOMY $548.63 20060701 99999999 

51990 

LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS 

INCONTINENCE $535.99 20060701 99999999 

51992 

LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS 

INCONTINENCE (EG, FASCIA OR SY $582.01 20060701 99999999 

52000 CYSTOURETHROSCOPY (SEPARATE PROCEDURE) $77.48 20060701 99999999 

52001 

CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF 

CLOTS $178.65 20060701 99999999 

52005 CYSTOURETHROSCOPY, $115.52 20060701 99999999 



52204 CYSTOURETHROSCOPY, WITH BIOPSY $118.32 20060701 99999999 

52214 

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING 

CRYOSURGERY OR $169.94 20060701 99999999 

52224 



52234 



52235 



52240 



52250 

CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE 

SUBSTANCE, $196.97 20060701 99999999 

52260 

CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR 

INTERSTITIAL $165.11 20060701 99999999 

52265 

CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR 

INTERSTITIAL $108.76 20060701 99999999 

52270 CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY $170.16 20060701 99999999 

52275 CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY $213.08 20060701 99999999 

52276 

CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL 

URETHROTOMY $242.69 20060701 99999999 

52277 CYSTOURETHROSCOPY, WITH RESECTION OF EXTERNAL SPHINCTER $285.52 20060701 99999999 

52281 

CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF 

URETHRAL $112.00 20060701 99999999 

52282 CYSTOURETHROSCOPY, WITH INSERTION OF URETHRAL STENT $288.76 20060701 99999999 

52283 CYSTOURETHROSCOPY, WITH STEROID INJECTION INTO STRICTURE $148.90 20060701 99999999 

52285 CYSTOURETHROSCOPY FOR TREATMENT OF THE FEMALE URETHRAL $144.23 20060701 99999999 

52290 CYSTOURETHROSCOPY $191.23 20060701 99999999 


52301 

CYSTOURETHROSCOPY; WITH URETERAL MEATOTOMY, 

UNILATERAL/BILATERAL WITH RESECTION $241.41 20060701 99999999 


52310 

CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, 

CALCULUS, $143.45 20060701 99999999 

52315 

CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, 

CALCULUS, $240.98 20060701 99999999 

52317 LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY $326.69 20060701 99999999 

52318 

LITHOLAPAXY;CRUSHING OR FRAGMENTATION OF CALCULUS;OVER 

2.5CM $436.67 20060701 99999999 

52320 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION) $237.10 20060701 99999999 




52327 

CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); 

WITH SUBURETERIC INJECTI $234.22 20060701 99999999 


52332 CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING $146.15 20060701 99999999 

52334 CYSTOURETHROSCOPY WITH INSERTION OF URETERAL GUIDE WIRE $215.51 20060701 99999999 

52335 

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR 

PYELOSCOPY $272.56 19990701 99999999 

52336 


PYELOSCOPY $355.17 19990701 99999999 

52337 


PYELOSCOPY $410.93 19990701 99999999 

52338 


PYELOSCOPY $342.45 19990701 99999999 

52339 


PYELOSCOPY (INCLUDES DILATION OF THE $391.45 19990701 99999999 

52340 

CYSTOURETHROSCOPY WITH INCISION, FULGURATION, OR 

RESECTION OF $434.73 19990701 99999999 

52341 

CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE 

(EG, BALLOON DILATION, L $234.26 20060701 99999999 

52342 

CYSTOURETHROSCOPY; WITH TREATMENT OF URETEROPELVIC 

JUNCTION STRICTURE (EG, BALLO $253.48 20060701 99999999 

52343 

CYSTOURETHROSCOPY; WITH TREATMENT OF INTRA-RENAL 

STRICTURE (EG, BALLOON DILATION $280.74 20060701 99999999 

52344 

CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF 

URETERAL STRICTURE (EG, B $415.48 20060701 99999999 

52345 


URETEROPELVIC JUNCTION ST $319.74 20060701 99999999 

52346 


INTRA-RENAL STRICTURE (EG $360.04 20060701 99999999 

52347 

CYSTOURETHROSCOPY WITH TRANSURETHRAL RESECTION OR 

INCISION OF EJACULATORY DUCTS $207.06 20020101 99999999 

52351 


PYELOSCOPY; DIAGNOSTIC $303.33 20060701 99999999 

52352 


PYELOSCOPY; WITH REMOVAL OR MANIPULA $256.17 20060701 99999999 

52353 


PYELOSCOPY; WITH LITHOTRIPSY (URETER $411.89 20060701 99999999 

52354 


PYELOSCOPY; WITH BIOPSY AND/OR FULGU $273.46 20060701 99999999 

52355 


PYELOSCOPY; WITH RESECTION OF TUMOR $328.74 20060701 99999999 

52400 

CYSTOURETHROSCOPY WITH INCISION, FULGURATION, OR 

RESECTION OF CONGENITAL POSTERI $433.03 20060701 99999999 

52402 

CYSTOURETHROSCOPY WITH TRANSURETHRAL RESECTION OR 

INCISION OF EJACULATORY DUCTS $204.53 20060701 99999999 

52450 TRANSURETHRAL INCISION OF PROSTATE $387.08 20060701 99999999 

52500 

TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE 

PROCEDURE) $455.39 20060701 99999999 

52510 

TRANSURETHRAL BALLOON DILATION OF THE PROSTATIC URETHRA, 

ANY METHOD $392.69 20030401 99999999 

52601 

TRANSURETHRAL RESECTION OF PROSTATE, INCLUDING CONTROL 

OF $659.28 20060701 99999999 

52606 TRANSURETHRAL FULGURATION FOR POSTOPERATIVE BLEEDING $369.48 20060701 99999999 

52612 TRANSURETHRAL RESECTION OF PROSTATE $462.59 20060701 99999999 

52614 TRANSURETHRAL RESECTION OF PROSTATE $395.59 20060701 99999999 

52620 TRANSURETHRAL RESECTION $358.47 20060701 99999999 





52647 

NON-CONTACT LASER COAGULATION OF PROSTATE, INCLUDING 

CONTROL OF POSTOPERATIVE BL $554.10 20060701 99999999 

52648 

CONTACT LASER VAPORIZATION WITH OR WITHOUT 

TRANSURETHRAL RESECTION OF PROSTATE, $620.08 20060701 99999999 

52649 

LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, 

INCLUDING CONTROL OF POSTOP $541.97 20080101 99999999 

52700 TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS $330.54 20060701 99999999 

53000 

URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE 

PROCEDURE) $127.75 20060701 99999999 

53010 

URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE 

PROCEDURE) $218.38 20060701 99999999 

53020 MEATOTOMY, CUTTING OF MEATUS (SEPARATE PROCEDURE) $72.72 20060701 99999999 

53025 MEATOTOMY, CUTTING OF MEATUS (SEPARATE PROCEDURE) $51.13 20060701 99999999 

53040 DRAINAGE OF DEEP PERIURETHRAL ABSCESS $350.40 20060701 99999999 

53060 DRAINAGE OF SKENE'S GLAND ABSCESS OR CYST $118.00 20060701 99999999 

53080 DRAINAGE OF PERINEAL URINARY EXTRAVASATION $368.83 20060701 99999999 

53085 DRAINAGE OF PERINEAL URINARY EXTRAVASATION $538.45 20060701 99999999 

53200 BIOPSY OF URETHRA $104.35 20060701 99999999 

53210 URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY $574.43 20060701 99999999 

53215 URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY $727.62 20060701 99999999 

53220 EXCISION OR FULGURATION OF CARCINOMA OF URETHRA $350.72 20060701 99999999 

53230 EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE) $488.48 20060701 99999999 

53235 EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE) $458.13 20060701 99999999 

53240 MARSUPIALIZATION OF URETHRAL DIVERTICULUM, MALE OR FEMALE $324.96 20060701 99999999 

53250 EXCISION OF BULBOURETHRAL GLAND (COWPER'S GLAND) $297.68 20060701 99999999 

53260 EXCISION OR FULGURATION $134.32 20060701 99999999 




53400 URETHROPLASTY $591.90 20060701 99999999 

53405 URETHROPLASTY $695.66 20060701 99999999 

53410 

URETHROPLASTY, ONE-STAGE RECONSTRUCTION OF MALE 

ANTERIOR $729.91 20060701 99999999 

53415 URETHROPLASTY, TRANSPUBIC OR PERINEAL, ONE STAGE, FOR $877.08 20060701 99999999 

53420 

URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF 

PROSTATIC $697.18 20060701 99999999 

53425 

URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF 

PROSTATIC $731.84 20060701 99999999 

53430 URETHROPLASTY, RECONSTRUCTION OF FEMALE URETHRA $705.64 20060701 99999999 

53431 

URETHROPLASTY WITH TUBULARIZATION OF POSTERIOR URETHRA 

AND/OR LOWER BLADDER FOR $776.62 20060701 99999999 

53440 

OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE, 

WITH OR $684.87 20060701 99999999 

53442 REMOVAL OF PERINEAL PROSTHESIS INTRODUCED FOR CONTINENCE $416.54 20060701 99999999 

53443 

URETHROPLASTY WITH TUBULARIZATION OF POSTERIOR URETHRA 

AND/OR $868.46 19990701 99999999 

53444 INSERTION OF TANDEM CUFF (DUAL CUFF) $560.48 20060701 99999999 

53445 

OPERATION FOR CORRECTION OF URINARY INCONTINENCE WITH 

PLACEMENT $774.74 20060701 99999999 

53446 

REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, 

INCLUDING PUMP, RESERVOIR $526.92 20060701 99999999 

53447 

REMOVAL, REPAIR OR REPLACEMENT OF INFLATABLE SPHINCTER 

INCLUDING $633.87 20060701 99999999 

53448 

REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER 

NECK SPHINCTER INCLUDING $938.99 20060701 99999999 



53449 

SURGICAL CORRECTION OF HYDRAULIC ABNORMALITY OF 

INFLATABLE $504.80 20060701 99999999 

53450 URETHROMEATOPLASTY, WITH MUCOSAL ADVANCEMENT $284.54 20060701 99999999 

53460 

URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL 

URETHRAL $312.65 20060701 99999999 

53500 

URETHROLYSIS, TRANSVAGINAL, SECONDARY, OPEN, INCLUDING 

CYSTOURETHROSCOPY (EG, PO $534.29 20060701 99999999 

53502 

URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY, 

FEMALE $377.78 20060701 99999999 

53505 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY $375.47 20060701 99999999 



53520 

CLOSURE OF URETHROSTOMY OR URETHROCUTANEOUS FISTULA, 

MALE $423.26 20060701 99999999 

53600 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND $42.95 20060701 99999999 

53601 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND $35.09 20060701 99999999 

53605 

DILATION OF URETHRAL STRICTURE OR VESICAL NECK BY PASSAGE 

OF $50.34 20060701 99999999 

53620 DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND $57.92 20060701 99999999 

53621 DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND $48.13 20060701 99999999 

53660 DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR $25.92 20060701 99999999 

53661 DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR $25.88 20060701 99999999 

53665 DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION $31.54 20060701 99999999 

53670 CATHETERIZATION, URETHRA $18.27 20030401 99999999 

53675 CATHETERIZATION, URETHRA $56.53 20030401 99999999 

53850 

TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY 

MICROWAVE THERMOTHERAPY $475.57 20060701 99999999 

53852 

TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY 

RADIOFREQUENCY THERMOTHERAPY $464.57 20060701 99999999 

53853 

TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY WATER- 

INDUCED THERMOTHERAPY $330.37 20060701 99999999 

54000 

SLITTING OF PREPUCE, DORSAL OR LATERAL, (SEPARATE 

PROCEDURE) $73.34 20060701 99999999 

54001 

SLITTING OF PREPUCE, DORSAL OR LATERAL, (SEPARATE 

PROCEDURE) $103.30 20060701 99999999 

54015 INCISION AND DRAINAGE OF PENIS, DEEP $207.58 20060701 99999999 

54050 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, $55.81 20060701 99999999 






54100 BIOPSY OF PENIS $73.71 20060701 99999999 

54105 BIOPSY OF PENIS $144.20 20060701 99999999 

54110 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE) $496.48 20060701 99999999 



54115 REMOVAL FOREIGN BODY FROM DEEP PENILE TISSUE $333.96 20060701 99999999 

54120 AMPUTATION OF PENIS $499.00 20060701 99999999 

54125 AMPUTATION OF PENIS $702.97 20060701 99999999 

54130 AMPUTATION OF PENIS, RADICAL $980.12 20060701 99999999 

54135 AMPUTATION OF PENIS, RADICAL $1,240.88 20060701 99999999 

54150 CIRCUMCISION, CLAMP PROCEDURE $84.95 20060701 99999999 

54152 CIRCUMCISION, CLAMP PROCEDURE $119.74 19990701 99999999 

54160 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP OR DORSAL $122.85 20060701 99999999 

54161 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP OR DORSAL $156.61 20060701 99999999 



54162 LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS $167.12 20060701 99999999 

54163 REPAIR INCOMPLETE CIRCUMCISION $156.28 20060701 99999999 

54164 FRENULOTOMY OF PENIS $137.66 20060701 99999999 

54200 INJECTION PROCEDURE FOR PEYRONIE DISEASE $50.18 20060701 99999999 

54205 INJECTION PROCEDURE FOR PEYRONIE DISEASE $407.32 20060701 99999999 

54220 IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM $106.48 20060701 99999999 

54230 INJECTION PROCEDURE FOR CORPORA CAVERNOSOGRAPHY $66.90 20060701 99999999 

54231 

DYNAMIC CAVERNOSOMETRY, INCLUDING INTRACAVERNOSAL 

INJECTION OF VASOCACTIVE DRUGS $92.12 20060701 99999999 

54235 INJ OF CORPORA CAVERNOSA W/PHARMACOLOGIC AGENT $43.05 20030401 99999999 

54240 PENILE PLETHYSMOGRAPHY $69.80 20060701 99999999 

54250 NOCTURNAL PENILE TUMESCENCE AND/OR RIGIDITY TEST $92.74 20060701 99999999 

54300 

PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE 

(EG, $533.72 20060701 99999999 

54304 

PLASTIC OPERATION ON PENIS FOR CORRECTION OF CHORDEE OR 

FOR $634.82 20060701 99999999 

54308 

URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR 

(INCLUDING $562.00 20060701 99999999 

54312 


(INCLUDING $685.61 20060701 99999999 

54316 


(INCLUDING $844.70 20060701 99999999 

54318 

URETHROPLASTY FOR THIRD STAGE HYPOSPADIAS REPAIR TO 

RELEASE $579.02 20060701 99999999 

54322 ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT $622.54 20060701 99999999 




54332 

ONE STAGE PROXIMAL PENILE OR PENOSCROTAL HYPOSPADIAS 

REPAIR $850.74 20060701 99999999 

54336 ONE STAGE PERINEAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE $1,078.15 20060701 99999999 

54340 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, $468.25 20060701 99999999 



54352 

REPAIR OF HYPOSPADIAS CRIPPLE REQUIRING EXTENSIVE 

DISSECTION $1,162.81 20060701 99999999 

54360 PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION $574.41 20060701 99999999 

54380 

PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO 

EXTERNAL $677.75 20060701 99999999 

54385 


EXTERNAL $781.26 20060701 99999999 

54390 


EXTERNAL $1,045.09 20060701 99999999 

54400 INSERTION OF PENILE PROSTHESIS $508.38 20060701 99999999 

54401 INSERTION OF PENILE PROSTHESIS INFLATABLE SELF CONTAINED $578.64 20060701 99999999 

54402 REMOVAL OR REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) $448.93 19990701 99999999 

54405 

INSERTION OF INFLATABLE (MULTI-COMPONENT) PENILE 

PROSTHESIS, $741.57 20060701 99999999 

54406 

REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, 

INFLATABLE PENILE PROSTHESIS WIT $510.22 20060701 99999999 

54407 

REMOVAL, REPAIR, OR REPLACEMENT OF INFLATABLE (MULTI- 

COMPONENT) $673.77 19990701 99999999 

54408 

REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE 

PENILE PROSTHESIS $537.95 20020101 99999999 



54409 

SURGICAL CORRECTION OF HYDRAULIC ABNORMALITY OF 

INFLATABLE $597.05 19990701 99999999 

54410 

REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI- 

COMPONENT, INFLATABLE PEN $635.77 20020101 99999999 

54411 

REMOVAL AND REPLACEMENT OF ALL COMPONENTS OF A MULTI- 

COMPONENT INFLATABLE PENILE $696.23 20020101 99999999 

54415 

REMOVAL OF NON-INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF- 

CONTAINED) PENILE PRO $381.77 20060701 99999999 

54416 

REMOVAL AND REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) OR 

INFLATABLE (SELF-CONTA $497.72 20020101 99999999 

54417 

REMOVAL AND REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) OR 

INFLATABLE (SELF-CONTA $611.83 20060701 99999999 

54420 

CORPORA CAVERNOSA-SAPHENOUS VEIN SHUNT (PRIAPISM 

OPERATION), $577.71 20060701 99999999 

54430 CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUNT $513.53 20060701 99999999 

54435 CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY $324.87 20060701 99999999 

54450 FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL $48.69 20060701 99999999 

54500 BIOPSY OF TESTIS, NEEDLE (SEPARATE PROCEDURE) $50.82 20060701 99999999 

54505 BIOPSY OF TESTIS, INCISIONAL (SEPARATE PROCEDURE) $165.54 20060701 99999999 

54510 EXCISION OF LOCAL LESION OF TESTIS $254.53 19990701 99999999 

54512 EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS $387.17 20060701 99999999 

54520 

ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR 

WITHOUT $287.86 20060701 99999999 

54522 ORCHIECTOMY, PARTIAL $440.50 20060701 99999999 

54530 ORCHIECTOMY, RADICAL, FOR TUMOR $439.28 20060701 99999999 

54535 ORCHIECTOMY, RADICAL, FOR TUMOR $589.28 20060701 99999999 

54550 

EXPLORATION FOR UNDESCENDED TESTIS (INGUINAL OR SCROTAL 

AREA) $375.87 20060701 99999999 

54560 

EXPLORATION FOR UNDESCENDED TESTIS WITH ABDOMINAL 

EXPLORATION $537.78 20060701 99999999 

54600 REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT $335.07 20060701 99999999 

54620 FIXATION OF CONTRALATERAL TESTIS (SEPARATE PROCEDURE) $238.81 20060701 99999999 

54640 ORCHIOPEXY, ANY TYPE, WITH OR WITHOUT HERNIA REPAIR $384.52 20060701 99999999 

54650 

ORCHIOPEXY, ABDOMINAL APPROACH, FOR INTRA-ABDOMINAL 

TESTIS (EG, FOWLER-STEPHENS) $550.67 20060701 99999999 

54660 INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE) $257.75 19990701 99999999 

54670 SUTURE OR REPAIR OF TESTICULAR INJURY $310.18 20060701 99999999 

54680 TRANSPLANTATION OF TESTIS(ES) TO THIGH (BECAUSE OF SCROTAL $604.86 20060701 99999999 

54690 LAPAROSCOPY, SURGICAL; ORCHIECTOMY $527.44 20060701 99999999 

54692 

LAPAROSCOPY, SURGICAL; ORCHIOPEXY FOR INTRA-ABDOMINAL 

TESTIS $534.14 20060701 99999999 

54700 INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL $160.02 20060701 99999999 

54800 BIOPSY OF EPIDIDYMIS, NEEDLE $111.29 20060701 99999999 

54820 EXPLORATION OF EPIDIDYMIS, WITH OR WITHOUT BIOPSY $241.27 19990701 99999999 

54830 EXCISION OF LOCAL LESION OF EPIDIDYMIS $262.74 20060701 99999999 

54840 EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY $278.70 20060701 99999999 

54860 EPIDIDYMECTOMY $323.78 20060701 99999999 

54861 EPIDIDYMECTOMY $446.88 20060701 99999999 

54900 

EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF EPIDIDYMIS TO VAS 

DEFERENS $617.88 20060701 99999999 

54901 

EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF EPIDIDYMIS TO VAS 

DEFERENS $855.31 20060701 99999999 

55000 PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, $51.36 20060701 99999999 

55040 EXCISION OF HYDROCELE $282.98 20060701 99999999 

55041 EXCISION OF HYDROCELE $408.63 20060701 99999999 

55060 REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE) $275.85 20060701 99999999 

55100 DRAINAGE OF SCROTAL WALL ABSCESS $121.99 20060701 99999999 



55110 SCROTAL EXPLORATION $270.10 20060701 99999999 

55120 REMOVAL OF FOREIGN BODY IN SCROTUM $221.61 20060701 99999999 

55150 RESECTION OF SCROTUM $360.26 20060701 99999999 

55175 SCROTOPLASTY $274.46 20060701 99999999 

55180 SCROTOPLASTY $507.84 20060701 99999999 

55200 VASOTOMY, CANNULIZATION WITH OR WITHOUT INCISION OF VAS, $197.24 20060701 99999999 

55250 VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), $157.08 20060701 99999999 

55300 VASOTOMY FOR VASOGRAMS, SEMINAL VESICULOGRAMS, OR $162.93 20060701 99999999 

55400 VASOVASOSTOMY, VASOVASORRHAPHY $422.94 20060701 99999999 

55450 LIGATION (PERCUTANEOUS) OF VAS DEFERENS, UNILATERAL OR $195.72 20060701 99999999 

55500 EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL $285.75 20060701 99999999 

55520 EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE) $283.07 20060701 99999999 

55530 EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR $301.10 20060701 99999999 



55550 

LAPAROSCOPY, SURGICAL, WITH LIGATION OF SPERMATIC VEINS 

FOR VARICOCELE $309.78 20060701 99999999 

55600 VESICULOTOMY $311.00 20060701 99999999 

55605 VESICULOTOMY $389.66 20060701 99999999 

55650 VESICULECTOMY, ANY APPROACH $542.61 20060701 99999999 

55680 EXCISION OF MULLERIAN DUCT CYST $274.76 20060701 99999999 

55700 BIOPSY, PROSTATE $64.46 20060701 99999999 

55705 BIOPSY, PROSTATE $236.92 20060701 99999999 

55720 

PROSTATOTOMY, EXTERNAL DRAINAGE OF PROSTATIC ABSCESS, 

ANY $353.65 20060701 99999999 

55725 

PROSTATOTOMY, EXTERNAL DRAINAGE OF PROSTATIC ABSCESS, 

ANY $429.18 20060701 99999999 

55801 PROSTATECTOMY, PERINEAL, SUBTOTAL (INCLUDING CONTROL OF $849.68 20060701 99999999 

55810 PROSTATECTOMY, PERINEAL RADICAL $1,094.74 20060701 99999999 



55821 

PROSTATECTOMY (INCLUDING CONTROL OF POSTOPERATIVE 

BLEEDING, $742.76 20060701 99999999 

55831 

PROSTATECTOMY (INCLUDING CONTROL OF POSTOPERATIVE 

BLEEDING, $805.70 20060701 99999999 

55840 PROSTATECTOMY, RETROPUBIC RADICAL $1,089.53 20060701 99999999 



55859 

TRANSPERINEAL PLACEMENT OF NEEDLES OR CATHETERS INTO 

PROSTATE FOR INTERSTITIAL R $555.07 19990701 99999999 

55860 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF $642.41 20060701 99999999 

55862 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF $860.85 20060701 99999999 

55865 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF $1,219.77 20060701 99999999 

55866 

LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, 

INCLUDING NERVE SPARING $1,192.98 20060701 99999999 

55870 ELECTROEJACULATION $115.99 20030401 99999999 

55873 

CRYOSURGICAL ABLATION OF THE PROSTATE (INCLUDES 

ULTRASONIC GUIDANCE FOR INTERSTI $840.10 20060701 99999999 

55875 

TRANSPERINEAL PLACEMENT OF NEEDLES OR CATHETERS INTO 

PROSTATE FOR INTERSTITIAL R $526.09 20070101 99999999 

55876 

PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY 

GUIDANCE (EG, FIDUCIAL $77.85 20070101 99999999 

55899 UNLISTED PROCEDURE, MALE GENITAL SYSTEM $245.62 19990701 99999999 

55920 

PLACEMENT OF NEEDLES OR CATHETERS INTO PELVIC ORGANS AND/ 

OR GENITALIA (EXCEPT P $231.25 20080101 99999999 

56300 LAPAROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) $252.03 19990701 99999999 



56301 

LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH 

OR WITHOUT TRANSECTION $271.66 19990701 99999999 

56302 

LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY 

DEVICE (EG, BAND, CLIP, OR $281.02 19990701 99999999 

56303 

LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF 

LESIONS OF THE OVARY, PEL $498.23 19990701 99999999 

56304 LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS $486.29 19990701 99999999 

56305 LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE) $270.35 19990701 99999999 

56306 LAPAROSCOPY, SURGICAL; WITH ASPIRATION (SINGLE OR MULTIPLE) $278.98 19990701 99999999 

56307 

LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL 

STRUCTURES (PARTIAL OR TOTAL OOPH $500.08 19990701 99999999 

56308 

LAPAROSCOPY, SURGICAL; WITH VAGINAL HYSTERECTOMY WITH OR 

WITHOUT REMOVAL OF TUBE $645.24 19990701 99999999 

56309 

LAPAROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA, 

SUBSEROSAL (SINGLE OR MULTIP $568.81 19990701 99999999 

56310 

LAPAROSCOPY, SURGICAL; ENTEROLYSIS (FREEING OF INTESTINAL 


56311 

LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE 

SAMPLING (BIOPSY), SINGLE $427.71 19990701 99999999 

56312 


LYMPHADENECTOMY $564.62 19990701 99999999 

56313 


LYMPHADENECTOMY AND PERI-AORT $658.12 19990701 99999999 

56314 

LAPAROSCOPY, SURGICAL; WITH DRAINAGE OF LYMPHOCELE TO 

PERITONEAL CAVITY $443.51 19990701 99999999 

56315 LAPAROSCOPY, SURGICAL; APPENDECTOMY $385.86 19990701 99999999 

56316 LAPAROSCOPY, SURGICAL; REPAIR OF INITIAL INGUINAL HERNIA $294.69 19990701 99999999 

56317 LAPAROSCOPY, SURGICAL; REPAIR OF RECURRENT INGUINAL HERNIA $375.82 19990701 99999999 

56318 LAPAROSCOPY, SURGICAL; ORCHIECTOMY $494.37 19990701 99999999 

56320 

LAPAROSCOPY, SURGICAL; WITH LIGATION OF SPERMATIC VEINS 

FOR VARICOCELE $297.30 19990701 99999999 

56322 


TRUNCAL $439.64 19990701 99999999 

56323 


SELECTIVE OR HIGHLY SELECTIV $525.34 19990701 99999999 

56324 LAPAROSCOPY, SURGICAL; CHOLECYSTOENTEROSTOMY $593.75 19990701 99999999 

56340 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY (ANY METHOD) $521.52 19990701 99999999 

56341 

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH 

CHOLANGIOGRAPHY $558.68 19990701 99999999 

56342 

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION 

OF COMMON DUCT $653.59 19990701 99999999 

56343 

LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY 

(SALPINGONEOSTOMY) $561.55 19990701 99999999 

56344 LAPAROSCOPY, SURGICAL; WITH FIMBRIOPLASTY $531.13 19990701 99999999 

56346 

LAPAROSCOPY, SURGICAL; GASTROSTOMY, TEMPORARY (TUBE OR 

RUBBER OR PLASTIC) (SEPAR $373.54 19990701 99999999 

56348 

LAPAROSCOPY, SURGICAL; INTESTINAL RESECTION, WITH 

ANASTOMOSIS (INTRA OR EXTRACOR $992.01 19990701 99999999 

56349 

LAPAROSCOPY, SURGICAL; ESOPHAGOGASTRIC FUNDOPLASTY (EG, 

NISSEN, BELSEY IV, HILL, $802.34 19990701 99999999 

56350 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) $147.85 19990701 99999999 

56351 

HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF 

ENDOMETRIUM AND/OR POLYPECTOMY $196.39 19990701 99999999 

56352 

HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE 

ADHESIONS (ANY METHOD) $275.19 19990701 99999999 



56353 

HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF 

INTRAUTERINE SEPTUM (ANY M $303.52 19990701 99999999 

56354 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA $425.72 19990701 99999999 

56355 

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN 

BODY $212.05 19990701 99999999 

56356 

HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (ANY 

METHOD) $285.80 19990701 99999999 

56362 

PERITONEOSCOPY WITH GUIDED TRANSHEPATIC 

CHOLANGIOGRAPHY; WITHOUT BIOPSY $216.88 19990701 99999999 

56363 

PERITONEOSCOPY WITH GUIDED TRANSHEPATIC 

CHOLANGIOGRAPHY; WITH BIOPSY $246.02 19990701 99999999 

56405 INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS $66.23 20060701 99999999 

56420 

INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS, 

UNILATERAL $63.97 20060701 99999999 

56440 MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST $157.90 20060701 99999999 

56441 LYSIS OF LABIAL ADHESIONS $112.80 20060701 99999999 

56442 HYMENOTOMY, SIMPLE INCISION $32.99 20070101 99999999 

56501 DESTRUCTION OF LESION(S), VULVA $69.56 20060701 99999999 

56515 DESTRUCTION OF LESION(S), VULVA $116.35 20060701 99999999 

56605 

BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); ONE 

LESION $43.68 20060701 99999999 

56606 

BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH 

SEPARATE ADDITIONAL LESIO $21.72 20060701 99999999 

56620 VULVECTOMY $390.56 20060701 99999999 

56625 VULVECTOMY $476.04 20060701 99999999 

56630 VULVECTOMY, RADICAL $686.25 20060701 99999999 

56631 

VULVECTOMY, RADICAL, PARTIAL; WITH UNILATERAL 

INGUINOFEMORAL LYMPHADENECTOMY $905.72 20060701 99999999 

56632 

VULVECTOMY, RADICAL, PARTIAL; WITH BILATERAL INGUINOFEMORAL 

LYMPHADENECTOMY $1,051.68 20060701 99999999 

56633 VULVECTOMY, RADICAL, COMPLETE; $868.98 20060701 99999999 

56634 

VULVECTOMY, RADICAL, COMPLETE; WITH UNILATERAL 

INGUINOFEMORAL LYMPHADENECTOMY $994.04 20060701 99999999 

56637 

VULVECTOMY, RADICAL, COMPLETE; WITH BILATERAL 

INGUINOFEMORAL LYMPHADENECTOMY $1,162.83 20060701 99999999 

56640 VULVECTOMY, RADICAL, WITH INGUINOFEMORAL, ILIAC, $1,141.58 20060701 99999999 

56700 HYMENECTOMY, PARTIAL EXCISION OF HYMEN $147.23 20060701 99999999 

56720 HYMENOTOMY, SIMPLE INCISION $44.04 20030401 99999999 

56740 EXCISION OF BARTHOLIN'S GLAND OR CYST $207.14 20060701 99999999 

56800 PLASTIC REPAIR OF INTROITUS $199.14 20060701 99999999 

56805 CLITOROPLASTY FOR ADRENOGENITAL SYNDROME $857.66 20060701 99999999 

56810 

PERINEOPLASTY, REPAIR OF PERINEUM, NON-OBSTETRICAL 


56820 COLPOSCOPY OF THE VULVA; $61.17 20060701 99999999 

56821 COLPOSCOPY OF THE VULVA; WITH BIOPSY (S) $84.39 20060701 99999999 

57000 COLPOTOMY $152.28 20060701 99999999 

57010 COLPOTOMY $272.07 20060701 99999999 

57020 COLPOCENTESIS (SEPARATE PROCEDURE) $61.88 20060701 99999999 

57022 

INCISION AND DRAINAGE OF VAGINAL HEMATOMA; POST- 

OBSTETRICAL $134.43 20060701 99999999 

57023 

INCISION AND DRAINAGE OF VAGINAL HEMATOMA; NON-OBSTETRICAL 

(EG, POST-TRAUMA, SPO $216.83 20060701 99999999 

57061 DESTRUCTION OF VAGINAL LESION(S) $60.98 20060701 99999999 

57065 DESTRUCTION OF VAGINAL LESION(S) $155.10 20060701 99999999 

57100 BIOPSY OF VAGINAL MUCOSA $42.10 20060701 99999999 

57105 BIOPSY OF VAGINAL MUCOSA $84.28 20060701 99999999 

57106 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; $264.24 20060701 99999999 



57107 

VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH 

REMOVAL OF PARAVAGINAL TISSUE $916.70 20060701 99999999 

57109 

VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH 

REMOVAL OF PARAVAGINAL TISSUE $1,123.86 20060701 99999999 

57110 COLPECTOMY, OBLITERATION OF VAGINA $643.00 20060701 99999999 

57111 

VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH 

REMOVAL OF PARAVAGINAL TISSU $1,126.59 20060701 99999999 

57112 

VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH 

REMOVAL OF PARAVAGINAL TISSU $1,198.76 20060701 99999999 

57120 COLPOCLEISIS (LE FORT TYPE) $394.59 20060701 99999999 

57130 EXCISION OF VAGINAL SEPTUM $143.24 20060701 99999999 

57135 EXCISION OF VAGINAL CYST OR TUMOR $140.46 20060701 99999999 

57150 IRRIGATION OF VAGINA AND/OR APPLICATION OF MEDICAMENT $20.46 20060701 99999999 

57155 

INSERTION OF UTERINE TANDEMS AND/OR VAGINAL OVOIDS FOR 

CLINICAL BRACHYTHERAPY $284.13 20060701 99999999 

57160 INSERTION OF PESSARY $32.66 20060701 99999999 

57170 DIAPHRAGM FITTING WITH INSTRUCTIONS $33.81 20060701 99999999 

57180 

INTRODUCTION OF ANY HEMOSTATIC AGENT OR PACK FOR 

SPONTANEOUS $71.39 20060701 99999999 

57200 COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL) $200.96 20060701 99999999 

57210 COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR $252.42 20060701 99999999 

57220 PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH $245.25 20060701 99999999 

57230 PLASTIC REPAIR OF URETHROCELE (SEPARATE PROCEDURE) $283.50 20060701 99999999 

57240 

ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR 

WITHOUT $347.59 20060701 99999999 

57250 POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE $314.47 20060701 99999999 

57260 COMBINED ANTEROPOSTERIOR COLPORRHAPHY $452.04 20060701 99999999 

57265 COMBINED ANTEROPOSTERIOR COLPORRHAPHY $578.51 20060701 99999999 

57267 

INSERTION OF MESH OR OTHER PROSTHESIS FOR REPAIR OF PELVIC 

FLOOR DEFECT, EACH $207.36 20060701 99999999 

57268 

REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE 

PROCEDURE) $372.74 20060701 99999999 

57270 REPAIR OF ENTEROCELE, ABDOMINAL APPROACH (SEPARATE $550.07 20060701 99999999 

57280 COLPOPEXY, ABDOMINAL APPROACH $678.90 20060701 99999999 

57282 SACROSPINOUS LIGAMENT FIXATION FOR PROLAPSE OF VAGINA $473.24 20060701 99999999 

57283 

COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH 

(UTEROSACRAL, LEVATOR MYORRHAPHY) $498.64 20060701 99999999 

57284 

PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, 

STRESS URINARY INCONTI $606.07 20060701 99999999 

57285 


IF PERFORMED); VAGINAL $336.59 20080101 99999999 

57287 

REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, 

FASCIA OR SYNTHETIC) $513.22 20060701 99999999 

57288 SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR $647.08 20060701 99999999 

57289 PEREYRA PROCEDURE, INCLUDING ANTERIOR COLPORRHAPHY $561.60 20060701 99999999 

57291 CONSTRUCTION OF ARTIFICIAL VAGINA $398.46 20060701 99999999 

57292 CONSTRUCTION OF ARTIFICIAL VAGINA $585.17 20060701 99999999 

57295 

REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT, 

VAGINAL APPROACH $332.96 20060701 99999999 

57296 

REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; 

OPEN ABDOMINAL APPROAC $628.96 20070101 99999999 

57300 CLOSURE OF RECTOVAGINAL FISTULA $421.21 20060701 99999999 



57308 

CLOSURE OF RECTOVAGINAL FISTULA; TRANSPERINEAL APPROACH, 

WITH PERINEAL BODY RECO $491.46 20060701 99999999 



57310 CLOSURE OF URETHROVAGINAL FISTULA $331.08 20060701 99999999 

57311 CLOSURE OF URETHROVAGINAL FISTULA $392.72 20060701 99999999 

57320 CLOSURE OF VESICOVAGINAL FISTULA $449.04 20060701 99999999 

57330 CLOSURE OF VESICOVAGINAL FISTULA $584.35 20060701 99999999 

57335 VAGINOPLASTY FOR ADRENOGENITAL SYNDROME $780.14 20060701 99999999 

57400 DILATION OF VAGINA UNDER ANESTHESIA $88.07 20060701 99999999 

57410 PELVIC EXAMINATION UNDER ANESTHESIA $70.32 20060701 99999999 

57415 

REMOVAL OF IMPACTED VAGINAL FOREIGN BODY (SEPARATE 

PROCEDURE) UNDER ANESTHESIA $97.29 20060701 99999999 

57420 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; $65.00 20060701 99999999 

57421 

COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; 

WITH BIOPSY(S) $90.14 20060701 99999999 

57423 


IF PERFORMED), LAPAROS $464.05 20080101 99999999 

57425 

LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL 

APEX) $663.24 20060701 99999999 

57452 COLPOSCOPY (VAGINOSCOPY) $56.75 20060701 99999999 

57454 COLPOSCOPY (VAGINOSCOPY) $87.39 20060701 99999999 

57455 

COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 

WITH BIOPSY(S) OF THE $81.91 20060701 99999999 

57456 


WITH ENDOCERVICAL CURE $76.73 20060701 99999999 

57460 

COLPOSCOPY (VAGINOSCOPY); WITH LOOP ELECTROSURGICAL 

EXCISION(S) OF THE CERVIX (L $114.04 20060701 99999999 

57461 


WITH LOOP ELECTRODE CO $141.67 20060701 99999999 

57500 BIOPSY, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, $40.27 20060701 99999999 

57505 ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION $56.39 20060701 99999999 

57510 CAUTERIZATION OF CERVIX $80.95 20060701 99999999 



57520 BIOPSY OF CERVIX, CIRCUMFERENTIAL (CONE), WITH OR WITHOUT $213.26 20060701 99999999 

57522 

CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR 

WITHOUT DILATION AND $190.06 20060701 99999999 

57530 TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX $248.22 20060701 99999999 

57531 

RADICAL TRACHELECTOMY, WITH BILATERAL TOTAL PELVIC 

LYMPHADENECTOMY AND PARA-AORT $1,293.39 20060701 99999999 

57540 EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH $554.03 20060701 99999999 

57545 EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH $543.41 20060701 99999999 

57550 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH $314.73 20060701 99999999 



57558 DILATION AND CURETTAGE OF CERVICAL STUMP $77.77 20070101 99999999 

57700 CERCLAGE OF UTERINE CERVIX (TRACHELOPLASTY) $178.52 20060701 99999999 

57720 TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL $210.64 20060701 99999999 

57800 DILATION OF CERVICAL CANAL, INSTRUMENTAL (SEPARATE $31.10 20060701 99999999 

57820 DILATION AND CURETTAGE OF CERVICAL STUMP $112.36 20030401 99999999 

58100 ENDOMETRIAL BIOPSY, SUCTION TYPE (SEPARATE PROCEDURE) $56.43 20060701 99999999 

58110 

ENDOMETRIAL SAMPLING (BIOPSY) PERFORMED IN CONJUNCTION 

WITH COLPOSCOPY (LIST SEP $30.14 20060701 99999999 

58120 DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC $173.40 20060701 99999999 

58140 MYOMECTOMY, EXCISION OF FIBROID TUMOR OF UTERUS, $663.23 20060701 99999999 

58145 MYOMECTOMY, EXCISION OF FIBROID TUMOR OF UTERUS, $436.81 20060701 99999999 

58146 

MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR 

MORE INTRAMURAL MYOMAS $806.36 20060701 99999999 

58150 

TOTAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT 

REMOVAL $837.47 20060701 99999999 



58152 

TOTAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT 

REMOVAL $764.59 20060701 99999999 

58180 

SUPRACERVICAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), 

WITH OR $710.45 20060701 99999999 

58200 

TOTAL HYSTERECTOMY, INCLUDING PARTIAL VAGINECTOMY, WITH 

LIMITED $991.85 20060701 99999999 

58210 

RADICAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC AND 

LIMITED $1,320.62 20060701 99999999 

58240 PELVIC EXENTERATION FOR GYNECOLOGIC MALIGNANCY, WITH $1,849.01 20060701 99999999 

58260 VAGINAL HYSTERECTOMY $591.29 20060701 99999999 

58262 

VAGINAL HYSTERECTOMY; WITH REMOVAL OF TUBE(S), AND/OR 

OVARY(S) $652.63 20060701 99999999 

58263 

VAGINAL HYSTERECTOMY; WITH REMOVAL OF TUBE(S), AND/OR 

OVARY(S), WITH REPAIR OF E $712.17 20060701 99999999 



58275 VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL COLPECTOMY $714.50 20060701 99999999 

58280 VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL COLPECTOMY $720.14 20060701 99999999 

58285 VAGINAL HYSTERECTOMY, RADICAL (SCHAUTA TYPE OPERATION) $864.51 20060701 99999999 

58290 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; $807.83 20060701 99999999 

58291 

VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; 

WITH REMOVAL OF TUBE(S) $888.17 20060701 99999999 

58292 


WITH REMOVAL OF TUBE(S) $940.29 20060701 99999999 

58293 


WITH COLPO-URETHROCYSTO $977.19 20060701 99999999 

58294 


WITH REPAIR OF ENTEROCE $866.46 20060701 99999999 

58300 INSERTION OF INTRAUTERINE DEVICE (IUD) $51.59 19990701 99999999 

58301 REMOVAL OF INTRAUTERINE DEVICE (IUD) $47.15 20060701 99999999 

58321 ARTIFICIAL INSEMINATION; INTRA-CERVICAL $43.74 20030401 99999999 

58322 ARTIFICIAL INSEMINATION; INTRA-UTERINE $49.67 20030401 99999999 

58323 SPERM WASHING FOR ARTIFICIAL INSEMINATION $10.61 20030401 99999999 

58340 INJECTION PROCEDURE FOR HYSTEROSALPINGOGRAPHY $38.69 20060701 99999999 

58345 

TRANSCERVICAL INTRODUCTION OF FALLOPIAN TUBE CATHETER FOR 

DIAGNOSIS AND/OR RE-ES $213.03 20060701 99999999 

58346 INSERTION OF HEYMAN CAPSULES FOR CLINICAL BRACHYTHERAPY $302.67 20060701 99999999 

58350 HYDROTUBATION OF OVIDUCT, INCLUDING MATERIALS $56.65 20060701 99999999 

58353 

ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC 

GUIDANCE $167.34 20060701 99999999 

58356 

ENDOMETRIAL CRYOABLATION WITH ULTRASONIC GUIDANCE, 

INCLUDING ENDOMETRIAL $272.46 20060701 99999999 

58400 UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND $334.02 20060701 99999999 

58410 UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND $551.60 20060701 99999999 

58520 

HYSTERORRHAPHY, REPAIR OF RUPTURED UTERUS 

(NONOBSTETRICAL) $503.86 20060701 99999999 

58540 HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY (STRASSMAN TYPE) $610.80 20060701 99999999 

58541 

LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR 

UTERUS 250 G OR LESS; $565.62 20070101 99999999 

58542 


UTERUS 250 G OR LESS; WIT $625.98 20070101 99999999 

58543 


UTERUS GREATER THAN 250 G $636.34 20070101 99999999 

58544 


UTERUS GREATER THAN 250 G $688.37 20070101 99999999 



58545 

LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 

INTRAMURAL MYOMAS WITH TOTAL $648.58 20060701 99999999 

58546 

LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE 

INTRAMURAL MYOMAS AND/OR $818.05 20060701 99999999 

58548 

LAPAROSCOPY, SURGICAL, WITH RADICAL HYSTERECTOMY, WITH 

BILATERAL TOTAL PELVIC LY $1,203.89 20070101 99999999 

58550 

LAPAROSCOPY, SURGICAL; WITH VAGINAL HYSTERECTOMY WITH OR 

WITHOUT REMOVAL OF TUBE $659.77 20060701 99999999 

58551 

LAPAROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA 

(SINGLE OR MULTIPLE) $582.41 20000101 99999999 

58552 

LAPAROSCOPY SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR 

UTERUS 250 GRAMS OR LESS; W $631.57 20060701 99999999 

58553 

LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR 

UTERUS GREATER THAN 250 GR $813.79 20060701 99999999 

58554 

LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR 

UTERUS GREATER THAN 250 GR $806.59 20060701 99999999 

58555 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) $147.79 20060701 99999999 

58558 

HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF 

ENDOMETRIUM AND/OR POLYPECTOMY $215.73 20060701 99999999 

58559 

HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE 

ADHESIONS (ANY METHOD) $275.75 20060701 99999999 

58560 

HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF 

INTRAUTERINE SEPTUM (ANY M $304.09 20060701 99999999 

58561 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA $426.54 20060701 99999999 

58562 

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN 

BODY $212.31 20060701 99999999 

58563 

HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (ANY 

METHOD) $285.73 20060701 99999999 

58565 

HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE 

CANNULATION TO INDUCE $336.69 20060701 99999999 

58570 

LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR 

UTERUS 250 G OR LESS; $460.67 20080101 99999999 

58571 


UTERUS 250 G OR LESS; WITH R $504.43 20080101 99999999 

58572 


UTERUS GREATER THAN 250 G; $570.28 20080101 99999999 

58573 


UTERUS GREATER THAN 250 G; W $643.31 20080101 99999999 

58600 

LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR 

VAGINAL $224.12 20060701 99999999 

58605 

LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR 

VAGINAL $203.59 20060701 99999999 

58611 

LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT 

THE TIME OF $29.69 19990701 99999999 

58615 

OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, 

FALOPE RING) $205.58 20060701 99999999 

58660 

LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS 

(SALPINGOLYSIS, OVARIOLYSIS) (SEP $500.64 20060701 99999999 

58661 

LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL 

STRUCTURES (PARTIAL OR TOTAL OOPH $510.94 20060701 99999999 

58662 

LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF 

LESIONS OF THE OVARY, PEL $508.46 20060701 99999999 

58670 

LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH 

OR WITHOUT TRANSECTION $288.81 20060701 99999999 

58671 

LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY 

DEVICE (EG, BAND, CLIP, OR $298.17 20060701 99999999 

58672 LAPAROSCOPY, SURGICAL; WITH FIMBRIOPLASTY $548.34 20060701 99999999 



58673 

LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY 

(SALPINGONEOSTOMY) $583.63 20060701 99999999 

58700 

SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR 

BILATERAL $453.95 20060701 99999999 

58720 

SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL 

OR $537.32 20060701 99999999 

58740 LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) $531.20 20060701 99999999 

58750 TUBOTUBAL ANASTOMOSIS $636.11 20060701 99999999 

58752 TUBOUTERINE IMPLANTATION $638.01 20060701 99999999 

58760 FIMBRIOPLASTY $555.89 20060701 99999999 

58770 SALPINGOSTOMY (SALPINGONEOSTOMY) $592.06 20060701 99999999 

58800 

DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL, 

(SEPARATE $221.06 20060701 99999999 

58805 

DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL, 

(SEPARATE $329.00 20060701 99999999 

58820 DRAINAGE OF OVARIAN ABSCESS $209.31 20060701 99999999 

58822 DRAINAGE OF OVARIAN ABSCESS $426.98 20060701 99999999 

58823 

DRAINAGE OF PELVIC ABSCESS, TRANSVAGINAL OR TRANSRECTAL 

APPROACH, PERCUTANEOUS ( $179.53 20060701 99999999 

58825 TRANSPOSITION OVARY(S) $421.25 20060701 99999999 

58900 BIOPSY OF OVARY, UNILATERAL OR $314.19 20060701 99999999 

58920 WEDGE RESECTION OR BISECTION OF OVARY, UNILATERAL OR $426.37 20060701 99999999 

58925 OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL $521.74 20060701 99999999 

58940 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL $379.92 20060701 99999999 

