Updated Fee Schedule - April 1

Procedure Code Modifier Description Fee Schedule Amount 10021 Fna w/o image $146.14 10022 Fna w/image $150.23 10040 Acne surgery $102.29 10060 Drainage of skin abscess $111.49 10061 Drainage of skin abscess $188.34 10080 Drainage of pilonidal cyst $169.54 10081 Drainage of pilonidal cyst $262.25 10120 Remove foreign body $137.97 10121 Remove foreign body $266.71 10140 Drainage of hematoma/fluid $157.75 10160 Puncture drainage of lesion $128.69 10180 Complex drainage, wound $238.12 11000 Debride infected skin $55.20 11001 Debride infected skin add-on $22.77 11004 Debride genitalia & perineum $589.24 11005 Debride abdom wall $768.09 11006 Debride genit/per/abdom wall $733.13 11008 Remove mesh from abd wall $280.22 11010 Debride skin, fx $483.81 11011 Debride skin/muscle, fx $536.89 11012 Debride skin/muscle/bone, fx $733.44 11040 Debride skin, partial $48.22 11041 Debride skin, full $56.76 11042 Debride skin/tissue $76.87$ 11043 Debride tissue/muscle $277.72 11044 Debride tissue/muscle/bone $379.75 11055 Trim skin lesion $50.16 11056 Trim skin lesions, 2 to 4 $60.83 11057 Trim skin lesions, over 4 $73.19 11100 Biopsy, skin lesion $106.89 11101 Biopsy, skin add-on $33.82 11200 Removal of skin tags $83.26 11201 Remove skin tags add-on $18.59 11300 Shave skin lesion $69.87 11301 Shave skin lesion $95.09 11302 Shave skin lesion $113.58 11303 Shave skin lesion $133.40 11305 Shave skin lesion $71.34 11306 Shave skin lesion $98.10 11307 Shave skin lesion $115.81 11308 Shave skin lesion $129.82 11310 Shave skin lesion $86.45 11311 Shave skin lesion $109.19 11312 Shave skin lesion $126.31 11313 Shave skin lesion $157.29 11400 Exc tr-ext b9+marg 0.5 < cm $118.96 11401 Exc tr-ext b9+marg 0.6-1 cm $145.42 11402 Exc tr-ext b9+marg 1.1-2 cm $162.25 11403 Exc tr-ext b9+marg 2.1-3 cm $185.56 11404 Exc tr-ext b9+marg 3.1-4 cm $211.20 11406 Exc tr-ext b9+marg > 4.0 cm $293.95

Page 1Page 1 Updated Fee Schedule - April 1

11420 Exc h-f-nk-sp b9+marg 0.5 < $119.85 11421 Exc h-f-nk-sp b9+marg 0.6-1 $154.63 11422 Exc h-f-nk-sp b9+marg 1.1-2 $172.46 11423 Exc h-f-nk-sp b9+marg 2.1-3 $200.24 11424 Exc h-f-nk-sp b9+marg 3.1-4 $230.27 11426 Exc h-f-nk-sp b9+marg > 4 cm $326.64 11440 Exc face-mm b9+marg 0.5 < cm $131.62 11441 Exc face-mm b9+marg 0.6-1 cm $165.58 11442 Exc face-mm b9+marg 1.1-2 cm $186.25 11443 Exc face-mm b9+marg 2.1-3 cm $222.42 11444 Exc face-mm b9+marg 3.1-4 cm $279.03 11446 Exc face-mm b9+marg > 4 cm $376.68 11450 Removal, sweat gland lesion $354.91 11451 Removal, sweat gland lesion $462.78 11462 Removal, sweat gland lesion $351.58 11463 Removal, sweat gland lesion $476.77 11470 Removal, sweat gland lesion $388.04 11471 Removal, sweat gland lesion $487.15 11600 Exc tr-ext mlg+marg 0.5 < cm $181.40 11601 Exc tr-ext mlg+marg 0.6-1 cm $223.78 11602 Exc tr-ext mlg+marg 1.1-2 cm $245.85 11603 Exc tr-ext mlg+marg 2.1-3 cm $277.92 11604 Exc tr-ext mlg+marg 3.1-4 cm $306.81 11606 Exc tr-ext mlg+marg > 4 cm $428.06 11620 Exc h-f-nk-sp mlg+marg 0.5 < $185.34$ 11621 Exc h-f-nk-sp mlg+marg 0.6-1 $226.25 11622 Exc h-f-nk-sp mlg+marg 1.1-2 $255.52 11623 Exc h-f-nk-sp mlg+marg 2.1-3 $296.38 11624 Exc h-f-nk-sp mlg+marg 3.1-4 $332.96 11626 Exc h-f-nk-sp mlg+mar > 4 cm $404.48 11640 Exc face-mm malig+marg 0.5 < $194.56 11641 Exc face-mm malig+marg 0.6-1 $238.46 11642 Exc face-mm malig+marg 1.1-2 $274.10 11643 Exc face-mm malig+marg 2.1-3 $320.18 11644 Exc face-mm malig+marg 3.1-4 $394.48 11646 Exc face-mm mlg+marg > 4 cm $516.76 11719 Trim nail(s) $22.17 11720 Debride nail, 1-5 $32.20 11721 Debride nail, 6 or more $45.57 11730 Removal of nail plate $100.72 11732 Remove nail plate, add-on $46.65 11740 Drain blood from under nail $46.74 11750 Removal of nail bed $217.32 11752 Remove nail bed/finger tip $309.04 11755 Biopsy, nail unit $136.77 11760 Repair of nail bed $208.10 11762 Reconstruction of nail bed $274.52 11765 Excision of nail fold, toe $134.22 11770 Removal of pilonidal lesion $263.02 11771 Removal of pilonidal lesion $536.22 11772 Removal of pilonidal lesion $650.99 11900 Injection into skin lesions $57.56

Page 2Page 2 Updated Fee Schedule - April 1

11901 Added skin lesions injection $72.27 11920 Correct skin color defects $188.05 11921 Correct skin color defects $213.68 11922 Correct skin color defects $63.17 11950 Therapy for contour defects $77.02 11951 Therapy for contour defects $102.77 11952 Therapy for contour defects $144.47 11954 Therapy for contour defects $166.25 11960 Insert tissue expander(s) $932.89 11970 Replace tissue expander $609.15 11971 Remove tissue expander(s) $470.91 11975 Insert contraceptive cap $137.35 11976 Removal of contraceptive cap $153.53 11977 Removal/reinsert contra cap $244.43 11980 Implant hormone pellet(s) $107.31 11981 Insert drug implant device $141.64 11982 Remove drug implant device $162.59 11983 Remove/insert drug implant $248.01 12001 Repair superficial wound(s) $148.26 12002 Repair superficial wound(s) $157.77 12004 Repair superficial wound(s) $185.98 12005 Repair superficial wound(s) $231.43 12006 Repair superficial wound(s) $286.31 12007 Repair superficial wound(s) $324.99 12011 Repair superficial wound(s) $157.82$ 12013 Repair superficial wound(s) $173.81 12014 Repair superficial wound(s) $204.69 12015 Repair superficial wound(s) $256.30 12016 Repair superficial wound(s) $305.94 12017 Repair superficial wound(s) $265.07 12018 Repair superficial wound(s) $330.97 12020 Closure of split wound $272.37 12021 Closure of split wound $160.09 12031 Intmd wnd repair s/tr/ext $241.51 12032 Intmd wnd repair s/tr/ext $313.15 12034 Intmd wnd repair s/tr/ext $305.77 12035 Intmd wnd repair s/tr/ext $374.54 12036 Intmd wnd repair s/tr/ext $409.65 12037 Intmd wnd repair s/tr/ext $461.79 12041 Intmd wnd repair n-hf/genit $252.31 12042 Intmd wnd repair n-hg/genit $294.18 12044 Intmd wnd repair n-hg/genit $340.29 12045 Intmd wnd repair n-hg/genit $376.63 12046 Intmd wnd repair n-hg/genit $447.17 12047 Intmd wnd repair n-hg/genit $479.18 12051 Intmd wnd repair face/mm $272.02 12052 Intmd wnd repair face/mm $307.85 12053 Intmd wnd repair face/mm $338.52 12054 Intmd wnd repair, face/mm $357.34 12055 Intmd wnd repair face/mm $429.58 12056 Intmd wnd repair face/mm $507.62 12057 Intmd wnd repair face/mm $565.62

Page 3Page 3 Updated Fee Schedule - April 1

13100 Repair of wound or lesion $321.62 13101 Repair of wound or lesion $405.67 13102 Repair wound/lesion add-on $109.27 13120 Repair of wound or lesion $333.75 13121 Repair of wound or lesion $448.77 13122 Repair wound/lesion add-on $121.98 13131 Repair of wound or lesion $367.16 13132 Repair of wound or lesion $584.15 13133 Repair wound/lesion add-on $171.00 13150 Repair of wound or lesion $366.02 13151 Repair of wound or lesion $415.87 13152 Repair of wound or lesion $571.54 13153 Repair wound/lesion add-on $188.35 13160 Late closure of wound $820.40 14000 Skin tissue rearrangement $625.99 14001 Skin tissue rearrangement $810.38 14020 Skin tissue rearrangement $704.48 14021 Skin tissue rearrangement $888.33 14040 Skin tissue rearrangement $777.68 14041 Skin tissue rearrangement $966.28 14060 Skin tissue rearrangement $787.91 14061 Skin tissue rearrangement $1,036.09 14300 Skin tissue rearrangement $1,115.74 14350 Skin tissue rearrangement $762.94 15002 Wound prep, trk/arm/leg $339.64$ 15003 Wound prep, addl 100 cm $73.93 15004 Wound prep, f/n/hf/g $411.45 15005 Wnd prep, f/n/hf/g, addl cm $122.81 15040 Harvest cultured skin graft $262.23 15050 Skin pinch graft $548.99 15100 Skin splt grft, trnk/arm/leg $877.22 15101 Skin splt grft t/a/l, add-on $195.54 15110 Epidrm autogrft trnk/arm/leg $857.56 15111 Epidrm autogrft t/a/l add-on $124.02 15115 Epidrm a-grft face/nck/hf/g $865.70 15116 Epidrm a-grft f/n/hf/g addl $168.28 15120 Skn splt a-grft fac/nck/hf/g $948.79 15121 Skn splt a-grft f/n/hf/g add $274.73 15130 Derm autograft, trnk/arm/leg $683.23 15131 Derm autograft t/a/l add-on $100.90 15135 Derm autograft face/nck/hf/g $871.04 15136 Derm autograft, f/n/hf/g add $92.18 15150 Cult epiderm grft t/arm/leg $705.18 15151 Cult epiderm grft t/a/l addl $130.17 15152 Cult epiderm graft t/a/l +% $170.34 15155 Cult epiderm graft, f/n/hf/g $739.18 15156 Cult epidrm grft f/n/hfg add $180.97 15157 Cult epiderm grft f/n/hfg +% $199.81 15170 Acell graft trunk/arms/legs $427.16 15171 Acell graft t/arm/leg add-on $94.93 15175 Acellular graft, f/n/hf/g $541.94 15176 Acell graft, f/n/hf/g add-on $152.25

Page 4Page 4 Updated Fee Schedule - April 1

15200 Skin full graft, trunk $813.55 15201 Skin full graft trunk add-on $152.61 15220 Skin full graft sclp/arm/leg $777.66 15221 Skin full graft add-on $142.41 15240 Skin full grft face/genit/hf $928.97 15241 Skin full graft add-on $188.71 15260 Skin full graft een & lips $1,002.44 15261 Skin full graft add-on $218.81 15300 Apply skinallogrft, t/arm/lg $344.56 15301 Apply sknallogrft t/a/l addl $64.61 15320 Apply skin allogrft f/n/hf/g $387.78 15321 Aply sknallogrft f/n/hfg add $96.07 15330 Aply acell alogrft t/arm/leg $320.99 15331 Aply acell grft t/a/l add-on $64.61 15335 Apply acell graft, f/n/hf/g $336.19 15336 Aply acell grft f/n/hf/g add $89.66 15340 Apply cult skin substitute $322.10 15341 Apply cult skin sub add-on $48.22 15360 Apply cult derm sub, t/a/l $366.75 15361 Aply cult derm sub t/a/l add $71.77 15365 Apply cult derm sub f/n/hf/g $358.92 15366 Apply cult derm f/hf/g add $88.38 15400 Apply skin xenograft, t/a/l $400.93 15401 Apply skn xenogrft t/a/l add $96.67 15420 Apply skin xgraft, f/n/hf/g $452.22$ 15421 Apply skn xgrft f/n/hf/g add $117.16 15430 Apply acellular xenograft $531.88 15570 Form skin pedicle flap $895.34 15572 Form skin pedicle flap $866.44 15574 Form skin pedicle flap $913.12 15576 Form skin pedicle flap $810.77 15600 Skin graft $339.73 15610 Skin graft $338.90 15620 Skin graft $446.24 15630 Skin graft $470.79 15650 Transfer skin pedicle flap $523.90 15731 Forehead flap w/vasc pedicle $1,142.56 15732 Muscle-skin graft, head/neck $1,508.18 15734 Muscle-skin graft, trunk $1,558.32 15736 Muscle-skin graft, arm $1,385.21 15738 Muscle-skin graft, leg $1,472.42 15740 Island pedicle flap graft $1,025.14 15750 Neurovascular pedicle graft $925.91 15756 Free myo/skin flap microvasc $2,423.53 15757 Free skin flap, microvasc $2,390.17 15758 Free fascial flap, microvasc $2,396.16 15760 Composite skin graft $852.98 15770 Derma-fat-fascia graft $666.13 15775 Hair transplant punch grafts $330.33 15776 Hair transplant punch grafts $457.03 15780 Abrasion treatment of skin $845.84 15781 Abrasion treatment of skin $545.52

Page 5Page 5 Updated Fee Schedule - April 1

15782 Abrasion treatment of skin $582.58 15783 Abrasion treatment of skin $497.12 15786 Abrasion, lesion, single $244.18 15787 Abrasion, lesions, add-on $51.01 15788 Chemical peel, face, epiderm $444.18 15789 Chemical peel, face, dermal $579.84 15792 Chemical peel, nonfacial $438.46 15793 Chemical peel, nonfacial $484.32 15819 Plastic surgery, neck $743.01 15820 Revision of lower eyelid $538.00 15821 Revision of lower eyelid $570.81 15822 Revision of upper eyelid $423.42 15823 Revision of upper eyelid $661.67 15830 Exc skin abd $1,192.08 15832 Excise excessive skin tissue $902.60 15833 Excise excessive skin tissue $852.66 15834 Excise excessive skin tissue $847.46 15835 Excise excessive skin tissue $894.36 15836 Excise excessive skin tissue $747.43 15837 Excise excessive skin tissue $781.67 15838 Excise excessive skin tissue $579.82 15839 Excise excessive skin tissue $864.48 15840 Graft for face nerve palsy $1,020.61 15841 Graft for face nerve palsy $1,703.39 15842 Flap for face nerve palsy $2,696.49$ 15845 Skin and muscle repair, face $952.61 15850 Removal of sutures $94.25 15851 Removal of sutures $95.75 15852 Dressing change not for burn $48.55 15860 Test for blood flow in graft $115.25 15920 Removal of tail bone ulcer $592.80 15922 Removal of tail bone ulcer $754.98 15931 Remove sacrum pressure sore $670.90 15933 Remove sacrum pressure sore $830.84 15934 Remove sacrum pressure sore $922.45 15935 Remove sacrum pressure sore $1,101.31 15936 Remove sacrum pressure sore $895.13 15937 Remove sacrum pressure sore $1,048.68 15940 Remove hip pressure sore $691.20 15941 Remove hip pressure sore $904.15 15944 Remove hip pressure sore $889.04 15945 Remove hip pressure sore $988.15 15946 Remove hip pressure sore $1,644.96 15950 Remove thigh pressure sore $575.44 15951 Remove thigh pressure sore $819.88 15952 Remove thigh pressure sore $861.05 15953 Remove thigh pressure sore $960.11 15956 Remove thigh pressure sore $1,152.79 15958 Remove thigh pressure sore $1,179.19 16000 Initial treatment of burn(s) $69.47 16020 Dress/debrid p-thick burn, s $83.35 16025 Dress/debrid p-thick burn, m $148.65

Page 6Page 6 Updated Fee Schedule - April 1

16030 Dress/debrid p-thick burn, l $178.93 16035 Incision of burn scab, initi $218.25 16036 Escharotomy; addÆl incision $86.91 17000 Destruct premalg lesion $81.23 17003 Destruct premalg les, 2-14 $7.73 17004 Destroy premlg lesions 15+ $179.29 17106 Destruction of skin lesions $352.75 17107 Destruction of skin lesions $469.46 17108 Destruction of skin lesions $594.96 17110 Destruct b9 lesion, 1-14 $114.09 17111 Destruct lesion, 15 or more $134.29 17250 Chemical cautery, tissue $77.22 17260 Destruction of skin lesions $96.66 17261 Destruction of skin lesions $145.78 17262 Destruction of skin lesions $176.60 17263 Destruction of skin lesions $194.57 17264 Destruction of skin lesions $207.82 17266 Destruction of skin lesions $235.20 17270 Destruction of skin lesions $150.32 17271 Destruction of skin lesions $165.97 17272 Destruction of skin lesions $189.54 17273 Destruction of skin lesions $211.27 17274 Destruction of skin lesions $248.91 17276 Destruction of skin lesions $287.40 17280 Destruction of skin lesions $141.83$ 17281 Destruction of skin lesions $179.39 17282 Destruction of skin lesions $207.84 17283 Destruction of skin lesions $250.13 17284 Destruction of skin lesions $289.72 17286 Destruction of skin lesions $364.65 17311 Mohs, 1 stage, h/n/hf/g $710.85 17312 Mohs addl stage $428.79 17313 Mohs, 1 stage, t/a/l $649.48 17314 Mohs, addl stage, t/a/l $397.07 17315 Mohs surg, addl block $84.02 17340 Cryotherapy of skin $48.73 17360 Skin peel therapy $134.01 19000 Drainage of breast lesion $119.50 19001 Drain breast lesion add-on $28.78 19020 Incision of breast lesion $444.11 19030 Injection for breast x-ray $181.42 19100 Bx breast percut w/o image $144.86 19101 Biopsy of breast, open $328.19 19102 Bx breast percut w/image $237.86 19103 Bx breast percut w/device $608.12 19105 Cryosurg ablate fa, each $2,400.43 19110 Nipple exploration $457.68 19112 Excise breast duct fistula $430.09 19120 Removal of breast lesion $465.87 19125 Excision, breast lesion $514.97 19126 Excision, addl breast lesion $162.21 19260 Removal of chest wall lesion $1,209.13

Page 7Page 7 Updated Fee Schedule - April 1

19271 Revision of chest wall $1,654.44 19272 Extensive chest wall surgery $1,829.65 19290 Place needle wire, breast $177.53 19291 Place needle wire, breast $76.25 19295 Place breast clip, percut $103.61 19296 Place po breast cath for rad $4,301.31 19297 Place breast cath for rad $93.65 19298 Place breast rad tube/caths $1,432.98 19300 Removal of breast tissue $503.47 19301 Partical mastectomy $601.63 19302 P-mastectomy w/ln removal $869.99 19303 Mast, simple, complete $928.78 19304 Mast, subq $550.30 19305 Mast, radical $1,083.14 19306 Mast, rad, urban type $1,137.20 19307 Mast, mod rad $1,143.99 19316 Suspension of breast $789.02 19318 Reduction of large breast $1,167.67 19324 Enlarge breast $480.41 19325 Enlarge breast with implant $657.64 19328 Removal of breast implant $496.00 19330 Removal of implant material $636.80 19340 Immediate breast prosthesis $409.56 19342 Delayed breast prosthesis $935.95 19350 Breast reconstruction $868.94$ 19355 Correct inverted nipple(s) $713.04 19357 Breast reconstruction $1,573.35 19361 Breast reconstr w/lat flap $1,680.75 19364 Breast reconstruction $2,859.44 19366 Breast reconstruction $1,406.93 19367 Breast reconstruction $1,855.57 19368 Breast reconstruction $2,299.50 19369 Breast reconstruction $2,089.18 19370 Surgery of breast capsule $690.51 19371 Removal of breast capsule $797.31 19380 Revise breast reconstruction $778.72 19396 Design custom breast implant $225.70 20000 Incision of abscess $210.02 20005 Incision of deep abscess $310.31 20100 Explore wound, neck $596.94 20101 Explore wound, chest $408.09 20102 Explore wound, abdomen $476.38 20103 Explore wound, extremity $578.12 20150 Excise epiphyseal bar $984.09 20200 Muscle biopsy $199.04 20205 Deep muscle biopsy $269.26 20206 Needle biopsy, muscle $282.60 20220 Bone biopsy, trocar/needle $190.64 20225 Bone biopsy, trocar/needle $741.33 20240 Bone biopsy, excisional $235.21 20245 Bone biopsy, excisional $643.86 20250 Open bone biopsy $389.99

Page 8Page 8 Updated Fee Schedule - April 1

20251 Open bone biopsy $433.04 20500 Injection of sinus tract $121.12 20501 Inject sinus tract for x-ray $140.60 20520 Removal of foreign body $195.36 20525 Removal of foreign body $483.89 20526 Ther injection, carp tunnel $77.96 20550 Inj tendon sheath/ligament $60.40 20551 Inj tendon origin/insertion $59.58 20552 Inj trigger point, 1/2 muscl $53.98 20553 Inject trigger points, =/> 3 $60.29 20555 Place ndl musc/tis for rt $344.86 20600 Drain/inject, joint/bursa $56.86 20605 Drain/inject, joint/bursa $61.09 20610 Drain/inject, joint/bursa $79.72 20612 Aspirate/inj ganglion cyst $60.80 20615 Treatment of bone cyst $223.08 20650 Insert and remove bone pin $202.96 20660 Apply, rem fixation device $259.18 20661 Application of head brace $484.67 20662 Application of pelvis brace $490.34 20663 Application of thigh brace $458.36 20664 Halo brace application $783.07 20665 Removal of fixation device $126.17 20670 Removal of support implant $416.80 20680 Removal of support implant $607.03$ 20690 Apply bone fixation device $546.40 20692 Apply bone fixation device $1,022.74 20693 Adjust bone fixation device $474.07 20694 Remove bone fixation device $439.03 20696 Comp multiplane ext fixation $1,110.01 20696 80 Comp multiplane ext fixation $177.60 20697 Comp ext fixate strut change $1,453.55 20697 80 Comp ext fixate strut change $232.57 20802 Replantation, arm, complete $2,494.71 20805 Replant forearm, complete $3,063.03 20808 Replantation hand, complete $4,199.92 20816 Replantation digit, complete $2,350.68 20822 Replantation digit, complete $2,000.07 20824 Replantation thumb, complete $2,341.29 20827 Replantation thumb, complete $2,075.43 20838 Replantation foot, complete $2,500.16 20900 Removal of bone for graft $447.39 20902 Removal of bone for graft $386.24 20910 Remove cartilage for graft $445.38 20912 Remove cartilage for graft $496.48 20920 Removal of fascia for graft $418.84 20922 Removal of fascia for graft $626.06 20924 Removal of tendon for graft $521.27 20926 Removal of tissue for graft $449.77 20931 Sp bone algrft struct add-on $118.80 20937 Sp bone agrft morsel add-on $179.45 20938 Sp bone agrft struct add-on $195.34

Page 9Page 9 Updated Fee Schedule - April 1

20950 Fluid pressure, muscle $260.64 20955 Fibula bone graft, microvasc $2,627.07 20956 Iliac bone graft, microvasc $2,763.01 20957 Mt bone graft, microvasc $2,615.89 20962 Other bone graft, microvasc $2,711.28 20969 Bone/skin graft, microvasc $2,899.04 20970 Bone/skin graft, iliac crest $2,935.57 20972 Bone/skin graft, metatarsal $2,645.68 20973 Bone/skin graft, great toe $2,772.02 20974 Electrical bone stimulation $68.39 20975 Electrical bone stimulation $186.05 20979 Us bone stimulation $55.35 20982 Ablate, bone tumor(s) perq $4,101.78 20985 Cptr-asst dir ms px $158.93 21010 Incision of jaw joint $739.69 21015 Resection of facial tumor $437.36 21025 Excision of bone, lower jaw $909.75 21026 Excision of facial bone(s) $606.67 21029 Contour of face bone lesion $766.05 21030 Excise max/zygoma b9 tumor $506.82 21031 Remove exostosis, mandible $393.45 21032 Remove exostosis, maxilla $398.63 21034 Excise max/zygoma mlg tumor $1,354.30 21040 Excise mandible lesion $511.21 21044 Removal of jaw bone lesion $894.68$ 21045 Extensive jaw surgery $1,243.23 21046 Remove mandible cyst complex $1,118.76 21047 Excise lwr jaw cyst w/repair $1,329.69 21048 Remove maxilla cyst complex $1,130.21 21049 Excis uppr jaw cyst w/repair $1,283.22 21050 Removal of jaw joint $887.52 21060 Remove jaw joint cartilage $808.09 21070 Remove coronoid process $660.83 21073 Mnpj of tmj w/anesth $379.09 21076 Prepare face/oral prosthesis $992.07 21077 Prepare face/oral prosthesis $2,437.15 21079 Prepare face/oral prosthesis $1,672.66 21080 Prepare face/oral prosthesis $1,903.05 21081 Prepare face/oral prosthesis $1,735.14 21082 Prepare face/oral prosthesis $1,619.59 21083 Prepare face/oral prosthesis $1,541.33 21084 Prepare face/oral prosthesis $1,742.77 21085 Prepare face/oral prosthesis $709.10 21086 Prepare face/oral prosthesis $1,779.98 21087 Prepare face/oral prosthesis $1,770.81 21100 Maxillofacial fixation $741.27 21110 Interdental fixation $775.95 21116 Injection, jaw joint x-ray $158.53 21120 Reconstruction of chin $643.30 21121 Reconstruction of chin $793.36 21122 Reconstruction of chin $740.10 21123 Reconstruction of chin $880.04

Page 10Page 10 Updated Fee Schedule - April 1

21125 Augmentation, lower jaw bone $3,228.28 21127 Augmentation, lower jaw bone $3,850.97 21137 Reduction of forehead $737.18 21138 Reduction of forehead $920.62 21139 Reduction of forehead $1,022.13 21141 Reconstruct midface, lefort $1,382.79 21142 Reconstruct midface, lefort $1,359.20 21143 Reconstruct midface, lefort $1,404.29 21145 Reconstruct midface, lefort $1,577.71 21146 Reconstruct midface, lefort $1,690.77 21147 Reconstruct midface, lefort $1,723.28 21150 Reconstruct midface, lefort $1,717.56 21151 Reconstruct midface, lefort $2,090.67 21154 Reconstruct midface, lefort $2,096.78 21155 Reconstruct midface, lefort $2,409.01 21159 Reconstruct midface, lefort $2,910.21 21160 Reconstruct midface, lefort $2,939.25 21172 Reconstruct orbit/forehead $1,821.57 21175 Reconstruct orbit/forehead $2,207.72 21179 Reconstruct entire forehead $1,511.98 21180 Reconstruct entire forehead $1,727.97 21181 Contour cranial bone lesion $724.85 21182 Reconstruct cranial bone $2,078.69 21183 Reconstruct cranial bone $2,341.01 21184 Reconstruct cranial bone $2,506.31$ 21188 Reconstruction of midface $1,666.05 21193 Reconst lwr jaw w/o graft $1,270.54 21194 Reconst lwr jaw w/graft $1,444.56 21195 Reconst lwr jaw w/o fixation $1,366.68 21196 Reconst lwr jaw w/fixation $1,491.86 21198 Reconstr lwr jaw segment $1,177.25 21199 Reconstr lwr jaw w/advance $1,045.23 21206 Reconstruct upper jaw bone $1,157.92 21208 Augmentation of facial bones $1,802.62 21209 Reduction of facial bones $841.75 21210 Face bone graft $2,171.61 21215 Lower jaw bone graft $3,744.48 21230 Rib cartilage graft $783.27 21235 Ear cartilage graft $741.42 21240 Reconstruction of jaw joint $1,137.39 21242 Reconstruction of jaw joint $1,040.84 21243 Reconstruction of jaw joint $1,707.48 21244 Reconstruction of lower jaw $1,069.98 21245 Reconstruction of jaw $1,163.85 21246 Reconstruction of jaw $868.88 21247 Reconstruct lower jaw bone $1,653.03 21248 Reconstruction of jaw $1,095.30 21249 Reconstruction of jaw $1,513.37 21255 Reconstruct lower jaw bone $1,486.83 21256 Reconstruction of orbit $1,189.44 21260 Revise eye sockets $1,350.30 21261 Revise eye sockets $2,295.98

Page 11Page 11 Updated Fee Schedule - April 1

21263 Revise eye sockets $2,059.94 21267 Revise eye sockets $1,582.63 21268 Revise eye sockets $1,966.81 21270 Augmentation, cheek bone $926.00 21275 Revision, orbitofacial bones $822.77 21280 Revision of eyelid $532.34 21282 Revision of eyelid $354.98 21295 Revision of jaw muscle/bone $179.83 21296 Revision of jaw muscle/bone $434.58 21310 Treatment of nose fracture $111.72 21315 Treatment of nose fracture $270.42 21320 Treatment of nose fracture $259.77 21325 Treatment of nose fracture $485.43 21330 Treatment of nose fracture $592.14 21335 Treatment of nose fracture $753.70 21336 Treat nasal septal fracture $658.78 21337 Treat nasal septal fracture $401.38 21338 Treat nasoethmoid fracture $761.62 21339 Treat nasoethmoid fracture $842.65 21340 Treatment of nose fracture $820.67 21343 Treatment of sinus fracture $1,178.70 21344 Treatment of sinus fracture $1,532.04 21345 Treat nose/jaw fracture $820.45 21346 Treat nose/jaw fracture $979.16 21347 Treat nose/jaw fracture $1,133.80$ 21348 Treat nose/jaw fracture $1,186.78 21355 Treat cheek bone fracture $446.72 21356 Treat cheek bone fracture $502.07 21360 Treat cheek bone fracture $539.44 21365 Treat cheek bone fracture $1,119.05 21366 Treat cheek bone fracture $1,247.68 21385 Treat eye socket fracture $727.90 21386 Treat eye socket fracture $675.19 21387 Treat eye socket fracture $759.14 21390 Treat eye socket fracture $778.78 21395 Treat eye socket fracture $980.05 21400 Treat eye socket fracture $182.17 21401 Treat eye socket fracture $487.29 21406 Treat eye socket fracture $549.08 21407 Treat eye socket fracture $649.12 21408 Treat eye socket fracture $891.10 21421 Treat mouth roof fracture $751.72 21422 Treat mouth roof fracture $684.97 21423 Treat mouth roof fracture $810.92 21431 Treat craniofacial fracture $757.05 21432 Treat craniofacial fracture $680.24 21433 Treat craniofacial fracture $1,727.16 21435 Treat craniofacial fracture $1,364.64 21436 Treat craniofacial fracture $2,005.50 21440 Treat dental ridge fracture $551.66 21445 Treat dental ridge fracture $775.78 21450 Treat lower jaw fracture $573.44

Page 12Page 12 Updated Fee Schedule - April 1

21451 Treat lower jaw fracture $753.39 21452 Treat lower jaw fracture $632.54 21453 Treat lower jaw fracture $871.46 21454 Treat lower jaw fracture $563.64 21461 Treat lower jaw fracture $2,006.24 21462 Treat lower jaw fracture $2,163.38 21465 Treat lower jaw fracture $928.51 21470 Treat lower jaw fracture $1,208.43 21480 Reset dislocated jaw $94.28 21485 Reset dislocated jaw $675.32 21490 Repair dislocated jaw $946.98 21495 Treat hyoid bone fracture $700.75 21497 Interdental wiring $683.08 21501 Drain neck/chest lesion $447.61 21502 Drain chest lesion $531.95 21510 Drainage of bone lesion $473.25 21550 Biopsy of neck/chest $263.81 21555 Remove lesion, neck/chest $438.82 21556 Remove lesion, neck/chest $420.25 21557 Remove tumor, neck/chest $589.76 21600 Partial removal of rib $566.69 21610 Partial removal of rib $1,097.63 21615 Removal of rib $686.94 21616 Removal of rib and nerves $881.85 21620 Partial removal of sternum $536.29$ 21627 Sternal debridement $565.73 21630 Extensive sternum surgery $1,302.18 21632 Extensive sternum surgery $1,283.92 21685 Hyoid myotomy & suspension $1,008.52 21700 Revision of neck muscle $428.05 21705 Revision of neck muscle/rib $663.33 21720 Revision of neck muscle $419.92 21725 Revision of neck muscle $547.59 21740 Reconstruction of sternum $1,114.68 21750 Repair of sternum separation $741.29 21800 Treatment of rib fracture $99.36 21805 Treatment of rib fracture $265.66 21810 Treatment of rib fracture(s) $511.72 21820 Treat sternum fracture $132.68 21825 Treat sternum fracture $582.80 21920 Biopsy soft tissue of back $263.07 21925 Biopsy soft tissue of back $427.79 21930 Remove lesion, back or flank $477.54 21935 Remove tumor, back $1,182.47 22010 I&d, p-spine, c/t/cerv-thor $921.14 22015 I&d, p-spine, l/s/ls $916.43 22100 Remove part of neck vertebra $840.32 22101 Remove part, thorax vertebra $835.52 22102 Remove part, lumbar vertebra $831.77 22103 Remove extra spine segment $149.99 22110 Remove part of neck vertebra $1,042.03 22112 Remove part, thorax vertebra $1,003.99

Page 13Page 13 Updated Fee Schedule - April 1

22114 Remove part, lumbar vertebra $1,033.13 22116 Remove extra spine segment $149.74 22206 Cut spine 3 col, thor $2,447.94 22207 Cut spine 3 col, lumb $2,415.77 22208 Cut spine 3 col, addl seg $616.96 22210 Revision of neck spine $1,819.86 22212 Revision of thorax spine $1,500.94 22214 Revision of lumbar spine $1,511.10 22216 Revise, extra spine segment $392.45 22220 Revision of neck spine $1,639.51 22222 Revision of thorax spine $1,476.01 22224 Revision of lumbar spine $1,613.55 22226 Revise, extra spine segment $390.69 22305 Treat spine process fracture $189.79 22310 Treat spine fracture $289.18 22315 Treat spine fracture $873.67 22318 Treat odontoid fx w/o graft $1,640.17 22319 Treat odontoid fx w/graft $1,801.25 22325 Treat spine fracture $1,431.70 22326 Treat neck spine fracture $1,493.84 22327 Treat thorax spine fracture $1,478.92 22328 Treat each add spine fx $295.37 22505 Manipulation of spine $126.26 22520 Percut vertebroplasty thor $2,479.76 22521 Percut vertebroplasty lumb $2,416.75$ 22522 Percut vertebroplasty addÆl $266.18 22523 Percut kyphoplasty, thor $637.50 22524 Percut kyphoplasty, lumbar $610.41 22525 Percut kyphoplasty, add-on $283.66 22526 Idet, single level $2,098.69 22527 Idet, 1 or more levels $1,637.42 22532 Lat thorax spine fusion $1,769.45 22533 Lat lumbar spine fusion $1,658.55 22534 Lat thor/lumb, addÆl seg $386.88 22548 Neck spine fusion $1,895.56 22554 Neck spine fusion $1,322.83 22556 Thorax spine fusion $1,690.17 22558 Lumbar spine fusion $1,541.69 22585 Additional spinal fusion $358.22 22590 Spine & skull spinal fusion $1,580.96 22595 Neck spinal fusion $1,500.46 22600 Neck spine fusion $1,288.31 22610 Thorax spine fusion $1,269.58 22612 Lumbar spine fusion $1,634.42 22614 Spine fusion, extra segment $417.53 22630 Lumbar spine fusion $1,579.05 22632 Spine fusion, extra segment $339.74 22800 Fusion of spine $1,392.49 22802 Fusion of spine $2,206.91 22804 Fusion of spine $2,545.33 22808 Fusion of spine $1,874.02 22810 Fusion of spine $2,081.73

Page 14Page 14 Updated Fee Schedule - April 1

22812 Fusion of spine $2,277.68 22818 Kyphectomy, 1-2 segments $2,304.79 22819 Kyphectomy, 3 or more $2,658.01 22830 Exploration of spinal fusion $833.06 22840 Insert spine fixation device $816.09 22842 Insert spine fixation device $817.36 22843 Insert spine fixation device $869.14 22844 Insert spine fixation device $1,062.92 22845 Insert spine fixation device $782.20 22846 Insert spine fixation device $812.02 22847 Insert spine fixation device $893.48 22848 Insert pelv fixation device $387.11 22849 Reinsert spinal fixation $1,345.48 22850 Remove spine fixation device $738.07 22851 Apply spine prosth device $434.80 22852 Remove spine fixation device $705.43 22855 Remove spine fixation device $1,143.36 22856 Cerv artific diskectomy $1,710.32 22856 80 Cerv artific diskectomy $273.65 22857 Lumbar artif diskectomy $1,754.05 22861 Revise cerv artific disc $2,053.18 22861 80 Revise cerv artific disc $328.51 22862 Revise lumbar artif disc $2,026.67 22864 Remove cerv artif disc $1,903.21 22864 80 Remove cerv artif disc $304.51$ 22865 Remove lumb artif disc $2,184.47 22900 Remove abdominal wall lesion $414.83 23000 Removal of calcium deposits $546.96 23020 Release shoulder joint $709.19 23030 Drain shoulder lesion $437.03 23031 Drain shoulder bursa $401.18 23035 Drain shoulder bone lesion $703.85 23040 Exploratory shoulder surgery $738.52 23044 Exploratory shoulder surgery $586.42 23065 Biopsy shoulder tissues $217.52 23066 Biopsy shoulder tissues $519.88 23075 Removal of shoulder lesion $264.76 23076 Removal of shoulder lesion $574.18 23077 Remove tumor of shoulder $1,207.81 23100 Biopsy of shoulder joint $500.76 23101 Shoulder joint surgery $459.90 23105 Remove shoulder joint lining $653.98 23106 Incision of collarbone joint $487.67 23107 Explore treat shoulder joint $679.28 23120 Partial removal, collar bone $589.41 23125 Removal of collar bone $721.67 23130 Remove shoulder bone, part $619.90 23140 Removal of bone lesion $524.13 23145 Removal of bone lesion $708.26 23146 Removal of bone lesion $616.01 23150 Removal of humerus lesion $669.12 23155 Removal of humerus lesion $812.05

Page 15Page 15 Updated Fee Schedule - April 1

23156 Removal of humerus lesion $690.42 23170 Remove collar bone lesion $541.61 23172 Remove shoulder blade lesion $555.10 23174 Remove humerus lesion $773.24 23180 Remove collar bone lesion $704.46 23182 Remove shoulder blade lesion $679.72 23184 Remove humerus lesion $766.65 23190 Partial removal of scapula $569.82 23195 Removal of head of humerus $772.28 23200 Removal of collar bone $906.92 23210 Removal of shoulder blade $949.47 23220 Partial removal of humerus $1,100.06 23221 Partial removal of humerus $1,282.38 23222 Partial removal of humerus $1,741.73 23330 Remove shoulder foreign body $229.86 23331 Remove shoulder foreign body $603.11 23332 Remove shoulder foreign body $911.49 23350 Injection for shoulder x-ray $167.94 23395 Muscle transfer,shoulder/arm $1,325.06 23397 Muscle transfers $1,185.97 23400 Fixation of shoulder blade $1,007.51 23405 Incision of tendon & muscle $650.07 23406 Incise tendon(s) & muscle(s) $810.52 23410 Repair rotator cuff, acute $863.81 23412 Repair rotator cuff, chronic $902.77$ 23415 Release of shoulder ligament $720.61 23420 Repair of shoulder $1,008.77 23430 Repair biceps tendon $763.55 23440 Remove/transplant tendon $786.69 23450 Repair shoulder capsule $985.29 23455 Repair shoulder capsule $1,050.45 23460 Repair shoulder capsule $1,137.47 23462 Repair shoulder capsule $1,114.05 23465 Repair shoulder capsule $1,163.62 23466 Repair shoulder capsule $1,147.38 23470 Reconstruct shoulder joint $1,264.63 23472 Reconstruct shoulder joint $1,562.92 23480 Revision of collar bone $847.90 23485 Revision of collar bone $1,000.19 23490 Reinforce clavicle $858.75 23491 Reinforce shoulder bones $1,054.02 23500 Treat clavicle fracture $209.76 23505 Treat clavicle fracture $345.51 23515 Treat clavicle fracture $717.73 23520 Treat clavicle dislocation $217.65 23525 Treat clavicle dislocation $336.61 23530 Treat clavicle dislocation $551.09 23532 Treat clavicle dislocation $636.76 23540 Treat clavicle dislocation $214.28 23545 Treat clavicle dislocation $308.98 23550 Treat clavicle dislocation $586.79 23552 Treat clavicle dislocation $675.48

Page 16Page 16 Updated Fee Schedule - April 1

23570 Treat shoulder blade fx $224.80 23575 Treat shoulder blade fx $382.12 23585 Treat scapula fracture $964.61 23600 Treat humerus fracture $315.18 23605 Treat humerus fracture $463.73 23615 Treat humerus fracture $890.06 23616 Treat humerus fracture $1,339.27 23620 Treat humerus fracture $259.93 23625 Treat humerus fracture $376.01 23630 Treat humerus fracture $763.43 23650 Treat shoulder dislocation $288.17 23655 Treat shoulder dislocation $385.47 23660 Treat shoulder dislocation $595.20 23665 Treat dislocation/fracture $417.39 23670 Treat dislocation/fracture $854.03 23675 Treat dislocation/fracture $545.02 23680 Treat dislocation/fracture $928.09 23700 Fixation of shoulder $200.17 23800 Fusion of shoulder joint $1,058.90 23802 Fusion of shoulder joint $1,281.50 23900 Amputation of arm & girdle $1,363.01 23920 Amputation at shoulder joint $1,106.99 23921 Amputation follow-up surgery $401.08 23930 Drainage of arm lesion $361.95 23931 Drainage of arm bursa $285.42$ 23935 Drain arm/elbow bone lesion $508.06 24000 Exploratory elbow surgery $482.77 24006 Release elbow joint $727.84 24065 Biopsy arm/elbow soft tissue $257.44 24066 Biopsy arm/elbow soft tissue $598.39 24075 Remove arm/elbow lesion $486.37 24076 Remove arm/elbow lesion $482.91 24077 Remove tumor of arm/elbow $830.56 24100 Biopsy elbow joint lining $412.83 24101 Explore/treat elbow joint $508.39 24102 Remove elbow joint lining $628.63 24105 Removal of elbow bursa $343.51 24110 Remove humerus lesion $596.41 24115 Remove/graft bone lesion $750.29 24116 Remove/graft bone lesion $890.26 24120 Remove elbow lesion $533.47 24125 Remove/graft bone lesion $613.02 24126 Remove/graft bone lesion $651.03 24130 Removal of head of radius $516.08 24134 Removal of arm bone lesion $772.61 24136 Remove radius bone lesion $609.55 24138 Remove elbow bone lesion $677.59 24140 Partial removal of arm bone $736.82 24145 Partial removal of radius $618.81 24147 Partial removal of elbow $644.91 24149 Radical resection of elbow $1,182.90 24150 Extensive humerus surgery $1,003.67

Page 17Page 17 Updated Fee Schedule - April 1

24151 Extensive humerus surgery $1,151.33 24152 Extensive radius surgery $752.74 24153 Extensive radius surgery $794.20 24155 Removal of elbow joint $872.55 24160 Remove elbow joint implant $619.54 24164 Remove radius head implant $506.69 24200 Removal of arm foreign body $200.17 24201 Removal of arm foreign body $563.42 24220 Injection for elbow x-ray $182.86 24300 Manipulate elbow w/anesth $401.85 24301 Muscle/tendon transfer $773.34 24305 Arm tendon lengthening $591.18 24310 Revision of arm tendon $484.71 24320 Repair of arm tendon $795.67 24330 Revision of arm muscles $735.57 24331 Revision of arm muscles $813.06 24332 Tenolysis, triceps $617.87 24340 Repair of biceps tendon $628.69 24341 Repair arm tendon/muscle $738.96 24342 Repair of ruptured tendon $808.92 24343 Repr elbow lat ligmnt w/tiss $719.01 24344 Reconstruct elbow lat ligmnt $1,117.27 24345 Repr elbw med ligmnt w/tissu $714.11 24346 Reconstruct elbow med ligmnt $1,119.67 24357 Repair elbow, perc $452.04$ 24358 Repair elbow w/deb, open $532.45 24359 Repair elbow deb/attch open $667.01 24360 Reconstruct elbow joint $928.54 24361 Reconstruct elbow joint $1,038.99 24362 Reconstruct elbow joint $1,100.75 24363 Replace elbow joint $1,531.69 24365 Reconstruct head of radius $656.74 24366 Reconstruct head of radius $702.66 24400 Revision of humerus $849.48 24410 Revision of humerus $1,082.11 24420 Revision of humerus $1,017.48 24430 Repair of humerus $1,075.68 24435 Repair humerus with graft $1,095.16 24470 Revision of elbow joint $645.05 24495 Decompression of forearm $674.51 24498 Reinforce humerus $900.79 24500 Treat humerus fracture $342.56 24505 Treat humerus fracture $496.82 24515 Treat humerus fracture $903.95 24516 Treat humerus fracture $892.98 24530 Treat humerus fracture $369.16 24535 Treat humerus fracture $620.06 24538 Treat humerus fracture $764.60 24545 Treat humerus fracture $934.65 24546 Treat humerus fracture $1,093.91 24560 Treat humerus fracture $308.20 24565 Treat humerus fracture $510.03

Page 18Page 18 Updated Fee Schedule - April 1

24566 Treat humerus fracture $715.19 24575 Treat humerus fracture $761.21 24576 Treat humerus fracture $325.01 24577 Treat humerus fracture $530.41 24579 Treat humerus fracture $861.44 24582 Treat humerus fracture $797.82 24586 Treat elbow fracture $1,133.97 24587 Treat elbow fracture $1,127.67 24600 Treat elbow dislocation $356.34 24605 Treat elbow dislocation $464.47 24615 Treat elbow dislocation $735.97 24620 Treat elbow fracture $558.43 24635 Treat elbow fracture $788.55 24640 Treat elbow dislocation $118.72 24650 Treat radius fracture $250.89 24655 Treat radius fracture $430.67 24665 Treat radius fracture $665.25 24666 Treat radius fracture $753.25 24670 Treat ulnar fracture $281.61 24675 Treat ulnar fracture $455.45 24685 Treat ulnar fracture $669.42 24800 Fusion of elbow joint $812.21 24802 Fusion/graft of elbow joint $1,032.72 24900 Amputation of upper arm $735.16 24920 Amputation of upper arm $730.83$ 24925 Amputation follow-up surgery $570.12 24930 Amputation follow-up surgery $774.26 24931 Amputate upper arm & implant $857.19 24935 Revision of amputation $1,037.96 25000 Incision of tendon sheath $358.54 25001 Incise flexor carpi radialis $336.80 25020 Decompress forearm 1 space $592.57 25023 Decompress forearm 1 space $1,128.26 25024 Decompress forearm 2 spaces $781.59 25025 Decompress forearm 2 spaces $1,194.42 25028 Drainage of forearm lesion $527.72 25031 Drainage of forearm bursa $386.57 25035 Treat forearm bone lesion $667.66 25040 Explore/treat wrist joint $586.26 25065 Biopsy forearm soft tissues $255.72 25066 Biopsy forearm soft tissues $387.38 25075 Removal forearm lesion subcu $338.13 25076 Removal forearm lesion deep $457.58 25077 Remove tumor, forearm/wrist $767.75 25085 Incision of wrist capsule $474.45 25100 Biopsy of wrist joint $353.22 25101 Explore/treat wrist joint $415.91 25105 Remove wrist joint lining $504.82 25107 Remove wrist joint cartilage $625.28 25109 Excise tendon forearm/wrist $532.30 25110 Remove wrist tendon lesion $371.31 25111 Remove wrist tendon lesion $321.77

Page 19Page 19 Updated Fee Schedule - April 1

25112 Reremove wrist tendon lesion $391.58 25115 Remove wrist/forearm lesion $824.44 25116 Remove wrist/forearm lesion $671.54 25118 Excise wrist tendon sheath $393.49 25119 Partial removal of ulna $520.11 25120 Removal of forearm lesion $574.28 25125 Remove/graft forearm lesion $664.83 25126 Remove/graft forearm lesion $673.34 25130 Removal of wrist lesion $460.86 25135 Remove & graft wrist lesion $573.69 25136 Remove & graft wrist lesion $508.85 25145 Remove forearm bone lesion $588.70 25150 Partial removal of ulna $594.97 25151 Partial removal of radius $661.15 25170 Extensive forearm surgery $915.64 25210 Removal of wrist bone $503.86 25215 Removal of wrist bones $648.17 25230 Partial removal of radius $446.74 25240 Partial removal of ulna $454.11 25246 Injection for wrist x-ray $185.13 25248 Remove forearm foreign body $450.99 25250 Removal of wrist prosthesis $534.54 25251 Removal of wrist prosthesis $725.67 25259 Manipulate wrist w/anesthes $402.93 25260 Repair forearm tendon/muscle $701.54$ 25263 Repair forearm tendon/muscle $700.21 25265 Repair forearm tendon/muscle $828.01 25270 Repair forearm tendon/muscle $564.94 25272 Repair forearm tendon/muscle $634.37 25274 Repair forearm tendon/muscle $749.44 25275 Repair forearm tendon sheath $686.08 25280 Revise wrist/forearm tendon $641.86 25290 Incise wrist/forearm tendon $548.86 25295 Release wrist/forearm tendon $598.70 25300 Fusion of tendons at wrist $699.49 25301 Fusion of tendons at wrist $666.64 25310 Transplant forearm tendon $694.87 25312 Transplant forearm tendon $801.54 25315 Revise palsy hand tendon(s) $858.78 25316 Revise palsy hand tendon(s) $988.91 25320 Repair/revise wrist joint $984.21 25332 Revise wrist joint $868.23 25335 Realignment of hand $983.70 25337 Reconstruct ulna/radioulnar $906.69 25350 Revision of radius $764.65 25355 Revision of radius $858.52 25360 Revision of ulna $742.77 25365 Revise radius & ulna $1,005.85 25370 Revise radius or ulna $1,095.62 25375 Revise radius & ulna $1,058.27 25390 Shorten radius or ulna $862.10 25391 Lengthen radius or ulna $1,091.73

Page 20Page 20 Updated Fee Schedule - April 1

25392 Shorten radius & ulna $1,106.64 25393 Lengthen radius & ulna $1,245.40 25394 Repair carpal bone, shorten $796.03 25400 Repair radius or ulna $904.50 25405 Repair/graft radius or ulna $1,145.56 25415 Repair radius & ulna $1,078.36 25420 Repair/graft radius & ulna $1,279.46 25425 Repair/graft radius or ulna $1,112.10 25426 Repair/graft radius & ulna $1,152.86 25430 Vasc graft into carpal bone $725.83 25431 Repair nonunion carpal bone $807.11 25440 Repair/graft wrist bone $800.90 25441 Reconstruct wrist joint $968.98 25442 Reconstruct wrist joint $825.34 25443 Reconstruct wrist joint $790.73 25444 Reconstruct wrist joint $845.35 25445 Reconstruct wrist joint $741.26 25446 Wrist replacement $1,213.10 25447 Repair wrist joint(s) $835.66 25449 Remove wrist joint implant $1,064.70 25450 Revision of wrist joint $623.13 25455 Revision of wrist joint $701.99 25490 Reinforce radius $783.74 25491 Reinforce ulna $828.78 25492 Reinforce radius and ulna $997.86$ 25500 Treat fracture of radius $255.92 25505 Treat fracture of radius $499.00 25515 Treat fracture of radius $687.38 25520 Treat fracture of radius $548.01 25525 Treat fracture of radius $832.94 25526 Treat fracture of radius $1,017.63 25530 Treat fracture of ulna $249.75 25535 Treat fracture of ulna $483.44 25545 Treat fracture of ulna $645.65 25560 Treat fracture radius & ulna $259.52 25565 Treat fracture radius & ulna $521.34 25574 Treat fracture radius & ulna $672.35 25575 Treat fracture radius/ulna $913.92 25600 Treat fracture radius/ulna $283.39 25605 Treat fracture radius/ulna $609.81 25606 Treat fx distal radial $676.94 25607 Treat fx rad extra-articul $727.47 25608 Treat fx rad intra-articul $830.87 25609 Treat fx radial 3+ frag $1,059.18 25622 Treat wrist bone fracture $291.01 25624 Treat wrist bone fracture $458.96 25628 Treat wrist bone fracture $730.02 25630 Treat wrist bone fracture $296.96 25635 Treat wrist bone fracture $433.55 25645 Treat wrist bone fracture $578.00 25650 Treat wrist bone fracture $309.09 25651 Pin ulnar styloid fracture $479.87

Page 21Page 21 Updated Fee Schedule - April 1

25652 Treat fracture ulnar styloid $629.57 25660 Treat wrist dislocation $399.05 25670 Treat wrist dislocation $623.28 25671 Pin radioulnar dislocation $528.13 25675 Treat wrist dislocation $423.73 25676 Treat wrist dislocation $645.98 25680 Treat wrist fracture $458.65 25685 Treat wrist fracture $748.86 25690 Treat wrist dislocation $467.86 25695 Treat wrist dislocation $646.42 25800 Fusion of wrist joint $765.04 25805 Fusion/graft of wrist joint $880.89 25810 Fusion/graft of wrist joint $887.89 25820 Fusion of hand bones $628.85 25825 Fuse hand bones with graft $772.57 25830 Fusion, radioulnar jnt/ulna $972.17 25900 Amputation of forearm $769.18 25905 Amputation of forearm $760.80 25907 Amputation follow-up surgery $665.34 25909 Amputation follow-up surgery $749.28 25915 Amputation of forearm $1,306.17 25920 Amputate hand at wrist $702.52 25922 Amputate hand at wrist $593.34 25924 Amputation follow-up surgery $686.08 25927 Amputation of hand $803.18$ 25929 Amputation follow-up surgery $571.58 25931 Amputation follow-up surgery $733.57 26010 Drainage of finger abscess $258.78 26011 Drainage of finger abscess $396.51 26020 Drain hand tendon sheath $432.17 26025 Drainage of palm bursa $421.70 26030 Drainage of palm bursa(s) $497.06 26034 Treat hand bone lesion $540.27 26035 Decompress fingers/hand $833.71 26037 Decompress fingers/hand $578.81 26040 Release palm contracture $311.26 26045 Release palm contracture $472.48 26055 Incise finger tendon sheath $580.85 26060 Incision of finger tendon $266.56 26070 Explore/treat hand joint $300.34 26075 Explore/treat finger joint $318.98 26080 Explore/treat finger joint $386.71 26100 Biopsy hand joint lining $324.33 26105 Biopsy finger joint lining $332.83 26110 Biopsy finger joint lining $319.35 26115 Removal hand lesion subcut $634.16 26116 Removal hand lesion, deep $486.34 26117 Remove tumor, hand/finger $659.00 26121 Release palm contracture $607.75 26123 Release palm contracture $828.92 26125 Release palm contracture $293.03 26130 Remove wrist joint lining $462.53

Page 22Page 22 Updated Fee Schedule - April 1

26135 Revise finger joint, each $560.14 26140 Revise finger joint, each $509.69 26145 Tendon excision, palm/finger $518.20 26160 Remove tendon sheath lesion $578.87 26170 Removal of palm tendon, each $408.14 26180 Removal of finger tendon $446.68 26185 Remove finger bone $532.48 26200 Remove hand bone lesion $457.91 26205 Remove/graft bone lesion $613.29 26210 Removal of finger lesion $444.30 26215 Remove/graft finger lesion $561.33 26230 Partial removal of hand bone $511.78 26235 Partial removal, finger bone $502.38 26236 Partial removal, finger bone $445.90 26250 Extensive hand surgery $591.73 26255 Extensive hand surgery $892.80 26260 Extensive finger surgery $554.29 26261 Extensive finger surgery $682.93 26262 Partial removal of finger $464.49 26320 Removal of implant from hand $347.76 26340 Manipulate finger w/anesth $317.61 26350 Repair finger/hand tendon $736.68 26352 Repair/graft hand tendon $832.28 26356 Repair finger/hand tendon $1,085.05 26357 Repair finger/hand tendon $892.87$ 26358 Repair/graft hand tendon $943.25 26370 Repair finger/hand tendon $794.45 26372 Repair/graft hand tendon $918.11 26373 Repair finger/hand tendon $872.81 26390 Revise hand/finger tendon $850.52 26392 Repair/graft hand tendon $997.40 26410 Repair hand tendon $586.52 26412 Repair/graft hand tendon $708.49 26415 Excision, hand/finger tendon $733.49 26416 Graft hand or finger tendon $780.67 26418 Repair finger tendon $590.71 26420 Repair/graft finger tendon $735.24 26426 Repair finger/hand tendon $587.84 26428 Repair/graft finger tendon $771.82 26432 Repair finger tendon $513.08 26433 Repair finger tendon $549.36 26434 Repair/graft finger tendon $655.66 26437 Realignment of tendons $639.68 26440 Release palm/finger tendon $646.86 26442 Release palm & finger tendon $968.46 26445 Release hand/finger tendon $602.03 26449 Release forearm/hand tendon $773.40 26450 Incision of palm tendon $413.17 26455 Incision of finger tendon $410.40 26460 Incise hand/finger tendon $399.36 26471 Fusion of finger tendons $629.99 26474 Fusion of finger tendons $604.74

Page 23Page 23 Updated Fee Schedule - April 1

26476 Tendon lengthening $589.39 26477 Tendon shortening $594.84 26478 Lengthening of hand tendon $645.04 26479 Shortening of hand tendon $637.99 26480 Transplant hand tendon $777.42 26483 Transplant/graft hand tendon $873.82 26485 Transplant palm tendon $838.50 26489 Transplant/graft palm tendon $898.00 26490 Revise thumb tendon $804.60 26492 Tendon transfer with graft $895.62 26494 Hand tendon/muscle transfer $815.08 26496 Revise thumb tendon $882.06 26497 Finger tendon transfer $882.48 26498 Finger tendon transfer $1,173.41 26499 Revision of finger $844.63 26500 Hand tendon reconstruction $642.46 26502 Hand tendon reconstruction $723.86 26508 Release thumb contracture $646.73 26510 Thumb tendon transfer $613.70 26516 Fusion of knuckle joint $721.35 26517 Fusion of knuckle joints $847.21 26518 Fusion of knuckle joints $853.95 26520 Release knuckle contracture $675.79 26525 Release finger contracture $678.57 26530 Revise knuckle joint $543.58$ 26531 Revise knuckle with implant $631.84 26535 Revise finger joint $405.39 26536 Revise/implant finger joint $689.56 26540 Repair hand joint $678.78 26541 Repair hand joint with graft $825.24 26542 Repair hand joint with graft $700.79 26545 Reconstruct finger joint $713.39 26546 Repair nonunion hand $996.65 26548 Reconstruct finger joint $783.21 26550 Construct thumb replacement $1,507.13 26551 Great toe-hand transfer $3,295.69 26553 Single transfer, toe-hand $2,808.87 26554 Double transfer, toe-hand $3,763.27 26555 Positional change of finger $1,405.50 26556 Toe joint transfer $2,903.00 26560 Repair of web finger $585.65 26561 Repair of web finger $925.16 26562 Repair of web finger $1,344.88 26565 Correct metacarpal flaw $694.21 26567 Correct finger deformity $701.22 26568 Lengthen metacarpal/finger $923.73 26580 Repair hand deformity $1,414.76 26587 Reconstruct extra finger $961.44 26590 Repair finger deformity $1,288.30 26591 Repair muscles of hand $452.36 26593 Release muscles of hand $612.51 26596 Excision constricting tissue $748.20

Page 24Page 24 Updated Fee Schedule - April 1

26600 Treat metacarpal fracture $270.55 26605 Treat metacarpal fracture $313.10 26607 Treat metacarpal fracture $442.63 26608 Treat metacarpal fracture $481.78 26615 Treat metacarpal fracture $553.27 26641 Treat thumb dislocation $354.01 26645 Treat thumb fracture $406.79 26650 Treat thumb fracture $483.86 26665 Treat thumb fracture $613.42 26670 Treat hand dislocation $319.31 26675 Treat hand dislocation $434.90 26676 Pin hand dislocation $505.28 26685 Treat hand dislocation $570.62 26686 Treat hand dislocation $630.38 26700 Treat knuckle dislocation $303.33 26705 Treat knuckle dislocation $398.92 26706 Pin knuckle dislocation $435.97 26715 Treat knuckle dislocation $555.01 26720 Treat finger fracture, each $187.79 26725 Treat finger fracture, each $334.46 26727 Treat finger fracture, each $473.48 26735 Treat finger fracture, each $577.43 26740 Treat finger fracture, each $218.78 26742 Treat finger fracture, each $365.10 26746 Treat finger fracture, each $700.41$ 26750 Treat finger fracture, each $174.43 26755 Treat finger fracture, each $306.42 26756 Pin finger fracture, each $418.46 26765 Treat finger fracture, each $470.07 26770 Treat finger dislocation $257.61 26775 Treat finger dislocation $372.90 26776 Pin finger dislocation $444.55 26785 Treat finger dislocation $510.89 26820 Thumb fusion with graft $807.89 26841 Fusion of thumb $751.12 26842 Thumb fusion with graft $812.71 26843 Fusion of hand joint $752.38 26844 Fusion/graft of hand joint $837.99 26850 Fusion of knuckle $714.32 26852 Fusion of knuckle with graft $815.53 26860 Fusion of finger joint $577.54 26861 Fusion of finger jnt, add-on $110.39 26862 Fusion/graft of finger joint $744.06 26863 Fuse/graft added joint $245.83 26910 Amputate metacarpal bone $730.79 26951 Amputation of finger/thumb $634.17 26952 Amputation of finger/thumb $665.14 26990 Drainage of pelvis lesion $630.57 26991 Drainage of pelvis bursa $714.46 26992 Drainage of bone lesion $989.41 27000 Incision of hip tendon $459.01 27001 Incision of hip tendon $555.69

Page 25Page 25 Updated Fee Schedule - April 1

27003 Incision of hip tendon $594.20 27005 Incision of hip tendon $751.58 27006 Incision of hip tendons $759.46 27025 Incision of hip/thigh fascia $914.79 27027 Buttock fasciotomy $890.15 27027 50 Buttock fasciotomy $1,335.23 27030 Drainage of hip joint $978.10 27033 Exploration of hip joint $1,012.66 27035 Denervation of hip joint $1,119.37 27036 Excision of hip joint/muscle $1,035.21 27040 Biopsy of soft tissues $349.96 27041 Biopsy of soft tissues $703.19 27047 Remove hip/pelvis lesion $631.52 27048 Remove hip/pelvis lesion $485.12 27049 Remove tumor, hip/pelvis $1,019.87 27050 Biopsy of sacroiliac joint $354.80 27052 Biopsy of hip joint $568.14 27054 Removal of hip joint lining $698.10 27057 Buttock fasciotomy w/dbrdmt $979.66 27057 50 Buttock fasciotomy w/dbrdmt $1,469.48 27060 Removal of ischial bursa $437.75 27062 Remove femur lesion/bursa $460.67 27065 Removal of hip bone lesion $512.63 27066 Removal of hip bone lesion $831.25 27067 Remove/graft hip bone lesion $1,047.62$ 27070 Partial removal of hip bone $870.61 27071 Partial removal of hip bone $935.20 27075 Extensive hip surgery $2,381.61 27076 Extensive hip surgery $1,648.62 27077 Extensive hip surgery $2,749.11 27078 Extensive hip surgery $1,045.75 27079 Extensive hip surgery $993.16 27080 Removal of tail bone $502.27 27086 Remove hip foreign body $252.48 27087 Remove hip foreign body $647.94 27090 Removal of hip prosthesis $859.02 27091 Removal of hip prosthesis $1,654.62 27093 Injection for hip x-ray $206.32 27095 Injection for hip x-ray $249.41 27096 Inject sacroiliac joint $187.78 27097 Revision of hip tendon $685.46 27098 Transfer tendon to pelvis $631.32 27100 Transfer of abdominal muscle $845.40 27105 Transfer of spinal muscle $882.35 27110 Transfer of iliopsoas muscle $985.40 27111 Transfer of iliopsoas muscle $877.11 27120 Reconstruction of hip socket $1,333.62 27122 Reconstruction of hip socket $1,144.39 27125 Partial hip replacement $1,162.66 27130 Total hip arthroplasty $1,499.46 27132 Total hip arthroplasty $1,750.33 27134 Revise hip joint replacement $2,029.40

Page 26Page 26 Updated Fee Schedule - April 1

27137 Revise hip joint replacement $1,548.16 27138 Revise hip joint replacement $1,611.25 27140 Transplant femur ridge $930.55 27146 Incision of hip bone $1,306.82 27147 Revision of hip bone $1,523.66 27151 Incision of hip bones $1,581.43 27156 Revision of hip bones $1,774.66 27158 Revision of pelvis $1,424.69 27161 Incision of neck of femur $1,266.73 27165 Incision/fixation of femur $1,412.17 27170 Repair/graft femur head/neck $1,223.76 27175 Treat slipped epiphysis $682.02 27176 Treat slipped epiphysis $944.68 27177 Treat slipped epiphysis $1,149.74 27178 Treat slipped epiphysis $932.88 27179 Revise head/neck of femur $1,004.80 27181 Treat slipped epiphysis $1,107.71 27185 Revision of femur epiphysis $717.02 27187 Reinforce hip bones $1,031.30 27193 Treat pelvic ring fracture $473.69 27194 Treat pelvic ring fracture $734.92 27200 Treat tail bone fracture $173.36 27202 Treat tail bone fracture $661.56 27215 Treat pelvic fracture(s) $763.03 27216 Treat pelvic ring fracture $1,110.92$ 27217 Treat pelvic ring fracture $1,052.32 27218 Treat pelvic ring fracture $1,433.21 27220 Treat hip socket fracture $534.03 27222 Treat hip socket fracture $1,008.86 27226 Treat hip wall fracture $1,071.16 27227 Treat hip fracture(s) $1,734.18 27228 Treat hip fracture(s) $1,985.06 27230 Treat thigh fracture $476.99 27232 Treat thigh fracture $798.66 27235 Treat thigh fracture $942.80 27236 Treat thigh fracture $1,229.50 27238 Treat thigh fracture $460.21 27240 Treat thigh fracture $984.42 27244 Treat thigh fracture $1,264.35 27245 Treat thigh fracture $1,319.94 27246 Treat thigh fracture $389.95 27248 Treat thigh fracture $779.22 27250 Treat hip dislocation $242.90 27252 Treat hip dislocation $776.26 27253 Treat hip dislocation $979.38 27254 Treat hip dislocation $1,321.48 27256 Treat hip dislocation $296.23 27257 Treat hip dislocation $342.75 27258 Treat hip dislocation $1,147.00 27259 Treat hip dislocation $1,606.14 27265 Treat hip dislocation $396.00 27266 Treat hip dislocation $594.18

Page 27Page 27 Updated Fee Schedule - April 1

27267 Cltx thigh fx $424.20 27268 Cltx thigh fx w/mnpj $524.11 27269 Optx thigh fx $1,251.50 27275 Manipulation of hip joint $184.98 27280 Fusion of sacroiliac joint $1,064.27 27282 Fusion of pubic bones $830.70 27284 Fusion of hip joint $1,602.18 27286 Fusion of hip joint $1,693.18 27290 Amputation of leg at hip $1,617.26 27295 Amputation of leg at hip $1,308.47 27301 Drain thigh/knee lesion $673.52 27303 Drainage of bone lesion $655.65 27305 Incise thigh tendon & fascia $478.56 27306 Incision of thigh tendon $389.07 27307 Incision of thigh tendons $477.62 27310 Exploration of knee joint $746.51 27323 Biopsy, thigh soft tissues $272.01 27324 Biopsy, thigh soft tissues $389.14 27325 Neurectomy, hamstring $538.37 27326 Neurectomy, popliteal $498.42 27327 Removal of thigh lesion $458.87 27328 Removal of thigh lesion $428.28 27329 Remove tumor, thigh/knee $1,060.57 27330 Biopsy, knee joint lining $409.74 27331 Explore/treat knee joint $484.22$ 27332 Removal of knee cartilage $655.82 27333 Removal of knee cartilage $594.59 27334 Remove knee joint lining $697.11 27335 Remove knee joint lining $788.01 27340 Removal of kneecap bursa $371.95 27345 Removal of knee cyst $490.11 27347 Remove knee cyst $523.95 27350 Removal of kneecap $666.61 27355 Remove femur lesion $618.08 27356 Remove femur lesion/graft $756.87 27357 Remove femur lesion/graft $840.59 27358 Remove femur lesion/fixation $303.06 27360 Partial removal, leg bone(s) $873.95 27365 Extensive leg surgery $1,266.60 27370 Injection for knee x-ray $177.34 27372 Removal of foreign body $609.84 27380 Repair of kneecap tendon $606.93 27381 Repair/graft kneecap tendon $825.48 27385 Repair of thigh muscle $649.82 27386 Repair/graft of thigh muscle $856.44 27390 Incision of thigh tendon $450.24 27391 Incision of thigh tendons $585.52 27392 Incision of thigh tendons $719.89 27393 Lengthening of thigh tendon $519.38 27394 Lengthening of thigh tendons $670.30 27395 Lengthening of thigh tendons $906.66 27396 Transplant of thigh tendon $630.31

Page 28Page 28 Updated Fee Schedule - April 1

27397 Transplants of thigh tendons $924.04 27400 Revise thigh muscles/tendons $699.11 27403 Repair of knee cartilage $659.61 27405 Repair of knee ligament $694.98 27407 Repair of knee ligament $791.61 27409 Repair of knee ligaments $995.57 27412 Autochondrocyte implant knee $1,722.37 27415 Osteochondral knee allograft $1,452.11 27416 Osteochondral knee autograft $995.95 27418 Repair degenerated kneecap $859.85 27420 Revision of unstable kneecap $770.80 27422 Revision of unstable kneecap $767.39 27424 Revision/removal of kneecap $769.71 27425 Lat retinacular release open $451.27 27427 Reconstruction, knee $738.88 27428 Reconstruction, knee $1,135.40 27429 Reconstruction, knee $1,271.11 27430 Revision of thigh muscles $762.58 27435 Incision of knee joint $817.49 27437 Revise kneecap $678.29 27438 Revise kneecap with implant $867.41 27440 Revision of knee joint $791.41 27441 Revision of knee joint $816.68 27442 Revision of knee joint $898.92 27443 Revision of knee joint $842.24$ 27445 Revision of knee joint $1,308.55 27446 Revision of knee joint $1,161.69 27447 Total knee arthroplasty $1,606.17 27448 Incision of thigh $847.87 27450 Incision of thigh $1,055.94 27454 Realignment of thigh bone $1,328.74 27455 Realignment of knee $976.36 27457 Realignment of knee $1,004.37 27465 Shortening of thigh bone $1,256.16 27466 Lengthening of thigh bone $1,226.26 27468 Shorten/lengthen thighs $1,387.75 27470 Repair of thigh $1,223.51 27472 Repair/graft of thigh $1,321.84 27475 Surgery to stop leg growth $673.45 27477 Surgery to stop leg growth $756.24 27479 Surgery to stop leg growth $977.90 27485 Surgery to stop leg growth $690.42 27486 Revise/replace knee joint $1,464.85 27487 Revise/replace knee joint $1,846.61 27488 Removal of knee prosthesis $1,240.08 27495 Reinforce thigh $1,176.05 27496 Decompression of thigh/knee $513.59 27497 Decompression of thigh/knee $555.78 27498 Decompression of thigh/knee $604.93 27499 Decompression of thigh/knee $673.01 27500 Treatment of thigh fracture $520.60 27501 Treatment of thigh fracture $510.64

Page 29Page 29 Updated Fee Schedule - April 1

27502 Treatment of thigh fracture $810.05 27503 Treatment of thigh fracture $826.41 27506 Treatment of thigh fracture $1,377.49 27507 Treatment of thigh fracture $1,022.30 27508 Treatment of thigh fracture $525.91 27509 Treatment of thigh fracture $661.22 27510 Treatment of thigh fracture $716.63 27511 Treatment of thigh fracture $1,057.02 27513 Treatment of thigh fracture $1,329.32 27514 Treatment of thigh fracture $1,077.61 27516 Treat thigh fx growth plate $492.64 27517 Treat thigh fx growth plate $687.55 27519 Treat thigh fx growth plate $973.10 27520 Treat kneecap fracture $313.16 27524 Treat kneecap fracture $778.52 27530 Treat knee fracture $392.12 27532 Treat knee fracture $623.14 27535 Treat knee fracture $943.03 27536 Treat knee fracture $1,228.69 27538 Treat knee fracture(s) $468.49 27540 Treat knee fracture $864.58 27550 Treat knee dislocation $490.70 27552 Treat knee dislocation $636.33 27556 Treat knee dislocation $956.67 27557 Treat knee dislocation $1,142.67$ 27558 Treat knee dislocation $1,276.92 27560 Treat kneecap dislocation $360.32 27562 Treat kneecap dislocation $469.49 27566 Treat kneecap dislocation $925.40 27570 Fixation of knee joint $151.33 27580 Fusion of knee $1,497.00 27590 Amputate leg at thigh $846.98 27591 Amputate leg at thigh $944.92 27592 Amputate leg at thigh $721.03 27594 Amputation follow-up surgery $525.40 27596 Amputation follow-up surgery $756.97 27598 Amputate lower leg at knee $771.48 27600 Decompression of lower leg $436.45 27601 Decompression of lower leg $453.11 27602 Decompression of lower leg $532.76 27603 Drain lower leg lesion $534.07 27604 Drain lower leg bursa $468.72 27605 Incision of achilles tendon $377.13 27606 Incision of achilles tendon $307.77 27607 Treat lower leg bone lesion $632.81 27610 Explore/treat ankle joint $676.00 27612 Exploration of ankle joint $588.46 27613 Biopsy lower leg soft tissue $254.77 27614 Biopsy lower leg soft tissue $572.42 27615 Remove tumor, lower leg $905.19 27618 Remove lower leg lesion $498.91 27619 Remove lower leg lesion $795.18

Page 30Page 30 Updated Fee Schedule - April 1

27620 Explore/treat ankle joint $477.10 27625 Remove ankle joint lining $614.42 27626 Remove ankle joint lining $664.72 27630 Removal of tendon lesion $550.77 27635 Remove lower leg bone lesion $613.60 27637 Remove/graft leg bone lesion $777.56 27638 Remove/graft leg bone lesion $809.64 27640 Partial removal of tibia $895.44 27641 Partial removal of fibula $717.06 27645 Extensive lower leg surgery $1,086.44 27646 Extensive lower leg surgery $959.42 27647 Extensive ankle/heel surgery $840.98 27648 Injection for ankle x-ray $170.75 27650 Repair achilles tendon $702.04 27652 Repair/graft achilles tendon $768.47 27654 Repair of achilles tendon $750.04 27656 Repair leg fascia defect $555.19 27658 Repair of leg tendon, each $397.83 27659 Repair of leg tendon, each $520.71 27664 Repair of leg tendon, each $380.17 27665 Repair of leg tendon, each $434.91 27675 Repair lower leg tendons $529.95 27676 Repair lower leg tendons $644.36 27680 Release of lower leg tendon $450.42 27681 Release of lower leg tendons $536.95$ 27685 Revision of lower leg tendon $649.29 27686 Revise lower leg tendons $585.52 27687 Revision of calf tendon $481.73 27690 Revise lower leg tendon $661.05 27691 Revise lower leg tendon $777.71 27692 Revise additional leg tendon $117.31 27695 Repair of ankle ligament $513.38 27696 Repair of ankle ligaments $609.68 27698 Repair of ankle ligament $685.14 27700 Revision of ankle joint $643.71 27702 Reconstruct ankle joint $1,036.76 27703 Reconstruction, ankle joint $1,198.41 27704 Removal of ankle implant $588.88 27705 Incision of tibia $796.52 27707 Incision of fibula $408.05 27709 Incision of tibia & fibula $1,145.64 27712 Realignment of lower leg $1,133.12 27715 Revision of lower leg $1,106.58 27720 Repair of tibia $911.87 27722 Repair/graft of tibia $909.26 27724 Repair/graft of tibia $1,333.77 27725 Repair of lower leg $1,243.20 27726 Repair fibula nonunion $935.26 27727 Repair of lower leg $1,006.18 27730 Repair of tibia epiphysis $613.38 27732 Repair of fibula epiphysis $411.90 27734 Repair lower leg epiphyses $615.44

Page 31Page 31 Updated Fee Schedule - April 1

27740 Repair of leg epiphyses $685.45 27742 Repair of leg epiphyses $719.12 27745 Reinforce tibia $783.15 27750 Treatment of tibia fracture $338.06 27752 Treatment of tibia fracture $540.90 27756 Treatment of tibia fracture $583.31 27758 Treatment of tibia fracture $918.35 27759 Treatment of tibia fracture $1,039.97 27760 Cltx medial ankle fx $325.81 27762 Cltx med ankle fx w/mnpj $484.60 27766 Optx medial ankle fx $630.48 27767 Cltx post ankle fx $257.66 27768 Cltx post ankle fx w/mnpj $412.12 27769 Optx post ankle fx $710.10 27780 Treatment of fibula fracture $291.57 27781 Treatment of fibula fracture $420.44 27784 Treatment of fibula fracture $707.68 27786 Treatment of ankle fracture $308.99 27788 Treatment of ankle fracture $423.93 27792 Treatment of ankle fracture $716.42 27808 Treatment of ankle fracture $323.93 27810 Treatment of ankle fracture $474.04 27814 Treatment of ankle fracture $804.17 27816 Treatment of ankle fracture $305.29 27818 Treatment of ankle fracture $487.23$ 27822 Treatment of ankle fracture $882.52 27823 Treatment of ankle fracture $1,003.45 27824 Treat lower leg fracture $305.38 27825 Treat lower leg fracture $554.27 27826 Treat lower leg fracture $841.23 27827 Treat lower leg fracture $1,125.89 27828 Treat lower leg fracture $1,341.07 27829 Treat lower leg joint $671.02 27830 Treat lower leg dislocation $354.34 27831 Treat lower leg dislocation $385.80 27832 Treat lower leg dislocation $717.67 27840 Treat ankle dislocation $351.35 27842 Treat ankle dislocation $495.91 27846 Treat ankle dislocation $765.88 27848 Treat ankle dislocation $866.57 27860 Fixation of ankle joint $185.31 27870 Fusion of ankle joint, open $1,088.07 27871 Fusion of tibiofibular joint $718.35 27880 Amputation of lower leg $947.76 27881 Amputation of lower leg $925.12 27882 Amputation of lower leg $648.91 27884 Amputation follow-up surgery $605.95 27886 Amputation follow-up surgery $690.81 27888 Amputation of foot at ankle $732.41 27889 Amputation of foot at ankle $710.28 27892 Decompression of leg $561.68 27893 Decompression of leg $569.47

Page 32Page 32 Updated Fee Schedule - April 1

27894 Decompression of leg $870.73 28001 Drainage of bursa of foot $276.94 28002 Treatment of foot infection $511.95 28003 Treatment of foot infection $701.63 28005 Treat foot bone lesion $643.54 28008 Incision of foot fascia $436.65 28010 Incision of toe tendon $240.85 28011 Incision of toe tendons $341.07 28020 Exploration of foot joint $520.62 28022 Exploration of foot joint $479.76 28024 Exploration of toe joint $456.47 28035 Decompression of tibia nerve $523.20 28043 Excision of foot lesion $347.86 28045 Excision of foot lesion $488.96 28046 Resection of tumor, foot $880.54 28050 Biopsy of foot joint lining $460.95 28052 Biopsy of foot joint lining $424.91 28054 Biopsy of toe joint lining $400.04 28055 Neurectomy, foot $416.69 28060 Partial removal, foot fascia $514.48 28062 Removal of foot fascia $603.15 28070 Removal of foot joint lining $511.06 28072 Removal of foot joint lining $506.42 28080 Removal of foot lesion $494.49 28086 Excise foot tendon sheath $544.65$ 28088 Excise foot tendon sheath $462.86 28090 Removal of foot lesion $464.07 28092 Removal of toe lesions $420.59 28100 Removal of ankle/heel lesion $599.31 28102 Remove/graft foot lesion $589.69 28103 Remove/graft foot lesion $474.50 28104 Removal of foot lesion $512.42 28106 Remove/graft foot lesion $499.34 28107 Remove/graft foot lesion $569.08 28108 Removal of toe lesions $431.81 28110 Part removal of metatarsal $454.86 28111 Part removal of metatarsal $516.13 28112 Part removal of metatarsal $489.66 28113 Part removal of metatarsal $582.12 28114 Removal of metatarsal heads $1,054.59 28116 Revision of foot $749.76 28118 Removal of heel bone $587.07 28119 Removal of heel spur $522.37 28120 Part removal of ankle/heel $582.26 28122 Partial removal of foot bone $671.36 28124 Partial removal of toe $478.55 28126 Partial removal of toe $388.93 28130 Removal of ankle bone $668.35 28140 Removal of metatarsal $632.24 28150 Removal of toe $432.44 28153 Partial removal of toe $403.87 28160 Partial removal of toe $414.89

Page 33Page 33 Updated Fee Schedule - April 1

28171 Extensive foot surgery $650.66 28173 Extensive foot surgery $749.53 28175 Extensive foot surgery $551.85 28190 Removal of foot foreign body $248.90 28192 Removal of foot foreign body $474.35 28193 Removal of foot foreign body $541.82 28200 Repair of foot tendon $474.66 28202 Repair/graft of foot tendon $627.14 28208 Repair of foot tendon $457.42 28210 Repair/graft of foot tendon $584.49 28220 Release of foot tendon $450.44 28222 Release of foot tendons $518.43 28225 Release of foot tendon $392.60 28226 Release of foot tendons $471.46 28230 Incision of foot tendon(s) $433.32 28232 Incision of toe tendon $386.15 28234 Incision of foot tendon $401.08 28238 Revision of foot tendon $686.92 28240 Release of big toe $446.16 28250 Revision of foot fascia $565.64 28260 Release of midfoot joint $687.57 28261 Revision of foot tendon $988.86 28262 Revision of foot and ankle $1,392.35 28264 Release of midfoot joint $891.87 28270 Release of foot contracture $481.97$ 28272 Release of toe joint, each $394.06 28280 Fusion of toes $529.61 28285 Repair of hammertoe $466.89 28286 Repair of hammertoe $455.92 28288 Partial removal of foot bone $583.93 28289 Repair hallux rigidus $735.14 28290 Correction of bunion $577.35 28292 Correction of bunion $779.17 28293 Correction of bunion $1,042.34 28294 Correction of bunion $753.63 28296 Correction of bunion $741.95 28297 Correction of bunion $837.44 28298 Correction of bunion $722.55 28299 Correction of bunion $921.44 28300 Incision of heel bone $700.42 28302 Incision of ankle bone $692.36 28304 Incision of midfoot bones $801.03 28305 Incise/graft midfoot bones $726.76 28306 Incision of metatarsal $605.95 28307 Incision of metatarsal $717.15 28308 Incision of metatarsal $548.19 28309 Incision of metatarsals $938.78 28310 Revision of big toe $538.82 28312 Revision of toe $496.01 28313 Repair deformity of toe $520.12 28315 Removal of sesamoid bone $475.48 28320 Repair of foot bones $661.09

Page 34Page 34 Updated Fee Schedule - April 1

28322 Repair of metatarsals $782.78 28340 Resect enlarged toe tissue $619.96 28341 Resect enlarged toe $711.43 28344 Repair extra toe(s) $481.68 28345 Repair webbed toe(s) $577.99 28360 Reconstruct cleft foot $1,015.69 28400 Treatment of heel fracture $245.62 28405 Treatment of heel fracture $396.70 28406 Treatment of heel fracture $544.90 28415 Treat heel fracture $1,189.23 28420 Treat/graft heel fracture $1,248.96 28430 Treatment of ankle fracture $229.39 28435 Treatment of ankle fracture $322.43 28436 Treatment of ankle fracture $438.47 28445 Treat ankle fracture $1,119.06 28446 Osteochondral talus autogrft $1,219.78 28450 Treat midfoot fracture, each $212.27 28455 Treat midfoot fracture, each $292.66 28456 Treat midfoot fracture $282.79 28465 Treat midfoot fracture, each $634.87 28470 Treat metatarsal fracture $211.82 28475 Treat metatarsal fracture $266.92 28476 Treat metatarsal fracture $349.66 28485 Treat metatarsal fracture $547.77 28490 Treat big toe fracture $137.02$ 28495 Treat big toe fracture $172.43 28496 Treat big toe fracture $426.88 28505 Treat big toe fracture $659.40 28510 Treatment of toe fracture $118.13 28515 Treatment of toe fracture $155.58 28525 Treat toe fracture $559.72 28530 Treat sesamoid bone fracture $114.06 28531 Treat sesamoid bone fracture $375.04 28540 Treat foot dislocation $201.48 28545 Treat foot dislocation $248.76 28546 Treat foot dislocation $476.49 28555 Repair foot dislocation $865.50 28570 Treat foot dislocation $174.67 28575 Treat foot dislocation $334.78 28576 Treat foot dislocation $363.52 28585 Repair foot dislocation $919.14 28600 Treat foot dislocation $211.54 28605 Treat foot dislocation $272.28 28606 Treat foot dislocation $402.57 28615 Repair foot dislocation $800.90 28630 Treat toe dislocation $148.80 28635 Treat toe dislocation $178.74 28636 Treat toe dislocation $297.19 28645 Repair toe dislocation $622.00 28660 Treat toe dislocation $108.32 28665 Treat toe dislocation $158.01 28666 Treat toe dislocation $204.49