58943 

OOPHORECTOMY PARTIAL OR TOTAL UNILAT OR BILAT OVARIAN 

MALIGN $870.14 20060701 99999999 

58950 RESECTION OF OVARIAN MALIGNANCY WITH BILATERAL $747.59 20060701 99999999 

58951 

RESECTION OF OVARIAN MALIGNANCY W/BILAT SALPINGO- 

OOPHORECTOM $1,090.58 20060701 99999999 

58952 RESECTION OF OVARIAN MALIGNANCY WITH BILATERAL $1,196.09 20060701 99999999 

58953 

BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL 

ABDOMINAL HYSTERECTOMY A $1,357.80 20060701 99999999 

58954 

BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL 

ABDOMINAL HYSTERECTOMY A $1,475.09 20060701 99999999 

58956 

BILATERAL SALPINGO-OOPHORECTOMY WITH TOTAL OMENTECTOMY, 

TOTAL ABDOMINAL $968.79 20060701 99999999 

58957 

RESECTION (TUMOR DEBULKING) OF RECURRENT OVARIAN, TUBAL, 

PRIMARY PERITONEAL, UTE $970.86 20070101 99999999 

58958 

RESECTION (TUMOR DEBULKING) OF RECURRENT OVARIAN, TUBAL, 

PRIMARY PERITONEAL, UTE $1,073.86 20070101 99999999 

58960 

LAPAROTOMY, FOR STAGING OR RESTAGING OF OVARIAN 

MALIGNANCY $753.90 20060701 99999999 

58970 FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL ANY METHOD $163.09 20060701 99999999 

58976 GAMETE INTRAFALLOPIAN TRANSFER ANY METHOD $177.29 20060701 99999999 

58982 LAPAROSCOPY FOR VISUALIZATION OF PELVIC VISCERA $600.00 19990701 99999999 

58999 

UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM 

(NONOBSTETRICAL) $375.03 19990701 99999999 

59000 AMNIOCENTESIS FOR DIAGNOSIS, ABDOMINAL APPROACH $60.73 20060701 99999999 

59001 

AMNIOCENTESIS; THERAPEUTIC AMNIOTIC FLUID REDUCTION 

(INCLUDES ULTRASOUND GUIDANC $123.09 20060701 99999999 

59012 CORDOCENTESIS INTRAUTERINE ANY METHOD $163.11 20060701 99999999 

59015 CHORIONIC VILLUS SAMPLING $95.59 20060701 99999999 

59020 FETAL OXYTOCIN STRESS TEST $53.69 20060701 99999999 

59025 FETAL NON-STRESS TEST $32.85 20060701 99999999 

59030 FETAL SCALP BLOOD SAMPLING $94.55 20060701 99999999 

59050 INITIATION AND/OR SUPERVISION OF INTERNAL FETAL $44.20 20060701 99999999 

59051 

FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, 

NON-ATTENDING PHYSICI $39.07 20060701 99999999 



59070 

TRANSABDOMINAL AMNIOINFUSION, INCLUDING ULTRASOUND 

GUIDANCE $301.72 20060701 99999999 

59072 

FETAL UMBILICAL CORD OCCLUSION, INCLUDING ULTRASOUND 

GUIDANCE $351.19 20060701 99999999 

59074 

FETAL FLUID DRAINAGE (EG, VESICOCENTESIS, THORACOCENTESIS, 

PARACENTESIS), INCLUD $286.32 20060701 99999999 

59076 FETAL SHUNT PLACEMENT, INCLUDING ULTRASOUND GUIDANCE $287.42 20060701 99999999 

59100 HYSTEROTOMY, ABDOMINAL, FOR REMOVAL OF HYDATIDIFORM MOLE $511.91 20060701 99999999 

59120 SURGICAL TREATMENT OF ECTOPIC PREGNANCY $546.28 20060701 99999999 




59136 SURG TX ECTPC PREG INTERSTITIAL IUP PARTIAL RESECT $587.66 20060701 99999999 


59150 LAPAROSCOP TRMT ECTP PREG W/O SALPINGEST OOPHOREC $468.62 20060701 99999999 

59151 LAPAROSCOP TRMT ECTP PREG W SALPINGEST OOPHORECT $465.12 20060701 99999999 

59160 

DILATION AND CURETTAGE FOR POSTPARTUM HEMORRHAGE 

(SEPARATE $158.35 20060701 99999999 

59200 INSERTION OF HYGROSCOPIC CERVICAL DILATOR (EG, LAMINARIA) $29.09 20060701 99999999 

59300 EPISIOTOMY OR VAGINAL REPAIR ONLY, BY OTHER THAN ATTENDING $90.70 20060701 99999999 

59320 CERCLAGE OF CERVIX DURING PREGNANCY VAGINAL $120.55 20060701 99999999 

59325 CERCLAGE OF CERVIX DURING PREGNANCY ABDOMINAL $193.77 20060701 99999999 

59350 HYSTERORRHAPHY OF RUPTURED UTERUS $228.36 20060701 99999999 

59400 TOTAL OBSTETRIC CARE (ALL-INCLUSIVE, ''GLOBAL'' CARE) $1,113.88 20060701 99999999 

59409 

VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR 

FORCEPS); $620.40 20060701 99999999 

59410 

VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY, FORCEPS 

OR BREECH $684.96 20060701 99999999 

59412 EXT CEPHALIC VERSION W OR W/O TOCOLYSIS IN ADD TO DELIVERY $86.93 20060701 99999999 

59414 DELIVERY OF PLACENTA FOLLOWING DELIVERY OUTSIDE HOSP $82.49 20060701 99999999 

59425 ANTEPARTUM CARE ONLY; 4-6 VISITS $256.60 20060701 99999999 

59426 ANTEPARTUM CARE ONLY; 7 OR MORE VISITS $397.16 20060701 99999999 

59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE) $84.38 20060701 99999999 

59510 C.SECTION;ALL CARE & DELIVERY $1,500.00 20060701 99999999 

59514 CAESAREAN DELIVERY ONLY; $930.03 20060701 99999999 

59515 CESAREAN DELIVERY ONLY INCL POSTPARTUM CARE $1,000.00 20060701 99999999 

59525 SUBTOTAL OR TOTAL HYSTERECTOMY POST CESAREAN DEL $355.67 20060701 99999999 

59610 

ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL 

DELIVERY (WITH OR WITH $1,093.81 20060701 99999999 

59612 

VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY 

(WITH OR WITHOUT EPISIOT $673.80 20060701 99999999 

59614 

VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY 

(WITH OR WITHOUT EPISIOT $732.38 20060701 99999999 

59618 

ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, 

CESAREAN DELIVERY, AND POSTPAR $1,233.70 20060701 99999999 

59620 

CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL 

DELIVERY AFTER PREVIOUS CESA $784.68 20060701 99999999 

59622 

CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL 

DELIVERY AFTER PREVIOUS CESA $847.42 20060701 99999999 

59812 SPONTANEOUS ABORTION ANY TRI COMPLETED SURGICALLY $187.22 20060701 99999999 

59820 

TREATMENT OF MISSED ABORTION, ANY TRIMESTER, COMPLETED 

MEDICALLY $216.21 20060701 99999999 

59821 MISSED ABORTION SECOND TRIMESTER COMP SURG $214.16 20060701 99999999 

59830 TREATMENT OF SEPTIC ABORTION $305.79 20060701 99999999 

59840 LEGAL (THERAPEUTIC) ABORTION, BY DILATION $172.92 20060701 99999999 



59841 LEGAL (THERAPEUTIC) ABORTION, BY DILATION $263.62 20060701 99999999 

59850 LEGAL (THERAPEUTIC) ABORTION, BY ONE OR MORE INTRA-AMNIOTIC $273.77 20060701 99999999 



59855 

INDUCED ABORTION, BY ONE OR MORE VAGINAL SUPPOSITORIES 

(EG, PROSTAGLANDIN) WITH $292.02 20060701 99999999 

59856 



59857 



59866 MULTIFETAL PREGNANCY REDUCTION(S) (MPR) $185.70 20060701 99999999 

59870 UTERINE EVACUATION & CURETTAGE FOR HYDATIDIFORM MOLE $276.37 20060701 99999999 

59871 

REMOVAL OF CERCLAGE SUTURE UNDER ANESTHESIA (OTHER THAN 

LOCAL) $102.03 20060701 99999999 

60000 INCISION AND DRAINAGE OF THYROGLOSSAL CYST, INFECTED $86.15 20060701 99999999 

60001 ASPIRATION AND/OR INJECTION, THYROID CYST $50.36 20030401 99999999 

60100 BIOPSY THYROID, PERCUTANEOUS NEEDLE $50.86 20060701 99999999 

60200 EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION $475.53 20060701 99999999 

60210 

PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT 

ISTHMUSECTOMY $558.64 20060701 99999999 

60212 

PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL 

SUBTOTAL LOBECTOMY, IN $742.08 20060701 99999999 

60220 TOTAL THYROID LOBECTOMY, UNILATERAL $545.93 20060701 99999999 

60225 TOTAL THYROID LOBECTOMY, UNILATERAL $707.59 20060701 99999999 

60240 THYROIDECTOMY, $782.77 20060701 99999999 

60252 THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY $912.70 20060701 99999999 

60254 THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY $1,225.94 20060701 99999999 

60260 THYROIDECTOMY, SECONDARY $652.67 20060701 99999999 

60270 

THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID GLAND, 

STERNAL $941.96 20060701 99999999 

60271 

THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID GLAND; 

CERVICAL APPROACH $776.92 20060701 99999999 

60280 EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS $361.02 20060701 99999999 

60281 EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS $428.90 20060701 99999999 

60300 ASPIRATION AND/OR INJECTION, THYROID CYST $25.85 20080101 99999999 

60500 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S) $784.83 20060701 99999999 

60502 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S) $934.53 20060701 99999999 

60505 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S) $1,037.98 20060701 99999999 

60512 PARATHYROID AUTOTRANSPLANTATION $195.50 20060701 99999999 

60520 THYMECTOMY, PARTIAL OR TOTAL (SEPARATE PROCEDURE) $902.32 20060701 99999999 

60521 

THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR 

TRANSTHORACIC APPROACH, WITHOUT R $1,020.68 20060701 99999999 

60522 

THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR 

TRANSTHORACIC APPROACH, WITH RADI $1,160.17 20060701 99999999 

60540 

ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF 

ADRENAL $810.40 20060701 99999999 

60545 

ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF 

ADRENAL $959.47 20060701 99999999 

60600 EXCISION OF CAROTID BODY TUMOR $947.39 20060701 99999999 

60605 EXCISION OF CAROTID BODY TUMOR $1,041.27 20060701 99999999 

60650 

LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR 

COMPLETE, OR EXPLORATION O $807.07 20060701 99999999 

61000 SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, $87.25 20060701 99999999 

61001 SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, $81.76 20060701 99999999 

61020 VENTRICULAR PUNCTURE THROUGH PREVIOUS BURR HOLE, $97.60 20060701 99999999 



61026 VENTRICULAR PUNCTURE THROUGH PREVIOUS BURR HOLE, $111.31 20060701 99999999 

61050 CISTERNAL OR LATERAL CERVICAL PUNCTURE $81.80 20060701 99999999 

61055 CISTERNAL OR LATERAL CERVICAL PUNCTURE $108.48 20060701 99999999 

61070 PUNCTURE OF SHUNT TUBING OR RESERVOIR FOR ASPIRATION $78.40 20060701 99999999 

61105 TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE $312.39 20060701 99999999 



61120 BURR HOLE(S) FOR VENTRICULAR PUNCTURE (INCLUDING $466.09 20060701 99999999 

61140 BURR HOLE(S) OR TREPHINE $888.21 20060701 99999999 



61154 BURR HOLE(S) WITH EVACUATION AND/OR DRAINAGE OF HEMATOMA, $896.50 20060701 99999999 

61156 BURR HOLE(S) $944.90 20060701 99999999 

61210 BURR HOLE(S) $338.18 20060701 99999999 

61215 INSERTION OF SUBCUTANEOUS RESERVOIR, PUMP OR $308.16 20060701 99999999 

61250 BURR HOLE(S) OR TREPHINE, SUPRATENTORIAL, EXPLORATORY, $566.02 20060701 99999999 

61253 BURR HOLE(S) OR TREPHINE, INFRATENTORIAL, UNILATERAL $663.72 20060701 99999999 

61304 CRANIECTOMY OR CRANIOTOMY, EXPLORATORY $1,288.38 20060701 99999999 

61305 CRANIECTOMY OR CRANIOTOMY, EXPLORATORY $1,554.65 20060701 99999999 

61312 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, $1,401.33 20060701 99999999 

61313 

CRANIECTOMY OR CRANIOTOMY EVACUATION OF HEMATOMA 

SUPRATENTOR $1,413.68 20060701 99999999 

61314 

CRANIECTOMY OR OTOMY FOR EVACUATION HEMATOMA 

INFRATENTORIAL $1,412.58 20060701 99999999 

61315 

CRANIECTOMY OR OTOMY EVACUATION HEMATOMA 

INFRATENTORIAL $1,528.49 20060701 99999999 

61316 

INCISION AND SUBCUTANEOUS PLACEMENT OF CRANIAL BONE 

GRAFT (LIST SEPARATELY IN AD $63.17 20060701 99999999 

61320 CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL $1,346.46 20060701 99999999 

61321 CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL $1,466.71 20060701 99999999 

61322 

CRANIECTOMY OR CRANIOTOMY, DECOMPRESSIVE, WITH OR 

WITHOUT DURAPLASTY, FOR TREATM $1,302.42 20060701 99999999 

61323 

CRANIECTOMY OR CRANIOTOMY, DECOMPRESSIVE, WITH OR 

WITHOUT DURAPLASTY, FOR TREATM $1,347.98 20060701 99999999 

61330 DECOMPRESSION OF ORBIT ONLY, TRANSCRANIAL $1,166.58 20060701 99999999 

61332 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH) $1,476.34 20060701 99999999 

61333 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH) $1,426.23 20060701 99999999 

61334 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH) $977.09 20060701 99999999 

61340 OTHER CRANIAL DECOMPRESSION (EG, SUBTEMPORAL), $1,010.43 20060701 99999999 

61343 

CRANIECTOMY SUBOCCIPITAL W/CERVICAL LAMINECTOMY 

DECOMPRESSIO $1,714.04 20060701 99999999 

61345 OTHER CRANIAL DECOMPRESSION, POSTERIOR FOSSA $1,436.19 20060701 99999999 

61440 

CRANIOTOMY FOR SECTION OF TENTORIUM CEREBELLI (SEPARATE 

PROCEDURE) $1,348.01 20060701 99999999 

61450 CRANIECTOMY, SUBTEMPORAL, FOR SECTION, COMPRESSION, OR $1,382.39 20060701 99999999 

61458 CRANIECTOMY, SUBOCCIPITAL $1,559.62 20060701 99999999 




61490 CRANIOTOMY FOR LOBOTOMY, INCLUDING CINGULOTOMY $1,224.24 20060701 99999999 

61500 CRANIECTOMY $1,053.77 20060701 99999999 

61501 CRANIECTOMY $871.64 20060701 99999999 

61510 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY $1,603.92 20060701 99999999 






61517 

IMPLANTATION OF BRAIN INTRACAVITARY CHEMOTHERAPY AGENT 

(LIST SEPARATELY IN ADDIT $54.88 20060701 99999999 

61518 

CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR 

POSTERIOR $2,016.50 20060701 99999999 

61519 


POSTERIOR $2,195.03 20060701 99999999 

61520 


POSTERIOR $2,756.59 20060701 99999999 

61521 


POSTERIOR $2,333.05 20060701 99999999 

61522 CRANIECTOMY, INFRATENTORIAL OR POSTERIOR FOSSA $1,532.92 20060701 99999999 

61524 CRANIECTOMY, INFRATENTORIAL OR POSTERIOR FOSSA $1,592.78 20060701 99999999 

61526 

CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANSTEMPORAL 

(MASTOID) $2,593.02 20060701 99999999 

61530 

CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANSTEMPORAL 

(MASTOID) $2,308.04 20060701 99999999 

61531 

SUBDURAL IMPLANTATION OF STRIP ELECTRODES THROUGH ONE OR 

MORE BURR OR TREPHINE H $863.69 20060701 99999999 


61534 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY $962.32 20060701 99999999 

61535 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY $609.65 20060701 99999999 


61537 

CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, 

TEMPORAL LOBE, WITHOUT EL $1,250.16 20060701 99999999 



61540 

CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, 

OTHER THAN TEMPORAL LOBE, $1,508.86 20060701 99999999 





61545 

CRANIECTOMY TREPHINATION BONE FLAP CRANIECTOMY EXCISION 

OF $2,198.30 20060701 99999999 

61546 CRANIOTOMY FOR HYPOPHYSECTOMY OR EXCISION OF PITUITARY $1,722.43 20060701 99999999 

61548 

HYPOPHYSECTOMY OR EXCISION OF PITUITARY TUMOR, 

TRANSNASAL OR $1,265.82 20060701 99999999 

61550 CRANIECTOMY FOR CRANIOSTENOSIS $733.77 20060701 99999999 

61552 CRANIECTOMY FOR CRANIOSTENOSIS $932.30 20060701 99999999 

61556 

CRANIOTOMY FOR CRANIOSYNOSTOSIS; FRONTAL OR PARIETAL 

BONE FLAP $1,118.05 20060701 99999999 

61557 CRANIOTOMY FOR CRANIOSYNOSTOSIS; BIFRONTAL BONE FLAP $1,146.79 20060701 99999999 

61558 

EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANIAL SUTURE 

CRANIOSYNOSTOSIS (EG, CLOVERLE $1,321.95 20060701 99999999 

61559 

EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANIAL SUTURE 

CRANIOSYNOSTOSIS (EG, CLOVERLE $1,713.64 20060701 99999999 

61563 

EXCISION, INTRA- AND EXTRACRANIAL, BENIGN TUMOR OF CRANIAL 

BONE (EG, FIBROUS DYS $1,383.83 20060701 99999999 

61564 

EXCISION, INTRA- AND EXTRACRANIAL, BENIGN TUMOR OF CRANIAL 

BONE (EG, FIBROUS DYS $1,645.74 20060701 99999999 

61566 

CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR SELECTIVE 

AMYGDALOHIPPOCAMPECTOMY $1,500.94 20060701 99999999 

61567 

CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR MULTIPLE 

SUBPIAL TRANSECTIONS, WITH $1,721.93 20060701 99999999 

61570 CRANIECTOMY OR CRANIOTOMY $1,252.79 20060701 99999999 

61571 CRANIECTOMY OR CRANIOTOMY $1,359.27 20060701 99999999 

61575 

TRANSORAL APPROACH TO SKULL BASE BRAIN STEM OR UPPER 

SPINAL $1,921.86 20060701 99999999 



61576 

TRANSORAL APPROACH TO SKULL BASE BRAIN STEM OR UPPER 

SPINAL $2,529.28 20060701 99999999 

61580 

CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; 

EXTRADURAL, INCLUDING LATERAL R $1,523.03 20060701 99999999 

61581 


EXTRADURAL, INCLUDING LATERAL R $1,711.58 20060701 99999999 

61582 


EXTRADURAL, INCLUDING UNILATERA $1,624.98 20060701 99999999 

61583 


INTRADURAL, INCLUDING UNILATERA $1,888.31 20060701 99999999 

61584 

ORBITOCRANIAL APPROACH TO ANTERIOR CRANIAL FOSSA, 

EXTRADURAL, INCLUDING SUPRAORB $1,797.65 20060701 99999999 

61585 

ORBITOCRANIAL APPROACH TO ANTERIOR CRANIAL FOSSA, 

EXTRADURAL, INCLUDING SUPRAORB $1,996.07 20060701 99999999 

61586 

BICORONAL, TRANSZYGOMATIC AND/OR LEFORT I OSTEOTOMY 

APPROACHTO ANTERIOR CRANIAL $1,344.89 20060701 99999999 

61590 

INFRATEMPORAL PRE-AURICULAR APPROACH TO MIDDLE CRANIAL 

FOSSA (PARAPHARYNGEAL SPA $2,105.65 20060701 99999999 

61591 

INFRATEMPORAL POST-AURICULAR APPROACH TO MIDDLE CRANIAL 

FOSSA (INTERNAL AUDITORY $2,227.64 20060701 99999999 

61592 

ORBITOCRANIAL ZYGOMATIC APPROACH TO MIDDLE CRANIAL FOSSA 

(CAVERNOUS SINUS AND CA $2,062.58 20060701 99999999 

61595 

TRANSTEMPORAL APPROACH TO POSTERIOR CRANIAL FOSSA, 

JUGULAR FORAMEN OR MIDLINE SK $1,503.46 20060701 99999999 

61596 

TRANSCOCHLEAR APPROACH TO POSTERIOR CRANIAL FOSSA, 

JUGULAR FORAMEN OR MIDLINE SK $1,805.30 20060701 99999999 

61597 

TRANSCONDYLAR (FAR LATERAL) APPROACH TO POSTERIOR 

CRANIAL FOSSA, JUGULAR FORAMEN $1,939.46 20060701 99999999 

61598 

TRANSPETROSAL APPROACH TO POSTERIOR CRANIAL FOSSA, 

CLIVUS OR FORAMEN MAGNUM, INC $1,714.92 20060701 99999999 

61600 

RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR 

INFECTIOUS LESION OF BASE OF AN $1,302.50 20060701 99999999 

61601 


INFECTIOUS LESION OF BASE OF AN $1,448.08 20060701 99999999 

61605 


INFECTIOUS LESION OF INFRATEMPO $1,470.31 20060701 99999999 

61606 


INFECTIOUS LESION OF INFRATEMPO $2,020.58 20060701 99999999 

61607 


INFECTIOUS LESION OF PARASELLAR $1,881.84 20060701 99999999 

61608 


INFECTIOUS LESION OF PARASELLAR $2,196.32 20060701 99999999 

61609 

TRANSECTION OR LIGATION, CAROTID ARTERY IN CAVERNOUS 

SINUS; WITHOUT REPAIR $505.41 20060701 99999999 

61610 

TRANSECTION OR LIGATION, CAROTID ARTERY IN CAVERNOUS 

SINUS; WITH REPAIR BY ANAST $1,495.50 20060701 99999999 

61611 

TRANSECTION OR LIGATION, CAROTID ARTERY IN PETROUS CANAL; 

WITHOUT REPAIR $368.91 20060701 99999999 

61612 

TRANSECTION OR LIGATION, CAROTID ARTERY IN PETROUS CANAL; 

WITH REPAIR BY ANASTOM $1,411.33 20060701 99999999 

61613 

OBLITERATION OF CAROTID ANEURYSM, ARTERIOVENOUS 

MALFORMATION, OR CAROTID-CAVERNO $2,143.09 20060701 99999999 

61615 


INFECTIOUS LESION OF BASE OF PO $1,642.86 20060701 99999999 

61616 


INFECTIOUS LESION OF BASE OF PO $2,250.28 20060701 99999999 

61618 

SECONDARY REPAIR OF DURA FOR CSF LEAK, ANTERIOR, MIDDLE OR 

POSTERIOR CRANIAL FOS $884.60 20060701 99999999 



61619 

SECONDARY REPAIR OF DURA FOR CSF LEAK, ANTERIOR, MIDDLE OR 

POSTERIOR CRANIAL FOS $1,070.72 20060701 99999999 

61623 

ENDOVASCULAR TEMPORARY BALLOON ARTERIAL OCCLUSION, HEAD 

OR NECK (EXTRACRANIAL/IN $399.97 20060701 99999999 

61624 



61626 



61680 

SURGERY INTRACRANIAL ARTERIOVENOUS MALFORMATION 

SUPRATENTORI $1,769.67 20060701 99999999 

61682 


SUPRATENTORI $3,049.05 20060701 99999999 

61684 


INFRATENTORI $2,125.53 20060701 99999999 

61686 


INFRATENTORI $3,193.88 20060701 99999999 

61690 

SURGERY INTRACRANIAL ARTERIOVENOUS MALFORMATION DURAL 

SIMPLE $1,635.70 20060701 99999999 

61692 

SURG INTRACRANIAL ARTERIOVENOUS MALFORMATION DURAL 

CMPLX $2,532.51 20060701 99999999 

61697 

SURGERY OF COMPLEX INTRACRANIAL ANEURYSM, INTRACRANIAL 

APPROACH; CAROTID CIRCULA $2,369.46 20060701 99999999 

61698 

SURGERY OF COMPLEX INTRACRANIAL ANEURYSM, INTRACRANIAL 

APPROACH; VERTEBROBASILAR $2,275.15 20060701 99999999 

61700 SURGERY OF INTRACRANIAL ANEURYSM, INTRACRANIAL $2,555.11 20060701 99999999 

61702 SURGERY OF INTRACRANIAL ANEURYSM, INTRACRANIAL $2,554.42 20060701 99999999 

61703 SURGERY OF INTRACRANIAL ANEURYSM, CERVICAL APPROACH $918.22 20060701 99999999 

61705 SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR $1,940.02 20060701 99999999 



61711 ANASTOMOSIS, ARTERIAL, EXTRACRANIAL-INTRACRANIAL $2,012.93 20060701 99999999 

61720 

CREATION OF LESION BY STEREOTACTIC METHOD, INCLUDING BURR 

HOLE(S) $1,002.65 20060701 99999999 

61735 

CREATION OF LESION BY STEREOTACTIC METHOD, INCLUDING BURR 

HOLE(S) $1,055.48 20060701 99999999 

61750 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION, INCLUDING $967.78 20060701 99999999 

61751 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION, INCLUDING $1,046.69 20060701 99999999 

61760 

STEREOTACTIC IMPLANTATION OF DEPTH ELECTRODES INTO THE 

CEREBRUM FOR LONG TERM SE $1,049.67 20060701 99999999 

61770 

STEREOTACTIC LOCALIZATION ANY METHOD INCL BURR HOLES 

W/INSER $1,195.73 20060701 99999999 

61790 

CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, 

BY $611.03 20060701 99999999 

61791 

CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, 

BY $765.42 20060701 99999999 

61793 STEREOTACTIC FOCUSED PROTON BEAM OR GAMMA RADIOSURGERY $1,025.81 20060701 99999999 

61795 

STEREOTACTIC COMPUTER ASSIST VOLUMETRIC INTRACRANIAL 

PROCEDU $234.94 20060701 99999999 

61850 TWIST DRILL OR BURR HOLE(S) FOR IMPLANTATION OF $699.38 20060701 99999999 

61855 TWIST DRILL OR BURR HOLE(S) FOR IMPLANTATION OF $675.09 19990701 99999999 

61860 CRANIECTOMY OR CRANIOTOMY FOR IMPLANTATION OF $997.32 20060701 99999999 

61862 

TWIST DRILL, BURR HOLE, CRANIOTOMY, OR CRANIECTOMY FOR 

STEREOTACTIC IMPLANTATION $981.50 20000101 99999999 

61863 

TWIST DRILL, BURR HOLE, CRANIOTOMY, OR CRANIECTOMY WITH 

STEREOTACTIC IMPLANTATIO $893.47 20060701 99999999 

61864 





61865 CRANIECTOMY OR CRANIOTOMY FOR IMPLANTATION OF $1,126.99 19990701 99999999 

61867 


STEREOTACTIC IMPLANTATIO $1,363.66 20060701 99999999 

61868 



61870 CRANIECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR $676.02 20060701 99999999 

61875 CRANIECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR $722.72 20060701 99999999 

61880 

REVISION OR REMOVAL OF INTRACRANIAL NEUROSTIMULATOR 

ELECTRODES $358.15 20060701 99999999 

61885 INCISION FOR SUBCUTANEOUS PLACEMENT OF NEUROSTIMULATOR $336.51 20060701 99999999 

61886 

INCISION AND SUBCUTANEOUS PLACEMENT OF CRANIAL 

NEUROSTIMULATOR PULSE GENERATOR O $432.93 20060701 99999999 

61888 

REVISION OR REMOVAL OF INTRACRANIAL NEUROSTIMULATOR 

RECEIVER $257.28 20060701 99999999 

62000 ELEVATION OF DEPRESSED SKULL FRACTURE $534.41 20060701 99999999 

62005 ELEVATION OF DEPRESSED SKULL FRACTURE $814.15 20060701 99999999 

62010 ELEVATION OF DEPRESSED SKULL FRACTURE $1,124.32 20060701 99999999 

62100 

CRANIOTOMY FOR REPAIR OF DURAL/CSF LEAK, INCLUDING 

SURGERY FOR $1,260.09 20060701 99999999 

62115 

REDUCTION OF CRANIOMEGALIC SKULL (EG, TREATED 

HYDROCEPHALUS); NOT REQUIRING BONE $1,071.55 20060701 99999999 

62116 


HYDROCEPHALUS); WITH CRANIOPLASTY $1,224.54 20060701 99999999 

62117 


HYDROCEPHALUS); REQUIRING CRANIOTO $1,404.89 20060701 99999999 

62120 REPAIR OF ENCEPHALOCELE, INCLUDING CRANIOPLASTY $1,210.60 20060701 99999999 

62121 CRANIOTOMY WITH REPAIR OF ENCEPHALOCELE, SKULL BASE $1,164.92 20060701 99999999 

62140 CRANIOPLASTY FOR SKULL DEFECT $783.76 20060701 99999999 

62141 CRANIOPLASTY FOR SKULL DEFECT $892.74 20060701 99999999 

62142 REMOVAL OF BONE FLAP OR PROSTHETIC PLATE OF SKULL $651.28 20060701 99999999 

62143 REPLACEMENT OF BONE FLAP OR PROSTHETIC PLATE OF SKULL $697.98 20060701 99999999 

62145 

CRANIOPLASTY FOR SKULL DEFECT WITH REPARATIVE BRAIN 

SURGERY $995.12 20060701 99999999 

62146 

CRANIOPLASTY WITH AUTOGRAFT (INCLUDES OBTAINING BONE 

GRAFTS); UP TO 5 CM DIAMETE $843.96 20060701 99999999 

62147 

CRANIOPLASTY WITH AUTOGRAFT (INCLUDES OBTAINING BONE 

GRAFTS); LARGER THAN 5 CM D $996.16 20060701 99999999 

62148 

INCISION AND RETRIEVAL OF SUBCUTANEOUS CRANIAL BONE GRAFT 

FOR CRANIOPLASTY (LIST $86.72 20060701 99999999 

62160 

NEUROENDOSCOPY, INTRACRANIAL, FOR PLACEMENT OR 

REPLACEMENT OF VENTRICULAR CATHET $125.24 20060701 99999999 

62161 

NEUROENDOSCOPY, INTRACRANIAL; WITH DISSECTION OF 

ADHESIONS, FENESTRATION OF SEPT $898.92 20060701 99999999 

62162 

NEUROENDOSCOPY, INTRACRANIAL; WITH FENESTRATION OR 

EXCISION OF COLLOID CYST, INC $1,148.17 20060701 99999999 

62163 

NEUROENDOSCOPY, INTRACRANIAL; WITH RETRIEVAL OF FOREIGN 

BODY $728.29 20060701 99999999 

62164 

NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF BRAIN 

TUMOR, INCLUDING PLACEMENT $1,244.20 20060701 99999999 

62165 

NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF PITUITARY 

TUMOR, TRANSNASAL OR TR $979.06 20060701 99999999 

62180 VENTRICULOCISTERNOSTOMY (TORKILDSEN TYPE OPERATION) $1,101.56 20060701 99999999 

62190 CREATION OF SHUNT $665.86 20060701 99999999 


62194 

REPLACEMENT OR IRRIGATION, SUBARACHNOID/SUBDURAL 

CATHETER $206.84 20060701 99999999 

62200 VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE $1,040.52 20060701 99999999 



62201 

VENTRICULUOCISTERNOSTOMY 3RD VENTRICLE STEREOTACTIC 

METHOD $761.93 20060701 99999999 



62225 REPLACEMENT OR IRRIGATION, VENTRICULAR CATHETER $313.32 20060701 99999999 

62230 

REPLACEMENT OR REVISION OF CSF SHUNT, OBSTRUCTED VALVE, 

OR $599.10 20060701 99999999 

62252 REPROGRAMMING OF PROGRAMMABLE CSF SHUNT $62.69 20060701 99999999 

62256 REMOVAL OF COMPLETE CSF SHUNT SYSTEM $396.88 20060701 99999999 

62258 REMOVAL OF COMPLETE CSF SHUNT SYSTEM $839.04 20060701 99999999 

62263 

PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION 

INJECTION (EG, HYPERTONI $248.50 20060701 99999999 

62264 

PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION 

INJECTION (EG, HYPERTONI $162.90 20060701 99999999 

62268 PERCUTANEOUS ASPIRATION, SPINAL CORD CYST OR SYRINX $217.91 20060701 99999999 

62269 BIOPSY OF SPINAL CORD, PERCUTANEOUS NEEDLE $202.42 20060701 99999999 

62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC $51.03 20060701 99999999 

62272 SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF SPINAL FLUID $65.87 20060701 99999999 

62273 INJECTION, LUMBAR EPIDURAL, OF BLOOD OR CLOT PATCH $94.08 20060701 99999999 

62274 INJECTION OF ANESTHETIC SUBSTANCE (INCLUDING NARCOTICS), $73.24 19990701 99999999 

62275 

INJECTION OF ANESTHETIC SUBSTANCE (INCLUDING NARCOTICS), 

DIAGNOSTIC OR THERAPEUT $71.01 19990701 99999999 





62280 INJECTION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, $95.93 20060701 99999999 

62281 

INJECTION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, 

ICED SALINE SOLUTIONS); $97.27 20060701 99999999 

62282 INJECTION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, $102.18 20060701 99999999 

62284 INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTERIZED $78.52 20060701 99999999 

62287 

ASPIRATION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS 

OF INTERVERTEBRAL DISK, $420.88 20060701 99999999 

62288 INJECTION OF SUBSTANCE OTHER THAN ANESTHETIC, CONTRAST, $78.93 19990701 99999999 

62289 INJECTION OF SUBSTANCE OTHER THAN ANESTHETIC, CONTRAST, $73.98 19990701 99999999 

62290 INJECTION PROCEDURE FOR DISKOGRAPHY, SINGLE OR MULTIPLE $131.61 20060701 99999999 

62291 INJECTION PROCEDURE FOR DISKOGRAPHY, SINGLE OR MULTIPLE $126.12 20060701 99999999 

62292 

INJECTION PROCEDURE FOR CHEMONUCLEOLYSIS, INCLUDING 

DISKOGRAPHY, $431.10 20060701 99999999 

62294 INJECTION PROCEDURE, ARTERIAL, FOR OCCLUSION OF $519.82 20060701 99999999 

62298 

INJECTION OF SUBSTANCE OTHER THAN ANESTHETIC, CONTRAST, 

OR NEUROLYTIC SOLUTIONS, $92.28 19990701 99999999 

62310 

INJECTION, SINGLE (NOT VIA INDWELLING CATHETER), NOT 

INCLUDING NEUROLYTIC SUBSTA $68.64 20060701 99999999 

62311 

INJECTION, SINGLE (NOT VIA INDWELLING CATHETER), NOT 

INCLUDING NEUROLYTIC SUBSTA $57.10 20060701 99999999 

62318 

INJECTION, INCLUDING CATHETER PLACEMENT, CONTINUOUS 

INFUSION OR INTERMITTENT BOL $74.20 20060701 99999999 

62319 

INJECTION, INCLUDING CATHETER PLACEMENT, CONTINUOUS 

INFUSION OR INTERMITTENT BOL $67.15 20060701 99999999 

62350 

IMPLANTATION, REVISION OR REPOSITIONING OF INTRATHECAL OR 

EPIDURAL CATHETER, FOR $308.61 20060701 99999999 

62351 

IMPLANTATION, REVISION OR REPOSITIONING OF INTRATHECAL OR 

EPIDURAL CATHETER, FOR $496.00 20060701 99999999 

62355 

REMOVAL OF PREVIOUSLY IMPLANTED INTRATHECAL OR EPIDURAL 

CATHETER $255.38 20060701 99999999 



62360 

IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR 

EPIDURAL DRUG INFUSION; $134.02 20060701 99999999 

62361 



62362 



62365 

REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY 

IMPLANTED FOR INTRATHECAL $265.18 20060701 99999999 

62367 

ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR 

INTRATHECAL OR EPIDURAL $22.00 20060701 99999999 

62368 

ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR 

INTRATHECAL OR EPIDURAL $33.72 20060701 99999999 

63001 

LAMINECTOMY FOR EXPLORATION/DECOMPRESSION OF SPINAL 

CORD $955.82 20060701 99999999 

63003 


CORD $966.24 20060701 99999999 

63005 


CORD $898.89 20060701 99999999 

63011 


CORD $734.51 20060701 99999999 

63012 

LAMINECTOMY WITH REMOVAL OF ABNORMAL FACETS AND/OR PARS 

INTER-ARTICULARIS WITH D $906.15 20060701 99999999 

63015 


CORD $1,166.02 20060701 99999999 

63016 


CORD $1,153.59 20060701 99999999 

63017 


CORD $961.89 20060701 99999999 

63020 LAMINOTOMY (HEMILAMINECTOMY), FOR DECOMPRESSION OF NERVE $900.45 20060701 99999999 



63040 LAMINOTOMY (HEMILAMINECTOMY), FOR DECOMPRESSION OF NERVE $1,126.14 20060701 99999999 

63042 LAMINOTOMY (HEMILAMINECTOMY), FOR DECOMPRESSION OF NERVE $1,046.52 20060701 99999999 

63045 

LAMINECTOMY INCL UNILAT OR BILAT CMPLT FACETECTOMY OR 

FORAMI $999.40 20060701 99999999 

63046 

LAMINECTOMY INCL UNIL/BILAT CMPLT FACETECTOMY OR 

FORAMINOTOM $956.79 20060701 99999999 

63047 


FORAMINOTOM $882.74 20060701 99999999 

63048 


FORAMINOTOM $186.23 20060701 99999999 

63050 

LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL 

CORD, TWO OR MORE $1,029.23 20060701 99999999 

63051 

LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL 

CORD, TWO OR MORE $1,174.55 20060701 99999999 

63055 

TRANSPEDICULAR APPROACH FOR DECOMPRESSION OF SPINAL 

CORD $1,307.28 20060701 99999999 

63056 


CORD $1,192.98 20060701 99999999 

63057 


CORD $267.29 20060701 99999999 

63064 

COSTOVERTEBRAL APPROACH FOR DECOMPRESSION OF SPINAL 

CORD OR $1,413.88 20060701 99999999 



63066 

COSTOVERTEBRAL APPROACH DECOMPRESSION OF SPINAL CORD 

OR NERV $167.08 20060701 99999999 

63075 

DISKECTOMY, ANTERIOR, FOR DECOMPRESSION OF SPINAL CORD 

AND/OR $1,103.69 20060701 99999999 

63076 

DISKECTOMY, ANTERIOR, FOR DECOMPRESSION OF SPINAL CORD 

AND/OR $233.00 20060701 99999999 

63077 

DISKECTOMY ANTERIOR FOR DECOMPRESSION OF SPINAL CORD 

AND/OR $1,174.80 20060701 99999999 

63078 

DISKECTOMY ANTERIOR FOR DECOMPRESSION OF SPINAL CORD 

AND/OR $166.83 20060701 99999999 

63081 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), $1,421.13 20060701 99999999 

63082 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), $251.15 20060701 99999999 


63086 

VERTEBRAL CORPECTOMY PARTIAL OR COMPLT TRANSTHORACIC 

APPROAC $181.70 20060701 99999999 


63088 

VERTEBRAL CORPECTOMY PARTIAL OR CMPLT COMBINED 

THORACOLUMBAR $245.28 20060701 99999999 

63090 

VERTEBRAL CORPECTOMY PART OR CMPLT TRANSPERITONEAL OR 

RETROP $1,605.39 20060701 99999999 

63091 

VERTEBRAL CORPECTOMY PART OR CMPLT TRANSPERITONEAL OR 

RETROP $159.50 20060701 99999999 

63101 

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL 

OR COMPLETE, LATERAL EX $1,568.27 20060701 99999999 

63102 


OR COMPLETE, LATERAL EX $1,568.27 20060701 99999999 

63103 


OR COMPLETE, LATERAL EX $186.11 20060701 99999999 

63170 LAMINECTOMY FOR MYELOTOMY (EG, BISCHOF OR DREZ TYPE), $1,147.51 20060701 99999999 

63172 LAMINECTOMY FOR DRAINAGE OF INTRAMEDULLARY CYST/STRINX TO $1,078.66 20060701 99999999 

63173 

LAMINECTOMY DRAINAGE OF INTRAMEDULLARY CYST/SYRINK TO 

PERITO $1,179.10 20060701 99999999 

63180 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, $947.70 20060701 99999999 

63182 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, $1,093.41 20060701 99999999 

63185 LAMINECTOMY FOR RHIZOTOMY $866.90 20060701 99999999 

63190 LAMINECTOMY FOR RHIZOTOMY $1,039.16 20060701 99999999 

63191 LAMINECTOMY FOR SECTION OF SPINAL ACCESSORY NERVE $920.89 20060701 99999999 

63194 LAMINECTOMY FOR CORDOTOMY, UNILATERAL, ONE STAGE $1,011.87 20060701 99999999 

63195 LAMINECTOMY FOR CORDOTOMY, UNILATERAL, ONE STAGE $1,021.83 20060701 99999999 

63196 LAMINECTOMY FOR CORDOTOMY, BILATERAL, ONE STAGE $1,146.95 20060701 99999999 

63197 LAMINECTOMY FOR CORDOTOMY, BILATERAL, ONE STAGE $1,093.77 20060701 99999999 

63198 LAMINECTOMY FOR CORDOTOMY, BILATERAL, TWO STAGES WITHIN $1,231.73 20060701 99999999 

63199 LAMINECTOMY FOR CORDOTOMY, BILATERAL, TWO STAGES WITHIN $1,441.73 20060701 99999999 

63200 LAMINECTOMY FOR RELEASE OF TETHERED SPINAL CORD LUMBAR $999.37 20060701 99999999 

63250 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS $2,024.60 20060701 99999999 

63251 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS $2,024.89 20060701 99999999 

63252 

LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS 

MALFO $2,106.70 20060701 99999999 

63265 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN $1,245.95 20060701 99999999 

63266 

LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL 

LESION OTHER THAN NEOPLASM $1,321.52 20060701 99999999 

63267 

LAMINECTOMY EXCISION OF INTRASPINAL LESION OTHER THAN 

NEOPLA $1,063.61 20060701 99999999 

63268 


NEOPLA $931.00 20060701 99999999 



63270 


NEOPLA $1,394.55 20060701 99999999 

63271 


NEOPLA $1,539.21 20060701 99999999 

63272 


NEOPLA $1,411.69 20060701 99999999 

63273 


NEOPLA $1,280.33 20060701 99999999 

63275 

LAMINECTOMY FOR BIOPSY/EXCISION INTRASPINAL NEOPLASM 

EXTRADU $1,393.78 20060701 99999999 

63276 

LAMINECTOMY FOR BIOPSY/EXCISION INTRASPINAL NEOPLASM 

EXTRADU $1,373.20 20060701 99999999 

63277 

LAMINECTOMY FOR BIOP/EXC INTRASPINAL NEOPLASM EXTRADURAL 

LUM $1,226.48 20060701 99999999 

63278 

LAMINECTOMY FOR BIOP/EXC INTRASPINAL NEOPLASM EXTRADURAL 

SAC $1,209.19 20060701 99999999 

63280 

LAMINECTOMY FOR BIOP/EXC INTRASPINAL NEOPLASM INTRADURAL 

EXT $1,621.05 20060701 99999999 

63281 


EXT $1,599.67 20060701 99999999 

63282 


EXT $1,474.94 20060701 99999999 

63283 


SAC $1,297.20 20060701 99999999 

63285 


INT $1,861.60 20060701 99999999 

63286 


INT $1,913.64 20060701 99999999 

63287 


INT $1,912.98 20060701 99999999 

63290 

LAMINECTOMY FOR BIOP/EXC INTRASPINAL NEOPLASM COMB 

EXTRADURA $1,953.54 20060701 99999999 

63295 

OSTEOPLASTIC RECONSTRUCTION OF DORSAL SPINAL ELEMENTS, 

FOLLOWING PRIMARY $231.16 20060701 99999999 

63300 

VERTEBRAL CORPECTOMY PART OR CMPLT FOR EXCISION OF 

INTRASPIN $1,276.06 20060701 99999999 

63301 

VERTEBRAL CORPECTOMY PART OR CMPLT FOR EXCISION 

INTRASPINAL $1,402.98 20060701 99999999 

63302 

VERTEBRAL CORPECTOMY PART OR CMPLT FOR EXCISION 

INTRASPINAL $1,460.08 20060701 99999999 

63303 

VERTEBRAL CORPECTOMY PART OR CMPLT FOR EXC INTRASPINAL 

LESIO $1,494.60 20060701 99999999 

63304 


LESIO $1,596.05 20060701 99999999 

63305 


LESIO $1,636.86 20060701 99999999 

63306 


LESIO $1,650.31 20060701 99999999 

63307 


LESIO $1,607.85 20060701 99999999 

63308 


LESIO $270.46 20060701 99999999 

63600 CREATION OF LESION OF SPINAL CORD BY STEREOTACTIC METHOD, $675.34 20060701 99999999 

63610 STEREOTACTIC STIMULATION OF SPINAL CORD, PERCUTANEOUS, $402.31 20060701 99999999 

63615 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION OF LESION, $857.19 20060701 99999999 

63650 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR $358.00 20060701 99999999 