Page 35Page 35 Updated Fee Schedule - April 1

28675 Repair of toe dislocation $573.17 28705 Fusion of foot bones $1,373.09 28715 Fusion of foot bones $1,018.70 28725 Fusion of foot bones $838.25 28730 Fusion of foot bones $876.89 28735 Fusion of foot bones $837.15 28737 Revision of foot bones $740.90 28740 Fusion of foot bones $860.56 28750 Fusion of big toe joint $840.34 28755 Fusion of big toe joint $507.48 28760 Fusion of big toe joint $788.28 28800 Amputation of midfoot $598.88 28805 Amputation thru metatarsal $777.90 28810 Amputation toe & metatarsal $461.97 28820 Amputation of toe $537.27 28825 Partial amputation of toe $577.15 28890 High energy eswt, plantar f $352.64 29000 Application of body cast $275.22 29010 Application of body cast $251.48 29015 Application of body cast $240.13 29020 Application of body cast $231.14 29025 Application of body cast $263.29 29035 Application of body cast $245.39 29040 Application of body cast $234.57 29044 Application of body cast $265.30$ 29046 Application of body cast $289.27 29049 Application of figure eight $86.70 29055 Application of shoulder cast $209.60 29058 Application of shoulder cast $111.09 29065 Application of long arm cast $95.07 29075 Application of forearm cast $88.52 29085 Apply hand/wrist cast $93.82 29086 Apply finger cast $71.74 29105 Apply long arm splint $86.49 29125 Apply forearm splint $67.58 29126 Apply forearm splint $77.07 29130 Application of finger splint $40.32 29131 Application of finger splint $50.15 29200 Strapping of chest $53.25 29220 Strapping of low back $55.09 29240 Strapping of shoulder $59.67 29260 Strapping of elbow or wrist $52.21 29280 Strapping of hand or finger $50.10 29305 Application of hip cast $237.01 29325 Application of hip casts $263.31 29345 Application of long leg cast $136.19 29355 Application of long leg cast $140.31 29358 Apply long leg cast brace $153.90 29365 Application of long leg cast $122.45 29405 Apply short leg cast $89.95 29425 Apply short leg cast $96.97 29435 Apply short leg cast $119.38

Page 36Page 36 Updated Fee Schedule - April 1

29440 Addition of walker to cast $53.17 29445 Apply rigid leg cast $147.86 29450 Application of leg cast $155.01 29505 Application, long leg splint $76.39 29515 Application lower leg splint $71.18 29520 Strapping of hip $50.67 29530 Strapping of knee $52.93 29540 Strapping of ankle and/or ft $43.31 29550 Strapping of toes $42.31 29580 Application of paste boot $53.84 29590 Application of foot splint $56.80 29700 Removal/revision of cast $65.47 29705 Removal/revision of cast $68.40 29710 Removal/revision of cast $119.00 29715 Removal/revision of cast $90.53 29720 Repair of body cast $81.03 29730 Windowing of cast $66.35 29740 Wedging of cast $94.58 29750 Wedging of clubfoot cast $103.31 29800 Jaw arthroscopy/surgery $532.29 29804 Jaw arthroscopy/surgery $659.68 29805 Shoulder arthroscopy, dx $483.70 29806 Shoulder arthroscopy/surgery $1,100.74 29807 Shoulder arthroscopy/surgery $1,072.62 29819 Shoulder arthroscopy/surgery $605.32$ 29820 Shoulder arthroscopy/surgery $558.35 29821 Shoulder arthroscopy/surgery $610.10 29822 Shoulder arthroscopy/surgery $592.66 29823 Shoulder arthroscopy/surgery $648.40 29824 Shoulder arthroscopy/surgery $689.74 29825 Shoulder arthroscopy/surgery $604.44 29826 Shoulder arthroscopy/surgery $692.61 29827 Arthroscop rotator cuff repr $1,128.90 29828 Arthroscopy biceps tenodesis $943.28 29830 Elbow arthroscopy $466.19 29834 Elbow arthroscopy/surgery $508.19 29835 Elbow arthroscopy/surgery $521.58 29836 Elbow arthroscopy/surgery $598.19 29837 Elbow arthroscopy/surgery $546.51 29838 Elbow arthroscopy/surgery $610.38 29840 Wrist arthroscopy $456.63 29843 Wrist arthroscopy/surgery $490.46 29844 Wrist arthroscopy/surgery $509.51 29845 Wrist arthroscopy/surgery $578.88 29846 Wrist arthroscopy/surgery $535.59 29847 Wrist arthroscopy/surgery $555.62 29848 Wrist endoscopy/surgery $506.50 29850 Knee arthroscopy/surgery $585.44 29851 Knee arthroscopy/surgery $969.99 29855 Tibial arthroscopy/surgery $813.60 29856 Tibial arthroscopy/surgery $1,037.96 29860 Hip arthroscopy, dx $667.86

Page 37Page 37 Updated Fee Schedule - April 1

29861 Hip arthroscopy/surgery $740.74 29862 Hip arthroscopy/surgery $827.01 29863 Hip arthroscopy/surgery $816.06 29866 Autgrft implnt, knee w/scope $1,079.78 29867 Allgrft implnt, knee w/scope $1,303.72 29868 Meniscal trnspl, knee w/scpe $1,745.74 29870 Knee arthroscopy, dx $419.64 29871 Knee arthroscopy/drainage $527.11 29873 Knee arthroscopy/surgery $528.87 29874 Knee arthroscopy/surgery $550.90 29875 Knee arthroscopy/surgery $510.08 29876 Knee arthroscopy/surgery $667.58 29877 Knee arthroscopy/surgery $632.04 29879 Knee arthroscopy/surgery $676.09 29880 Knee arthroscopy/surgery $705.60 29881 Knee arthroscopy/surgery $657.69 29882 Knee arthroscopy/surgery $711.69 29883 Knee arthroscopy/surgery $869.75 29884 Knee arthroscopy/surgery $630.07 29885 Knee arthroscopy/surgery $763.90 29886 Knee arthroscopy/surgery $644.39 29887 Knee arthroscopy/surgery $759.53 29888 Knee arthroscopy/surgery $1,029.33 29889 Knee arthroscopy/surgery $1,257.23 29891 Ankle arthroscopy/surgery $715.26$ 29892 Ankle arthroscopy/surgery $728.27 29893 Scope, plantar fasciotomy $603.75 29894 Ankle arthroscopy/surgery $536.56 29895 Ankle arthroscopy/surgery $518.86 29897 Ankle arthroscopy/surgery $544.56 29898 Ankle arthroscopy/surgery $606.44 29899 Ankle arthroscopy/surgery $1,090.87 29900 Mcp joint arthroscopy, dx $470.08 29901 Mcp joint arthroscopy, surg $514.41 29902 Mcp joint arthroscopy, surg $549.27 29904 Subtalar arthro w/fb rmvl $634.61 29905 Subtalar arthro w/exc $683.64 29906 Subtalar arthro w/deb $720.54 29907 Subtalar arthro w/fusion $881.74 30000 Drainage of nose lesion $236.76 30020 Drainage of nose lesion $228.85 30100 Intranasal biopsy $143.38 30110 Removal of nose polyp(s) $230.58 30115 Removal of nose polyp(s) $441.31 30117 Removal of intranasal lesion $862.36 30118 Removal of intranasal lesion $785.13 30120 Revision of nose $530.46 30124 Removal of nose lesion $276.88 30125 Removal of nose lesion $630.05 30130 Excise inferior turbinate $387.18 30140 Resect inferior turbinate $444.78 30150 Partial removal of nose $808.72

Page 38Page 38 Updated Fee Schedule - April 1

30160 Removal of nose $809.83 30200 Injection treatment of nose $114.83 30210 Nasal sinus therapy $150.26 30220 Insert nasal septal button $299.15 30300 Remove nasal foreign body $233.22 30310 Remove nasal foreign body $210.20 30320 Remove nasal foreign body $462.87 30400 Reconstruction of nose $1,067.39 30410 Reconstruction of nose $1,259.14 30420 Reconstruction of nose $1,406.73 30430 Revision of nose $940.15 30435 Revision of nose $1,230.88 30450 Revision of nose $1,619.56 30460 Revision of nose $779.04 30462 Revision of nose $1,574.02 30465 Repair nasal stenosis $1,001.26 30520 Repair of nasal septum $614.85 30540 Repair nasal defect $686.77 30545 Repair nasal defect $997.80 30560 Release of nasal adhesions $276.09 30580 Repair upper jaw fistula $646.06 30600 Repair mouth/nose fistula $594.57 30620 Intranasal reconstruction $633.98 30630 Repair nasal septum defect $637.89 30801 Ablate inf turbinate, superf $231.89$ 30802 Cauterization, inner nose $296.55 30901 Control of nosebleed $106.57 30903 Control of nosebleed $198.65 30905 Control of nosebleed $247.12 30906 Repeat control of nosebleed $283.32 30915 Ligation, nasal sinus artery $588.28 30920 Ligation, upper jaw artery $843.90 30930 Ther fx, nasal inf turbinate $124.84 31000 Irrigation, maxillary sinus $183.09 31002 Irrigation, sphenoid sinus $206.71 31020 Exploration, maxillary sinus $497.96 31030 Exploration, maxillary sinus $717.07 31032 Explore sinus, remove polyps $583.88 31040 Exploration behind upper jaw $763.82 31050 Exploration, sphenoid sinus $506.50 31051 Sphenoid sinus surgery $660.38 31070 Exploration of frontal sinus $446.45 31075 Exploration of frontal sinus $801.89 31080 Removal of frontal sinus $1,035.50 31081 Removal of frontal sinus $1,281.44 31084 Removal of frontal sinus $1,206.50 31085 Removal of frontal sinus $1,281.05 31086 Removal of frontal sinus $1,140.50 31087 Removal of frontal sinus $1,130.86 31090 Exploration of sinuses $1,026.09 31200 Removal of ethmoid sinus $549.66 31201 Removal of ethmoid sinus $750.03

Page 39Page 39 Updated Fee Schedule - April 1

31205 Removal of ethmoid sinus $874.02 31225 Removal of upper jaw $1,860.09 31230 Removal of upper jaw $2,079.64 31231 Nasal endoscopy, dx $198.58 31233 Nasal/sinus endoscopy, dx $276.37 31235 Nasal/sinus endoscopy, dx $317.01 31237 Nasal/sinus endoscopy, surg $340.84 31238 Nasal/sinus endoscopy, surg $349.61 31239 Nasal/sinus endoscopy, surg $678.98 31240 Nasal/sinus endoscopy, surg $170.21 31254 Revision of ethmoid sinus $290.87 31255 Removal of ethmoid sinus $429.43 31256 Exploration maxillary sinus $211.03 31267 Endoscopy, maxillary sinus $339.31 31276 Sinus endoscopy, surgical $540.86 31287 Nasal/sinus endoscopy, surg $247.69 31288 Nasal/sinus endoscopy, surg $287.04 31290 Nasal/sinus endoscopy, surg $1,195.28 31291 Nasal/sinus endoscopy, surg $1,261.55 31292 Nasal/sinus endoscopy, surg $1,035.70 31293 Nasal/sinus endoscopy, surg $1,127.25 31294 Nasal/sinus endoscopy, surg $1,292.87 31300 Removal of larynx lesion $1,290.95 31320 Diagnostic incision, larynx $671.12 31360 Removal of larynx $2,029.00$ 31365 Removal of larynx $2,532.44 31367 Partial removal of larynx $2,206.20 31368 Partial removal of larynx $2,466.15 31370 Partial removal of larynx $2,083.56 31375 Partial removal of larynx $1,970.63 31380 Partial removal of larynx $1,943.87 31382 Partial removal of larynx $2,123.65 31390 Removal of larynx & pharynx $2,826.22 31395 Reconstruct larynx & pharynx $3,007.65 31400 Revision of larynx $1,031.98 31420 Removal of epiglottis $855.84 31500 Insert emergency airway $114.54 31502 Change of windpipe airway $36.93 31505 Diagnostic laryngoscopy $87.32 31510 Laryngoscopy with biopsy $220.78 31511 Remove foreign body, larynx $219.93 31512 Removal of larynx lesion $217.63 31513 Injection into vocal cord $139.27 31515 Laryngoscopy for aspiration $218.42 31520 Dx laryngoscopy, newborn $161.21 31525 Dx laryngoscopy excl nb $260.31 31526 Dx laryngoscopy w/oper scope $166.78 31527 Laryngoscopy for treatment $202.87 31528 Laryngoscopy and dilation $151.87 31529 Laryngoscopy and dilation $171.48 31530 Laryngoscopy w/fb removal $209.20 31531 Laryngoscopy w/fb & op scope $225.56

Page 40Page 40 Updated Fee Schedule - April 1

31535 Laryngoscopy w/biopsy $200.66 31536 Laryngoscopy w/bx & op scope $224.03 31540 Laryngoscopy w/exc of tumor $256.91 31541 Larynscop w/tumr exc + scope $281.01 31545 Remove vc lesion w/scope $378.33 31546 Remove vc lesion scope/graft $577.10 31560 Laryngoscop w/arytenoidectom $332.21 31561 Larynscop, remve cart + scop $363.86 31570 Laryngoscope w/vc inj $361.52 31571 Laryngoscop w/vc inj + scope $265.26 31575 Diagnostic laryngoscopy $121.26 31576 Laryngoscopy with biopsy $236.34 31577 Remove foreign body, larynx $253.66 31578 Removal of larynx lesion $294.47 31579 Diagnostic laryngoscopy $228.36 31580 Revision of larynx $1,234.74 31582 Revision of larynx $1,965.23 31584 Treat larynx fracture $1,562.26 31587 Revision of larynx $1,007.67 31588 Revision of larynx $1,159.64 31590 Reinnervate larynx $931.37 31595 Larynx nerve surgery $791.02 31600 Incision of windpipe $415.73 31601 Incision of windpipe $275.73 31603 Incision of windpipe $233.61$ 31605 Incision of windpipe $191.95 31610 Incision of windpipe $729.13 31611 Surgery/speech prosthesis $552.19 31612 Puncture/clear windpipe $84.25 31613 Repair windpipe opening $458.96 31614 Repair windpipe opening $755.31 31615 Visualization of windpipe $191.69 31620 Endobronchial us add-on $311.46 31622 Dx bronchoscope/wash $342.28 31623 Dx bronchoscope/brush $375.58 31624 Dx bronchoscope/lavage $347.90 31625 Bronchoscopy w/biopsy(s) $373.51 31628 Bronchoscopy/lung bx, each $449.84 31629 Bronchoscopy/needle bx, each $698.89 31630 Bronchoscopy dilate/fx repr $218.20 31631 Bronchoscopy, dilate w/stent $245.21 31632 Bronchoscopy/lung bx, addÆl $82.11 31633 Bronchoscopy/needle bx addÆl $97.90 31635 Bronchoscopy w/fb removal $382.45 31636 Bronchoscopy, bronch stents $239.29 31637 Bronchoscopy, stent add-on $84.56 31638 Bronchoscopy, revise stent $267.17 31640 Bronchoscopy w/tumor excise $279.22 31641 Bronchoscopy, treat blockage $274.34 31643 Diag bronchoscope/catheter $187.41 31645 Bronchoscopy, clear airways $333.56 31646 Bronchoscopy, reclear airway $303.92

Page 41Page 41 Updated Fee Schedule - April 1

31656 Bronchoscopy, inj for x-ray $353.23 31715 Injection for bronchus x-ray $58.94 31717 Bronchial brush biopsy $331.28 31720 Clearance of airways $55.38 31725 Clearance of airways $99.35 31730 Intro, windpipe wire/tube $961.37 31750 Repair of windpipe $1,383.94 31755 Repair of windpipe $1,767.33 31760 Repair of windpipe $1,464.67 31766 Reconstruction of windpipe $1,910.09 31770 Repair/graft of bronchus $1,410.43 31775 Reconstruct bronchus $1,457.40 31780 Reconstruct windpipe $1,232.02 31781 Reconstruct windpipe $1,489.43 31785 Remove windpipe lesion $1,126.77 31786 Remove windpipe lesion $1,576.95 31800 Repair of windpipe injury $725.78 31805 Repair of windpipe injury $873.32 31820 Closure of windpipe lesion $442.93 31825 Repair of windpipe defect $615.92 31830 Revise windpipe scar $446.88 32035 Exploration of chest $742.32 32036 Exploration of chest $804.97 32095 Biopsy through chest wall $660.65 32100 Exploration/biopsy of chest $1,020.64$ 32110 Explore/repair chest $1,530.30 32120 Re-exploration of chest $912.72 32124 Explore chest free adhesions $970.71 32140 Removal of lung lesion(s) $1,037.13 32141 Remove/treat lung lesions $1,544.34 32150 Removal of lung lesion(s) $1,044.83 32151 Remove lung foreign body $1,070.40 32160 Open chest heart massage $799.09 32200 Drain, open, lung lesion $1,173.78 32201 Drain, percut, lung lesion $1,040.03 32215 Treat chest lining $845.57 32220 Release of lung $1,687.58 32225 Partial release of lung $1,047.17 32310 Removal of chest lining $967.94 32320 Free/remove chest lining $1,686.68 32400 Needle biopsy chest lining $165.41 32402 Open biopsy chest lining $596.13 32405 Biopsy, lung or mediastinum $109.46 32420 Puncture/clear lung $120.08 32421 Thoracentesis for aspiration $173.94 32422 Thoracentesis w/tube insert $217.97 32440 Removal of lung $1,687.07 32442 Sleeve pneumonectomy $3,071.02 32445 Removal of lung $3,487.69 32480 Partial removal of lung $1,591.87 32482 Bilobectomy $1,698.20 32484 Segmentectomy $1,529.37

Page 42Page 42 Updated Fee Schedule - April 1

32486 Sleeve lobectomy $2,412.69 32488 Completion pneumonectomy $2,450.04 32491 Lung volume reduction $1,579.76 32500 Partial removal of lung $1,540.37 32501 Repair bronchus add-on $266.81 32503 Resect apical lung tumor $1,942.41 32504 Resect apical lung tum/chest $2,230.72 32540 Removal of lung lesion $1,740.00 32550 Insert pleural cath $882.26 32551 Insertion of chest tube $189.71 32560 Treat lung lining chemically $326.61 32601 Thoracoscopy, diagnostic $334.56 32602 Thoracoscopy, diagnostic $362.51 32603 Thoracoscopy, diagnostic $469.32 32604 Thoracoscopy, diagnostic $526.54 32605 Thoracoscopy, diagnostic $415.99 32606 Thoracoscopy, diagnostic $503.09 32650 Thoracoscopy, surgical $720.87 32651 Thoracoscopy, surgical $1,121.51 32652 Thoracoscopy, surgical $1,697.83 32653 Thoracoscopy, surgical $1,087.75 32654 Thoracoscopy, surgical $1,195.35 32655 Thoracoscopy, surgical $997.37 32656 Thoracoscopy, surgical $861.01 32657 Thoracoscopy, surgical $851.23$ 32658 Thoracoscopy, surgical $777.84 32659 Thoracoscopy, surgical $789.39 32660 Thoracoscopy, surgical $1,105.96 32661 Thoracoscopy, surgical $867.13 32662 Thoracoscopy, surgical $970.53 32663 Thoracoscopy, surgical $1,478.28 32664 Thoracoscopy, surgical $923.79 32665 Thoracoscopy, surgical $1,277.03 32800 Repair lung hernia $986.87 32810 Close chest after drainage $956.96 32815 Close bronchial fistula $2,771.87 32820 Reconstruct injured chest $1,421.07 32851 Lung transplant, single $2,769.15 32852 Lung transplant with bypass $3,069.03 32853 Lung transplant, double $3,304.31 32854 Lung transplant with bypass $3,599.16 32900 Removal of rib(s) $1,446.25 32905 Revise & repair chest wall $1,430.13 32906 Revise & repair chest wall $1,773.61 32940 Revision of lung $1,310.48 32960 Therapeutic pneumothorax $150.24 32997 Total lung lavage $378.09 32998 Perq rf ablate tx, pul tumor $3,224.40 33010 Drainage of heart sac $133.90 33011 Repeat drainage of heart sac $130.75 33015 Incision of heart sac $575.41 33020 Incision of heart sac $926.83

Page 43Page 43 Updated Fee Schedule - April 1

33025 Incision of heart sac $857.32 33030 Partial removal of heart sac $1,368.94 33031 Partial removal of heart sac $1,525.19 33050 Removal of heart sac lesion $1,060.20 33120 Removal of heart lesion $1,672.13 33130 Removal of heart lesion $1,470.90 33140 Heart revascularize (tmr) $1,668.30 33141 Heart tmr w/other procedure $166.87 33202 Insert epicard eltrd, open $837.48 33203 Insert epicard eltrd, endo $879.02 33206 Insertion of heart pacemaker $513.59 33207 Insertion of heart pacemaker $549.12 33208 Insertion of heart pacemaker $590.42 33210 Insertion of heart electrode $200.90 33211 Insertion of heart electrode $201.31 33212 Insertion of pulse generator $384.01 33213 Insertion of pulse generator $437.50 33214 Upgrade of pacemaker system $543.52 33215 Reposition pacing-defib lead $347.79 33216 Insert lead pace-defib, one $429.05 33217 Insert lead pace-defib, dual $425.57 33218 Repair lead pace-defib, one $443.90 33220 Repair lead pace-defib, dual $447.66 33222 Revise pocket, pacemaker $393.44 33223 Revise pocket, pacing-defib $472.86$ 33224 Insert pacing lead & connect $569.07 33225 L ventric pacing lead add-on $511.80 33226 Reposition l ventric lead $551.00 33233 Removal of pacemaker system $275.95 33234 Removal of pacemaker system $551.89 33235 Removal pacemaker electrode $715.04 33236 Remove electrode/thoracotomy $843.61 33237 Remove electrode/thoracotomy $931.73 33238 Remove electrode/thoracotomy $1,004.50 33240 Insert pulse generator $525.87 33241 Remove pulse generator $259.72 33243 Remove eltrd/thoracotomy $1,464.19 33244 Remove eltrd, transven $969.31 33249 Eltrd/insert pace-defib $1,021.22 33250 Ablate heart dysrhythm focus $1,570.56 33251 Ablate heart dysrhythm focus $1,739.33 33254 Ablate atria, lmtd $1,471.16 33255 Ablate atria w/o bypass, ext $1,798.04 33256 Ablate atria w/bypass, exten $2,144.14 33257 Ablate atria, lmtd, add-on $618.52 33258 Ablate atria, x10sv, add-on $698.55 33259 Ablate atria w/bypass add-on $915.45 33261 Ablate heart dysrhythm focus $1,728.84 33265 Ablate atria, lmtd, endo $1,467.64 33266 Ablate atria, x10sv, endo $2,011.92 33282 Implant pat-active ht record $368.31 33284 Remove pat-active ht record $267.50

Page 44Page 44 Updated Fee Schedule - April 1

33300 Repair of heart wound $2,435.06 33305 Repair of heart wound $4,039.77 33310 Exploratory heart surgery $1,255.29 33315 Exploratory heart surgery $1,593.67 33320 Repair major blood vessel(s) $1,135.24 33321 Repair major vessel $1,285.16 33322 Repair major blood vessel(s) $1,486.56 33330 Insert major vessel graft $1,495.49 33332 Insert major vessel graft $1,500.34 33335 Insert major vessel graft $2,022.67 33400 Repair of aortic valve $2,424.04 33401 Valvuloplasty, open $1,629.33 33403 Valvuloplasty, w/cp bypass $1,631.11 33404 Prepare heart-aorta conduit $1,925.96 33405 Replacement of aortic valve $2,489.75 33406 Replacement of aortic valve $3,051.76 33410 Replacement of aortic valve $2,692.87 33411 Replacement of aortic valve $3,500.98 33412 Replacement of aortic valve $2,696.87 33413 Replacement of aortic valve $3,468.97 33414 Repair of aortic valve $2,324.68 33415 Revision, subvalvular tissue $2,148.50 33416 Revise ventricle muscle $2,167.72 33417 Repair of aortic valve $1,818.13 33420 Revision of mitral valve $1,450.15$ 33422 Revision of mitral valve $1,821.74 33425 Repair of mitral valve $2,798.33 33426 Repair of mitral valve $2,563.94 33427 Repair of mitral valve $2,684.23 33430 Replacement of mitral valve $2,954.68 33460 Revision of tricuspid valve $2,486.88 33463 Valvuloplasty, tricuspid $3,134.62 33464 Valvuloplasty, tricuspid $2,542.59 33465 Replace tricuspid valve $2,838.65 33468 Revision of tricuspid valve $2,028.59 33470 Revision of pulmonary valve $1,265.06 33471 Valvotomy, pulmonary valve $1,434.93 33472 Revision of pulmonary valve $1,451.24 33474 Revision of pulmonary valve $2,181.90 33475 Replacement, pulmonary valve $2,480.91 33476 Revision of heart chamber $1,567.02 33478 Revision of heart chamber $1,702.45 33496 Repair, prosth valve clot $1,817.84 33500 Repair heart vessel fistula $1,706.00 33501 Repair heart vessel fistula $1,176.77 33502 Coronary artery correction $1,371.34 33503 Coronary artery graft $1,465.07 33504 Coronary artery graft $1,561.49 33505 Repair artery w/tunnel $2,103.74 33506 Repair artery, translocation $2,213.34 33507 Repair art, intramural $1,877.35 33508 Endoscopic vein harvest $17.42

Page 45Page 45 Updated Fee Schedule - April 1

33510 CABG, vein, single $2,117.47 33511 CABG, vein, two $2,307.13 33512 CABG, vein, three $2,589.89 33513 CABG, vein, four $2,643.34 33514 CABG, vein, five $2,797.98 33516 Cabg, vein, six or more $2,912.20 33517 CABG, artery-vein, single $199.17 33518 CABG, artery-vein, two $429.32 33519 CABG, artery-vein, three $573.98 33521 CABG, artery-vein, four $696.36 33522 CABG, artery-vein, five $795.08 33523 Cabg, art-vein, six or more $908.92 33530 Coronary artery, bypass/reop $545.45 33533 CABG, arterial, single $2,066.42 33534 CABG, arterial, two $2,393.23 33535 CABG, arterial, three $2,652.28 33536 Cabg, arterial, four or more $2,838.46 33542 Removal of heart lesion $2,717.51 33545 Repair of heart damage $3,205.30 33548 Restore/remodel, ventricle $3,162.15 33572 Open coronary endarterectomy $255.16 33600 Closure of valve $1,852.25 33602 Closure of valve $1,757.99 33606 Anastomosis/artery-aorta $1,920.09 33608 Repair anomaly w/conduit $1,976.91$ 33610 Repair by enlargement $1,926.25 33611 Repair double ventricle $2,103.84 33612 Repair double ventricle $2,179.84 33615 Repair, modified fontan $2,169.62 33617 Repair single ventricle $2,331.10 33619 Repair single ventricle $2,846.03 33641 Repair heart septum defect $1,724.13 33645 Revision of heart veins $1,710.91 33647 Repair heart septum defects $1,817.32 33660 Repair of heart defects $1,904.11 33665 Repair of heart defects $2,050.80 33670 Repair of heart chambers $2,133.41 33675 Close mult vsd $2,136.34 33676 Close mult vsd w/resection $2,228.99 33677 Cl mult vsd w/rem pul band $2,316.51 33681 Repair heart septum defect $1,982.26 33684 Repair heart septum defect $2,003.47 33688 Repair heart septum defect $2,020.33 33690 Reinforce pulmonary artery $1,242.92 33692 Repair of heart defects $1,912.28 33694 Repair of heart defects $2,153.96 33697 Repair of heart defects $2,313.32 33702 Repair of heart defects $1,657.38 33710 Repair of heart defects $2,025.56 33720 Repair of heart defect $1,683.31 33722 Repair of heart defect $1,640.61 33724 Repair venous anomaly $1,708.73

Page 46Page 46 Updated Fee Schedule - April 1

33726 Repair pul venous stenosis $2,222.86 33730 Repair heart-vein defect(s) $2,114.50 33732 Repair heart-vein defect $1,770.86 33735 Revision of heart chamber $1,341.41 33736 Revision of heart chamber $1,506.32 33737 Revision of heart chamber $1,409.13 33750 Major vessel shunt $1,406.54 33755 Major vessel shunt $1,399.05 33762 Major vessel shunt $1,395.46 33764 Major vessel shunt & graft $1,371.73 33766 Major vessel shunt $1,523.82 33767 Major vessel shunt $1,530.31 33768 Cavopulmonary shunting $464.26 33770 Repair great vessels defect $2,319.99 33771 Repair great vessels defect $2,372.07 33774 Repair great vessels defect $1,966.51 33775 Repair great vessels defect $2,045.62 33776 Repair great vessels defect $2,151.32 33777 Repair great vessels defect $2,110.30 33778 Repair great vessels defect $2,581.14 33779 Repair great vessels defect $2,435.77 33780 Repair great vessels defect $2,544.86 33781 Repair great vessels defect $2,519.34 33786 Repair arterial trunk $2,481.40 33788 Revision of pulmonary artery $1,683.65$ 33800 Aortic suspension $1,054.54 33802 Repair vessel defect $1,133.58 33803 Repair vessel defect $1,236.14 33813 Repair septal defect $1,411.15 33814 Repair septal defect $1,653.19 33820 Revise major vessel $1,059.95 33822 Revise major vessel $1,127.08 33824 Revise major vessel $1,271.87 33840 Remove aorta constriction $1,273.28 33845 Remove aorta constriction $1,487.94 33851 Remove aorta constriction $1,362.65 33852 Repair septal defect $1,465.93 33853 Repair septal defect $2,042.43 33860 Ascending aortic graft $3,357.15 33861 Ascending aortic graft $2,646.83 33863 Ascending aortic graft $3,365.04 33864 Ascending aortic graft $3,460.68 33870 Transverse aortic arch graft $2,761.90 33875 Thoracic aortic graft $2,141.39 33877 Thoracoabdominal graft $3,747.16 33880 Endovasc taa repr incl subcl $1,945.57 33881 Endovasc taa repr w/o subcl $1,671.02 33883 Insert endovasc prosth, taa $1,227.54 33884 Endovasc prosth, taa, add-on $445.93 33886 Endovasc prosth, delayed $1,054.87 33889 Artery transpose/endovas taa $880.49 33891 Car-car bp grft/endovas taa $1,100.65

Page 47Page 47 Updated Fee Schedule - April 1

33910 Remove lung artery emboli $1,791.00 33915 Remove lung artery emboli $1,411.73 33916 Surgery of great vessel $1,803.13 33917 Repair pulmonary artery $1,638.30 33920 Repair pulmonary atresia $1,961.26 33922 Transect pulmonary artery $1,485.80 33924 Remove pulmonary shunt $312.58 33925 Rpr pul art unifocal w/o cpb $1,914.86 33926 Repr pul art, unifocal w/cpb $2,525.81 33935 Transplantation, heart/lung $3,766.39 33945 Transplantation of heart $4,913.49 33960 External circulation assist $1,082.84 33961 External circulation assist $597.51 33967 Insert ia percut device $297.36 33968 Remove aortic assist device $38.19 33970 Aortic circulation assist $400.25 33971 Aortic circulation assist $773.47 33973 Insert balloon device $584.27 33974 Remove intra-aortic balloon $988.26 33975 Implant ventricular device $1,206.77 33976 Implant ventricular device $1,341.93 33977 Remove ventricular device $1,310.87 33978 Remove ventricular device $1,442.45 33979 Insert intracorporeal device $2,648.42 33980 Remove intracorporeal device $3,897.99$ 34001 Removal of artery clot $1,040.89 34051 Removal of artery clot $1,052.74 34101 Removal of artery clot $667.79 34111 Removal of arm artery clot $667.41 34151 Removal of artery clot $1,539.17 34201 Removal of artery clot $1,070.86 34203 Removal of leg artery clot $1,066.06 34401 Removal of vein clot $1,588.38 34421 Removal of vein clot $806.70 34451 Removal of vein clot $1,663.11 34471 Removal of vein clot $1,144.97 34490 Removal of vein clot $671.90 34501 Repair valve, femoral vein $1,043.47 34502 Reconstruct vena cava $1,682.26 34510 Transposition of vein valve $1,176.59 34520 Cross-over vein graft $1,130.28 34530 Leg vein fusion $1,060.16 34800 Endovas aaa repr w/sm tube $1,262.64 34802 Endovas aaa repr w/2-p part $1,373.75 34803 Endovas aaa repr w/3-p part $1,399.47 34804 Endovas aaa repr w/1-p part $1,372.63 34805 Endovas aaa repr w/long tube $1,285.81 34806 Aneurysm press sensor add-on $117.18 34808 Endovas iliac a device addon $229.68 34812 Xpose for endoprosth, femorl $382.46 34813 Femoral endovas graft add-on $263.98 34820 Xpose for endoprosth, iliac $547.15

Page 48Page 48 Updated Fee Schedule - April 1

34825 Endovasc extend prosth, init $773.17 34826 Endovasc exten prosth, addÆl $226.74 34830 Open aortic tube prosth repr $2,016.24 34831 Open aortoiliac prosth repr $2,132.33 34832 Open aortofemor prosth repr $2,165.10 34833 Xpose for endoprosth, iliac $680.28 34834 Xpose, endoprosth, brachial $308.97 34900 Endovasc iliac repr w/graft $1,004.73 35001 Repair defect of artery $1,256.92 35002 Repair artery rupture, neck $1,325.63 35005 Repair defect of artery $1,147.24 35011 Repair defect of artery $1,101.47 35013 Repair artery rupture, arm $1,365.19 35021 Repair defect of artery $1,341.68 35022 Repair artery rupture, chest $1,511.41 35045 Repair defect of arm artery $1,071.19 35081 Repair defect of artery $1,908.46 35082 Repair artery rupture, aorta $2,399.93 35091 Repair defect of artery $2,025.61 35092 Repair artery rupture, aorta $2,860.70 35102 Repair defect of artery $2,070.39 35103 Repair artery rupture, groin $2,479.86 35111 Repair defect of artery $1,531.63 35112 Repair artery rupture,spleen $1,872.64 35121 Repair defect of artery $1,817.64$ 35122 Repair artery rupture, belly $2,171.39 35131 Repair defect of artery $1,554.75 35132 Repair artery rupture, groin $1,871.61 35141 Repair defect of artery $1,232.37 35142 Repair artery rupture, thigh $1,472.76 35151 Repair defect of artery $1,388.63 35152 Repair artery rupture, knee $1,610.46 35180 Repair blood vessel lesion $919.16 35182 Repair blood vessel lesion $1,899.80 35184 Repair blood vessel lesion $1,118.24 35188 Repair blood vessel lesion $942.69 35189 Repair blood vessel lesion $1,747.70 35190 Repair blood vessel lesion $821.32 35201 Repair blood vessel lesion $1,030.02 35206 Repair blood vessel lesion $841.48 35207 Repair blood vessel lesion $770.55 35211 Repair blood vessel lesion $1,493.61 35216 Repair blood vessel lesion $2,048.05 35221 Repair blood vessel lesion $1,529.68 35226 Repair blood vessel lesion $928.60 35231 Repair blood vessel lesion $1,291.45 35236 Repair blood vessel lesion $1,074.40 35241 Repair blood vessel lesion $1,562.21 35246 Repair blood vessel lesion $1,695.49 35251 Repair blood vessel lesion $1,817.96 35256 Repair blood vessel lesion $1,129.51 35261 Repair blood vessel lesion $1,143.60

Page 49Page 49 Updated Fee Schedule - April 1

35266 Repair blood vessel lesion $946.58 35271 Repair blood vessel lesion $1,490.80 35276 Repair blood vessel lesion $1,566.38 35281 Repair blood vessel lesion $1,740.67 35286 Repair blood vessel lesion $1,038.24 35301 Rechanneling of artery $1,162.39 35302 Rechanneling of artery $1,233.92 35303 Rechanneling of artery $1,357.14 35304 Rechanneling of artery $1,410.77 35305 Rechanneling of artery $1,355.38 35306 Rechanneling of artery $504.87 35311 Rechanneling of artery $1,659.35 35321 Rechanneling of artery $988.92 35331 Rechanneling of artery $1,631.12 35341 Rechanneling of artery $1,535.81 35351 Rechanneling of artery $1,424.28 35355 Rechanneling of artery $1,157.34 35361 Rechanneling of artery $1,754.22 35363 Rechanneling of artery $1,912.31 35371 Rechanneling of artery $914.98 35372 Rechanneling of artery $1,096.98 35390 Reoperation, carotid add-on $178.44 35400 Angioscopy $168.79 35450 Repair arterial blockage $570.47 35452 Repair arterial blockage $396.86$ 35454 Repair arterial blockage $348.70 35456 Repair arterial blockage $421.57 35458 Repair arterial blockage $540.34 35459 Repair arterial blockage $497.23 35460 Repair venous blockage $345.01 35470 Repair arterial blockage $3,289.78 35471 Repair arterial blockage $3,610.74 35472 Repair arterial blockage $2,505.68 35473 Repair arterial blockage $2,396.01 35474 Repair arterial blockage $3,200.01 35475 Repair arterial blockage $2,564.93 35476 Repair venous blockage $1,943.37 35480 Atherectomy, open $617.29 35481 Atherectomy, open $449.08 35482 Atherectomy, open $391.85 35483 Atherectomy, open $473.05 35484 Atherectomy, open $585.72 35485 Atherectomy, open $548.08 35490 Atherectomy, percutaneous $676.46 35491 Atherectomy, percutaneous $454.77 35492 Atherectomy, percutaneous $412.07 35493 Atherectomy, percutaneous $502.48 35494 Atherectomy, percutaneous $635.09 35495 Atherectomy, percutaneous $581.94 35500 Harvest vein for bypass $356.78 35501 Artery bypass graft $1,733.08 35506 Artery bypass graft $1,466.05

Page 50Page 50 Updated Fee Schedule - April 1

35508 Artery bypass graft $1,513.59 35509 Artery bypass graft $1,665.15 35510 Artery bypass graft $1,382.22 35511 Artery bypass graft $1,312.62 35512 Artery bypass graft $1,347.21 35515 Artery bypass graft $1,455.61 35516 Artery bypass graft $1,329.08 35518 Artery bypass graft $1,336.23 35521 Artery bypass graft $1,403.72 35522 Artery bypass graft $1,317.76 35523 Artery bypass graft $1,397.62 35525 Artery bypass graft $1,237.98 35526 Artery bypass graft $1,833.96 35531 Artery bypass graft $2,237.96 35533 Artery bypass graft $1,734.31 35535 Artery bypass graft $2,226.31 35535 50 Artery bypass graft $3,339.47 35535 80 Artery bypass graft $356.21 35536 Artery bypass graft $1,931.03 35537 Artery bypass graft $2,394.28 35538 Artery bypass graft $2,687.61 35539 Artery bypass graft $2,488.96 35540 Artery bypass graft $2,788.55 35548 Artery bypass graft $1,332.62 35549 Artery bypass graft $1,449.91$ 35551 Artery bypass graft $1,652.32 35556 Artery bypass graft $1,526.03 35558 Artery bypass graft $1,357.50 35560 Artery bypass graft $1,974.73 35563 Artery bypass graft $1,512.58 35565 Artery bypass graft $1,465.93 35566 Artery bypass graft $1,830.00 35570 Artery bypass graft $1,721.54 35570 50 Artery bypass graft $2,582.31 35570 80 Artery bypass graft $275.45 35571 Artery bypass graft $1,487.39 35572 Harvest femoropopliteal vein $387.57 35583 Vein bypass graft $1,574.85 35585 Vein bypass graft $1,847.18 35587 Vein bypass graft $1,534.64 35600 Harvest art for cabg add-on $285.68 35601 Artery bypass graft $1,600.07 35606 Artery bypass graft $1,297.13 35612 Artery bypass graft $1,020.85 35616 Artery bypass graft $1,236.18 35621 Artery bypass graft $1,229.53 35623 Bypass graft, not vein $1,507.61 35626 Artery bypass graft $1,736.10 35631 Artery bypass graft $2,060.48 35632 Artery bypass graft $2,114.10 35632 50 Artery bypass graft $3,171.15 35632 80 Artery bypass graft $338.26

Page 51Page 51 Updated Fee Schedule - April 1

35633 Artery bypass graft $2,282.23 35633 50 Artery bypass graft $3,423.35 35633 80 Artery bypass graft $365.16 35634 Artery bypass graft $2,069.16 35634 50 Artery bypass graft $3,103.75 35634 80 Artery bypass graft $331.07 35636 Artery bypass graft $1,828.67 35637 Artery bypass graft $1,891.70 35638 Artery bypass graft $1,933.68 35642 Artery bypass graft $1,150.01 35645 Artery bypass graft $1,089.08 35646 Artery bypass graft $1,910.85 35647 Artery bypass graft $1,730.39 35650 Artery bypass graft $1,184.44 35651 Artery bypass graft $1,532.70 35654 Artery bypass graft $1,527.28 35656 Artery bypass graft $1,205.47 35661 Artery bypass graft $1,207.42 35663 Artery bypass graft $1,397.16 35665 Artery bypass graft $1,309.84 35666 Artery bypass graft $1,415.28 35671 Artery bypass graft $1,247.48 35681 Composite bypass graft $89.36 35682 Composite bypass graft $397.78 35683 Composite bypass graft $468.97$ 35685 Bypass graft patency/patch $223.35 35686 Bypass graft/av fist patency $187.22 35691 Arterial transposition $1,099.62 35693 Arterial transposition $979.15 35694 Arterial transposition $1,135.21 35695 Arterial transposition $1,182.09 35697 Reimplant artery each $166.29 35700 Reoperation, bypass graft $171.17 35701 Exploration, carotid artery $592.23 35721 Exploration, femoral artery $504.19 35741 Exploration popliteal artery $550.27 35761 Exploration of artery/vein $409.50 35800 Explore neck vessels $523.50 35820 Explore chest vessels $1,998.52 35840 Explore abdominal vessels $681.72 35860 Explore limb vessels $442.40 35870 Repair vessel graft defect $1,416.68 35875 Removal of clot in graft $657.22 35876 Removal of clot in graft $1,048.58 35879 Revise graft w/vein $1,026.36 35881 Revise graft w/vein $1,141.19 35883 Revise graft w/nonauto graft $1,327.56 35884 Revise graft w/vein $1,398.96 35901 Excision, graft, neck $555.98 35903 Excision, graft, extremity $627.88 35905 Excision, graft, thorax $1,928.26 35907 Excision, graft, abdomen $2,122.13

Page 52Page 52 Updated Fee Schedule - April 1

36000 Place needle in vein $28.31 36002 Pseudoaneurysm injection trt $187.01 36005 Injection ext venography $391.64 36010 Place catheter in vein $672.33 36011 Place catheter in vein $1,068.79 36012 Place catheter in vein $1,001.06 36013 Place catheter in artery $929.95 36014 Place catheter in artery $967.12 36015 Place catheter in artery $1,059.18 36100 Establish access to artery $609.06 36120 Establish access to artery $506.18 36140 Establish access to artery $560.52 36145 Artery to vein shunt $554.71 36160 Establish access to aorta $615.79 36200 Place catheter in aorta $747.58 36215 Place catheter in artery $1,319.79 36216 Place catheter in artery $1,441.52 36217 Place catheter in artery $2,362.65 36218 Place catheter in artery $220.07 36245 Place catheter in artery $1,458.77 36246 Place catheter in artery $1,429.63 36247 Place catheter in artery $2,256.14 36248 Place catheter in artery $188.44 36260 Insertion of infusion pump $628.76 36261 Revision of infusion pump $385.40$ 36262 Removal of infusion pump $294.71 36400 Bl draw < 3 yrs fem/jugular $27.84 36405 Bl draw < 3 yrs scalp vein $25.40 36406 Bl draw < 3 yrs other vein $18.65 36410 Non-routine bl draw > 3 yrs $20.84 36420 Vein access cutdown < 1 yr $51.82 36425 Vein access cutdown > 1 yr $41.19 36430 Blood transfusion service $43.53 36440 Bl push transfuse, 2 yr or < $54.97 36450 Bl exchange/transfuse, nb $126.99 36455 Bl exchange/transfuse non-nb $138.05 36460 Transfusion service, fetal $362.25 36470 Injection therapy of vein $152.33 36471 Injection therapy of veins $186.71 36475 Endovenous rf, 1st vein $2,025.28 36476 Endovenous rf, vein add-on $422.99 36478 Endovenous laser, 1st vein $1,661.99 36479 Endovenous laser vein addon $445.83 36481 Insertion of catheter, vein $452.37 36500 Insertion of catheter, vein $197.80 36510 Insertion of catheter, vein $120.84 36511 Apheresis wbc $95.85 36512 Apheresis rbc $97.61 36513 Apheresis platelets $101.84 36514 Apheresis plasma $591.81 36515 Apheresis, adsorp/reinfuse $2,236.52 36516 Apheresis, selective $2,536.85