63655 LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR $616.30 20060701 99999999 



63660 REVISION OR REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODES $351.13 20060701 99999999 


63688 REVISION OR REMOVAL OF SPINAL NEUROSTIMULATOR RECEIVER $311.41 20060701 99999999 

63700 REPAIR OF MENINGOCELE $854.03 20060701 99999999 

63702 REPAIR OF MENINGOCELE $963.39 20060701 99999999 

63704 REPAIR OF MYELOMENINGOCELE $1,083.99 20060701 99999999 

63706 REPAIR OF MYELOMENINGOCELE $1,193.94 20060701 99999999 

63707 REPAIR OF DURAL/CSF LEAK NOT REQUIRING LAMINECTOMY $671.89 20060701 99999999 

63709 

REPAIR OF DURAL/CSF LEAK OR PSEUDOMENINGOCELE 

W/LAMINECTOMY $845.73 20060701 99999999 

63710 DURAL GRAFT, SPINAL $742.15 20060701 99999999 

63740 CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, $684.14 20060701 99999999 

63741 

CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, - 

PLEURAL, OR OTHER; PERCUTAN $476.90 20060701 99999999 

63744 

REPLACEMENT, IRRIGATION OR REVISION OF LUMBOSUBARACHNOID 

SHUNT $475.29 20060701 99999999 

63746 

REMOVAL OF ENTIRE LUMBOSUBARACHNOID SHUNT SYSTEM 

WITHOUT REPLACEMENT $339.09 20060701 99999999 

64400 INJECTION, ANESTHETIC AGENT $39.26 20060701 99999999 








64416 

INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, CONTINUOUS 

INFUSION BY CATHETER (I $116.52 20060701 99999999 













64446 

INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS 

INFUSION BY CATHETER, (IN $121.82 20060701 99999999 

64447 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE $56.86 20060701 99999999 

64448 

INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS 

INFUSION BY CATHETER (INC $111.95 20060701 99999999 

64449 

INJECTION, ANESTHETIC AGENT; LUMBAR PLEXUS, POSTERIOR 

APPROACH, CONTINUOUS INFUS $112.15 20060701 99999999 


64470 

INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL 

FACET JOINT OR FACET J $66.04 20060701 99999999 

64472 



64475 



64476 





64479 

INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL 

EPIDURAL; CERVICAL OR $78.80 20060701 99999999 

64480 


EPIDURAL; CERVICAL OR $54.51 20060701 99999999 

64483 


EPIDURAL; LUMBAR OR S $67.16 20060701 99999999 

64484 


EPIDURAL; LUMBAR OR S $47.17 20060701 99999999 




64517 INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS $88.29 20060701 99999999 



64550 APPLICATION OF SURFACE (TRANSCUTANEOUS) $8.98 20060701 99999999 




64561 

PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR 

ELECTRODES; SACRAL NERVE (TRANSFORA $387.86 20060701 99999999 


64573 INCISION FOR IMPLANTATION OF NEUROSTIMULATOR $355.35 20060701 99999999 




64581 

INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 

SACRAL NERVE (TRANSFORA $555.71 20060701 99999999 

64585 

REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR 

ELECTRODES $105.96 20060701 99999999 


64595 

REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR 

RECEIVER $98.94 20060701 99999999 

64600 DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE $157.01 20060701 99999999 



64612 

DESTRUCTION BY NEUROLYTIC AGENT (CHEMODENERVATION OF 

MUSCLE ENDPLATE); MUSCLES E $92.20 20060701 99999999 

64613 

DESTRUCTION BY NEUROLYTIC AGENT (CHEMODENERVATION OF 

MUSCLE ENDPLATE); CERVICAL $91.18 20060701 99999999 

64614 

CHEMODENERVATION OF MUSCLE(S); EXTREMITY(S) AND/OR TRUNK 

MUSCLE(S) (EG, FOR DYST $124.74 20060701 99999999 

64620 DESTRUCTION BY NEUROLYTIC AGENT $105.63 20060701 99999999 



64626 

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET 

JOINT NERVE; CERVICAL OR TH $128.36 20060701 99999999 

64627 

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET 

JOINT NERVE; CERVICAL OR TH $42.51 20060701 99999999 



64650 CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE $27.47 20060701 99999999 

64653 

CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, 

SCALP, FACE, NECK), PER D $34.71 20060701 99999999 

64680 DESTRUCTION BY NEUROLYTIC AGENT, CELIAC PLEXUS, WITH $109.13 20060701 99999999 

64681 

DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT 

RADIOLOGIC MONITORING; SUPERIOR $162.58 20060701 99999999 

64702 NEUROPLASTY $248.34 20060701 99999999 

64704 NEUROPLASTY $260.27 20060701 99999999 



64708 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG $364.73 20060701 99999999 




64716 NEUROPLASTY AND/OR TRANSPOSITION $336.15 20060701 99999999 




64722 DECOMPRESSION $266.26 20060701 99999999 

64726 DECOMPRESSION $175.85 20060701 99999999 

64727 

INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING 

MICROSCOPE $167.82 20060701 99999999 

64732 TRANSECTION OR AVULSION OF $260.88 20060701 99999999 












64763 

TRANSECTION OR AVULSION OF OBTURATOR NERVE, EXTRAPELVIC, 

WITH $359.23 20060701 99999999 

64766 TRANSECTION OR AVULSION OF OBTURATOR NERVE, INTRAPELVIC, $454.85 20060701 99999999 

64771 

TRANSECTION OR AVULSION OF OTHER CRANIAL NERVE, 

EXTRADURAL $407.11 20060701 99999999 

64772 TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL $408.90 20060701 99999999 

64774 EXCISION OF NEUROMA $249.83 20060701 99999999 







64787 

IMPLANTATION OF NERVE END INTO BONE OR MUSCLE (LIST 

SEPARATELY $216.88 20060701 99999999 

64788 EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA $244.32 20060701 99999999 



64795 BIOPSY OF NERVE $157.68 20060701 99999999 

64802 SYMPATHECTOMY, CERVICAL $453.43 20060701 99999999 

64804 SYMPATHECTOMY, CERVICOTHORACIC $769.25 20060701 99999999 

64809 SYMPATHECTOMY, THORACOLUMBAR $688.81 20060701 99999999 

64818 SYMPATHECTOMY, LUMBAR $541.85 20060701 99999999 

64820 

SYMPATHECTOMY, DIGITAL ARTERIES, WITH MAGNIFICATION, EACH 

DIGIT $536.69 20060701 99999999 

64821 SYMPATHECTOMY; RADIAL ARTERY $456.60 20060701 99999999 

64822 SYMPATHECTOMY; ULNAR ARTERY $456.60 20060701 99999999 

64823 SYMPATHECTOMY; SUPERFICIAL PALMAR ARCH $526.04 20060701 99999999 

64831 SUTURE OF DIGITAL NERVE, HAND OR FOOT $432.62 20060701 99999999 

64832 SUTURE OF DIGITAL NERVE, HAND OR FOOT $234.23 20060701 99999999 

64834 SUTURE OF ONE NERVE, HAND OR FOOT $457.54 20060701 99999999 





64837 SUTURE OF EACH ADDITIONAL NERVE, HAND OR FOOT $305.47 20060701 99999999 

64840 SUTURE OF POSTERIOR TIBIAL NERVE $680.00 20060701 99999999 

64856 SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, $676.98 20060701 99999999 

64857 SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, $725.57 20060701 99999999 

64858 SUTURE OF SCIATIC NERVE $835.80 20060701 99999999 

64859 SUTURE OF EACH ADDITIONAL MAJOR PERIPHERAL NERVE $217.89 20060701 99999999 

64861 SUTURE OF $976.31 20060701 99999999 

64862 SUTURE OF $1,156.04 20060701 99999999 

64864 SUTURE OF FACIAL NERVE $619.37 20060701 99999999 

64865 SUTURE OF FACIAL NERVE $803.71 20060701 99999999 

64866 ANASTOMOSIS $791.93 20060701 99999999 

64868 ANASTOMOSIS $745.68 20060701 99999999 

64870 ANASTOMOSIS $842.60 20060701 99999999 

64872 SUTURE OF NERVE $99.05 20060701 99999999 



64885 

NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; UP TO 

4 CM IN LENGTH $884.87 20060701 99999999 

64886 

NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; MORE 

THAN 4 CM IN LENGTH $1,048.11 20060701 99999999 

64890 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, $797.64 20060701 99999999 




64895 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS $958.01 20060701 99999999 

64896 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS $1,084.15 20060701 99999999 



64901 NERVE GRAFT, EACH ADDITIONAL NERVE $556.80 20060701 99999999 

64902 NERVE GRAFT, EACH ADDITIONAL NERVE $631.92 20060701 99999999 

64905 NERVE PEDICLE TRANSFER $675.81 20060701 99999999 

64907 NERVE PEDICLE TRANSFER $939.45 20060701 99999999 

64910 

NERVE REPAIR; WITH SYNTHETIC CONDUIT OR VEIN ALLOGRAFT (EG, 

NERVE TUBE), EACH NE $458.90 20070101 99999999 

64911 

NERVE REPAIR; WITH AUTOGENOUS VEIN GRAFT (INCLUDES 

HARVEST OF VEIN GRAFT), EACH $556.87 20070101 99999999 

64999 UNLISTED PROCEDURE, NERVOUS SYSTEM $932.99 19990701 99999999 

65091 EVISCERATION OF OCULAR CONTENTS $447.75 20060701 99999999 

65093 EVISCERATION OF OCULAR CONTENTS $469.40 20060701 99999999 

65101 ENUCLEATION OF EYE $478.48 20060701 99999999 



65110 

EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), 

REMOVAL $852.84 20060701 99999999 

65112 


REMOVAL $895.29 20060701 99999999 

65114 


REMOVAL $941.19 20060701 99999999 

65125 

MODIFICATION OF OCULAR IMPLANT (EG, DRILLING RECEPTACLE FOR 

PROSTHESIS APPENDAGE $152.85 20030401 99999999 

65130 INSERTION OF OCULAR IMPLANT SECONDARY $480.38 20060701 99999999 



65150 REINSERTION OF OCULAR IMPLANT $430.14 20060701 99999999 

65155 REINSERTION OF OCULAR IMPLANT $566.60 20060701 99999999 

65175 REMOVAL OF OCULAR IMPLANT $431.60 20060701 99999999 

65205 REMOVAL OF FOREIGN BODY, EXTERNAL EYE $25.92 20060701 99999999 






65235 REMOVAL OF FOREIGN BODY, INTRAOCULAR $405.55 20060701 99999999 



65270 REPAIR OF LACERATION $104.08 20060701 99999999 






65286 

REPAIR OF LACERATION APP OF TISSUE GLUE CORNEA 

WOUNDS/SCLERA $296.76 20060701 99999999 

65290 REPAIR OF WOUND, EXTRAOCULAR MUSCLE, TENDON AND/OR $339.97 20060701 99999999 

65400 EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), $375.66 20060701 99999999 

65410 BIOPSY OF CORNEA $78.54 20060701 99999999 

65420 EXCISION OR TRANSPOSITION OF PTERYGIUM $280.89 20060701 99999999 

65426 EXCISION OR TRANSPOSITION OF PTERYGIUM $335.82 20060701 99999999 

65430 SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE $59.62 20060701 99999999 

65435 REMOVAL OF CORNEAL EPITHELIUM $39.69 20060701 99999999 

65436 REMOVAL OF CORNEAL EPITHELIUM $195.34 20060701 99999999 

65450 

DESTRUCTION OF LESION OF CORNEA BY CRYOTHERAPY, 

PHOTOCOAGULATION $232.50 20060701 99999999 

65600 TATTOO CORNEA, MECHANICAL OR CHEMICAL $165.44 20060701 99999999 

65710 

KERATOPLASTY (CORNEAL TRANSPLANT), LAMELLAR, INCLUDES 

AUTOGRAFTS, AND $733.62 20060701 99999999 

65730 KERATOPLASTY (CORNEAL TRANSPLANT), PENETRATING (EXCEPT IN $858.72 20060701 99999999 

65750 KERATOPLASTY (CORNEAL TRANSPLANT), $901.97 20060701 99999999 

65755 

KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN 

PSEUDOPHAKIA) $897.20 20060701 99999999 

65770 KERATOPROSTHESIS $945.89 20060701 99999999 

65772 

CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY 

INDUC $296.15 20060701 99999999 

65775 

CORNEAL WEDGE RESECTION FOR CORRECTION OF SURGICALLY 

INDUCED $392.01 20060701 99999999 

65780 

OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE 

TRANSPLANTATION $583.05 20060701 99999999 

65781 

OCULAR SURFACE RECONSTRUCTION; IIMBAL STEM CELL 

ALLOGRAFT (EG, CADAVERIC OR LIVI $884.08 20060701 99999999 

65782 

OCULAR SURFACE RECONSTRUCTION; LIMBAL CONJUNCTIVAL 

AUTOGRAFT (INCLUDES OBTAINING $762.72 20060701 99999999 

65800 

PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE 

PROCEDURE) $103.10 20060701 99999999 

65805 


PROCEDURE) $89.37 20060701 99999999 

65810 


PROCEDURE) $340.60 20060701 99999999 

65815 


PROCEDURE) $322.51 20060701 99999999 

65820 GONIOTOMY $534.43 20060701 99999999 

65850 TRABECULOTOMY AB EXTERNO $632.31 20060701 99999999 

65855 TRABECULOPLASTY BY LASER SURGERY, ONE OR MORE SESSIONS $219.07 20060701 99999999 

65860 

SEVERING ADHESIONS OF ANTERIOR SEGMENT, LASER TECHNIQUE 


65865 SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL $354.33 20060701 99999999 






65900 REMOVAL OF EPITHELIAL DOWNGROWTH, ANTERIOR CHAMBER EYE $613.68 20060701 99999999 

65920 REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT EYE $489.70 20060701 99999999 

65930 REMOVAL OF BLOOD CLOT, ANTERIOR SEGMENT EYE $458.14 20060701 99999999 

66020 INJECTION, ANTERIOR CHAMBER (SEPARATE PROCEDURE) $95.98 20060701 99999999 

66030 INJECTION, ANTERIOR CHAMBER (SEPARATE PROCEDURE) $61.99 20060701 99999999 

66130 EXCISION OF LESION, SCLERA $395.05 20060701 99999999 

66150 FISTULIZATION OF SCLERA FOR GLAUCOMA $522.99 20060701 99999999 





66172 

FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB 

EXTERNO WITH SCARRING FR $819.06 20060701 99999999 

66180 

AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR, (EG, MOLTENO, 

SCHOCKET, DENVER-KRUPIN) $856.20 20060701 99999999 

66185 REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR $503.50 20060701 99999999 

66220 REPAIR OF SCLERAL STAPHYLOMA $463.83 20060701 99999999 

66225 REPAIR OF SCLERAL STAPHYLOMA $656.43 20060701 99999999 

66250 

REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR 

SEGMENT, $374.80 20060701 99999999 

66500 IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE) $235.23 20060701 99999999 

66505 IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE) $233.30 20060701 99999999 

66600 IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION $540.35 20060701 99999999 





66680 REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS) $345.19 20060701 99999999 

66682 

SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH 

RETRIEVAL OF $412.36 20060701 99999999 

66700 CYCLODIATHERMY $319.77 20060701 99999999 

66710 CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION $319.52 20060701 99999999 

66711 

CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, 

ENDOSCOPIC $384.19 20060701 99999999 

66720 CYCLOCRYOTHERAPY $319.15 20060701 99999999 

66740 CYCLODIALYSIS $310.48 19990701 99999999 

66761 IRIDOTOMY BY PHOTOCOAGULATION (ONE OR MORE SESSIONS) (EG, $205.55 20060701 99999999 

66762 

COREOPLASTY BY PHOTOCOAGULATION (ONE OR MORE SESSIONS) 

(EG, $224.50 20060701 99999999 

66770 DESTRUCTION OF CYST OR LESION IRIS OR CILIARY BODY $251.09 20060701 99999999 

66820 

DISCISSION OF SECONDARY MEMBRANEOUS CATARACT ('AFTER 

CATARACT') $287.31 20060701 99999999 

66821 

DISCISSION OF SECONDARY MEMBRANEOUS CATARACT ('AFTER 

CATARACT') $147.41 20060701 99999999 

66825 

REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN 

INCISION (SEPARATE PR $491.52 20060701 99999999 

66830 

REMOVAL OF SECONDARY MEMBRANOUS CATARACT (''AFTER 

CATARACT''), WITH $419.63 20060701 99999999 

66840 REMOVAL OF LENS MATERIAL $460.34 20060701 99999999 

66850 REMOVAL OF LENS MATERIAL $524.10 20060701 99999999 

66852 

REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR 

WITHOUT VITRECTOMY $571.50 20060701 99999999 

66920 EXTRACTION OF LENS WITH OR WITHOUT IRIDECTOMY $511.03 20060701 99999999 





66982 

EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF 

INTRAOCULAR LENS PROSTHESIS (ON $778.50 20060701 99999999 

66983 INTRACAPSULAR CATARACT EXTRACTION WITH INSERTION OF $494.28 20060701 99999999 

66984 EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF $584.09 20060701 99999999 

66985 INSERTION OF INTRAOCULAR LENS SUBSEQUENT TO CATARACT $484.39 20060701 99999999 

66986 EXCHANGE OF INTRAOCULAR LENS $673.14 20060701 99999999 

67005 

REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY 

TECHNIQUE $306.43 20060701 99999999 

67010 

REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY 

TECHNIQUE $369.97 20060701 99999999 

67015 ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR $416.20 20060701 99999999 

67025 INJECTION OF VITREOUS SUBSTITUTE, PARS PLANA APPROACH $411.60 20060701 99999999 

67027 

IMPLANTATION OR REPLACEMENT OF INTRAVITREAL DRUG DELIVERY 

SYSTEM (EG, GANCICLOVI $590.72 20060701 99999999 

67028 

INTRAVITREAL INJECTION OF A PHARMACOLOGIC AGENT (SEPARATE 

PROCEDURE) $135.55 20060701 99999999 

67030 

DISCISSION OF VITREOUS STRANDS (WITHOUT REMOVAL), PARS 

PLANA $318.92 20060701 99999999 

67031 

SEVERING OF VITREOUS STRANDS, VITREOUS FACE ADHESIONS, 

SHEETS, $181.47 20060701 99999999 

67036 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH $821.70 20060701 99999999 

67038 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH $1,209.64 19990701 99999999 

67039 

VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL 

ENDOLASER PHOTOCOAGULATI $847.98 20060701 99999999 

67040 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH $1,214.68 20060701 99999999 

67041 

VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL 

OF PRERETINAL CELLULAR $595.81 20080101 99999999 

67042 


OF INTERNAL LIMITING M $680.36 20080101 99999999 

67043 


OF SUBRETINAL MEMBRANE $715.45 20080101 99999999 

67101 REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS $406.49 20060701 99999999 



67108 REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS $1,430.57 20060701 99999999 

67110 

REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; BY 

INJECTION OF AIR OR OTHER $555.94 20060701 99999999 


67113 

REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE 

VITREORETINOPATHY, STAGE $718.34 20080101 99999999 

67115 RELEASE OF ENCIRCLING MATERIAL (POSTERIOR SEGMENT) $326.30 20060701 99999999 

67120 REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT $378.24 20060701 99999999 

67121 REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT $627.47 20060701 99999999 

67141 

PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, 

LATTICE $290.59 20060701 99999999 

67145 

PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, 

LATTICE $266.00 20060701 99999999 

67208 DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULOPATHY, $350.59 20060701 99999999 



67220 

DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL 

NEOVASCULARIZATION), O $564.34 20060701 99999999 

67221 


NEOVASCULARIZATION); P $216.25 20060701 99999999 



67225 


NEOVASCULARIZATION); P $26.23 20060701 99999999 

67227 DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, $407.87 20060701 99999999 

67228 DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, $544.54 20060701 99999999 

67229 

TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY, ONE 

OR MORE SESSIONS; PRETERM $519.84 20080101 99999999 

67250 SCLERAL REINFORCEMENT (SEPARATE PROCEDURE) $517.69 20060701 99999999 

67255 SCLERAL REINFORCEMENT (SEPARATE PROCEDURE) $572.28 20060701 99999999 

67299 UNLISTED PROCEDURE, POSTERIOR SEGMENT $738.96 19990701 99999999 

67311 

STRABISMUS SURGERY ON PATIENT NOT PREVIOUSLY OPERATED 

ON, ANY $402.54 20060701 99999999 

67312 

STRABISMUS SURGERY ON PATIENT NOT PREVIOUSLY OPERATED 

ON, ANY $503.99 20060701 99999999 

67314 

STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE 

(PATIENT NOT PREVIOUSLY OPE $448.96 20060701 99999999 

67316 

STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE 

(PATIENT NOT PREVIOUSLY OPE $558.10 20060701 99999999 

67318 

STRABISMUS SURGERY, ANY PROCEDURE (PATIENT NOT 

PREVIOUSLY OPERATED ON), SUPERIOR $429.51 20060701 99999999 

67320 

TRANSPOSITION OF EXTRAOCULAR MUSCLE (EG, FOR PARETIC 

MUSCLE), $246.44 20060701 99999999 

67331 STRABISMUS SURGERY ON PATIENT PREVIOUSLY OPERATED ON $233.85 20060701 99999999 

67332 STRABISMUS SURGERY ON PATIENT PREVIOUSLY OPERATED ON $255.37 20060701 99999999 

67334 

STRABISMUS SURGERY BY POSTERIOR FIXATION SUTURE 

TECHNIQUE, WITH OR WITHOUT MUSCL $225.78 20060701 99999999 

67335 ADJUSTABLE SUTURE TECHNIQUE DURING STRABISMUS SURGERY $133.83 20060701 99999999 

67340 

STRABISMUS SURGERY INVOLVING EXPLORATION AND/OR REPAIR OF 

DETACHED EXTRAOCULAR M $280.91 20060701 99999999 

67343 

RELEASE OF EXTENSIVE SCAR TISSUE WITHOUT DETACHING 

EXTRAOCULAR MUSCLE (SEPARATE $407.43 20060701 99999999 

67345 CHEMODENERVATION OF EXTRAOCULAR MUSCLE $126.45 20060701 99999999 

67346 BIOPSY OF EXTRAOCULAR MUSCLE $125.95 20070101 99999999 

67350 BIOPSY OF EXTRAOCULAR MUSCLE $155.56 19990701 99999999 

67400 ORBITOTOMY WITHOUT BONE FLAP (FRONTAL APPROACH) $630.29 20060701 99999999 




67414 

ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR 

TRANSCONJUNCTIVAL APPROACH); WITH REMOV $667.35 20060701 99999999 

67415 TRANSCONJUNCTIVAL OR ASPIRATIONAL BIOPSY $94.41 20060701 99999999 

67420 

ORBITOTOMY WITH BONE FLAP, LATERAL APPROACH (EG, 

KROENLEIN) $1,121.32 20060701 99999999 

67430 


KROENLEIN) $784.07 20060701 99999999 

67440 


KROENLEIN) $823.57 20060701 99999999 

67445 

ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH 

(EG, KROENLEIN); WITH REMO $825.08 20060701 99999999 

67450 


KROENLEIN) $851.67 20060701 99999999 

67500 RETROBULBAR INJECTION $37.86 20060701 99999999 

67505 RETROBULBAR INJECTION $33.49 20060701 99999999 

67515 INJECTION OF THERAPEUTIC AGENT INTO TENON'S CAPSULE $26.47 20060701 99999999 

67550 ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE) $618.16 20060701 99999999 

67560 ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE) $608.73 20060701 99999999 

67570 

OPTIC NERVE DECOMPRESSION (EG, INCISION OR FENESTRATION OF 

OPTIC NERVE SHEATH) $742.21 20060701 99999999 

67700 BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID $64.21 20060701 99999999 



67710 SEVERING OF TARSORRHAPHY $54.79 20060701 99999999 

67715 CANTHOTOMY (SEPARATE PROCEDURE) $65.79 20060701 99999999 

67800 EXCISION OF CHALAZION $59.08 20060701 99999999 




67810 BIOPSY OF EYELID $58.85 20060701 99999999 

67820 CORRECTION OF TRICHIASIS $35.21 20060701 99999999 




67840 

EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT 

CLOSURE $90.12 20060701 99999999 

67850 DESTRUCTION OF LESION OF LID MARGIN (UP TO 1 CM) $81.46 20060701 99999999 

67875 TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE) $78.56 20060701 99999999 

67880 

CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN 

TARSORRHAPHY, $216.64 20060701 99999999 

67882 

CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN 

TARSORRHAPHY, $301.15 20060701 99999999 

67900 

REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR 

CORONAL APPROACH) $326.89 20060701 99999999 

67901 REPAIR OF BLEPHAROPTOSIS $421.77 20060701 99999999 






67909 REDUCTION OF OVERCORRECTION OF PTOSIS $343.64 20060701 99999999 

67911 CORRECTION OF LID RETRACTION $339.60 20060701 99999999 

67912 

CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER 

EYELID LID LOAD (EG, GOL $317.82 20060701 99999999 

67914 REPAIR OF ECTROPION $220.03 20060701 99999999 




67921 REPAIR OF ENTROPION $204.68 20060701 99999999 




67930 SUTURE OF RECENT WOUND, EYELID, INVOLVING $153.89 20060701 99999999 

67935 SUTURE OF RECENT WOUND, EYELID, INVOLVING $313.08 20060701 99999999 

67938 REMOVAL OF EMBEDDED FOREIGN BODY, EYELID $63.32 20060701 99999999 

67950 CANTHOPLASTY (RECONSTRUCTION OF CANTHUS) $371.29 20060701 99999999 

67961 EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, $353.02 20060701 99999999 

67966 EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, $391.77 20060701 99999999 

67971 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF $569.76 20060701 99999999 




68020 INCISION OF CONJUNCTIVA, DRAINAGE OF CYST $62.96 20060701 99999999 

68040 EXPRESSION OF CONJUNCTIVAL FOLLICLES, EG, FOR TRACHOMA $33.35 20060701 99999999 

68100 BIOPSY OF CONJUNCTIVA $56.12 20060701 99999999 

68110 EXCISION OF LESION, CONJUNCTIVA $83.77 20060701 99999999 



68135 DESTRUCTION OF LESION, CONJUNCTIVA $85.37 20060701 99999999 

68200 SUBCONJUNCTIVAL INJECTION $21.82 20060701 99999999 



68320 CONJUNCTIVOPLASTY $328.63 20060701 99999999 

68325 CONJUNCTIVOPLASTY $438.26 20060701 99999999 

68326 CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE-SAC $427.00 20060701 99999999 

68328 CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE-SAC $483.18 20060701 99999999 

68330 REPAIR OF SYMBLEPHARON $300.57 20060701 99999999 



68360 CONJUNCTIVAL FLAP $276.11 20060701 99999999 

68362 CONJUNCTIVAL FLAP $452.38 20060701 99999999 

68371 HARVESTING CONJUNCTIVAL ALLOGRAFT, LIVING DONOR $275.67 20060701 99999999 

68400 INCISION, DRAINAGE OF LACRIMAL GLAND $86.30 20060701 99999999 

68420 INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR $107.86 20060701 99999999 

68440 SNIP INCISION OF LACRIMAL PUNCTUM $54.47 20060701 99999999 

68500 

EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR 

TUMOR $568.09 20060701 99999999 

68505 

EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR 

TUMOR $595.45 20060701 99999999 

68510 BIOPSY OF LACRIMAL GLAND $225.30 20060701 99999999 

68520 EXCISION OF LACRIMAL SAC (DACRYOCYSTECTOMY) $448.26 20060701 99999999 

68525 BIOPSY OF LACRIMAL SAC $218.07 20060701 99999999 

68530 REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES $167.43 20060701 99999999 

68540 EXCISION OF LACRIMAL GLAND TUMOR $565.08 20060701 99999999 

68550 EXCISION OF LACRIMAL GLAND TUMOR $713.92 20060701 99999999 

68700 PLASTIC REPAIR OF CANALICULI $321.70 20060701 99999999 

68705 CORRECTION OF EVERTED PUNCTUM, CAUTERY $94.37 20060701 99999999 

68720 DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL $525.96 20060701 99999999 

68745 CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA $454.77 20060701 99999999 

68750 CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA $516.63 20060701 99999999 

68760 CLOSURE OF LACRIMAL PUNCTUM $82.35 20060701 99999999 

68761 CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH $65.51 20060701 99999999 

68770 CLOSURE OF LACRIMAL FISTULA (SEPARATE PROCEDURE) $314.42 20060701 99999999 

68801 DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION $59.78 20060701 99999999 

68810 PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION $112.94 20060701 99999999 

68811 

PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION 

REQUIRING GEN ANESTHES $123.60 20060701 99999999 

68815 

PROBING OF NASOLACRIMAL DUCT, WITH/WITHOUT IRRIGATION WITH 

INSERTION OF TUBE/STE $147.46 20060701 99999999 

68816 

PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 

WITH TRANSLUMINAL BALL $114.67 20080101 99999999 

68840 PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION $57.95 20060701 99999999 

68850 INJECTION OF CONTRAST MEDIUM FOR DACRYOCYSTOGRAPHY $36.19 20060701 99999999 

69000 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA $69.68 20060701 99999999 

69005 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA $97.79 20060701 99999999 

69020 DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS $88.30 20060701 99999999 

69100 BIOPSY EXTERNAL EAR $34.48 20060701 99999999 

69105 BIOPSY EXTERNAL AUDITORY CANAL $43.83 20060701 99999999 

69110 EXCISION EXTERNAL EAR $197.02 20060701 99999999 

69120 EXCISION EXTERNAL EAR $255.86 20060701 99999999 

69140 EXCISION EXOSTOSIS(ES), EXTERNAL AUDITORY CANAL $530.23 20060701 99999999 

69145 EXCISION SOFT TISSUE LESION, EXTERNAL AUDITORY CANAL $150.43 20060701 99999999 

69150 RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION $715.85 20060701 99999999 

69155 RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION $1,079.28 20060701 99999999 

69200 REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL $35.80 20060701 99999999 

69205 REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL $71.57 20060701 99999999 

69210 

REMOVAL IMPACTED CERUMEN (SEPARATE PROCEDURE), ONE OR 

BOTH $22.98 20060701 99999999 

69220 DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPLE (EG, ROUTINE $38.68 20060701 99999999 



69222 

DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPLEX (EG, WITH 

ANESTHESIA $86.47 20060701 99999999 

69300 OTOPLASTY, PROTRUDING EAR, WITH OR WITHOUT SIZE REDUCTION $335.77 20060701 99999999 

69310 RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (MEATOPLASTY) $674.12 20060701 99999999 

69320 

RECONSTRUCTION EXTERNAL AUDITORY CANAL FOR CONGENITAL 

ATRESIA, $965.06 20060701 99999999 

69400 EUSTACHIAN TUBE INFLATION, TRANSNASAL $37.16 20060701 99999999 

69401 EUSTACHIAN TUBE INFLATION, TRANSNASAL $31.73 20060701 99999999 

69405 EUSTACHIAN TUBE CATHETERIZATION, TRANSTYMPANIC $122.53 20060701 99999999 

69410 

FOCAL APPLICATION OF PHASE CONTROL SUBSTANCE, MIDDLE EAR 

(BAFFLE $16.67 20030401 99999999 

69420 MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE $72.56 20060701 99999999 

69421 MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE $97.08 20060701 99999999 

69424 

VENTILATING TUBE REMOVAL WHEN ORIGINALLY INSERTED BY 

ANOTHER $40.09 20060701 99999999 

69433 

TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), 

LOCAL OR $78.53 20060701 99999999 

69436 

TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), 

GENERAL $158.37 20060701 99999999 

69440 

MIDDLE EAR EXPLORATION THROUGH POSTAURICULAR OR EAR 

CANAL $455.43 20060701 99999999 

69450 TYMPANOLYSIS, TRANSCANAL $342.78 20060701 99999999 

69501 TRANSMASTOID ANTROTOMY (''SIMPLE'' MASTOIDECTOMY) $539.64 20060701 99999999 

69502 MASTOIDECTOMY $727.00 20060701 99999999 



69530 PETROUS APICECTOMY INCLUDING RADICAL MASTOIDECTOMY $1,043.24 20060701 99999999 

69535 RESECTION TEMPORAL BONE, EXTERNAL APPROACH $1,809.83 20060701 99999999 

69540 EXCISION AURAL POLYP $79.26 20060701 99999999 

69550 EXCISION AURAL GLOMUS TUMOR $649.05 20060701 99999999 

69552 EXCISION AURAL GLOMUS TUMOR $1,045.66 20060701 99999999 

69554 EXCISION AURAL GLOMUS TUMOR $1,663.32 20060701 99999999 

69601 REVISION MASTOIDECTOMY $776.40 20060701 99999999 





69610 

TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE 

PREPARATION $190.42 20060701 99999999 

69620 

MYRINGOPLASTY (SURGERY CONFINED TO DRUMHEAD AND DONOR 

AREA) $329.88 20060701 99999999 

69631 

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING 

CANALPLASTY, $590.44 20060701 99999999 

69632 


CANALPLASTY, $758.45 20060701 99999999 

69633 


CANALPLASTY, $722.62 20060701 99999999 

69635 TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING $784.69 20060701 99999999 



69641 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, $750.22 20060701 99999999 







69646 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, $1,052.75 20060701 99999999 

69650 STAPES MOBILIZATION $571.51 20060701 99999999 

69660 

STAPEDECTOMY WITH REESTABLISHMENT OF OSSICULAR 

CONTINUITY, $696.53 20060701 99999999 

69661 

STAPEDECTOMY WITH REESTABLISHMENT OF OSSICULAR 

CONTINUITY, $917.11 20060701 99999999 

69662 REVISION OF STAPEDECTOMY OR STAPEDOTOMY $900.11 20060701 99999999 

69666 REPAIR OVAL WINDOW FISTULA $576.99 20060701 99999999 

69667 REPAIR ROUND WINDOW FISTULA $577.26 20060701 99999999 

69670 MASTOID OBLITERATION (SEPARATE PROCEDURE) $639.22 20060701 99999999 

69676 TYMPANIC NEURECTOMY $536.51 20060701 99999999 

69700 

CLOSURE POSTAURICULAR FISTULA, MASTOID (SEPARATE 

PROCEDURE) $453.54 20060701 99999999 

69711 

REMOVAL OR REPAIR OF ELECTROMAGNETIC BONE CONDUCTION 

DEVICE $567.15 20060701 99999999 

69714 

IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, 

WITH PERCUTANEOUS ATTACHME $723.52 20060701 99999999 

69715 

IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, 

WITH PERCUTANEOUS ATTACHME $914.52 20060701 99999999 

69717 

REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), 

OSSEOINTEGRATED IMPLANT, TEM $748.46 20060701 99999999 

69718 

REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), 

OSSEOINTEGRATED IMPLANT, TEM $925.85 20060701 99999999 

69720 DECOMPRESSION FACIAL NERVE, INTRATEMPORAL $849.88 20060701 99999999 

69725 DECOMPRESSION FACIAL NERVE, INTRATEMPORAL $1,228.96 20060701 99999999 

69740 

SUTURE FACIAL NERVE, INTRATEMPORAL, WITH OR WITHOUT GRAFT 

OR $818.30 20060701 99999999 

69745 

SUTURE FACIAL NERVE, INTRATEMPORAL, WITH OR WITHOUT GRAFT 

OR $933.13 20060701 99999999 

69801 LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURGERY OR OTHER $511.24 20060701 99999999 

69802 LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURGERY OR OTHER $719.78 20060701 99999999 

69805 ENDOLYMPHATIC SAC OPERATION $768.15 20060701 99999999 

69806 ENDOLYMPHATIC SAC OPERATION $730.32 20060701 99999999 

69820 FENESTRATION SEMICIRCULAR CANAL $566.86 20060701 99999999 

69840 REVISION FENESTRATION OPERATION $582.10 20060701 99999999 

69905 LABYRINTHECTOMY $659.12 20060701 99999999 

69910 LABYRINTHECTOMY $798.08 20060701 99999999 

69915 VESTIBULAR NERVE SECTION, TRANSLABYRINTHINE APPROACH $1,130.49 20060701 99999999 

69930 

COCHLEAR DEVICE IMPLANTATION, WITH OR WITHOUT 

MASTOIDECTOMY $972.60 20060701 99999999 

69950 VESTIBULAR NERVE SECTION, TRANSCRANIAL APPROACH $1,290.71 20060701 99999999 

69955 

TOTAL FACIAL NERVE DECOMPRESSION AND/OR REPAIR (MAY 

INCLUDE GRAFT) $1,402.57 20060701 99999999 

69960 DECOMPRESSION INTERNAL AUDITORY CANAL $1,352.34 20060701 99999999 

69970 REMOVAL OF TUMOR, TEMPORAL BONE $1,475.41 20060701 99999999 

69990 

USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO 

CODE FOR PRIMARY PRO $155.12 20060701 99999999 

70010 MYELOGRAPHY, POSTERIOR FOSSA $188.91 20060701 99999999 

70015 CISTERNOGRAPHY, POSITIVE CONTRAST $91.40 20060701 99999999 

70030 RADIOLOGIC EXAMINATION, EYE, $21.02 20060701 99999999 

70100 RADIOLOGIC EXAMINATION, MANDIBLE $27.78 20060701 99999999 



70110 RADIOLOGIC EXAMINATION, MANDIBLE $34.71 20060701 99999999 

70120 RADIOLOGIC EXAMINATION, MASTOIDS $34.15 20060701 99999999 

70130 RADIOLOGIC EXAMINATION, MASTOIDS $39.20 20060701 99999999 

70134 RADIOLOGIC EXAMINATION, INTERNAL AUDITORY MEATI, COMPLETE $37.65 20060701 99999999 

70140 RADIOLOGIC EXAMINATION, FACIAL BONES $31.49 20060701 99999999 

70150 RADIOLOGIC EXAMINATION, FACIAL BONES $40.82 20060701 99999999 

70160 RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF $27.12 20060701 99999999 

70170 DACRYOCYSTOGRAPHY, NASOLACRIMAL DUCT $43.39 20060701 99999999 

70190 RADIOLOGIC EXAMINATION $28.99 20060701 99999999 


70210 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, LESS THAN THREE $30.52 20060701 99999999 

70220 

RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, 

MINIMUM $40.07 20060701 99999999 

70240 RADIOLOGIC EXAMINATION, SELLA TURCICA $21.66 20060701 99999999 

70250 RADIOLOGIC EXAMINATION, SKULL $30.09 20060701 99999999 

70260 RADIOLOGIC EXAMINATION, SKULL $48.43 20060701 99999999 

70300 RADIOLOGIC EXAMINATION, TEETH $13.36 20060701 99999999 



70328 RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND $23.89 20060701 99999999 

70330 RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND $40.04 20060701 99999999 

70332 TEMPOROMANDIBULAR JOINT ARTHROGRAPHY $90.82 20060701 99999999 

70336 

MAGNETIC RENONANCE(EG,PROTON)IMAGING,TEMPOROMANDIBULAR 

JOINT $423.20 20060701 99999999 

70350 CEPHALOGRAM, ORTHODONTIC $19.57 20060701 99999999 

70355 ORTHOPANTOGRAM $26.85 20060701 99999999 



70371 COMPLEX DYNAMIC PHARY. & SPEECH EVAL. BY CINE OR VIDEO REC. $82.48 20060701 99999999 

70373 LARYNGOGRAPHY, CONTRAST $61.18 20060701 99999999 

70380 RADIOLOGIC EXAMINATION, SALIVARY GLAND FOR CALCULUS $23.24 20060701 99999999 

70390 SIALOGRAPHY $73.89 20060701 99999999 

70450 COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN $203.07 20060701 99999999 



70480 COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR $231.00 20060701 99999999 



70486 COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA $209.20 20060701 99999999 



70490 COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK $205.75 20060701 99999999 



70496 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITHOUT 

CONTRAST MATERIAL(S), FOLLOWED B $334.94 20060701 99999999 

70498 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITHOUT 

CONTRAST MATERIAL(S), FOLLOWED B $334.94 20060701 99999999 

70540 MAGNETIC RESONANCE (EG, PROTON) IMAGING $427.26 20060701 99999999 

70541 

MAGNETIC RESONANCE ANGIOGRAPHY, HEAD AND/OR NECK, WITH 

OR WITHOUT CONTRAST MATER $437.44 19990701 99999999 



70542 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND 

NECK; WITH CONTRAST MA $442.17 20060701 99999999 

70543 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND 

NECK; WITHOUT CONTRAST $787.12 20060701 99999999 

70544 

MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST 

MATERIAL(S) $366.93 20060701 99999999 

70545 

MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST 

MATERIAL(S) $366.93 20060701 99999999 

70546 

MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST 

MATERIAL(S), FOLLOWED BY $701.32 20060701 99999999 

70547 

MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST 

MATERIAL(S) $366.93 20060701 99999999 

70548 

MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST 

MATERIAL(S) $366.93 20060701 99999999 

70549 

MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST 

MATERIAL(S), FOLLOWED BY $701.32 20060701 99999999 

70551 MAGNETIC RESONANCE (EG, PROTON) IMAGING, $427.26 20060701 99999999 

70552 MRI BRAIN, INCL BRAIN STEM; WITH CONTRAST $512.45 20060701 99999999 

70553 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 

BRAIN STEM); WITHOUT C $912.41 20060701 99999999 

70554 

MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; 

INCLUDING TEST SELECTION AND $444.48 20070101 99999999 

71010 RADIOLOGIC EXAMINATION, CHEST $22.95 20060701 99999999 

71015 RADIOLOGIC EXAMINATION, CHEST $25.62 20060701 99999999 

71020 

RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND 

LATERAL $29.95 20060701 99999999 

71021 


LATERAL $39.42 20060701 99999999 

71022 


LATERAL $41.36 20060701 99999999 

71023 


LATERAL $40.88 20060701 99999999 

71030 RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR $38.10 20060701 99999999 

71034 RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR $66.13 20060701 99999999 

71035 RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS, EG, LATERAL $24.20 20060701 99999999 

71036 

NEEDLE BIOPSY OF INTRATHORACIC LESION, INCLUDING FOLLOW-UP 

FILMS $82.50 19990701 99999999 

71040 BRONCHOGRAPHY, UNILATERAL $71.16 20060701 99999999 

71060 BRONCHOGRAPHY, BILATERAL $102.20 20060701 99999999 

71090 

INSERTION PACEMAKER, FLUOROSCOPY AND RADIOGRAPHY, 

SUPERVISION $78.41 20060701 99999999 

71100 RADIOLOGIC EXAMINATION, RIBS, UNILATERAL $27.69 20060701 99999999 

71101 RADIOLOGIC EXAMINATION, RIBS, UNILATERAL $37.39 20060701 99999999 

71110 RADIOLOGIC EXAMINATION, RIBS, BILATERAL $38.95 20060701 99999999 

71111 RADIOLOGIC EXAMINATION, RIBS, BILATERAL $42.36 20060701 99999999 



71250 COMPUTERIZED AXIAL TOMOGRAPHY, THORAX $266.42 20060701 99999999 



71275 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST, WITHOUT 

CONTRAST MATERIAL(S), FOLLOWED $382.28 20060701 99999999 

71550 MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR $431.66 20060701 99999999 

71551 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR 

EVALUATION OF HILAR AND $446.99 20060701 99999999 

71552 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR 

EVALUATION OF HILAR AND $788.32 20060701 99999999 



71555 

MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING 

MYOCARDIUM), WITH OR WITHOUT CO $438.68 20060701 99999999 

72010 RADIOLOGIC EXAMINATION, SPINE, ENTIRE, SURVEY STUDY, $58.32 20060701 99999999 

72020 RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL $22.39 20060701 99999999 

72040 RADIOLOGIC EXAMINATION, SPINE, CERVICAL $32.09 20060701 99999999 



72069 

RADIOLOGIC EXAMINATION, SPINE, THORACOLUMBAR, STANDING 

(SCOLIOSIS) $25.26 20060701 99999999 

72070 RADIOLOGIC EXAMINATION, SPINE $33.59 20060701 99999999 





72100 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL $34.48 20060701 99999999 



72120 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL, BENDING VIEWS $38.48 20060701 99999999 

72125 COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE $266.42 20060701 99999999 



72128 COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE $240.34 20060701 99999999 



72131 COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE $247.17 20060701 99999999 



72141 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND $431.66 20060701 99999999 

72142 MAGNETIC RESONANCE IMAGING,SPINAL CANAL & W/CONT MATERIAL $517.94 20060701 99999999 

72146 

MRI,SPINAL CANAL & CONTENTS,THORACIC W/O CONTRAST 

MATERIALS $472.21 20060701 99999999 

72147 

MRI,SPINAL CONAL & CONTENTS,THORACIC W/CONTRAST 

MATERIAL(S) $517.94 20060701 99999999 

72148 MRI SPINAL CANAL & CONTENTS; W/O CONTRAST LUMBAR $467.81 20060701 99999999 

72149 

MAGNETIC RESONANCE IMAGING,SPINAL CANAL W/CONTRAST 

MATERIAL $512.45 20060701 99999999 

72156 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 

CONTENTS, WITHOUT CONT $920.36 20060701 99999999 

72157 



72158 



72170 RADIOLOGIC EXAMINATION, PELVIS $26.78 20060701 99999999 

72190 RADIOLOGIC EXAMINATION, PELVIS $34.17 20060701 99999999 

72191 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, PELVIS, WITHOUT 

CONTRAST MATERIAL(S), FOLLOWED $369.74 20060701 99999999 

72192 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS $262.48 20060701 99999999 



72195 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT 

CONTRAST MATERIAL(S) $373.71 20060701 99999999 

72196 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS $431.66 20060701 99999999 

72197 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT 

CONTRAST MATERIAL(S), F $792.67 20060701 99999999 

72198 

MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT 




72200 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS $27.12 20060701 99999999 

72202 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS $28.90 20060701 99999999 

72220 RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF TWO $28.81 20060701 99999999 

72240 MYELOGRAPHY, CERVICAL $156.47 20060701 99999999 

72255 MYELOGRAPHY, THORACIC $178.17 20060701 99999999 

72265 MYELOGRAPHY, LUMBOSACRAL $166.71 20060701 99999999 

72270 MYELOGRAPHY, ENTIRE SPINAL CANAL $253.11 20060701 99999999 

72275 

EPIDUROGRAPHY, RADIOLOGICAL SUPERVISION AND 

INTERPRETATION $108.61 20060701 99999999 

72285 DISKOGRAPHY, CERVICAL $319.32 20060701 99999999 

72295 DISKOGRAPHY, LUMBAR $291.79 20060701 99999999 



73020 RADIOLOGIC EXAMINATION, SHOULDER $23.44 20060701 99999999 

73030 RADIOLOGIC EXAMINATION, SHOULDER $28.13 20060701 99999999 

73040 RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY $90.51 20060701 99999999 



73070 RADIOLOGIC EXAMINATION, ELBOW $23.75 20060701 99999999 

73080 RADIOLOGIC EXAMINATION, ELBOW $25.75 20060701 99999999 

73085 RADIOLOGIC EXAMINATION, ELBOW, ARTHROGRAPHY $90.82 20060701 99999999 



73100 RADIOLOGIC EXAMINATION, WRIST $25.44 20060701 99999999 

73110 RADIOLOGIC EXAMINATION, WRIST $24.25 20060701 99999999 

73115 RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY $73.79 20060701 99999999 

73120 RADIOLOGIC EXAMINATION, HAND $28.24 20060701 99999999 

73130 RADIOLOGIC EXAMINATION, HAND $27.34 20060701 99999999 

73140 RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO $21.42 20060701 99999999 

73200 COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY $205.80 20060701 99999999 



73206 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, UPPER EXTREMITY, 

WITHOUT CONTRAST MATERIAL(S), $342.45 20060701 99999999 

73218 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, 

OTHER THAN JOINT; WITH $368.37 20060701 99999999 

73219 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, 


73220 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, $714.47 20060701 99999999 