Page 53Page 53 Updated Fee Schedule - April 1

36522 Photopheresis $1,576.92 36555 Insert non-tunnel cv cath $302.68 36556 Insert non-tunnel cv cath $257.51 36557 Insert tunneled cv cath $950.86 36558 Insert tunneled cv cath $921.23 36560 Insert tunneled cv cath $1,308.68 36561 Insert tunneled cv cath $1,296.22 36563 Insert tunneled cv cath $1,311.65 36565 Insert tunneled cv cath $1,091.07 36566 Insert tunneled cv cath $4,161.95 36568 Insert picc cath $350.71 36569 Insert picc cath $304.83 36570 Insert picvad cath $1,337.39 36571 Insert picvad cath $1,388.50 36575 Repair tunneled cv cath $184.69 36576 Repair tunneled cv cath $398.42 36578 Replace tunneled cv cath $562.91 36580 Replace cvad cath $263.39 36581 Replace tunneled cv cath $861.22 36582 Replace tunneled cv cath $1,198.19 36583 Replace tunneled cv cath $1,198.60 36584 Replace picc cath $260.30 36585 Replace picvad cath $1,234.36 36589 Removal tunneled cv cath $182.19 36590 Removal tunneled cv cath $299.16$ 36591 Draw blood off venous device $26.73 36592 Collect blood from picc $29.37 36593 Declot vascular device $44.96 36595 Mech remov tunneled cv cath $690.34 36596 Mech remov tunneled cv cath $155.55 36597 Reposition venous catheter $142.86 36598 Inj w/fluor, eval cv device $130.23 36600 Withdrawal of arterial blood $34.09 36620 Insertion catheter, artery $53.35 36625 Insertion catheter, artery $113.98 36640 Insertion catheter, artery $129.33 36660 Insertion catheter, artery $71.85 36680 Insert needle, bone cavity $63.60 36800 Insertion of cannula $172.08 36810 Insertion of cannula $226.61 36815 Insertion of cannula $161.49 36818 Av fuse, uppr arm, cephalic $738.27 36819 Av fuse, uppr arm, basilic $863.80 36820 Av fusion/forearm vein $866.94 36821 Av fusion direct any site $716.67 36822 Insertion of cannula(s) $412.79 36823 Insertion of cannula(s) $1,378.18 36825 Artery-vein autograft $628.18 36830 Artery-vein nonautograft $715.10 36831 Open thrombect av fistula $495.60 36832 Av fistula revision, open $630.96 36833 Av fistula revision $712.48

Page 54Page 54 Updated Fee Schedule - April 1

36834 Repair A-V aneurysm $668.13 36835 Artery to vein shunt $499.38 36838 Dist revas ligation, hemo $1,271.92 36860 External cannula declotting $210.30 36861 Cannula declotting $163.69 36870 Percut thrombect av fistula $2,122.10 37140 Revision of circulation $1,440.19 37145 Revision of circulation $1,569.82 37160 Revision of circulation $1,362.00 37180 Revision of circulation $1,525.72 37181 Splice spleen/kidney veins $1,647.48 37182 Insert hepatic shunt (tips) $977.28 37183 Remove hepatic shunt (tips) $465.22 37184 Prim art mech thrombectomy $2,780.83 37185 Prim art m-thrombect add-on $916.54 37186 Sec art m-thrombect add-on $1,880.14 37187 Venous mech thrombectomy $2,666.36 37188 Venous m-thrombectomy add-on $2,273.03 37200 Transcatheter biopsy $259.04 37201 Transcatheter therapy infuse $309.49 37202 Transcatheter therapy infuse $375.21 37203 Transcatheter retrieval $1,540.34 37204 Transcatheter occlusion $1,032.36 37205 Transcath iv stent, percut $3,847.24 37206 Transcath iv stent/perc addl $2,303.70$ 37207 Transcath iv stent, open $474.49 37208 Transcath iv stent/open addl $228.80 37209 Change iv cath at thromb tx $127.00 37210 Embolization uterine fibroid $4,070.11 37215 Transcath stent, cca w/eps $1,213.52 37216 Transcath stent, cca w/o eps $1,107.37 37250 Iv us first vessel add-on $121.43 37251 Iv us each add vessel add-on $90.51 37500 Endoscopy ligate perf veins $750.43 37565 Ligation of neck vein $740.39 37600 Ligation of neck artery $757.00 37605 Ligation of neck artery $868.68 37606 Ligation of neck artery $569.68 37607 Ligation of a-v fistula $406.80 37609 Temporal artery procedure $314.95 37615 Ligation of neck artery $500.79 37616 Ligation of chest artery $1,164.29 37617 Ligation of abdomen artery $1,378.61 37618 Ligation of extremity artery $402.95 37620 Revision of major vein $721.66 37650 Revision of major vein $549.07 37660 Revision of major vein $1,288.45 37700 Revise leg vein $272.53 37718 Ligate/strip short leg vein $436.56 37722 Ligate/strip long leg vein $511.09 37735 Removal of leg veins/lesion $682.13 37760 Ligation, leg veins, open $671.12

Page 55Page 55 Updated Fee Schedule - April 1

37765 Phleb veins - extrem - to 20 $478.68 37766 Phleb veins - extrem 20+ $579.05 37780 Revision of leg vein $280.89 37785 Ligate/divide/excise vein $384.06 37788 Revascularization, penis $1,483.73 37790 Penile venous occlusion $536.46 38100 Removal of spleen, total $1,111.29 38101 Removal of spleen, partial $1,118.77 38102 Removal of spleen, total $266.44 38115 Repair of ruptured spleen $1,234.25 38120 Laparoscopy, splenectomy $1,041.38 38200 Injection for spleen x-ray $147.81 38204 Bl donor search management $107.04 38205 Harvest allogenic stem cells $85.59 38206 Harvest auto stem cells $85.59 38207 Cryopreserve stem cells $53.24 38208 Thaw preserved stem cells $34.32 38209 Wash harvest stem cells $14.66 38210 T-cell depletion of harvest $94.53 38211 Tumor cell deplete of harvst $85.67 38212 Rbc depletion of harvest $56.74 38213 Platelet deplete of harvest $14.66 38214 Volume deplete of harvest $48.60 38215 Harvest stem cell concentrte $56.74 38220 Bone marrow aspiration $172.21$ 38221 Bone marrow biopsy $189.92 38230 Bone marrow collection $337.66 38240 Bone marrow/stem transplant $133.22 38241 Bone marrow/stem transplant $134.10 38242 Lymphocyte infuse transplant $101.36 38300 Drainage, lymph node lesion $282.20 38305 Drainage, lymph node lesion $468.19 38308 Incision of lymph channels $446.25 38380 Thoracic duct procedure $574.35 38381 Thoracic duct procedure $855.77 38382 Thoracic duct procedure $691.97 38500 Biopsy/removal, lymph nodes $324.64 38505 Needle biopsy, lymph nodes $138.52 38510 Biopsy/removal, lymph nodes $520.00 38520 Biopsy/removal, lymph nodes $466.47 38525 Biopsy/removal, lymph nodes $422.49 38530 Biopsy/removal, lymph nodes $543.44 38542 Explore deep node(s), neck $516.04 38550 Removal, neck/armpit lesion $482.58 38555 Removal, neck/armpit lesion $996.86 38562 Removal, pelvic lymph nodes $716.97 38564 Removal, abdomen lymph nodes $709.14 38570 Laparoscopy, lymph node biop $578.45 38571 Laparoscopy, lymphadenectomy $904.05 38572 Laparoscopy, lymphadenectomy $992.77 38700 Removal of lymph nodes, neck $797.01 38720 Removal of lymph nodes, neck $1,318.61

Page 56Page 56 Updated Fee Schedule - April 1

38724 Removal of lymph nodes, neck $1,428.59 38740 Remove armpit lymph nodes $673.31 38745 Remove armpit lymph nodes $855.12 38746 Remove thoracic lymph nodes $280.07 38747 Remove abdominal lymph nodes $271.38 38760 Remove groin lymph nodes $843.88 38765 Remove groin lymph nodes $1,304.72 38770 Remove pelvis lymph nodes $877.96 38780 Remove abdomen lymph nodes $1,107.01 38790 Inject for lymphatic x-ray $86.91 38792 Identify sentinel node $42.80 38794 Access thoracic lymph duct $331.50 39000 Exploration of chest $515.77 39010 Exploration of chest $852.39 39200 Removal chest lesion $941.45 39220 Removal chest lesion $1,210.46 39400 Visualization of chest $528.68 39501 Repair diaphragm laceration $861.26 39502 Repair paraesophageal hernia $1,030.43 39503 Repair of diaphragm hernia $5,927.74 39520 Repair of diaphragm hernia $1,033.29 39530 Repair of diaphragm hernia $986.59 39531 Repair of diaphragm hernia $1,028.91 39540 Repair of diaphragm hernia $877.55 39541 Repair of diaphragm hernia $946.59$ 39545 Revision of diaphragm $938.59 39560 Resect diaphragm, simple $807.71 39561 Resect diaphragm, complex $1,259.21 40490 Biopsy of lip $134.57 40500 Partial excision of lip $511.23 40510 Partial excision of lip $492.77 40520 Partial excision of lip $507.74 40525 Reconstruct lip with flap $571.68 40527 Reconstruct lip with flap $673.36 40530 Partial removal of lip $558.52 40650 Repair lip $422.65 40652 Repair lip $498.23 40654 Repair lip $585.68 40700 Repair cleft lip/nasal $944.76 40701 Repair cleft lip/nasal $1,178.48 40702 Repair cleft lip/nasal $907.67 40720 Repair cleft lip/nasal $1,011.73 40761 Repair cleft lip/nasal $1,096.17 40800 Drainage of mouth lesion $208.07 40801 Drainage of mouth lesion $315.02 40804 Removal, foreign body, mouth $211.60 40805 Removal, foreign body, mouth $329.87 40806 Incision of lip fold $111.87 40808 Biopsy of mouth lesion $187.59 40810 Excision of mouth lesion $206.97 40812 Excise/repair mouth lesion $289.08 40814 Excise/repair mouth lesion $387.07

Page 57Page 57 Updated Fee Schedule - April 1

40816 Excision of mouth lesion $407.06 40818 Excise oral mucosa for graft $360.56 40819 Excise lip or cheek fold $309.95 40820 Treatment of mouth lesion $272.35 40830 Repair mouth laceration $247.68 40831 Repair mouth laceration $328.38 40840 Reconstruction of mouth $826.03 40842 Reconstruction of mouth $812.41 40843 Reconstruction of mouth $1,054.45 40844 Reconstruction of mouth $1,401.31 40845 Reconstruction of mouth $1,515.91 41000 Drainage of mouth lesion $163.18 41005 Drainage of mouth lesion $232.47 41006 Drainage of mouth lesion $366.48 41007 Drainage of mouth lesion $368.29 41008 Drainage of mouth lesion $378.61 41009 Drainage of mouth lesion $402.31 41010 Incision of tongue fold $208.97 41015 Drainage of mouth lesion $431.82 41016 Drainage of mouth lesion $443.66 41017 Drainage of mouth lesion $447.17 41018 Drainage of mouth lesion $510.16 41019 Place needles h&n for rt $511.01 41100 Biopsy of tongue $172.90 41105 Biopsy of tongue $172.64$ 41108 Biopsy of floor of mouth $149.11 41110 Excision of tongue lesion $214.54 41112 Excision of tongue lesion $336.86 41113 Excision of tongue lesion $368.26 41114 Excision of tongue lesion $653.27 41115 Excision of tongue fold $250.10 41116 Excision of mouth lesion $331.28 41120 Partial removal of tongue $1,085.29 41130 Partial removal of tongue $1,325.84 41135 Tongue and neck surgery $2,187.31 41140 Removal of tongue $2,264.34 41145 Tongue removal, neck surgery $2,823.58 41150 Tongue, mouth, jaw surgery $2,233.79 41153 Tongue, mouth, neck surgery $2,412.91 41155 Tongue, jaw, & neck surgery $2,982.09 41250 Repair tongue laceration $231.99 41251 Repair tongue laceration $238.40 41252 Repair tongue laceration $312.58 41500 Fixation of tongue $465.32 41510 Tongue to lip surgery $426.26 41512 Tongue suspension $643.38 41520 Reconstruction, tongue fold $353.18 41530 Tongue base vol reduction $3,389.18 41800 Drainage of gum lesion $234.77 41805 Removal foreign body, gum $242.06 41806 Removal foreign body,jawbone $349.75 41822 Excision of gum lesion $293.11

Page 58Page 58 Updated Fee Schedule - April 1

41823 Excision of gum lesion $435.69 41825 Excision of gum lesion $211.07 41826 Excision of gum lesion $294.50 41827 Excision of gum lesion $434.47 41828 Excision of gum lesion $309.67 41830 Removal of gum tissue $393.57 41872 Repair gum $370.33 41874 Repair tooth socket $375.78 42000 Drainage mouth roof lesion $161.54 42100 Biopsy roof of mouth $152.49 42104 Excision lesion, mouth roof $213.68 42106 Excision lesion, mouth roof $271.24 42107 Excision lesion, mouth roof $465.80 42120 Remove palate/lesion $997.11 42140 Excision of uvula $257.01 42145 Repair palate, pharynx/uvula $719.41 42160 Treatment mouth roof lesion $247.42 42180 Repair palate $247.12 42182 Repair palate $336.47 42200 Reconstruct cleft palate $914.21 42205 Reconstruct cleft palate $974.15 42210 Reconstruct cleft palate $1,105.02 42215 Reconstruct cleft palate $730.34 42220 Reconstruct cleft palate $563.79 42225 Reconstruct cleft palate $983.10$ 42226 Lengthening of palate $973.34 42227 Lengthening of palate $947.21 42235 Repair palate $773.43 42260 Repair nose to lip fistula $857.31 42280 Preparation, palate mold $160.75 42281 Insertion, palate prosthesis $207.74 42300 Drainage of salivary gland $212.64 42305 Drainage of salivary gland $443.47 42310 Drainage of salivary gland $164.95 42320 Drainage of salivary gland $255.85 42330 Removal of salivary stone $237.83 42335 Removal of salivary stone $380.76 42340 Removal of salivary stone $476.02 42400 Biopsy of salivary gland $114.39 42405 Biopsy of salivary gland $311.29 42408 Excision of salivary cyst $466.18 42409 Drainage of salivary cyst $339.81 42410 Excise parotid gland/lesion $641.33 42415 Excise parotid gland/lesion $1,150.05 42420 Excise parotid gland/lesion $1,316.44 42425 Excise parotid gland/lesion $869.56 42426 Excise parotid gland/lesion $1,407.47 42440 Excise submaxillary gland $482.30 42450 Excise sublingual gland $464.88 42500 Repair salivary duct $443.90 42505 Repair salivary duct $572.35 42507 Parotid duct diversion $534.65

Page 59Page 59 Updated Fee Schedule - April 1

42508 Parotid duct diversion $760.15 42509 Parotid duct diversion $861.20 42510 Parotid duct diversion $654.59 42550 Injection for salivary x-ray $160.55 42600 Closure of salivary fistula $499.18 42650 Dilation of salivary duct $85.85 42660 Dilation of salivary duct $109.17 42665 Ligation of salivary duct $318.64 42700 Drainage of tonsil abscess $193.39 42720 Drainage of throat abscess $467.83 42725 Drainage of throat abscess $834.62 42800 Biopsy of throat $162.02 42802 Biopsy of throat $250.39 42804 Biopsy of upper nose/throat $209.47 42806 Biopsy of upper nose/throat $235.44 42808 Excise pharynx lesion $234.85 42809 Remove pharynx foreign body $174.48 42810 Excision of neck cyst $399.16 42815 Excision of neck cyst $575.12 42820 Remove tonsils and adenoids $301.38 42821 Remove tonsils and adenoids $314.94 42825 Removal of tonsils $271.29 42826 Removal of tonsils $261.89 42830 Removal of adenoids $214.49 42831 Removal of adenoids $231.99$ 42835 Removal of adenoids $193.78 42836 Removal of adenoids $251.67 42842 Extensive surgery of throat $1,001.14 42844 Extensive surgery of throat $1,404.40 42845 Extensive surgery of throat $2,273.07 42860 Excision of tonsil tags $195.05 42870 Excision of lingual tonsil $602.82 42890 Partial removal of pharynx $1,420.41 42892 Revision of pharyngeal walls $1,855.81 42894 Revision of pharyngeal walls $2,375.51 42900 Repair throat wound $357.91 42950 Reconstruction of throat $830.33 42953 Repair throat, esophagus $1,026.49 42955 Surgical opening of throat $781.24 42960 Control throat bleeding $175.31 42961 Control throat bleeding $435.98 42962 Control throat bleeding $538.23 42970 Control nose/throat bleeding $400.25 42971 Control nose/throat bleeding $473.82 42972 Control nose/throat bleeding $531.32 43020 Incision of esophagus $545.26 43030 Throat muscle surgery $539.94 43045 Incision of esophagus $1,365.67 43100 Excision of esophagus lesion $645.68 43101 Excision of esophagus lesion $1,068.87 43107 Removal of esophagus $2,626.06 43108 Removal of esophagus $4,325.53

Page 60Page 60 Updated Fee Schedule - April 1

43112 Removal of esophagus $2,806.41 43113 Removal of esophagus $4,343.74 43116 Partial removal of esophagus $4,912.00 43117 Partial removal of esophagus $2,564.20 43118 Partial removal of esophagus $3,574.67 43121 Partial removal of esophagus $2,858.21 43122 Partial removal of esophagus $2,594.54 43123 Partial removal of esophagus $4,350.18 43124 Removal of esophagus $3,733.96 43130 Removal of esophagus pouch $815.23 43135 Removal of esophagus pouch $1,506.02 43200 Esophagus endoscopy $230.32 43201 Esoph scope w/submucous inj $317.39 43202 Esophagus endoscopy, biopsy $304.11 43204 Esoph scope w/sclerosis inj $238.05 43205 Esophagus endoscopy/ligation $238.47 43215 Esophagus endoscopy $162.96 43216 Esophagus endoscopy/lesion $209.11 43217 Esophagus endoscopy $405.30 43219 Esophagus endoscopy $181.82 43220 Esoph endoscopy, dilation $134.44 43226 Esoph endoscopy, dilation $149.91 43227 Esoph endoscopy, repair $222.47 43228 Esoph endoscopy, ablation $238.22 43231 Esoph endoscopy w/us exam $202.38$ 43232 Esoph endoscopy w/us fn bx $278.53 43234 Upper GI endoscopy, exam $300.83 43235 Uppr gi endoscopy, diagnosis $323.91 43236 Uppr gi scope w/submuc inj $403.72 43237 Endoscopic us exam, esoph $256.46 43238 Uppr gi endoscopy w/us fn bx $316.42 43239 Upper GI endoscopy, biopsy $374.25 43240 Esoph endoscope w/drain cyst $423.53 43241 Upper GI endoscopy with tube $165.74 43242 Uppr gi endoscopy w/us fn bx $451.22 43243 Upper gi endoscopy & inject $284.48 43244 Upper GI endoscopy/ligation $315.78 43245 Uppr gi scope dilate strictr $199.19 43246 Place gastrostomy tube $266.17 43247 Operative upper GI endoscopy $213.28 43248 Uppr gi endoscopy/guide wire $201.82 43249 Esoph endoscopy, dilation $185.92 43250 Upper GI endoscopy/tumor $199.03 43251 Operative upper GI endoscopy $231.72 43255 Operative upper GI endoscopy $301.55 43256 Uppr gi endoscopy w/stent $270.54 43257 Uppr gi scope w/thrml txmnt $330.97 43258 Operative upper GI endoscopy $283.76 43259 Endoscopic ultrasound exam $323.08 43260 Endo cholangiopancreatograph $370.29 43261 Endo cholangiopancreatograph $389.10 43262 Endo cholangiopancreatograph $457.04

Page 61Page 61 Updated Fee Schedule - April 1

43263 Endo cholangiopancreatograph $452.19 43264 Endo cholangiopancreatograph $548.43 43265 Endo cholangiopancreatograph $615.21 43267 Endo cholangiopancreatograph $454.84 43268 Endo cholangiopancreatograph $463.19 43269 Endo cholangiopancreatograph $506.54 43271 Endo cholangiopancreatograph $456.60 43272 Endo cholangiopancreatograph $455.72 43273 Endoscopic pancreatoscopy $138.16 43279 Lap myotomy, heller $1,282.64 43279 80 Lap myotomy, heller $205.22 43280 Laparoscopy, fundoplasty $1,073.98 43300 Repair of esophagus $644.60 43305 Repair esophagus and fistula $1,140.60 43310 Repair of esophagus $1,594.31 43312 Repair esophagus and fistula $1,758.08 43313 Esophagoplasty congenital $2,778.90 43314 Tracheo-esophagoplasty cong $3,204.37 43320 Fuse esophagus & stomach $1,395.97 43324 Revise esophagus & stomach $1,351.50 43325 Revise esophagus & stomach $1,329.80 43326 Revise esophagus & stomach $1,362.43 43330 Repair of esophagus $1,304.87 43331 Repair of esophagus $1,422.59 43340 Fuse esophagus & intestine $1,352.63$ 43341 Fuse esophagus & intestine $1,499.23 43350 Surgical opening, esophagus $1,150.69 43351 Surgical opening, esophagus $1,363.30 43352 Surgical opening, esophagus $1,116.79 43360 Gastrointestinal repair $2,380.66 43361 Gastrointestinal repair $2,643.92 43400 Ligate esophagus veins $1,641.51 43401 Esophagus surgery for veins $1,544.74 43405 Ligate/staple esophagus $1,503.10 43410 Repair esophagus wound $1,031.27 43415 Repair esophagus wound $1,753.32 43420 Repair esophagus opening $1,026.71 43425 Repair esophagus opening $1,542.33 43450 Dilate esophagus $171.12 43453 Dilate esophagus $328.17 43456 Dilate esophagus $667.20 43458 Dilate esophagus $419.99 43460 Pressure treatment esophagus $233.36 43500 Surgical opening of stomach $767.72 43501 Surgical repair of stomach $1,317.17 43502 Surgical repair of stomach $1,491.26 43510 Surgical opening of stomach $951.96 43520 Incision of pyloric muscle $697.20 43600 Biopsy of stomach $112.49 43605 Biopsy of stomach $814.13 43610 Excision of stomach lesion $961.06 43611 Excision of stomach lesion $1,195.54

Page 62Page 62 Updated Fee Schedule - April 1

43620 Removal of stomach $1,942.61 43621 Removal of stomach $2,202.17 43622 Removal of stomach $2,237.11 43631 Removal of stomach, partial $1,429.19 43632 Removal of stomach, partial $1,925.06 43633 Removal of stomach, partial $1,835.67 43634 Removal of stomach, partial $2,026.85 43635 Removal of stomach, partial $113.87 43640 Vagotomy & pylorus repair $1,148.94 43641 Vagotomy & pylorus repair $1,157.94 43644 Lap gastric bypass/roux-en-y $1,695.61 43645 Lap gastr bypass incl smll i $1,814.78 43651 Laparoscopy, vagus nerve $643.91 43652 Laparoscopy, vagus nerve $751.64 43653 Laparoscopy, gastrostomy $550.26 43752 Nasal/orogastric w/stent $43.70 43760 Change gastrostomy tube $374.19 43761 Reposition gastrostomy tube $130.22 43770 Lap place gastr adj device $1,094.73 43771 Lap revise gastr adj device $1,246.83 43772 Lap rmvl gastr adj device $942.67 43773 Lap replace gastr adj device $1,248.08 43774 Lap rmvl gastr adj all parts $943.25 43800 Reconstruction of pylorus $912.66 43810 Fusion of stomach and bowel $987.77$ 43820 Fusion of stomach and bowel $1,270.93 43825 Fusion of stomach and bowel $1,271.23 43830 Place gastrostomy tube $681.51 43831 Place gastrostomy tube $573.85 43832 Place gastrostomy tube $1,043.91 43840 Repair of stomach lesion $1,289.36 43842 V-band gastroplasty $1,267.34 43843 Gastroplasty w/o v-band $1,238.99 43845 Gastroplasty duodenal switch $1,916.76 43846 Gastric bypass for obesity $1,597.71 43847 Gastric bypass incl small i $1,743.40 43848 Revision gastroplasty $1,893.09 43850 Revise stomach-bowel fusion $1,584.31 43855 Revise stomach-bowel fusion $1,656.94 43860 Revise stomach-bowel fusion $1,609.27 43865 Revise stomach-bowel fusion $1,674.33 43870 Repair stomach opening $692.23 43880 Repair stomach-bowel fistula $1,573.18 43886 Revise gastric port, open $329.98 43887 Remove gastric port, open $312.22 43888 Change gastric port, open $438.18 44005 Freeing of bowel adhesion $1,074.86 44010 Incision of small bowel $847.03 44015 Insert needle cath bowel $146.11 44020 Explore small intestine $950.68 44021 Decompress small bowel $962.20 44025 Incision of large bowel $967.82

Page 63Page 63 Updated Fee Schedule - April 1

44050 Reduce bowel obstruction $917.76 44055 Correct malrotation of bowel $1,463.34 44100 Biopsy of bowel $121.60 44110 Excise intestine lesion(s) $829.67 44111 Excision of bowel lesion(s) $964.87 44120 Removal of small intestine $1,191.83 44121 Removal of small intestine $245.53 44125 Removal of small intestine $1,159.64 44126 Enterectomy w/o taper, cong $2,388.00 44127 Enterectomy w/taper, cong $2,782.00 44128 Enterectomy cong, add-on $247.08 44130 Bowel to bowel fusion $1,242.51 44139 Mobilization of colon $122.57 44140 Partial removal of colon $1,322.55 44141 Partial removal of colon $1,732.49 44143 Partial removal of colon $1,627.85 44144 Partial removal of colon $1,701.72 44145 Partial removal of colon $1,644.08 44146 Partial removal of colon $2,053.45 44147 Partial removal of colon $1,833.15 44150 Removal of colon $1,807.06 44151 Removal of colon/ileostomy $2,062.88 44155 Removal of colon/ileostomy $2,018.74 44156 Removal of colon/ileostomy $2,224.13 44157 Colectomy w/ileoanal anast $2,112.94$ 44158 Colectomy w/neo-rectum pouch $2,165.31 44160 Removal of colon $1,216.99 44180 Lap, enterolysis $910.22 44186 Lap, jejunostomy $644.73 44187 Lap, ileo/jejuno-stomy $1,086.13 44188 Lap, colostomy $1,201.48 44202 Lap, enterectomy $1,368.68 44203 Lap resect s/intestine, addl $244.28 44204 Laparo partial colectomy $1,525.56 44205 Lap colectomy part w/ileum $1,332.68 44206 Lap part colectomy w/stoma $1,731.67 44207 L colectomy/coloproctostomy $1,814.41 44208 L colectomy/coloproctostomy $1,977.36 44210 Laparo total proctocolectomy $1,769.87 44211 Lap colectomy w/proctectomy $2,171.17 44212 Laparo total proctocolectomy $2,037.49 44213 Lap, mobil splenic fl add-on $192.31 44227 Lap, close enterostomy $1,651.51 44300 Open bowel to skin $825.34 44310 Ileostomy/jejunostomy $1,028.77 44312 Revision of ileostomy $588.25 44314 Revision of ileostomy $997.20 44316 Devise bowel pouch $1,359.64 44320 Colostomy $1,174.82 44322 Colostomy with biopsies $950.64 44340 Revision of colostomy $594.34 44345 Revision of colostomy $1,029.81

Page 64Page 64 Updated Fee Schedule - April 1

44346 Revision of colostomy $1,153.37 44360 Small bowel endoscopy $168.07 44361 Small bowel endoscopy/biopsy $184.98 44363 Small bowel endoscopy $218.57 44364 Small bowel endoscopy $235.85 44365 Small bowel endoscopy $210.08 44366 Small bowel endoscopy $277.90 44369 Small bowel endoscopy $283.55 44370 Small bowel endoscopy/stent $306.41 44372 Small bowel endoscopy $269.79 44373 Small bowel endoscopy $218.57 44376 Small bowel endoscopy $322.94 44377 Small bowel endoscopy/biopsy $342.40 44378 Small bowel endoscopy $438.73 44379 S bowel endoscope w/stent $466.42 44380 Small bowel endoscopy $73.84 44382 Small bowel endoscopy $88.90 44383 Ileoscopy w/stent $188.75 44385 Endoscopy of bowel pouch $267.76 44386 Endoscopy, bowel pouch/biop $374.81 44388 Colonoscopy $369.11 44389 Colonoscopy with biopsy $429.70 44390 Colonoscopy for foreign body $494.87 44391 Colonoscopy for bleeding $553.98 44392 Colonoscopy & polypectomy $463.19$ 44393 Colonoscopy, lesion removal $535.94 44394 Colonoscopy w/snare $542.23 44397 Colonoscopy w/stent $293.44 44500 Intro, gastrointestinal tube $27.42 44602 Suture, small intestine $1,341.53 44603 Suture, small intestine $1,539.16 44604 Suture, large intestine $1,041.63 44605 Repair of bowel lesion $1,285.51 44615 Intestinal stricturoplasty $1,059.38 44620 Repair bowel opening $845.24 44625 Repair bowel opening $1,000.38 44626 Repair bowel opening $1,589.66 44640 Repair bowel-skin fistula $1,387.11 44650 Repair bowel fistula $1,443.50 44660 Repair bowel-bladder fistula $1,397.72 44661 Repair bowel-bladder fistula $1,565.68 44680 Surgical revision, intestine $1,045.69 44700 Suspend bowel w/prosthesis $1,011.16 44701 Intraop colon lavage add-on $169.65 44720 Prep donor intestine/venous $277.00 44721 Prep donor intestine/artery $391.84 44800 Excision of bowel pouch $750.67 44820 Excision of mesentery lesion $825.57 44850 Repair of mesentery $728.46 44900 Drain app abscess, open $744.45 44901 Drain app abscess, percut $1,095.35 44950 Appendectomy $632.11

Page 65Page 65 Updated Fee Schedule - April 1

44955 Appendectomy add-on $85.36 44960 Appendectomy $848.88 44970 Laparoscopy, appendectomy $583.10 45000 Drainage of pelvic abscess $407.62 45005 Drainage of rectal abscess $257.77 45020 Drainage of rectal abscess $528.71 45100 Biopsy of rectum $286.42 45108 Removal of anorectal lesion $347.25 45110 Removal of rectum $1,821.64 45111 Partial removal of rectum $1,071.06 45112 Removal of rectum $1,866.26 45113 Partial proctectomy $1,919.50 45114 Partial removal of rectum $1,751.32 45116 Partial removal of rectum $1,572.43 45119 Remove rectum w/reservoir $1,919.56 45120 Removal of rectum $1,538.34 45121 Removal of rectum and colon $1,682.59 45123 Partial proctectomy $1,089.07 45126 Pelvic exenteration $2,834.60 45130 Excision of rectal prolapse $1,064.11 45135 Excision of rectal prolapse $1,306.85 45136 Excise ileoanal reservior $1,806.34 45150 Excision of rectal stricture $394.30 45160 Excision of rectal lesion $972.73 45170 Excision of rectal lesion $761.93$ 45190 Destruction, rectal tumor $666.40 45300 Proctosigmoidoscopy dx $112.61 45303 Proctosigmoidoscopy dilate $902.80 45305 Proctosigmoidoscopy w/bx $184.01 45307 Proctosigmoidoscopy fb $202.72 45308 Proctosigmoidoscopy removal $186.84 45309 Proctosigmoidoscopy removal $211.54 45315 Proctosigmoidoscopy removal $225.82 45317 Proctosigmoidoscopy bleed $216.70 45320 Proctosigmoidoscopy ablate $219.76 45321 Proctosigmoidoscopy volvul $105.54 45327 Proctosigmoidoscopy w/stent $123.51 45330 Diagnostic sigmoidoscopy $146.15 45331 Sigmoidoscopy and biopsy $185.89 45332 Sigmoidoscopy w/fb removal $306.22 45333 Sigmoidoscopy & polypectomy $308.05 45334 Sigmoidoscopy for bleeding $174.73 45335 Sigmoidoscopy w/submuc inj $263.99 45337 Sigmoidoscopy & decompress $149.62 45338 Sigmoidoscopy w/tumr remove $341.88 45339 Sigmoidoscopy w/ablate tumr $350.62 45340 Sig w/balloon dilation $474.99 45341 Sigmoidoscopy w/ultrasound $166.67 45342 Sigmoidoscopy w/us guide bx $254.58 45345 Sigmoidoscopy w/stent $185.26 45355 Surgical colonoscopy $212.54 45378 Diagnostic colonoscopy $424.50

Page 66Page 66 Updated Fee Schedule - April 1

45378 53 Diagnostic colonoscopy $146.15 45379 Colonoscopy w/fb removal $539.16 45380 Colonoscopy and biopsy $509.84 45381 Colonoscopy, submucous inj $496.77 45382 Colonoscopy/control bleeding $672.66 45383 Lesion removal colonoscopy $603.49 45384 Lesion remove colonoscopy $498.73 45385 Lesion removal colonoscopy $572.95 45386 Colonoscopy dilate stricture $718.90 45387 Colonoscopy w/stent $366.83 45391 Colonoscopy w/endoscope us $316.81 45392 Colonoscopy w/endoscopic fnb $399.31 45395 Lap, removal of rectum $1,970.71 45397 Lap, remove rectum w/pouch $2,127.41 45400 Laparoscopic proc $1,134.29 45402 Lap proctopexy w/sig resect $1,514.06 45500 Repair of rectum $504.03 45505 Repair of rectum $554.44 45520 Treatment of rectal prolapse $133.48 45540 Correct rectal prolapse $1,045.08 45541 Correct rectal prolapse $902.97 45550 Repair rectum/remove sigmoid $1,438.54 45560 Repair of rectocele $715.90 45562 Exploration/repair of rectum $1,096.00 45563 Exploration/repair of rectum $1,587.69$ 45800 Repair rect/bladder fistula $1,228.00 45805 Repair fistula w/colostomy $1,383.96 45820 Repair rectourethral fistula $1,215.79 45825 Repair fistula w/colostomy $1,469.26 45900 Reduction of rectal prolapse $195.02 45905 Dilation of anal sphincter $167.10 45910 Dilation of rectal narrowing $197.07 45915 Remove rectal obstruction $315.05 45990 Surg dx exam, anorectal $107.96 46020 Placement of seton $252.65 46030 Removal of rectal marker $128.53 46040 Incision of rectal abscess $496.36 46045 Incision of rectal abscess $401.64 46050 Incision of anal abscess $181.92 46060 Incision of rectal abscess $443.64 46070 Incision of anal septum $229.81 46080 Incision of anal sphincter $232.18 46083 Incise external hemorrhoid $178.37 46200 Removal of anal fissure $393.12 46210 Removal of anal crypt $363.77 46211 Removal of anal crypts $488.47 46220 Removal of anal tag $189.72 46221 Ligation of hemorrhoid(s) $246.96 46230 Removal of anal tags $257.83 46250 Hemorrhoidectomy $430.27 46255 Hemorrhoidectomy $478.69 46257 Remove hemorrhoids & fissure $397.44

Page 67Page 67 Updated Fee Schedule - April 1

46258 Remove hemorrhoids & fistula $433.95 46260 Hemorrhoidectomy $450.20 46261 Remove hemorrhoids & fissure $501.64 46262 Remove hemorrhoids & fistula $525.00 46270 Removal of anal fistula $462.47 46275 Removal of anal fistula $488.29 46280 Removal of anal fistula $439.80 46285 Removal of anal fistula $473.01 46288 Repair anal fistula $517.94 46320 Removal of hemorrhoid clot $170.37 46500 Injection into hemorrhoid(s) $209.00 46505 Chemodenervation anal musc $265.40 46600 Diagnostic anoscopy $84.72 46604 Anoscopy and dilation $541.14 46606 Anoscopy and biopsy $217.48 46608 Anoscopy, remove for body $224.57 46610 Anoscopy, remove lesion $222.16 46611 Anoscopy $173.85 46612 Anoscopy, remove lesions $267.36 46614 Anoscopy, control bleeding $134.05 46615 Anoscopy $152.81 46700 Repair of anal stricture $620.43 46705 Repair of anal stricture $517.49 46706 Repr of anal fistula w/glue $165.45 46710 Repr per/vag pouch sngl proc $1,051.29$ 46712 Repr per/vag pouch dbl proc $2,140.79 46715 Rep perf anoper fistu $509.46 46716 Rep perf anoper/vestib fistu $1,250.93 46730 Construction of absent anus $1,864.74 46735 Construction of absent anus $2,177.42 46740 Construction of absent anus $1,991.65 46742 Repair of imperforated anus $2,355.48 46744 Repair of cloacal anomaly $3,361.77 46746 Repair of cloacal anomaly $3,904.73 46748 Repair of cloacal anomaly $4,018.98 46750 Repair of anal sphincter $747.69 46751 Repair of anal sphincter $627.07 46753 Reconstruction of anus $567.40 46754 Removal of suture from anus $278.09 46760 Repair of anal sphincter $1,057.02 46761 Repair of anal sphincter $912.46 46762 Implant artificial sphincter $900.25 46900 Destruction, anal lesion(s) $227.82 46910 Destruction, anal lesion(s) $238.46 46916 Cryosurgery, anal lesion(s) $235.49 46917 Laser surgery, anal lesions $465.00 46922 Excision of anal lesion(s) $249.25 46924 Destruction, anal lesion(s) $522.73 46930 Destroy internal hemorrhoids $220.25 46937 Cryotherapy of rectal lesion $250.93 46938 Cryotherapy of rectal lesion $440.65 46940 Treatment of anal fissure $211.66

Page 68Page 68 Updated Fee Schedule - April 1

46942 Treatment of anal fissure $196.63 46945 Ligation of hemorrhoids $278.15 46946 Ligation of hemorrhoids $299.68 46947 Hemorrhoidopexy by stapling $369.72 47000 Needle biopsy of liver $360.90 47001 Needle biopsy, liver add-on $105.24 47010 Open drainage, liver lesion $1,170.35 47011 Percut drain, liver lesion $209.35 47015 Inject/aspirate liver cyst $1,110.40 47100 Wedge biopsy of liver $819.79 47120 Partial removal of liver $2,290.22 47122 Extensive removal of liver $3,399.54 47125 Partial removal of liver $3,046.76 47130 Partial removal of liver $3,274.69 47135 Transplantation of liver $4,822.18 47136 Transplantation of liver $4,117.04 47140 Partial removal, donor liver $3,418.15 47141 Partial removal, donor liver $4,054.30 47142 Partial removal, donor liver $4,453.73 47146 Prep donor liver/venous $333.83 47147 Prep donor liver/arterial $389.65 47300 Surgery for liver lesion $1,094.74 47350 Repair liver wound $1,342.67 47360 Repair liver wound $1,820.87 47361 Repair liver wound $2,987.19$ 47362 Repair liver wound $1,390.35 47370 Laparo ablate liver tumor rf $1,227.64 47371 Laparo ablate liver cryosurg $1,253.22 47380 Open ablate liver tumor rf $1,432.68 47381 Open ablate liver tumor cryo $1,461.20 47382 Percut ablate liver rf $900.88 47400 Incision of liver duct $2,066.46 47420 Incision of bile duct $1,315.27 47425 Incision of bile duct $1,327.55 47460 Incise bile duct sphincter $1,255.39 47480 Incision of gallbladder $838.78 47490 Incision of gallbladder $565.61 47500 Injection for liver x-rays $111.35 47505 Injection for liver x-rays $43.08 47510 Insert catheter, bile duct $533.84 47511 Insert bile duct drain $665.68 47525 Change bile duct catheter $678.33 47530 Revise/reinsert bile tube $1,620.40 47550 Bile duct endoscopy add-on $168.39 47552 Biliary endoscopy thru skin $360.50 47553 Biliary endoscopy thru skin $358.24 47554 Biliary endoscopy thru skin $529.64 47555 Biliary endoscopy thru skin $429.95 47556 Biliary endoscopy thru skin $486.37 47560 Laparoscopy w/cholangio $272.19 47561 Laparo w/cholangio/biopsy $295.68 47562 Laparoscopic cholecystectomy $727.34

Page 69Page 69 Updated Fee Schedule - April 1

47563 Laparo cholecystectomy/graph $744.32 47564 Laparo cholecystectomy/explr $858.29 47570 Laparo cholecystoenterostomy $766.76 47600 Removal of gallbladder $1,035.98 47605 Removal of gallbladder $962.14 47610 Removal of gallbladder $1,230.21 47612 Removal of gallbladder $1,241.97 47620 Removal of gallbladder $1,348.34 47630 Remove bile duct stone $606.10 47700 Exploration of bile ducts $1,030.69 47701 Bile duct revision $1,771.40 47711 Excision of bile duct tumor $1,527.65 47712 Excision of bile duct tumor $1,952.43 47715 Excision of bile duct cyst $1,285.15 47720 Fuse gallbladder & bowel $1,112.05 47721 Fuse upper gi structures $1,309.82 47740 Fuse gallbladder & bowel $1,265.45 47741 Fuse gallbladder & bowel $1,433.22 47760 Fuse bile ducts and bowel $2,138.07 47765 Fuse liver ducts & bowel $2,800.50 47780 Fuse bile ducts and bowel $2,333.02 47785 Fuse bile ducts and bowel $3,030.16 47800 Reconstruction of bile ducts $1,542.38 47801 Placement, bile duct support $1,089.41 47802 Fuse liver duct & intestine $1,481.51$ 47900 Suture bile duct injury $1,336.07 48000 Drainage of abdomen $1,844.36 48001 Placement of drain, pancreas $2,267.20 48020 Removal of pancreatic stone $1,141.80 48100 Biopsy of pancreas, open $867.04 48102 Needle biopsy, pancreas $594.81 48105 Resect/debride pancreas $2,790.75 48120 Removal of pancreas lesion $1,080.86 48140 Partial removal of pancreas $1,529.16 48145 Partial removal of pancreas $1,587.87 48146 Pancreatectomy $1,815.81 48148 Removal of pancreatic duct $1,205.09 48150 Partial removal of pancreas $3,059.79 48152 Pancreatectomy $2,830.39 48153 Pancreatectomy $3,055.19 48154 Pancreatectomy $2,837.03 48155 Removal of pancreas $1,762.21 48400 Injection, intraop add-on $110.35 48500 Surgery of pancreatic cyst $1,106.17 48510 Drain pancreatic pseudocyst $1,050.08 48511 Drain pancreatic pseudocyst $1,057.16 48520 Fuse pancreas cyst and bowel $1,068.76 48540 Fuse pancreas cyst and bowel $1,276.78 48545 Pancreatorrhaphy $1,290.85 48547 Duodenal exclusion $1,739.57 48548 Fuse pancreas and bowel $1,632.42 48552 Prep donor pancreas/venous $230.51