73221 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF 

UPPER EXTREMITY $423.20 20060701 99999999 

73222 


UPPER EXTREMITY; WITH CONT $442.17 20060701 99999999 

73223 


UPPER EXTREMITY; WITHOUT C $787.12 20060701 99999999 

73500 RADIOLOGIC EXAMINATION, HIP $25.41 20060701 99999999 

73510 RADIOLOGIC EXAMINATION, HIP $30.75 20060701 99999999 

73520 

RADIOLOGIC EXAMINATION, HIPS, BILATERAL, MINIMUM OF TWO 

VIEWS $36.74 20060701 99999999 

73525 RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY $92.67 20060701 99999999 

73530 RADIOLOGIC EXAMINATION, HIP, DURING OPERATIVE PROCEDURE $28.35 20060701 99999999 

73540 RADIOLOGIC EXAMINATION, PELVIS AND HIPS, INFANT OR CHILD, $27.17 20060701 99999999 

73542 

RADIOLOGICAL EXAMINATION, SACROILIAC JOINT ARTHROGRAPHY, 

RADIOLOGICAL SUPERVISIO $88.21 20060701 99999999 

73550 RADIOLOGIC EXAMINATION, FEMUR, ANTEROPOSTERIOR $25.75 20060701 99999999 

73560 RADIOLOGIC EXAMINATION, KNEE $23.94 20060701 99999999 





73565 

RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, 

ANTEROPOSTERIOR $25.75 20060701 99999999 

73580 RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY $107.55 20060701 99999999 



73600 RADIOLOGIC EXAMINATION, ANKLE $25.44 20060701 99999999 

73610 RADIOLOGIC EXAMINATION, ANKLE $24.25 20060701 99999999 

73615 RADIOLOGIC EXAMINATION, ANKLE, ARTHROGRAPHY $90.82 20060701 99999999 

73620 RADIOLOGIC EXAMINATION, FOOT $23.05 20060701 99999999 

73630 RADIOLOGIC EXAMINATION, FOOT $27.46 20060701 99999999 



73700 COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY $229.20 20060701 99999999 



73706 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, 

WITHOUT CONTRAST MATERIAL(S), $345.26 20060701 99999999 

73718 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY 

OTHER THAN JOINT; WITHO $368.37 20060701 99999999 

73719 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY 


73720 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY, $714.22 20060701 99999999 

73721 


LOWER EXTREMITY $423.20 20060701 99999999 

73722 


LOWER EXTREMITY; WITH CONT $442.38 20060701 99999999 

73723 


LOWER EXTREMITY; WITHOUT C $787.12 20060701 99999999 

73725 

MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR 

WITHOUT CONTRAST MATERI $437.70 20060701 99999999 

74000 RADIOLOGIC EXAMINATION, ABDOMEN $27.43 20060701 99999999 




74150 COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN $259.18 20060701 99999999 



74175 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN, WITHOUT 

CONTRAST MATERIAL(S), FOLLOWE $372.30 20060701 99999999 

74181 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN $431.45 20060701 99999999 

74182 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH 


74183 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT 

CONTRAST MATERIAL(S), $792.67 20060701 99999999 

74185 

MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR 

WITHOUT CONTRAST MATERIAL(S) $438.11 20060701 99999999 

74190 

PERITONEOGRAM (EG, AFTER INJECTION OF AIR OR CONTRAST), 

RADIOLOGICAL SUPERVISION $49.74 20060701 99999999 



74230 SWALLOWING FUNCTION, PHARYNX AND/OR ESOPHAGUS, WITH $73.05 20060701 99999999 

74235 REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF $132.88 19990701 99999999 

74240 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER $88.76 20060701 99999999 





74246 

RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, 

AIR CONTRAST, $93.04 20060701 99999999 

74247 


AIR CONTRAST, $94.38 20060701 99999999 

74249 


AIR CONTRAST, $120.59 20060701 99999999 

74250 

RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES MULTIPLE 

SERIAL $69.48 20060701 99999999 

74251 

RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES MULTIPLE 

SERIAL FILMS; VIA ENTEROC $68.44 20060701 99999999 

74260 DUODENOGRAPHY, HYPOTONIC $69.06 20060701 99999999 

74270 RADIOLOGIC EXAMINATION, COLON $90.00 20060701 99999999 

74280 RADIOLOGIC EXAMINATION, COLON $124.50 20060701 99999999 

74283 

BARIUM ENEMA,THREAPEUTIC,FOR REDUCTION OF 

INTUSSUSCEPTION $163.58 20060701 99999999 

74290 CHOLECYSTOGRAPHY, ORAL CONTRAST $42.01 20060701 99999999 

74291 CHOLECYSTOGRAPHY, ORAL CONTRAST $17.50 20060701 99999999 

74300 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY $18.78 20030401 99999999 

74305 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY $42.49 20060701 99999999 

74320 CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC $125.20 20060701 99999999 

74327 

POSTOPERATIVE BILIARY DUCT STONE REMOVAL, PERCUTANEOUS 

VIA $85.99 20060701 99999999 

74328 ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, $131.53 20060701 99999999 

74329 

ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL 

SYSTEM, $131.53 19990701 99999999 

74330 COMBINED ENDOSCOPIC CATHETERIZATION OF THE BILIARY AND $137.98 20060701 99999999 

74340 

INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER- 

ABBOTT), $107.55 20060701 99999999 

74350 PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE $134.04 19990701 99999999 

74355 PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS TUBE $116.39 20060701 99999999 

74360 INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS $125.82 20060701 99999999 

74363 

PERCUTANEOUS TRANSHEPATIC DILATATION OF BILIARY DUCT 

STRICTURE WITH OR WITHOUT P $235.78 19990701 99999999 

74400 

UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT 

KUB $84.06 20060701 99999999 

74410 

UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS 

TECHNIQUE $93.26 20060701 99999999 

74415 

UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS 

TECHNIQUE $98.06 20060701 99999999 

74420 UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB $100.63 20060701 99999999 

74425 

UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, 

LOOPOGRAM) $57.07 20060701 99999999 

74430 CYSTOGRAPHY, MINIMUM OF THREE VIEWS $47.66 20060701 99999999 

74440 VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY $52.61 20060701 99999999 

74445 CORPORA CAVERNOSOGRAPHY $66.31 20060701 99999999 

74450 URETHROCYSTOGRAPHY, RETROGRADE $61.21 20060701 99999999 

74455 URETHROCYSTOGRAPHY, VOIDING $65.21 20060701 99999999 

74470 RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, $62.37 20060701 99999999 

74475 INTRODUCTION OF INTRACATHETER OR CATHETER INTO $155.46 20060701 99999999 

74480 INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER $155.46 20060701 99999999 

74485 DILATION OF NEPHROSTOMY OR URETERS WITH FLUOROSCOPIC $125.20 20060701 99999999 

74710 PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION $48.19 20060701 99999999 

74740 HYSTEROSALPINGOGRAPHY $58.16 20060701 99999999 

74742 

TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, 

RADIOLOGICAL SUPERVISION AND IN $127.35 19990701 99999999 

74775 

PERINEOGRAM (EG, VAGINOGRAM, FOR SEX DETERMINATION OR 

EXTENT $73.09 20060701 99999999 

75552 MAGNETIC RESONANCE (EG, PROTON) IMAGING, MYOCARDIUM $431.97 19990701 99999999 



75553 

CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY; WITH 

CONTRAST MATERIAL $444.25 19990701 99999999 

75554 

CARDIAC MAGNETIC RESONANCE IMAGING FOR FUNCTION, WITH OR 

WITHOUT MORPHOLOGY; COM $440.14 19990701 99999999 

75555 

CARDIAC MAGNETIC RESONANCE IMAGING FOR FUNCTION, WITH OR 

WITHOUT MORPHOLOGY; LIM $438.46 19990701 99999999 

75557 

CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND 

FUNCTION WITHOUT CONTRAST $293.12 20080101 99999999 

75559 



75561 



75563 



75600 AORTOGRAPHY, THORACIC, WITHOUT SERIALOGRAPHY $435.08 20060701 99999999 

75605 AORTOGRAPHY, THORACIC, BY SERIALOGRAPHY $460.17 20060701 99999999 

75625 AORTOGRAPHY, ABDOMINAL, TRANSLUMBAR, BY SERIALOGRAPHY $459.80 20060701 99999999 

75630 

AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER 

EXTREMITY, $571.32 20060701 99999999 

75635 

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMINAL AORTA AND 

BILATERAL ILIOFEMORAL LOWE $487.09 20060701 99999999 

75650 ANGIOGRAPHY, CERVICOCEREBRAL, CATHETER, INCLUDING $473.31 20060701 99999999 

75658 ANGIOGRAPHY, BRACHIAL, RETROGRADE $467.70 20060701 99999999 

75660 

ANGIOGRAPHY, EXTERNAL CAROTID, CEREBRAL, UNILATERAL, 

SELECTIVE $466.45 20060701 99999999 

75662 

ANGIOGRAPHY, EXTERNAL CAROTID, CEREBRAL, BILATERAL, 

SELECTIVE $479.77 20060701 99999999 

75665 ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL $466.70 20060701 99999999 

75671 ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL $480.22 20060701 99999999 

75676 ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL $466.70 20060701 99999999 

75680 ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL $480.22 20060701 99999999 

75685 ANGIOGRAPHY, VERTEBRAL $466.14 20060701 99999999 

75705 ANGIOGRAPHY, SPINAL, SELECTIVE $500.64 20060701 99999999 

75710 ANGIOGRAPHY, EXTREMITY, UNILATERAL $550.27 20060701 99999999 

75716 ANGIOGRAPHY, EXTREMITY, BILATERAL $466.14 20060701 99999999 

75722 ANGIOGRAPHY, RENAL, UNILATERAL, SELECTIVE (INCLUDING FLUSH $460.17 20060701 99999999 

75724 ANGIOGRAPHY, RENAL, BILATERAL, SELECTIVE (INCLUDING FLUSH $475.24 20060701 99999999 

75726 ANGIOGRAPHY, VISCERAL $459.48 20060701 99999999 

75731 ANGIOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE $459.48 20060701 99999999 

75733 ANGIOGRAPHY, ADRENAL, BILATERAL, SELECTIVE $466.45 20060701 99999999 

75736 ANGIOGRAPHY, PELVIC $459.48 20060701 99999999 

75741 ANGIOGRAPHY, PULMONARY, UNILATERAL, SELECTIVE $466.14 20060701 99999999 

75743 ANGIOGRAPHY, PULMONARY, BILATERAL, SELECTIVE $479.91 20060701 99999999 

75746 ANGIOGRAPHY, PULMONARY $459.23 20060701 99999999 

75756 ANGIOGRAPHY, INTERNAL MAMMARY $461.73 20060701 99999999 

75774 

ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED 

AFTER $428.91 20060701 99999999 

75790 ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS PATIENT) $120.00 20060701 99999999 

75801 LYMPHANGIOGRAPHY, EXTREMITY ONLY, UNILATERAL $210.73 20060701 99999999 

75803 LYMPHANGIOGRAPHY, EXTREMITY ONLY, BILATERAL $224.19 20060701 99999999 

75805 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, UNILATERAL $233.06 20060701 99999999 

75807 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, BILATERAL $246.78 19990701 99999999 

75809 

SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED 

INDWELLING NONVASCULAR SHUNT ( $44.12 20060701 99999999 

75810 SPLENOPORTOGRAPHY $367.45 20060701 99999999 

75820 VENOGRAPHY, EXTREMITY, UNILATERAL $59.10 20060701 99999999 



75822 VENOGRAPHY, EXTREMITY, BILATERAL $90.22 20060701 99999999 

75825 VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY $459.48 20060701 99999999 

75827 VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY $459.48 20060701 99999999 

75831 VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE $459.48 20060701 99999999 

75833 VENOGRAPHY, RENAL, BILATERAL, SELECTIVE $473.31 20060701 99999999 

75840 VENOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE $459.48 20060701 99999999 

75842 VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE $473.31 20060701 99999999 

75860 VENOGRAPHY, SINUS OR JUGULAR, CATHETER $459.80 20060701 99999999 

75870 VENOGRAPHY, SUPERIOR SAGITTAL SINUS $459.48 20060701 99999999 

75872 VENOGRAPHY, EPIDURAL $459.48 20060701 99999999 

75880 VENOGRAPHY, ORBITAL $59.10 20060701 99999999 

75885 PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITH $471.06 20060701 99999999 

75887 PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITHOUT $377.02 20060701 99999999 

75889 HEPATIC VENOGRAPHY WEDGED OR FREE, WITH $459.48 20060701 99999999 

75891 HEPATIC VENOGRAPHY, WEDGED OR FREE, WITHOUT $459.48 20060701 99999999 

75893 VENOUS SAMPLING THRU CATHETER WITHOUT ANGIOGRAPHY $436.08 20060701 99999999 

75894 

TRANSCATHETER THERAPY, EMBOLIZATION (EG, PARTICULATE OR 

LIQUID), $845.96 20060701 99999999 

75896 

TRANSCATHETER THERAPY, INFUSION (EG, THROMBOLYSIS OTHER 

THAN $742.96 20060701 99999999 

75898 ANGIOGRAM THROUGH EXISTING CATHETER FOR FOLLOW-UP $100.07 20060701 99999999 

75900 

EXCHANGE OF A PREVIOUSLY PLACED ARTERIAL CATHETER DURING 

THROMBOLYTIC THERAPY WI $710.28 19990701 99999999 

75901 



75902 



75940 PERCUTANEOUS PLACEMENT OF IVC FILTER $436.08 20060701 99999999 

75945 

INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL) 

RADIOLOGICAL SUPERVISION INIT VES $168.13 20060701 99999999 

75946 

INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL) 

RADIOLOGICAL SUPERVISION/INT ADDL $93.00 19990701 99999999 

75960 

TRANSCATHETER INTRODUCTION OF INTRAVASCULAR STENT(S), 


75961 

TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF FRACTURED 

VENOUS $512.50 20060701 99999999 

75962 

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY, ANY METHOD, 

PERIPHERAL ARTERY $539.96 20060701 99999999 

75964 

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY, ANY METHOD, EACH 

ADDITIONAL $290.60 20060701 99999999 

75966 

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY, ANY METHOD, 

VISCERAL ARTERY $570.95 20060701 99999999 

75968 

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY, ANY METHOD, EACH 

ADDITIONAL $290.66 20060701 99999999 

75970 TRANSCATHETER BIOPSY $413.98 20060701 99999999 

75978 

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY,VENOUS & 

INTERPRETAT. $543.71 20060701 99999999 

75980 

PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE WITH CONTRAST 

MONITORING $234.67 20060701 99999999 

75982 

PERCUTANEOUS PLACEMENT OF DRAINAGE CATHETER FOR 

COMBINED INTERNAL AND $257.26 19990701 99999999 

75984 CHANGE OF PERCUTANEOUS DRAINAGE CATHETER WITH CONTRAST $92.75 20060701 99999999 

75989 

RADIOLOGICAL GUIDANCE FOR PERCUTANEOUS DRAINAGE OF 

ABSCESS, $150.54 20060701 99999999 

75992 

TRANSLUMINAL ATHERECTOMY, PERIPHERAL ARTERY, 

RADIOLOGICAL SUPERVISION AND INTERP $540.27 20060701 99999999 



75993 

TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL PERIPHERAL 

ARTERY, RADIOLOGICAL SUPERV $290.97 19990701 99999999 

75994 

TRANSLUMINAL ATHERECTOMY, RENAL, RADIOLOGICAL SUPERVISION 

AND INTERPRETATION $571.20 19990701 99999999 

75995 

TRANSLUMINAL ATHERECTOMY, VISCERAL, RADIOLOGICAL 

SUPERVISION AND INTERPRETATION $570.08 19990701 99999999 

75996 

TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL RENAL OR 

VISCERAL ARTERY, RADIOLOGICAL $290.66 19990701 99999999 

75998 

FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE 

PLACEMENT, REPLACEMENT (C $57.02 20040101 99999999 

76000 

FLUOROSCOPY (SEPARATE PROCEDURE), UP TO ONE HOUR 

PHYSICIAN TIME, $49.90 20060701 99999999 

76001 

FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING 

A $113.08 20060701 99999999 

76003 FLUOROSCOPIC LOCALIZATION FOR NEEDLE BIOPSY OR FINE $64.25 19990701 99999999 

76005 

FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR 

CATHETER TIP FOR SPINE OR PA $80.72 20000101 99999999 

76006 

RADIOLOGIC EXAMINATION, STRESS VIEW(S), ANY JOINT, STRESS 

APPLIED BY A PHYSICIAN $19.73 19990701 99999999 

76010 RADIOLOGIC EXAMINATION FROM NOSE TO RECTUM FOR FOREIGN $24.20 20060701 99999999 

76020 BONE AGE STUDIES $24.78 19990701 99999999 

76040 BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) $36.74 19990701 99999999 

76061 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY $50.71 19990701 99999999 

76062 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY $68.86 19990701 99999999 

76065 RADIOLOGIC EXAMINATION OSSEOUS SURVEY $35.45 19990701 99999999 

76066 JOINT SURVEY, SINGLE VIEW, ONE OR MORE JOINTS (SPECIFY) $49.27 19990701 99999999 

76070 COMPUTERIZED TOMOGRAPHY, BONE DENSITY STUDY $102.72 20020101 99999999 

76071 

COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, ONE OR 

MORE SITES; APPENDICULAR $96.52 20030401 99999999 

76075 

DUAL ENERGY X-RAY ABSORPTIOMETRY (DEXA), BONE DENSITY 

STUDY $113.64 19990701 99999999 

76076 

DUAL ENERGY X-RAY ABSORPTIOMETRY (DEXA), BONE DENSITY 

STUDY, ONE OR MORE SITES; $33.87 19990701 99999999 

76077 

DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY 

STUDY, ONE OR MORE SITES; $30.66 20050101 99999999 

76078 

RADIOGRAPHIC ABSORPTIOMETRY (PHOTODENSITOMETRY), ONE OR 

MORE SITES $29.72 19990701 99999999 

76080 RADIOLOGIC EXAMINATION, FISTULA OR SINUS TRACT STUDY $56.20 20060701 99999999 

76082 

COMPUTER AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF 

DIGITAL IMAGE DATA FOR $15.05 20040101 99999999 

76083 

COMPUTER AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF 


76085 

DIGITIZATION OF FILM RADIOGRAPHIC IMAGES WITH COMPUTER 

ANALYSIS FOR LESION DETEC $15.38 20020101 99999999 

76090 MAMMOGRAPHY $55.38 19990701 99999999 

76091 MAMMOGRAPHY $68.13 19990701 99999999 

76092 

SCREENING MAMMOGRAPHY,BILAT.(TWO VIEW FILM STUDY EACH 

BREAST $48.82 19990701 99999999 

76093 

MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH 

CONTRAST MATERIAL(S); UN $643.76 19990701 99999999 

76094 


CONTRAST MATERIAL(S); BI $850.70 19990701 99999999 

76095 

STEREOTACTIC LOCALIZATION FOR BREAST BIOPSY, EACH LESION, 

RADIOLOGICAL SUPERVISI $299.20 19990701 99999999 

76096 LOCALIZATION OF BREAST NODULE $65.08 19990701 99999999 

76098 RADIOLOGICAL EXAMINATION, BREAST SURGICAL SPECIMEN $20.56 20060701 99999999 

76100 

RADIOLOGIC EXAMINATION, SINGLE PLANE BODY SECTION (EG, 

TOMOGRAPHY), $64.05 20060701 99999999 



76101 RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) $69.91 20060701 99999999 

76102 RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) $80.40 20060701 99999999 

76120 CINERADIOGRAPHY, EXCEPT WHERE SPECIFICALLY INCLUDED $50.43 20060701 99999999 

76125 CINERADIOGRAPHY TO COMPLEMENT ROUTINE EXAMINATION $36.74 20060701 99999999 

76150 XERORADIOGRAPHY $13.91 20060701 99999999 

76355 

COMPUTERIZED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC 

LOCALIZATION $319.08 19990701 99999999 

76360 COMPUTERIZED TOMOGRAPHY GUIDANCE FOR NEEDLE BIOPSY $316.83 19990701 99999999 

76362 

COMPUTERIZED AXIAL TOMOGRAPHIC GUIDANCE FOR, AND 

MONITORING OF, TISSUE ABLATION $404.63 20020101 99999999 

76365 COMPUTERIZED TOMOGRAPHY GUIDANCE FOR CYST ASPIRATION $316.83 19990701 99999999 

76370 COMPUTERIZED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF $130.55 19990701 99999999 

76375 COMPUTERIZED TOMOGRAPHY, CORONAL, SAGITTAL, MULTIPLANAR, $149.76 19990701 99999999 

76376 

3D RENDERING WITH INTERPRETATION AND REPORTING OF 

COMPUTED TOMOGRAPHY, MAGNETIC $105.59 20060701 99999999 

76377 

3D RENDERING WITH INTERPRETATION AND REPORTING OF 

COMPUTED TOMOGRAPHY, MAGNETIC $132.10 20060701 99999999 

76380 

COMPUTERIZED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP 

STUDY $153.75 20060701 99999999 

76390 MAGNETIC RESONANCE SPECTROSCOPY $424.53 19990701 99999999 

76393 

MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (EG, 

FOR BIOPSY, NEEDLE ASPIRAT $377.43 20010101 99999999 

76394 

MAGNETIC RESONANCE GUIDANCE FOR, AND MONITORING OF, 

TISSUE ABLATION $496.84 20020101 99999999 

76400 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW $431.66 19990701 99999999 

76490 

ULTRASOUND GUIDANCE FOR, AND MONITORING OF, TISSUE 

ABLATION $122.19 20020101 99999999 

76499 UNLISTED DIAGNOSTIC RADIOLOGIC PROCEDURE $66.48 19990701 99999999 

76506 ECHOENCEPHALOGRAPHY, B-SCAN AND/OR REAL TIME WITH IMAGE $72.42 20060701 99999999 

76510 

OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITATIVE 

A-SCAN PERFORMED $131.77 20060701 99999999 

76511 OPHTHALMIC ULTRASOUND, ECHOGRAPHY $84.94 20060701 99999999 

76512 OPHTHALMIC ULTRASOUND, ECHOGRAPHY $80.25 20060701 99999999 

76513 OPHTHALMIC ULTRASOUND,ECHOGRAPHY IMMERSION B-SCAN $74.16 20060701 99999999 

76514 

OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CORNEAL 

PACHYMETRY, UNILATERAL OR $9.23 20060701 99999999 

76516 OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, $53.24 20060701 99999999 

76519 OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, $56.60 20060701 99999999 

76529 OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION $56.34 20060701 99999999 

76536 ECHOGRAPHY, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, $78.41 20060701 99999999 

76604 

ECHOGRAPHY, CHEST, B-SCAN (INCLUDES MEDIASTINUM) AND/OR 

REAL $64.82 20060701 99999999 

76645 ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL), $66.65 20060701 99999999 

76700 ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE $96.88 20060701 99999999 

76705 ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE $70.18 20060701 99999999 

76770 ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), $106.53 20060701 99999999 

76775 ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), $69.91 20060701 99999999 

76776 

ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX 

DOPPLER WITH IMAGE DOCUMEN $88.77 20070101 99999999 

76778 

ECHOGRAPHY TRANSPLANT KIDNEY,W OR W/O DUPLEX DOPPLER 

STUDIES $94.21 19990701 99999999 

76800 ECHOGRAPHY, SPINAL CANAL AND CONTENTS $91.69 20060701 99999999 



76801 

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE 

DOCUMENTATION, FETAL AND MATER $87.43 20060701 99999999 

76802 



76805 

ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH 

IMAGE $108.78 20060701 99999999 

76810 


IMAGE DOCUMENTATION; C $101.50 20060701 99999999 

76811 



76812 



76813 


DOCUMENTATION, FIRST TRIMESTER $88.39 20070101 99999999 

76814 


DOCUMENTATION, FIRST TRIMESTER $57.43 20070101 99999999 

76815 


IMAGE $84.72 20060701 99999999 

76816 


IMAGE $70.34 20060701 99999999 

76817 


DOCUMENTATION, TRANSVAGINAL $74.64 20060701 99999999 

76818 FETAL BIOPHYSICAL PROFILE $84.46 20060701 99999999 

76819 

FETAL BIOPHYSICAL PROFILE; WITHOUT STRESS OR NON-STRESS 

TESTING $75.79 20060701 99999999 

76820 DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY $71.84 20060701 99999999 

76821 DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY $79.75 20060701 99999999 

76825 ECHOCARDIOGRAPHY, FETAL HEART IN UTERO $125.99 20060701 99999999 

76826 

ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME 

WITH IMAGE DOCUMENTATI $62.27 20060701 99999999 

76827 

DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, 

PULSED WAVE AND/OR CONTI $87.20 20060701 99999999 

76828 

DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, 

PULSED WAVE AND/OR CONTI $60.66 20060701 99999999 

76830 ECHOGRAPHY, TRANSVAGINAL $77.68 20060701 99999999 

76831 HYSTEROSONOGRAPHY, WITH OR WITHOUT COLOR FLOW DOPPLER $98.58 20060701 99999999 

76856 ECHOGRAPHY, PELVIC (NON-OBSTETRIC), B-SCAN AND/OR REAL TIME $90.72 20060701 99999999 

76857 ECHOGRAPHY, PELVIC (NON-OBSTETRIC), B-SCAN AND/OR REAL TIME $56.37 20060701 99999999 

76870 ECHOGRAPHY, SCROTUM AND CONTENTS $86.02 20060701 99999999 

76872 ECHOGRAPHY, PROSTATE, TRANSRECTAL $90.72 20060701 99999999 

76873 

ECHOGRAPHY, TRANSRECTAL; PROSTATE VOLUME STUDY FOR 

BRACHYTHERAPY TREATMENT PLANN $164.68 20060701 99999999 

76880 ECHOGRAPHY, EXTREMITY, B-SCAN AND/OR REAL TIME WITH IMAGE $81.43 20060701 99999999 

76885 

ECHOGRAPHY OF INFANT HIPS, REAL TIME WITH IMAGING 

DOCUMENTATION; DYNAMIC (EG, RE $85.79 20060701 99999999 

76886 

ECHOGRAPHY OF INFANT HIPS, REAL TIME WITH IMAGING 

DOCUMENTATION; LIMITED, STATIC $70.97 20060701 99999999 

76930 ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS $77.84 20060701 99999999 

76932 

ULTRASOUND GUIDANCE FOR ENDOMYOCARDIAL BIOPSY 

SUPERVISION $78.15 20060701 99999999 

76934 ULTRASONIC GUIDANCE FOR THORACENTESIS $76.84 19990701 99999999 

76936 

ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDO- 

ANEURYSM OR ARTERIOVENOU $293.19 20060701 99999999 

76937 

ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING 

ULTRASOUND EVALUATION OF POTEN $25.56 20060701 99999999 



76938 ULTRASONIC GUIDANCE FOR CYST (ANY LOCATION), OR RENAL $87.97 19990701 99999999 

76940 

ULTRASOUND GUIDANCE FOR, AND MONITORING OF, VISCERAL 

TISSUE ABLATION $128.56 20060701 99999999 

76941 

ULTRASONIC GUIDANCE FOR INTRAUTERINE FETAL TRANSFUSION OR 

CORDOCENTESIS, RADIOLO $105.32 20060701 99999999 

76942 ULTRASONIC GUIDANCE FOR NEEDLE BIOPSY $94.48 20060701 99999999 

76945 

ULTRASONIC GUIDANCE FOR ABSCESS OR COLLECTION 

DRAINAGE,CMPLT $82.20 20060701 99999999 

76946 ULTRASONIC GUIDANCE FOR AMNIOCENTESIS $65.59 20060701 99999999 

76948 

ULTRASONIC GUIDANCE FOR ASPIRATION OF OVASUPERVIS. & 

INTERP $65.53 20060701 99999999 

76950 

ECHOGRAPHY FOR PLACEMENT OF RADIATION THERAPY FIELDS, B- 

SCAN $75.30 20060701 99999999 

76960 ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY $75.30 19990701 99999999 

76965 

ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT 

APPLICATION $291.68 20060701 99999999 

76970 ULTRASOUND STUDY FOLLOW-UP (SPECIFY) $50.95 20060701 99999999 

76975 

GASTROINTESTINAL ENDOSCOPIC ULTRASOUND, RADIOLOGICAL 

SUPERVISION AND INTERPRETAT $82.40 20060701 99999999 

76977 

ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, 

PERIPHERAL SITE(S), ANY $35.86 20060701 99999999 

76986 ECHOGRAPHY, INTRAOPERATIVE $134.33 19990701 99999999 

77001 

FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE 

PLACEMENT, REPLACEMENT (C $59.33 20070101 99999999 

77002 

FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, 

ASPIRATION, INJECTION, L $53.33 20070101 99999999 

77003 

FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR 

CATHETER TIP FOR SPINE OR PA $51.53 20070101 99999999 

77011 

COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC 

LOCALIZATION $355.92 20070101 99999999 

77012 

COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, 

BIOPSY, ASPIRATION, INJEC $232.54 20070101 99999999 

77014 

COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF 

RADIATION THERAPY FIELDS $122.28 20070101 99999999 

77021 

MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (EG, 

FOR BIOPSY, NEEDLE ASPIRAT $357.48 20070101 99999999 

77031 

STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR 

NEEDLE PLACEMENT (EG, FO $218.86 20070101 99999999 

77032 

MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST (EG, 

FOR WIRE LOCALIZATION OR $49.86 20070101 99999999 

77051 

COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF 


77052 

COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF 


77053 

MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, 

RADIOLOGICAL SUPERVISION AND INTE $73.33 20070101 99999999 

77054 

MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, 

RADIOLOGICAL SUPERVISION AND I $105.53 20070101 99999999 

77055 MAMMOGRAPHY; UNILATERAL $55.29 20070101 99999999 

77056 MAMMOGRAPHY; BILATERAL $69.09 20070101 99999999 

77057 

SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF 

EACH BREAST) $58.01 20070101 99999999 

77058 


CONTRAST MATERIAL(S); UN $582.69 20070101 99999999 

77059 


CONTRAST MATERIAL(S); BI $720.80 20070101 99999999 

77071 

MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR 

JOINT RADIOGRAPHY, INCLU $19.76 20070101 99999999 



77072 BONE AGE STUDIES $15.86 20070101 99999999 

77073 BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) $30.04 20070101 99999999 

77074 

RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR 

METASTASES) $43.20 20070101 99999999 

77075 

RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL 

AND APPENDICULAR SKELETO $63.62 20070101 99999999 

77076 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT $51.17 20070101 99999999 

77077 JOINT SURVEY, SINGLE VIEW, 2 OR MORE JOINTS (SPECIFY) $38.64 20070101 99999999 

77078 

COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR 

MORE SITES; AXIAL SKELETON $104.66 20070101 99999999 

77079 

COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR 

MORE SITES; APPENDICULAR S $74.89 20070101 99999999 

77080 

DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY 

STUDY, 1 OR MORE SITES; AXI $80.74 20070101 99999999 

77081 


STUDY, 1 OR MORE SITES; APP $28.63 20070101 99999999 

77082 


STUDY, 1 OR MORE SITES; VER $24.96 20070101 99999999 

77083 

RADIOGRAPHIC ABSORPTIOMETRY (EG, PHOTODENSITOMETRY, 

RADIOGRAMMETRY), 1 OR MORE S $25.65 20070101 99999999 

77084 

MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW 

BLOOD SUPPLY $392.67 20070101 99999999 

77261 THERAPEUTIC RADIOLOGY TREATMENT PLANNING $69.73 20060701 99999999 



77280 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING $142.39 20060701 99999999 



77295 

THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; BY 

THREE-DIMENSIONAL RECON $1,163.72 20060701 99999999 

77300 

BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL AXIS DEPTH 

DOSE, $68.85 20060701 99999999 

77301 

INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE- 

VOLUME HISTOGRAMS FOR TARG $1,078.48 20060701 99999999 

77305 

TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER 

CALCULATED) $89.73 20060701 99999999 

77310 


CALCULATED) $118.72 20060701 99999999 

77315 


CALCULATED) $150.04 20060701 99999999 

77321 SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMI-BODY, TOTAL $171.17 20060701 99999999 

77326 BRACHYTHERAPY ISODOSE CALCULATION $115.25 20060701 99999999 



77331 SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY) $51.68 20060701 99999999 

77332 TREATMENT DEVICES, DESIGN AND CONSTRUCTION $65.81 20060701 99999999 



77336 

CONTINUING MEDICAL RADIATION PHYSICS CONSULTATION IN 

SUPPORT $105.25 20060701 99999999 

77370 SPECIAL MEDICAL RADIATION PHYSICS CONSULTATION $123.30 20060701 99999999 

77371 

RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY 

(SRS), COMPLETE COURSE O $850.66 20070101 99999999 

77372 

RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY 

(SRS), COMPLETE COURSE O $645.44 20070101 99999999 

77373 

STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, 

PER FRACTION TO 1 OR MO $1,204.26 20070101 99999999 



77401 

RADIATION TREATMENT DELIVERY, SUPERFICIAL AND/OR ORTHO 

VOLTAGE $58.71 20060701 99999999 

77402 

RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, 

SINGLE PORT OR PARALLEL OPP $58.71 20060701 99999999 

77403 



77404 



77406 A $58.71 20060701 99999999 

77407 

RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT 

AREAS, THREE OR MORE PORTS $68.94 20060701 99999999 

77408 



77409 



77411 



77412 

RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE 

TREATMENT AREAS, CUSTOM BLO $76.99 20060701 99999999 

77413 



77414 



77416 



77417 THERAPEUTIC RADIOLOGY PORT FILM(S) $21.11 20060701 99999999 

77418 

INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE 

FIELDS/ARCS, VIA NARR $460.46 20060701 99999999 

77419 WEEKLY RADIOLOGY THERAPY MANAGEMENT; CONFORMAL $146.94 19990701 99999999 

77420 WEEKLY MEGAVOLTAGE TREATMENT MANAGEMENT $65.70 19990701 99999999 

77421 

STEREOSCOPIC X-RAY GUIDANCE FOR LOCALIZATION OF TARGET 

VOLUME FOR THE DELIVERY O $110.54 20060701 99999999 

77422 

HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; SINGLE 

TREATMENT AREA USING A $50.74 20060701 99999999 

77423 

HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; 1 OR 

MORE ISOCENTER(S) WITH CO $66.22 20060701 99999999 

77425 WEEKLY MEGAVOLTAGE TREATMENT MANAGEMENT $100.80 19990701 99999999 

77427 RADIATION TREATMENT MANAGEMENT, FIVE TREATMENTS $164.97 20060701 99999999 

77431 

RADIATION THERAPY MANAGEMENT WITH COMPLETE COURSE OF 

THERAPY CONSISTING OF ONE O $97.14 20060701 99999999 

77432 

STEREOTACTIC RADIATION TREATMENT MANAGEMENT OF CEREBRAL 

LESION(S) (COMPLETE COUR $391.40 20060701 99999999 

77435 

STEREOTACTIC BODY RADIATION THERAPY, TREATMENT 

MANAGEMENT, PER TREATMENT COURSE, $439.08 20070101 99999999 

77470 SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, $493.81 20060701 99999999 

77600 HYPERTHERMIA, EXTERNALLY GENERATED $162.14 20060701 99999999 

77605 HYPERTHERMIA, EXTERNALLY GENERATED $218.27 20060701 99999999 

77610 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S) $162.14 20060701 99999999 

77615 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S) $217.08 20060701 99999999 

77620 HYPERTHERMIA GENERATED BY INTRACAVITARY PROBE(S) $164.02 20060701 99999999 

77750 INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION $236.88 20060701 99999999 

77761 INTRACAVITARY RADIOELEMENT APPLICATION $231.09 20060701 99999999 



77776 INTERSTITIAL RADIOELEMENT APPLICATION $252.65 20060701 99999999 





77781 

REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 1-4 

SOURCE POSITIONS OR CATHET $734.14 20060701 99999999 

77782 


SOURCE POSITIONS OR CATHET $767.02 20060701 99999999 

77783 


SOURCE POSITIONS OR CATHE $815.31 20060701 99999999 

77784 

REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; OVER 12 

SOURCE POSITIONS OR CA $889.48 20060701 99999999 

77789 SURFACE APPLICATION OF RADIOELEMENT $59.36 20060701 99999999 

77790 SUPERVISION, HANDLING, LOADING OF RADIOELEMENT $58.45 20060701 99999999 

78000 THYROID UPTAKE $39.87 20060701 99999999 



78006 THYROID IMAGING, WITH UPTAKE $97.87 20060701 99999999 

78007 THYROID IMAGING, WITH UPTAKE $104.62 20060701 99999999 

78010 THYROID IMAGING $75.71 20060701 99999999 

78011 THYROID IMAGING $97.44 20060701 99999999 

78015 THYROID CARCINOMA METASTASES IMAGING $111.53 20060701 99999999 



78020 

THYROID CARCINOMA METASTASES UPTAKE (LIST SEPARATELY IN 

ADDITION TO CODE FOR PRI $55.02 20060701 99999999 

78070 PARATHYROID IMAGING $136.66 20060701 99999999 

78075 ADRENAL IMAGING, CORTICAL $193.92 20060701 99999999 

78102 BONE MARROW IMAGING $89.22 20060701 99999999 



78110 PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE $39.25 20060701 99999999 

78111 PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE $93.57 20060701 99999999 

78120 RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE) $66.88 20060701 99999999 

78121 RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE) $108.37 20060701 99999999 

78122 

WHOLE BLOOD VOLUME DETERMINATION,INC. SEPARATE MEASUR 

PLASMA $169.50 20060701 99999999 

78130 RED CELL SURVIVAL STUDY $117.81 20060701 99999999 

78135 RED CELL SURVIVAL STUDY $185.67 20060701 99999999 

78140 RED CELL SPLENIC AND/OR HEPATIC SEQUESTRATION $153.62 20060701 99999999 

78160 PLASMA RADIOIRON DISAPPEARANCE (TURNOVER) RATE $133.65 19990701 99999999 

78162 RADIOIRON ORAL ABSORPTION $123.83 19990701 99999999 

78170 RADIOIRON RED CELL UTILIZATION $191.03 19990701 99999999 

78172 CHELATABLE IRON FOR ESTIMATION OF TOTAL BODY IRON $21.30 19990701 99999999 

78185 SPLEEN IMAGING ONLY $93.94 20060701 99999999 

78190 

KINETICS, STUDY OF PLATELET SURVIVAL, WITH OR WITHOUT 

DIFFERENTIAL ORGAN/TISSUE $232.38 20060701 99999999 

78191 PLATELET SURVIVAL $265.36 20060701 99999999 

78195 LYMPHATICS AND LYMPH GLANDS IMAGING $177.94 20060701 99999999 

78201 LIVER IMAGING $95.31 20060701 99999999 

78202 LIVER IMAGING $114.86 20060701 99999999 

78205 LIVER IMAGING (SPECT) $223.01 20060701 99999999 

78206 LIVER IMAGING (SPECT); WITH VASCULAR FLOW $222.19 20060701 99999999 

78215 LIVER AND SPLEEN IMAGING $115.90 20060701 99999999 

78216 LIVER AND SPLEEN IMAGING $135.84 20060701 99999999 

78220 LIVER FUNCTION STUDY WITH HEPATOBILIARY AGENTS, $141.85 20060701 99999999 

78223 

HEPATOBILIARY DUCTAL SYSTEM IMAGING, INCLUDING 

GALLBLADDER $153.50 20060701 99999999 

78230 SALIVARY GLAND IMAGING $90.27 20060701 99999999 

78231 SALIVARY GLAND IMAGING $125.29 20060701 99999999 

78232 SALIVARY GLAND FUNCTION STUDY $135.15 20060701 99999999 

78258 ESOPHAGEAL MOTILITY $123.97 20060701 99999999 



78261 GASTRIC MUCOSA IMAGING $162.78 20060701 99999999 

78262 GASTROESOPHAGEAL REFLUX STUDY $166.94 20060701 99999999 

78264 GASTRIC EMPTYING STUDY $167.02 20060701 99999999 

78267 UREA BREATH TEST, C-14; ACQUISITION FOR ANALYSIS $10.86 20060701 99999999 

78268 UREA BREATH TEST, C-14; ANALYSIS $93.09 20060701 99999999 

78270 VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST) $59.61 20060701 99999999 

78271 VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST) $62.73 20060701 99999999 

78272 VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH $87.47 20060701 99999999 

78278 ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING $199.74 20060701 99999999 

78282 GASTROINTESTINAL PROTEIN LOSS $14.93 19990701 99999999 

78290 BOWEL IMAGING (EG, ECTOPIC GASTRIC MUCOSA, MECKEL'S $127.32 20060701 99999999 

78291 PERITONEAL-VENOUS SHUNT PATENCY TEST $135.39 20060701 99999999 

78300 BONE IMAGING $106.53 20060701 99999999 

78305 BONE IMAGING $153.23 20060701 99999999 

78306 BONE IMAGING $188.43 20060701 99999999 

78315 BONE IMAGING BY THREE PHASE TECHNIQUE $197.41 20060701 99999999 

78320 BONE IMAGING TOMOGRAPHIC (SPECT) $235.68 20060701 99999999 

78350 BONE DENSITY (BONE MINERAL CONTENT) STUDY $39.00 20060701 99999999 

78414 DETERMINATION OF VENTRICULAR EJECTION FRACTION WITH PROBE $18.27 19990701 99999999 

78428 CARDIAC SHUNT DETECTION $106.68 20060701 99999999 

78445 VASCULAR FLOW IMAGING (IE, ANGIOGRAPHY, VENOGRAPHY) $81.15 20060701 99999999 

78455 VENOUS THROMBOSIS STUDY (EG, RADIOACTIVE FIBRINOGEN) $160.15 19990701 99999999 

78456 ACUTE VENOUS THROMBOSIS IMAGING, PEPTIDE $153.65 20060701 99999999 

78457 VENOUS THROMBOSIS IMAGING (EG, VENOGRAM) $132.32 20060701 99999999 

78458 VENOUS THROMBOSIS IMAGING (EG, VENOGRAM) $167.74 20060701 99999999 

78459 

MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), 

METABOLIC EVALUATION $1,495.20 19960101 99999999 

78460 

MYOCARDIAL IMAGING,RESTING ONLY,QUANTITATIVE OR 

QUALITATIVE $111.91 20060701 99999999 

78461 MYOCARDIAL IMAGING $204.49 20060701 99999999 

78464 

MYOCARDIAL IMAGING,TOMOGRAPHIC(SPECT)AT REST ONLY 

QUALITATIV $275.99 20060701 99999999 

78465 

MYOCARDIAL IMAGING TOMOGRAPHIC W/EXERCISE & 

REDISTRIBUTION $489.67 20060701 99999999 

78466 MYOCARDIAL IMAGING, INFARCT AVID, AT REST QUALITATIVE $113.93 20060701 99999999 

78468 MYOCARDIAL IMAGING, INFARCT AVID, AT REST WITH FIRST PASS_TE $152.13 20060701 99999999 

78469 

MYOCARDIAL IMAGING,INFARCT AVID, AT REST W/EMISSION COM. 

TOM $208.76 20060701 99999999 

78472 CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, AT REST $221.07 20060701 99999999 

78473 

CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE 

STUDIES, WALL MOTION STU $329.97 20060701 99999999 

78478 

MYOCARDIAL PERFUSION STUDY WITH WALL MOTION, QUALITATIVE 

OR QUANTITATIVE STUDY ( $77.27 20060701 99999999 

78480 

MYOCARDIAL PERFUSION STUDY WITH EJECTION FRACTION (LIST 

SEPARATELY IN ADDITION T $76.52 20060701 99999999 

78481 CARDIAC BLOOD POOL IMAGING,FIRST PASS TECHNIQUE $211.58 20060701 99999999 

78483 

CARDIAC BLOOD POOL IMAGING, FIRST PASS TECHNIQUE; MULTIPLE 

STUDIES, RESTING AND $318.81 20060701 99999999 

78494 

CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT 

REST, WALL MOTION STUDY $271.81 20060701 99999999 

78496 

CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SINGLE 

STUDY, AT REST, WITH RIGHT $200.90 20060701 99999999 

78499 

UNLISTED CARDIOVASCULAR PROCEDURE, DIAGNOSTIC NUCLEAR 

MEDICINE $63.79 19990701 99999999 

78580 PULMONARY PERFUSION IMAGING $142.19 20060701 99999999 

78584 PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION $115.87 20060701 99999999 



78585 PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION $228.33 20060701 99999999 

78586 PULMONARY VENTILATION IMAGING, AEROSOL $101.37 20060701 99999999 

78587 PULMONARY VENTILATION IMAGING, AEROSOL $111.53 20060701 99999999 

78588 

PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION 

IMAGING, AEROSOL, ONE $184.94 20060701 99999999 

78591 PULMONARY VENTILATION IMAGING, GASEOUS, $109.70 20060701 99999999 

78593 PULMONARY VENTILATION IMAGING, GASEOUS, WITH $132.87 20060701 99999999 

78594 PULMONARY VENTILATION IMAGING, GASEOUS, WITH $184.95 20060701 99999999 

78596 

PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION 

(VENTILATION/PERFUSION) STUDY $282.85 20060701 99999999 

78600 BRAIN IMAGING, LIMITED PROCEDURE $112.40 20060701 99999999 

78601 BRAIN IMAGING, LIMITED PROCEDURE $132.15 20060701 99999999 

78605 BRAIN IMAGING, COMPLETE STUDY $133.29 20060701 99999999 

78606 BRAIN IMAGING, COMPLETE STUDY $152.60 20060701 99999999 

78607 BRAIN IMAGING,COMPLETE STUDY TOMOGRAPHIC(ECT) $264.77 20060701 99999999 

78608 

BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); 


78610 BRAIN IMAGING, VASCULAR FLOW ONLY $64.11 20060701 99999999 

78615 CEREBRAL BLOOD FLOW $144.00 19990701 99999999 

78630 

CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING 

INTRODUCTION $193.15 20060701 99999999 

78635 


INTRODUCTION $109.38 20060701 99999999 

78645 


INTRODUCTION $135.28 20060701 99999999 

78647 


INTRODUCTION OF MATERIAL); TOMO $230.19 20060701 99999999 

78650 


INTRODUCTION $176.82 20060701 99999999 

78660 DACRYOCYSTOGRAPHY (LACRIMAL FLOW STUDY) $90.87 20060701 99999999 

78700 KIDNEY IMAGING $117.90 20060701 99999999 




78708 

KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; SINGLE 

STUDY, WITH PHARMACOLOGIC $192.80 20060701 99999999 

78709 

KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; MULTIPLE 

STUDIES, WITH AND WITHO $199.00 20060701 99999999 

78710 KIDNEY IMAGING(SPECT) $221.07 20060701 99999999 

78715 KIDNEY VASCULAR FLOW ONLY $64.42 19990701 99999999 

78725 KIDNEY FUNCTION STUDY ONLY $73.95 20060701 99999999 

78730 URINARY BLADDER RESIDUAL STUDY $62.88 20060701 99999999 

78740 URETERAL REFLUX STUDY (RADIONUCLIDE VOIDING CYSTOGRAM) $92.24 20060701 99999999 

78760 TESTICULAR IMAGING $114.39 19990701 99999999 

78761 TESTICULAR IMAGING $133.67 20060701 99999999 

78800 RADIONUCLIDE LOCALIZATION OF TUMOR $152.44 20060701 99999999 



78803 TUMOR LOCALIZATION (SPECT) $259.27 20060701 99999999 

78804 

RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION 

OF RADIOPHARMACEUTICAL $320.14 20060701 99999999 

78805 RADIONUCLIDE LOCALIZATION OF ABSCESS $140.99 20060701 99999999 

78806 RADIONUCLIDE LOCALIZATION OF ABSCESS $252.31 20060701 99999999 

78807 RADIONUCLIDE LOCALIZATION OF ABSCESS, SPECT $258.96 20060701 99999999 

78810 

TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), 


78990 PROVISION OF DIAGNOSTIC RADIONUCLIDE(S) $10.92 19990701 99999999 



79000 RADIONUCLIDE THERAPY, HYPERTHYROIDISM $191.83 19990701 99999999 

79001 RADIONUCLIDE THERAPY, HYPERTHYROIDISM $84.41 19990701 99999999 

79005 RADIOPHARMACEUTICAL THERAPY, BY ORAL ADMINISTRATION $152.19 20060701 99999999 

79020 RADIONUCLIDE THERAPY, THYROID SUPPRESSION $157.49 19990701 99999999 

79030 RADIONUCLIDE ABLATION OF GLAND FOR THYROID $169.12 19990701 99999999 

79035 RADIONUCLIDE THERAPY FOR METASTASES OF THYROID $186.03 19990701 99999999 

79100 RADIONUCLIDE THERAPY, POLYCYTHEMIA VERA, CHRONIC $138.48 19990701 99999999 

79101 

RADIOPHARMACEUTICAL THERAPY, BY INTRAVENOUS 

ADMINISTRATION $158.70 20060701 99999999 

79200 INTRACAVITARY RADIOACTIVE COLLOID THERAPY $165.04 20060701 99999999 

79400 RADIONUCLIDE THERAPY, NONTHYROID, NONHEMATOLOGIC $163.31 19990701 99999999 

79403 

RADIOPHARMACEUTICAL THERAPY, RADIOLABELED MONOCLONAL 

ANTIBODY BY INTRAVENOUS INF $222.58 20060701 99999999 

79440 INTRA-ARTICULAR RADIONUCLIDE THERAPY $165.29 20060701 99999999 

79445 

RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL 

PARTICULATE ADMINISTRATION $176.60 20050101 99999999 

79900 PROVISION OF THERAPEUTIC RADIONUCLIDE(S) $12.00 19990701 99999999 

79999 UNLISTED RADIONUCLIDE THERAPEUTIC PROCEDURE $32.54 19990701 99999999 

80047 BASIC METABOLIC PANEL (CALCIUM, IONIZED) $30.51 20080101 99999999 

80048 BASIC METABOLIC PANEL $11.70 20060701 99999999 

80050 GENERAL HEALTH SCREEN PANEL $41.19 19940101 99999999 

80051 ELECTROLYTE PANEL $9.69 20060701 99999999 

80053 EXECUTIVE PROFILE $14.61 20060701 99999999 

80055 OBSTETRIC PROFILE $21.14 20000601 99999999 

80061 LIPID PROFILE $18.51 20060701 99999999 

80069 RENAL FUNCTION PANEL $12.00 20060701 99999999 

80072 ARTHRITIS PANEL $35.67 19990701 99999999 

80074 ACUTE HEPATITIS PANEL $65.82 20060701 99999999 

80076 HEPATIC FUNCTION PANEL $11.29 20060701 99999999 

80090 ANTIBODY PANEL (EG, TORCH: TOXOPLASMA IFA, RUBELLA HI, $79.56 19990701 99999999 

80100 DRUG, SCREEN; MULTIPLE DRUG CLASSES, EACH PROCEDURE $20.10 20060701 99999999 

80101 DRUG, SCREEN; SINGLE DRUG CLASS, EACH DRUG CLASS $19.03 20060701 99999999 

80102 DRUG, CONFIRMATION, EACH PROCEDURE $18.31 20060701 99999999 

80150 AMIKACIN $20.83 20060701 99999999 

80152 AMITRIPTYLINE $24.74 20060701 99999999 

80154 BENZODIAZEPINES $25.56 20060701 99999999 

80156 CARBAMAZEPINE $20.12 20060701 99999999 

80157 CARBAMAZEPINE; FREE $11.11 20060701 99999999 

80158 CYCLOSPORINE $24.95 20060701 99999999 

80160 DESIPRAMINE $23.79 20060701 99999999 

80162 DIGOXIN $18.35 20060701 99999999 

80164 DIPROPYLACETIC ACID (VALPROIC ACID) $18.72 20060701 99999999 

80166 DOXEPIN $13.00 20060701 99999999 

80168 ETHOSUXIMIDE $22.58 20060701 99999999 

80170 GENTAMICIN $22.65 20060701 99999999 

80172 GOLD $13.66 20060701 99999999 

80173 HALOPERIDOL $20.34 20060701 99999999 

80174 IMIPRAMINE $14.43 20060701 99999999 

80176 LIDOCAINE $20.30 20060701 99999999 

80178 LITHIUM $9.13 20060701 99999999 

80182 NORTRIPTYLINE $18.72 20060701 99999999 

80184 PHENOBARBITAL $15.83 20060701 99999999 

80185 PHENYTOIN; TOTAL $18.32 20060701 99999999 

80186 PHENYTOIN; FREE $19.03 20060701 99999999 

80188 PRIMIDONE $22.93 20060701 99999999 

80190 PROCAINAMIDE; $14.05 20060701 99999999 

80192 PROCAINAMIDE; WITH METABOLITES (EG, N-ACETYL PROCAINAMIDE) $23.15 20060701 99999999 



80194 QUINIDINE $20.17 20060701 99999999 

80195 SIROLIMUS $11.50 20060701 99999999 

80196 SALICYLATE $9.81 20060701 99999999 

80197 TACROLIMUS $18.97 20060701 99999999 

80198 THEOPHYLLINE $19.56 20060701 99999999 

80200 TOBRAMYCIN $22.27 20060701 99999999 

80201 TOPIRAMATE $16.48 20060701 99999999 

80202 VANCOMYCIN $18.72 20060701 99999999 

80299 QUANTITATION OF DRUG, NOT ELSEWHERE SPECIFIED $18.92 20060701 99999999 

80400 ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY $45.06 20060701 99999999 

80402 ACTH STIMULATION PANEL; FOR 21 HYDROXYLASE DEFICIENCY $72.88 20060701 99999999 

80406 

ACTH STIMULATION PANEL; FOR 3 BETA-HYDROXYDEHYDROGENASE 

DEFICIENCY $65.60 20060701 99999999 

80408 

ALDOSTERONE SUPPRESSION EVALUATION PANEL (EG, SALINE 

INFUSION) $105.20 20060701 99999999 

80410 CALCIUM-PENTAGASTRIN STIMULATION PANEL $67.34 20060701 99999999 

80412 CORTICOTROPIC RELEASING HORMONE (CRH) STIMULATION PANEL $276.30 20060701 99999999 

80414 

CHORIONIC GONADOTROPHIN STIMULATION PANEL; TESTOSTERONE 

RESPONSE $43.30 20060701 99999999 

80415 

CHORIONIC GONADOTROPHIN STIMULATION PANEL; ESTRADIOL 

RESPONSE $46.85 20060701 99999999 

80416 RENAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL) $110.63 20060701 99999999 

80417 PERIPHERAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL) $36.88 20060701 99999999 

80418 COMBINED RAPID ANTERIOR PITUITARY EVALUATION PANEL $485.86 20060701 99999999 

80420 DEXAMETHASONE SUPPRESSION PANEL, 48 HOUR $60.38 20060701 99999999 

80422 GLUCAGON TOLERANCE PANEL; FOR INSULINOMA $38.63 20060701 99999999 

80424 GLUCAGON TOLERANCE PANEL; FOR PHEOCHROMOCYTOMA $42.34 20060701 99999999 

80426 GONADOTROPIN RELEASING HORMONE STIMULATION PANEL $124.44 20060701 99999999 

80428 

GROWTH HORMONE STIMULATION PANEL (EG, ARGININE INFUSION, L- 

DOPA ADMINISTRATION) $55.90 20060701 99999999 

80430 

GROWTH HORMONE SUPPRESSION PANEL (GLUCOSE 

ADMINISTRATION) $65.76 20060701 99999999 

80432 INSULIN-INDUCED C-PEPTIDE SUPPRESSION PANEL $113.24 20060701 99999999 

80434 INSULIN TOLERANCE PANEL; FOR ACTH INSUFFICIENCY $84.78 20060701 99999999 

80435 INSULIN TOLERANCE PANEL; FOR GROWTH HORMONE DEFICIENCY $86.31 20060701 99999999 

80436 METYRAPONE PANEL $76.42 20060701 99999999 

80438 

THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; 

ONE HOUR $69.63 20060701 99999999 

80439 


TWO HOUR $92.84 20060701 99999999 

80440 


FOR HYPERPROLACTEMIA $48.74 20060701 99999999 

80500 CLINICAL PATHOLOGY CONSULTATION $20.57 20060701 99999999 

80502 CLINICAL PATHOLOGY CONSULTATION $70.69 20060701 99999999 

81000 URINALYSIS $4.37 20060701 99999999 

81001 

URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, 

GLUCOSE, HEMOGLOBIN, K $4.37 20060701 99999999 

81002 URINALYSIS $3.54 20060701 99999999 

81003 

URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, 

GLUCOSE, HEMOGLOBIN, K $3.10 20060701 99999999 

81005 URINALYSIS $3.00 20060701 99999999 

81007 

URINALYSIS BACTERIURIA SCREEN,NON CULTURE 

TECH,COMMERCIALI K $3.55 20060701 99999999 

81015 URINALYSIS $4.20 20060701 99999999 

81020 URINALYSIS $4.29 20060701 99999999 

81025 URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS $8.74 20060701 99999999 

81050 VOLUME MEASUREMENT FOR TIMED COLLECTION, EACH $2.70 20060701 99999999 



82000 ACETALDEHYDE, BLOOD $10.39 20060701 99999999 

82003 ACETAMINOPHEN, URINE $27.96 20060701 99999999 

82009 ACETONE $6.25 20060701 99999999 

82010 ACETONE $11.29 20060701 99999999 

82013 ACETYLCHOLINESTERASE $15.44 20060701 99999999 

82016 ACYLCARNITINES; QUALITATIVE, EACH SPECIMEN $11.62 20060701 99999999 

82017 

ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN (FOR CARNITINE, 

SEE 82379) $23.31 20060701 99999999 

82024 ADRENOCORTICOTROPIC HORMONE (ACTH), RIA $53.38 20060701 99999999 

82030 ADENOSINE $21.63 20060701 99999999 

82040 ALBUMIN $6.85 20060701 99999999 

82042 ALBUMIN $7.15 20060701 99999999 

82043 ALBUMIN; URINE, MICROALBUMIN, QUANTITATIVE $8.00 20060701 99999999 

82044 

ALBUMIN; URINE, MICROALBUMIN, SEMIQUANTITATIVE (EG, REAGENT 

STRIP ASSAY) $6.33 20060701 99999999 

82045 ALBUMIN; ISCHEMIA MODIFIED $28.46 20060701 99999999 

82055 ALCOHOL (ETHANOL), BLOOD $14.93 20060701 99999999 

82075 ALCOHOL (ETHANOL), BREATH $16.66 20060701 99999999 

82085 ALDOLASE, BLOOD $13.42 20060701 99999999 

82088 ALDOSTERONE $56.32 20060701 99999999 

82101 ALKALOIDS, URINE $25.16 20060701 99999999 

82103 ALPHA-1-ANTITRYPSIN; TOTAL $18.56 20060701 99999999 

82104 ALPHA-1-ANTITRYPSIN; PHENOTYPE $19.98 20060701 99999999 

82105 ALPHA-FETOPROTEIN; SERUM $23.18 20060701 99999999 

82106 ALPHA-FETOPROTEIN; AMNIOTIC FLUID $23.18 20060701 99999999 

82107 

ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL 

AFP (INCLUDING RATIO) $62.99 20070101 99999999 

82108 ALUMINUM, BLOOD (SERUM) $21.73 20060701 99999999 

82120 AMINES, VAGINAL FLUID, QUALITATIVE $5.19 20060701 99999999 

82127 AMINO ACIDS; SINGLE, QUALITATIVE, EACH SPECIMEN $11.62 20060701 99999999 

82128 AMINO ACIDS, QUALITATIVE $19.16 20060701 99999999 

82131 AMINO ACIDS, FRACTIONATION AND QUANTITATION, EACH $23.31 20060701 99999999 

82135 AMINOLEVULINIC ACID, DELTA (ALA) $22.75 20060701 99999999 

82136 AMINO ACIDS, 2 TO 5 AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN $14.14 20060701 99999999 

82139 

AMINO ACIDS, 6 OR MORE AMINO ACIDS, QUANTITATIVE, EACH 

SPECIMEN $23.31 20060701 99999999 

82140 AMMONIA $20.14 20060701 99999999 

82143 AMNIOTIC FLUID SCAN (SPECTROPHOTOMETRIC) $5.77 20060701 99999999 

82145 AMPHETAMINE OR METHAMPHETAMINE, CHEMICAL, QUANTITATIVE $21.48 20060701 99999999 

82150 AMYLASE, SERUM $8.96 20060701 99999999 

82154 ANDROSTANEDIOL GLUCURONIDE $24.17 20060701 99999999 

82157 ANDROSTENEDIONE, RIA $40.46 20060701 99999999 

82160 ANDROSTERONE $20.96 20060701 99999999 

82163 ANGIOTENSIN II, RIA $17.21 20060701 99999999 

82164 ANGIOTENSIN-CONVERTING ENZYME $20.17 20060701 99999999 

82172 APOLIPOPROTEIN, IMMUNOASSAY $21.41 20060701 99999999 

82175 ARSENIC, BLOOD, URINE, GASTRIC CONTENTS, HAIR OR NAILS, $26.22 20060701 99999999 

82180 ASCORBIC ACID (VITAMIN C), BLOOD $13.66 20060701 99999999 

82190 ATOMIC ABSORPTION SPECTROSCOPY, EACH ANALYTE $12.50 20060701 99999999 

82205 BARBITURATES $15.80 20060701 99999999 

82232 BETA-2 MICROGLOBULIN, RIA $22.36 20060701 99999999 

82239 BILE ACIDS; TOTAL $23.67 20060701 99999999 

82240 BILE ACIDS, BLOOD, FRACTIONATED $22.28 20060701 99999999 

82247 BILIRUBIN; TOTAL $6.94 20060701 99999999 

82248 BILIRUBIN; DIRECT $6.94 20060701 99999999 

82251 BILIRUBIN $7.33 19990701 99999999 

82252 BILIRUBIN $3.81 20060701 99999999 

82261 BIOTINIDASE, EACH SPECIMEN $23.31 20060701 99999999 



82270 BLOOD $4.49 20060701 99999999 

82271 

BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), 

QUALITATIVE; OTHER SOURCES $4.54 20060701 99999999 

82272 

BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), 

QUALITATIVE, FECES, SINGLE S $4.54 20060701 99999999 

82273 BLOOD $4.49 19990701 99999999 

82274 

BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY 

IMMUNOASSAY, QUALITATIVE, FE $13.33 20060701 99999999 

82286 BRADYKININ $5.77 20060701 99999999 

82300 CADMIUM, URINE $19.40 20060701 99999999 

82306 CALCIFEDIOL (25-OH VITAMIN D-3), CHROMATOGRAPHIC TECHNIQUE $40.91 20060701 99999999 

82307 CALCIFEROL (VITAMIN D), RIA $27.01 20060701 99999999 

82308 CALCITONIN, RIA $37.01 20060701 99999999 

82310 CALCIUM, BLOOD $7.12 20060701 99999999 

82330 CALCIUM, BLOOD $18.88 20060701 99999999 

82331 CALCIUM, BLOOD $4.34 20060701 99999999 

82340 CALCIUM, URINE $8.34 20060701 99999999 

82355 CALCULUS (STONE), QUALITATIVE, CHEMICAL $15.99 20060701 99999999 

82360 CALCULUS (STONE), QUANTITATIVE $17.80 20060701 99999999 



82373 CARBOHYDRATE DEFICIENT TRANSFERRIN $25.23 20060701 99999999 

82374 CARBON DIOXIDE, COMBINING POWER OR CONTENT $6.76 20060701 99999999 

82375 CARBON MONOXIDE, (CARBOXYHEMOGLOBIN) $17.03 20060701 99999999 

82376 CARBON MONOXIDE, (CARBOXYHEMOGLOBIN) $5.02 20060701 99999999 

82378 CARCINOEMBRYONIC ANTIGEN (CEA) $26.22 20060701 99999999 

82379 CARNITINE (TOTAL AND FREE), QUANTITATIVE, EACH SPECIMEN $23.31 20060701 99999999 

82380 CAROTENE, BLOOD $12.75 20060701 99999999 

82382 CATECHOLAMINES (DOPAMINE, NOREPINEPHRINE, EPINEPHRINE) $14.41 20060701 99999999 



82387 CATHEPSIN-D $17.44 20060701 99999999 

82390 CERULOPLASMIN, CHEMICAL (COPPER OXIDASE), BLOOD $14.84 20060701 99999999 

82397 CHEMILUMINESCENT ASSAY $11.84 20060701 99999999 

82415 CHLORAMPHENICOL, BLOOD $10.62 20060701 99999999 

82435 CHLORIDES $6.35 20060701 99999999 

82436 CHLORIDES $6.95 20060701 99999999 

82438 CHLORIDES $6.76 20060701 99999999 

82441 CHLORINATED HYDROCARBONS, SCREEN $5.03 20060701 99999999 

82465 CHOLESTEROL, SERUM $6.02 20060701 99999999 

82480 CHOLINESTERASE $10.89 20060701 99999999 

82482 CHOLINESTERASE $6.44 20060701 99999999 

82485 CHONDROITIN B SULFATE, QUANTITATIVE $17.31 20060701 99999999 

82486 CHROMATOGRAPHY $15.14 20060701 99999999 




82491 

CHROMOTOGRAPHY, QUANTITATIVE; COLUMN (EG, GAS LIQUID OR 

HIGH PERFORMANCE LIQUID $24.96 20060701 99999999 

82492 

CHROMATOGRAPHY, QUANTITATIVE, COLUMN (EG, GAS LIQUID OR 

HPLC); MULTIPLE ANALYTES $24.96 20060701 99999999 

82495 CHROMIUM, URINE $28.03 20060701 99999999 

82507 CITRATE $38.43 20060701 99999999 

82520 COCAINE, QUANTITATIVE $20.94 20060701 99999999 

82523 COLLAGEN CROSS LINKS, ANY METHOD $25.83 20060701 99999999 

82525 COPPER $17.15 20060701 99999999 

82528 CORTICOSTERONE, RIA $18.87 20060701 99999999 

82530 CORTISOL; FREE $23.10 20060701 99999999 



82533 CORTISOL $22.53 20060701 99999999 

82540 CREATINE $6.40 20060701 99999999 

82541 

COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR 

HPLC/MS), ANALYTE NOT ELS $24.96 20060701 99999999 

82542 



82543 



82544 



82550 CREATINE PHOSPHOKINASE (CPK), BLOOD $9.01 20060701 99999999 

82552 CREATINE PHOSPHOKINASE (CPK), BLOOD $18.51 20060701 99999999 

82553 CREATINE KINASE (CK), (CPK); MB FRACTION ONLY $15.95 20060701 99999999 

82554 CREATINE KINASE (CK), (CPK); ISOFORMS $9.95 20060701 99999999 

82565 CREATININE $7.07 20060701 99999999 

82570 CREATININE $7.15 20060701 99999999 

82575 CREATININE $13.06 20060701 99999999 

82585 CRYOFIBRINOGEN, BLOOD $11.85 20060701 99999999 

82595 CRYOGLOBULIN, BLOOD $8.95 20060701 99999999 

82600 CYANIDE $16.27 20060701 99999999 

82607 CYANOCOBALAMIN (VITAMIN B-12) $20.83 20060701 99999999 

82608 CYANOCOBALAMIN (VITAMIN B-12) $19.80 20060701 99999999 

82610 CYSTATIN C $19.00 20080101 99999999 

82615 CYSTINE AND HOMOCYSTINE, URINE $11.29 20060701 99999999 

82626 DEHYDROEPIANDROSTERONE (DHEA), RIA $34.93 20060701 99999999 

82627 DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) $30.72 20060701 99999999 

82633 DESOXYCORTICOSTERONE, 11-, RIA $25.97 20060701 99999999 

82634 DEOXYCORTISOL, 11-(COMPOUND S), RIA $24.54 20060701 99999999 

82638 DIBUCAINE NUMBER $10.27 20060701 99999999 

82646 DIHYDROCODEINONE $17.31 20060701 99999999 

82649 DIHYDROMORPHINONE, QUANTITATIVE $21.55 20060701 99999999 

82651 DIHYDROTESTOSTERONE (DHT) $35.68 20060701 99999999 

82652 DIHYDROXYVITAMIN D, 1,25- $53.19 20060701 99999999 

82654 DIMETHADIONE $11.60 20060701 99999999 

82656 DOXEPIN $15.95 20060701 99999999 

82657 

ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, 

NOT ELSEWHERE SPECIFI $24.96 20060701 99999999 

82658 

ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, 

NOT ELSEWHERE SPECIFI $15.14 20060701 99999999 

82664 ELECTROPHORETIC TECHNIQUE, NOT ELSEWHERE SPECIFIED $47.48 20060701 99999999 

82666 EPIANDROSTERONE $18.01 20060701 99999999 

82668 ERYTHROPOIETIN, BIOASSAY $25.97 20060701 99999999 

82670 ESTRADIOL, RIA (PLACENTAL) $38.62 20060701 99999999 

82671 ESTROGENS $27.08 20060701 99999999 

82672 ESTROGENS $29.97 20060701 99999999 

82677 ESTRIOL $33.43 20060701 99999999 

82679 ESTRONE $20.93 20060701 99999999 

82690 ETHCHLORVYNOL $14.49 20060701 99999999 

82693 ETHYLENE GLYCOL $20.59 20060701 99999999 

82696 ETIOCHOLANOLONE, RIA $19.77 20060701 99999999 

82705 FAT OR LIPIDS, FECES $7.04 20060701 99999999 

82710 FAT OR LIPIDS, FECES $23.21 20060701 99999999 

82715 FAT DIFFERENTIAL, FECES, QUANTITATIVE $23.79 20060701 99999999 

82725 FATTY ACIDS, BLOOD $18.40 20060701 99999999 

82726 VERY LONG CHAIN FATTY ACIDS $25.23 20060701 99999999 

82728 FERRITIN, SPECIFY METHOD (EG, RIA, IMMUNORADIOMETRIC ASSAY) $15.81 20060701 99999999 

82731 

FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI- 

QUANTITATIVE $89.01 20060701 99999999 



82735 FLUORIDE $25.63 20060701 99999999 

82742 FLURAZEPAM $16.60 20060701 99999999 

82746 FOLIC ACID (FOLATE), BLOOD $20.32 20060701 99999999 

82747 FOLIC ACID; RBC $23.93 20060701 99999999 

82757 FRUCTOSE, SEMEN $14.54 20060701 99999999 

82759 GALACTOKINASE, RBC $18.01 20060701 99999999 

82760 GALACTOSE $15.47 20060701 99999999 

82775 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE $17.66 20060701 99999999 

82776 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE $11.59 20060701 99999999 

82784 GAMMAGLOBULIN, A, D, G, M NEPHELOMETRIC, EACH $10.55 20060701 99999999 

82785 GAMMAGLOBULIN, E (EG, RIA, EIA) $22.76 20060701 99999999 

82787 

GAMMAGLOBULIN; IMMUNOGLOBULIN SUBCLASSES, (IGG1, 2, 3, AND 

4) $11.20 20060701 99999999 

82800 GASES, BLOOD $11.71 20060701 99999999 

82803 GASES, BLOOD $26.74 20060701 99999999 

82805 

GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO2 

(INCLUDING CALCULATED $39.21 20060701 99999999 

82810 

GASES, BLOOD, O2 SATURATION ONLY, BY DIRECT MEASUREMENT, 

EXCEPT PULSE OXIMETRY $12.06 20060701 99999999 

82820 

HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 50% HEMOGLOBIN 

SATURATION WITH OXYGEN) $7.80 20060701 99999999 

82926 GASTRIC ACID, FREE AND TOTAL $4.57 20060701 99999999 

82928 GASTRIC ACID, FREE OR TOTAL $5.49 20060701 99999999 

82938 GASTRIN (SERUM) AFTER SECRETIN STIMULATION (EG, FOR $14.83 20060701 99999999 

82941 GASTRIN, RIA $24.38 20060701 99999999 

82943 GLUCAGON, RIA $19.75 20060701 99999999 

82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD $5.42 20060701 99999999 

82946 GLUCAGON TOLERANCE TEST $20.83 20060701 99999999 

82947 GLUCOSE $5.42 20060701 99999999 

82948 GLUCOSE $4.37 20060701 99999999 

82950 GLUCOSE $6.56 20060701 99999999 

82951 GLUCOSE $17.80 20060701 99999999 

82952 GLUCOSE $5.42 20060701 99999999 

82953 GLUCOSE $12.70 20060701 99999999 

82955 GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) $13.40 20060701 99999999 

82960 GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) $8.38 20060701 99999999 

82962 

GLUCOSE, BLOOD, BY GLUCOSE MONITORING DEVICE(S) CLEARED BY 

THE FDA SPECIFICALLY $2.50 20060701 99999999 

82963 GLUCOSIDASE, BETA $18.01 20060701 99999999 

82965 GLUTAMATE DEHYDROGENASE, BLOOD $6.48 20060701 99999999 

82975 GLUTAMINE (GLUTAMIC ACID AMIDE), SPINAL FLUID $13.28 20060701 99999999 

82977 GLUTAMYL TRANSPEPTIDASE, GAMMA (GGT) $9.95 20060701 99999999 

82978 GLUTATHIONE $11.95 20060701 99999999 

82979 GLUTATHIONE REDUCTASE, RBC $5.77 20060701 99999999 

82980 GLUTETHIMIDE $15.36 20060701 99999999 

82985 GLYCOPROTEIN, ELECTROPHORESIS $20.83 20060701 99999999 

83001 GONADOTROPIN, PITUITARY, FOLLICLE STIMULATING HORMONE (FSH) $25.69 20060701 99999999 

83002 GONADOTROPIN, PITUITARY, LUTEINIZING HORMONE (LH)(ICSH), RIA $25.60 20060701 99999999 

83003 GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN) $23.04 20060701 99999999 

83008 GUANOSINE MONOPHOSPHATE (GMP), CYCLIC, RIA $14.07 20060701 99999999 

83009 

HELICOBACTER PYLORI, BLOOD TEST ANALYSIS FOR UREASE 

ACTIVITY, NON-RADIOACTIVE $56.47 20060701 99999999 

83010 HAPTOGLOBIN $17.38 20060701 99999999 

83012 HAPTOGLOBIN $14.41 20060701 99999999 

83013 HELICOBACTER PYLORI, BREATH TEST ANALYSIS; $93.09 20060701 99999999 

83014 

HELICOBACTER PYLORI, BREATH TEST ANALYSIS; DRUG 

ADMINISTRATION AND SAMPLE COLLEC $10.86 20060701 99999999 



83015 HEAVY METAL SCREEN (ARSENIC, BISMUTH, MERCURY, $19.80 20060701 99999999 

83018 HEAVY METAL SCREEN (ARSENIC, BISMUTH, MERCURY, $30.35 20060701 99999999 

83020 HEMOGLOBIN $17.80 20060701 99999999 

83021 

HEMOGLOBIN FRACTIONATION AND QUANTITATION; 

CHROMOTOGRAPHY (EG, A2, S, C, AND/OR $24.96 20060701 99999999 

83026 HEMOGLOBIN; BY COPPER SULFATE METHOD, NON-AUTOMATED $3.26 20060701 99999999 

83030 HEMOGLOBIN $11.43 20060701 99999999 

83033 HEMOGLOBIN $8.24 20060701 99999999 

83036 HEMOGLOBIN $13.42 20060701 99999999 

83045 HEMOGLOBIN $4.16 20060701 99999999 

83050 HEMOGLOBIN $10.12 20060701 99999999 

83051 HEMOGLOBIN $6.13 20060701 99999999 

83055 HEMOGLOBIN $4.12 20060701 99999999 

83060 HEMOGLOBIN $6.94 20060701 99999999 

83065 HEMOGLOBIN $5.77 20060701 99999999 

83068 HEMOGLOBIN $7.10 20060701 99999999 

83069 HEMOGLOBIN $3.31 20060701 99999999 

83070 HEMOSIDERIN, URINE $6.56 20060701 99999999 

83071 HEMOSIDERIN, RIA $5.77 20060701 99999999 

83080 B-HEXOSAMINIDASE, EACH ASSAY $23.31 20060701 99999999 

83088 HISTAMINE $40.81 20060701 99999999 

83090 HOMOCYSTINE $23.31 20060701 99999999 

83150 HOMOVANILLIC ACID (HVA), URINE $19.80 20060701 99999999 

83491 HYDROXYCORTICOSTEROIDS, 17- (17-OHCS) $14.68 20060701 99999999 

83497 HYDROXYINDOLACETIC ACID, 5-(HIAA), URINE $17.82 20060701 99999999 

83498 HYDROXYPROGESTERONE, 17-D, RIA $37.54 20060701 99999999 

83499 HYDROXYPROGESTERONE, 20- $21.13 20060701 99999999 

83500 HYDROXYPROLINE, URINE $18.99 20060701 99999999 

83505 HYDROXYPROLINE, URINE $20.38 20060701 99999999 

83516 

IMMUNOASSAY FOR ANALYTE OTHER THAN ANTIBODY OR 

INFECTIOUS AGENT ANTIGEN, QUALITA $15.95 20060701 99999999 

83518 

IMMUNOASSAY, FOR ANALYTE OTHER THAN ANTIBODY, QUALITATIVE 

OR SEMIQUANTITATIVE $11.72 20060701 99999999 

83519 IMMUNOASSAY, ANALYTE; BY RADIONUCLIDE TECHNIQUE (EG, RIA) $18.67 20060701 99999999 

83520 IMMUNOASSAY, ANALYTE; NOT OTHERWISE SPECIFIED $17.89 20060701 99999999 

83525 INSULIN, RIA $15.81 20060701 99999999 

83527 INSULIN; FREE $10.85 20060701 99999999 

83528 INTRINSIC FACTOR LEVEL $13.33 20060701 99999999 

83540 IRON, SERUM $8.95 20060701 99999999 

83550 IRON BINDING CAPACITY, SERUM $12.08 20060701 99999999 

83570 ISOCITRIC DEHYDROGENASE (IDH), BLOOD $7.42 20060701 99999999 

83582 KETOGENIC STEROIDS, URINE $11.88 20060701 99999999 

83586 KETOSTEROIDS, 17- (17-KS), BLOOD $10.73 20060701 99999999 

83593 KETOSTEROIDS, 17- (17-KS), URINE $22.05 20060701 99999999 

83605 LACTATE (LACTIC ACID) $14.76 20060701 99999999 

83615 LACTIC DEHYDROGENASE (LDH), BLOOD $8.35 20060701 99999999 

83625 LACTIC DEHYDROGENASE (LDH), BLOOD $10.73 20060701 99999999 

83630 LACTOFERRIN, FECAL, QUALITATIVE $16.45 20060701 99999999 

83631 LACTIC DEHYDROGENASE (LDH), CSF $16.45 20060701 99999999 

83632 

LACTOGEN, HUMAN PLACENTAL (HPL) CHORIONIC 

SOMATOMAMMOTROPIN, $16.94 20060701 99999999 

83633 LACTOSE, URINE $4.61 20060701 99999999 

83634 LACTOSE, URINE $9.66 20060701 99999999 

83655 LEAD, QUANTITATIVE $16.72 20060701 99999999 

83661 LECITHIN-SPHINGOMYELIN RATIO (L/S RATIO), AMNIOTIC FLUID $18.43 20060701 99999999 

83662 LECITHIN-SPHINGOMYELIN RATIO (L/S RATIO); FOAM STABILITY TEST $15.86 20060701 99999999 



83663 

FETAL LUNG MATURITY ASSESSMENT; FLUORESCENCE 

POLARIZATION $26.43 20060701 99999999 

83664 FETAL LUNG MATURITY ASSESSMENT; LAMELLAR BODY DENSITY $26.43 20060701 99999999 

83670 LEUCINE AMINOPEPTIDASE (LAP), BLOOD $7.68 20060701 99999999 

83690 LIPASE, BLOOD $9.52 20060701 99999999 

83695 LIPOPROTEIN (A) $12.66 20060701 99999999 

83698 LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2, (LP-PLA2) $47.43 20070101 99999999 

83700 LIPIDS, BLOOD $9.44 20060701 99999999 

83701 

LIPOPROTEIN, BLOOD; HIGH RESOLUTION FRACTIONATION AND 

QUANTITATION OF LIPOPROTEI $24.28 20060701 99999999 

83704 

LIPOPROTEIN, BLOOD; QUANTITATION OF LIPOPROTEIN PARTICLE 

NUMBERS AND LIPOPROTEIN $30.86 20060701 99999999 

83715 LIPOPROTEIN, BLOOD $15.56 19990701 99999999 

83718 LIPOPROTEIN HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) $11.31 20060701 99999999 

83719 

LIPOPROTEIN VERY LOW DENSITY CHOLESTEROL (VLDL 

CHOLESTEROL) $9.76 20060701 99999999 

83721 LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL $13.18 20060701 99999999 

83727 LUTEINIZING RELEASING FACTOR (LRH), RIA $14.41 20060701 99999999 

83735 MAGNESIUM, BLOOD $9.26 20060701 99999999 

83775 MALATE DEHYDROGENASE, KINETIC ULTRAVIOLET METHOD $6.18 20060701 99999999 

83785 MANGANESE, BLOOD OR URINE $20.62 20060701 99999999 

83788 

MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (MS, MS/ 

MS), ANALYTE NOT ELSEWHE $24.96 20060701 99999999 

83789 

MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (MS, MS/ 

MS), ANALYTE NOT ELSEWHE $24.96 20060701 99999999 

83805 MEPROBAMATE, BLOOD OR URINE $24.36 20060701 99999999 

83825 MERCURY, QUANTITATIVE $22.47 20060701 99999999 

83835 METANEPHRINES, URINE $23.41 20060701 99999999 

83840 METHADONE $22.56 20060701 99999999 

83857 METHEMALBUMIN $14.84 20060701 99999999 

83858 METHSUXIMIDE, SERUM $12.43 20060701 99999999 

83864 MUCOPOLYSACCHARIDES, ACID, BLOOD $16.69 20060701 99999999 

83866 MUCOPOLYSACCHARIDES, ACID, URINE $8.26 20060701 99999999 

83872 MUCIN, SYNOVIAL FLUID (ROPES TEST) $8.10 20060701 99999999 

83873 MYELIN BASIC PROTEIN, CSF, RIA $14.42 20060701 99999999 

83874 MYOGLOBIN, ELECTROPHORESIS $17.84 20060701 99999999 

83880 NALORPHINE $28.46 20060701 99999999 

83883 NEPHELOMETRY, EACH ANALYTE NOT ELSEWHERE SPECIFIED $18.79 20060701 99999999 

83885 NICKEL, URINE $20.54 20060701 99999999 

83887 NICOTINE $19.85 20060701 99999999 

83890 

NUCLEAR MOLECULAR DIAGNOSTICS; MOLECULAR ISOLATION OR 

EXTRACTION $5.54 20060701 99999999 

83891 

MOLECULAR DIAGNOSTICS; ISOLATION OR EXTRACTION OF HIGHLY 

PURIFIED NUCLEIC ACID $5.54 20060701 99999999 

83892 NUCLEAR MOLECULAR DIAGNOSTICS; ENZYMATIC DIGESTION $5.54 20060701 99999999 

83893 MOLECULAR DIAGNOSTICS; DOT/SLOT BLOT PRODUCTION $5.54 20060701 99999999 

83894 

NUCLEAR MOLECULAR DIAGNOSTICS; SEPARATION (EG, DOT BLOT, 

ELECTROPHORESIS) $5.54 20060701 99999999 

83896 NUCLEAR MOLECULAR DIAGNOSTICS; NUCLEIC ACID PROBE, EACH $5.54 20060701 99999999 

83897 

MOLECULAR DIAGNOSTICS; NUCLEIC ACID TRANSFER (EG, 

SOUTHERN, NORTHERN) $5.54 20060701 99999999 

83898 

NUCLEAR MOLECULAR DIAGNOSTICS; NUCLEIC ACID PROBE WITH 

AMPLIFICATION, EG, POLYME $23.17 20060701 99999999 

83900 NITROGEN, TOTAL $28.10 20060701 99999999 

83901 

MOLECULAR DIAGNOSTICS; AMPLIFICATION OF PATIENT NUCLEIC 

ACID, MULTIPLEX, EACH MU $23.17 20060701 99999999 

83902 

MOLECULAR DIAGNOSTICS AMPLIFICATION EG POLYMERASE CHAIN 

REACTION (PCR) REVERSE T $19.61 20060701 99999999 



83903 

MOLECULAR DIAGNOSTICS; MUTATION SCANNING, BY PHYSICAL 

PROPERTIES (EG, SINGLE STR $23.17 20060701 99999999 

83904 

MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY 

SEQUENCING, SINGLE SEGMENT, EA $23.17 20060701 99999999 

83905 

MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE 

SPECIFIC TRANSCRIPTION, $14.05 20060701 99999999 

83906 

MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE 

SPECIFIC TRANSLATION, S $14.05 20060701 99999999 

83907 

MOLECULAR DIAGNOSTICS; LYSIS OF CELLS PRIOR TO NUCLEIC ACID 

EXTRACTION (EG, STOO $13.06 20060701 99999999 

83908 

MOLECULAR DIAGNOSTICS; SIGNAL AMPLIFICATION OF PATIENT 

NUCLEIC ACID, EACH NUCLEI $16.39 20060701 99999999 

83909 

MOLECULAR DIAGNOSTICS; SEPARATION AND IDENTIFICATION BY 

HIGH RESOLUTION TECHNIQU $16.39 20060701 99999999 

83912 NUCLEIC ACID PROBE, WITH ELECTROPHORESIS W/EXAM & REPORT $5.60 20060701 99999999 

83914 

MUTATION IDENTIFICATION BY ENZYMATIC LIGATION OR PRIMER 

EXTENSION, SINGLE SEGMEN $16.39 20060701 99999999 

83915 NUCLEOTIDASE 5'- $9.35 20060701 99999999 

83916 OLIGOCLONAL IMMUNE GLOBULIN (IG), CSF, BY ELECTROPHORESIS $27.79 20060701 99999999 

83918 ORGANIC ACIDS $22.75 20060701 99999999 

83919 ORGANIC ACIDS; QUALITATIVE, EACH SPECIMEN $22.75 20060701 99999999 

83921 ORGANIC ACID, SINGLE, QUANTITATIVE $22.75 20060701 99999999 

83925 OPIATES, (EG, MORPHINE, MEPERIDINE) $26.89 20060701 99999999 

83930 OSMOLALITY $9.13 20060701 99999999 

83935 OSMOLALITY $9.42 20060701 99999999 

83937 OSTEOCALCIN (BONE G1A PROTEIN) $41.26 20060701 99999999 

83945 OXALATE, URINE $17.80 20060701 99999999 

83950 ONCOPROTEIN, HER-2/NEU $53.99 20060701 99999999 

83970 PARATHORMONE (PARATHYROID HORMONE), RIA $57.04 20060701 99999999 

83986 PH, BODY FLUID, EXCEPT BLOOD $4.95 20060701 99999999 

83992 PHENCYCLIDINE (PCP) $12.32 20060701 99999999 

83993 CALPROTECTIN, FECAL $27.42 20080101 99999999 

84022 PHENOTHIAZINE, URINE $13.06 20060701 99999999 

84030 PHENYLALANINE (PKU), BLOOD $7.61 20060701 99999999 

84035 PHENYLKETONES $3.07 20060701 99999999 

84060 PHOSPHATASE, ACID $6.19 20060701 99999999 

84061 PHOSPHATASE, ACID; FORENSIC EXAMINATION $6.64 20060701 99999999 

84066 PHOSPHATASE, ACID $13.35 20060701 99999999 

84075 PHOSPHATASE, ALKALINE, BLOOD $7.15 20060701 99999999 



84081 PHOSPHATYDYLGLYCEROL $22.84 20060701 99999999 

84085 PHOSPHOGLUCONATE, 6-, DEHYDROGENASE, RBC $5.65 20060701 99999999 

84087 PHOSPHOHEXOSE ISOMERASE $8.65 20060701 99999999 

84100 PHOSPHORUS (PHOSPHATE) $6.56 20060701 99999999 

84105 PHOSPHORUS (PHOSPHATE) $7.15 20060701 99999999 

84106 PORPHOBILINOGEN, URINE $3.59 20060701 99999999 

84110 PORPHOBILINOGEN, URINE $11.68 20060701 99999999 

84119 PORPHYRINS, COPRO-, URINE $11.90 20060701 99999999 

84120 PORPHYRINS $20.33 20060701 99999999 

84126 PORPHYRINS, FECES, QUANTITATIVE $21.35 20060701 99999999 

84127 PORPHYRINS, FECES; QUALITATIVE $9.77 20060701 99999999 

84132 POTASSIUM $6.35 20060701 99999999 

84133 POTASSIUM $5.94 20060701 99999999 

84134 PREALBUMIN $20.16 20060701 99999999 

84135 PREGNANEDIOL $16.04 20060701 99999999 

84138 PREGNANETRIOL $15.88 20060701 99999999 

84140 PREGNENOLONE $28.58 20060701 99999999 



84143 17-HYDROXYPREGNENOLONE $19.13 20060701 99999999 

84144 PROGESTERONE, ANY METHOD $28.83 20060701 99999999 

84146 PROLACTIN (MAMMOTROPIN), RIA $26.78 20060701 99999999 

84150 PROSTAGLANDIN, ANY ONE, RIA $34.50 20060701 99999999 

84152 

PROSTATE SPECIFIC ANTIGEN (PSA); COMPLEXED (DIRECT 

MEASUREMENT) $25.42 20060701 99999999 

84153 PROSTATE SPECIFIC ANTIGEN (PSA) $25.42 20060701 99999999 

84154 PROSTATE SPECIFIC ANTIGEN (PSA); FREE $25.42 20060701 99999999 

84155 PROTEIN, TOTAL, SERUM $5.06 20060701 99999999 

84156 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE $3.69 20060701 99999999 