Page 70Page 70 Updated Fee Schedule - April 1

48554 Transpl allograft pancreas $2,449.97 48556 Removal, allograft pancreas $1,215.42 49000 Exploration of abdomen $763.82 49002 Reopening of abdomen $988.53 49010 Exploration behind abdomen $939.87 49020 Drain abdominal abscess $1,557.59 49021 Drain abdominal abscess $1,012.90 49040 Drain, open, abdom abscess $976.79 49041 Drain, percut, abdom abscess $1,030.81 49060 Drain, open, retrop abscess $1,092.09 49061 Drain, percut, retroper absc $1,014.13 49062 Drain to peritoneal cavity $746.64 49080 Puncture, peritoneal cavity $187.82 49081 Removal of abdominal fluid $175.72 49180 Biopsy, abdominal mass $186.29 49203 Exc abd tum 5 cm or less $1,192.48 49204 Exc abd tum over 5 cm $1,519.91 49205 Exc abd tum over 10 cm $1,739.11 49215 Excise sacral spine tumor $2,181.25 49220 Multiple surgery, abdomen $953.65 49250 Excision of umbilicus $572.47 49255 Removal of omentum $774.76 49320 Diag laparo separate proc $328.45 49321 Laparoscopy, biopsy $345.44 49322 Laparoscopy, aspiration $374.48$ 49323 Laparo drain lymphocele $635.99 49324 Lap insertion perm ip cath $388.97 49325 Lap revision perm ip cath $418.19 49326 Lap w/omentopexy add-on $190.11 49400 Air injection into abdomen $193.93 49402 Remove foreign body, adbomen $840.67 49419 Insrt abdom cath for chemotx $452.87 49420 Insert abdom drain, temp $143.33 49421 Insert abdom drain, perm $389.93 49422 Remove perm cannula/catheter $388.81 49423 Exchange drainage catheter $644.99 49424 Assess cyst, contrast inject $173.11 49425 Insert abdomen-venous drain $759.61 49426 Revise abdomen-venous shunt $646.99 49427 Injection, abdominal shunt $51.08 49428 Ligation of shunt $436.01 49429 Removal of shunt $460.17 49435 Insert subq exten to ip cath $121.90 49436 Embedded ip cath exit-site $182.86 49440 Place gastrostomy tube perc $1,248.96 49441 Place duod/jej tube perc $1,352.25 49442 Place cecostomy tube perc $1,213.91 49446 Change g-tube to g-j perc $1,136.51 49450 Replace g/c tube perc $856.78 49451 Replace duod/jej tube perc $812.59 49452 Replace g-j tube perc $1,019.92 49460 Fix g/colon tube w/device $942.79

Page 71Page 71 Updated Fee Schedule - April 1

49465 Fluoro exam of g/colon tube $194.57 49491 Rpr hern preemie reduc $760.83 49492 Rpr ing hern premie, blocked $929.22 49495 Rpr ing hernia baby, reduc $388.52 49496 Rpr ing hernia baby, blocked $589.08 49500 Rpr ing hernia, init, reduce $388.87 49501 Rpr ing hernia, init blocked $585.10 49505 Prp i/hern init reduc >5 yr $508.53 49507 Prp i/hern init block >5 yr $624.12 49520 Rerepair ing hernia, reduce $619.69 49521 Rerepair ing hernia, blocked $753.87 49525 Repair ing hernia, sliding $560.90 49540 Repair lumbar hernia $662.16 49550 Rpr rem hernia, init, reduce $563.44 49553 Rpr fem hernia, init blocked $615.76 49555 Rerepair fem hernia, reduce $586.53 49557 Rerepair fem hernia, blocked $710.48 49560 Rpr ventral hern init, reduc $726.52 49561 Rpr ventral hern init, block $913.47 49565 Rerepair ventrl hern, reduce $752.70 49566 Rerepair ventrl hern, block $923.06 49568 Hernia repair w/mesh $270.50 49570 Rpr epigastric hern, reduce $401.37 49572 Rpr epigastric hern, blocked $494.43 49580 Rpr umbil hern, reduc < 5 yr $314.28$ 49582 Rpr umbil hern, block < 5 yr $463.22 49585 Rpr umbil hern, reduc > 5 yr $431.13 49587 Rpr umbil hern, block > 5 yr $509.05 49590 Repair spigelian hernia $558.58 49600 Repair umbilical lesion $719.51 49605 Repair umbilical lesion $4,917.48 49606 Repair umbilical lesion $1,121.45 49610 Repair umbilical lesion $666.71 49611 Repair umbilical lesion $602.92 49650 Lap ing hernia repair init $420.70 49651 Lap ing hernia repair recur $542.19 49652 Lap vent/abd hernia repair $782.87 49652 50 Lap vent/abd hernia repair $1,174.30 49652 80 Lap vent/abd hernia repair $125.26 49653 Lap vent/abd hern proc comp $976.92 49653 50 Lap vent/abd hern proc comp $1,465.37 49653 80 Lap vent/abd hern proc comp $156.31 49654 Lap inc hernia repair $897.01 49654 50 Lap inc hernia repair $1,345.51 49654 80 Lap inc hernia repair $143.52 49655 Lap inc hern repair comp $1,080.09 49655 50 Lap inc hern repair comp $1,620.14 49655 80 Lap inc hern repair comp $172.81 49656 Lap inc hernia repair recur $900.73 49656 50 Lap inc hernia repair recur $1,351.09 49656 80 Lap inc hernia repair recur $144.12 49657 Lap inc hern recur comp $1,297.72

Page 72Page 72 Updated Fee Schedule - April 1

49657 50 Lap inc hern recur comp $1,946.57 49657 80 Lap inc hern recur comp $207.63 49900 Repair of abdominal wall $804.98 49904 Omental flap, extra-abdom $1,502.61 49905 Omental flap, intra-abdom $360.19 50010 Exploration of kidney $782.15 50020 Renal abscess, open drain $1,111.62 50021 Renal abscess, percut drain $1,066.94 50040 Drainage of kidney $1,048.38 50045 Exploration of kidney $1,059.90 50060 Removal of kidney stone $1,302.24 50065 Incision of kidney $1,367.65 50070 Incision of kidney $1,361.08 50075 Removal of kidney stone $1,671.58 50080 Removal of kidney stone $996.60 50081 Removal of kidney stone $1,461.26 50100 Revise kidney blood vessels $1,069.35 50120 Exploration of kidney $1,079.72 50125 Explore and drain kidney $1,117.58 50130 Removal of kidney stone $1,181.02 50135 Exploration of kidney $1,277.31 50200 Biopsy of kidney $160.93 50205 Biopsy of kidney $751.96 50220 Remove kidney, open $1,162.43 50225 Removal kidney open, complex $1,344.19$ 50230 Removal kidney open, radical $1,456.09 50234 Removal of kidney & ureter $1,479.49 50236 Removal of kidney & ureter $1,676.70 50240 Partial removal of kidney $1,505.61 50250 Cryoablate renal mass open $1,398.41 50280 Removal of kidney lesion $1,075.52 50290 Removal of kidney lesion $991.78 50320 Remove kidney, living donor $1,476.19 50327 Prep renal graft/venous $215.95 50328 Prep renal graft/arterial $189.56 50329 Prep renal graft/ureteral $188.25 50340 Removal of kidney $910.69 50360 Transplantation of kidney $2,475.26 50365 Transplantation of kidney $2,788.74 50370 Remove transplanted kidney $1,158.08 50380 Reimplantation of kidney $1,969.75 50382 Change ureter stent, percut $1,497.42 50384 Remove ureter stent, percut $1,286.46 50385 Change stent via transureth $1,471.03 50386 Remove stent via transureth $951.07 50387 Change ext/int ureter stent $696.17 50389 Remove renal tube w/fluoro $404.30 50390 Drainage of kidney lesion $111.35 50391 Instll rx agnt into rnal tub $146.80 50392 Insert kidney drain $205.92 50393 Insert ureteral tube $250.98 50394 Injection for kidney x-ray $122.53

Page 73Page 73 Updated Fee Schedule - April 1

50395 Create passage to kidney $207.61 50396 Measure kidney pressure $134.78 50398 Change kidney tube $626.97 50400 Revision of kidney/ureter $1,314.01 50405 Revision of kidney/ureter $1,594.80 50500 Repair of kidney wound $1,273.21 50520 Close kidney-skin fistula $1,181.81 50525 Repair renal-abdomen fistula $1,471.27 50526 Repair renal-abdomen fistula $1,534.98 50540 Revision of horseshoe kidney $1,285.24 50541 Laparo ablate renal cyst $1,050.18 50542 Laparo ablate renal mass $1,332.72 50543 Laparo partial nephrectomy $1,699.61 50544 Laparoscopy, pyeloplasty $1,430.28 50545 Laparo radical nephrectomy $1,535.65 50546 Laparoscopic nephrectomy $1,365.12 50547 Laparo removal donor kidney $1,644.28 50548 Laparo remove w/ureter $1,547.70 50551 Kidney endoscopy $427.51 50553 Kidney endoscopy $445.00 50555 Kidney endoscopy & biopsy $485.80 50557 Kidney endoscopy & treatment $495.95 50561 Kidney endoscopy & treatment $562.14 50562 Renal scope w/tumor resect $674.15 50570 Kidney endoscopy $570.20$ 50572 Kidney endoscopy $621.76 50574 Kidney endoscopy & biopsy $655.01 50575 Kidney endoscopy $828.16 50576 Kidney endoscopy & treatment $654.30 50580 Kidney endoscopy & treatment $699.96 50590 Fragmenting of kidney stone $1,090.09 50592 Perc rf ablate renal tumor $4,305.29 50593 Perc cryo ablate renal tum $5,554.81 50600 Exploration of ureter $1,065.47 50605 Insert ureteral support $1,027.38 50610 Removal of ureter stone $1,091.39 50620 Removal of ureter stone $1,032.83 50630 Removal of ureter stone $1,005.95 50650 Removal of ureter $1,177.00 50660 Removal of ureter $1,299.80 50684 Injection for ureter x-ray $214.78 50686 Measure ureter pressure $104.13 50688 Change of ureter tube/stent $91.70 50690 Injection for ureter x-ray $115.65 50700 Revision of ureter $1,056.76 50715 Release of ureter $1,246.01 50722 Release of ureter $1,084.70 50725 Release/revise ureter $1,237.97 50727 Revise ureter $574.88 50728 Revise ureter $787.62 50740 Fusion of ureter & kidney $1,220.60 50750 Fusion of ureter & kidney $1,323.62

Page 74Page 74 Updated Fee Schedule - April 1

50760 Fusion of ureters $1,234.84 50770 Splicing of ureters $1,277.47 50780 Reimplant ureter in bladder $1,239.20 50782 Reimplant ureter in bladder $1,217.17 50783 Reimplant ureter in bladder $1,262.59 50785 Reimplant ureter in bladder $1,372.81 50800 Implant ureter in bowel $1,047.15 50810 Fusion of ureter & bowel $1,375.52 50815 Urine shunt to intestine $1,393.45 50820 Construct bowel bladder $1,482.76 50825 Construct bowel bladder $1,878.02 50830 Revise urine flow $2,036.35 50840 Replace ureter by bowel $1,401.68 50845 Appendico-vesicostomy $1,424.57 50860 Transplant ureter to skin $1,079.32 50900 Repair of ureter $949.55 50920 Closure ureter/skin fistula $1,003.36 50930 Closure ureter/bowel fistula $1,206.71 50940 Release of ureter $1,010.84 50945 Laparoscopy ureterolithotomy $1,119.03 50947 Laparo new ureter/bladder $1,586.13 50948 Laparo new ureter/bladder $1,470.75 50951 Endoscopy of ureter $446.57 50953 Endoscopy of ureter $470.80 50955 Ureter endoscopy & biopsy $522.01$ 50957 Ureter endoscopy & treatment $506.32 50961 Ureter endoscopy & treatment $457.14 50970 Ureter endoscopy $430.66 50972 Ureter endoscopy & catheter $414.10 50974 Ureter endoscopy & biopsy $548.05 50976 Ureter endoscopy & treatment $539.79 50980 Ureter endoscopy & treatment $413.16 51020 Incise & treat bladder $532.45 51030 Incise & treat bladder $526.82 51040 Incise & drain bladder $334.84 51045 Incise bladder/drain ureter $529.85 51050 Removal of bladder stone $539.03 51060 Removal of ureter stone $663.13 51065 Remove ureter calculus $658.23 51080 Drainage of bladder abscess $462.83 51100 Drain bladder by needle $70.53 51101 Drain bladder by trocar/cath $148.18 51102 Drain bl w/cath insertion $275.91 51500 Removal of bladder cyst $708.88 51520 Removal of bladder lesion $667.12 51525 Removal of bladder lesion $978.01 51530 Removal of bladder lesion $873.07 51535 Repair of ureter lesion $888.30 51550 Partial removal of bladder $1,074.78 51555 Partial removal of bladder $1,427.04 51565 Revise bladder & ureter(s) $1,458.36 51570 Removal of bladder $1,660.97

Page 75Page 75 Updated Fee Schedule - April 1

51575 Removal of bladder & nodes $2,078.15 51580 Remove bladder/revise tract $2,167.54 51585 Removal of bladder & nodes $2,412.37 51590 Remove bladder/revise tract $2,195.90 51595 Remove bladder/revise tract $2,495.52 51596 Remove bladder/create pouch $2,683.98 51597 Removal of pelvic structures $2,588.08 51600 Injection for bladder x-ray $230.46 51605 Preparation for bladder xray $44.10 51610 Injection for bladder x-ray $130.58 51700 Irrigation of bladder $102.19 51701 Insert bladder catheter $71.64 51702 Insert temp bladder cath $93.17 51703 Insert bladder cath, complex $164.69 51705 Change of bladder tube $133.37 51710 Change of bladder tube $187.67 51715 Endoscopic injection/implant $342.03 51720 Treatment of bladder lesion $135.64 51725 Simple cystometrogram $262.38 51725 26 Simple cystometrogram $86.49 51726 Complex cystometrogram $384.47 51726 26 Complex cystometrogram $98.39 51736 Urine flow measurement $62.66 51736 26 Urine flow measurement $35.49 51741 Electro-uroflowmetry, first $97.97$ 51741 26 Electro-uroflowmetry, first $66.04 51772 Urethra pressure profile $294.63 51772 26 Urethra pressure profile $92.01 51784 Anal/urinary muscle study $239.82 51784 26 Anal/urinary muscle study $87.21 51785 Anal/urinary muscle study $260.97 51785 26 Anal/urinary muscle study $87.28 51792 Urinary reflex study $277.35 51792 26 Urinary reflex study $62.53 51795 Urine voiding pressure study $363.30 51795 26 Urine voiding pressure study $87.65 51797 Intraabdominal pressure test $179.83 51797 26 Intraabdominal pressure test $51.02 51798 Us urine capacity measure $25.82 51800 Revision of bladder/urethra $1,188.14 51820 Revision of urinary tract $1,211.38 51840 Attach bladder/urethra $725.90 51841 Attach bladder/urethra $859.78 51845 Repair bladder neck $661.70 51860 Repair of bladder wound $809.25 51865 Repair of bladder wound $999.45 51880 Repair of bladder opening $526.97 51900 Repair bladder/vagina lesion $927.86 51920 Close bladder-uterus fistula $859.06 51925 Hysterectomy/bladder repair $1,123.55 51940 Correction of bladder defect $1,818.24 51960 Revision of bladder & bowel $1,576.16

Page 76Page 76 Updated Fee Schedule - April 1

51980 Construct bladder opening $810.86 51990 Laparo urethral suspension $833.93 51992 Laparo sling operation $906.59 52000 Cystoscopy $246.95 52001 Cystoscopy, removal of clots $447.21 52005 Cystoscopy & ureter catheter $345.29 52007 Cystoscopy and biopsy $654.58 52010 Cystoscopy & duct catheter $482.88 52204 Cystoscopy w/biopsy(s) $535.45 52214 Cystoscopy and treatment $701.88 52224 Cystoscopy and treatment $1,015.09 52234 Cystoscopy and treatment $285.25 52235 Cystoscopy and treatment $334.31 52240 Cystoscopy and treatment $583.13 52250 Cystoscopy and radiotracer $280.26 52260 Cystoscopy and treatment $241.40 52265 Cystoscopy and treatment $509.80 52270 Cystoscopy & revise urethra $488.64 52275 Cystoscopy & revise urethra $667.76 52276 Cystoscopy and treatment $307.16 52277 Cystoscopy and treatment $375.08 52281 Cystoscopy and treatment $365.71 52282 Cystoscopy, implant stent $386.75 52283 Cystoscopy and treatment $330.81 52285 Cystoscopy and treatment $334.10$ 52290 Cystoscopy and treatment $282.99 52300 Cystoscopy and treatment $324.58 52301 Cystoscopy and treatment $342.16 52305 Cystoscopy and treatment $322.38 52310 Cystoscopy and treatment $298.42 52315 Cystoscopy and treatment $526.70 52317 Remove bladder stone $1,150.88 52318 Remove bladder stone $548.27 52320 Cystoscopy and treatment $285.14 52325 Cystoscopy, stone removal $370.77 52327 Cystoscopy, inject material $632.73 52330 Cystoscopy and treatment $938.84 52332 Cystoscopy and treatment $582.42 52334 Create passage to kidney $297.08 52341 Cysto w/ureter stricture tx $338.78 52342 Cysto w/up stricture tx $367.88 52343 Cysto w/renal stricture tx $409.17 52344 Cysto/uretero, stricture tx $443.91 52345 Cysto/uretero w/up stricture $473.01 52346 Cystouretero w/renal strict $533.45 52351 Cystouretero & or pyeloscope $363.38 52352 Cystouretero w/stone remove $426.92 52353 Cystouretero w/lithotripsy $490.78 52354 Cystouretero w/biopsy $453.69 52355 Cystouretero w/excise tumor $540.49 52400 Cystouretero w/congen repr $558.46 52402 Cystourethro cut ejacul duct $310.18

Page 77Page 77 Updated Fee Schedule - April 1

52450 Incision of prostate $536.26 52500 Revision of bladder neck $560.55 52601 Prostatectomy (TURP) $938.86 52630 Remove prostate regrowth $506.44 52640 Relieve bladder contracture $350.21 52647 Laser surgery of prostate $2,632.22 52648 Laser surgery of prostate $2,684.57 52649 Prostate laser enucleation $1,123.01 52700 Drainage of prostate abscess $495.14 53000 Incision of urethra $171.07 53010 Incision of urethra $335.57 53020 Incision of urethra $111.98 53025 Incision of urethra $73.65 53040 Drainage of urethra abscess $449.14 53060 Drainage of urethra abscess $199.50 53080 Drainage of urinary leakage $500.47 53085 Drainage of urinary leakage $700.61 53200 Biopsy of urethra $178.11 53210 Removal of urethra $877.14 53215 Removal of urethra $1,064.32 53220 Treatment of urethra lesion $514.62 53230 Removal of urethra lesion $684.74 53235 Removal of urethra lesion $729.00 53240 Surgery for urethra pouch $492.10 53250 Removal of urethra gland $456.97$ 53260 Treatment of urethra lesion $228.86 53265 Treatment of urethra lesion $255.43 53270 Removal of urethra gland $233.29 53275 Repair of urethra defect $303.59 53400 Revise urethra, stage 1 $913.73 53405 Revise urethra, stage 2 $1,005.77 53410 Reconstruction of urethra $1,120.13 53415 Reconstruction of urethra $1,290.16 53420 Reconstruct urethra, stage 1 $913.48 53425 Reconstruct urethra, stage 2 $1,079.00 53430 Reconstruction of urethra $1,073.32 53431 Reconstruct urethra/bladder $1,318.47 53440 Male sling procedure $1,001.10 53442 Remove/revise male sling $882.76 53444 Insert tandem cuff $910.29 53445 Insert uro/ves nck sphincter $1,006.83 53446 Remove uro sphincter $737.55 53447 Remove/replace ur sphincter $930.96 53448 Remov/replc ur sphinctr comp $1,464.72 53449 Repair uro sphincter $700.74 53450 Revision of urethra $467.63 53460 Revision of urethra $524.51 53500 Urethrlys, transvag w/ scope $840.00 53502 Repair of urethra injury $554.68 53505 Repair of urethra injury $556.98 53510 Repair of urethra injury $723.84 53515 Repair of urethra injury $910.64

Page 78Page 78 Updated Fee Schedule - April 1

53520 Repair of urethra defect $635.86 53600 Dilate urethra stricture $100.55 53601 Dilate urethra stricture $99.06 53605 Dilate urethra stricture $74.08 53620 Dilate urethra stricture $144.48 53621 Dilate urethra stricture $137.60 53660 Dilation of urethra $86.54 53661 Dilation of urethra $86.02 53665 Dilation of urethra $43.39 53850 Prostatic microwave thermotx $3,040.66 53852 Prostatic rf thermotx $2,919.18 54000 Slitting of prepuce $185.01 54001 Slitting of prepuce $225.52 54015 Drain penis lesion $354.65 54050 Destruction, penis lesion(s) $138.88 54055 Destruction, penis lesion(s) $132.53 54056 Cryosurgery, penis lesion(s) $145.17 54057 Laser surg, penis lesion(s) $160.78 54060 Excision of penis lesion(s) $215.47 54065 Destruction, penis lesion(s) $233.87 54100 Biopsy of penis $216.95 54105 Biopsy of penis $322.66 54110 Treatment of penis lesion $712.42 54111 Treat penis lesion, graft $918.37 54112 Treat penis lesion, graft $1,077.44$ 54115 Treatment of penis lesion $518.64 54120 Partial removal of penis $720.33 54125 Removal of penis $926.49 54130 Remove penis & nodes $1,370.09 54135 Remove penis & nodes $1,735.51 54150 Circumcision w/regionl block $197.65 54160 Circumcision, neonate $274.65 54161 Circum 28 days or older $225.76 54162 Lysis penil circumic lesion $315.67 54163 Repair of circumcision $250.65 54164 Frenulotomy of penis $221.55 54200 Treatment of penis lesion $130.27 54205 Treatment of penis lesion $614.88 54220 Treatment of penis lesion $250.01 54230 Prepare penis study $113.59 54231 Dynamic cavernosometry $164.41 54235 Penile injection $105.61 54240 Penis study $119.44 54240 26 Penis study $76.35 54250 Penis study $144.41 54250 26 Penis study $129.17 54300 Revision of penis $743.70 54304 Revision of penis $869.84 54308 Reconstruction of urethra $828.53 54312 Reconstruction of urethra $959.88 54316 Reconstruction of urethra $1,155.38 54318 Reconstruction of urethra $841.51

Page 79Page 79 Updated Fee Schedule - April 1

54322 Reconstruction of urethra $904.69 54324 Reconstruction of urethra $1,123.04 54326 Reconstruction of urethra $1,051.65 54328 Revise penis/urethra $1,068.48 54332 Revise penis/urethra $1,169.84 54336 Revise penis/urethra $1,328.17 54340 Secondary urethral surgery $645.70 54344 Secondary urethral surgery $1,113.46 54348 Secondary urethral surgery $1,177.21 54352 Reconstruct urethra/penis $1,661.55 54360 Penis plastic surgery $834.30 54380 Repair penis $924.65 54385 Repair penis $1,119.72 54390 Repair penis and bladder $1,343.88 54400 Insert semi-rigid prosthesis $612.74 54401 Insert self-contd prosthesis $754.98 54405 Insert multi-comp penis pros $927.24 54406 Remove muti-comp penis pros $837.18 54408 Repair multi-comp penis pros $901.37 54410 Remove/replace penis prosth $990.61 54411 Remov/replc penis pros, comp $1,167.57 54415 Remove self-contd penis pros $604.11 54416 Remv/repl penis contain pros $808.63 54417 Remv/replc penis pros, compl $1,024.43 54420 Revision of penis $812.17$ 54430 Revision of penis $736.80 54435 Revision of penis $479.53 54450 Preputial stretching $84.71 54500 Biopsy of testis $86.96 54505 Biopsy of testis $245.52 54512 Excise lesion testis $612.75 54520 Removal of testis $374.68 54522 Orchiectomy, partial $665.59 54530 Removal of testis $582.28 54535 Extensive testis surgery $838.53 54550 Exploration for testis $559.34 54560 Exploration for testis $758.65 54600 Reduce testis torsion $517.92 54620 Suspension of testis $347.35 54640 Suspension of testis $534.44 54650 Orchiopexy (Fowler-Stephens) $815.25 54660 Revision of testis $408.76 54670 Repair testis injury $464.19 54680 Relocation of testis(es) $896.02 54690 Laparoscopy, orchiectomy $721.74 54692 Laparoscopy, orchiopexy $887.18 54700 Drainage of scrotum $242.18 54800 Biopsy of epididymis $152.35 54830 Remove epididymis lesion $423.02 54840 Remove epididymis lesion $371.40 54860 Removal of epididymis $478.30 54861 Removal of epididymis $644.90

Page 80Page 80 Updated Fee Schedule - April 1

54865 Explore epididymis $408.79 54900 Fusion of spermatic ducts $856.84 54901 Fusion of spermatic ducts $1,232.43 55000 Drainage of hydrocele $142.54 55040 Removal of hydrocele $386.35 55041 Removal of hydroceles $579.05 55060 Repair of hydrocele $431.68 55100 Drainage of scrotum abscess $252.36 55110 Explore scrotum $438.30 55120 Removal of scrotum lesion $402.74 55150 Removal of scrotum $554.95 55175 Revision of scrotum $413.04 55180 Revision of scrotum $782.49 55200 Incision of sperm duct $581.03 55250 Removal of sperm duct(s) $517.00 55300 Prepare, sperm duct x-ray $205.01 55400 Repair of sperm duct $578.28 55450 Ligation of sperm duct $447.82 55500 Removal of hydrocele $428.25 55520 Removal of sperm cord lesion $439.99 55530 Revise spermatic cord veins $405.23 55535 Revise spermatic cord veins $487.62 55540 Revise hernia & sperm veins $531.94 55550 Laparo ligate spermatic vein $482.92 55600 Incise sperm duct pouch $488.99$ 55605 Incise sperm duct pouch $573.90 55650 Remove sperm duct pouch $815.02 55680 Remove sperm pouch lesion $388.39 55700 Biopsy of prostate $271.04 55705 Biopsy of prostate $309.35 55706 Prostate saturation sampling $439.63 55706 80 Prostate saturation sampling $70.34 55720 Drainage of prostate abscess $533.64 55725 Drainage of prostate abscess $672.43 55801 Removal of prostate $1,240.96 55810 Extensive prostate surgery $1,498.11 55812 Extensive prostate surgery $1,842.05 55815 Extensive prostate surgery $2,018.60 55821 Removal of prostate $998.84 55831 Removal of prostate $1,081.77 55840 Extensive prostate surgery $1,530.15 55842 Extensive prostate surgery $1,639.21 55845 Extensive prostate surgery $1,872.33 55860 Surgical exposure, prostate $1,002.02 55862 Extensive prostate surgery $1,267.18 55865 Extensive prostate surgery $1,532.24 55866 Laparo radical prostatectomy $1,991.06 55870 Electroejaculation $203.49 55873 Cryoablate prostate $1,307.98 55875 Transperi needle place, pros $871.95 55876 Place rt device/marker, pros $167.51 55920 Place needles pelvic for rt $485.61

Page 81Page 81 Updated Fee Schedule - April 1

56405 I & D of vulva/perineum $115.10 56420 Drainage of gland abscess $134.45 56440 Surgery for vulva lesion $192.10 56441 Lysis of labial lesion(s) $159.34 56442 Hymenotomy $51.87 56501 Destroy, vulva lesions, sim $138.93 56515 Destroy vulva lesion/s compl $234.68 56605 Biopsy of vulva/perineum $88.93 56606 Biopsy of vulva/perineum $41.10 56620 Partial removal of vulva $519.44 56625 Complete removal of vulva $619.59 56630 Extensive vulva surgery $901.13 56631 Extensive vulva surgery $1,145.96 56632 Extensive vulva surgery $1,329.50 56633 Extensive vulva surgery $1,173.71 56634 Extensive vulva surgery $1,241.05 56637 Extensive vulva surgery $1,464.51 56640 Extensive vulva surgery $1,461.92 56700 Partial removal of hymen $195.11 56740 Remove vagina gland lesion $310.09 56800 Repair of vagina $255.34 56805 Repair clitoris $1,194.45 56810 Repair of perineum $273.98 56820 Exam of vulva w/scope $117.80 56821 Exam/biopsy of vulva w/scope $157.57$ 57000 Exploration of vagina $199.98 57010 Drainage of pelvic abscess $449.74 57020 Drainage of pelvic fluid $99.35 57022 I & d vaginal hematoma, pp $173.69 57023 I & d vag hematoma, non-ob $325.53 57061 Destroy vag lesions, simple $121.64 57065 Destroy vag lesions, complex $203.41 57100 Biopsy of vagina $94.14 57105 Biopsy of vagina $144.49 57106 Remove vagina wall, partial $495.98 57107 Remove vagina tissue, part $1,454.33 57109 Vaginectomy partial w/nodes $1,661.14 57110 Remove vagina wall, complete $938.44 57111 Remove vagina tissue, compl $1,680.29 57112 Vaginectomy w/nodes, compl $1,779.04 57120 Closure of vagina $535.14 57130 Remove vagina lesion $191.94 57135 Remove vagina lesion $205.58 57150 Treat vagina infection $55.15 57155 Insert uteri tandems/ovoids $441.13 57160 Insert pessary/other device $82.95 57170 Fitting of diaphragm/cap $73.94 57180 Treat vaginal bleeding $152.89 57200 Repair of vagina $311.77 57210 Repair vagina/perineum $385.31 57220 Revision of urethra $335.57 57230 Repair of urethral lesion $417.43

Page 82Page 82 Updated Fee Schedule - April 1

57240 Repair bladder & vagina $685.06 57250 Repair rectum & vagina $668.61 57260 Repair of vagina $833.41 57265 Extensive repair of vagina $934.62 57267 Insert mesh/pelvic flr addon $283.24 57268 Repair of bowel bulge $504.29 57270 Repair of bowel pouch $830.69 57280 Suspension of vagina $1,009.02 57282 Colpopexy, extraperitoneal $537.02 57283 Colpopexy, intraperitoneal $715.38 57284 Repair paravag defect, open $875.26 57285 Repair paravag defect, vag $693.87 57287 Revise/remove sling repair $740.47 57288 Repair bladder defect $776.27 57289 Repair bladder & vagina $815.61 57291 Construction of vagina $568.79 57292 Construct vagina with graft $866.40 57295 Revise vag graft via vagina $518.42 57296 Revise vag graft, open abd $986.19 57300 Repair rectum-vagina fistula $554.38 57305 Repair rectum-vagina fistula $922.48 57307 Fistula repair & colostomy $1,032.86 57308 Fistula repair, transperine $660.80 57310 Repair urethrovaginal lesion $518.52 57311 Repair urethrovaginal lesion $590.87$ 57320 Repair bladder-vagina lesion $589.08 57330 Repair bladder-vagina lesion $832.93 57335 Repair vagina $1,211.74 57400 Dilation of vagina $142.52 57410 Pelvic examination $111.80 57415 Remove vaginal foreign body $167.68 57420 Exam of vagina w/scope $123.89 57421 Exam/biopsy of vag w/scope $166.36 57423 Repair paravag defect, lap $964.69 57425 Laparoscopy, surg, colpopexy $1,017.31 57452 Exam of cervix w/scope $116.48 57454 Bx/curett of cervix w/scope $163.44 57455 Biopsy of cervix w/scope $152.92 57456 Endocerv curettage w/scope $144.93 57460 Bx of cervix w/scope, leep $324.56 57461 Conz of cervix w/scope, leep $362.63 57500 Biopsy of cervix $143.92 57505 Endocervical curettage $108.60 57510 Cauterization of cervix $140.96 57511 Cryocautery of cervix $154.42 57513 Laser surgery of cervix $152.22 57520 Conization of cervix $327.03 57522 Conization of cervix $278.91 57530 Removal of cervix $360.64 57531 Removal of cervix, radical $1,765.05 57540 Removal of residual cervix $810.96 57545 Remove cervix/repair pelvis $854.60

Page 83Page 83 Updated Fee Schedule - April 1

57550 Removal of residual cervix $425.63 57555 Remove cervix/repair vagina $625.11 57556 Remove cervix, repair bowel $597.15 57558 D&c of cervical stump $132.78 57700 Revision of cervix $322.72 57720 Revision of cervix $321.42 57800 Dilation of cervical canal $64.63 58100 Biopsy of uterus lining $117.12 58110 Bx done w/colposcopy add-on $51.89 58120 Dilation and curettage $263.86 58140 Myomectomy abdom method $949.81 58145 Myomectomy vag method $565.44 58146 Myomectomy abdom complex $1,208.12 58150 Total hysterectomy $1,026.72 58152 Total hysterectomy $1,297.20 58180 Partial hysterectomy $985.19 58200 Extensive hysterectomy $1,356.56 58210 Extensive hysterectomy $1,806.31 58240 Removal of pelvis contents $2,825.90 58260 Vaginal hysterectomy $860.25 58262 Vag hyst including t/o $960.42 58263 Vag hyst w/t/o & vag repair $1,034.46 58267 Vag hyst w/urinary repair $1,098.98 58270 Vag hyst w/enterocele repair $920.61 58275 Hysterectomy/revise vagina $1,024.45$ 58280 Hysterectomy/revise vagina $1,095.70 58285 Extensive hysterectomy $1,372.30 58290 Vag hyst complex $1,202.28 58291 Vag hyst incl t/o, complex $1,306.40 58292 Vag hyst t/o & repair, compl $1,376.05 58293 Vag hyst w/uro repair, compl $1,428.27 58294 Vag hyst w/enterocele, compl $1,268.83 58300 Insert intrauterine device $83.99 58301 Remove intrauterine device $102.75 58321 Artificial insemination $84.47 58322 Artificial insemination $93.76 58323 Sperm washing $20.75 58340 Catheter for hysterography $141.52 58345 Reopen fallopian tube $290.03 58346 Insert heyman uteri capsule $473.69 58350 Reopen fallopian tube $104.04 58353 Endometr ablate, thermal $1,282.07 58356 Endometrial cryoablation $2,350.77 58400 Suspension of uterus $468.85 58410 Suspension of uterus $832.98 58520 Repair of ruptured uterus $813.92 58540 Revision of uterus $945.01 58541 Lsh, uterus 250 g or less $892.37 58542 Lsh w/t/o ut 250 g or less $988.12 58543 Lsh uterus above 250 g $1,004.58 58544 Lsh w/t/o uterus above 250 g $1,084.73 58545 Laparoscopic myomectomy $930.52

Page 84Page 84 Updated Fee Schedule - April 1

58546 Laparo-myomectomy, complex $1,177.73 58548 Lap radical hyst $1,832.66 58550 Laparo-asst vag hysterectomy $920.37 58552 Laparo-vag hyst incl t/o $1,012.61 58553 Laparo-vag hyst, complex $1,183.74 58554 Laparo-vag hyst w/t/o, compl $1,352.82 58555 Hysteroscopy, dx, sep proc $256.29 58558 Hysteroscopy, biopsy $344.63 58559 Hysteroscopy, lysis $361.65 58560 Hysteroscopy, resect septum $408.61 58561 Hysteroscopy, remove myoma $577.80 58562 Hysteroscopy, remove fb $363.30 58563 Hysteroscopy, ablation $2,084.99 58565 Hysteroscopy, sterilization $2,216.91 58570 Tlh, uterus 250 g or less $957.68 58571 Tlh w/t/o 250 g or less $1,049.12 58572 Tlh, uterus over 250 g $1,188.57 58573 Tlh w/t/o uterus over 250 g $1,340.08 58600 Division of fallopian tube $379.56 58605 Division of fallopian tube $345.52 58611 Ligate oviduct(s) add-on $81.73 58615 Occlude fallopian tube(s) $261.65 58660 Laparoscopy, lysis $700.41 58661 Laparoscopy, remove adnexa $671.59 58662 Laparoscopy, excise lesions $736.58$ 58670 Laparoscopy, tubal cautery $382.57 58671 Laparoscopy, tubal block $382.50 58672 Laparoscopy, fimbrioplasty $774.96 58673 Laparoscopy, salpingostomy $842.49 58700 Removal of fallopian tube $793.97 58720 Removal of ovary/tube(s) $746.08 58740 Adhesiolysis tube, ovary $909.55 58750 Repair oviduct $945.88 58752 Revise ovarian tube(s) $953.17 58760 Fimbrioplasty $858.81 58770 Create new tubal opening $876.45 58800 Drainage of ovarian cyst(s) $336.68 58805 Drainage of ovarian cyst(s) $423.31 58820 Drain ovary abscess, open $328.78 58822 Drain ovary abscess, percut $733.11 58823 Drain pelvic abscess, percut $1,025.37 58825 Transposition, ovary(s) $725.09 58900 Biopsy of ovary(s) $431.56 58920 Partial removal of ovary(s) $730.40 58925 Removal of ovarian cyst(s) $761.03 58940 Removal of ovary(s) $522.74 58943 Removal of ovary(s) $1,159.76 58950 Resect ovarian malignancy $1,107.38 58951 Resect ovarian malignancy $1,424.20 58952 Resect ovarian malignancy $1,607.32 58953 Tah, rad dissect for debulk $1,992.50 58954 Tah rad debulk/lymph remove $2,162.34

Page 85Page 85 Updated Fee Schedule - April 1

58956 Bso, omentectomy w/tah $1,414.69 58957 Resect recurrent gyn mal $1,533.87 58958 Resect recur gyn mal w/lym $1,704.50 58960 Exploration of abdomen $957.93 58970 Retrieval of oocyte $236.95 58976 Transfer of embryo $272.02 59000 Amniocentesis, diagnostic $140.98 59001 Amniocentesis, therapeutic $197.66 59012 Fetal cord puncture,prenatal $217.03 59015 Chorion biopsy $167.32 59020 Fetal contract stress test $78.05 59020 26 Fetal contract stress test $40.07 59025 Fetal non-stress test $50.90 59025 26 Fetal non-stress test $32.14 59030 Fetal scalp blood sample $120.19 59050 Fetal monitor w/report $53.66 59051 Fetal monitor/interpret only $44.20 59070 Transabdom amnioinfus w/us $419.29 59072 Umbilical cord occlud w/us $490.75 59074 Fetal fluid drainage w/us $395.57 59076 Fetal shunt placement, w/us $478.45 59100 Remove uterus lesion $868.71 59120 Treat ectopic pregnancy $830.24 59121 Treat ectopic pregnancy $834.04 59130 Treat ectopic pregnancy $972.85$ 59135 Treat ectopic pregnancy $986.94 59136 Treat ectopic pregnancy $920.23 59140 Treat ectopic pregnancy $415.31 59150 Treat ectopic pregnancy $808.30 59151 Treat ectopic pregnancy $789.04 59160 D & c after delivery $229.77 59200 Insert cervical dilator $80.94 59300 Episiotomy or vaginal repair $206.99 59320 Revision of cervix $163.62 59325 Revision of cervix $256.32 59350 Repair of uterus $294.15 59400 Obstetrical care $1,862.94 59409 Obstetrical care $817.21 59410 Obstetrical care $949.61 59412 Antepartum manipulation $110.20 59414 Deliver placenta $97.50 59425 Antepartum care only $465.68 59426 Antepartum care only $833.71 59430 Care after delivery $149.12 59510 Cesarean delivery $2,109.89 59514 Cesarean delivery only $967.79 59515 Cesarean delivery $1,143.79 59525 Remove uterus after cesarean $514.14 59610 Vbac delivery $1,962.60 59612 Vbac delivery only $916.05 59614 Vbac care after delivery $1,026.93 59618 Attempted vbac delivery $2,207.26

Page 86Page 86 Updated Fee Schedule - April 1

59620 Attempted vbac delivery only $1,062.39 59622 Attempted vbac after care $1,241.02 59812 Treatment of miscarriage $333.05 59820 Care of miscarriage $396.15 59821 Treatment of miscarriage $402.28 59830 Treat uterus infection $459.91 59840 Abortion $231.41 59841 Abortion $400.07 59850 Abortion $411.11 59851 Abortion $422.81 59852 Abortion $594.39 59855 Abortion $438.54 59856 Abortion $516.91 59857 Abortion $617.57 59866 Abortion (mpr) $254.31 59870 Evacuate mole of uterus $497.89 59871 Remove cerclage suture $142.97 60000 Drain thyroid/tongue cyst $166.24 60100 Biopsy of thyroid $122.69 60200 Remove thyroid lesion $664.56 60210 Partial thyroid excision $707.85 60212 Partial thyroid excision $1,016.23 60220 Partial removal of thyroid $775.57 60225 Partial removal of thyroid $933.07 60240 Removal of thyroid $984.63$ 60252 Removal of thyroid $1,327.90 60254 Extensive thyroid surgery $1,707.96 60260 Repeat thyroid surgery $1,109.55 60270 Removal of thyroid $1,396.15 60271 Removal of thyroid $1,071.28 60280 Remove thyroid duct lesion $450.04 60281 Remove thyroid duct lesion $596.83 60300 Aspir/inj thyroid cyst $118.47 60500 Explore parathyroid glands $1,022.07 60502 Re-explore parathyroids $1,282.93 60505 Explore parathyroid glands $1,409.31 60512 Autotransplant parathyroid $248.06 60520 Removal of thymus gland $1,054.99 60521 Removal of thymus gland $1,217.18 60522 Removal of thymus gland $1,464.64 60540 Explore adrenal gland $1,109.07 60545 Explore adrenal gland $1,259.47 60600 Remove carotid body lesion $1,455.89 60605 Remove carotid body lesion $1,826.46 60650 Laparoscopy adrenalectomy $1,233.28 61000 Remove cranial cavity fluid $113.99 61001 Remove cranial cavity fluid $112.30 61020 Remove brain cavity fluid $136.85 61026 Injection into brain canal $135.43 61050 Remove brain canal fluid $113.79 61055 Injection into brain canal $145.86 61070 Brain canal shunt procedure $87.31

Page 87Page 87 Updated Fee Schedule - April 1

61105 Twist drill hole $448.39 61107 Drill skull for implantation $328.09 61108 Drill skull for drainage $885.62 61120 Burr hole for puncture $725.04 61140 Pierce skull for biopsy $1,257.12 61150 Pierce skull for drainage $1,341.07 61151 Pierce skull for drainage $971.60 61154 Pierce skull & remove clot $1,261.89 61156 Pierce skull for drainage $1,254.54 61210 Pierce skull, implant device $383.02 61215 Insert brain-fluid device $487.02 61250 Pierce skull & explore $849.07 61253 Pierce skull & explore $925.89 61304 Open skull for exploration $1,653.55 61305 Open skull for exploration $1,985.48 61312 Open skull for drainage $2,056.52 61313 Open skull for drainage $1,974.17 61314 Open skull for drainage $1,830.18 61315 Open skull for drainage $2,082.43 61316 Implt cran bone flap to abdo $90.28 61320 Open skull for drainage $1,925.42 61321 Open skull for drainage $2,106.52 61322 Decompressive craniotomy $2,333.90 61323 Decompressive lobectomy $2,374.74 61330 Decompress eye socket $1,595.49$ 61332 Explore/biopsy eye socket $1,869.69 61333 Explore orbit/remove lesion $1,879.08 61334 Explore orbit/remove object $1,209.72 61340 Subtemporal decompression $1,435.66 61343 Incise skull (press relief) $2,213.92 61345 Relieve cranial pressure $2,050.67 61440 Incise skull for surgery $2,007.13 61450 Incise skull for surgery $1,891.81 61458 Incise skull for brain wound $2,028.48 61460 Incise skull for surgery $2,041.14 61470 Incise skull for surgery $1,899.17 61480 Incise skull for surgery $1,844.81 61490 Incise skull for surgery $1,921.98 61500 Removal of skull lesion $1,353.97 61501 Remove infected skull bone $1,158.81 61510 Removal of brain lesion $2,188.44 61512 Remove brain lining lesion $2,580.90 61514 Removal of brain abscess $1,916.34 61516 Removal of brain lesion $1,869.37 61517 Implt brain chemotx add-on $90.00 61518 Removal of brain lesion $2,777.11 61519 Remove brain lining lesion $2,988.37 61520 Removal of brain lesion $3,791.43 61521 Removal of brain lesion $3,208.73 61522 Removal of brain abscess $2,204.79 61524 Removal of brain lesion $2,080.46 61526 Removal of brain lesion $3,403.65