84157 

PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, 

SYNOVIAL FLUID, CEREB $3.69 20060701 99999999 


84163 PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A) $20.80 20060701 99999999 


84166 

PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, 

OTHER FLUIDS WITH $24.92 20060701 99999999 

84181 

PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, 

BLOOD OR OTHER BODY FLUID $14.28 20060701 99999999 

84182 

PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, 

BLOOD OR OTHER BODY FLUID $15.09 20060701 99999999 

84202 PROTOPORPHYRIN, RBC $19.83 20060701 99999999 

84203 PROTOPORPHYRIN, RBC $7.22 20060701 99999999 

84206 PROINSULIN, RIA $23.03 20060701 99999999 

84207 PYRIDOXINE (VITAMIN B-6) $26.36 20060701 99999999 

84210 PYRUVATE, BLOOD $15.01 20060701 99999999 

84220 PYRUVIC KINASE, RBC $7.91 20060701 99999999 

84228 QUININE $9.76 20060701 99999999 

84233 RECEPTOR ASSAY $53.99 20060701 99999999 




84244 RENIN (ANGIOTENSIN I) $30.40 20060701 99999999 

84252 RIBOFLAVIN (VITAMIN B-2) $15.99 20060701 99999999 

84255 SELENIUM, BLOOD, URINE OR TISSUE $35.28 20060701 99999999 

84260 SEROTONIN, BLOOD $42.81 20060701 99999999 

84270 SEX HORMONE BINDING GLOBULIN (SHBG) $13.11 20060701 99999999 

84275 SIALIC ACID, BLOOD $11.26 20060701 99999999 

84285 SILICA, BLOOD, URINE OR TISSUE $19.74 20060701 99999999 

84295 SODIUM $6.65 20060701 99999999 

84300 SODIUM $6.72 20060701 99999999 

84302 SODIUM; OTHER SOURCE $6.79 20060701 99999999 

84305 SOMATOMEDIN $29.38 20060701 99999999 

84307 SOMATOSTATIN $15.32 20060701 99999999 

84311 SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED $9.66 20060701 99999999 

84315 SPECIFIC GRAVITY (EXCEPT URINE) $2.10 20060701 99999999 

84375 SUGARS, CHROMATOGRAPHIC, TLC OR PAPER CHROMATOGRAPHY $16.43 20060701 99999999 

84376 

SUGARS (MON-, DI, AND OLIGOSACCHARIDES); SINGLE QUALITATIVE, 

EACH SPECIMEN $7.61 20060701 99999999 

84377 

SUGARS (MON-, DI, AND OLIGOSACCHARIDES); MULTIPLE 

QUALITATIVE, EACH SPECIMEN $4.61 20060701 99999999 

84378 

SUGARS (MON-, DI, AND OLIGOSACCHARIDES); SINGLE 

QUANTITATIVE, EACH SPECIMEN $9.66 20060701 99999999 

84379 

SUGARS (MON-, DI, AND OLIGOSACCHARIDES); MULTIPLE 

QUANTITATIVE, EACH SPECIMEN $9.66 20060701 99999999 

84392 SULFATE, URINE $3.98 20060701 99999999 

84402 TESTOSTERONE; FREE $35.19 20060701 99999999 

84403 TESTOSTERONE, BLOOD, RIA $35.68 20060701 99999999 



84425 THIAMINE (VITAMIN B-1) $26.36 20060701 99999999 

84430 THIOCYANATE, BLOOD $9.76 20060701 99999999 

84432 THYROGLOBULIN $22.20 20060701 99999999 

84436 THYROXINE, TRUE (TT-4), RIA $9.50 20060701 99999999 

84437 THYROXINE (T-4) NEONATAL $8.95 20060701 99999999 

84439 THYROXINE, FREE (FT-4), RIA (UNBOUND T-4 ONLY) $12.46 20060701 99999999 

84442 THYROXINE BINDING GLOBULIN (TBG) $20.44 20060701 99999999 

84443 THYROID STIMULATING HORMONE (TSH), RIA OR EIA $23.21 20060701 99999999 

84445 THYROTROPIN RELEASING FACTOR (TRF), RIA $32.92 20060701 99999999 

84446 TOCOPHEROL ALPHA (VITAMIN E) $19.60 20060701 99999999 

84449 TRANSCORTIN (CORTISOL BINDING GLOBULIN) $24.87 20060701 99999999 

84450 TRANSAMINASE, GLUTAMIC OXALOACETIC (SGOT), BLOOD $7.14 20060701 99999999 

84460 TRANSAMINASE, GLUTAMIC PYRUVIC (SGPT), BLOOD $7.32 20060701 99999999 

84466 TRANSFERRIN $17.65 20060701 99999999 

84478 TRIGLYCERIDES, BLOOD $7.95 20060701 99999999 

84479 TRIIODOTHYRONINE (T-3), RESIN UPTAKE $8.95 20060701 99999999 

84480 TRIIODOTHYRONINE TRUE (TT-3), RIA $19.60 20060701 99999999 

84481 TRIIODOTHYRONINE, FREE (FT-3), RIA (UNBOUND T-3 ONLY) $23.41 20060701 99999999 

84482 TRIDOTHYRONINE (T-3); REVERSE $21.78 20060701 99999999 

84484 TROPONIN $13.60 20060701 99999999 

84485 TRYPSIN, DUODENAL FLUID $6.29 20060701 99999999 

84488 TRYPSIN, FECES $6.12 20060701 99999999 

84490 TRYPSIN, FECES $6.38 20060701 99999999 

84510 TYROSINE, BLOOD $8.72 20060701 99999999 

84512 TROPONIN, QUALITATIVE $10.64 20060701 99999999 

84520 UREA NITROGEN, BLOOD (BUN) $5.45 20060701 99999999 

84525 UREA NITROGEN, BLOOD (BUN) $4.02 20060701 99999999 

84540 UREA NITROGEN, URINE $6.56 20060701 99999999 

84545 UREA NITROGEN, CLEARANCE $9.12 20060701 99999999 

84550 URIC ACID $6.25 20060701 99999999 

84560 URIC ACID, URINE $6.56 20060701 99999999 

84565 UROBILIN, URINE $7.73 20010101 99999999 

84577 UROBILINOGEN, FECES, QUANTITATIVE $10.46 20060701 99999999 

84578 UROBILINOGEN, URINE $2.72 20060701 99999999 



84585 VANILLYMANDELIC ACID (VMA), URINE $21.42 20060701 99999999 

84586 VASOACTIVE INTESTINAL PEPTIDE (VIP) $46.25 20060701 99999999 

84588 VASOPRESSIN (ANTIDIURETIC HORMONE), RIA $46.91 20060701 99999999 

84590 VITAMIN A, BLOOD $16.02 20060701 99999999 

84591 VITAMIN, NOT OTHERWISE SPECIFIED $9.72 20060701 99999999 

84597 VITAMIN K $18.94 20060701 99999999 

84600 VOLATILES (ACETIC ANHYDRIDE, CARBON TETRACHLORIDE, $13.47 20060701 99999999 

84620 XYLOSE ABSORPTION TEST, BLOOD AND/OR URINE $9.93 20060701 99999999 

84630 ZINC, QUANTITATIVE $15.74 20060701 99999999 

84681 C-PEPTIDE, ANY METHOD $28.75 20060701 99999999 

84702 GONADOTROPIN, CHORIONIC $20.80 20060701 99999999 

84703 GONADOTROPIN, CHORIONIC $10.38 20060701 99999999 

84704 GONADOTROPIN, CHORIONIC (HCG); FREE BETA CHAIN $21.03 20080101 99999999 

84830 

OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR 

HUMAN LUTEINIZING HORMON $8.41 20060701 99999999 

85002 BLEEDING TIME $6.22 20060701 99999999 

85004 BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT $9.04 20060701 99999999 

85007 BLOOD COUNT $4.76 20060701 99999999 

85008 

BLOOD COUNT; MANUAL BLOOD SMEAR EXAMINATION WITHOUT 

DIFFERENTIAL PARAMETERS $4.76 20060701 99999999 

85009 BLOOD COUNT $5.14 20060701 99999999 

85013 BLOOD COUNT; SPUN MICROHEMATOCRIT $3.27 20060701 99999999 



85014 BLOOD COUNT $3.27 20060701 99999999 

85018 BLOOD COUNT $3.27 20060701 99999999 

85021 BLOOD COUNT $7.72 19990701 99999999 

85022 BLOOD COUNT $7.59 19990701 99999999 

85023 BLOOD COUNT $11.71 19990701 99999999 

85024 BLOOD COUNT $11.70 19990701 99999999 

85025 BLOOD COUNT $10.74 20060701 99999999 

85027 BLOOD COUNT $8.95 20060701 99999999 

85032 

BLOOD COUNT; MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, 

OR PLATELET) EACH $6.01 20060701 99999999 

85041 BLOOD COUNT $4.20 20060701 99999999 

85044 BLOOD COUNT $5.94 20060701 99999999 

85045 BLOOD COUNT RETICULOCYTE COUNT, FLOW CYTOMETRY $5.59 20060701 99999999 

85046 BLOOD COUNT; RETICULOCYTES, HEMOGLOBIN CONCENTRATION $7.72 20060701 99999999 

85048 BLOOD COUNT $3.52 20060701 99999999 

85049 BLOOD COUNT; PLATELET, AUTOMATED $6.25 20060701 99999999 

85055 RETICULATED PLATELET ASSAY $18.20 20060701 99999999 

85060 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN $15.19 20060701 99999999 

85095 BONE MARROW SMEAR AND/OR CELL BLOCK $58.43 19990701 99999999 

85097 BONE MARROW SMEAR AND/OR CELL BLOCK $34.18 20060701 99999999 

85102 BONE MARROW NEEDLE BIOPSY $165.81 19990701 99999999 

85130 CHROMOGENIC SUBSTRATE ASSAY $16.44 20060701 99999999 

85170 CLOT RETRACTION $3.03 20060701 99999999 

85175 CLOT LYSIS TIME, WHOLE BLOOD DILUTION $3.81 20060701 99999999 

85210 CLOTTING $17.95 20060701 99999999 

85220 CLOTTING $24.39 20060701 99999999 

85230 CLOTTING $24.75 20060701 99999999 

85240 CLOTTING $24.75 20060701 99999999 

85244 CLOTTING $17.12 20060701 99999999 

85245 CLOTTING; FACTOR VIII, VW FACTOR, RISTOCETIN COFACTOR $31.72 20060701 99999999 

85246 CLOTTING; FACTOR VIII, VW FACTOR ANTIGEN $31.72 20060701 99999999 

85247 

CLOTTING; FACTOR VIII, VON WILLEBRAND'S FACTOR, MULTIMETRIC 

ANALYSIS $31.72 20060701 99999999 

85250 CLOTTING $26.31 20060701 99999999 

85260 CLOTTING $24.75 20060701 99999999 

85270 CLOTTING $24.75 20060701 99999999 

85280 CLOTTING $22.58 20060701 99999999 

85290 CLOTTING $13.70 20060701 99999999 

85291 CLOTTING $7.45 20060701 99999999 

85292 CLOTTING $15.88 20060701 99999999 

85293 CLOTTING $15.88 20060701 99999999 

85300 CLOTTING INHIBITORS OR ANTICOAGULANTS $16.38 20060701 99999999 



85303 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY $19.11 20060701 99999999 

85305 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S ASSAY $16.02 20060701 99999999 

85306 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE $21.18 20060701 99999999 

85307 ACTIVATED PROTEIN C (APC) RESISTANCE ASSAY $21.41 20060701 99999999 

85335 FACTOR INHIBITOR TEST $17.99 20060701 99999999 

85337 THROMBOMODULIN $8.74 20060701 99999999 

85345 COAGULATION TIME $3.61 20060701 99999999 



85360 EUGLOBULIN LYSIS $7.04 20060701 99999999 

85362 FIBRIN DEGRADATION (SPLIT) PRODUCTS (FDP) $9.52 20060701 99999999 

85366 

FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP)(FSP); 

PARACOAGULATION $7.22 20060701 99999999 



85370 

FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP)(FSP); 

QUANTITATIVE $9.52 20060701 99999999 

85378 FIBRIN DEGRADATION PRODUCTS, D-DIMER; SEMIQUANTITATIVE $9.86 20060701 99999999 

85379 FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE $14.06 20060701 99999999 

85380 

FIBRIN DEGRADATION PRODUCTS, D-DIMER; ULTRASENSITIVE (EG, 

FOR EVALUATION FOR VEN $14.22 20060701 99999999 

85384 FIBRINOGEN; ACTIVITY $11.74 20060701 99999999 

85385 FIBRINOGEN; ANTIGEN $7.12 20060701 99999999 

85390 FIBRINOLYSINS $4.33 20060701 99999999 

85396 FIBRINOLYSINS; $13.22 20060701 99999999 

85400 FIBRINOLYTIC MECHANISMS $12.22 20060701 99999999 


85415 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN ACTIVATOR $23.76 20060701 99999999 



85441 HEINZ BODIES $3.53 20060701 99999999 

85445 HEINZ BODIES $5.71 20060701 99999999 

85460 HEMOGLOBIN, FETAL, DIFFERENTIAL LYSIS (KLEIHAUER) $10.69 20060701 99999999 

85461 

HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; 

ROSETTE $5.56 20060701 99999999 

85475 HEMOLYSIN, ACID $12.26 20060701 99999999 

85520 HEPARIN ASSAY $15.81 20060701 99999999 

85525 HEPARIN NEUTRALIZATION $16.12 20060701 99999999 

85530 HEPARIN-PROTAMINE TOLERANCE TEST $11.89 20060701 99999999 

85535 IRON STAIN (RBC OR BONE MARROW SMEARS) $8.95 19990701 99999999 

85536 IRON STAIN, PERIPHERAL BLOOD $5.42 20060701 99999999 

85540 LEUKOCYTE ALKALINE PHOSPHATASE WITH COUNT $11.88 20060701 99999999 

85547 MECHANICAL FRAGILITY, RBC $7.21 20060701 99999999 

85549 MURAMIDASE, SERUM $15.73 20060701 99999999 

85555 OSMOTIC FRAGILITY, RBC $5.60 20060701 99999999 

85557 OSMOTIC FRAGILITY, RBC $11.20 20060701 99999999 

85576 PLATELET $22.53 20060701 99999999 

85595 PLATELET $6.18 19990701 99999999 

85597 PLATELET NEUTRALIZATION $24.84 20060701 99999999 

85610 PROTHROMBIN TIME $5.43 20060701 99999999 

85611 PROTHROMBIN TIME; SUBSTITUTION, PLASMA FRACTIONS, EACH $5.43 20060701 99999999 

85612 PROTHROMBIN TIME $13.22 20060701 99999999 

85613 RUSSELL VIPER VENOM TIME (INCLUDES VENOM); DILUTED $13.22 20060701 99999999 

85635 REPTILASE TEST $8.26 20060701 99999999 

85651 SEDIMENTATION RATE (ESR) $4.91 20060701 99999999 

85652 SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED $3.73 20060701 99999999 

85660 SICKLING OF RBC, REDUCTION, SLIDE METHOD $7.63 20060701 99999999 

85670 THROMBIN TIME $7.98 20060701 99999999 

85675 THROMBIN TIME $5.75 20060701 99999999 

85705 THROMBOPLASTIN INHIBITION; TISSUE $13.31 20060701 99999999 

85730 THROMBOPLASTIN TIME, PARTIAL (PTT) $8.30 20060701 99999999 

85732 THROMBOPLASTIN TIME, PARTIAL (PTT) $8.95 20060701 99999999 

85810 VISCOSITY $16.14 20060701 99999999 

85999 UNLISTED HEMATOLOGY PROCEDURE $12.34 19990701 99999999 

86000 AGGLUTININS $9.26 20060701 99999999 

86001 

ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, 

EACH ALLERGEN $7.30 20060701 99999999 

86003 

ALLERGEN SPECIFIC IGE; QUANTITATIVE, EACH PANEL OF UP TO 12 

ALLERGENS $7.22 20060701 99999999 

86005 

ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN 

(DIPSTICK OR DISK) $1.73 20060701 99999999 

86021 ANTIBODY IDENTIFICATION $20.80 20060701 99999999 





86038 ANTINUCLEAR ANTIBODIES (ANA), RIA $16.70 20060701 99999999 

86039 ANTINUCLEAR ANTIBODIES (ANA); TITER $15.43 20060701 99999999 

86060 ANTISTREPTOLYSIN 0 $10.09 20060701 99999999 

86063 ANTISTREPTOLYSIN 0 $7.98 20060701 99999999 

86064 ANTITRYPSIN, ALPHA-1 $52.70 20050101 99999999 

86077 BLOOD BANK PHYSICIAN SERVICES $51.86 20060701 99999999 



86140 C-REACTIVE PROTEIN $7.15 20060701 99999999 

86141 C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) $17.20 20060701 99999999 

86146 BETA 2 GLYCOPROTEIN I ANTIBODY, EACH $35.54 20060701 99999999 

86147 CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY $35.16 20060701 99999999 

86148 ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY $22.20 20060701 99999999 

86155 CHEMOTAXIS ASSAY, SPECIFY METHOD $13.40 20060701 99999999 

86156 COLD AGGLUTININ; SCREEN $9.26 20060701 99999999 

86157 COLD AGGLUTININ; TITER $11.14 20060701 99999999 

86160 COMPLEMENT; ANTIGEN, EACH COMPONENT $16.59 20060701 99999999 

86161 COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT $16.59 20060701 99999999 

86162 COMPLEMENT $28.08 20060701 99999999 

86171 COMPLEMENT FIXATION TESTS, EACH ANTIGEN $8.40 20060701 99999999 

86185 COUNTERELECTROPHORESIS, EACH ANTIGEN $7.50 20060701 99999999 

86200 CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY $12.66 20060701 99999999 

86215 DEOXYRIBONUCLEASE, ANTIBODY $18.32 20060701 99999999 

86225 DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY $18.99 20060701 99999999 

86226 DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; SINGLE STRANDED $16.73 20060701 99999999 

86235 ANTIBODY TO SPECIFIC NUCLEAR ANTIGEN, ANY METHOD, EACH $24.78 20060701 99999999 

86243 FC RECEPTOR ASSAY, SPECIFY METHOD $17.21 20060701 99999999 

86255 FLUORESCENT ANTIBODY $16.66 20060701 99999999 

86256 FLUORESCENT ANTIBODY $16.66 20060701 99999999 

86277 GROWTH HORMONE, HUMAN (HGH), ANTIBODY, RIA $13.19 20060701 99999999 

86280 HEMAGGLUTINATION INHIBITION TEST (HAI), EACH $6.86 20060701 99999999 

86294 

IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE OR 

SEMIQUANTITATIVE (EG, BLADDER TUMO $16.45 20060701 99999999 

86300 HETEROPHILE ANTIBODIES $28.76 20060701 99999999 

86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9 $28.76 20060701 99999999 

86304 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125 $28.76 20060701 99999999 

86308 HETEROPHILE ANTIBODIES; SCREENING $7.15 20060701 99999999 

86309 HETEROPHILE ANTIBODIES; TITER $5.42 20060701 99999999 

86310 HETEROPHILE ANTIBODIES $6.18 20060701 99999999 

86316 

IMMUNOASSAY FOR TUMOR ANTIGEN (EG, PROSTATE SPECIFIC 

ANTIGEN, $28.76 20060701 99999999 

86317 

IMMUNOASSAY FOR INFECTIOUS AGENT ANTIGEN OR ANTIBODY, 

EACH $20.72 20060701 99999999 

86318 IMMUNOASSAY FOR CHEMICAL CONSTITUENT $17.89 20060701 99999999 

86320 IMMUNOELECTROPHORESIS $22.10 20060701 99999999 



86329 IMMUNODIFFUSION $11.77 20060701 99999999 

86331 IMMUNODIFFUSION $10.05 20060701 99999999 

86332 IMMUNE COMPLEX ASSAY CIQ BINDING CELL $32.38 20060701 99999999 

86334 IMMUNOFIXATION ELECTROPHORESIS $30.87 20060701 99999999 

86335 IMMUNOGLOBULIN TYPING (GC, GM, INV), EACH $30.87 20060701 99999999 

86336 INHIBIN A $18.09 20060701 99999999 

86337 INSULIN ANTIBODIES, RIA $29.59 20060701 99999999 

86340 INTRINSIC FACTOR ANTIBODIES, RIA $20.83 20060701 99999999 

86341 ISLET CELL ANTIBODY $25.15 20060701 99999999 



86343 LEUKOCYTE HISTAMINE RELEASE TEST (LHR) $10.45 20060701 99999999 

86344 LEUKOCYTE PHAGOCYTOSIS $6.70 20060701 99999999 

86353 

LYMPHOCYTE TRANSFORMATION, SPONTANEOUS BLASTOGENESIS 

OR PHYTOMITOGEN $41.09 20060701 99999999 

86355 B CELLS, TOTAL COUNT $36.89 20060701 99999999 

86356 

MONONUCLEAR CELL ANTIGEN, QUANTITATIVE (EG, FLOW 

CYTOMETRY), NOT OTHERWISE SPECI $25.28 20080101 99999999 

86357 LYMPHOCYTES $31.62 20060701 99999999 

86359 T CELLS; TOTAL COUNT $52.13 20060701 99999999 

86360 T CELLS; T4 AND T8, INCLUDING RATIO $64.93 20060701 99999999 

86361 T CELLS; ABSOLUTE CD4 COUNT $25.00 20060701 99999999 

86367 STEM CELLS (IE, CD34), TOTAL COUNT $36.89 20060701 99999999 

86376 MICROSOMAL ANTIBODY (THYROID) $20.11 20060701 99999999 

86378 MIGRATION INHIBITORY FACTOR TEST (MIF) $16.51 20060701 99999999 

86379 NATURAL KILLER (NK) CELLS, TOTAL COUNT $52.70 20050101 99999999 

86382 NEUTRALIZATION TEST, VIRAL $14.17 20060701 99999999 

86384 NITROBLUE TETRAZOLIUM DYE TEST (NTD) $9.55 20060701 99999999 

86403 PARTICLE AGGLUTINATION, RAPID TEST FOR $14.08 20060701 99999999 

86406 PARTICLE AGGLUTINATION; TITER, EACH ANTIBODY $14.58 20060701 99999999 

86430 RHEUMATOID FACTOR, LATEX FIXATION $7.85 20060701 99999999 

86431 RHEUMATOID FACTOR; QUANTITATIVE $7.85 20060701 99999999 

86480 SKIN TEST;CAT SCRATCH FEVER $51.95 20060701 99999999 

86485 SKIN TEST; CANDIDA $13.04 19990701 99999999 

86486 SKIN TEST; UNLISTED ANTIGEN, EACH $3.31 20080101 99999999 

86490 SKIN TEST $7.69 20060701 99999999 

86510 SKIN TEST $8.45 20060701 99999999 

86540 SKIN TEST $7.89 19920401 99999999 

86580 SKIN TEST $6.68 20060701 99999999 

86585 SKIN TEST $6.00 19990701 99999999 

86587 SPLITTING OF BLOOD OR BLOOD PRODUCTS, EACH $52.70 20050101 99999999 

86590 STREPTOKINASE, ANTIBODY $15.24 20060701 99999999 

86592 SYPHILIS TEST $5.90 20060701 99999999 

86593 SYPHILIS TEST $6.09 20060701 99999999 

86602 ANTIBODY; ACTINOMYCES $8.53 20060701 99999999 

86603 ANTIBODY; ADENOVIRUS $10.79 20060701 99999999 

86606 ANTIBODY; ASPIRGILLUS $20.80 20060701 99999999 

86609 ANTIBODY; BACTERIUM, NOT ELSEWHERE SPECIFIED $17.81 20060701 99999999 

86611 ANTIBODY; BARTONELLA $14.22 20060701 99999999 

86612 ANTIBODY; BLASTOMYCES $10.82 20060701 99999999 

86615 ANTIBODY; BORDETELLA $11.06 20060701 99999999 

86617 

ANTIBODY; BORRELIA BURGDORFERI (LYME DISEASE) 

CONFIRMATORY TEST (EG, WESTERN BLO $21.40 20060701 99999999 

86618 ANTIBODY; BORELLIA BUFGDORFERI (LYME DISEASE) $23.54 20060701 99999999 

86619 ANTIBODY; BORRELIA (RELAPSING FEVER) $11.21 20060701 99999999 

86622 ANTIBODY; BRUCELLA $12.35 20060701 99999999 

86625 ANTIBODY; CAMPYLOBACTER $11.00 20060701 99999999 

86628 ANTIBODY; CANDIDA $16.60 20060701 99999999 

86631 ANTIBODY; CHLAMYDIA $16.35 20060701 99999999 

86632 ANTIBODY; CHLAMYDIA, IGM $17.55 20060701 99999999 

86635 ANTIBODY; COCCIDIOIDES $9.62 20060701 99999999 

86638 ANTIBODY; COXIELLA BRUNETII (Q FEVER) $10.16 20060701 99999999 

86641 ANTIBODY; CRYPTOCOCCUS $12.08 20060701 99999999 

86644 ANTIBODY; CYTOMEGALOVIRUS (CMV) $19.89 20060701 99999999 

86645 ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM $23.28 20060701 99999999 

86648 ANTIBODY; DIPTHERIA $21.02 20060701 99999999 

86651 ANTIBODY; ENCEPHALITIS, CALIFORNIA (LA CROSSE) $11.06 20060701 99999999 

86652 ANTIBODY; ENCEPHALITIS, EASTERN EQUINE $11.06 20060701 99999999 

86653 ANTIBODY; ENCEPHALITIS, ST. LOUIS $11.06 20060701 99999999 



86654 ANTIBODY; ENCEPHALITIS, WESTERN EQUINE $11.06 20060701 99999999 

86658 ANTIBODY; ENTEROVIRUS (EG, COXSACKIE, ECHO, POLIO) $10.92 20060701 99999999 

86663 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, EARLY ANTIGEN (EA) $18.13 20060701 99999999 

86664 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA) $21.14 20060701 99999999 

86665 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA) $25.07 20060701 99999999 

86666 ANTIBODY; EHRLICHIA $8.53 20060701 99999999 

86668 ANTIBODY; FRANCISELLA TULARENSIS $8.72 20060701 99999999 

86671 ANTIBODY; FUNGUS, NOT ELSEWHERE SPECIFIED $16.95 20060701 99999999 

86674 ANTIBODY; GIARDIA LAMBLIA $20.34 20060701 99999999 

86677 ANTIBODY; HELICOBACTER PYLORI $20.05 20060701 99999999 

86682 ANTIBODY; HELMINTH, NOT ELSEWHERE SPECIFIED $12.60 20060701 99999999 

86684 ANTIBODY; HEMOPHILUS INFLUENZA $13.28 20060701 99999999 

86687 HTLV I, ANTIBODY DETECTION IMMUNOASSAY $11.60 20060701 99999999 

86688 ANTIBODY; HTLV-II $11.74 20060701 99999999 

86689 HTLV I, ANTIBODY DETECTION CONFIRMATORY TEST $26.75 20060701 99999999 

86692 ANTIBODY; HEPATITIS, DELTA AGENT $23.72 20060701 99999999 

86694 ANTIBODY; HERPES SIMPLEX, NON-SPECIFIC TYPE TEST $19.89 20060701 99999999 

86695 ANTIBODY; HERPES SIMPLEX, TYPE I $18.23 20060701 99999999 

86696 ANTIBODY; HERPES SIMPLEX, TYPE 2 $27.05 20060701 99999999 

86698 ANTIBODY; HISTOPLASMA $10.48 20060701 99999999 

86701 ANTIBODY; HIV-1 $12.28 20060701 99999999 

86702 ANTIBODY; HIV-2 $18.69 20060701 99999999 

86703 ANTIBODY; HIV-1 AND HIV-2, SINGLE ASSAY $18.96 20060701 99999999 

86704 HEPATITIS B CORE ANTIBODY (HBCAB); IGG AND IGM $16.66 20060701 99999999 

86705 HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY $16.27 20060701 99999999 

86706 HEPATITIS B SURFACE ANTIBODY (HBSAB) $14.84 20060701 99999999 

86707 HEPATITIS BE ANTIBODY (HBEAB) $15.98 20060701 99999999 

86708 HEPATITIS A ANTIBODY (HAAB); IGG AND IGM $17.12 20060701 99999999 

86709 HEPATITIS A ANTIBODY (HAAB); IGM ANTIBODY $15.55 20060701 99999999 

86710 ANTIBODY; INFLUENZA VIRUS $11.36 20060701 99999999 

86713 ANTIBODY; LEGIONELLA $21.15 20060701 99999999 

86717 ANTIBODY; LEISHMANIA $10.27 20060701 99999999 

86720 ANTIBODY; LEPTOSPIRA $18.23 20060701 99999999 

86723 ANTIBODY; LISTERIA MONOCYTOGENES $11.06 20060701 99999999 

86727 ANTIBODY; LYMPHOCYTIC CHORIOMENINGITIS $10.79 20060701 99999999 

86729 ANTIBODY; LYMPHOGRANULOMA VENEREUM $10.01 20060701 99999999 

86732 ANTIBODY; MUCORMYCOSIS $11.06 20060701 99999999 

86735 ANTIBODY; MUMPS $18.03 20060701 99999999 

86738 ANTIBODY; MYCOPLASMA $18.31 20060701 99999999 

86741 ANTIBODY; NEISSERIA MENINGITIDIS $11.06 20060701 99999999 

86744 ANTIBODY; NOCARDIA $11.06 20060701 99999999 

86747 ANTIBODY; PARVOVIRUS $20.77 20060701 99999999 

86750 ANTIBODY; PLASMODIUM (MALARIA) $11.06 20060701 99999999 

86753 ANTIBODY; PROTOZOA, NOT ELSEWHERE SPECIFIED $10.39 20060701 99999999 

86756 ANTIBODY; RESPIRATORY SYNCYTIAL VIRUS $10.81 20060701 99999999 

86757 ANTIBODY; RICKETTSIA $26.75 20060701 99999999 

86759 ANTIBODY; ROTAVIRUS $11.06 20060701 99999999 

86762 ANTIBODY; RUBELLA $19.89 20060701 99999999 

86765 ANTIBODY; RUBEOLA $17.81 20060701 99999999 

86768 ANTIBODY; SALMONELLA $11.06 20060701 99999999 

86771 ANTIBODY; SHIGELLA $11.06 20060701 99999999 

86774 ANTIBODY; TETANUS $12.41 20060701 99999999 

86777 ANTIBODY; TOXOPLASMA $19.89 20060701 99999999 

86778 ANTIBODY; TOXOPLASMA, IGM $19.90 20060701 99999999 

86781 

ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA- 

ABS) $18.30 20060701 99999999 

86784 ANTIBODY; TRICHINELLA $17.36 20060701 99999999 

86787 ANTIBODY; VARICELLA-ZOSTER $17.81 20060701 99999999 



86788 ANTIBODY; WEST NILE VIRUS, IGM $23.54 20070101 99999999 

86789 ANTIBODY; WEST NILE VIRUS $20.11 20070101 99999999 

86790 ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED $17.81 20060701 99999999 

86793 ANTIBODY; YERSINIA $11.06 20060701 99999999 

86800 THYROGLOBULIN ANTIBODY, RIA $21.98 20060701 99999999 

86803 HEPATITIS C ANTIBODY; $19.73 20060701 99999999 

86804 HEPATITIS C ANTIBODY; CONFIRMATORY TEST (EG, IMMUNOBLOT) $21.40 20060701 99999999 

86805 

LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH WITH 

TITRATION $44.08 20060701 99999999 

86806 

LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH WITHOUT 

TITRATIO $39.68 20060701 99999999 

86807 

SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY 

STAN $28.22 20060701 99999999 

86808 LYMPHOCYTOTOXICITY ASSAY,VISUAL CROSSMATCH W/O TITRATION $24.88 20060701 99999999 

86812 TISSUE TYPING $35.66 20060701 99999999 

86813 TISSUE TYPING $80.13 20060701 99999999 

86816 TISSUE TYPING $38.49 20060701 99999999 

86817 TISSUE TYPING $88.98 20060701 99999999 

86821 TISSUE TYPING $47.33 20060701 99999999 

86822 TISSUE TYPING $30.64 20060701 99999999 

86849 UNLISTED IMMUNOLOGY PROCEDURE $18.98 19990701 99999999 

86850 ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE $19.65 19990701 99999999 

86860 ANTIBODY ELUTION (RBC), EACH ELUTION $16.20 19990701 99999999 

86870 

ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH 

SERUM TECHNIQUE $55.70 19990701 99999999 

86880 

ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH 

ANTISERUM $7.42 20060701 99999999 

86885 

ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, 

QUALITATIVE, EACH ANTISERUM $7.90 20060701 99999999 

86886 

ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, TITER, EACH 

ANTISERUM $7.15 20060701 99999999 

86890 

AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING 

AND STORAGE; PREDEPOSITED $32.95 19990701 99999999 

86900 BLOOD TYPING; ABO $4.12 20060701 99999999 

86901 BLOOD TYPING; RH (D) $8.22 19990701 99999999 

86903 

BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE BLOOD UNIT 

USING REAGENT SERUM, P $6.63 20060701 99999999 

86904 

BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE UNIT USING 

PATIENT SERUM, PER UNI $4.02 20060701 99999999 

86905 BLOOD TYPING; RBC ANTIGENS, OTHER THAN ABO OR RH (D), EACH $5.28 20060701 99999999 

86906 BLOOD TYPING; RH PHENOTYPING, COMPLETE $10.71 20060701 99999999 

86920 COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE $20.80 19990701 99999999 

86921 COMPATIBILITY TEST EACH UNIT; INCUBATION TECHNIQUE $20.80 19990701 99999999 

86922 COMPATIBILITY TEST EACH UNIT; ANTIGLOBULIN TECHNIQUE $20.80 19990701 99999999 

86927 FRESH FROZEN PLASMA, THAWING, EACH UNIT $5.35 19990701 99999999 

86930 FROZEN BLOOD, PREPARATION FOR FREEZING, EACH UNIT; $9.00 19990701 99999999 

86940 HEMOLYSINS AND AGGLUTININS, AUTO, SCREEN, EACH; $11.32 20060701 99999999 

86941 HEMOLYSINS AND AGGLUTININS, AUTO, SCREEN, EACH; INCUBATED $16.73 20060701 99999999 

86945 IRRADIATION OF BLOOD PRODUCT, EACH UNIT $54.60 20010101 99999999 

86965 POOLING OF PLATELETS OR OTHER BLOOD PRODUCTS $16.20 19990701 99999999 

86985 SPLITTING OF BLOOD OR BLOOD PRODUCTS, EACH UNIT $9.00 20010101 99999999 

86999 UNLISTED IMMUNOLOGY PROCEDURE $21.15 19990701 99999999 

87001 ANIMAL INOCULATION, SMALL ANIMAL $11.08 20060701 99999999 

87003 ANIMAL INOCULATION, SMALL ANIMAL $14.11 20060701 99999999 

87015 CONCENTRATION (ANY TYPE), FOR PARASITES, OVA, OR $9.23 20060701 99999999 

87040 CULTURE, BACTERIAL, DEFINITIVE $14.27 20060701 99999999 




87046 

CULTURE, BACTERIAL; STOOL, ADDITIONAL PATHOGENS, ISOLATION 

AND PRELIMINARY EXAMI $7.91 20060701 99999999 



87071 

CULTURE, BACTERIAL; QUANTITATIVE, AEROBIC WITH ISOLATION AND 

PRESUMPTIVE IDENTIF $7.91 20060701 99999999 

87072 CULTURE OR DIRECT BACTERIAL IDENTIFICATION METHOD, EACH $11.16 19990701 99999999 

87073 

CULTURE, BACTERIAL; QUANTITATIVE, ANAEROBIC WITH ISOLATION 

AND PRESUMPTIVE IDENT $7.91 20060701 99999999 

87075 CULTURE, BACTERIAL, ANY SOURCE $13.08 20060701 99999999 

87076 CULTURE, BACTERIAL, ANY SOURCE $11.16 20060701 99999999 

87077 

CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS 

REQUIRED FOR DEFINITIVE $11.16 20060701 99999999 

87081 CULTURE, BACTERIAL, SCREENING ONLY, FOR SINGLE $9.16 20060701 99999999 

87084 

CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING 

ONLY, BY $11.90 20060701 99999999 

87085 

CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING 

ONLY, BY $11.90 19990701 99999999 

87086 CULTURE, BACTERIAL, URINE $11.16 20060701 99999999 

87088 CULTURE, BACTERIAL, URINE $10.55 20060701 99999999 

87101 CULTURE, FUNGI, ISOLATION $10.66 20060701 99999999 

87102 CULTURE, FUNGI, ISOLATION $11.61 20060701 99999999 

87103 CULTURE, FUNGI, ISOLATION BLOOD $12.46 20060701 99999999 

87106 CULTURE, FUNGI, DEFINITIVE IDENTIFICATION OF EACH FUNGUS $14.27 20060701 99999999 

87107 

CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; 

MOLD $14.42 20060701 99999999 

87109 CULTURE, MYCOPLASMA, ANY SOURCE $21.26 20060701 99999999 

87110 CULTURE, CHLAMYDIA $27.08 20060701 99999999 

87116 CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, $13.63 20060701 99999999 

87117 CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, $15.99 19990701 99999999 

87118 

CULTURE, MYCOBACTERIA, DEFINITIVE IDENTIFICATION OF EACH 

ORGANISM $15.13 20060701 99999999 

87140 CULTURE, TYPING $7.71 20060701 99999999 



87149 CULTURE, TYPING; IDENTIFICATION BY NUCLEIC ACID PROBE $27.71 20060701 99999999 

87152 CULTURE, TYPING; IDENTIFICATION BY PULSE FIELD GEL TYPING $4.39 20060701 99999999 


87163 

CULTURE, ANY SOURCE, ADDITIONAL IDENTIFICATION METHODS 

REQUIRED $15.30 19990701 99999999 

87164 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, $9.01 20060701 99999999 

87166 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, $9.47 20060701 99999999 

87168 MACROSCOPIC EXAMINATION; ARTHROPOD $5.40 20060701 99999999 

87169 MACROSCOPIC EXAMINATION; PARASITE $5.90 20060701 99999999 

87172 PINWORM EXAM (EG, CELLOPHANE TAPE PREP) $5.90 20060701 99999999 

87176 ENDOTOXIN, BACTERIAL (PYROGENS) $4.93 20060701 99999999 

87177 

OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND 

IDENTIFICATION $12.30 20060701 99999999 

87181 SENSITIVITY STUDIES, ANTIBIOTIC $2.57 20060701 99999999 


87185 

SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; ENZYME 

DETECTION (EG, BETA LACTAMAS $2.57 20060701 99999999 


87187 SENSITIVITY STUDIES,ANTIBIOTIC MBC(USE IN ADDIT.87186-87188) $8.69 20060701 99999999 



87197 SERUM BACTERICIDAL TITER (SCHLICTER TEST) $9.79 20060701 99999999 

87205 SMEAR, PRIMARY SOURCE, WITH INTERPRETATION $5.90 20060701 99999999 





87209 

SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX 

SPECIAL STAIN (EG, TRICHROME, $17.57 20060701 99999999 


87220 TISSUE EXAMINATION FOR FUNGI (EG, KOH SLIDE) $5.90 20060701 99999999 

87230 TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM $27.28 20060701 99999999 

87250 VIRUS IDENTIFICATION $27.02 20060701 99999999 

87252 VIRUS IDENTIFICATION $36.02 20060701 99999999 

87253 VIRUS IDENTIFICATION TISSUE CULTURE,ADDITIONAL STUDIES_ISOLA $12.39 20060701 99999999 

87254 

VIRUS ISOLATION; SHELL VIAL, INCLUDES IDENTIFICATION WITH 

IMMUNOFLUORESCENCE STA $16.39 20060701 99999999 

87255 

VIRUS ISOLATION; INCLUDING IDENTIFICATION BY NON-IMMUNOLOGIC 

METHOD, OTHER THAN $42.92 20060701 99999999 

87260 

INFECTIOUS AGENT ANTIGEN DETECTION BY DIRECT FLUORESCENT 

ANTIBODY TECHNIQUE; ADE $10.06 20060701 99999999 

87265 


ANTIBODY TECHNIQUE; BOR $16.58 20060701 99999999 

87267 

INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 

TECHNIQUE; ENTEROVIRUS, $16.76 20060701 99999999 

87269 


TECHNIQUE; GIARDIA $12.02 20060701 99999999 

87270 


ANTIBODY TECHNIQUE; CHL $16.58 20060701 99999999 

87271 


TECHNIQUE; CYTOMEGALOVIR $16.76 20060701 99999999 

87272 


ANTIBODY TECHNIQUE; CRY $16.58 20060701 99999999 

87273 


TECHNIQUE; HERPES SIMPLE $10.06 20060701 99999999 

87274 


ANTIBODY TECHNIQUE; HER $16.58 20060701 99999999 

87275 


TECHNIQUE; INFLUENZA B V $16.58 20060701 99999999 

87276 


ANTIBODY TECHNIQUE; INF $16.58 20060701 99999999 

87277 


TECHNIQUE; LEGIONELLA MI $10.06 20060701 99999999 

87278 


ANTIBODY TECHNIQUE; LEG $16.58 20060701 99999999 

87279 


TECHNIQUE; PARAINFLUENZA $10.06 20060701 99999999 

87280 


ANTIBODY TECHNIQUE; RES $16.58 20060701 99999999 

87281 


TECHNIQUE; PNEUMOCYSTIS $10.06 20060701 99999999 

87283 


TECHNIQUE; RUBEOLA $10.06 20060701 99999999 

87285 


ANTIBODY TECHNIQUE; TRE $10.06 20060701 99999999 

87290 


ANTIBODY TECHNIQUE; VAR $10.06 20060701 99999999 

87299 


ANTIBODY TECHNIQUE, NOT $16.58 20060701 99999999 

87300 


TECHNIQUE, POLYVALENT FO $10.06 20060701 99999999 



87301 

INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 

TECHNIQUE, QUALITATIVE $16.58 20060701 99999999 

87305 



87320 



87324 



87327 



87328 



87329 



87332 



87335 



87336 



87337 



87338 



87339 



87340 



87341 



87350 



87380 



87385 



87390 



87391 



87400 



87420 



87425 



87427 



87430 



87449 


TECHNIQUE QUALITATIVE O $16.58 20060701 99999999 

87450 



87451 



87470 

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 

BARTONELLA HENSELAE AND $16.81 20060701 99999999 



87471 



87472 



87475 


BORRELIA BURGDORFERI, D $16.81 20060701 99999999 

87476 


BORRELIA BURGDORFERI, A $29.42 20060701 99999999 

87477 


BORRELIA BURGDORFERI, Q $35.91 20060701 99999999 

87480 


CANDIDA SPECIES, DIRECT $27.71 20060701 99999999 

87481 


CANDIDA SPECIES, AMPLIF $29.42 20060701 99999999 

87482 


CANDIDA SPECIES, QUANTI $35.00 20060701 99999999 

87485 


CHLAMYDIA PNEUMONIAE, D $16.81 20060701 99999999 

87486 


CHLAMYDIA PNEUMONIAE, A $29.42 20060701 99999999 

87487 


CHLAMYDIA PNEUMONIAE, Q $35.91 20060701 99999999 

87490 


CHLAMYDIA TRACHOMATIS, $27.71 20060701 99999999 

87491 



87492 



87495 


CYTOMEGALOVIRUS, DIRECT $16.81 20060701 99999999 

87496 


CYTOMEGALOVIRUS, AMPLIF $48.50 20060701 99999999 

87497 


CYTOMEGALOVIRUS, QUANTI $59.20 20060701 99999999 

87498 


ENTEROVIRUS, AMPLIFIED $49.04 20070101 99999999 

87500 


VANCOMYCIN RESISTANCE ( $49.04 20080101 99999999 

87510 


GARDNERELLA VAGINALIS, $27.71 20060701 99999999 

87511 



87512 



87515 


HEPATITIS B VIRUS, DIRE $16.81 20060701 99999999 

87516 


HEPATITIS B VIRUS, AMPL $48.50 20060701 99999999 

87517 


HEPATITIS B VIRUS, QUAN $59.20 20060701 99999999 

87520 


HEPATITIS C, DIRECT PRO $27.71 20060701 99999999 

87521 


HEPATITIS C, AMPLIFIED $48.50 20060701 99999999 

87522 


HEPATITIS C, QUANTIFICA $59.20 20060701 99999999 

87525 


HEPATITIS G, DIRECT PRO $16.81 20060701 99999999 



87526 


HEPATITIS G, AMPLIFIED $29.42 20060701 99999999 

87527 


HEPATITIS G, QUANTIFICA $35.00 20060701 99999999 

87528 


HERPES SIMPLEX VIRUS, D $16.81 20060701 99999999 

87529 


HERPES SIMPLEX VIRUS, A $46.44 20060701 99999999 

87530 


HERPES SIMPLEX VIRUS, Q $59.20 20060701 99999999 

87531 


HERPES VIRUS-6, DIRECT $16.81 20060701 99999999 

87532 


HERPES VIRUS-6, AMPLIFI $29.42 20060701 99999999 

87533 


HERPES VIRUS-6, QUANTIF $35.00 20060701 99999999 

87534 

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV- 

1, DIRECT PROBE TEC $16.81 20060701 99999999 

87535 


1, AMPLIFIED PROBE $48.50 20060701 99999999 

87536 


1, QUANTIFICATION $117.59 20060701 99999999 

87537 


2, DIRECT PROBE TEC $16.81 20060701 99999999 

87538 


2, AMPLIFIED PROBE $29.42 20060701 99999999 

87539 


2, QUANTIFICATION $35.91 20060701 99999999 

87540 


LEGIONELLA PNEUMOPHILA, $16.81 20060701 99999999 

87541 



87542 



87550 


MYCOBACTERIA SPECIES, D $16.81 20060701 99999999 

87551 


MYCOBACTERIA SPECIES, A $29.42 20060701 99999999 

87552 


MYCOBACTERIA SPECIES, Q $35.91 20060701 99999999 

87555 


MYCOBACTERIA TUBERCULOS $27.71 20060701 99999999 

87556 



87557 



87560 


MYCOBACTERIA AVIUM-INTR $27.71 20060701 99999999 

87561 



87562 



87580 


MYCOPLASMA PNEUMONIAE, $16.81 20060701 99999999 

87581 



87582 





87590 


NEISSERIA GONORRHOEAE, $27.71 20060701 99999999 

87591 



87592 



87620 


PAPILLOMAVIRUS, HUMAN, $16.81 20060701 99999999 

87621 



87622 



87640 


STAPHYLOCOCCUS AUREUS, $49.04 20070101 99999999 

87641 


STAPHYLOCOCCUS AUREUS, $49.04 20070101 99999999 

87650 


STREPTOCOCCUS, GROUP A, $27.71 20060701 99999999 

87651 



87652 



87653 


STREPTOCOCCUS, GROUP B, $49.04 20070101 99999999 

87660 


TRICHOMONAS VAGINALIS, $20.17 20060701 99999999 

87797 

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NOT 


87798 



87799 



87800 

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), 

MULTIPLE ORGANISMS; DIR $33.62 20060701 99999999 

87801 

INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), 

MULTIPLE ORGANISMS; AMP $58.84 20060701 99999999 

87802 

INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH 

DIRECT OPTICAL OBSERVATIO $10.06 20060701 99999999 

87803 



87804 



87807 


DIRECT OPTICAL $16.58 20060701 99999999 

87808 



87809 


DIRECT OPTICAL OBSERVATIO $16.76 20080101 99999999 

87810 

INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT 

OPTICAL OBSERVATION; CHLAM $16.58 20060701 99999999 

87850 


OPTICAL OBSERVATION; NEISS $16.58 20060701 99999999 

87880 


OPTICAL OBSERVATION; STREP $16.58 20060701 99999999 

87899 


OPTICAL OBSERVATION; NOT O $16.58 20060701 99999999 

87900 

INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION 

USING REGULARLY UPDATE $127.48 20060701 99999999 



87901 

INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 

RNA), HIV 1, REVERSE $355.78 20060701 99999999 

87902 

INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 

RNA); HEPATITIS C VIR $256.16 20060701 99999999 

87903 

INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA 

OR RNA) WITH DRUG RESIS $486.21 20060701 99999999 

87904 

INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA 

OR RNA) WITH DRUG RESIS $35.94 20060701 99999999 

87999 UNLISTED MICROBIOLOGY PROCEDURE $7.90 19990701 99999999 

88104 CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, WITH $35.00 20060701 99999999 




88112 

CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT TECHNIQUE 

WITH INTERPRETATION (EG, $93.30 20060701 99999999 

88125 CYTOPATHOLOGY, FORENSIC (EG, SPERM) $13.13 20060701 99999999 

88130 SEX CHROMATIN IDENTIFICATION $12.61 20060701 99999999 

88140 SEX CHROMATIN IDENTIFICATION $11.05 20060701 99999999 

88141 

CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING 

SYSTEM); REQUIRING INTERPRETAT $22.89 20060701 99999999 

88142 


SYSTEM), COLLECTED IN PRESERVA $28.00 20060701 99999999 

88143 



88147 

CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY 

AUTOMATED SYSTEM UNDER P $15.73 20060701 99999999 

88148 

CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY 

AUTOMATED SYSTEM WITH MA $21.00 20060701 99999999 

88150 CYTOPATHOLOGY, SMEARS, CERVICAL OR VAGINAL $14.60 20060701 99999999 

88152 

CYTOPATHOLOGY, SMEARS, CERVICAL OR VAGINAL, UP TO THREE 

SMEARS; WITH MANUAL CYTO $8.86 20060701 99999999 

88153 

CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL 

SCREENING AND RESCREENIN $8.86 20060701 99999999 

88154 

CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL 

SCREENING AND COMPUTER-A $14.60 20060701 99999999 

88155 CYTOPATHOLOGY, SMEARS, CERVICAL OR VAGINAL $7.59 20060701 99999999 

88160 CYTOPATHOLOGY, ANY OTHER SOURCE $33.12 20060701 99999999 



88164 

CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 

SYSTEM); MANUAL SCREENI $14.60 20060701 99999999 

88165 


SYSTEM); WITH MANUAL SC $14.60 20060701 99999999 

88166 



88167 



88170 FINE NEEDLE ASPIRATION WITH OR WITHOUT PREPARATION OF $51.02 19990701 99999999 

88171 FINE NEEDLE ASPIRATION WITH OR WITHOUT PREPARATION OF $87.34 19990701 99999999 

88172 EVALUATION OF FINE NEEDLE ASPIRATE WITH OR WITHOUT $39.40 20060701 99999999 

88173 EVALUATION OF FINE NEEDLE ASPIRATE WITH OR WITHOUT $87.10 20060701 99999999 

88174 



88175 



88180 FLOW CYTOMETRY $20.97 20021101 99999999 

88182 FLOW CYTOMETRY $68.89 20060701 99999999 



88184 

FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR 

MARKER, TECHNICAL $40.70 20060701 99999999 

88185 

FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR 

MARKER, TECHNICAL $19.96 20060701 99999999 

88187 FLOW CYTOMETRY, INTERPRETATION; 2 TO 8 MARKERS $51.09 20060701 99999999 

88188 FLOW CYTOMETRY, INTERPRETATION; 9 TO 15 MARKERS $63.76 20060701 99999999 

88189 FLOW CYTOMETRY, INTERPRETATION; 16 OR MORE MARKERS $84.00 20060701 99999999 

88199 UNLISTED CYTOPATHOLOGY PROCEDURE $15.32 19990701 99999999 

88230 TISSUE CULTURE FOR CHROMOSOME ANALYSIS LYMPHOCYTE $161.00 20060701 99999999 

88233 

TISSUE CULT. FOR CHROMOSOME ANALYSIS SKIN OR OTHER SOL. 

TISS $117.98 20060701 99999999 

88235 TISSUE CULTURE FOR CHROMOSOME ANALYSIS $146.52 20060701 99999999 

88237 

TISSUE CULTURE FOR CHROMOSOME ANALYSIS BONE MARROW 

CELLS $125.68 20060701 99999999 

88239 TISSUE CULTURE FOR CHROMOSOME ANALYSIS OTHER TISSUE $123.67 20060701 99999999 

88240 

CRYOPRESERVATION, FREEZING AND STORAGE OF CELLS, EACH 

CELL LINE $3.76 20060701 99999999 

88241 THAWING AND EXPANSION OF FROZEN CELLS, EACH ALIQUOT $3.76 20060701 99999999 

88245 

CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES SCORE 25 

CELLS $95.85 20060701 99999999 

88248 

CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES SCORE 100 

CELLS $145.18 20060701 99999999 

88249 

CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; SCORE 100 

CELLS, CLASTOGEN STRESS (E $145.18 20060701 99999999 

88261 CHROMOSOME ANALYSIS $148.16 20060701 99999999 


88263 

CHROMOSOME ANALYSIS COUNT 45 CELLS FOR MOSAICISM,2 

KARYOTYYP $125.98 20060701 99999999 

88264 CHROMOSOME ANALYSIS; ANALYZE 20-25 CELLS $104.48 20060701 99999999 

88267 CHROMOSOME ANALYSIS, AMNIOTIC FLUID OR CHORIONIC VILLUS, $178.88 20060701 99999999 

88269 

CHROMOSOME ANALYSIS, IN SITU FOR AMNIOTIC FLUID CELLS, 

COUNT $139.43 20060701 99999999 

88271 MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH) $29.60 20060701 99999999 

88272 

MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU 

HYBRIDIZATION, ANALYZE 3-5 CELLS (EG $22.45 20060701 99999999 

88273 

MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU 

HYBRIDIZATION, ANALYZE 10-30 CELLS ( $44.40 20060701 99999999 

88274 

MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, 

ANALYZE 25-99 CELLS $29.18 20060701 99999999 

88275 

MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, 

ANALYZE 100-300 CELLS $55.50 20060701 99999999 


88283 

CHROMOSOME ANALYSIS ADDITIONAL SPECIALIZED BANDING 

TECHNIQUE $28.43 20060701 99999999 


88289 CHROMOSOME ANALYSIS ADDITIONAL HIGH RESOLUTION STUDY $13.11 20060701 99999999 

88291 

CYTOGENETICS AND MOLECULAR CYTOGENETICS, INTERPRETATION 

AND REPORT $16.54 20060701 99999999 

88300 SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY $13.56 20060701 99999999 

88302 SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION $29.54 20060701 99999999 





88311 DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION $12.61 20060701 99999999 

88312 SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR $51.28 20060701 99999999 





88318 DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL $51.83 20060701 99999999 

88319 DETERMINATIVE HISTOCHEMISTRY OR CYTOCHEMISTRY TO IDENTIFY $99.23 20060701 99999999 

88321 

CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED 

ELSEWHERE $70.99 20060701 99999999 

88323 CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING $85.05 20060701 99999999 

88325 CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND $106.09 20060701 99999999 

88329 CONSULTATION DURING SURGERY $37.40 20060701 99999999 



88333 

PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC 

EXAMINATION (EG, TOUCH PREP, SQ $62.55 20060701 99999999 

88334 

PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC 

EXAMINATION (EG, TOUCH PREP, SQ $32.70 20060701 99999999 

88342 IMMUNOCYTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), $57.22 20060701 99999999 

88346 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY $60.22 20060701 99999999 

88347 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY INDIRECT METHOD $61.12 20060701 99999999 

88348 ELECTRON MICROSCOPY $273.83 20060701 99999999 

88349 ELECTRON MICROSCOPY $109.19 20060701 99999999 

88355 MORPHOMETRIC ANALYSIS $266.70 20060701 99999999 

88356 MORPHOMETRIC ANALYSIS $178.32 20060701 99999999 

88358 MORPHOMETRIC ANALYSIS TUMOR $46.95 20060701 99999999 

88360 WHOLE ORGAN SECTIONS FOR SPECIAL STUDIES $84.56 20060701 99999999 

88361 

MORPHOMETRIC ANALYSIS; TUMOR IMMUNOHISTOCHEMISTRY (EG, 

HER-2/NEU, ESTROGEN RECEP $107.70 20060701 99999999 

88362 NERVE TEASING PREPARATION $171.05 20060701 99999999 

88365 TISSUE IN SITU HYBRIDIZATION,INTERPRETATION AND REPORT $82.14 20060701 99999999 

88367 

MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (QUANTITATIVE 

OR $163.50 20060701 99999999 

88368 

MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (QUANTITATIVE 

OR $94.81 20060701 99999999 

88371 

PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH 

INTERPRETATION AND REPORT; $18.63 20060701 99999999 

88372 

PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH 

INTERPRETATION AND REPORT; IMMU $19.07 20060701 99999999 

88381 

MICRODISSECTION (IE, SAMPLE PREPARATION OF MICROSCOPICALLY 

IDENTIFIED TARGET); M $126.26 20080101 99999999 

88385 

ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 51 

THROUGH 250 PROBES $215.83 20060701 99999999 

88386 

ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 251 

THROUGH 500 PROBES $223.97 20060701 99999999 

88399 UNLISTED SURGICAL PATHOLOGY PROCEDURE $22.00 19990701 99999999 

88400 BILIRUBIN, TOTAL, TRANSCUTANEOUS $4.21 20060701 99999999 

89049 

CAFFEINE HALOTHANE CONTRACTURE TEST (CHCT) FOR MALIGNANT 

HYPERTHERMIA SUSCEPTIBI $44.44 20060701 99999999 

89050 CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CSF, $6.53 20060701 99999999 

89051 CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CSF, $7.61 20060701 99999999 

89055 LEUKOCYTE COUNT, FECAL $5.96 20060701 99999999 

89060 CRYSTAL IDENTIFICATION BY COMPENSATED POLARIZING LENS $9.88 20060701 99999999 

89100 DUODENAL INTUBATION AND ASPIRATION $31.62 20060701 99999999 

89105 DUODENAL INTUBATION AND ASPIRATION $25.97 20060701 99999999 

89125 FAT STAIN, FECES, URINE, OR SPUTUM $5.96 20060701 99999999 

89130 GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH $22.13 20060701 99999999 

89132 GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH $9.19 20060701 99999999 

89135 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS $39.59 20060701 99999999 






89160 MEAT FIBERS, FECES $5.09 20060701 99999999 

89190 NASAL SMEAR FOR EOSINOPHILS $6.56 20060701 99999999 

89220 

SPUTUM, OBTAINING SPECIMEN, AEROSOL INDUCED TECHNIQUE 


89225 STARCH GRANULES, FECES $3.36 20060701 99999999 

89230 SWEAT COLLECTION BY IONTOPHORESIS $3.14 20060701 99999999 

89235 WATER LOAD TEST $4.61 20060701 99999999 

89240 UNLISTED MISCELLANEOUS PATHOLOGY TEST $10.50 20040101 99999999 

89300 SEMEN ANALYSIS $12.32 20060701 99999999 



89321 SEMEN ANALYSIS, PRESENCE AND/OR MOTILITY OF SPERM $16.66 20060701 99999999 

89322 

SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL 

USING STRICT MORPHOLOG $21.65 20080101 99999999 

89325 SPERM ANTIBODIES $8.95 20060701 99999999 

89329 SPERM EVALUATION $17.58 20060701 99999999 

89330 SPERM EVALUATION $8.30 20060701 99999999 

89331 

SPERM EVALUATION, FOR RETROGRADE EJACULATION, URINE 

(SPERM CONCENTRATION, MOTILI $27.37 20080101 99999999 

89360 SWEAT COLLECTION BY IONTOPHORESIS $16.49 19990701 99999999 

89399 UNLISTED MISCELLANEOUS PATHOLOGY TEST $14.11 19990701 99999999 

90050 OFFICE MEDICAL SERVICE, ESTABLISHED PATIENT $48.18 19990701 99999999 

90060 OFFICE MEDICAL SERVICE, ESTABLISHED PATIENT $48.18 19990701 99999999 

90384 

RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, FULL-DOSE, FOR 

INTRAMUSCULAR USE $4.00 19990701 99999999 

90471 

IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, 

INTRADERMAL, SUBCUTANEOUS, I $4.00 19990701 99999999 

90472 

IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, 

INTRADERMAL, SUBCUTANEOUS, I $4.00 19990701 99999999 

90476 ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE $4.00 20010101 99999999 

90477 ADENOVIRUS VACCINE, TYPE 7, LIVE, FOR ORAL USE $4.00 20010101 99999999 

90581 ANTHRAX VACCINE, FOR SUBCUTANEOUS USE $4.00 20010101 99999999 

90585 

BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TUBERCULOSIS, 

LIVE, FOR PERCUTANEOUS $4.00 20010101 99999999 

90586 

BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR BLADDER CANCER, 

LIVE, FOR INTRAVESICA $4.00 20010101 99999999 

90632 HEPATITIS A VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE $4.00 19990701 99999999 

90633 

HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE 

SCHEDULE, FOR INTRAMUSCU $4.00 19990701 99999999 

90634 

HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-3 DOSE 

SCHEDULE, FOR INTRAMUSCU $4.00 19990701 99999999 

90636 

HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT 

DOSAGE, FOR INTRAMUSCULAR $4.00 19990701 99999999 

90645 

HEMOPHILUS INFLUENZA B VACCINE (HIB), HBOC CONJUGATE (4 

DOSE SCHEDULE), FOR INTR $4.00 19990701 99999999 

90646 

HEMOPHILUS INFLUENZA B VACCINE (HIB), PRP-D CONJUGATE, FOR 

BOOSTER USE ONLY, INT $4.00 20010101 99999999 

90647 

HEMOPHILUS INFLUENZA B VACCINE (HIB), PRP-OMP CONJUGATE (3 

DOSE SCHEDULE), FOR I $4.00 19990701 99999999 

90648 

HEMOPHILUS INFLUENZA B VACCINE (HIB), PRP-T CONJUGATE (4 

DOSE SCHEDULE), FOR INT $4.00 19990701 99999999 

90649 

HUMAN PAPILLOMA VIRUS (HPV) VACCINE, TYPES 6, 11, 16, 18 

(QUADRIVALENT), 3 DOSE $4.00 20060101 99999999 



90655 

INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, FOR 

CHILDREN 6-35 MONTH $4.00 20040101 99999999 

90656 

INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, FOR 

USE IN INDIVIDUALS $4.00 20050101 99999999 

90657 

INFLUENZA VIRUS VACCINE, SPLIT VIRUS, 6-35 MONTHS DOSAGE, FOR 

INTRAMUSCULAR OR J $4.00 19990701 99999999 

90658 

INFLUENZA VIRUS VACCINE, SPLIT VIRUS, 3 YEARS AND ABOVE 

DOSAGE, FOR INTRAMUSCULA $4.00 19990701 99999999 

90659 

INFLUENZA VIRUS VACCINE, WHOLE VIRUS, FOR INTRAMUSCULAR OR 

JET INJECTION USE $4.00 19990701 99999999 

90660 INFLUENZA VIRUS VACCINE, LIVE, FOR INTRANASAL USE $4.00 20010101 99999999 

90665 LYME DISEASE VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE $4.00 20010101 99999999 

90669 

PNEUMOCOCCAL CONJUGATE VACCINE, POLYVALENT, FOR 


90675 RABIES VACCINE, FOR INTRAMUSCULAR USE $4.00 20010101 99999999 

90676 RABIES VACCINE, FOR INTRADERMAL USE $4.00 20010101 99999999 

90680 ROTAVIRUS VACCINE, TETRAVALENT, LIVE, FOR ORAL USE $4.00 20010101 99999999 

90690 TYPHOID VACCINE, LIVE, ORAL $4.00 20010101 99999999 

90691 

TYPHOID VACCINE, VI CAPSULAR POLYSACCHARIDE (VICPS), FOR 


90692 

TYPHOID VACCINE, HEAT- AND PHENOL-INACTIVATED (H-P), FOR 

SUBCUTANEOUS OR INTRADE $4.00 20010101 99999999 

90693 

TYPHOID VACCINE, ACETONE-KILLED, DRIED (AKD), FOR 

SUBCUTANEOUS OR JET INJECTION $4.00 19990701 99999999 

90698 

DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, 

HAEMOPHILUS INFLUENZA $4.00 20040101 99999999 

90700 

IMMUNIZATION, ACTIVE; DIPHTHERIA, TETANUS TOXOIDS, AND 

ACELLULAR PERTUSSIS VACCI $4.00 19990701 99999999 

90701 IMMUNIZATION, ACTIVE $4.00 20010101 99999999 








90710 

IMMUNIZATION, ACTIVE; MEASLES, MUMPS, RUBELLA, AND VARICELLA 

VACCINE $4.00 20010101 99999999 




90715 

TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS 

VACCINE (TDAP), FOR USE IN I $4.00 20040101 99999999 

90716 IMMUNIZATION, ACTIVE; VARICELLA (CHICKEN POX) VACCINE $4.00 19990701 99999999 




90720 

IMMUNIZATION, ACTIVE; DIPHTHERIA, TETANUS, AND PERTUSSIS 

(DTP) AND HEMOPHILUS IN $4.00 20010101 99999999 

90721 

IMMUNIZATION, ACTIVE; DIPHTHERIA, TETANUS TOXOIDS, AND 

ACELLULAR PERTUSSIS VACCI $4.00 19990701 99999999 

90723 

DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, 

HEPATITIS B, AND POLIO $4.00 20010101 99999999 







90734 

MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND 

W-135 (TETRAVALENT), FOR $4.00 20040101 99999999 

90735 IMMUNIZATION, ACTIVE; ENCEPHALITIS VIRUS VACCINE $4.00 20010101 99999999 

90736 ZOSTER (SHINGLES) VACCINE, LIVE, FOR SUBCUTANEOUS INJECTION $4.00 20060101 99999999 

90740 

HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT 

DOSAGE (3 DOSE SCHEDUL $4.00 20010101 99999999 

90743 

HEPATITIS B VACCINE, ADOLESCENT (2 DOSE SCHEDULE), FOR 


90744 

IMMUNIZATION, ACTIVE, HEPATITIS B VACCINE; NEWBORN TO 11 

YEARS $4.00 19990701 99999999 

90746 IMMUNIZATION, ACTIVE, HEPATITIS B VACCINE; 20 YEARS AND ABOVE $4.00 19990701 99999999 

90747 

IMMUNIZATION, ACTIVE, HEPATITIS B VACCINE; DIALYSIS OR 

IMMUNOSUPPRESSED PATIENT, $4.00 19990701 99999999 

90748 

IMMUNIZATION, ACTIVE, HEPATITIS B AND HEMOPHILUS INFLUENZA B 

(HIB) VACCINE $4.00 20010101 99999999 

90749 UNLISTED IMMUNIZATION PROCEDURE $4.00 19990701 99999999 

90760 INTERVAL HISTORY AND EXAMINATION RELATED TO THE HEALTHY $41.29 20060701 99999999 

90761 INTERVAL HISTORY AND EXAMINATION RELATED TO THE HEALTHY $18.53 20060701 99999999 

90765 

INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR 

DIAGNOSIS (SPECIFY SUBSTANCE $50.53 20060701 99999999 

90766 



90767 



90768 



90769 

SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY 

SUBSTANCE OR DRUG); IN $95.83 20080101 99999999 

90770 


SUBSTANCE OR DRUG); EA $8.97 20080101 99999999 

90771 


SUBSTANCE OR DRUG); AD $43.34 20080101 99999999 

90772 

THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY 

SUBSTANCE OR DRUG); S $11.90 20060701 99999999 

90773 


SUBSTANCE OR DRUG); I $13.60 20060701 99999999 

90774 

ADMINISTRATION AND MEDICAL INTERPRETATION OF 

DEVELOPMENTAL $37.68 20060701 99999999 

90775 


SUBSTANCE OR DRUG); E $17.41 20060701 99999999 

90779 

UNLISTED THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC 

INTRAVENOUS OR INTRA-ARTERIAL I $4.00 20060101 99999999 

90780 

IV INFUSION THERAPY, ADMINISTERED BY PHYSICIAN OR UNDER 

DIRECT $37.06 19990701 99999999 

90781 

IV INFUSION THERAPY, ADMINISTERED BY PHYSICIAN OR UNDER 

DIRECT $18.53 19990701 99999999 

90782 THERAPEUTIC INJECTION OF MEDICATION (SPECIFY) $3.68 19990701 99999999 

90783 THERAPEUTIC OR DIAGNOSTIC INJECTION,INTRA-ARTERIAL $13.60 19990701 99999999 

90784 THERAPEUTIC INJECTION OF MEDICATION (SPECIFY) $5.00 19990701 99999999 

90788 INTRAMUSCULAR INJECTION OF ANTIBIOTIC (SPECIFY) $4.00 19990701 99999999 

90799 UNLISTED THERAPEUTIC INJECTION $4.00 19990701 99999999 

90801 

PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION INCLUDING 

HISTORY, $104.43 20060701 99999999 

90802 

INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION 

USING PLAY EQUIPMENT, P $105.53 20060701 99999999 



90804 



90805 



90806 



90807 



90808 



90809 



90810 

INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY 

EQUIPMENT, PHYSICAL DEVICES, L $54.19 20060701 99999999 

90811 



90812 



90813 



90814 



90815 



90816 



90817 



90818 



90819 



90821 



90822 



90823 



90824 



90826 



90827 



90828 



90829 



90841 

INDIVIDUAL MEDICAL PSYCHOTHERAPY BY A PHYSICIAN, WITH 

CONTINUING $25.36 19990701 99999999 

90843 


CONTINUING $42.00 19990701 99999999 

90844 


CONTINUING $78.00 19990701 99999999 

90845 MEDICAL PSYCHOANALYSIS $65.82 20060701 99999999 

90846 

FAMILY MEDICAL PSYCHOTHERAPY(WITHOUT_THE PATIENT 

PRESENT) $71.55 20060701 99999999 



90847 FAMILY MEDICAL PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) BY $82.73 20060701 99999999 

90849 

MULTIPLE-FAMILY GROUP MEDICAL PSYCHOTHERAPY BY A 

PHYSICIAN, $25.38 20060701 99999999 

90853 

GROUP MEDICAL PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE- 

FAMILY $27.20 20060701 99999999 

90857 INTERACTIVE GROUP MEDICAL PSYCHOTHERAPY $24.88 20060701 99999999 

90862 

CHEMOTHERAPY MANAGEMENT, INCLUDING PRESCRIPTION, USE, 

AND REVIEW $38.28 20060701 99999999 

90870 ELECTROCONVULSIVE THERAPY $70.99 20060701 99999999 

90871 ELECTROCONVULSIVE THERAPY $122.66 19990701 99999999 

90880 MEDICAL HYPNOTHERAPY $83.76 20060701 99999999 

90918 

END STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL 

MONTH; FOR PATIENTS UND $424.09 19990701 99999999 

90919 


MONTH; BETWEEN THE SECO $338.03 19990701 99999999 

90920 


MONTH; THROUGH AGE NINE $294.07 19990701 99999999 

90921 


MONTH; FOR PATIENTS TWE $200.55 19990701 99999999 

90922 

END STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN 

FULL MONTH), PER DAY $13.98 19990701 99999999 

90923 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS TH $11.05 19990701 99999999 

90924 


FULL MONTH), PER DAY; $9.68 19990701 99999999 

90925 


FULL MONTH), PER DAY; $6.70 19990701 99999999 

90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALUATION $62.86 20060701 99999999 

90937 

HEMODIALYSIS PROCEDURE REQUIRING REPEATED EVALUATION(S) 

WITH OR $108.49 20060701 99999999 

90945 

DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, 

PERITONEAL, $63.76 20060701 99999999 

90947 

DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, 

PERITONEAL, $106.32 20060701 99999999 

90997 HEMOPERFUSION (EG, WITH ACTIVATED CHARCOAL OR RESIN) $94.90 20060701 99999999 

91000 ESOPHAGEAL INTUBATION AND COLLECTION OF WASHINGS FOR $36.49 20060701 99999999 

91010 ESOPHAGEAL MOTILITY STUDY $142.41 20060701 99999999 



91020 ESOPHAGOGASTRIC MANOMETRIC STUDIES $149.71 20060701 99999999 

91022 DUODENAL MOTILITY (MANOMETRIC) STUDY $163.36 20060701 99999999 

91030 ESOPHAGUS, ACID PERFUSION (BERNSTEIN) TEST FOR ESOPHAGITIS $83.53 20060701 99999999 

91032 

ESOPHAGUS, ACID REFLUX TEST, WITH INTRALUMINAL PH 

ELECTRODE $85.56 19990701 99999999 

91033 

ESOPHAGUS, ACID REFLUX TEST, WITH INTRALUMINAL PH 

ELECTRODE $111.63 19990701 99999999 

91034 

ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL 

CATHETER PH ELECTRODE(S) $188.96 20060701 99999999 

91035 

ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH MUCOSAL 

ATTACHED TELEMETRY PH $375.51 20060701 99999999 

91037 

ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST 

WITH NASAL CATHETER $118.50 20060701 99999999 

91038 

ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST 

WITH NASAL CATHETER $100.39 20060701 99999999 

91040 ESOPHAGEAL BALLOON DISTENSION PROVOCATION STUDY $368.65 20060701 99999999 

91052 GASTRIC ANALYSIS TEST WITH INJECTION OF STIMULANT OF $81.11 20060701 99999999 

91055 GASTRIC INTUBATION, WASHINGS, AND PREPARING SLIDES $97.28 20060701 99999999 

91060 GASTRIC SALINE LOAD TEST $28.84 19990701 99999999 



91065 

BREATH HYDROGEN TEST (EG, FOR DETECTION OF LACTASE 

DEFICIENCY) $42.00 20060701 99999999 

91100 

INTESTINAL BLEEDING TUBE, PASSAGE, POSITIONING AND 

MONITORING $44.21 20060701 99999999 

91105 

GASTRIC INTUBATION, AND ASPIRATION OR LAVAGE FOR TREATMENT 

(EG, FOR INGESTED POI $18.20 20060701 99999999 

91110 

GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE 

ENDOSCOPY), ESOPHAGUS $738.30 20060701 99999999 

91111 

GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE 

ENDOSCOPY), ESOPHAGUS $575.70 20070101 99999999 

91120 

RECTAL SENSATION, TONE, AND COMPLIANCE TEST (IE, RESPONSE 

TO GRADED BALLOON $363.85 20060701 99999999 

91122 ANORECTAL MANOMETRY $173.36 20060701 99999999 

92002 

OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 

EVALUATION $48.16 20060701 99999999 

92004 


EVALUATION $81.31 20060701 99999999 

92012 


EVALUATION, $37.49 20060701 99999999 

92014 


EVALUATION, $60.20 20060701 99999999 

92018 

OPHTHALMOLOGICAL EXAMINATION AND EVALUATION, UNDER 

GENERAL $85.43 20060701 99999999 

92019 

OPHTHALMOLOGICAL EXAMINATION AND EVALUATION, UNDER 

GENERAL $72.95 20060701 99999999 

92020 GONIOSCOPY WITH MEDICAL DIAGNOSTIC EVALUATION (SEPARATE $12.68 20060701 99999999 

92025 

COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERAL OR 

BILATERAL, WITH INTERPRETATION AN $21.67 20070101 99999999 

92060 

SENSORIMOTOR EXAMINATION WITH MEDICAL DIAGNOSTIC 

EVALUATION $34.76 20060701 99999999 

92065 

ORTHOPTIC AND/OR PLEOPTIC TRAINING, WITH CONTINUING 

MEDICAL $28.32 19990701 99999999 

92070 

FITTING OF CONTACT LENS FOR TREATMENT OF DISEASE, INCLUDING 

SUPPLY OF $39.87 20060701 99999999 

92081 VISUAL FIELD EXAMINATION WITH MEDICAL DIAGNOSTIC EVALUATION $38.66 20060701 99999999 



SERIAL TONOMETRY WITH MEDICAL DIAGNOSTIC EVALUATION 

92100 (SEPARATE $30.48 20060701 99999999 

92120 TONOGRAPHY WITH MEDICAL DIAGNOSTIC EVALUATION, RECORDING $38.91 20060701 99999999 

92130 TONOGRAPHY WITH WATER PROVOCATION $43.58 20060701 99999999 

92135 

SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING (EG, 

SCANNING LASER) WITH IN $46.41 20060701 99999999 

92136 

OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY 

WITH INTRAOCULAR LENS PO $60.08 20060701 99999999 

92140 PROVOCATIVE TESTS FOR GLAUCOMA, WITH MEDICAL DIAGNOSTIC $27.79 20060701 99999999 

92225 OPHTHALMOSCOPY, EXTENDED AS FOR RETINAL DETACHMENT (MAY $23.34 20060701 99999999 

92226 OPHTHALMOSCOPY, EXTENDED AS FOR RETINAL DETACHMENT (MAY $21.09 20060701 99999999 

92230 OPHTHALMOSCOPY, WITH MEDICAL DIAGNOSTIC EVALUATION $49.97 20060701 99999999 


92240 

INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME 

IMAGING) W/INTERPRETATION/RPT $181.38 20060701 99999999 





92265 

OCULOELECTROMYOGRAPHY, ONE OR MORE EXTRAOCULAR 

MUSCLES, ONE $57.24 20060701 99999999 

92270 ELECTRO-OCULOGRAPHY, WITH MEDICAL DIAGNOSTIC EVALUATION $58.07 20060701 99999999 

92275 ELECTRORETINOGRAPHY, WITH MEDICAL DIAGNOSTIC EVALUATION $73.00 20060701 99999999 

92283 COLOR VISION EXAMINATION, EXTENDED, EG, ANOMALOSCOPE OR $25.47 20060701 99999999 

92284 DARK ADAPTATION EXAMINATION, WITH MEDICAL DIAGNOSTIC $53.59 20060701 99999999 

92285 EXTERNAL OCULAR PHOTOGRAPHY WITH MEDICAL DIAGNOSTIC $40.37 20060701 99999999 

92286 SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH MEDICAL $93.11 20060701 99999999 

92287 SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH MEDICAL $43.86 20060701 99999999 

92310 

PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF 

AND $139.79 19990701 99999999 

92311 


AND $56.23 20060701 99999999 

92312 


AND $68.83 20060701 99999999 

92313 


AND $47.13 20060701 99999999 

92314 PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF $73.26 19990701 99999999 




92325 MODIFICATION OF CONTACT LENS (SEPARATE PROCEDURE), WITH $12.41 20060701 99999999 

92326 REPLACEMENT OF CONTACT LENS $42.27 20060701 99999999 

92330 

PRESCRIPTION, FITTING, AND SUPPLY OF OCULAR PROSTHESIS 

(ARTIFICIAL $55.44 20050916 99999999 

92335 PRESCRIPTION OF OCULAR PROSTHESIS (ARTIFICIAL EYE) $24.15 20050916 99999999 

92340 FITTING OF SPECTACLES, EXCEPT FOR APHAKIA $28.88 19990701 99999999 



92354 FITTING OF SPECTACLE MOUNTED LOW VISION AID $100.00 19990701 99999999 

92355 FITTING OF SPECTACLE MOUNTED LOW VISION AID $150.00 20010101 99999999 

92358 

PROSTHESIS SERVICE FOR APHAKIA, TEMPORARY (DISPOSABLE OR 

LOAN, $33.74 20010101 99999999 

92370 REPAIR AND REFITTING SPECTACLES $10.00 19990701 99999999 

92371 REPAIR AND REFITTING SPECTACLES $21.49 20010101 99999999 

92392 SUPPLY OF LOW VISION AIDS (A LOW VISION AID IS ANY LENS OR $75.00 19990701 99999999 

92499 UNLISTED OPHTHALMOLOGICAL SERVICE OR PROCEDURE $65.23 19990701 99999999 

92502 OTOLARYNGOLOGIC EXAMINATION UNDER GENERAL ANESTHESIA $78.41 20060701 99999999 

92504 BINOCULAR MICROSCOPY (SEPARATE DIAGNOSTIC PROCEDURE) $8.73 20060701 99999999 

92506 

MEDICAL EVALUATION SPEECH, LANGUAGE AND/OR HEARING 

PROBLEMS $34.29 20060701 99999999 

92507 

SPEECH, LANGUAGE OR HEARING THERAPY, WITH CONTINUING 

MEDICAL $21.05 20060701 99999999 

92508 

SPEECH, LANGUAGE OR HEARING THERAPY, WITH CONTINUING 

MEDICAL $11.15 20060701 99999999 

92510 

AURAL REHABILITATION FOLLOWING COCHLEAR IMPLANT (INCLUDES 

EVALUATION OF AURAL RE $88.44 19990701 99999999 

92511 NASOPHARYNGOSCOPY WITH ENDOSCOPE (SEPARATE PROCEDURE) $39.44 20060701 99999999 

92512 NASAL FUNCTION STUDIES, EG, RHINOMANOMETRY $23.08 20060701 99999999 

92516 FACIAL NERVE FUNCTION STUDIES $18.42 20060701 99999999 

92520 LARYNGEAL FUNCTION STUDIES $32.28 20060701 99999999 

92525 EVALUATION OF SWALLOWING AND ORAL FUNCTION FOR FEEDING $80.95 19990701 99999999 

92526 

TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL 

FUNCTION FOR FEEDING $22.46 20060701 99999999 



92532 POSITIONAL NYSTAGMUS $22.00 20010101 99999999 

92533 CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, $28.00 19990701 99999999 

92541 SPONTANEOUS NYSTAGMUS TEST, INCLUDING GAZE AND FIXATION $35.89 20060701 99999999 

92542 POSITIONAL NYSTAGMUS TEST, MINIMUM OF 4 POSITIONS, WITH $36.89 20060701 99999999 

92543 

CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, 

BITHERMAL $17.05 20060701 99999999 

92544 

OPTOKINETIC NYSTAGMUS TEST, BIDIRECTIONAL, FOVEAL OR 

PERIPHERAL $29.23 20060701 99999999 

92545 OSCILLATING TRACKING TEST, WITH RECORDING $26.01 20060701 99999999 

92546 TORSION SWING TEST, WITH RECORDING $57.44 20060701 99999999 

92547 USE OF VERTICAL ELECTRODES IN ANY OR ALL OF ABOVE TESTS $5.21 20060701 99999999 

92548 COMPUTERIZED DYNAMIC POSTUROGRAPHY $75.05 20060701 99999999 

92551 SCREENING TEST, PURE TONE, AIR ONLY $10.13 19990701 99999999 

92552 PURE TONE AUDIOMETRY (THRESHOLD) $15.10 20060701 99999999 

92553 PURE TONE AUDIOMETRY (THRESHOLD) $22.15 20060701 99999999 

92555 SPEECH AUDIOMETRY $12.92 20060701 99999999 

92556 SPEECH AUDIOMETRY $19.35 20060701 99999999 

92557 

BASIC COMPREHENSIVE AUDIOMETRY (92553 AND 92556 COMBINED), 

(PURE $40.56 20060701 99999999 

92561 BEKESY AUDIOMETRY $24.03 20060701 99999999 

92562 LOUDNESS BALANCE TEST, ALTERNATE BINAURAL OR MONAURAL $13.85 20060701 99999999 

92563 TONE DECAY TEST $12.92 20060701 99999999 

92564 SHORT INCREMENT SENSITIVITY INDEX (SISI) $16.29 20060701 99999999 

92565 STENGER TEST, PURE TONE $13.54 20060701 99999999 

92567 TYMPANOMETRY $17.78 20060701 99999999 

92568 ACOUSTIC REFLEX TESTING $12.92 20060701 99999999 

92569 ACOUSTIC REFLEX DECAY TEST $13.85 20060701 99999999 

92571 FILTERED SPEECH TEST $13.23 20060701 99999999 

92572 STAGGERED SPONDAIC WORD TEST $3.06 20060701 99999999 

92573 LOMBARD TEST $11.90 19990701 99999999 

92575 SENSORINEURAL ACUITY LEVEL TEST $10.17 20060701 99999999 

92576 SYNTHETIC SENTENCE IDENTIFICATION TEST $15.35 20060701 99999999 

92577 STENGER TEST, SPEECH $24.27 20060701 99999999 

92579 VISUAL REINFORCEMENT AUDIOMETRY (VRA) $24.34 20060701 99999999 

92582 CONDITIONING PLAY AUDIOMETRY $24.34 20060701 99999999 

92583 SELECT PICTURE AUDIOMETRY $30.14 20060701 99999999 

92584 ELECTROCOCHLEOGRAPHY $83.43 20060701 99999999 

92585 BRAINSTEM EVOKED RESPONSE RECORDING $102.83 20060701 99999999 

92586 

AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE 

AUDIOMETRY AND/OR TESTING OF THE $53.88 20060701 99999999 

92587 

EVOKED OTOACOUSTIC EMISSIONS; LIMITED (SINGLE STIMULUS 

LEVEL, EITHER TRANSIENT O $50.22 20060701 99999999 

92588 

EVOKED OTOACOUSTIC EMISSIONS; COMPREHENSIVE OR 

DIAGNOSTIC EVALUATION (COMPARISON $66.75 20060701 99999999 

92589 CENTRAL AUDITORY FUNCTION TEST(S) (SPECIFY) $18.10 19990701 99999999 

92590 HEARING AID EXAMINATION AND SELECTION $82.87 19990701 99999999 

92591 HEARING AID EXAMINATION AND SELECTION $84.00 19990701 99999999 

92592 HEARING AID CHECK $22.71 19990701 99999999 

92593 HEARING AID CHECK $25.15 19990701 99999999 

92594 ELECTROACOUSTIC EVALUATION FOR HEARING AID $42.65 19990701 99999999 

92595 ELECTROACOUSTIC EVALUATION FOR HEARING AID $59.75 19990701 99999999 

92596 EAR PROTECTOR ATTENUATION MEASUREMENTS $19.97 20060701 99999999 

92597 

EVALUATION FOR USE AND/OR FITTING OF VOICE PROSTHETIC OR 

AUGMENTATIVE/ALTERNATIV $49.72 20030401 99999999 

92598 

MODIFICATION OF VOICE PROSTHETIC OR 

AUGMENTATIVE/ALTERNATIVE COMMUNICATION DEVIC $53.62 19990701 99999999 

92601 

DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, PATIENT UNDER 7 

YEARS OF AGE; WITH PROG $105.52 20060701 99999999 



92602 

DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, PATIENT UNDER 7 

YEARS OF AGE; SUBSEQUEN $73.97 20060701 99999999 

92603 

DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, AGE 7 YEARS OR 

OLDER; WITH PROGRAMMING $70.98 20060701 99999999 

92604 

DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, AGE 7 YEARS OR 

OLDER; SUBSEQUENT REPROG $48.36 20060701 99999999 

92606 

THERAPEUTIC SERVICE(S) FOR THE USE OF NON-SPEECH- 

GENERATING DEVICE, INCLUDING PR $45.54 20030101 99999999 

92607 

EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING 

AUGMENTATIVE AND ALTERNATIVE C $88.11 20060701 99999999 

92608 

EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING 

AUGMENTATIVE AND ALTERNATIVE C $17.26 20060701 99999999 

92609 

THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING 

DEVICE, INCLUDING PROGRAMM $47.70 20060701 99999999 

92610 EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION $88.36 20060701 99999999 

92611 

MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION 

BY CINE OR VIDEO RECORDING $88.36 20060701 99999999 

92612 

FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING 

BY CINE OR VIDEO RECORDI $49.97 20060701 99999999 

92613 


BY CINE OR VIDEO RECORDI $26.99 20060701 99999999 

92614 

FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL 

SENSORY TESTING BY CINE OR $49.97 20060701 99999999 

92615 

FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL 

SENSORY TESTING BY CINE OR $24.15 20060701 99999999 

92616 


AND LARYNGEAL SENSORY TE $72.92 20060701 99999999 

92617 


AND LARYNGEAL SENSORY TE $30.08 20060701 99999999 

92620 

EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; 

INITIAL 60 MINUTES $36.09 20060701 99999999 

92621 

EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; EACH 

ADDITIONAL 15 MINUTES $8.94 20060701 99999999 

92625 

ASSESSMENT OF TINNITUS (INCLUDES PITCH, LOUDNESS MATCHING, 

AND MASKING) $35.47 20060701 99999999 

92626 EVALUATION OF AUDITORY REHABILITATION STATUS; FIRST HOUR $56.67 20060701 99999999 

92627 

EVALUATION OF AUDITORY REHABILITATION STATUS; EACH 

ADDITIONAL 15 MINUTES (LIST S $16.69 20060701 99999999 

92630 AUDITORY REHABILITATION; PRE-LINGUAL HEARING LOSS $88.44 20060101 99999999 

92633 AUDITORY REHABILITATION; POST-LINGUAL HEARING LOSS $88.44 20060101 99999999 

92640 

DIAGNOSTIC ANALYSIS WITH PROGRAMMING OF AUDITORY 

BRAINSTEM IMPLANT, PER HOUR $41.55 20070101 99999999 

92950 CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST) $168.25 20060701 99999999 

92953 TEMPORARY TRANSCUTANEOUS PACING $11.61 20060701 99999999 

92960 CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF $125.14 20060701 99999999 

92961 

CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF 

ARRHYTHMIA; INTERNAL (SEPARATE $176.85 20060701 99999999 

92970 CARDIOASSIST-METHOD OF CIRCULATORY ASSIST $172.04 20060701 99999999 

92971 CARDIOASSIST-METHOD OF CIRCULATORY ASSIST $78.33 20060701 99999999 

92973 

PERCUTANEOUS TRANSLUMINAL CORONARY THROMBECTOMY (LIST 

SEPARATELY IN ADDITION TO $129.06 20060701 99999999 

92974 

TRANSCATHETER PLACEMENT OF RADIATION DELIVERY DEVICE FOR 

SUBSEQUENT CORONARY INT $140.52 20060701 99999999 

92975 THROMBOLYSIS, CORONARY $340.98 19990701 99999999 

92977 THROMBOLYSIS, CORONARY $265.85 19990701 99999999 

92978 

INTRAVASCULAR ULTRASOUND (CORONARY VESSEL/GRAFT) DURING 

THERAPEUTIC INTERVENTION $229.41 20060701 99999999 



92979 

INTRAVASCULAR ULTRASOUND (CORONARY VESSEL/GRAFT) DURING 

THERAPEUTIC EACH ADDL $138.64 20060701 99999999 

92980 

TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), 

PERCUTANEOUS, WITH OR WITH $812.21 20060701 99999999 

92981 

TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), 

PERCUTANEOUS, WITH OR WITH $228.04 20060701 99999999 

92982 PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY $600.24 20060701 99999999 

92984 PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY $162.42 20060701 99999999 

92986 PERCUTANEOUS BALLOON VALVULOPLASTY; AORTIC VALVE $1,018.07 20060701 99999999 

92987 PERCUTANEOUS BALLOON VALVULOPLASTY; MITRAL VALVE $1,053.82 20060701 99999999 

92990 PERCUTANEOUS BALLOON VALVULOPLASTY; PULMONARY VALVE $799.62 20060701 99999999 

92992 

ATRIAL SEPTECTOMY OR SEPTOSTOMY; TRANSVENOUS METHOD, 

BALLOON, RASHKIND TYPE (INC $603.65 19990701 99999999 

92995 

PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH 

OR WITHOUT BALLOON ANGIOPLA $661.24 20060701 99999999 

92996 

PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH 

OR WITHOUT BALLOON ANGIOPLA $178.22 20060701 99999999 

92997 

PERCUTANEOUS TRANSLUMINAL PULMONARY ARTERY BALLOON 

ANGIOPLASTY; SINGLE VESSEL $637.24 20060701 99999999 

92998 

PERCUTANEOUS TRANSLUMINAL PULMONARY ARTERY BALLOON 

ANGIOPLASTY; EACH ADDITIONAL $278.81 20060701 99999999 

93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS $23.63 20060701 99999999 



93012 TELEPHONIC OR TELEMETRIC TRANSMISSION OF $155.61 20060701 99999999 

93014 TELEPHONIC OR TELEMETRIC TRANSMISSION OF $24.16 20060701 99999999 

93015 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL $92.98 20060701 99999999 

93016 

CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL 

TREADMILL OR BICYCLE EXER $21.45 20060701 99999999 



93024 ERGONOVINE PROVOCATION TEST $98.73 20060701 99999999 

93025 

MICROVOLT T-WAVE ALTERNANS FOR ASSESSMENT OF 

VENTRICULAR ARRHYTHMIAS $211.93 20060701 99999999 

93040 RHYTHM ECG, ONE TO THREE LEADS $12.20 20060701 99999999 



93224 

ELECTROCARDIOGRAPHIC MONITORING FOR 24HOURS BY 

CONTINUOUS $140.59 20060701 99999999 

93225 

ELECTROCARDIOGRAPHIC MONITORING FOR 24HRS BY CONTINUOUS 

ECG $41.05 20060701 99999999 

93226 

ELECTROCARDIOGRAPHIC MONITOR 24HRS BY CONTIN. ORIG. ECG 

WAVE $72.56 20060701 99999999 

93227 

ELECTROCARDIOGRAPHIC MONITORING 24HRS,WITH VISUAL 

SUPERIMPOS $26.97 20060701 99999999 

93230 

ELECTROCARDIOGRAPHIC ORIG. ECG WAVEFORM RECORD & 

STORAGE $149.57 20060701 99999999 

93231 

ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY 

CONTINUOUS $50.60 20060701 99999999 

93232 


CONTINUOUS $72.00 20060701 99999999 

93233 


CONTINUOUS $26.97 20060701 99999999 

93235 


CONTINUOUS $109.61 20060701 99999999 

93236 


CONTINUOUS $86.28 20060701 99999999 



93237 


CONTINUOUS $23.32 20060701 99999999 

93268 PATIENT DEMAND SINGLE EVENT ECG RECORDING $205.43 20060701 99999999 

93270 

ELECTROCARDIOGRAPHIC MONITORING UTILIZING A SYSTEM SUCH 

AS $41.05 20060701 99999999 

93271 


AS $155.61 20060701 99999999 

93272 


AS $23.85 20060701 99999999 

93278 

SIGNAL-AVERAGED ELECTROCARDIOGRAPHY (SAECG), WITH OR 

WITHOUT ECG $52.13 20060701 99999999 

93303 

TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENIAL CARDIAC 

ANOMALIES; COMPLETE $187.44 20060701 99999999 

93304 

TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENIAL CARDIAC 

ANOMALIES/FOLLOW UP LTD STD $100.97 20060701 99999999 

93307 ECHOCARDIOGRAPHY, REAL-TIME WITH IMAGE DOCUMENTATION (2D) $175.94 20060701 99999999 

93308 ECHOCARDIOGRAPHY, REAL-TIME WITH IMAGE DOCUMENTATION (2D) $92.06 20060701 99999999 

93312 ECHOCARDIOGRAPHY,REAL TIME W/DOC., TRANSESOPHAGEAL $223.29 20060701 99999999 

93313 

ECHOCARDIOGRAPHY, REAL TIME WITH IMAGE DOCUMENTATION (2D) 

(WITH OR WITHOUT M-MOD $46.11 20060701 99999999 

93314 

ECHOCARDIOGRAPHY, REAL TIME WITH IMAGE DOCUMENTATION (2D) 

(WITH OR WITHOUT M-MOD $179.58 20060701 99999999 

93315 

TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENIAL 

CARDIAC ANOMALIES; INCLUDING PROB $242.18 19990701 99999999 

93316 

TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL 

CARDIAC PLACEMENT OF PROBE ONLY $47.37 20060701 99999999 

93317 

TRANSESOPHAGEAL ECHOCARDIOGRAPHY/IMAGE ACQUISITION, 

INTERPRETATION AND REPORT $199.34 19990701 99999999 

93320 DOPPLER ECHOCARDIOGRAPHY $77.00 20060701 99999999 

93321 DOPPLER ECHOCARDIOGRAPHY; FLUOR LIMITED $45.25 20060701 99999999 

93325 DOPPLER COLORFLOW VELOCITY FOR MAPPING EKG $100.18 20060701 99999999 

93350 ECHOCARDIOGRAPHY,REAL-TIME WITH IMAGE DOCUMENTATION $99.58 20060701 99999999 

93501 RIGHT HEART CATHETERIZATION $719.33 20060701 99999999 

93503 RIGHT HEART CATHETERIZATION $138.23 20060701 99999999 

93505 ENDOMYOCARDIAL BIOPSY $275.05 20060701 99999999 

93508 

CATHETER PLACEMENT IN CORONARY ARTERY(S), ARTERIAL 

CORONARY CONDUIT(S), AND/OR V $607.00 20060701 99999999 

93510 LEFT HEART CATHETERIZATION, RETROGRADE, FROM THE BRACHIAL $1,423.00 20060701 99999999 



93524 

COMBINED TRANSSEPTAL AND RETROGRADE LEFT HEART 

CATHETERIZATION $1,875.07 20060701 99999999 

93526 

COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT 

HEART $1,895.83 20060701 99999999 

93527 COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT $1,928.85 20060701 99999999 

93528 

COMBINED RIGHT HEART CATHETERIZATION WITH LEFT 

VENTRICULAR $1,946.97 20060701 99999999 

93529 

COMBINED RIGHT HEART CATHETERIZATION AND LEFT HEAR 

CATHETERI $1,764.60 20060701 99999999 

93530 

RIGHT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC 

ANOMALIES $767.74 20060701 99999999 



93531 

COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT 

HEART CATHETERIZATION, $1,980.57 20060701 99999999 

93532 

COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT 

HEART CATHETERIZATION $2,024.52 19990701 99999999 

93533 

COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT 

HEART CATHETERIZATION $1,829.82 19990701 99999999 

93536 PERCUTANEOUS INSERTION OF INTRA-AORTIC BALLOON CATHETER $262.13 19990701 99999999 

93539 

INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR 

SELECTIVE OPACIFICATION $21.59 20060701 99999999 

93540 

INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR 

SELECTIVE OPACIFICATION $23.11 20060701 99999999 

93541 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION $15.36 20060701 99999999 