Page 88Page 88 Updated Fee Schedule - April 1

61530 Removal of brain lesion $2,894.78 61531 Implant brain electrodes $1,209.79 61533 Implant brain electrodes $1,524.17 61534 Removal of brain lesion $1,642.55 61535 Remove brain electrodes $985.50 61536 Removal of brain lesion $2,615.05 61537 Removal of brain tissue $2,384.83 61538 Removal of brain tissue $2,550.36 61539 Removal of brain tissue $2,366.42 61540 Removal of brain tissue $2,228.71 61541 Incision of brain tissue $2,123.89 61542 Removal of brain tissue $2,313.51 61543 Removal of brain tissue $2,159.63 61544 Remove & treat brain lesion $1,769.47 61545 Excision of brain tumor $3,175.37 61546 Removal of pituitary gland $2,302.58 61548 Removal of pituitary gland $1,543.94 61550 Release of skull seams $1,001.42 61552 Release of skull seams $1,313.49 61556 Incise skull/sutures $1,634.25 61557 Incise skull/sutures $1,699.79 61558 Excision of skull/sutures $1,698.48 61559 Excision of skull/sutures $2,428.96 61563 Excision of skull tumor $1,931.93 61564 Excision of skull tumor $2,443.18$ 61566 Removal of brain tissue $2,243.17 61567 Incision of brain tissue $2,510.46 61570 Remove foreign body, brain $1,837.05 61571 Incise skull for brain wound $2,001.04 61575 Skull base/brainstem surgery $2,344.86 61576 Skull base/brainstem surgery $3,747.62 61580 Craniofacial approach, skull $2,473.25 61581 Craniofacial approach, skull $2,775.66 61582 Craniofacial approach, skull $2,903.87 61583 Craniofacial approach, skull $2,931.61 61584 Orbitocranial approach/skull $2,847.60 61585 Orbitocranial approach/skull $2,988.45 61586 Resect nasopharynx, skull $2,169.26 61590 Infratemporal approach/skull $3,135.51 61591 Infratemporal approach/skull $3,162.15 61592 Orbitocranial approach/skull $3,207.62 61595 Transtemporal approach/skull $2,384.52 61596 Transcochlear approach/skull $2,598.14 61597 Transcondylar approach/skull $2,894.41 61598 Transpetrosal approach/skull $2,549.50 61600 Resect/excise cranial lesion $2,151.20 61601 Resect/excise cranial lesion $2,378.79 61605 Resect/excise cranial lesion $2,236.53 61606 Resect/excise cranial lesion $3,040.82 61607 Resect/excise cranial lesion $2,796.82 61608 Resect/excise cranial lesion $3,286.80 61609 Transect artery, sinus $630.75

Page 89Page 89 Updated Fee Schedule - April 1

61610 Transect artery, sinus $1,936.62 61611 Transect artery, sinus $489.04 61612 Transect artery, sinus $1,692.35 61613 Remove aneurysm, sinus $3,174.69 61615 Resect/excise lesion, skull $2,495.69 61616 Resect/excise lesion, skull $3,293.19 61618 Repair dura $1,303.41 61619 Repair dura $1,496.36 61623 Endovasc tempory vessel occl $590.61 61624 Transcath occlusion, cns $1,172.45 61626 Transcath occlusion, non-cns $951.06 61630 Intracranial angioplasty $1,339.63 61635 Intracran angioplsty w/stent $1,466.04 61640 Dilate ic vasospasm, init $673.11 61641 Dilate ic vasospasm add-on $236.38 61642 Dilate ic vasospasm add-on $473.13 61680 Intracranial vessel surgery $2,284.97 61682 Intracranial vessel surgery $4,285.60 61684 Intracranial vessel surgery $2,854.98 61686 Intracranial vessel surgery $4,588.55 61690 Intracranial vessel surgery $2,167.31 61692 Intracranial vessel surgery $3,705.37 61697 Brain aneurysm repr, complx $4,161.44 61698 Brain aneurysm repr, complx $4,459.30 61700 Brain aneurysm repr, simple $3,511.68$ 61702 Inner skull vessel surgery $3,883.57 61703 Clamp neck artery $1,345.35 61705 Revise circulation to head $2,574.73 61708 Revise circulation to head $2,161.33 61710 Revise circulation to head $1,998.96 61711 Fusion of skull arteries $2,630.56 61720 Incise skull/brain surgery $1,160.23 61735 Incise skull/brain surgery $1,414.96 61750 Incise skull/brain biopsy $1,409.31 61751 Brain biopsy w/ct/mr guide $1,377.17 61760 Implant brain electrodes $1,549.11 61770 Incise skull for treatment $1,508.09 61790 Treat trigeminal nerve $855.93 61791 Treat trigeminal tract $1,103.57 61795 Brain surgery using computer $254.09 61796 Srs, cranial lesion simple $806.73 61796 80 Srs, cranial lesion simple $129.08 61797 Srs, cran les simple, addl $216.95 61797 80 Srs, cran les simple, addl $34.71 61798 Srs, cranial lesion complex $806.73 61798 80 Srs, cranial lesion complex $129.08 61799 Srs, cran les complex, addl $300.27 61799 80 Srs, cran les complex, addl $48.04 61800 Apply srs headframe add-on $155.09 61800 80 Apply srs headframe add-on $24.82 61850 Implant neuroelectrodes $983.31 61860 Implant neuroelectrodes $1,558.68

Page 90Page 90 Updated Fee Schedule - April 1

61863 Implant neuroelectrode $1,523.78 61864 Implant neuroelectrde, addl $455.09 61867 Implant neuroelectrode $2,209.57 61868 Implant neuroelectrde, addÆl $647.46 61870 Implant neuroelectrodes $1,189.88 61875 Implant neuroelectrodes $1,149.34 61880 Revise/remove neuroelectrode $551.29 61885 Insrt/redo neurostim 1 array $639.41 61886 Implant neurostim arrays $803.26 61888 Revise/remove neuroreceiver $402.53 62000 Treat skull fracture $858.66 62005 Treat skull fracture $1,241.20 62010 Treatment of head injury $1,520.11 62100 Repair brain fluid leakage $1,608.94 62115 Reduction of skull defect $1,427.36 62116 Reduction of skull defect $1,784.00 62117 Reduction of skull defect $1,900.91 62120 Repair skull cavity lesion $1,815.18 62121 Incise skull repair $1,663.41 62140 Repair of skull defect $1,053.51 62141 Repair of skull defect $1,155.92 62142 Remove skull plate/flap $882.76 62143 Replace skull plate/flap $1,033.32 62145 Repair of skull & brain $1,410.42 62146 Repair of skull with graft $1,208.37$ 62147 Repair of skull with graft $1,434.07 62148 Retr bone flap to fix skull $128.39 62160 Neuroendoscopy add-on $197.70 62161 Dissect brain w/scope $1,522.31 62162 Remove colloid cyst w/scope $1,885.89 62163 Neuroendoscopy w/fb removal $1,228.46 62164 Remove brain tumor w/scope $1,998.45 62165 Remove pituit tumor w/scope $1,539.31 62180 Establish brain cavity shunt $1,589.43 62190 Establish brain cavity shunt $908.90 62192 Establish brain cavity shunt $966.28 62194 Replace/irrigate catheter $390.29 62200 Establish brain cavity shunt $1,378.68 62201 Brain cavity shunt w/scope $1,185.20 62220 Establish brain cavity shunt $1,016.28 62223 Establish brain cavity shunt $1,044.03 62225 Replace/irrigate catheter $500.89 62230 Replace/revise brain shunt $840.80 62252 Csf shunt reprogram $108.07 62252 26 Csf shunt reprogram $48.46 62256 Remove brain cavity shunt $586.45 62258 Replace brain cavity shunt $1,129.72 62263 Epidural lysis mult sessions $685.14 62264 Epidural lysis on single day $416.45 62267 Interdiscal perq aspir, dx $270.29 62268 Drain spinal cord cyst $497.65 62269 Needle biopsy, spinal cord $540.06

Page 91Page 91 Updated Fee Schedule - April 1

62270 Spinal fluid tap, diagnostic $165.69 62272 Drain cerebro spinal fluid $197.69 62273 Inject epidural patch $172.09 62280 Treat spinal cord lesion $327.36 62281 Treat spinal cord lesion $301.43 62282 Treat spinal canal lesion $314.85 62284 Injection for myelogram $241.70 62287 Percutaneous diskectomy $563.47 62290 Inject for spine disk x-ray $348.04 62291 Inject for spine disk x-ray $325.71 62292 Injection into disk lesion $501.75 62294 Injection into spinal artery $817.86 62310 Inject spine c/t $229.91 62311 Inject spine l/s (cd) $203.75 62318 Inject spine w/cath, c/t $245.94 62319 Inject spine w/cath l/s (cd) $222.39 62350 Implant spinal canal cath $400.20 62351 Implant spinal canal cath $851.54 62355 Remove spinal canal catheter $301.18 62360 Insert spine infusion device $286.25 62361 Implant spine infusion pump $399.27 62362 Implant spine infusion pump $422.90 62365 Remove spine infusion device $335.00 62367 Analyze spine infusion pump $40.24 62368 Analyze spine infusion pump $57.52$ 63001 Removal of spinal lamina $1,237.20 63003 Removal of spinal lamina $1,244.27 63005 Removal of spinal lamina $1,183.31 63011 Removal of spinal lamina $1,116.99 63012 Removal of spinal lamina $1,203.35 63015 Removal of spinal lamina $1,490.28 63016 Removal of spinal lamina $1,526.32 63017 Removal of spinal lamina $1,248.65 63020 Neck spine disk surgery $1,184.55 63030 Low back disk surgery $985.73 63035 Spinal disk surgery add-on $208.17 63040 Laminotomy, single cervical $1,435.75 63042 Laminotomy, single lumbar $1,345.24 63045 Removal of spinal lamina $1,284.09 63046 Removal of spinal lamina $1,224.70 63047 Removal of spinal lamina $1,120.73 63048 Remove spinal lamina add-on $222.30 63050 Cervical laminoplasty $1,539.12 63051 C-laminoplasty w/graft/plate $1,729.11 63055 Decompress spinal cord $1,650.13 63056 Decompress spinal cord $1,522.20 63057 Decompress spine cord add-on $342.18 63064 Decompress spinal cord $1,801.02 63066 Decompress spine cord add-on $210.17 63075 Neck spine disk surgery $1,413.35 63076 Neck spine disk surgery $264.29 63077 Spine disk surgery, thorax $1,532.13

Page 92Page 92 Updated Fee Schedule - April 1

63078 Spine disk surgery, thorax $208.90 63081 Removal of vertebral body $1,805.68 63082 Remove vertebral body add-on $285.02 63085 Removal of vertebral body $1,908.98 63086 Remove vertebral body add-on $200.85 63087 Removal of vertebral body $2,441.79 63088 Remove vertebral body add-on $275.25 63090 Removal of vertebral body $1,990.73 63091 Remove vertebral body add-on $187.99 63101 Removal of vertebral body $2,294.96 63102 Removal of vertebral body $2,284.42 63103 Remove vertebral body add-on $300.07 63170 Incise spinal cord tract(s) $1,549.74 63172 Drainage of spinal cyst $1,397.42 63173 Drainage of spinal cyst $1,724.56 63180 Revise spinal cord ligaments $1,395.73 63182 Revise spinal cord ligaments $1,497.32 63185 Incise spinal column/nerves $1,134.53 63190 Incise spinal column/nerves $1,304.63 63191 Incise spinal column/nerves $1,262.44 63194 Incise spinal column & cord $1,475.32 63195 Incise spinal column & cord $1,509.79 63196 Incise spinal column & cord $1,778.10 63197 Incise spinal column & cord $1,694.33 63198 Incise spinal column & cord $1,860.39$ 63199 Incise spinal column & cord $1,932.77 63200 Release of spinal cord $1,517.22 63250 Revise spinal cord vessels $2,922.34 63251 Revise spinal cord vessels $3,046.87 63252 Revise spinal cord vessels $3,051.11 63265 Excise intraspinal lesion $1,678.93 63266 Excise intraspinal lesion $1,724.27 63267 Excise intraspinal lesion $1,391.69 63268 Excise intraspinal lesion $1,388.10 63270 Excise intraspinal lesion $2,063.63 63271 Excise intraspinal lesion $2,077.00 63272 Excise intraspinal lesion $1,912.83 63273 Excise intraspinal lesion $1,802.15 63275 Biopsy/excise spinal tumor $1,801.07 63276 Biopsy/excise spinal tumor $1,795.26 63277 Biopsy/excise spinal tumor $1,576.61 63278 Biopsy/excise spinal tumor $1,538.99 63280 Biopsy/excise spinal tumor $2,134.87 63281 Biopsy/excise spinal tumor $2,109.94 63282 Biopsy/excise spinal tumor $1,992.49 63283 Biopsy/excise spinal tumor $1,886.08 63285 Biopsy/excise spinal tumor $2,615.61 63286 Biopsy/excise spinal tumor $2,609.28 63287 Biopsy/excise spinal tumor $2,747.69 63290 Biopsy/excise spinal tumor $2,774.43 63295 Repair of laminectomy defect $327.20 63300 Removal of vertebral body $1,855.92

Page 93Page 93 Updated Fee Schedule - April 1

63301 Removal of vertebral body $2,060.95 63302 Removal of vertebral body $2,051.17 63303 Removal of vertebral body $2,128.42 63304 Removal of vertebral body $2,283.15 63305 Removal of vertebral body $2,312.04 63306 Removal of vertebral body $2,462.31 63307 Removal of vertebral body $2,243.17 63308 Remove vertebral body add-on $343.54 63600 Remove spinal cord lesion $833.45 63610 Stimulation of spinal cord $1,445.47 63615 Remove lesion of spinal cord $1,147.77 63620 Srs, spinal lesion $806.73 63620 80 Srs, spinal lesion $129.08 63621 Srs, spinal lesion, addl $249.66 63621 80 Srs, spinal lesion, addl $39.95 63650 Implant neuroelectrodes $414.19 63655 Implant neuroelectrodes $855.52 63660 Revise/remove neuroelectrode $442.98 63685 Insrt/redo spine n generator $407.03 63688 Revise/remove neuroreceiver $365.48 63700 Repair of spinal herniation $1,237.31 63702 Repair of spinal herniation $1,394.72 63704 Repair of spinal herniation $1,547.87 63706 Repair of spinal herniation $1,815.72 63707 Repair spinal fluid leakage $915.43$ 63709 Repair spinal fluid leakage $1,110.45 63710 Graft repair of spine defect $1,113.49 63740 Install spinal shunt $948.35 63741 Install spinal shunt $607.84 63744 Revision of spinal shunt $643.95 63746 Removal of spinal shunt $564.40 64400 N block inj, trigeminal $112.09 64402 N block inj, facial $114.29 64405 N block inj, occipital $106.78 64408 N block inj, vagus $124.31 64410 N block inj, phrenic $145.75 64412 N block inj, spinal accessor $146.54 64413 N block inj, cervical plexus $119.25 64415 N block inj, brachial plexus $136.13 64416 N block cont infuse, b plex $95.88 64417 N block inj, axillary $138.07 64418 N block inj, suprascapular $141.11 64420 N block inj, intercost, sng $170.70 64421 N block inj, intercost, mlt $252.07 64425 N block inj, ilio-ing/hypogi $132.34 64430 N block inj, pudendal $165.65 64435 N block inj, paracervical $153.47 64445 N block inj, sciatic, sng $141.77 64446 N blk inj, sciatic, cont inf $94.86 64447 N block inj fem, single $70.52 64448 N block inj fem, cont inf $83.75 64449 N block inj, lumbar plexus $93.44

Page 94Page 94 Updated Fee Schedule - April 1

64450 N block, other peripheral $107.72 64455 N block inj, plantar digit $54.69 64455 50 N block inj, plantar digit $82.03 64470 Inj paravertebral c/t $279.65 64472 Inj paravertebral c/t add-on $118.00 64475 Inj paravertebral l/s $252.15 64476 Inj paravertebral l/s add-on $99.94 64479 Inj foramen epidural c/t $294.33 64480 Inj foramen epidural add-on $145.25 64483 Inj foramen epidural l/s $288.04 64484 Inj foramen epidural add-on $143.60 64505 N block, spenopalatine gangl $105.02 64508 N block, carotid sinus s/p $151.11 64510 N block, stellate ganglion $149.81 64517 N block inj, hypogas plxs $175.34 64520 N block, lumbar/thoracic $197.48 64530 N block inj, celiac pelus $202.93 64550 Apply neurostimulator $16.45 64553 Implant neuroelectrodes $211.55 64555 Implant neuroelectrodes $225.86 64560 Implant neuroelectrodes $223.19 64561 Implant neuroelectrodes $1,254.07 64565 Implant neuroelectrodes $178.23 64573 Implant neuroelectrodes $600.46 64575 Implant neuroelectrodes $292.44$ 64577 Implant neuroelectrodes $369.50 64580 Implant neuroelectrodes $302.67 64581 Implant neuroelectrodes $863.08 64585 Revise/remove neuroelectrode $362.82 64590 Insrt/redo pn/gastr stimul $337.29 64595 Revise/rmv pn/gastr stimul $353.34 64600 Injection treatment of nerve $426.12 64605 Injection treatment of nerve $597.30 64610 Injection treatment of nerve $729.42 64612 Destroy nerve, face muscle $159.14 64613 Destroy nerve, neck muscle $156.51 64614 Destroy nerve, extrem musc $175.41 64620 Injection treatment of nerve $283.09 64622 Destr paravertebrl nerve l/s $341.19 64623 Destr paravertebral n add-on $127.60 64626 Destr paravertebrl nerve c/t $395.08 64627 Destr paravertebral n add-on $174.96 64630 Injection treatment of nerve $242.09 64632 N block inj, common digit $89.04 64632 50 N block inj, common digit $133.56 64640 Injection treatment of nerve $240.07 64650 Chemodenerv eccrine glands $70.29 64653 Chemodenerv eccrine glands $81.41 64680 Injection treatment of nerve $324.13 64681 Injection treatment of nerve $416.82 64702 Revise finger/toe nerve $468.86 64704 Revise hand/foot nerve $345.39

Page 95Page 95 Updated Fee Schedule - April 1

64708 Revise arm/leg nerve $490.17 64712 Revision of sciatic nerve $556.96 64713 Revision of arm nerve(s) $781.72 64714 Revise low back nerve(s) $659.46 64716 Revision of cranial nerve $532.36 64718 Revise ulnar nerve at elbow $579.29 64719 Revise ulnar nerve at wrist $402.22 64721 Carpal tunnel surgery $426.16 64722 Relieve pressure on nerve(s) $339.09 64726 Release foot/toe nerve $299.52 64727 Internal nerve revision $193.95 64732 Incision of brow nerve $395.29 64734 Incision of cheek nerve $424.01 64736 Incision of chin nerve $397.97 64738 Incision of jaw nerve $472.36 64740 Incision of tongue nerve $469.49 64742 Incision of facial nerve $477.21 64744 Incise nerve, back of head $425.02 64746 Incise diaphragm nerve $452.24 64752 Incision of vagus nerve $510.24 64755 Incision of stomach nerves $898.54 64760 Incision of vagus nerve $478.96 64761 Incision of pelvis nerve $452.82 64763 Incise hip/thigh nerve $556.96 64766 Incise hip/thigh nerve $636.43$ 64771 Sever cranial nerve $604.41 64772 Incision of spinal nerve $582.34 64774 Remove skin nerve lesion $417.70 64776 Remove digit nerve lesion $401.49 64778 Digit nerve surgery add-on $192.25 64782 Remove limb nerve lesion $470.99 64783 Limb nerve surgery add-on $229.21 64784 Remove nerve lesion $733.35 64786 Remove sciatic nerve lesion $1,102.63 64787 Implant nerve end $263.04 64788 Remove skin nerve lesion $393.85 64790 Removal of nerve lesion $843.23 64792 Removal of nerve lesion $1,090.56 64795 Biopsy of nerve $198.86 64802 Remove sympathetic nerves $608.61 64804 Remove sympathetic nerves $927.56 64809 Remove sympathetic nerves $868.59 64818 Remove sympathetic nerves $676.08 64820 Remove sympathetic nerves $770.89 64821 Remove sympathetic nerves $697.54 64822 Remove sympathetic nerves $688.79 64823 Remove sympathetic nerves $780.88 64831 Repair of digit nerve $693.58 64832 Repair nerve add-on $358.05 64834 Repair of hand or foot nerve $761.66 64835 Repair of hand or foot nerve $826.73 64836 Repair of hand or foot nerve $825.82

Page 96Page 96 Updated Fee Schedule - April 1

64837 Repair nerve add-on $397.62 64840 Repair of leg nerve $930.51 64856 Repair/transpose nerve $1,036.53 64857 Repair arm/leg nerve $1,083.31 64858 Repair sciatic nerve $1,257.92 64859 Nerve surgery $269.78 64861 Repair of arm nerves $1,415.82 64862 Repair of low back nerves $1,384.95 64864 Repair of facial nerve $891.44 64865 Repair of facial nerve $1,189.17 64866 Fusion of facial/other nerve $1,239.17 64868 Fusion of facial/other nerve $1,080.10 64870 Fusion of facial/other nerve $1,036.49 64872 Subsequent repair of nerve $126.23 64874 Repair & revise nerve add-on $185.27 64876 Repair nerve/shorten bone $201.48 64885 Nerve graft, head or neck $1,159.38 64886 Nerve graft, head or neck $1,377.12 64890 Nerve graft, hand or foot $1,116.65 64891 Nerve graft, hand or foot $1,142.33 64892 Nerve graft, arm or leg $1,088.42 64893 Nerve graft, arm or leg $1,144.02 64895 Nerve graft, hand or foot $1,333.24 64896 Nerve graft, hand or foot $1,477.69 64897 Nerve graft, arm or leg $1,293.45$ 64898 Nerve graft, arm or leg $1,412.04 64901 Nerve graft add-on $629.47 64902 Nerve graft add-on $722.60 64905 Nerve pedicle transfer $1,037.46 64907 Nerve pedicle transfer $1,366.46 64910 Nerve repair w/allograft $841.38 64911 Neurorraphy w/vein autograft $1,008.84 65091 Revise eye $600.25 65093 Revise eye with implant $600.45 65101 Removal of eye $692.27 65103 Remove eye/insert implant $721.92 65105 Remove eye/attach implant $795.44 65110 Removal of eye $1,152.15 65112 Remove eye/revise socket $1,359.41 65114 Remove eye/revise socket $1,408.08 65125 Revise ocular implant $443.46 65130 Insert ocular implant $683.78 65135 Insert ocular implant $695.92 65140 Attach ocular implant $757.78 65150 Revise ocular implant $552.09 65155 Reinsert ocular implant $799.28 65175 Removal of ocular implant $617.18 65205 Remove foreign body from eye $53.72 65210 Remove foreign body from eye $66.17 65220 Remove foreign body from eye $55.35 65222 Remove foreign body from eye $72.50 65235 Remove foreign body from eye $650.97

Page 97Page 97 Updated Fee Schedule - April 1

65260 Remove foreign body from eye $891.74 65265 Remove foreign body from eye $1,002.05 65270 Repair of eye wound $259.47 65272 Repair of eye wound $472.67 65273 Repair of eye wound $353.33 65275 Repair of eye wound $523.17 65280 Repair of eye wound $619.37 65285 Repair of eye wound $962.39 65286 Repair of eye wound $668.19 65290 Repair of eye socket wound $456.09 65400 Removal of eye lesion $628.72 65410 Biopsy of cornea $137.66 65420 Removal of eye lesion $493.91 65426 Removal of eye lesion $618.98 65430 Corneal smear $109.55 65435 Curette/treat cornea $76.09 65436 Curette/treat cornea $359.51 65450 Treatment of corneal lesion $301.24 65600 Revision of cornea $364.68 65710 Corneal transplant $1,026.49 65730 Corneal transplant $1,139.83 65750 Corneal transplant $1,153.42 65755 Corneal transplant $1,146.88 65756 Corneal trnspl, endothelial $1,099.82 65756 50 Corneal trnspl, endothelial $1,649.73$ 65770 Revise cornea with implant $1,315.69 65772 Correction of astigmatism $419.92 65775 Correction of astigmatism $512.01 65780 Ocular reconst, transplant $827.11 65781 Ocular reconst, transplant $1,240.97 65782 Ocular reconst, transplant $1,072.41 65800 Drainage of eye $143.13 65805 Drainage of eye $157.19 65810 Drainage of eye $434.47 65815 Drainage of eye $605.19 65820 Relieve inner eye pressure $702.20 65850 Incision of eye $790.02 65855 Laser surgery of eye $320.28 65860 Incise inner eye adhesions $296.30 65865 Incise inner eye adhesions $446.14 65870 Incise inner eye adhesions $549.17 65875 Incise inner eye adhesions $583.58 65880 Incise inner eye adhesions $614.04 65900 Remove eye lesion $899.64 65920 Remove implant of eye $728.86 65930 Remove blood clot from eye $598.70 66020 Injection treatment of eye $179.02 66030 Injection treatment of eye $159.15 66130 Remove eye lesion $666.94 66150 Glaucoma surgery $805.30 66155 Glaucoma surgery $802.20 66160 Glaucoma surgery $910.07

Page 98Page 98 Updated Fee Schedule - April 1

66165 Glaucoma surgery $786.18 66170 Glaucoma surgery $1,101.69 66172 Incision of eye $1,384.86 66180 Implant eye shunt $1,086.37 66185 Revise eye shunt $690.86 66220 Repair eye lesion $675.91 66225 Repair/graft eye lesion $864.37 66250 Follow-up surgery of eye $711.06 66500 Incision of iris $332.50 66505 Incision of iris $363.57 66600 Remove iris and lesion $762.25 66605 Removal of iris $984.91 66625 Removal of iris $401.00 66630 Removal of iris $525.52 66635 Removal of iris $530.88 66680 Repair iris & ciliary body $476.19 66682 Repair iris & ciliary body $582.15 66700 Destruction, ciliary body $420.61 66710 Ciliary transsleral therapy $412.77 66711 Ciliary endoscopic ablation $588.28 66720 Destruction, ciliary body $436.18 66740 Destruction, ciliary body $409.69 66761 Revision of iris $422.45 66762 Revision of iris $441.95 66770 Removal of inner eye lesion $489.80$ 66820 Incision, secondary cataract $374.95 66821 After cataract laser surgery $303.57 66825 Reposition intraocular lens $711.96 66830 Removal of lens lesion $659.69 66840 Removal of lens material $643.47 66850 Removal of lens material $734.34 66852 Removal of lens material $784.98 66920 Extraction of lens $700.73 66930 Extraction of lens $795.27 66940 Extraction of lens $723.67 66982 Cataract surgery, complex $990.35 66983 Cataract surg w/iol, 1 stage $680.77 66984 Cataract surg w/iol, 1 stage $711.59 66985 Insert lens prosthesis $707.31 66986 Exchange lens prosthesis $864.54 66990 Ophthalmic endoscope add-on $86.83 67005 Partial removal of eye fluid $438.25 67010 Partial removal of eye fluid $505.93 67015 Release of eye fluid $542.36 67025 Replace eye fluid $678.97 67027 Implant eye drug system $794.46 67028 Injection eye drug $202.92 67030 Incise inner eye strands $486.53 67031 Laser surgery, eye strands $359.78 67036 Removal of inner eye fluid $896.05 67039 Laser treatment of retina $1,149.64 67040 Laser treatment of retina $1,324.34

Page 99Page 99 Updated Fee Schedule - April 1

67041 Vit for macular pucker $1,232.16 67042 Vit for macular hole $1,409.26 67043 Vit for membrane dissect $1,480.50 67101 Repair detached retina $726.27 67105 Repair detached retina $669.88 67107 Repair detached retina $1,127.41 67108 Repair detached retina $1,496.63 67110 Repair detached retina $811.16 67112 Rerepair detached retina $1,235.52 67113 Repair retinal detach, cplx $1,621.94 67115 Release encircling material $457.76 67120 Remove eye implant material $614.92 67121 Remove eye implant material $841.29 67141 Treatment of retina $484.38 67145 Treatment of retina $487.73 67208 Treatment of retinal lesion $556.34 67210 Treatment of retinal lesion $646.66 67218 Treatment of retinal lesion $1,303.84 67220 Treatment of choroid lesion $993.72 67221 Ocular photodynamic ther $284.81 67225 Eye photodynamic ther add-on $28.52 67227 Treatment of retinal lesion $568.27 67228 Treatment of retinal lesion $1,126.02 67229 Tr retinal les preterm inf $1,069.83 67250 Reinforce eye wall $737.41$ 67255 Reinforce/graft eye wall $789.15 67311 Revise eye muscle $556.17 67312 Revise two eye muscles $662.32 67314 Revise eye muscle $622.54 67316 Revise two eye muscles $742.63 67318 Revise eye muscle(s) $652.16 67320 Revise eye muscle(s) add-on $303.34 67331 Eye surgery follow-up add-on $287.16 67332 Rerevise eye muscles add-on $312.48 67334 Revise eye muscle w/suture $283.46 67335 Eye suture during surgery $143.34 67340 Revise eye muscle add-on $337.72 67343 Release eye tissue $605.34 67345 Destroy nerve of eye muscle $221.21 67346 Biopsy, eye muscle $191.10 67400 Explore/biopsy eye socket $879.37 67405 Explore/drain eye socket $750.17 67412 Explore/treat eye socket $813.59 67413 Explore/treat eye socket $814.60 67414 Explr/decompress eye socket $1,231.25 67415 Aspiration, orbital contents $100.02 67420 Explore/treat eye socket $1,541.13 67430 Explore/treat eye socket $1,180.83 67440 Explore/drain eye socket $1,136.68 67445 Explr/decompress eye socket $1,323.57 67450 Explore/biopsy eye socket $1,179.26 67500 Inject/treat eye socket $84.00

Page 100Page 100 Updated Fee Schedule - April 1

67505 Inject/treat eye socket $82.78 67515 Inject/treat eye socket $87.52 67550 Insert eye socket implant $916.87 67560 Revise eye socket implant $930.98 67570 Decompress optic nerve $1,092.64 67700 Drainage of eyelid abscess $262.40 67710 Incision of eyelid $222.16 67715 Incision of eyelid fold $233.18 67800 Remove eyelid lesion $120.28 67801 Remove eyelid lesions $153.39 67805 Remove eyelid lesions $190.77 67808 Remove eyelid lesion(s) $339.72 67810 Biopsy of eyelid $223.75 67820 Revise eyelashes $49.70 67825 Revise eyelashes $121.96 67830 Revise eyelashes $260.75 67835 Revise eyelashes $412.35 67840 Remove eyelid lesion $271.40 67850 Treat eyelid lesion $217.84 67875 Closure of eyelid by suture $168.99 67880 Revision of eyelid $431.09 67882 Revision of eyelid $529.83 67900 Repair brow defect $613.65 67901 Repair eyelid defect $662.36 67902 Repair eyelid defect $667.95$ 67903 Repair eyelid defect $587.57 67904 Repair eyelid defect $692.31 67906 Repair eyelid defect $484.46 67908 Repair eyelid defect $466.76 67909 Revise eyelid defect $514.36 67911 Revise eyelid defect $516.57 67912 Correction eyelid w/implant $886.94 67914 Repair eyelid defect $375.52 67915 Repair eyelid defect $337.12 67916 Repair eyelid defect $515.35 67917 Repair eyelid defect $562.51 67921 Repair eyelid defect $358.17 67922 Repair eyelid defect $326.71 67923 Repair eyelid defect $541.69 67924 Repair eyelid defect $562.32 67930 Repair eyelid wound $353.75 67935 Repair eyelid wound $572.23 67938 Remove eyelid foreign body $238.91 67950 Revision of eyelid $554.06 67961 Revision of eyelid $553.60 67966 Revision of eyelid $720.79 67971 Reconstruction of eyelid $686.18 67973 Reconstruction of eyelid $888.54 67974 Reconstruction of eyelid $884.82 67975 Reconstruction of eyelid $648.76 68020 Incise/drain eyelid lining $112.44 68040 Treatment of eyelid lesions $62.14

Page 101Page 101 Updated Fee Schedule - April 1

68100 Biopsy of eyelid lining $167.68 68110 Remove eyelid lining lesion $217.96 68115 Remove eyelid lining lesion $303.37 68130 Remove eyelid lining lesion $516.13 68135 Remove eyelid lining lesion $147.48 68200 Treat eyelid by injection $40.22 68320 Revise/graft eyelid lining $684.08 68325 Revise/graft eyelid lining $614.23 68326 Revise/graft eyelid lining $597.24 68328 Revise/graft eyelid lining $667.50 68330 Revise eyelid lining $573.24 68335 Revise/graft eyelid lining $599.05 68340 Separate eyelid adhesions $517.95 68360 Revise eyelid lining $503.05 68362 Revise eyelid lining $607.02 68371 Harvest eye tissue, alograft $394.58 68400 Incise/drain tear gland $275.76 68420 Incise/drain tear sac $312.26 68440 Incise tear duct opening $102.86 68500 Removal of tear gland $904.72 68505 Partial removal, tear gland $911.14 68510 Biopsy of tear gland $438.07 68520 Removal of tear sac $642.08 68525 Biopsy of tear sac $253.81 68530 Clearance of tear duct $421.95$ 68540 Remove tear gland lesion $865.19 68550 Remove tear gland lesion $1,063.65 68700 Repair tear ducts $558.51 68705 Revise tear duct opening $229.51 68720 Create tear sac drain $709.02 68745 Create tear duct drain $713.50 68750 Create tear duct drain $732.98 68760 Close tear duct opening $194.55 68761 Close tear duct opening $140.71 68770 Close tear system fistula $549.14 68801 Dilate tear duct opening $118.24 68810 Probe nasolacrimal duct $227.23 68811 Probe nasolacrimal duct $193.85 68815 Probe nasolacrimal duct $432.14 68816 Probe nl duct w/balloon $675.35 68840 Explore/irrigate tear ducts $118.29 68850 Injection for tear sac x-ray $66.05 69000 Drain external ear lesion $186.09 69005 Drain external ear lesion $218.10 69020 Drain outer ear canal lesion $239.44 69100 Biopsy of external ear $110.85 69105 Biopsy of external ear canal $146.72 69110 Remove external ear, partial $473.75 69120 Removal of external ear $413.71 69140 Remove ear canal lesion(s) $908.70 69145 Remove ear canal lesion(s) $399.85 69150 Extensive ear canal surgery $1,088.41

Page 102Page 102 Updated Fee Schedule - April 1

69155 Extensive ear/neck surgery $1,737.60 69200 Clear outer ear canal $127.65 69205 Clear outer ear canal $104.96 69210 Remove impacted ear wax $50.86 69220 Clean out mastoid cavity $143.37 69222 Clean out mastoid cavity $229.53 69300 Revise external ear $671.55 69310 Rebuild outer ear canal $1,129.28 69320 Rebuild outer ear canal $1,600.76 69400 Inflate middle ear canal $149.08 69401 Inflate middle ear canal $86.29 69405 Catheterize middle ear canal $266.74 69420 Incision of eardrum $197.72 69421 Incision of eardrum $156.81 69424 Remove ventilating tube $134.86 69433 Create eardrum opening $205.24 69436 Create eardrum opening $170.03 69440 Exploration of middle ear $707.64 69450 Eardrum revision $557.49 69501 Mastoidectomy $754.23 69502 Mastoidectomy $1,001.45 69505 Remove mastoid structures $1,251.75 69511 Extensive mastoid surgery $1,286.18 69530 Extensive mastoid surgery $1,719.92 69535 Remove part of temporal bone $2,770.55$ 69540 Remove ear lesion $217.26 69550 Remove ear lesion $1,083.51 69552 Remove ear lesion $1,636.21 69554 Remove ear lesion $2,569.50 69601 Mastoid surgery revision $1,080.73 69602 Mastoid surgery revision $1,125.30 69603 Mastoid surgery revision $1,322.17 69604 Mastoid surgery revision $1,160.95 69605 Mastoid surgery revision $1,627.36 69610 Repair of eardrum $405.15 69620 Repair of eardrum $721.47 69631 Repair eardrum structures $909.61 69632 Rebuild eardrum structures $1,113.20 69633 Rebuild eardrum structures $1,073.63 69635 Repair eardrum structures $1,268.93 69636 Rebuild eardrum structures $1,437.21 69637 Rebuild eardrum structures $1,430.76 69641 Revise middle ear & mastoid $1,076.25 69642 Revise middle ear & mastoid $1,385.28 69643 Revise middle ear & mastoid $1,265.37 69644 Revise middle ear & mastoid $1,542.74 69645 Revise middle ear & mastoid $1,512.55 69646 Revise middle ear & mastoid $1,604.30 69650 Release middle ear bone $819.75 69660 Revise middle ear bone $961.00 69661 Revise middle ear bone $1,255.74 69662 Revise middle ear bone $1,201.73

Page 103Page 103 Updated Fee Schedule - April 1

69666 Repair middle ear structures $832.15 69667 Repair middle ear structures $835.15 69670 Remove mastoid air cells $973.02 69676 Remove middle ear nerve $861.94 69700 Close mastoid fistula $716.74 69711 Remove/repair hearing aid $895.55 69714 Implant temple bone w/stimul $1,113.44 69715 Temple bne implnt w/stimulat $1,379.45 69717 Temple bone implant revision $1,173.66 69718 Revise temple bone implant $1,460.10 69720 Release facial nerve $1,213.91 69725 Release facial nerve $1,958.96 69740 Repair facial nerve $1,213.50 69745 Repair facial nerve $1,288.79 69801 Incise inner ear $773.24 69802 Incise inner ear $1,077.09 69805 Explore inner ear $1,086.06 69806 Explore inner ear $979.22 69820 Establish inner ear window $894.55 69840 Revise inner ear window $942.92 69905 Remove inner ear $952.11 69910 Remove inner ear & mastoid $1,056.95 69915 Incise inner ear nerve $1,590.09 69930 Implant cochlear device $1,282.01 69950 Incise inner ear nerve $1,881.40$ 69955 Release facial nerve $2,062.68 69960 Release inner ear canal $1,991.84 69970 Remove inner ear lesion $2,226.99 69990 Microsurgery add-on $227.82 70010 Contrast x-ray of brain $199.22 70010 26 Contrast x-ray of brain $65.83 70015 Contrast x-ray of brain $164.81 70015 26 Contrast x-ray of brain $67.83 70030 X-ray eye for foreign body $32.65 70030 26 X-ray eye for foreign body $9.50 70100 X-ray exam of jaw $35.21 70100 26 X-ray exam of jaw $9.86 70110 X-ray exam of jaw $45.50 70110 26 X-ray exam of jaw $13.70 70120 X-ray exam of mastoids $38.59 70120 26 X-ray exam of mastoids $9.86 70130 X-ray exam of mastoids $63.47 70130 26 X-ray exam of mastoids $19.00 70134 X-ray exam of middle ear $54.25 70134 26 X-ray exam of middle ear $19.00 70140 X-ray exam of facial bones $34.55 70140 26 X-ray exam of facial bones $10.22 70150 X-ray exam of facial bones $49.31 70150 26 X-ray exam of facial bones $14.06 70160 X-ray exam of nasal bones $37.04 70160 26 X-ray exam of nasal bones $9.50 70170 26 X-ray exam of tear duct $16.39

Page 104Page 104 Updated Fee Schedule - April 1

70190 X-ray exam of eye sockets $40.99 70190 26 X-ray exam of eye sockets $11.38 70200 X-ray exam of eye sockets $50.91 70200 26 X-ray exam of eye sockets $15.22 70210 X-ray exam of sinuses $34.71 70210 26 X-ray exam of sinuses $9.50 70220 X-ray exam of sinuses $45.00 70220 26 X-ray exam of sinuses $13.26 70240 X-ray exam, pituitary saddle $33.81 70240 26 X-ray exam, pituitary saddle $10.66 70250 X-ray exam of skull $41.63 70250 26 X-ray exam of skull $12.90 70260 X-ray exam of skull $55.50 70260 26 X-ray exam of skull $18.56 70300 X-ray exam of teeth $16.14 70300 26 X-ray exam of teeth $5.74 70310 X-ray exam of teeth $39.32 70310 26 X-ray exam of teeth $9.14 70320 Full mouth x-ray of teeth $55.34 70320 26 Full mouth x-ray of teeth $12.18 70328 X-ray exam of jaw joint $34.33 70328 26 X-ray exam of jaw joint $9.86 70330 X-ray exam of jaw joints $54.74 70330 26 X-ray exam of jaw joints $13.34 70332 X-ray exam of jaw joint $98.25$ 70332 26 X-ray exam of jaw joint $29.21 70336 Magnetic image, jaw joint $607.62 70336 26 Magnetic image, jaw joint $82.23 70350 X-ray head for orthodontia $23.42 70350 26 X-ray head for orthodontia $9.50 70355 Panoramic x-ray of jaws $26.13 70355 26 Panoramic x-ray of jaws $11.02 70360 X-ray exam of neck $31.33 70360 26 X-ray exam of neck $9.50 70370 Throat x-ray & fluoroscopy $86.84 70370 26 Throat x-ray & fluoroscopy $17.47 70371 Speech evaluation, complex $111.93 70371 26 Speech evaluation, complex $45.09 70373 Contrast x-ray of larynx $93.47 70373 26 Contrast x-ray of larynx $22.61 70380 X-ray exam of salivary gland $43.06 70380 26 X-ray exam of salivary gland $9.50 70390 X-ray exam of salivary duct $116.79 70390 26 X-ray exam of salivary duct $21.32 70450 Ct head/brain w/o dye $259.02 70450 26 Ct head/brain w/o dye $47.65 70460 Ct head/brain w/dye $334.54 70460 26 Ct head/brain w/dye $62.87 70470 Ct head/brain w/o & w/dye $405.74 70470 26 Ct head/brain w/o & w/dye $70.85 70480 Ct orbit/ear/fossa w/o dye $393.73 70480 26 Ct orbit/ear/fossa w/o dye $71.21

Page 105Page 105 Updated Fee Schedule - April 1

70481 Ct orbit/ear/fossa w/dye $458.50 70481 26 Ct orbit/ear/fossa w/dye $76.57 70482 Ct orbit/ear/fossa w/o&w/dye $526.37 70482 26 Ct orbit/ear/fossa w/o&w/dye $80.34 70486 Ct maxillofacial w/o dye $332.60 70486 26 Ct maxillofacial w/o dye $63.23 70487 Ct maxillofacial w/dye $402.90 70487 26 Ct maxillofacial w/dye $72.81 70488 Ct maxillofacial w/o & w/dye $491.46 70488 26 Ct maxillofacial w/o & w/dye $78.82 70490 Ct soft tissue neck w/o dye $328.71 70490 26 Ct soft tissue neck w/o dye $71.65 70491 Ct soft tissue neck w/dye $395.24 70491 26 Ct soft tissue neck w/dye $76.57 70492 Ct sft tsue nck w/o & w/dye $481.56 70492 26 Ct sft tsue nck w/o & w/dye $80.34 70496 Ct angiography, head $771.03 70496 26 Ct angiography, head $97.97 70498 Ct angiography, neck $774.54 70498 26 Ct angiography, neck $98.41 70540 Mri orbit/face/neck w/o dye $658.01 70540 26 Mri orbit/face/neck w/o dye $74.61 70542 Mri orbit/face/neck w/dye $730.68 70542 26 Mri orbit/face/neck w/dye $89.84 70543 Mri orbt/fac/nck w/o & w/dye $1,008.78$ 70543 26 Mri orbt/fac/nck w/o & w/dye $119.14 70544 Mr angiography head w/o dye $712.83 70544 26 Mr angiography head w/o dye $66.63 70545 Mr angiography head w/dye $709.75 70545 26 Mr angiography head w/dye $66.63 70546 Mr angiograph head w/o&w/dye $1,128.15 70546 26 Mr angiograph head w/o&w/dye $99.78 70547 Mr angiography neck w/o dye $711.07 70547 26 Mr angiography neck w/o dye $66.63 70548 Mr angiography neck w/dye $739.18 70548 26 Mr angiography neck w/dye $66.63 70549 Mr angiograph neck w/o&w/dye $1,129.03 70549 26 Mr angiograph neck w/o&w/dye $99.78 70551 Mri brain w/o dye $680.54 70551 26 Mri brain w/o dye $82.23 70552 Mri brain w/dye $759.89 70552 26 Mri brain w/dye $99.05 70553 Mri brain w/o & w/dye $1,014.44 70553 26 Mri brain w/o & w/dye $131.02 70554 Fmri brain by tech $735.11 70554 26 Fmri brain by tech $118.57 70555 26 Fmri brain by phys/psych $143.08 70557 26 Mri brain w/o dye $162.26 70558 26 Mri brain w/dye $176.82 70559 26 Mri brain w/o & w/dye $180.20 71010 Chest x-ray $27.74 71010 26 Chest x-ray $9.86