93555 

IMAGING SUPERVISION, INTERPRETATION AND REPORT FOR 

INJECTION PROCEDURE(S) DURING $237.06 20060701 99999999 

93556 

IMAGING SUPERVISION, INTERPRETATION AND REPORT FOR 

INJECTION PROCEDURE(S) DURING $358.37 20060701 99999999 

93561 INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMAL DILUTION, $43.92 20060701 99999999 

93562 INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMAL DILUTION, $19.25 20060701 99999999 

93571 

INTRAVASCULAR DOPPLER VELOCITY AND/OR PRESSURE DERIVED 

CORONARY FLOW RESERVE MEA $219.12 20060701 99999999 

93572 

INTRAVASCULAR DOPPLER VELOCITY AND/OR PRESSURE DERIVED 

CORONARY FLOW RESERVE MEA $170.28 19990701 99999999 

93580 

PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL 

INTERATRIAL COMMUNICATION (IE, $719.01 20060701 99999999 

93581 

PERCUTANEOUS TRANSCATHETER CLOSURE OF A CONGENITAL 

VENTRICULAR SEPTAL DEFECT WIT $963.22 20060701 99999999 

93600 BUNDLE OF HIS RECORDING $124.21 20060701 99999999 

93602 INTRA-ATRIAL RECORDING $139.08 20060701 99999999 

93603 RIGHT VENTRICULAR RECORDING $165.09 20060701 99999999 

93607 LEFT VENTRICULAR RECORDING $197.20 19990701 99999999 

93609 

INTRAVENTRICULAR MAPPING OF TACHYCARDIA SITE W/ CATH MULT 

SI $380.28 20060701 99999999 

93610 INTRA-ATRIAL PACING $186.21 20060701 99999999 

93612 INTRAVENTRICULAR PACING $195.76 20060701 99999999 

93613 

INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING 

(LIST SEPARATELY IN ADDITI $238.63 20060701 99999999 

93615 RHYTHM ECG; ESOPHGL LEAD $49.26 20060701 99999999 

93616 

ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM WITH OR 

WITHOUT $80.70 19990701 99999999 

93618 INDUCTION OF ARRHYTHMIA BY ELECTRICAL PACING $353.96 20060701 99999999 

93619 

COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT 

ATRIAL PACING AND RECORDI $637.92 20060701 99999999 

93620 

COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT 

ATRIA $900.80 19990701 99999999 

93624 ELECTROPHYSIOLOGIC FOLLOW-UP STUDY TO TEST EFFECTIVENESS $278.41 20060701 99999999 

93631 LFT VENTRICULAR ENDO RESECT,W/WO CRYOABL,W/MAP $565.96 19990701 99999999 

93640 

ELECTROPHYSIOLOGIC EVALUATION OF CARDIOVERTER- 

DEFIBRILLATOR $421.81 20060701 99999999 

93641 


DEFIBRILLATOR LEADS (INCLUDES DEFI $547.26 20060701 99999999 

93642 


DEFIBRILLATOR (INCLUDES DEFIBRILLA $491.76 20060701 99999999 



93650 

INTRACARDIAC CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS 

OR TR $550.26 20060701 99999999 

93651 

INTRACARDIAC CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS; 

FOR TREATMENT OF SUPRAVE $848.33 20060701 99999999 

93652 

INTRACARDIAC CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS; 

FOR TREATMENT OF VENTRIC $896.93 20060701 99999999 

93660 

AUTONOMIC NERVOUS SYSTEM EVALUATION OF CARDIOVASCULAR 

FUNCTION WITH TILT TABLE E $120.87 20060701 99999999 

93701 BIOIMPEDANCE, THORACIC, ELECTRICAL $29.00 20060701 99999999 

93720 PLETHYSMOGRAPHY, TOTAL BODY $33.11 20060701 99999999 



93724 

ELECTRONIC ANALYSIS OF ANTITACHYCARDIA PACEMAKER SYSTEM 

(INCLUDES ELECTROCARDIOG $344.84 20060701 99999999 

93727 PLTHYSMGRPHY, RGNL; INTER & REPORT ONLY $20.74 20060701 99999999 

93731 

ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTERNAL PACEMAKER 

SYSTEM $37.42 20060701 99999999 

93732 


SYSTEM $55.03 20060701 99999999 

93733 


SYSTEM $33.42 20060701 99999999 

93734 

ELECTRONIC ANALYSIS OF SINGLE-CHAMBER INTERNAL PACEMAKER 

SYSTEM $29.77 20060701 99999999 

93735 


SYS $47.48 20060701 99999999 

93736 


SYSTEM $29.47 20060701 99999999 

93737 

ELECTRONIC ANALYSIS OF CARDIOVERTER/DEFIBRILLATOR; 

WITHOUT REPROGRAMMING $36.24 19990701 99999999 

93738 

ELECTRONIC ANALYSIS OF CARDIOVERTER/DEFIBRILLATOR; WITH 

REPROGRAMMING $54.72 19990701 99999999 

93741 

ELECTRONIC ANALYSIS OF PACING CARDIOVERTER-DEFIBRILLATOR 

(INCLUDES INTERROGATION $54.89 20060701 99999999 

93742 



93743 



93744 



93770 DETERMINATION OF VENOUS PRESSURE $40.26 19990701 99999999 

93784 AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM $48.38 20060701 99999999 




93797 PHYSICIAN SERVICES FOR OUTPATIENT CARDIAC REHABILITATION $9.96 20060701 99999999 

93798 PHYSICIAN SERVICES FOR O/P CARDIAC REHAB. W/ECG MONITORING $15.38 20060701 99999999 

93875 

NON-INVASIVE PHYSIOLOGIC STUDIES OF EXTRACRANIAL ARTERIES, 

BILATERAL, (EG, PERIO $66.32 20060701 99999999 

93880 

DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL 

STUDY $161.52 20060701 99999999 

93882 

DUPLEX SCAN OF EXTRACRANIAL ARTERIES; FOLLOW-UP OR LIMITED 

STUDY $102.54 20060701 99999999 



93886 

TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; 

COMPLETE STUDY $200.44 20060701 99999999 

93888 


FOLLOW-UP OR LIMITED ST $127.36 20060701 99999999 

93890 NON-INVASIVE STUDIES OF UPPER EXTREMITY ARTERIES (EG, $186.62 20060701 99999999 

93892 


EMBOLI DETECTION $198.64 20060701 99999999 

93893 


EMBOLI DETECTION WITH $194.68 20060701 99999999 

93922 

NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER 

EXTREMITY ARTERIES, SINGLE LEV $76.40 20060701 99999999 

93923 

NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER 

EXTREMITY ARTERIES, MULTIPLE L $117.07 20060701 99999999 

93924 

NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER EXTREMITY 

ARTERIES, AT REST AND FOLLOWI $138.14 20060701 99999999 

93925 

DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL 

BYPASS GRAFTS; COMPLETE BILA $192.13 20060701 99999999 

93926 

DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL 

BYPASS GRAFTS; FOLLOW-UP OR $116.39 20060701 99999999 

93930 

DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL 

BYPASS GRAFTS; COMPLETE BILA $156.25 20060701 99999999 

93931 

DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL 

BYPASS GRAFTS; FOLLOW-UP OR $103.76 20060701 99999999 

93965 

NON-INVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, 

BILATERAL, (EG, CONTINUOUS $81.28 20060701 99999999 

93970 

DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO 

COMPRESSION AND OTHER MANE $169.29 20060701 99999999 

93971 

DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO 

COMPRESSION AND OTHER MANE $112.56 20060701 99999999 

93975 

DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF 

ABDOMINAL, PELVIC, AND/OR R $244.58 20060701 99999999 

93976 


ABDOMINAL, PELVIC, AND/OR R $149.97 20060701 99999999 

93978 

DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC 

VASCULATURE, OR BYPASS GRAFTS; C $149.97 20060701 99999999 

93979 

DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC 

VASCULATURE, OR BYPASS GRAFTS; F $105.87 20060701 99999999 

93980 


PENILE VESSELS; COMPLETE ST $173.48 20060701 99999999 

93981 


PENILE VESSELS; FOLLOW-UP O $130.77 20060701 99999999 

93982 

NONINVASIVE PHYSIOLOGIC STUDY OF IMPLANTED WIRELESS 

PRESSURE SENSOR IN ANEURYSMA $24.04 20080101 99999999 

93990 

DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL 

INFLOW, BODY OF ACCESS AN $111.49 20060701 99999999 

94002 

VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE 

OR VOLUME PRESET VENTI $59.64 20070101 99999999 

94003 



94004 



94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL $24.25 20060701 99999999 

94014 

PATIENT INITIATED SPIROMETRIC RECORDING PER 30 DAY PERIOD 

OF TIME; INCLUDES REIN $33.77 20060701 99999999 

94015 


OF TIME; RECORDING (IN $15.08 20060701 99999999 



94016 


OF TIME; PHYSICIAN REV $20.42 20060701 99999999 

94060 

BRONCHOSPASM EVALUATION: SPIROMETRY AS IN 94010, BEFORE 

AND $46.78 20060701 99999999 

94070 

PROLONGED POSTEXPOSURE EVALUATION OF BRONCHOSPASM 

WITH $61.45 20060701 99999999 

94150 VITAL CAPACITY, TOTAL (SEPARATE PROCEDURE) $7.54 19990701 99999999 

94200 MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION $14.25 20060701 99999999 

94240 

FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME: HELIUM 

METHOD, $35.23 20060701 99999999 

94250 EXPIRED GAS COLLECTION, QUANTITATIVE, SINGLE PROCEDURE $19.04 20060701 99999999 

94260 THORACIC GAS VOLUME $21.36 20060701 99999999 

94350 DETERMINATION OF MALDISTRIBUTION OF INSPIRED GAS: MULTIPLE $29.99 20060701 99999999 

94360 DETERMINATION OF RESISTANCE TO AIRFLOW, OSCILLATORY OR $31.54 20060701 99999999 

94370 

DETERMINATION OF AIRWAY CLOSING VOLUME, SINGLE BREATH 

TESTS $24.68 20060701 99999999 

94375 RESPIRATORY FLOW VOLUME LOOP $29.49 20060701 99999999 

94400 BREATHING RESPONSE TO CO2 (CO2 RESPONSE CURVE) $32.56 20060701 99999999 

94450 BREATHING RESPONSE TO HYPOXIA (HYPOXIA RESPONSE CURVE) $31.34 20060701 99999999 

94452 

HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN 


94453 

HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN 


94610 

INTRAPULMONARY SURFACTANT ADMINISTRATION BY A PHYSICIAN 

THROUGH ENDOTRACHEAL TUB $43.49 20070101 99999999 

94620 PULMONARY STRESS TESTING, SIMPLE OR COMPLEX $80.15 20060701 99999999 

94621 

PULMONARY STRESS TESTING; COMPLEX (INCLUDING 

MEASUREMENTS OF CO2 PRODUCTION, O2 $104.05 20060701 99999999 

94640 

NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY 

OBSTRUCTION $13.32 20060701 99999999 

94642 AEROSOL INHALATION OF PENTAMIDINE FOR PNEUMOCYSTIS CARINII $5.50 19910101 99999999 

94644 

CONTINUOUS INHALATION TREATMENT WITH AEROSOL MEDICATION 

FOR ACUTE AIRWAY OBSTRUC $27.58 20070101 99999999 

94645 

CONTINUOUS INHALATION TREATMENT WITH AEROSOL MEDICATION 

FOR ACUTE AIRWAY OBSTRUC $10.46 20070101 99999999 

94656 


OR $57.93 19990701 99999999 

94657 


OR $36.94 19990701 99999999 

94660 CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP), $39.67 20060701 99999999 

94662 CONTINUOUS NEGATIVE PRESSURE VENTILATION (CNP), INITIATION $29.54 20060701 99999999 

94664 AEROSOL OR VAPOR INHALATIONS FOR SPUTUM MOBILIZATION, $14.35 20060701 99999999 

94667 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND $20.34 20060701 99999999 

94668 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND $16.41 20060701 99999999 

94680 OXYGEN UPTAKE, EXPIRED GAS ANALYSIS $54.46 20060701 99999999 



94720 CARBON MONOXIDE DIFFUSING CAPACITY, ANY METHOD $40.47 20060701 99999999 

94725 MEMBRANE DIFFUSION CAPACITY $82.07 20060701 99999999 

94750 PULMONARY COMPLIANCE STUDY, ANY METHOD $40.02 20060701 99999999 

94760 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION $2.29 20060701 99999999 

94761 NONIVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION $4.77 20060701 99999999 

94762 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION $19.84 20060701 99999999 



94770 

CARBON DIOXIDE, EXPIRED GAS DETERMINATION BY INFRARED 

ANALYZER $23.83 20060701 99999999 

94799 UNLISTED PULMONARY SERVICE OR PROCEDURE $20.00 20010101 99999999 

95004 

PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) WITH 

ALLERGENIC EXTRACTS, IMMEDIAT $3.37 20060701 99999999 

95010 

PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) SEQUENTIAL 

AND INCREMENTAL, WITH D $8.42 20060701 99999999 

95012 NITRIC OXIDE EXPIRED GAS DETERMINATION $14.38 20070101 99999999 

95015 

INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND 

INCREMENTAL, WITH DRUGS, BIOL $8.42 20060701 99999999 

95024 

INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC 

EXTRACTS, IMMEDIATE TYPE REAC $4.93 20060701 99999999 

95027 SKIN END POINT TITRATION $4.93 20060701 99999999 

95028 

INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC 

EXTRACTS, DELAYED TYPE REACTI $7.73 20060701 99999999 

95044 PATCH OR APPLICATION TEST(S) (SPECIFY NUMBER OF TESTS) $6.80 20060701 99999999 

95052 PHOTO PATCH TEST(S) (SPECIFY NUMBER OF TESTS) $8.36 20060701 99999999 

95056 PHOTO TESTS $5.87 20060701 99999999 

95060 OPHTHALMIC MUCOUS MEMBRANE TESTS $11.73 20060701 99999999 

95065 DIRECT NASAL MUCOUS MEMBRANE TEST $6.80 20060701 99999999 

95070 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING $73.17 20060701 99999999 

95071 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING $93.43 20060701 99999999 

95075 INGESTION CHALLENGE TEST (EG, METABISULFITE) $52.64 20060701 99999999 

95078 PROVOCATIVE TESTING (EG, RINKEL TEST) $8.61 19990701 99999999 

95115 

PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT 

INCLUDING $12.97 20060701 99999999 

95117 

PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT 

INCLUD $16.72 20060701 99999999 

95144 

PROFESSIONAL SERVICES FOR THE SUPERVISION AND PROVISION 

OF ANTIGENS FOR ALLERGEN $3.38 20060701 99999999 

95145 


OF $3.38 20060701 99999999 

95146 


OF $3.80 20060701 99999999 

95147 


OF $3.38 20060701 99999999 

95148 


OF $3.80 20060701 99999999 

95149 


OF $3.80 20060701 99999999 

95165 


OF ANTIGENS FOR ALLERGEN $3.38 20060701 99999999 

95170 PROFESSIONAL SERVICE FOR THE SUPERVISION AND PROVISION OF $3.38 20060701 99999999 

95180 RAPID DESENSITIZATION PROCEDURE, EACH HOUR (EG, INSULIN, $80.90 20060701 99999999 

95250 

GLUCOSE MONITORING FOR UP TO 72 HOURS BY CONTINUOUS 

RECORDING AND STORAGE OF GLU $104.01 20060701 99999999 

95251 

AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL 

TISSUE FLUID VIA A SUBC $18.98 20060701 99999999 

95805 

MULTIPLE SLEEP LATENCY TESTING RECORDING,ANALYSIS & 

INTERPRE $488.08 20060701 99999999 

95806 

SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, 

RESPIRATORY EFFORT, ECG OR H $209.21 19990701 99999999 

95807 

SLEEP STUDY, 3 OR MORE PARAMETERS OF SLEEP OTHER THAN 

SLEEP STAGING, ATTENDED BY $347.15 20060701 99999999 

95808 

POLYSOMNOGRAPHY; SLEEP STAGING WITH 1-3 ADDITIONAL 

PARAMETERS OF SLEEP, ATTENDED $404.78 20060701 99999999 

95810 

POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE ADDITIONAL 

PARAMETERS OF SLEEP, AT $534.28 20060701 99999999 



95811 

POLYSOMNOGRAPHY; OF SLEEP, ATTENDED BY A TECHNOLOGIST 

SLEEP STAGING WITH 4 OR MO $583.76 20060701 99999999 

95812 

ELECTROENCEPHALOGRAM (EEG) EXTENDED MONITORING; UP TO 

ONE HOUR $129.83 20060701 99999999 

95813 

ELECTROENCEPHALOGRAM (EEG) EXTENDED MONITORING; GREATER 

THAN ONE HOUR $170.24 20060701 99999999 

95816 

EEG INCLUDING RECORDING AWAKE & DROWSY,WITH 

HYPERVENTILATION $121.57 20060701 99999999 

95819 

ELECTROENCEPHALOGRAM (EEG) INCLUDING RECORDING AWAKE, 

DROWSY, $103.13 20060701 99999999 

95822 ELECTROENCEPHALOGRAM (EEG) $144.59 20060701 99999999 



95829 ELECTROCORTICOGRAM AT SURGERY (SEPARATE PROCEDURE) $936.19 20060701 99999999 

95830 INSERTION BY PHYSICIAN OF SPHENOIDAL ELECTRODES FOR $70.81 20060701 99999999 

95831 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) $12.30 20060701 99999999 




95851 

RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE 

PROCEDURE) $7.89 20060701 99999999 

95852 

RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE 

PROCEDURE) $5.33 20060701 99999999 

95857 TENSILON TEST FOR MYASTHENIA GRAVIS $22.24 20060701 99999999 

95858 TENSILON TEST FOR MYASTHENIA GRAVIS $76.99 19990701 99999999 

95860 ELECTROMYOGRAPHY $59.08 20060701 99999999 




95865 NEEDLE ELECTROMYOGRAPHY; LARYNX $82.98 20060701 99999999 

95866 NEEDLE ELECTROMYOGRAPHY; HEMIDIAPHRAGM $55.22 20060701 99999999 

95867 ELECTROMYOGRAPHY, CRANIAL NERVE SUPPLIED MUSCLES $55.97 20060701 99999999 

95868 ELECTROMYOGRAPHY, CRANIAL NERVE SUPPLIED MUSCLES $84.46 20060701 99999999 

95869 ELECTROMYOGRAPHY, LIMITED STUDY OF SPECIFIC MUSCLES (EG, $25.46 20060701 99999999 

95870 

NEEDLE ELECTROMYOGRAPHY; OTHER THAN PARASPINAL (EG, 

ABDOMEN, THORAX) $25.46 20060701 99999999 

95872 ELECTROMYOGRAPHY, SINGLE FIBER, ANY TECHNIQUE $82.21 20060701 99999999 

95873 

ELECTRICAL STIMULATION FOR GUIDANCE IN CONJUNCTION WITH 

CHEMODENERVATION (LIST S $20.36 20060701 99999999 

95874 

NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE IN CONJUNCTION 

WITH CHEMODENERVATION (LIST $20.64 20060701 99999999 

95875 

ISCHEMIC LIMB EXERCISE WITH EMG, WITH LACTIC ACID 

DETERMINATION $63.77 20060701 99999999 

95900 NERVE CONDUCTION, VELOCITY AND/OR LATENCY STUDY $42.16 20060701 99999999 

95903 

NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, 

EACH NERVE, ANY/ALL SITE $44.68 20060701 99999999 

95904 NERVE CONDUCTION, VELOCITY AND/OR LATENCY STUDY $36.04 20060701 99999999 

95920 INTRAOPERATIVE NEUROPHYSIOLOGY TESTING, PER HOUR $108.99 20060701 99999999 

95921 

TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION: 

CARDIOVAGAL INNERVATION (PARASYMPA $47.70 20060701 99999999 

95922 

TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; 


95923 

TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION: 


95925 SOMATOSENSORY TESTING (EG, CEREBRAL EVOKED POTENTIALS), $59.31 20060701 99999999 

95926 

SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, 

STIMULATION OF ANY/ALL PERIP $59.31 20060701 99999999 



95927 

SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, 

STIMULATION OF ANY/ALL PERIP $59.94 20060701 99999999 

95928 

CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL 

MOTOR STIMULATION); UPPER $135.06 20060701 99999999 

95929 

CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL 

MOTOR STIMULATION); LOWER $140.86 20060701 99999999 

95930 

VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL NERVOUS 

SYSTEM, CHECKERBOARD OR FL $65.38 20060701 99999999 

95933 

ORBICULARIS OCULI (BLINK) REFLEX, BY ELECTRODIAGNOSTIC 

TESTING $54.08 20060701 99999999 

95934 

H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD 

GASTROCNEMIUS/SOLEUS MUSCLE $30.64 20060701 99999999 

95936 

H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD MUSCLE 

OTHER THAN GASTROCNEMIUS/SO $31.69 20060701 99999999 

95937 NEUROMUSCULAR JUNCTION TESTING (REPETITIVE STIMULATION, $40.81 20060701 99999999 

95950 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS, $230.74 20060701 99999999 

95951 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS, $227.20 19990701 99999999 

95953 

MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY 

COMPUTERIZED PORTABLE 1 $334.74 20060701 99999999 

95954 PHARMACOLOGICAL ACTIVATION DURING PROLONGED MONITORING $166.30 20060701 99999999 

95955 

ELECTROENCEPHALOGRAM (EEG) DURING NONINTRACRANIAL 

SURGERY $116.80 20060701 99999999 

95956 

MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY 

CABLE OR RADIO, 16 OR M $599.51 20060701 99999999 

95957 

DIGITAL ANALYSIS OF ELECTROENCEPHALOGRAM (EEG) (EG, FOR 

EPILEPTIC SPIKE ANALYSIS $134.27 20060701 99999999 

95958 WADA ACTIVATION TEST FOR HEMISPHERIC FUNCTION, INCLUDING $254.26 20060701 99999999 

95961 FUNCTIONAL CORTICAL MAPING,INITIAL HOUR OF PHYSICIAN ATTEND $168.18 20060701 99999999 

95962 

FUNCTIONAL CORTICAL MAPPING,EACH ADDITIONAL HOUR OF 

PHYSICIA $175.92 20060701 99999999 

95970 

ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 

GENERATOR SYSTEM (EG, RAT $16.65 20060701 99999999 

95971 



95972 



95973 



95974 



95975 



95978 


GENERATOR SYSTEM (EG, $139.18 20060701 99999999 

95979 


GENERATOR SYSTEM (EG, $67.59 20060701 99999999 

95980 


GENERATOR SYSTEM (EG, RAT $21.16 20080101 99999999 

95981 



95982 



95990 

REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR 

RESERVOIR FOR DRUG DELIVERY, SP $45.46 20060701 99999999 

95991 


RESERVOIR FOR DRUG DELIVERY, SP $27.76 20060701 99999999 



96000 

COMPREHENSIVE COMPUTER-BASED MOTION ANALYSIS BY VIDEO- 

TAPING AND 3-D KINEMATICS; $68.30 20020101 99999999 

96001 

COMPREHENSIVE COMPUTER-BASED MOTION ANALYSIS BY VIDEO- 

TAPING AND 3-D KINEMATICS; $81.50 20020101 99999999 

96002 

DYNAMIC SURFACE ELECTROMYOGRAPHY, DURING WALKING OR 

OTHER FUNCTIONAL ACTIVITIES, $15.78 20020101 99999999 

96003 

DYNAMIC FINE WIRE ELECTROMYOGRAPHY, DURING WALKING OR 

OTHER FUNCTIONAL ACTIVITIE $14.66 20020101 99999999 

96004 

PHYSICIAN REVIEW AND INTERPRETATION OF COMPREHENSIVE 

COMPUTER BASED MOTION ANALY $69.60 20020101 99999999 

96101 

PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC 

ASSESSMENT OF EMOTIONALITY, INT $59.90 20060701 99999999 

96103 

PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC 

ASSESSMENT OF EMOTIONALITY, INT $16.31 20060701 99999999 

96105 

ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE 

AND RECEPTIVE SPEECH AN $59.90 20060701 99999999 

96111 

DEVELOPMENTAL TESTING; EXTENDED (INCLUDES ASSESSMENT OF 

MOTOR, LANGUAGE, SOCIAL, $59.90 19990701 99999999 

96115 

NEUROBEHAVORIAL STATUS EXAM (CLINICAL ASSESSMENT OF 

THINKING, REASONING AND JUDG $59.90 19990701 99999999 

96116 

NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF 

THINKING, REASONING AND JUDG $61.95 20060701 99999999 

96117 

NEUROPSYCHOLOGICAL TESTING BATTERY (EG, HALSTEAD-REITAN, 

LURIA, WAIS-R) WITH INT $59.90 19990701 99999999 

96118 

NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN 

NEUROPSYCHOLOGICAL BATTERY, WECH $61.69 20060701 99999999 

96120 

NEUROPSYCHOLOGICAL TESTING (EG, WISCONSIN CARD SORTING 

TEST), ADMINISTERED BY A $18.17 20060701 99999999 

96125 

STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS 

INFORMATION PROCESSING ASSE $41.65 20080101 99999999 

96150 

HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED 

CLINICAL INTERVIEW, BEHAVIORA $19.58 20060701 99999999 

96151 

HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED 

CLINICAL INTERVIEW, BEHAVIORA $19.06 20060701 99999999 

96152 

HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- 

FACE; INDIVIDUAL $18.24 20060701 99999999 

96153 


FACE; GROUP (2 OR MOR $3.99 20060701 99999999 

96154 


FACE; FAMILY (WITH TH $17.70 20060701 99999999 

96155 


FACE; FAMILY (WITHOUT $17.14 20020101 99999999 

96400 

CHEMOTHERAPY ADMIN SUBCATANEOUS OR INTRAMUSCULAR W OR 

W/O LO $4.73 19990701 99999999 

96401 

CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR 

INTRAMUSCULAR; NON-HORMONAL ANTI-NE $34.54 20060701 99999999 

96402 

CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR 

INTRAMUSCULAR; HORMONAL ANTI-NEOPLA $30.04 20060701 99999999 

96405 

CHEMOTHERAPY ADMINISTRATION, INTRALESIONAL; UP TO AND 

INCLUDING 7 LESIONS $30.10 20060701 99999999 

96406 

CHEMOTHERAPY ADMINISTRATION, INTRALESIONAL; MORE THAN 7 

LESIONS $43.07 20060701 99999999 

96408 CHEMOTHERAPY ADMINISTRATION INTRAVENOUS PUSH $32.13 19990701 99999999 

96409 

CHEMOTHERAPY ADMINISTRATION; INTRAVENOUS, PUSH 

TECHNIQUE, SINGLE OR INITIAL SUBS $80.60 20060701 99999999 

96410 CHEMOTHERAPY ADMIN, IV INFUSION TECHNIQUE, UP TO ONE HOUR $48.31 19990701 99999999 

96411 

CHEMOTHERAPY ADMINISTRATION; INTRAVENOUS, PUSH 

TECHNIQUE, EACH ADDITIONAL SUBSTA $46.33 20060701 99999999 



96412 CHEMOTHERAPY ADMIN.,IV INFUSION TECHNIQUE, ONE TO 8 HOURS $38.31 19990701 99999999 

96413 

CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION 

TECHNIQUE; UP TO 1 HOUR, SINGL $113.96 20060701 99999999 

96414 

CHEMOTHERAPY ADMIN, IV INFUSION TECHNIQUE,INITIAT. OF 

PROLON $44.17 19990701 99999999 

96415 


TECHNIQUE; EACH ADDITIONAL HOU $38.31 20060701 99999999 

96416 


TECHNIQUE; INITIATION OF PROLO $122.71 20060701 99999999 

96417 


TECHNIQUE; EACH ADDITIONAL SEQ $55.33 20060701 99999999 

96420 

CHEMOTHERAPY ADMINISTRATION,INTRA-ARTERIAL PUSH 

TECHNIQUE $72.79 20060701 99999999 

96422 

CHEMOTHERAPY ADMIN,INTRA-ARTERIAL INFUSION TECHNIQUE,UP 

TO 1 $127.61 20060701 99999999 

96423 

CHEMOTHERAPY ADMIN,INTRA-ARTERIAL INFUSION TECHNIQUE,1-8 

HRS $52.00 20060701 99999999 

96425 CHEMOTHERAPY ADMIN,INTRA-ARTERIAL INFUSION TECHNIQUE $118.52 20060701 99999999 

96440 CHEMOTHERAPY INTROCAVITARY $144.80 20060701 99999999 

96445 CHEMOTHERAPY ADMINISTRATION INTO PERITONEAL CAVITY $134.52 20060701 99999999 

96450 CHEMOTHERAPY LUMBAR PUNCTURE $118.87 20060701 99999999 

96520 PORTABLE PUMP REFILLING AND MAINTENANCE $29.64 19990701 99999999 

96521 REFILLING AND MAINTENANCE OF PORTABLE PUMP $101.13 20060701 99999999 

96522 


RESERVOIR FOR DRUG DELIVERY, SY $72.83 20060701 99999999 

96523 

IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG 

DELIVERY SYSTEMS $20.64 20060701 99999999 

96530 IMPLANTABLE PUMP FILLING AND MAINTENANCE $35.25 19990701 99999999 

96542 

CHEMOTHERAPY INJECTION, SUBARACHNOID OR INTRAVENTRICULAR 

VIA SUBCUTANEOUS RESERV $82.55 20060701 99999999 

96549 UNLISTED CHEMOTHERAPY PROCEDURE $41.60 20030401 99999999 

96567 

PHOTODYNAMIC THERAPY BY EXTERNAL APPLICATION OF LIGHT TO 

DESTROY PREMALIGNANT AN $50.24 20060701 99999999 

96570 

PHOTODYNAMIC THERAPY BY ENDOSCOPIC APPLICATION OF LIGHT 

TO ABLATE ABNORMAL TISSU $58.12 20060701 99999999 

96571 

PHOTODYNAMIC THERAPY BY ENDOSCOPIC APPLICATION OF LIGHT 

TO ABLATE ABNORMAL TISSU $29.40 20060701 99999999 

96900 ACTINOTHERAPY (ULTRAVIOLET LIGHT) $13.29 20060701 99999999 

96910 PHOTOCHEMOTHERAPY $25.74 20060701 99999999 

96912 PHOTOCHEMOTHERAPY $32.74 20060701 99999999 

96913 

PHOTOCHEMOTHERAPY FOR SEVERE PHOTORESPONSIVE 

DERMATOSES $45.05 20060701 99999999 

96920 

LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 

TOTAL AREA LESS THAN $45.75 20060701 99999999 

96921 


250 SQ CM TO 500 SQ C $46.58 20060701 99999999 

96922 


OVER 500 SQ CM $83.40 20060701 99999999 

97001 PHYSICAL THERAPY EVALUATION $46.55 20060701 99999999 

97002 PHYSICAL THERAPY RE-EVALUATION $20.66 20060701 99999999 

97003 OCCUPATIONAL THERAPY EVALUATION $44.99 20060701 99999999 

97004 OCCUPATIONAL THERAPY RE-EVALUATION $20.03 20060701 99999999 

97010 PHYSICAL MEDICINE TREATMENT TO ONE AREA $10.08 19990701 99999999 












97032 

APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL 

STIMULATION (MANUAL), $13.64 20060701 99999999 

97033 

APPLICATION OF A MODALITY TO ONE OR MORE AREAS; 

IONTOPHORESIS, EACH 15 MINUTES $13.64 20060701 99999999 

97034 

APPLICATION OF A MODALITY TO ONE OR MORE AREAS; CONTRAST 

BATHS, EACH 15 MINUTES $11.39 20060701 99999999 

97035 

APPLICATION OF A MODALITY TO ONE OR MORE AREAS; 

ULTRASOUND, EACH 15 MINUTES $9.52 20060701 99999999 

97036 

APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HUBBARD 

TANK, EACH 15 MINUTES $16.04 20060701 99999999 


97110 PHYSICAL MEDICINE TREATMENT TO ONE AREA, INITIAL 30 MINUTES, $17.65 20060701 99999999 


97113 

THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 

MINUTES; AQUATIC THERAPY WITH $20.09 20060701 99999999 




97140 

MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, 

MANUAL LYMPHATIC DRAI $20.55 20060701 99999999 

97150 THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS) $14.78 19990701 99999999 

97504 

ORTHOTICS FITTING & TRAINING, UPPER AND/OR LOWER 

EXTREMITIESEACH 15 MIN $18.83 19990701 99999999 

97520 PROSTHETIC TRAINING $18.89 19990701 99999999 

97530 KINETIC ACTIVITIES TO INCREASE COORDINATION, STRENGTH $18.32 20060701 99999999 

97532 

DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, 

MEMORY, PROBLEM SOLVING, ( $16.63 20060701 99999999 

97533 

SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY 

PROCESSING AND PROMOTE ADAPTIV $17.81 20060701 99999999 

97535 

SELF CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF DAILY 

LIVING (ADL) AND COM $19.20 20060701 99999999 

97537 

COMMUNITY/WORK REINTEGRATION TRAINING (EG, SHOPPING, 

TRANSPORTATION, MONEY MANAG $18.95 19990701 99999999 

97542 

WHEELCHAIR MANAGEMENT/PROPULSION TRAINING, EACH 15 

MINUTES $17.54 20060701 99999999 

97597 

REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), SELECTIVE 

DEBRIDEMENT, WITHOUT ANES $37.07 20060701 99999999 

97598 

REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), SELECTIVE 

DEBRIDEMENT, WITHOUT $47.04 20060701 99999999 

97601 

REMOVAL OF DEVITALIZED TISSUE FROM WOUND; SELECTIVE 

DEBRIDEMENT, WITHOUT ANESTHE $40.76 20041001 99999999 

97602 

REMOVAL OF DEVITALIZED TISSUE FROM WOUND; NON-SELECTIVE 

DEBRIDEMENT, WITHOUT ANE $20.46 20010101 99999999 

97605 

NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED 

DRAINAGE COLLECTION), $18.49 20060701 99999999 

97606 

NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED 

DRAINAGE COLLECTION), $20.32 20060701 99999999 

97703 

CHECKOUT FOR ORTHOTIC/PROSTHETIC USE, ESTABLISHED 

PATIENT, EACH 15 MINUTES $11.82 19990701 99999999 

97750 

PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, 

MUSCULOSKELETAL, FUNCTIONAL CAPACI $19.83 20060701 99999999 

97755 

ASSISTIVE TECHNOLOGY ASSESSMENT (EG, TO RESTORE, AUGMENT 

OR COMPENSATE FOR EXIST $25.87 20060701 99999999 



97760 

ORTHOTIC(S) MANAGEMENT AND TRAINING (INCLUDING ASSESSMENT 

AND FITTING WHEN NOT O $17.21 20060701 99999999 

97761 

PROSTHETIC TRAINING, UPPER AND/OR LOWER EXTREMITY(S), EACH 

15 MINUTES $17.70 20060701 99999999 

97762 

CHECKOUT FOR ORTHOTIC/PROSTHETIC USE, ESTABLISHED 

PATIENT, EACH 15 MINUTES $12.11 20060701 99999999 

97770 

DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, 

MEMORY, PROBLEM SOLVING, I $20.25 19990701 99999999 

97802 

MEDICAL NUTRITION THERAPY; INITIAL ASSESSMENT AND 

INTERVENTION, INDIVIDUAL, FACE $13.40 20010101 99999999 

97803 

MEDICAL NUTRITION THERAPY; RE-ASSESSMENT AND INTERVENTION, 

INDIVIDUAL, FACE-TO-F $13.40 20010101 99999999 

97804 

MEDICAL NUTRITION THERAPY; GROUP (2 OR MORE INDIVIDUAL(S)), 

EACH 30 MINUTES $5.20 20010101 99999999 

98925 

OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); ONE TO TWO BODY 

REGIONS INVOLVED $22.01 20060701 99999999 

98926 

OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); THREE TO FOUR 

BODY REGIONS INVOLVED $30.70 20060701 99999999 

98927 

OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); FIVE TO SIX BODY 


98928 

OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); SEVEN TO EIGHT 

BODY REGIONS INVOLVED $43.75 20060701 99999999 

98929 

OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); NINE TO TEN BODY 


99025 INITIAL (NEW PATIENT) VISIT WHEN STARRED (*) SURGICAL $14.00 19990701 99999999 

99052 SERVICES REQUESTED BETWEEN 10:00 PM AND 8:00 AM IN ADDITION $23.46 19990701 99999999 

99056 

SERVICES PROVIDED AT REQUEST OF PATIENT IN A LOCATION 

OTHER $37.80 19990701 99999999 

99071 

EDUCATIONAL SUPPLIES, SUCH AS BOOKS, TAPES, AND PAMPHLETS, 

PROVIDED $2.63 19990701 99999999 

99080 

SPECIAL REPORTS SUCH AS INSURANCE FORMS, OR THE REVIEW OF 

MEDICAL $125.00 19990701 99999999 

99082 UNUSUAL TRAVEL (EG, TRANSPORTATION AND ESCORT OF PATIENT) $8.00 19990701 99999999 

99170 GASTRIC INTUBATION, AND ASPIRATION OR LAVAGE FOR TREATMENT $89.60 20060701 99999999 

99175 IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND $46.30 20060701 99999999 

99183 

PHYSICIAN ATTENDANCE AND SUPERVISION OF HYPERBARIC 

OXYGEN THERAPY, PER SESSION $74.57 20060701 99999999 

99185 HYPOTHERMIA $21.02 20060701 99999999 

99186 HYPOTHERMIA $66.31 20060701 99999999 

99195 PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE) $14.85 20060701 99999999 

99201 

OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND 

MANAGEMENT OF A NEW PATI $24.13 20060701 99999999 

99202 



99203 



99204 



99205 



99211 


MANAGEMENT OF AN ESTABLI $9.17 20060701 99999999 

99212 



99213 





99214 



99215 



99217 

OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS 

TO BE UTILIZED BY THE PH $50.53 20060701 99999999 

99218 

INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND 

MANAGEMENT OF A PATIEN $53.33 19990701 99999999 

99219 



99220 



99221 

INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND 

MANAGEMENT OF A PATIENT W $53.33 20060701 99999999 

99222 


MANAGEMENT OF A PATIENT, $87.63 20060701 99999999 

99223 


MANAGEMENT OF A PATIENT, $116.67 20060701 99999999 

99231 

SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND 


99232 



99233 



99234 

OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE EVALUATION 

AND MANAGEMENT OF A P $95.13 20060701 99999999 

99235 



99236 



99238 HOSPITAL DISCHARGE DAY MANAGEMENT $50.28 20060701 99999999 

99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE THAN 30 MINUTES $65.64 20060701 99999999 

99241 

OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, 

WHICH REQUIRES THESE THREE $34.65 20060701 99999999 

99242 



99243 



99244 



99245 



99251 

INITIAL INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED 

PATIENT, WHICH REQUIRES $34.27 20060701 99999999 

99252 



99253 



99254 



99255 



99261 

FOLLOW-UP INPATIENT CONSULTATION FOR AN ESTABLISHED 

PATIENT, WHICH REQUIRES AT L $20.28 19990701 99999999 

99262 


PATIENT WHICH REQUIRES AT LE $36.53 19990701 99999999 

99263 


PATIENT WHICH REQUIRES AT LE $54.01 19990701 99999999 



99271 

CONFIRMATORY CONSULTATION FOR A NEW OR ESTABLISHED 

PATIENT, WHICH REQUIRES THESE $24.74 20041001 99999999 

99272 



99273 



99274 

CONFIRMATORY CONSULTATION FOR A PATIENT, WHICH REQUIRES 

THESE THREE KEY COMPONEN $89.26 20030401 99999999 

99275 

CONFIRMATORY CONSULTATION FOR A PATIENT, WHICH REQUIRES 

THESE THREE KEY COMPONEN $116.93 20030401 99999999 

99281 

EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND 

MANAGEMENT OF A PATIENT, WHICH $15.42 20060701 99999999 

99282 



99283 



99284 



99285 



99288 

PHYSICIAN DIRECTION OF EMERGENCY MEDICAL SYSTEMS (EMS) 

EMERGENCY CARE, ADVANCED $16.59 19990701 99999999 

99289 

PHYSICIAN CONSTANT ATTENTION OF THE CRITICALLY ILL OR 

INJURED PATIENT DURING AN $150.46 20060701 99999999 

99290 

PHYSICIAN CONSTANT ATTENTION OF THE CRITICALLY ILL OR 

INJURED PATIENT DURING AN $77.49 20060701 99999999 

99291 

CRITICAL CARE, INCLUDING THE DIAGNOSTIC AND THERAPEUTIC 

SERVICES AND DIRECTION O $144.08 20060701 99999999 

99292 

CRITICAL CARE, INCLUDING THE DIAGNOSTIC AND THERAPEUTIC 

SERVICES EACH ADDITIONAL $71.82 20060701 99999999 

99293 

INITIAL PEDIATRIC CRITICAL CARE, 31 DAYS UP THROUGH 24 MONTHS 

OF AGE, PER DAY, F $144.08 20060701 99999999 

99294 

SUBSEQUENT PEDIATRIC CRITICAL CARE, 31 DAYS UP THROUGH 24 

MONTHS OF AGE, PER DAY $100.00 20060701 99999999 

99295 

INITIAL NICU CARE, PER DAY, FOR THE EVALUATION AND 

MANAGEMENT OF A CRITICALLY IL $300.00 20060701 99999999 

99296 

SUBSEQUENT NICU CARE, PER DAY, FOR THE EVALUATION AND 

MANAGEMENT OF A CRITICALLY $100.00 20060701 99999999 

99297 

SUBSEQUENT NICU CARE, PER DAY, FOR THE EVALUATION AND 

MANAGEMENT OF A CRITICALLY $108.00 20000101 99999999 

99298 

SUBSEQUENT NEONATAL INTENSIVE CARE, PER DAY, FOR THE 

EVALUATION AND MANAGEMENT O $89.43 20060701 99999999 

99299 

SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE EVALUATION AND 

MANAGEMENT OF THE REC $81.77 20060701 99999999 

99300 

SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE EVALUATION AND 

MANAGEMENT OF THE REC $78.79 20060701 99999999 

99301 

EVALUATION AND MANAGEMENT OF A NEW OR ESTABLISHED 

PATIENT INVOLVING AN ANNUAL NU $46.61 20030401 99999999 

99302 


PATIENT INVOLVING A NURSING FA $60.71 20030401 99999999 

99303 


PATIENT INVOLVING A NURSING FA $81.15 20030401 99999999 

99304 

INITIAL NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION 


99305 



99306 





99307 

SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE 

EVALUATION AND MANAGEMENT OF $23.47 20060701 99999999 

99308 



99309 



99310 



99311 



99312 



99313 



99315 

NURSING FACILITY DISCHARGE DAY MANAGEMENT; 30 MINUTES OR 

LESS $45.08 20060701 99999999 

99316 

NURSING FACILITY DISCHARGE DAY MANAGEMENT; 30 MINUTES OR 

LESS MORE THAN 30 MINUT $57.25 20060701 99999999 

99318 

EVALUATION AND MANAGEMENT OF A PATIENT INVOLVING AN 

ANNUAL NURSING FACILITY ASSE $45.34 20060701 99999999 

99321 

DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND 

MANAGEMENT OF A NEW PATIEN $32.22 19990701 99999999 

99322 



99323 



99324 



99325 



99326 



99327 



99328 



99331 


MANAGEMENT OF AN ESTABLISH $27.83 19990701 99999999 

99332 



99333 



99334 



99335 



99336 



99337 



99341 

HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 

PATIENT, WHICH REQUIRES TH $44.73 20060701 99999999 

99342 



99343 



99344 





99345 



99347 

HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 

ESTABLISHED PATIENT, WHICH RE $35.41 20060701 99999999 

99348 



99349 



99350 



99354 

PROLONGED PHYSICIAN SERVICE IN THE OFFICE OR OTHER 

OUTPATIENT SETTING REQUIRING $66.64 20060701 99999999 

99355 

PROLONGED PHYSICIAN SERVICE IN THE OFFICE OR OTHER 

OUTPATIENT SETTING REQUIRING $66.34 20060701 99999999 

99356 

PROLONGED PHYSICIAN SERVICE IN THE INPATIENT SETTING, 

REQUIRING DIRECT (FACE-TO- $68.89 20060701 99999999 

99357 

PROLONGED PHYSICIAN SERVICE IN THE INPATIENT SETTING, 

REQUIRING DIRECT (FACE-TO- $56.45 20060701 99999999 

99358 

PROLONGED EVALUATION AND MANAGEMENT SERVICE BEFORE 

AND/OR AFTER DIRECT (FACE-TO- $38.23 19990701 99999999 

99381 

INITIAL EVALUATION AND MANAGEMENT OF A HEALTHY INDIVIDUAL 

REQUIRING A COMPREHENS $48.67 19990701 99999999 

99382 


EARLY CHILDHOOD (AGE 1 $66.86 19990701 99999999 

99383 


LATE CHILDHOOD (AGE 5 $65.52 19990701 99999999 

99384 


ADOLESCENT (AGE 12 THR $59.27 19990701 99999999 

99385 

INITIAL EVALUATION AND MANAGEMENT OF A HEALTHY INDIVIDUAL 18- 

39 YEARS $61.58 19990701 99999999 

99386 

INITIAL EVALUATION AND MANAGEMENT OF A HEALTHY INDIVIDUAL 40- 

64 YEARS $59.80 19990701 99999999 

99387 

INITIAL EVALUATION AND MANAGEMENT OF A HEALTHY INDIVIDUAL 65 

YEARS AND OVER $51.38 19990701 99999999 

99391 

PERIODIC REEVALUATION AND MANAGEMENT OF A HEALTHY 

INDIVIDUAL REQUIRING A COMPREH $34.35 19990701 99999999 

99392 


INDIVIDUAL EARLY CHILDHOOD (AG $33.27 19990701 99999999 

99393 


INDIVIDUAL LATE CHILDHOOD (AGE $40.89 19990701 99999999 

99394 


INDIVIDUAL ADOLESCENT (AGE 12 $45.94 19990701 99999999 

99395 


INDIVIDUAL 18-39 YEARS $53.86 19990701 99999999 

99396 


INDIVIDUAL 40-64 YEARS $55.27 19990701 99999999 

99397 


INDIVIDUAL 65 YEARS AND OVER $50.97 19990701 99999999 

99431 

HISTORY AND EXAMINATION OF THE NORMAL NEWBORN INFANT, 

INITIATION OF DIAGNOSTIC A $58.30 20060701 99999999 

99432 

NORMAL NEWBORN CARE IN OTHER THAN HOSPITAL OR BIRTHING 

ROOM SETTING, INCLUDING P $48.69 19990701 99999999 

99433 

SUBSEQUENT HOSPITAL CARE, FOR THE EVALUATION AND 

MANAGEMENT OF A NORMAL NEWBORN, $31.16 20060701 99999999 

99435 

HISTORY AND EXAMINATION OF THE NORMAL NEWBORN INFANT, 

INCLUDING THE PREPARATION $74.71 20060701 99999999 

99436 

ATTENDANCE AT DELIVERY (WHEN REQUESTED BY DELIVERING 

PHYSICIAN) AND INITIAL STAB $47.24 20060701 99999999 



99440 

NEWBORN RESUSCITATION: CARE OF THE HIGH RISK NEWBORN AT 

DELIVERY, INCLUDING, FOR $92.63 20060701 99999999 

99477 


MANAGEMENT OF THE NEONATE $144.08 20080101 99999999 

99499 UNLISTED EVALUATION AND MANAGEMENT SERVICE $32.99 19990701 99999999 

99507 

HOME VISIT FOR CARE AND MAINTENANCE OF CATHETER(S) (EG, 

URINARY, DRAINAGE, AND E $5.20 20030401 99999999 

99600 INPATIENT ALTERNATIVE CARE $83.20 20030401 99999999 

99601 

HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, PER VISIT (UP 

TO 2 HOURS) $16.64 20040101 99999999

Medicaid Fee Schedule without Mods 200801

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