Page 106Page 106 Updated Fee Schedule - April 1

71015 Chest x-ray $34.09 71015 26 Chest x-ray $11.38 71020 Chest x-ray $36.95 71020 26 Chest x-ray $12.18 71021 Chest x-ray $44.40 71021 26 Chest x-ray $14.42 71022 Chest x-ray $53.31 71022 26 Chest x-ray $16.75 71023 Chest x-ray and fluoroscopy $77.72 71023 26 Chest x-ray and fluoroscopy $21.39 71030 Chest x-ray $53.75 71030 26 Chest x-ray $16.75 71034 Chest x-ray and fluoroscopy $107.14 71034 26 Chest x-ray and fluoroscopy $27.28 71035 Chest x-ray $40.04 71035 26 Chest x-ray $10.30 71040 Contrast x-ray of bronchi $111.32 71040 26 Contrast x-ray of bronchi $32.34 71060 Contrast x-ray of bronchi $162.44 71060 26 Contrast x-ray of bronchi $40.75 71090 26 X-ray & pacemaker insertion $32.72 71100 X-ray exam of ribs $37.83 71100 26 X-ray exam of ribs $12.18 71101 X-ray exam of ribs/chest $45.35 71101 26 X-ray exam of ribs/chest $14.42$ 71110 X-ray exam of ribs $47.04 71110 26 X-ray exam of ribs $14.42 71111 X-ray exam of ribs/chest $60.55 71111 26 X-ray exam of ribs/chest $17.47 71120 X-ray exam of breastbone $37.99 71120 26 X-ray exam of breastbone $11.02 71130 X-ray exam of breastbone $43.54 71130 26 X-ray exam of breastbone $12.18 71250 Ct thorax w/o dye $337.31 71250 26 Ct thorax w/o dye $64.39 71260 Ct thorax w/dye $406.04 71260 26 Ct thorax w/dye $68.96 71270 Ct thorax w/o & w/dye $502.24 71270 26 Ct thorax w/o & w/dye $76.57 71275 Ct angiography, chest $617.07 71275 26 Ct angiography, chest $107.47 71550 Mri chest w/o dye $735.30 71550 26 Mri chest w/o dye $80.70 71551 Mri chest w/dye $824.30 71551 26 Mri chest w/dye $95.49 71552 Mri chest w/o & w/dye $1,131.47 71552 26 Mri chest w/o & w/dye $126.54 71555 Mri angio chest w or w/o dye $721.65 71555 26 Mri angio chest w or w/o dye $101.82 72010 X-ray exam of spine $79.67 72010 26 X-ray exam of spine $23.85 72020 X-ray exam of spine $27.53

Page 107Page 107 Updated Fee Schedule - April 1

72020 26 X-ray exam of spine $8.78 72040 X-ray exam of neck spine $42.66 72040 26 X-ray exam of neck spine $12.18 72050 X-ray exam of neck spine $60.27 72050 26 X-ray exam of neck spine $16.75 72052 X-ray exam of neck spine $75.99 72052 26 X-ray exam of neck spine $20.16 72069 X-ray exam of trunk spine $40.16 72069 26 X-ray exam of trunk spine $12.18 72070 X-ray exam of thoracic spine $39.15 72070 26 X-ray exam of thoracic spine $12.18 72072 X-ray exam of thoracic spine $44.79 72072 26 X-ray exam of thoracic spine $12.18 72074 X-ray exam of thoracic spine $52.63 72074 26 X-ray exam of thoracic spine $12.18 72080 X-ray exam of trunk spine $40.91 72080 26 X-ray exam of trunk spine $12.18 72090 X-ray exam of trunk spine $53.61 72090 26 X-ray exam of trunk spine $15.66 72100 X-ray exam of lower spine $44.86 72100 26 X-ray exam of lower spine $12.18 72110 X-ray exam of lower spine $62.47 72110 26 X-ray exam of lower spine $16.75 72114 X-ray exam of lower spine $82.14 72114 26 X-ray exam of lower spine $20.16$ 72120 X-ray exam of lower spine $56.59 72120 26 X-ray exam of lower spine $12.18 72125 Ct neck spine w/o dye $338.19 72125 26 Ct neck spine w/o dye $64.39 72126 Ct neck spine w/dye $405.32 72126 26 Ct neck spine w/dye $67.79 72127 Ct neck spine w/o & w/dye $495.19 72127 26 Ct neck spine w/o & w/dye $70.41 72128 Ct chest spine w/o dye $337.31 72128 26 Ct chest spine w/o dye $64.39 72129 Ct chest spine w/dye $405.76 72129 26 Ct chest spine w/dye $68.23 72130 Ct chest spine w/o & w/dye $496.51 72130 26 Ct chest spine w/o & w/dye $70.85 72131 Ct lumbar spine w/o dye $336.87 72131 26 Ct lumbar spine w/o dye $64.39 72132 Ct lumbar spine w/dye $405.32 72132 26 Ct lumbar spine w/dye $68.23 72133 Ct lumbar spine w/o & w/dye $496.07 72133 26 Ct lumbar spine w/o & w/dye $70.85 72141 Mri neck spine w/o dye $621.09 72141 26 Mri neck spine w/o dye $88.68 72142 Mri neck spine w/dye $766.55 72142 26 Mri neck spine w/dye $106.59 72146 Mri chest spine w/o dye $637.45 72146 26 Mri chest spine w/o dye $89.12 72147 Mri chest spine w/dye $700.21

Page 108Page 108 Updated Fee Schedule - April 1

72147 26 Mri chest spine w/dye $107.03 72148 Mri lumbar spine w/o dye $630.13 72148 26 Mri lumbar spine w/o dye $82.23 72149 Mri lumbar spine w/dye $758.57 72149 26 Mri lumbar spine w/dye $99.05 72156 Mri neck spine w/o & w/dye $1,013.52 72156 26 Mri neck spine w/o & w/dye $142.41 72157 Mri chest spine w/o & w/dye $962.56 72157 26 Mri chest spine w/o & w/dye $142.85 72158 Mri lumbar spine w/o & w/dye $1,001.26 72158 26 Mri lumbar spine w/o & w/dye $130.59 72159 Mr angio spine w/o&w/dye $774.49 72159 26 Mr angio spine w/o&w/dye $99.20 72170 X-ray exam of pelvis $30.01 72170 26 X-ray exam of pelvis $9.50 72190 X-ray exam of pelvis $45.82 72190 26 X-ray exam of pelvis $11.82 72191 Ct angiograph pelv w/o&w/dye $595.16 72191 26 Ct angiograph pelv w/o&w/dye $101.38 72192 Ct pelvis w/o dye $321.17 72192 26 Ct pelvis w/o dye $60.99 72193 Ct pelvis w/dye $385.29 72193 26 Ct pelvis w/dye $64.39 72194 Ct pelvis w/o & w/dye $493.22 72194 26 Ct pelvis w/o & w/dye $67.79$ 72195 Mri pelvis w/o dye $672.92 72195 26 Mri pelvis w/o dye $80.70 72196 Mri pelvis w/dye $745.23 72196 26 Mri pelvis w/dye $96.37 72197 Mri pelvis w/o & w/dye $1,023.55 72197 26 Mri pelvis w/o & w/dye $125.66 72198 Mr angio pelvis w/o & w/dye $716.98 72198 26 Mr angio pelvis w/o & w/dye $100.22 72200 X-ray exam sacroiliac joints $33.53 72200 26 X-ray exam sacroiliac joints $9.50 72202 X-ray exam sacroiliac joints $40.70 72202 26 X-ray exam sacroiliac joints $10.66 72220 X-ray exam of tailbone $34.27 72220 26 X-ray exam of tailbone $9.50 72240 Contrast x-ray of neck spine $185.19 72240 26 Contrast x-ray of neck spine $50.25 72255 Contrast x-ray, thorax spine $168.70 72255 26 Contrast x-ray, thorax spine $48.93 72265 Contrast x-ray, lower spine $172.40 72265 26 Contrast x-ray, lower spine $46.05 72270 Contrast x-ray, spine $268.48 72270 26 Contrast x-ray, spine $73.89 72275 Epidurography $121.12 72275 26 Epidurography $39.57 72285 X-ray c/t spine disk $207.22 72285 26 X-ray c/t spine disk $61.18 72291 26 Perq vertebroplasty, fluor $75.54

Page 109Page 109 Updated Fee Schedule - April 1

72292 26 Perq vertebroplasty, ct $78.26 72295 X-ray of lower spine disk $186.00 72295 26 X-ray of lower spine disk $45.03 73000 X-ray exam of collar bone $31.85 73000 26 X-ray exam of collar bone $9.14 73010 X-ray exam of shoulder blade $32.65 73010 26 X-ray exam of shoulder blade $9.50 73020 X-ray exam of shoulder $27.09 73020 26 X-ray exam of shoulder $8.34 73030 X-ray exam of shoulder $34.63 73030 26 X-ray exam of shoulder $10.30 73040 Contrast x-ray of shoulder $124.61 73040 26 Contrast x-ray of shoulder $30.09 73050 X-ray exam of shoulders $41.50 73050 26 X-ray exam of shoulders $11.46 73060 X-ray exam of humerus $33.83 73060 26 X-ray exam of humerus $9.50 73070 X-ray exam of elbow $31.05 73070 26 X-ray exam of elbow $8.34 73080 X-ray exam of elbow $39.98 73080 26 X-ray exam of elbow $9.50 73085 Contrast x-ray of elbow $112.31 73085 26 Contrast x-ray of elbow $29.65 73090 X-ray exam of forearm $31.41 73090 26 X-ray exam of forearm $8.70$ 73092 X-ray exam of arm, infant $32.29 73092 26 X-ray exam of arm, infant $8.70 73100 X-ray exam of wrist $32.73 73100 26 X-ray exam of wrist $9.14 73110 X-ray exam of wrist $39.24 73110 26 X-ray exam of wrist $9.50 73115 Contrast x-ray of wrist $119.03 73115 26 Contrast x-ray of wrist $30.09 73120 X-ray exam of hand $30.97 73120 26 X-ray exam of hand $8.70 73130 X-ray exam of hand $35.72 73130 26 X-ray exam of hand $9.50 73140 X-ray exam of finger(s) $33.40 73140 26 X-ray exam of finger(s) $7.62 73200 Ct upper extremity w/o dye $319.81 73200 26 Ct upper extremity w/o dye $60.55 73201 Ct upper extremity w/dye $384.75 73201 26 Ct upper extremity w/dye $64.39 73202 Ct uppr extremity w/o&w/dye $494.37 73202 26 Ct uppr extremity w/o&w/dye $67.79 73206 Ct angio upr extrm w/o&w/dye $569.68 73206 26 Ct angio upr extrm w/o&w/dye $102.25 73218 Mri upper extremity w/o dye $673.39 73218 26 Mri upper extremity w/o dye $74.17 73219 Mri upper extremity w/dye $739.03 73219 26 Mri upper extremity w/dye $89.84 73220 Mri uppr extremity w/o&w/dye $1,018.00

Page 110Page 110 Updated Fee Schedule - April 1

73220 26 Mri uppr extremity w/o&w/dye $119.58 73221 Mri joint upr extrem w/o dye $636.92 73221 26 Mri joint upr extrem w/o dye $74.61 73222 Mri joint upr extrem w/dye $702.13 73222 26 Mri joint upr extrem w/dye $89.84 73223 Mri joint upr extr w/o&w/dye $973.19 73223 26 Mri joint upr extr w/o&w/dye $119.14 73225 Mr angio upr extr w/o&w/dye $755.17 73225 26 Mr angio upr extr w/o&w/dye $95.36 73500 X-ray exam of hip $29.13 73500 26 X-ray exam of hip $9.50 73510 X-ray exam of hip $42.30 73510 26 X-ray exam of hip $11.82 73520 X-ray exam of hips $45.42 73520 26 X-ray exam of hips $14.06 73525 Contrast x-ray of hip $112.24 73525 26 Contrast x-ray of hip $30.46 73530 26 X-ray exam of hip $16.02 73540 X-ray exam of pelvis & hips $42.38 73540 26 X-ray exam of pelvis & hips $11.02 73542 X-ray exam, sacroiliac joint $91.20 73542 26 X-ray exam, sacroiliac joint $30.51 73550 X-ray exam of thigh $32.95 73550 26 X-ray exam of thigh $9.50 73560 X-ray exam of knee, 1 or 2 $32.65$ 73560 26 X-ray exam of knee, 1 or 2 $9.50 73562 X-ray exam of knee, 3 $39.46 73562 26 X-ray exam of knee, 3 $10.30 73564 X-ray exam, knee, 4 or more $45.74 73564 26 X-ray exam, knee, 4 or more $12.18 73565 X-ray exam of knees $34.84 73565 26 X-ray exam of knees $9.94 73580 Contrast x-ray of knee joint $140.66 73580 26 Contrast x-ray of knee joint $30.46 73590 X-ray exam of lower leg $31.33 73590 26 X-ray exam of lower leg $9.50 73592 X-ray exam of leg, infant $32.29 73592 26 X-ray exam of leg, infant $8.70 73600 X-ray exam of ankle $30.97 73600 26 X-ray exam of ankle $8.70 73610 X-ray exam of ankle $35.72 73610 26 X-ray exam of ankle $9.50 73615 Contrast x-ray of ankle $115.32 73615 26 Contrast x-ray of ankle $30.02 73620 X-ray exam of foot $30.09 73620 26 X-ray exam of foot $8.70 73630 X-ray exam of foot $35.28 73630 26 X-ray exam of foot $9.50 73650 X-ray exam of heel $30.53 73650 26 X-ray exam of heel $8.70 73660 X-ray exam of toe(s) $31.64 73660 26 X-ray exam of toe(s) $7.18

Page 111Page 111 Updated Fee Schedule - April 1

73700 Ct lower extremity w/o dye $320.25 73700 26 Ct lower extremity w/o dye $60.55 73701 Ct lower extremity w/dye $387.39 73701 26 Ct lower extremity w/dye $64.83 73702 Ct lwr extremity w/o&w/dye $495.68 73702 26 Ct lwr extremity w/o&w/dye $68.23 73706 Ct angio lwr extr w/o&w/dye $619.05 73706 26 Ct angio lwr extr w/o&w/dye $107.26 73718 Mri lower extremity w/o dye $661.52 73718 26 Mri lower extremity w/o dye $74.61 73719 Mri lower extremity w/dye $731.12 73719 26 Mri lower extremity w/dye $89.84 73720 Mri lwr extremity w/o&w/dye $1,017.56 73720 26 Mri lwr extremity w/o&w/dye $119.58 73721 Mri jnt of lwr extre w/o dye $647.91 73721 26 Mri jnt of lwr extre w/o dye $74.61 73722 Mri joint of lwr extr w/dye $707.84 73722 26 Mri joint of lwr extr w/dye $90.28 73723 Mri joint lwr extr w/o&w/dye $971.00 73723 26 Mri joint lwr extr w/o&w/dye $119.58 73725 Mr ang lwr ext w or w/o dye $718.06 73725 26 Mr ang lwr ext w or w/o dye $101.74 74000 X-ray exam of abdomen $29.49 74000 26 X-ray exam of abdomen $9.86 74010 X-ray exam of abdomen $43.46$ 74010 26 X-ray exam of abdomen $12.54 74020 X-ray exam of abdomen $46.22 74020 26 X-ray exam of abdomen $14.86 74022 X-ray exam series, abdomen $56.23 74022 26 X-ray exam series, abdomen $17.91 74150 Ct abdomen w/o dye $323.44 74150 26 Ct abdomen w/o dye $66.27 74160 Ct abdomen w/dye $432.17 74160 26 Ct abdomen w/dye $71.29 74170 Ct abdomen w/o & w/dye $567.66 74170 26 Ct abdomen w/o & w/dye $78.09 74175 Ct angio abdom w/o & w/dye $629.59 74175 26 Ct angio abdom w/o & w/dye $106.38 74181 Mri abdomen w/o dye $609.22 74181 26 Mri abdomen w/o dye $81.14 74182 Mri abdomen w/dye $809.37 74182 26 Mri abdomen w/dye $96.37 74183 Mri abdomen w/o & w/dye $1,024.43 74183 26 Mri abdomen w/o & w/dye $125.66 74185 Mri angio, abdom w orw/o dye $715.22 74185 26 Mri angio, abdom w orw/o dye $100.22 74190 26 X-ray exam of peritoneum $26.68 74210 Contrst x-ray exam of throat $89.61 74210 26 Contrst x-ray exam of throat $20.60 74220 Contrast x-ray, esophagus $101.12 74220 26 Contrast x-ray, esophagus $25.52 74230 Cine/vid x-ray, throat/esoph $103.58

Page 112Page 112 Updated Fee Schedule - April 1

74230 26 Cine/vid x-ray, throat/esoph $29.37 74235 26 Remove esophagus obstruction $68.03 74240 X-ray exam, upper gi tract $124.51 74240 26 X-ray exam, upper gi tract $38.51 74241 X-ray exam, upper gi tract $132.86 74241 26 X-ray exam, upper gi tract $38.07 74245 X-ray exam, upper gi tract $200.05 74245 26 X-ray exam, upper gi tract $50.69 74246 Contrst x-ray uppr gi tract $143.27 74246 26 Contrst x-ray uppr gi tract $38.51 74247 Contrst x-ray uppr gi tract $157.69 74247 26 Contrst x-ray uppr gi tract $38.51 74249 Contrst x-ray uppr gi tract $214.92 74249 26 Contrst x-ray uppr gi tract $50.69 74250 X-ray exam of small bowel $118.11 74250 26 X-ray exam of small bowel $25.88 74251 X-ray exam of small bowel $373.22 74251 26 X-ray exam of small bowel $38.51 74260 X-ray exam of small bowel $311.53 74260 26 X-ray exam of small bowel $27.41 74270 Contrast x-ray exam of colon $169.56 74270 26 Contrast x-ray exam of colon $38.51 74280 Contrast x-ray exam of colon $234.49 74280 26 Contrast x-ray exam of colon $55.25 74283 Contrast x-ray exam of colon $236.22$ 74283 26 Contrast x-ray exam of colon $111.96 74290 Contrast x-ray, gallbladder $75.56 74290 26 Contrast x-ray, gallbladder $17.91 74291 Contrast x-rays, gallbladder $65.36 74291 26 Contrast x-rays, gallbladder $11.02 74300 26 X-ray bile ducts/pancreas $20.16 74301 26 X-rays at surgery add-on $11.82 74305 26 X-ray bile ducts/pancreas $23.64 74320 Contrast x-ray of bile ducts $134.82 74320 26 Contrast x-ray of bile ducts $30.53 74327 X-ray bile stone removal $151.91 74327 26 X-ray bile stone removal $39.31 74328 26 X-ray bile duct endoscopy $39.31 74329 26 X-ray for pancreas endoscopy $39.31 74330 26 X-ray bile/panc endoscopy $50.33 74340 26 X-ray guide for GI tube $30.09 74355 26 X-ray guide, intestinal tube $42.71 74360 26 X-ray guide, GI dilation $31.41 74363 26 X-ray, bile duct dilation $49.61 74400 Contrst x-ray, urinary tract $128.22 74400 26 Contrst x-ray, urinary tract $27.05 74410 Contrst x-ray, urinary tract $135.25 74410 26 Contrst x-ray, urinary tract $27.48 74415 Contrst x-ray, urinary tract $155.39 74415 26 Contrst x-ray, urinary tract $27.05 74420 26 Contrst x-ray, urinary tract $20.60 74425 26 Contrst x-ray, urinary tract $20.60

Page 113Page 113 Updated Fee Schedule - April 1

74430 Contrast x-ray, bladder $92.12 74430 26 Contrast x-ray, bladder $18.28 74440 X-ray, male genital tract $98.67 74440 26 X-ray, male genital tract $21.32 74445 26 X-ray exam of penis $65.29 74450 26 X-ray, urethra/bladder $19.08 74455 X-ray, urethra/bladder $107.14 74455 26 X-ray, urethra/bladder $19.08 74470 26 X-ray exam of kidney lesion $30.53 74475 X-ray control, cath insert $146.34 74475 26 X-ray control, cath insert $30.53 74480 X-ray control, cath insert $146.78 74480 26 X-ray control, cath insert $30.53 74485 X-ray guide, GU dilation $139.58 74485 26 X-ray guide, GU dilation $30.90 74710 X-ray measurement of pelvis $50.67 74710 26 X-ray measurement of pelvis $19.44 74740 X-ray, female genital tract $91.14 74740 26 X-ray, female genital tract $21.32 74742 26 X-ray, fallopian tube $33.86 74775 26 X-ray exam of perineum $34.66 75557 Cardiac mri for morph $609.81 75557 26 Cardiac mri for morph $136.38 75558 Cardiac mri flow/velocity $744.15 75558 26 Cardiac mri flow/velocity $140.41$ 75559 Cardiac mri w/stress img $886.44 75559 26 Cardiac mri w/stress img $174.47 75560 Cardiac mri flow/vel/stress $972.38 75560 26 Cardiac mri flow/vel/stress $161.27 75561 Cardiac mri for morph w/dye $824.54 75561 26 Cardiac mri for morph w/dye $150.52 75562 Card mri flow/vel w/dye $964.14 75562 26 Card mri flow/vel w/dye $154.11 75563 Card mri w/stress img & dye $1,014.02 75563 26 Card mri w/stress img & dye $180.60 75564 Ht mri w/flo/vel/strs & dye $1,134.12 75564 26 Ht mri w/flo/vel/strs & dye $180.63 75600 Contrast x-ray exam of aorta $385.54 75600 26 Contrast x-ray exam of aorta $29.24 75605 Contrast x-ray exam of aorta $325.52 75605 26 Contrast x-ray exam of aorta $65.87 75625 Contrast x-ray exam of aorta $321.06 75625 26 Contrast x-ray exam of aorta $64.04 75630 X-ray aorta, leg arteries $369.58 75630 26 X-ray aorta, leg arteries $102.73 75635 Ct angio abdominal arteries $714.48 75635 26 Ct angio abdominal arteries $136.35 75650 Artery x-rays, head & neck $342.68 75650 26 Artery x-rays, head & neck $84.35 75658 Artery x-rays, arm $339.78 75658 26 Artery x-rays, arm $72.22 75660 Artery x-rays, head & neck $346.00

Page 114Page 114 Updated Fee Schedule - April 1

75660 26 Artery x-rays, head & neck $74.05 75662 Artery x-rays, head & neck $395.81 75662 26 Artery x-rays, head & neck $95.30 75665 Artery x-rays, head & neck $355.47 75665 26 Artery x-rays, head & neck $74.73 75671 Artery x-rays, head & neck $401.01 75671 26 Artery x-rays, head & neck $93.92 75676 Artery x-rays, neck $346.37 75676 26 Artery x-rays, neck $73.98 75680 Artery x-rays, neck $384.76 75680 26 Artery x-rays, neck $94.35 75685 Artery x-rays, spine $346.88 75685 26 Artery x-rays, spine $74.05 75705 Artery x-rays, spine $395.05 75705 26 Artery x-rays, spine $123.97 75710 Artery x-rays, arm/leg $339.88 75710 26 Artery x-rays, arm/leg $64.41 75716 Artery x-rays, arms/legs $378.44 75716 26 Artery x-rays, arms/legs $73.98 75722 Artery x-rays, kidney $335.62 75722 26 Artery x-rays, kidney $65.43 75724 Artery x-rays, kidneys $389.38 75724 26 Artery x-rays, kidneys $89.31 75726 Artery x-rays, abdomen $336.06 75726 26 Artery x-rays, abdomen $64.11$ 75731 Artery x-rays, adrenal gland $347.86 75731 26 Artery x-rays, adrenal gland $68.00 75733 Artery x-rays, adrenals $393.45 75733 26 Artery x-rays, adrenals $79.32 75736 Artery x-rays, pelvis $339.07 75736 26 Artery x-rays, pelvis $64.92 75741 Artery x-rays, lung $324.48 75741 26 Artery x-rays, lung $74.05 75743 Artery x-rays, lungs $353.57 75743 26 Artery x-rays, lungs $94.35 75746 Artery x-rays, lung $328.59 75746 26 Artery x-rays, lung $63.67 75756 Artery x-rays, chest $348.87 75756 26 Artery x-rays, chest $68.57 75774 Artery x-ray, each vessel $259.61 75774 26 Artery x-ray, each vessel $20.60 75790 Visualize A-V shunt $200.26 75790 26 Visualize A-V shunt $100.63 75801 26 Lymph vessel x-ray, arm/leg $44.62 75803 26 Lymph vessel x-ray,arms/legs $65.63 75805 26 Lymph vessel x-ray, trunk $46.14 75807 26 Lymph vessel x-ray, trunk $65.63 75809 Nonvascular shunt, x-ray $101.55 75809 26 Nonvascular shunt, x-ray $25.88 75810 26 Vein x-ray, spleen/liver $64.55 75820 Vein x-ray, arm/leg $139.06 75820 26 Vein x-ray, arm/leg $39.75

Page 115Page 115 Updated Fee Schedule - April 1

75822 Vein x-ray, arms/legs $169.19 75822 26 Vein x-ray, arms/legs $59.03 75825 Vein x-ray, trunk $309.57 75825 26 Vein x-ray, trunk $63.54 75827 Vein x-ray, chest $308.83 75827 26 Vein x-ray, chest $61.91 75831 Vein x-ray, kidney $313.15 75831 26 Vein x-ray, kidney $63.60 75833 Vein x-ray, kidneys $347.82 75833 26 Vein x-ray, kidneys $82.46 75840 Vein x-ray, adrenal gland $310.45 75840 26 Vein x-ray, adrenal gland $62.66 75842 Vein x-ray, adrenal glands $349.71 75842 26 Vein x-ray, adrenal glands $83.47 75860 Vein x-ray, neck $319.44 75860 26 Vein x-ray, neck $65.05 75870 Vein x-ray, skull $316.73 75870 26 Vein x-ray, skull $63.23 75872 Vein x-ray, skull $346.44 75872 26 Vein x-ray, skull $67.90 75880 Vein x-ray, eye socket $140.38 75880 26 Vein x-ray, eye socket $37.99 75885 Vein x-ray, liver $331.72 75885 26 Vein x-ray, liver $81.29 75887 Vein x-ray, liver $334.36$ 75887 26 Vein x-ray, liver $81.29 75889 Vein x-ray, liver $314.10 75889 26 Vein x-ray, liver $64.11 75891 Vein x-ray, liver $314.10 75891 26 Vein x-ray, liver $64.11 75893 Venous sampling by catheter $279.64 75893 26 Venous sampling by catheter $30.09 75894 26 X-rays, transcath therapy $73.91 75896 26 X-rays, transcath therapy $74.12 75898 26 Follow-up angiography $93.55 75900 26 Intravascular cath exchange $27.42 75901 Remove cva device obstruct $202.90 75901 26 Remove cva device obstruct $27.05 75902 Remove cva lumen obstruct $115.83 75902 26 Remove cva lumen obstruct $21.68 75940 26 X-ray placement, vein filter $30.39 75945 26 Intravascular us $23.23 75946 26 Intravascular us add-on $22.72 75952 26 Endovasc repair abdom aorta $247.90 75953 26 Abdom aneurysm endovas rpr $74.94 75954 26 Iliac aneurysm endovas rpr $121.89 75956 26 Xray, endovasc thor ao repr $388.89 75957 26 Xray, endovasc thor ao repr $332.80 75958 26 Xray, place prox ext thor ao $219.67 75959 26 Xray, place dist ext thor ao $192.98 75960 Transcath iv stent rs&i $315.89 75960 26 Transcath iv stent rs&i $46.94

Page 116Page 116 Updated Fee Schedule - April 1

75961 Retrieval, broken catheter $475.92 75961 26 Retrieval, broken catheter $236.68 75962 Repair arterial blockage $339.86 75962 26 Repair arterial blockage $30.46 75964 Repair artery blockage, each $199.95 75964 26 Repair artery blockage, each $20.53 75966 Repair arterial blockage $393.56 75966 26 Repair arterial blockage $75.81 75968 Repair artery blockage, each $200.46 75968 26 Repair artery blockage, each $21.04 75970 26 Vascular biopsy $46.92 75978 Repair venous blockage $334.22 75978 26 Repair venous blockage $29.65 75980 26 Contrast xray exam bile duct $80.85 75982 26 Contrast xray exam bile duct $80.85 75984 Xray control catheter change $133.30 75984 26 Xray control catheter change $40.47 75989 Abscess drainage under x-ray $167.05 75989 26 Abscess drainage under x-ray $66.71 75992 26 Atherectomy, x-ray exam $31.34 75993 26 Atherectomy, x-ray exam $20.60 75994 26 Atherectomy, x-ray exam $67.83 75995 26 Atherectomy, x-ray exam $72.36 75996 26 Atherectomy, x-ray exam $20.16 76000 Fluoroscope examination $114.46$ 76000 26 Fluoroscope examination $9.50 76001 26 Fluoroscope exam, extensive $38.09 76010 X-ray, nose to rectum $32.57 76010 26 X-ray, nose to rectum $10.30 76080 X-ray exam of fistula $73.61 76080 26 X-ray exam of fistula $30.53 76098 X-ray exam, breast specimen $23.06 76098 26 X-ray exam, breast specimen $9.14 76100 X-ray exam of body section $157.95 76100 26 X-ray exam of body section $32.34 76101 Complex body section x-ray $219.82 76101 26 Complex body section x-ray $31.90 76102 Complex body section x-rays $296.06 76102 26 Complex body section x-rays $31.46 76120 Cine/video x-rays $88.57 76120 26 Cine/video x-rays $20.88 76125 26 Cine/video x-rays add-on $15.74 76150 X-ray exam, dry process $22.27 76376 3d render w/o postprocess $95.64 76376 26 3d render w/o postprocess $11.83 76377 3d rendering w/postprocess $131.43 76377 26 3d rendering w/postprocess $45.65 76380 CAT scan follow-up study $242.14 76380 26 CAT scan follow-up study $54.45 76390 Mr spectroscopy $549.38 76390 26 Mr spectroscopy $76.27 76506 Echo exam of head $135.76

Page 117Page 117 Updated Fee Schedule - April 1

76506 26 Echo exam of head $36.14 76510 Ophth us, b & quant a $168.90 76510 26 Ophth us, b & quant a $87.22 76511 Ophth us, quant a only $110.67 76511 26 Ophth us, quant a only $52.72 76512 Ophth us, b w/non-quant a $103.51 76512 26 Ophth us, b w/non-quant a $52.78 76513 Echo exam of eye, water bath $97.00 76513 26 Echo exam of eye, water bath $36.17 76514 Echo exam of eye, thickness $14.27 76514 26 Echo exam of eye, thickness $9.94 76516 Echo exam of eye $77.57 76516 26 Echo exam of eye $30.16 76519 Echo exam of eye $83.28 76519 26 Echo exam of eye $30.59 76529 Echo exam of eye $78.52 76529 26 Echo exam of eye $32.05 76536 Us exam of head and neck $129.55 76536 26 Us exam of head and neck $30.37 76604 Us exam, chest $100.71 76604 26 Us exam, chest $30.45 76645 Us exam, breast(s) $106.56 76645 26 Us exam, breast(s) $30.09 76700 Us exam, abdom, complete $159.68 76700 26 Us exam, abdom, complete $44.88$ 76705 Echo exam of abdomen $121.34 76705 26 Echo exam of abdomen $33.14 76770 Us exam abdo back wall, comp $152.91 76770 26 Us exam abdo back wall, comp $40.75 76775 Us exam abdo back wall, lim $131.09 76775 26 Us exam abdo back wall, lim $33.22 76776 Us exam k transpl w/doppler $170.68 76776 26 Us exam k transpl w/doppler $42.27 76800 Us exam, spinal canal $140.97 76800 26 Us exam, spinal canal $58.48 76801 Ob us < 14 wks, single fetus $151.97 76801 26 Ob us < 14 wks, single fetus $54.37 76802 Ob us < 14 wks, addÆl fetus $84.34 76802 26 Ob us < 14 wks, addÆl fetus $45.17 76805 Ob us >/= 14 wks, sngl fetus $169.98 76805 26 Ob us >/= 14 wks, sngl fetus $53.93 76810 Ob us >/= 14 wks, addl fetus $116.23 76810 26 Ob us >/= 14 wks, addl fetus $53.13 76811 Ob us, detailed, sngl fetus $237.41 76811 26 Ob us, detailed, sngl fetus $101.92 76812 Ob us, detailed, addl fetus $232.92 76812 26 Ob us, detailed, addl fetus $95.10 76813 Ob us nuchal meas, 1 gest $147.12 76813 26 Ob us nuchal meas, 1 gest $62.40 76814 Ob us nuchal meas, add-on $94.66 76814 26 Ob us nuchal meas, add-on $52.55 76815 Ob us, limited, fetus(s) $105.50

Page 118Page 118 Updated Fee Schedule - April 1

76815 26 Ob us, limited, fetus(s) $35.31 76816 Ob us, follow-up, per fetus $128.95 76816 26 Ob us, follow-up, per fetus $45.89 76817 Transvaginal us, obstetric $117.50 76817 26 Transvaginal us, obstetric $40.59 76818 Fetal biophys profile w/nst $139.26 76818 26 Fetal biophys profile w/nst $56.47 76819 Fetal biophys profil w/o nst $108.29 76819 26 Fetal biophys profil w/o nst $41.75 76820 Umbilical artery echo $62.56 76820 26 Umbilical artery echo $26.90 76821 Middle cerebral artery echo $113.18 76821 26 Middle cerebral artery echo $37.55 76825 Echo exam of fetal heart $240.70 76825 26 Echo exam of fetal heart $89.88 76826 Echo exam of fetal heart $133.20 76826 26 Echo exam of fetal heart $43.92 76827 Echo exam of fetal heart $83.44 76827 26 Echo exam of fetal heart $31.09 76828 Echo exam of fetal heart $60.96 76828 26 Echo exam of fetal heart $30.30 76830 Transvaginal us, non-ob $140.19 76830 26 Transvaginal us, non-ob $37.63 76831 Echo exam, uterus $139.95 76831 26 Echo exam, uterus $38.27$ 76856 Us exam, pelvic, complete $141.07 76856 26 Us exam, pelvic, complete $38.07 76857 Us exam, pelvic, limited $118.88 76857 26 Us exam, pelvic, limited $21.76 76870 Us exam, scrotum $140.14 76870 26 Us exam, scrotum $35.82 76872 Us, transrectal $167.36 76872 26 Us, transrectal $39.76 76873 Echograp trans r, pros study $206.55 76873 26 Echograp trans r, pros study $86.38 76880 Us exam, extremity $147.26 76880 26 Us exam, extremity $31.82 76885 Us exam infant hips, dynamic $159.13 76885 26 Us exam infant hips, dynamic $40.75 76886 Us exam infant hips, static $117.15 76886 26 Us exam infant hips, static $33.79 76930 Echo guide, cardiocentesis $114.50 76930 26 Echo guide, cardiocentesis $40.05 76932 26 Echo guide for heart biopsy $40.05 76936 Echo guide for artery repair $367.51 76936 26 Echo guide for artery repair $111.93 76937 Us guide, vascular access $41.94 76937 26 Us guide, vascular access $17.13 76940 26 Us guide, tissue ablation $117.23 76941 26 Echo guide for transfusion $72.43 76942 Echo guide for biopsy $218.98 76942 26 Echo guide for biopsy $37.35

Page 119Page 119 Updated Fee Schedule - April 1

76945 26 Echo guide, villus sampling $36.03 76946 Echo guide for amniocentesis $51.84 76946 26 Echo guide for amniocentesis $20.44 76948 Echo guide, ova aspiration $51.84 76948 26 Echo guide, ova aspiration $20.44 76950 Echo guidance radiotherapy $81.95 76950 26 Echo guidance radiotherapy $31.90 76965 Echo guidance radiotherapy $170.57 76965 26 Echo guidance radiotherapy $75.87 76970 Ultrasound exam follow-up $97.64 76970 26 Ultrasound exam follow-up $21.16 76975 26 GI endoscopic ultrasound $45.76 76977 Us bone density measure $16.78 76977 26 Us bone density measure $3.05 76998 26 Us guide, intraop $67.41 77001 Fluoroguide for vein device $123.51 77001 26 Fluoroguide for vein device $20.95 77002 Needle localization by xray $82.33 77002 26 Needle localization by xray $29.21 77003 Fluoroguide for spine inject $67.74 77003 26 Fluoroguide for spine inject $30.43 77011 Ct scan for localization $811.41 77011 26 Ct scan for localization $66.56 77012 Ct scan for needle biopsy $233.78 77012 26 Ct scan for needle biopsy $64.83$ 77013 26 Ct guide for tissue ablation $224.23 77014 Ct scan for therapy guide $218.77 77014 26 Ct scan for therapy guide $46.33 77021 Mr guidance for needle place $532.04 77021 26 Mr guidance for needle place $84.57 77022 26 Mri for tissue ablation $234.52 77031 Stereotact guide for brst bx $224.15 77031 26 Stereotact guide for brst bx $88.26 77032 Guidance for needle, breast $69.00 77032 26 Guidance for needle, breast $31.25 77051 Computer dx mammogram add-on $14.33 77051 26 Computer dx mammogram add-on $3.41 77052 Comp screen mammogram add-on $14.33 77052 26 Comp screen mammogram add-on $3.41 77053 X-ray of mammary duct $90.39 77053 26 X-ray of mammary duct $20.16 77054 X-ray of mammary ducts $121.85 77054 26 X-ray of mammary ducts $25.16 77055 Mammogram, one breast $98.21 77055 26 Mammogram, one breast $38.87 77056 Mammogram, both breasts $124.77 77056 26 Mammogram, both breasts $48.37 77057 Mammogram, screening $94.19 77057 26 Mammogram, screening $38.87 77058 Mri, one breast $1,006.54 77058 26 Mri, one breast $90.64 77059 Mri, both breasts $1,083.46

Page 120Page 120 Updated Fee Schedule - April 1

77059 26 Mri, both breasts $90.64 77071 X-ray stress view $44.98 77072 X-rays for bone age $27.22 77072 26 X-rays for bone age $10.66 77073 X-rays, bone length studies $43.52 77073 26 X-rays, bone length studies $14.86 77074 X-rays, bone survey, limited $80.11 77074 26 X-rays, bone survey, limited $25.16 77075 X-rays, bone survey complete $116.97 77075 26 X-rays, bone survey complete $30.09 77076 X-rays, bone survey, infant $107.50 77076 26 X-rays, bone survey, infant $37.11 77077 Joint survey, single view $49.22 77077 26 Joint survey, single view $17.12 77078 Ct bone density, axial $204.60 77078 26 Ct bone density, axial $13.70 77079 Ct bone density, peripheral $68.08 77079 26 Ct bone density, peripheral $11.30 77080 Dxa bone density, axial $85.00 77080 26 Dxa bone density, axial $11.02 77081 Dxa bone density/peripheral $35.13 77081 26 Dxa bone density/peripheral $11.74 77082 Dxa bone density, vert fx $34.20 77082 26 Dxa bone density, vert fx $9.06 77083 Radiographic absorptiometry $30.89$ 77083 26 Radiographic absorptiometry $10.58 77084 Magnetic image, bone marrow $690.94 77084 26 Magnetic image, bone marrow $89.55 77261 Radiation therapy planning $77.67 77262 Radiation therapy planning $116.31 77263 Radiation therapy planning $172.50 77280 Set radiation therapy field $218.58 77280 26 Set radiation therapy field $38.36 77285 Set radiation therapy field $377.78 77285 26 Set radiation therapy field $57.35 77290 Set radiation therapy field $586.13 77290 26 Set radiation therapy field $85.05 77295 Set radiation therapy field $802.37 77295 26 Set radiation therapy field $248.69 77300 Radiation therapy dose plan $82.52 77300 26 Radiation therapy dose plan $33.79 77301 Radiotherapy dose plan, imrt $2,565.23 77301 26 Radiotherapy dose plan, imrt $436.25 77305 Teletx isodose plan simple $84.63 77305 26 Teletx isodose plan simple $38.36 77310 Teletx isodose plan intermed $117.10 77310 26 Teletx isodose plan intermed $57.35 77315 Teletx isodose plan complex $170.21 77315 26 Teletx isodose plan complex $85.05 77321 Special teletx port plan $142.47 77321 26 Special teletx port plan $51.62 77326 Brachytx isodose calc simp $166.88

Page 121Page 121 Updated Fee Schedule - April 1

77326 26 Brachytx isodose calc simp $50.46 77327 Brachytx isodose calc interm $237.68 77327 26 Brachytx isodose calc interm $75.91 77328 Brachytx isodose plan compl $324.33 77328 26 Brachytx isodose plan compl $114.27 77331 Special radiation dosimetry $70.20 77331 26 Special radiation dosimetry $47.49 77332 Radiation treatment aid(s) $91.05 77332 26 Radiation treatment aid(s) $29.58 77333 Radiation treatment aid(s) $78.62 77333 26 Radiation treatment aid(s) $45.97 77334 Radiation treatment aid(s) $184.16 77334 26 Radiation treatment aid(s) $67.57 77336 Radiation physics consult $75.36 77370 Radiation physics consult $142.44 77372 Srs, linear based $984.46 77373 Sbrt delivery $1,822.63 77401 Radiation treatment delivery $38.80 77402 Radiation treatment delivery $164.44 77403 Radiation treatment delivery $144.67 77404 Radiation treatment delivery $159.16 77406 Radiation treatment delivery $160.48 77407 Radiation treatment delivery $257.50 77408 Radiation treatment delivery $193.80 77409 Radiation treatment delivery $213.57$ 77411 Radiation treatment delivery $212.25 77412 Radiation treatment delivery $249.52 77413 Radiation treatment delivery $251.28 77414 Radiation treatment delivery $278.96 77416 Radiation treatment delivery $280.27 77417 Radiology port film(s) $19.50 77418 Radiation tx delivery, imrt $628.63 77421 Stereoscopic x-ray guidance $134.79 77421 26 Stereoscopic x-ray guidance $21.24 77422 Neutron beam tx, simple $235.03 77423 Neutron beam tx, complex $269.73 77427 Radiation tx management, x5 $205.21 77431 Radiation therapy management $105.70 77432 Stereotactic radiation trmt $436.38 77435 Sbrt management $724.91 77470 Special radiation treatment $298.77 77470 26 Special radiation treatment $114.27 77600 Hyperthermia treatment $437.60 77600 26 Hyperthermia treatment $85.05 77605 Hyperthermia treatment $787.21 77605 26 Hyperthermia treatment $111.30 77610 Hyperthermia treatment $737.20 77610 26 Hyperthermia treatment $82.41 77615 Hyperthermia treatment $1,043.65 77615 26 Hyperthermia treatment $113.83 77620 Hyperthermia treatment $459.64 77620 26 Hyperthermia treatment $86.44

Page 122Page 122 Updated Fee Schedule - April 1

77750 Infuse radioactive materials $380.24 77750 26 Infuse radioactive materials $269.57 77761 Apply intrcav radiat simple $402.11 77761 26 Apply intrcav radiat simple $206.69 77762 Apply intrcav radiat interm $545.28 77762 26 Apply intrcav radiat interm $312.86 77763 Apply intrcav radiat compl $768.25 77763 26 Apply intrcav radiat compl $469.32 77776 Apply interstit radiat simpl $472.14 77776 26 Apply interstit radiat simpl $261.27 77777 Apply interstit radiat inter $648.99 77777 26 Apply interstit radiat inter $414.57 77778 Apply interstit radiat compl $925.45 77778 26 Apply interstit radiat compl $614.05 77785 Hdr brachytx, 1 channel $216.69 77785 26 Hdr brachytx, 1 channel $77.87 77786 Hdr brachytx, 2-12 channel $656.35 77786 26 Hdr brachytx, 2-12 channel $174.64 77787 Hdr brachytx over 12 chan $975.15 77787 26 Hdr brachytx over 12 chan $269.08 77789 Apply surface radiation $119.26 77789 26 Apply surface radiation $62.28 77790 Radiation handling $99.39 77790 26 Radiation handling $57.35 78000 Thyroid, single uptake $81.86$ 78000 26 Thyroid, single uptake $10.66 78001 Thyroid, multiple uptakes $103.65 78001 26 Thyroid, multiple uptakes $14.50 78003 Thyroid suppress/stimul $89.91 78003 26 Thyroid suppress/stimul $18.27 78006 Thyroid imaging with uptake $255.92 78006 26 Thyroid imaging with uptake $27.05 78007 Thyroid image, mult uptakes $155.18 78007 26 Thyroid image, mult uptakes $27.85 78010 Thyroid imaging $178.21 78010 26 Thyroid imaging $21.68 78011 Thyroid imaging with flow $202.64 78011 26 Thyroid imaging with flow $25.16 78015 Thyroid met imaging $239.80 78015 26 Thyroid met imaging $37.35 78016 Thyroid met imaging/studies $365.23 78016 26 Thyroid met imaging/studies $45.75 78018 Thyroid met imaging, body $368.94 78018 26 Thyroid met imaging, body $48.01 78020 Thyroid met uptake $105.99 78020 26 Thyroid met uptake $33.57 78070 Parathyroid nuclear imaging $201.77 78070 26 Parathyroid nuclear imaging $46.12 78075 Adrenal nuclear imaging $481.17 78075 26 Adrenal nuclear imaging $41.19 78102 Bone marrow imaging, ltd $188.67 78102 26 Bone marrow imaging, ltd $30.89

Page 123Page 123 Updated Fee Schedule - April 1

78103 Bone marrow imaging, mult $253.39 78103 26 Bone marrow imaging, mult $41.91 78104 Bone marrow imaging, body $290.88 78104 26 Bone marrow imaging, body $45.03 78110 Plasma volume, single $90.65 78110 26 Plasma volume, single $10.66 78111 Plasma volume, multiple $116.23 78111 26 Plasma volume, multiple $12.62 78120 Red cell mass, single $103.18 78120 26 Red cell mass, single $12.98 78121 Red cell mass, multiple $125.03 78121 26 Red cell mass, multiple $17.91 78122 Blood volume $154.90 78122 26 Blood volume $25.16 78130 Red cell survival study $179.65 78130 26 Red cell survival study $34.30 78135 Red cell survival kinetics $378.11 78135 26 Red cell survival kinetics $35.82 78140 Red cell sequestration $174.35 78140 26 Red cell sequestration $34.30 78185 Spleen imaging $220.17 78185 26 Spleen imaging $22.48 78190 Platelet survival, kinetics $430.85 78190 26 Platelet survival, kinetics $60.35 78191 Platelet survival $235.65$ 78191 26 Platelet survival $33.86 78195 Lymph system imaging $390.61 78195 26 Lymph system imaging $67.45 78201 Liver imaging $202.72 78201 26 Liver imaging $23.92 78202 Liver imaging with flow $233.73 78202 26 Liver imaging with flow $27.77 78205 Liver imaging (3D) $280.08 78205 26 Liver imaging (3D) $39.67 78206 Liver image (3d) with flow $392.13 78206 26 Liver image (3d) with flow $53.73 78215 Liver and spleen imaging $216.32 78215 26 Liver and spleen imaging $27.05 78216 Liver & spleen image/flow $163.07 78216 26 Liver & spleen image/flow $31.61 78220 Liver function study $170.30 78220 26 Liver function study $27.05 78223 Hepatobiliary imaging $361.86 78223 26 Hepatobiliary imaging $46.85 78230 Salivary gland imaging $184.19 78230 26 Salivary gland imaging $24.72 78231 Serial salivary imaging $156.58 78231 26 Serial salivary imaging $28.57 78232 Salivary gland function exam $159.98 78232 26 Salivary gland function exam $26.32 78258 Esophageal motility study $255.50 78258 26 Esophageal motility study $41.63

Page 124Page 124 Updated Fee Schedule - April 1

78261 Gastric mucosa imaging $283.47 78261 26 Gastric mucosa imaging $38.51 78262 Gastroesophageal reflux exam $279.60 78262 26 Gastroesophageal reflux exam $37.27 78264 Gastric emptying study $321.78 78264 26 Gastric emptying study $43.43 78270 Vit B-12 absorption exam $93.82 78270 26 Vit B-12 absorption exam $11.02 78271 Vit b-12 absrp exam, int fac $94.69 78271 26 Vit b-12 absrp exam, int fac $10.58 78272 Vit B-12 absorp, combined $107.12 78272 26 Vit B-12 absorp, combined $13.99 78278 Acute GI blood loss imaging $387.44 78278 26 Acute GI blood loss imaging $55.25 78282 26 GI protein loss exam $21.32 78290 MeckelÆs divert exam $347.21 78290 26 MeckelÆs divert exam $38.15 78291 Leveen/shunt patency exam $280.92 78291 26 Leveen/shunt patency exam $49.17 78300 Bone imaging, limited area $197.58 78300 26 Bone imaging, limited area $34.66 78305 Bone imaging, multiple areas $262.66 78305 26 Bone imaging, multiple areas $46.05 78306 Bone imaging, whole body $291.22 78306 26 Bone imaging, whole body $48.01$ 78315 Bone imaging, 3 phase $387.64 78315 26 Bone imaging, 3 phase $56.77 78320 Bone imaging (3D) $298.34 78320 26 Bone imaging (3D) $57.93 78350 Bone mineral, single photon $39.08 78350 26 Bone mineral, single photon $11.74 78351 Bone mineral, dual photon $16.39 78414 26 Non-imaging heart function $23.41 78428 Cardiac shunt imaging $228.82 78428 26 Cardiac shunt imaging $45.63 78445 Vascular flow imaging $192.80 78445 26 Vascular flow imaging $27.05 78456 Acute venous thrombus image $408.61 78456 26 Acute venous thrombus image $59.57 78457 Venous thrombosis imaging $220.48 78457 26 Venous thrombosis imaging $42.63 78458 Ven thrombosis images, bilat $243.09 78458 26 Ven thrombosis images, bilat $50.33 78459 26 Heart muscle imaging (PET) $87.04 78460 Heart muscle blood, single $220.21 78460 26 Heart muscle blood, single $48.45 78461 Heart muscle blood, multiple $247.03 78461 26 Heart muscle blood, multiple $69.47 78464 Heart image (3d), single $324.78 78464 26 Heart image (3d), single $64.13 78465 Heart image (3d), multiple $577.40 78465 26 Heart image (3d), multiple $86.91

Page 125Page 125 Updated Fee Schedule - April 1

78466 Heart infarct image $210.65 78466 26 Heart infarct image $39.82 78468 Heart infarct image (ef) $266.48 78468 26 Heart infarct image (ef) $47.67 78469 Heart infarct image (3D) $303.15 78469 26 Heart infarct image (3D) $53.31 78472 Gated heart, planar, single $308.55 78472 26 Gated heart, planar, single $56.65 78473 Gated heart, multiple $420.89 78473 26 Gated heart, multiple $86.33 78478 Heart wall motion add-on $68.47 78478 26 Heart wall motion add-on $30.04 78480 Heart function add-on $57.82 78480 26 Heart function add-on $19.39 78481 Heart first pass, single $270.09 78481 26 Heart first pass, single $58.91 78483 Heart first pass, multiple $381.05 78483 26 Heart first pass, multiple $89.47 78491 26 Heart image (pet), single $88.29 78492 26 Heart image (pet), multiple $111.51 78494 Heart image, spect $335.74 78494 26 Heart image, spect $69.35 78496 Heart first pass add-on $139.17 78496 26 Heart first pass add-on $29.60 78580 Lung perfusion imaging $243.81$ 78580 26 Lung perfusion imaging $41.19 78584 Lung V/Q image single breath $183.26 78584 26 Lung V/Q image single breath $55.25 78585 Lung V/Q imaging $403.38 78585 26 Lung V/Q imaging $60.99 78586 Aerosol lung image, single $187.16 78586 26 Aerosol lung image, single $22.48 78587 Aerosol lung image, multiple $235.21 78587 26 Aerosol lung image, multiple $27.48 78588 Perfusion lung image $373.00 78588 26 Perfusion lung image $60.99 78591 Vent image, 1 breath, 1 proj $189.79 78591 26 Vent image, 1 breath, 1 proj $22.48 78593 Vent image, 1 proj, gas $223.52 78593 26 Vent image, 1 proj, gas $27.05 78594 Vent image, mult proj, gas $261.83 78594 26 Vent image, mult proj, gas $29.37 78596 Lung differential function $433.05 78596 26 Lung differential function $69.16 78600 Brain image < 4 views $203.53 78600 26 Brain image < 4 views $24.80 78601 Brain image w/flow < 4 views $242.25 78601 26 Brain image w/flow < 4 views $28.21 78605 Brain image 4+ views $226.28 78605 26 Brain image 4+ views $29.81 78606 Brain image w/flow 4 + views $355.54 78606 26 Brain image w/flow 4 + views $35.82

Page 126Page 126 Updated Fee Schedule - April 1

78607 Brain imaging (3D) $424.27 78607 26 Brain imaging (3D) $68.59 78608 26 Brain imaging (PET) $83.46 78609 Brain imaging (PET) $80.38 78609 26 Brain imaging (PET) $80.38 78610 Brain flow imaging only $205.93 78610 26 Brain flow imaging only $17.26 78630 Cerebrospinal fluid scan $377.66 78630 26 Cerebrospinal fluid scan $38.15 78635 CSF ventriculography $343.13 78635 26 CSF ventriculography $34.37 78645 CSF shunt evaluation $348.01 78645 26 CSF shunt evaluation $32.05 78647 Cerebrospinal fluid scan $397.48 78647 26 Cerebrospinal fluid scan $49.89 78650 CSF leakage imaging $368.75 78650 26 CSF leakage imaging $34.30 78660 Nuclear exam of tear flow $190.66 78660 26 Nuclear exam of tear flow $29.37 78700 Kidney imaging, morphol $202.00 78700 26 Kidney imaging, morphol $25.16 78701 Kidney imaging with flow $241.97 78701 26 Kidney imaging with flow $27.05 78707 K flow/funct image w/o drug $279.74 78707 26 K flow/funct image w/o drug $53.73$ 78708 K flow/funct image w/drug $225.35 78708 26 K flow/funct image w/drug $67.87 78709 K flow/funct image, multiple $411.21 78709 26 K flow/funct image, multiple $78.89 78710 Kidney imaging (3D) $278.27 78710 26 Kidney imaging (3D) $36.98 78725 Kidney function study $116.79 78725 26 Kidney function study $20.88 78730 Urinary bladder retention $90.76 78730 26 Urinary bladder retention $10.03 78740 Ureteral reflux study $239.84 78740 26 Ureteral reflux study $32.42 78761 Testicular imaging w/flow $239.72 78761 26 Testicular imaging w/flow $39.67 78800 Tumor imaging, limited area $214.50 78800 26 Tumor imaging, limited area $36.48 78801 Tumor imaging, mult areas $287.75 78801 26 Tumor imaging, mult areas $44.54 78802 Tumor imaging, whole body $377.66 78802 26 Tumor imaging, whole body $48.01 78803 Tumor imaging (3D) $415.34 78803 26 Tumor imaging (3D) $60.99 78804 Tumor imaging, whole body $666.74 78804 26 Tumor imaging, whole body $59.89 78805 Abscess imaging, ltd area $214.46 78805 26 Abscess imaging, ltd area $40.39 78806 Abscess imaging, whole body $395.77

Page 127Page 127 Updated Fee Schedule - April 1

78806 26 Abscess imaging, whole body $48.01 78807 Nuclear localization/abscess $415.85 78807 26 Nuclear localization/abscess $61.05 78808 Iv inj ra drug dx study $52.71 78811 26 Pet image, ltd area $87.64 78812 26 Pet image, skull-thigh $109.02 78813 26 Pet image, full body $112.86 78814 26 Pet image w/ct, lmtd $123.51 78815 26 Pet image w/ct, skull-thigh $136.48 78816 26 Pet image w/ct, full body $140.32 79005 Nuclear rx, oral admin $174.39 79005 26 Nuclear rx, oral admin $98.90 79101 Nuclear rx, iv admin $196.78 79101 26 Nuclear rx, iv admin $114.69 79200 Nuclear rx, intracav admin $199.55 79200 26 Nuclear rx, intracav admin $111.32 79300 26 Nuclr rx, interstit colloid $90.91 79403 Hematopoietic nuclear tx $251.32 79403 26 Hematopoietic nuclear tx $127.06 79440 Nuclear rx, intra-articular $183.37 79440 26 Nuclear rx, intra-articular $110.94 79445 26 Nuclear rx, intra-arterial $134.97 80500 Lab pathology consultation $22.78 80502 Lab pathology consultation $69.63 83020 26 Hemoglobin electrophoresis $20.15$ 83912 26 Genetic examination $19.27 84165 26 Protein e-phoresis, serum $19.71 84166 26 Protein e-phoresis/urine/csf $19.71 84181 26 Western blot test $19.71 84182 26 Protein, western blot test $20.52 85060 Blood smear interpretation $24.29 85097 Bone marrow interpretation $98.33 85390 26 Fibrinolysins screen $20.15 85396 Clotting assay, whole blood $20.83 85576 26 Blood platelet aggregation $20.15 86077 Physician blood bank service $53.15 86078 Physician blood bank service $54.03 86079 Physician blood bank service $54.47 86255 26 Fluorescent antibody, screen $20.15 86256 26 Fluorescent antibody, titer $20.15 86320 26 Serum immunoelectrophoresis $20.15 86325 26 Other immunoelectrophoresis $19.71 86327 26 Immunoelectrophoresis assay $23.20 86334 26 Immunofix e-phoresis, serum $20.15 86335 26 Immunfix e-phorsis/urine/csf $19.71 86486 Skin test, nos antigen $6.02 86490 Coccidioidomycosis skin test $8.21 86510 Histoplasmosis skin test $8.21 86580 TB intradermal test $8.65 87164 26 Dark field examination $19.71 87207 26 Smear, special stain $20.15 88104 Cytopath fl nongyn, smears $70.21

Page 128Page 128 Updated Fee Schedule - April 1

88104 26 Cytopath fl nongyn, smears $29.93 88106 Cytopath fl nongyn, filter $88.22 88106 26 Cytopath fl nongyn, filter $29.93 88107 Cytopath fl nongyn, sm/fltr $110.67 88107 26 Cytopath fl nongyn, sm/fltr $41.39 88108 Cytopath, concentrate tech $83.39 88108 26 Cytopath, concentrate tech $29.93 88112 Cytopath, cell enhance tech $115.18 88112 26 Cytopath, cell enhance tech $60.84 88125 Forensic cytopathology $24.10 88125 26 Forensic cytopathology $14.06 88141 Cytopath, c/v, interpret $30.23 88160 Cytopath smear, other source $58.90 88160 26 Cytopath smear, other source $26.53 88161 Cytopath smear, other source $61.54 88161 26 Cytopath smear, other source $26.09 88162 Cytopath smear, other source $89.14 88162 26 Cytopath smear, other source $40.95 88172 Cytopathology eval of fna $59.35 88172 26 Cytopathology eval of fna $32.25 88173 Cytopath eval, fna, report $151.47 88173 26 Cytopath eval, fna, report $74.29 88182 Cell marker study $117.92 88182 26 Cell marker study $38.24 88184 Flowcytometry/ tc, 1 marker $95.19$ 88185 Flowcytometry/tc, add-on $56.53 88187 Flowcytometry/read, 2-8 $69.60 88188 Flowcytometry/read, 9-15 $85.74 88189 Flowcytometry/read, 16 & > $108.57 88291 Cyto/molecular report $31.20 88300 Surgical path, gross $27.35 88300 26 Surgical path, gross $4.58 88302 Tissue exam by pathologist $58.00 88302 26 Tissue exam by pathologist $7.18 88304 Tissue exam by pathologist $73.11 88304 26 Tissue exam by pathologist $11.74 88305 Tissue exam by pathologist $121.59 88305 26 Tissue exam by pathologist $40.59 88307 Tissue exam by pathologist $242.25 88307 26 Tissue exam by pathologist $85.83 88309 Tissue exam by pathologist $362.16 88309 26 Tissue exam by pathologist $147.75 88311 Decalcify tissue $20.30 88311 26 Decalcify tissue $12.90 88312 Special stains $115.68 88312 26 Special stains $28.77 88313 Special stains $85.32 88313 26 Special stains $12.46 88314 Histochemical stain $103.22 88314 26 Histochemical stain $24.29 88318 Chemical histochemistry $116.71 88318 26 Chemical histochemistry $22.32

Page 129Page 129 Updated Fee Schedule - April 1

88319 Enzyme histochemistry $162.34 88319 26 Enzyme histochemistry $28.05 88321 Microslide consultation $96.04 88323 Microslide consultation $160.59 88323 26 Microslide consultation $92.19 88325 Comprehensive review of data $213.07 88329 Path consult introp $54.98 88331 Path consult intraop, 1 bloc $100.34 88331 26 Path consult intraop, 1 bloc $65.02 88332 Path consult intraop, addÆl $44.50 88332 26 Path consult intraop, addÆl $31.89 88333 Intraop cyto path consult, 1 $102.89 88333 26 Intraop cyto path consult, 1 $64.94 88334 Intraop cyto path consult, 2 $61.85 88334 26 Intraop cyto path consult, 2 $38.70 88342 Immunohistochemistry $113.91 88342 26 Immunohistochemistry $44.64 88346 Immunofluorescent study $114.27 88346 26 Immunofluorescent study $45.44 88347 Immunofluorescent study $89.23 88347 26 Immunofluorescent study $43.24 88348 Electron microscopy $741.85 88348 26 Electron microscopy $80.30 88349 Scanning electron microscopy $352.89 88349 26 Scanning electron microscopy $41.39$ 88355 Analysis, skeletal muscle $275.56 88355 26 Analysis, skeletal muscle $93.66 88356 Analysis, nerve $328.83 88356 26 Analysis, nerve $148.75 88358 Analysis, tumor $87.28 88358 26 Analysis, tumor $49.09 88360 Tumor immunohistochem/manual $137.14 88360 26 Tumor immunohistochem/manual $58.21 88361 Tumor immunohistochem/comput $174.93 88361 26 Tumor immunohistochem/comput $62.94 88362 Nerve teasing preparations $301.39 88362 26 Nerve teasing preparations $115.09 88365 Insitu hybridization (fish) $180.41 88365 26 Insitu hybridization (fish) $62.38 88367 Insitu hybridization, auto $280.19 88367 26 Insitu hybridization, auto $66.66 88368 Insitu hybridization, manual $245.06 88368 26 Insitu hybridization, manual $70.19 88371 26 Protein, western blot tissue $19.71 88372 26 Protein analysis w/probe $19.71 88380 Microdissection, laser $226.10 88380 26 Microdissection, laser $83.36 88381 Microdissection, manual $250.21 88381 26 Microdissection, manual $63.65 88385 Eval molecul probes, 51-250 $620.75 88385 26 Eval molecul probes, 51-250 $73.79 88386 Eval molecul probes, 251-500 $795.25

Page 130Page 130 Updated Fee Schedule - April 1

88386 26 Eval molecul probes, 251-500 $105.66 89049 Chct for mal hyperthermia $277.97 89060 26 Exam,synovial fluid crystals $20.15 89100 Sample intestinal contents $286.97 89105 Sample intestinal contents $295.37 89130 Sample stomach contents $250.08 89132 Sample stomach contents $286.97 89135 Sample stomach contents $339.37 89136 Sample stomach contents $242.89 89140 Sample stomach contents $279.76 89141 Sample stomach contents $290.20 89220 Sputum specimen collection $17.88 89230 Collect sweat for test $4.70 90465 Immune admin 1 inj, < 8 yrs $24.44 90466 Immune admin addl inj, < 8 y $11.85 90467 Immune admin o or n, < 8 yrs $15.65 90468 Immune admin o/n, addl < 8 y $11.41 90471 Immunization admin $24.44 90472 Immunization admin, each add $11.85 90473 Immune admin oral/nasal $15.65 90474 Immune admin oral/nasal addl $10.10 90801 Psy dx interview $168.53 90802 Intac psy dx interview $179.47 90804 Psytx, office, 20-30 min $70.20 90805 Psytx, off, 20-30 min w/e&m $77.73$ 90806 Psytx, off, 45-50 min $96.86 90807 Psytx, off, 45-50 min w/e&m $108.71 90808 Psytx, office, 75-80 min $141.81 90809 Psytx, off, 75-80, w/e&m $153.59 90810 Intac psytx, off, 20-30 min $74.10 90811 Intac psytx, 20-30, w/e&m $86.82 90812 Intac psytx, off, 45-50 min $105.66 90813 Intac psytx, 45-50 min w/e&m $117.87 90814 Intac psytx, off, 75-80 min $153.17 90815 Intac psytx, 75-80 w/e&m $162.39 90816 Psytx, hosp, 20-30 min $64.18 90817 Psytx, hosp, 20-30 min w/e&m $71.19 90818 Psytx, hosp, 45-50 min $95.30 90819 Psytx, hosp, 45-50 min w/e&m $102.25 90821 Psytx, hosp, 75-80 min $140.18 90822 Psytx, hosp, 75-80 min w/e&m $147.50 90823 Intac psytx, hosp, 20-30 min $69.02 90824 Intac psytx, hsp 20-30 w/e&m $76.85 90826 Intac psytx, hosp, 45-50 min $100.88 90827 Intac psytx, hsp 45-50 w/e&m $107.09 90828 Intac psytx, hosp, 75-80 min $145.83 90829 Intac psytx, hsp 75-80 w/e&m $152.33 90845 Psychoanalysis $88.26 90846 Family psytx w/o patient $94.90 90847 Family psytx w/patient $118.12 90849 Multiple family group psytx $36.28 90853 Group psychotherapy $34.16

Page 131Page 131 Updated Fee Schedule - April 1

90857 Intac group psytx $38.67 90862 Medication management $61.05 90865 Narcosynthesis $170.01 90870 Electroconvulsive therapy $154.69 90875 Psychophysiological therapy $79.00 90876 Psychophysiological therapy $115.81 90880 Hypnotherapy $115.20 90885 Psy evaluation of records $52.47 90887 Consultation with family $92.54 90901 Biofeedback train, any meth $38.22 90911 Biofeedback peri/uro/rectal $98.59 90935 Hemodialysis, one evaluation $73.13 90937 Hemodialysis, repeated eval $119.21 90945 Dialysis, one evaluation $75.74 90947 Dialysis, repeated eval $121.90 90951 Esrd serv, 4 visits p mo, <2 $1,053.73 90954 Esrd serv, 4 vsts p mo, 2-11 $857.50 90955 Esrd srv 2-3 vsts p mo, 2-11 $487.88 90956 Esrd srv, 1 visit p mo, 2-11 $330.54 90957 Esrd srv, 4 vsts p mo, 12-19 $691.05 90958 Esrd srv 2-3 vsts p mo 12-19 $467.17 90959 Esrd serv, 1 vst p mo, 12-19 $306.32 90960 Esrd srv, 4 visits p mo, 20+ $309.87 90961 Esrd srv, 2-3 vsts p mo, 20+ $249.53 90962 Esrd serv, 1 visit p mo, 20+ $179.85$ 90963 Esrd home pt, serv p mo, <2 $594.16 90964 Esrd home pt serv p mo, 2-11 $492.74 90965 Esrd home pt serv p mo 12-19 $468.59 90966 Esrd home pt, serv p mo, 20+ $246.46 90967 Esrd home pt serv p day, <2 $21.62 90968 Esrd home pt srv p day, 2-11 $16.39 90969 Esrd home pt srv p day 12-19 $16.02 90970 Esrd home pt serv p day, 20+ $8.86 90997 Hemoperfusion $96.44 91000 Esophageal intubation $101.38 91000 26 Esophageal intubation $39.07 91010 Esophagus motility study $216.89 91010 26 Esophagus motility study $73.20 91011 Esophagus motility study $291.21 91011 26 Esophagus motility study $89.98 91012 Esophagus motility study $296.36 91012 26 Esophagus motility study $86.41 91020 Gastric motility studies $264.01 91020 26 Gastric motility studies $83.86 91022 Duodenal motility study $215.69 91022 26 Duodenal motility study $86.50 91030 Acid perfusion of esophagus $157.74 91030 26 Acid perfusion of esophagus $54.20 91034 Gastroesophageal reflux test $229.71 91034 26 Gastroesophageal reflux test $57.03 91035 G-esoph reflx tst w/electrod $544.04 91035 26 G-esoph reflx tst w/electrod $92.41

Page 132Page 132 Updated Fee Schedule - April 1

91037 Esoph imped function test $183.15 91037 26 Esoph imped function test $57.91 91038 Esoph imped funct test > 1h $159.72 91038 26 Esoph imped funct test > 1h $65.24 91040 Esoph balloon distension tst $442.77 91040 26 Esoph balloon distension tst $59.67 91052 Gastric analysis test $140.74 91052 26 Gastric analysis test $44.23 91055 Gastric intubation for smear $151.29 91055 26 Gastric intubation for smear $49.95 91065 Breath hydrogen test $76.34 91065 26 Breath hydrogen test $11.46 91105 Gastric intubation treatment $91.62 91110 Gi tract capsule endoscopy $1,043.92 91110 26 Gi tract capsule endoscopy $212.37 91111 Esophageal capsule endoscopy $826.94 91111 26 Esophageal capsule endoscopy $59.63 91120 Rectal sensation test $453.82 91120 26 Rectal sensation test $53.45 91122 Anal pressure record $263.87 91122 26 Anal pressure record $98.80 91132 26 Electrogastrography $30.76 91133 26 Electrogastrography w/test $39.62 92002 Eye exam, new patient $76.10 92004 Eye exam, new patient $142.42$ 92012 Eye exam established pat $80.18 92014 Eye exam & treatment $116.80 92015 Refraction $35.88 92018 New eye exam & treatment $139.71 92019 Eye exam & treatment $68.98 92020 Special eye evaluation $26.74 92025 Corneal topography $35.61 92025 26 Corneal topography $19.43 92060 Special eye evaluation $60.91 92060 26 Special eye evaluation $38.13 92065 Orthoptic/pleoptic training $49.08 92065 26 Orthoptic/pleoptic training $19.27 92070 Fitting of contact lens $68.81 92081 Visual field examination(s) $56.18 92081 26 Visual field examination(s) $19.79 92082 Visual field examination(s) $74.44 92082 26 Visual field examination(s) $23.99 92083 Visual field examination(s) $84.95 92083 26 Visual field examination(s) $27.47 92100 Serial tonometry exam(s) $92.04 92120 Tonography & eye evaluation $75.77 92130 Water provocation tonography $84.12 92135 Ophth dx imaging post seg $49.23 92135 26 Ophth dx imaging post seg $19.87 92136 Ophthalmic biometry $88.55 92136 26 Ophthalmic biometry $30.59 92140 Glaucoma provocative tests $59.98

Page 133Page 133 Updated Fee Schedule - April 1

92225 Special eye exam, initial $25.34 92226 Special eye exam, subsequent $23.10 92230 Eye exam with photos $63.00 92235 Eye exam with photos $136.87 92235 26 Eye exam with photos $45.90 92240 Icg angiography $256.13 92240 26 Icg angiography $62.36 92250 Eye exam with photos $76.64 92250 26 Eye exam with photos $23.99 92260 Ophthalmoscopy/dynamometry $18.49 92265 Eye muscle evaluation $81.21 92265 26 Eye muscle evaluation $43.13 92270 Electro-oculography $94.02 92270 26 Electro-oculography $43.63 92275 Electroretinography $141.57 92275 26 Electroretinography $56.92 92283 Color vision examination $49.41 92283 26 Color vision examination $9.50 92284 Dark adaptation eye exam $65.99 92284 26 Dark adaptation eye exam $12.46 92285 Eye photography $45.22 92285 26 Eye photography $11.46 92286 Internal eye photography $128.29 92286 26 Internal eye photography $36.61 92287 Internal eye photography $120.58$ 92310 Contact lens fitting $99.52 92311 Contact lens fitting $96.78 92312 Contact lens fitting $109.79 92313 Contact lens fitting $93.79 92314 Prescription of contact lens $79.49 92315 Prescription of contact lens $69.16 92316 Prescription of contact lens $89.61 92317 Prescription of contact lens $71.36 92325 Modification of contact lens $32.00 92326 Replacement of contact lens $43.97 92340 Fitting of spectacles $39.04 92341 Fitting of spectacles $44.40 92342 Fitting of spectacles $47.44 92352 Special spectacles fitting $43.43 92353 Special spectacles fitting $50.25 92354 Special spectacles fitting $111.79 92355 Special spectacles fitting $64.51 92358 Eye prosthesis service $21.19 92370 Repair & adjust spectacles $34.09 92371 Repair & adjust spectacles $16.56 92502 Ear and throat examination $101.46 92504 Ear microscopy examination $32.26 92506 Speech/hearing evaluation $173.71 92507 Speech/hearing therapy $71.18 92508 Speech/hearing therapy $33.83 92511 Nasopharyngoscopy $170.79 92512 Nasal function studies $66.47

Page 134Page 134 Updated Fee Schedule - April 1

92516 Facial nerve function test $69.32 92520 Laryngeal function studies $66.51 92526 Oral function therapy $91.95 92541 Spontaneous nystagmus test $66.72 92541 26 Spontaneous nystagmus test $22.04 92542 Positional nystagmus test $69.97 92542 26 Positional nystagmus test $18.27 92543 Caloric vestibular test $32.47 92543 26 Caloric vestibular test $5.74 92544 Optokinetic nystagmus test $56.10 92544 26 Optokinetic nystagmus test $14.06 92545 Oscillating tracking test $52.82 92545 26 Oscillating tracking test $12.54 92546 Sinusoidal rotational test $95.40 92546 26 Sinusoidal rotational test $15.59 92547 Supplemental electrical test $6.63 92548 Posturography $107.80 92548 26 Posturography $27.41 92551 Pure tone hearing test, air $12.67 92552 Pure tone audiometry, air $25.65 92553 Audiometry, air & bone $34.30 92555 Speech threshold audiometry $19.06 92556 Speech audiometry, complete $29.47 92557 Comprehensive hearing test $50.47 92561 Bekesy audiometry, diagnosis $33.42$ 92562 Loudness balance test $26.97 92563 Tone decay hearing test $24.33 92564 Sisi hearing test $23.39 92565 Stenger test, pure tone $15.11 92567 Tympanometry $19.91 92568 Acoustic refl threshold tst $19.78 92569 Acoustic reflex decay test $16.09 92571 Filtered speech hearing test $19.50 92572 Staggered spondaic word test $20.58 92575 Sensorineural acuity test $41.60 92576 Synthetic sentence test $25.14 92577 Stenger test, speech $20.62 92579 Visual audiometry (vra) $48.33 92582 Conditioning play audiometry $48.80 92583 Select picture audiometry $39.44 92584 Electrocochleography $80.30 92585 Auditor evoke potent, compre $116.89 92585 26 Auditor evoke potent, compre $27.78 92586 Auditor evoke potent, limit $74.18 92587 Evoked auditory test $45.54 92587 26 Evoked auditory test $7.62 92588 Evoked auditory test $73.39 92588 26 Evoked auditory test $19.79 92596 Ear protector evaluation $41.33 92597 Oral speech device eval $116.60 92601 Cochlear implt f/up exam < 7 $170.36 92602 Reprogram cochlear implt < 7 $107.45

Page 135Page 135 Updated Fee Schedule - April 1

92603 Cochlear implt f/up exam 7 > $152.30 92604 Reprogram cochlear implt 7 > $91.15 92607 Ex for speech device rx, 1hr $182.85 92608 Ex for speech device rx addl $35.25 92609 Use of speech device service $97.25 92610 Evaluate swallowing function $94.35 92611 Motion fluoroscopy/swallow $102.70 92612 Endoscopy swallow tst (fees) $176.41 92613 Endoscopy swallow tst (fees) $41.29 92614 Laryngoscopic sensory test $156.21 92615 Eval laryngoscopy sense tst $37.09 92616 Fees w/laryngeal sense test $213.86 92617 Interprt fees/laryngeal test $45.41 92620 Auditory function, 60 min $77.44 92621 Auditory function, + 15 min $18.11 92625 Tinnitus assessment $61.53 92626 Eval aud rehab status $86.57 92627 Eval aud status rehab add-on $21.34 92640 Aud brainstem implt programg $79.65 92950 Heart/lung resuscitation cpr $303.84 92953 Temporary external pacing $12.91 92960 Cardioversion electric, ext $296.39 92961 Cardioversion, electric, int $289.26 92970 Cardioassist, internal $198.50 92971 Cardioassist, external $114.64$ 92973 Percut coronary thrombectomy $204.75 92974 Cath place, cardio brachytx $187.84 92975 Dissolve clot, heart vessel $449.70 92977 Dissolve clot, heart vessel $160.33 92978 26 Intravasc us, heart add-on $109.57 92979 26 Intravasc us, heart add-on $88.76 92980 Insert intracoronary stent $934.59 92981 Insert intracoronary stent $259.86 92982 Coronary artery dilation $693.17 92984 Coronary artery dilation $185.44 92986 Revision of aortic valve $1,544.33 92987 Revision of mitral valve $1,598.48 92990 Revision of pulmonary valve $1,229.64 92995 Coronary atherectomy $763.90 92996 Coronary atherectomy add-on $198.75 92997 Pul art balloon repr, percut $697.79 92998 Pul art balloon repr, percut $359.12 93000 Electrocardiogram, complete $24.30 93005 Electrocardiogram, tracing $14.36 93010 Electrocardiogram report $9.94 93012 Transmission of ecg $220.63 93014 Report on transmitted ecg $30.32 93015 Cardiovascular stress test $116.73 93016 Cardiovascular stress test $26.92 93017 Cardiovascular stress test $71.75 93018 Cardiovascular stress test $17.70 93024 Cardiac drug stress test $140.28

Page 136Page 136 Updated Fee Schedule - April 1

93024 26 Cardiac drug stress test $69.21 93025 Microvolt t-wave assess $254.23 93025 26 Microvolt t-wave assess $45.42 93040 Rhythm ECG with report $15.22 93041 Rhythm ECG, tracing $6.52 93042 Rhythm ECG, report $8.70 93224 ECG monitor/report, 24 hrs $140.43 93225 ECG monitor/record, 24 hrs $42.95 93226 ECG monitor/report, 24 hrs $66.27 93227 ECG monitor/review, 24 hrs $31.20 93228 Remote 30 day ecg rev/report $27.69 93230 ECG monitor/report, 24 hrs $143.81 93231 Ecg monitor/record, 24 hrs $43.19 93232 ECG monitor/report, 24 hrs $70.73 93233 ECG monitor/review, 24 hrs $29.88 93237 ECG monitor/review, 24 hrs $26.92 93268 ECG record/review $318.07 93270 ECG recording $25.82 93271 Ecg/monitoring and analysis $262.37 93272 Ecg/review, interpret only $29.88 93278 ECG/signal-averaged $47.23 93278 26 ECG/signal-averaged $14.14 93279 Pm device progr eval, sngl $63.66 93279 26 Pm device progr eval, sngl $39.77 93280 Pm device progr eval, dual $75.44$ 93280 26 Pm device progr eval, dual $47.97 93281 Pm device progr eval, multi $87.97 93281 26 Pm device progr eval, multi $55.73 93282 Icd device prog eval, 1 sngl $81.27 93282 26 Icd device prog eval, 1 sngl $52.11 93283 Icd device progr eval, dual $98.88 93283 26 Icd device progr eval, dual $65.76 93284 Icd device progr eval, mult $115.68 93284 26 Icd device progr eval, mult $78.17 93285 Ilr device eval progr $55.10 93285 26 Ilr device eval progr $32.52 93286 Pre-op pm device eval $31.12 93286 26 Pre-op pm device eval $16.32 93287 Pre-op icd device eval $40.78 93287 26 Pre-op icd device eval $23.91 93288 Pm device eval in person $49.72 93288 26 Pm device eval in person $26.71 93289 Icd device interrogate $75.80 93289 26 Icd device interrogate $48.33 93290 Icm device eval $36.03 93290 26 Icm device eval $23.12 93291 Ilr device interrogate $47.52 93291 26 Ilr device interrogate $27.08 93292 Wcd device interrogate $42.69 93292 26 Wcd device interrogate $26.71 93293 Pm phone r-strip device eval $70.26 93293 26 Pm phone r-strip device eval $18.72

Page 137Page 137 Updated Fee Schedule - April 1

93294 Pm device interrogate remote $40.58 93295 Icd device interrogat remote $73.17 93296 Pm/icd remote tech serv $44.30 93297 Icm device interrogat remote $27.69 93298 Ilr device interrogat remote $32.52 93303 Echo transthoracic $255.90 93303 26 Echo transthoracic $75.58 93304 Echo transthoracic $158.83 93304 26 Echo transthoracic $42.86 93306 Tte w/doppler, complete $315.41 93306 26 Tte w/doppler, complete $79.09 93307 Tte w/o doppler, complete $208.16 93307 26 Tte w/o doppler, complete $54.63 93308 Tte, f-up or lmtd $131.73 93308 26 Tte, f-up or lmtd $32.00 93312 Echo transesophageal $380.51 93312 26 Echo transesophageal $127.22 93313 Echo transesophageal $44.09 93314 Echo transesophageal $331.45 93314 26 Echo transesophageal $72.02 93315 26 Echo transesophageal $163.22 93316 Echo transesophageal $48.99 93317 26 Echo transesophageal $100.78 93318 26 Echo transesophageal intraop $122.87 93320 Doppler echo exam, heart $92.19$ 93320 26 Doppler echo exam, heart $22.71 93321 Doppler echo exam, heart $41.19 93321 26 Doppler echo exam, heart $9.22 93325 Doppler color flow add-on $63.87 93325 26 Doppler color flow add-on $4.21 93350 Stress tte only $247.70 93350 26 Stress tte only $88.67 93351 Stress tte complete $324.29 93352 Admin ecg contrast agent $45.60 93501 Right heart catheterization $951.96 93501 26 Right heart catheterization $186.80 93503 Insert/place heart catheter $117.45 93505 Biopsy of heart lining $879.46 93505 26 Biopsy of heart lining $270.36 93508 Cath placement, angiography $1,260.41 93508 26 Cath placement, angiography $260.11 93510 Left heart catheterization $1,580.24 93510 26 Left heart catheterization $274.35 93511 26 Left heart catheterization $318.27 93514 26 Left heart catheterization $436.92 93524 26 Left heart catheterization $438.65 93526 Rt & Lt heart catheters $2,024.75 93526 26 Rt & Lt heart catheters $378.03 93527 26 Rt & Lt heart catheters $457.74 93528 26 Rt & Lt heart catheters $541.26 93529 26 Rt, lt heart catheterization $303.60 93530 26 Rt heart cath, congenital $257.63

Page 138Page 138 Updated Fee Schedule - April 1

93531 26 R & l heart cath, congenital $503.82 93532 26 R & l heart cath, congenital $596.67 93533 26 R & l heart cath, congenital $401.75 93539 Injection, cardiac cath $95.03 93540 Injection, cardiac cath $288.08 93541 Injection for lung angiogram $17.34 93542 Injection for heart x-rays $174.61 93543 Injection for heart x-rays $94.66 93544 Injection for aortography $68.61 93545 Inject for coronary x-rays $200.90 93555 Imaging, cardiac cath $136.24 93555 26 Imaging, cardiac cath $49.34 93556 Imaging, cardiac cath $192.05 93556 26 Imaging, cardiac cath $50.51 93561 26 Cardiac output measurement $25.65 93562 26 Cardiac output measurement $8.26 93571 26 Heart flow reserve measure $109.14 93572 26 Heart flow reserve measure $85.82 93580 Transcath closure of asd $1,121.62 93581 Transcath closure of vsd $1,463.55 93600 26 Bundle of His recording $131.27 93602 26 Intra-atrial recording $130.76 93603 26 Right ventricular recording $131.14 93609 26 Map tachycardia, add-on $309.36 93610 26 Intra-atrial pacing $185.72$ 93612 26 Intraventricular pacing $184.78 93613 Electrophys map 3d, add-on $435.12 93615 26 Esophageal recording $59.27 93616 26 Esophageal recording $74.99 93618 26 Heart rhythm pacing $266.11 93619 26 Electrophysiology evaluation $459.63 93620 26 Electrophysiology evaluation $721.77 93621 26 Electrophysiology evaluation $130.62 93622 26 Electrophysiology evaluation $190.86 93623 26 Stimulation, pacing heart $176.86 93624 26 Electrophysiologic study $302.20 93631 26 Heart pacing, mapping $444.08 93640 26 Evaluation heart device $216.86 93641 26 Electrophysiology evaluation $367.59 93642 Electrophysiology evaluation $542.01 93642 26 Electrophysiology evaluation $300.15 93650 Ablate heart dysrhythm focus $663.47 93651 Ablate heart dysrhythm focus $1,007.58 93652 Ablate heart dysrhythm focus $1,096.67 93660 Tilt table evaluation $196.51 93660 26 Tilt table evaluation $114.50 93662 26 Intracardiac ecg (ice) $169.65 93668 Peripheral vascular rehab $20.58 93701 Bioimpedance, thoracic $40.18 93701 26 Bioimpedance, thoracic $9.94 93720 Total body plethysmography $54.78 93721 Plethysmography tracing $45.72

Page 139Page 139 Updated Fee Schedule - April 1

93722 Plethysmography report $9.06 93724 Analyze pacemaker system $374.97 93724 26 Analyze pacemaker system $294.43 93740 Temperature gradient studies $10.83 93740 26 Temperature gradient studies $8.70 93770 Measure venous pressure $9.51 93770 26 Measure venous pressure $8.70 93784 Ambulatory BP monitoring $77.04 93786 Ambulatory BP recording $35.95 93788 Ambulatory BP analysis $20.14 93790 Review/report BP recording $20.95 93797 Cardiac rehab $20.84 93798 Cardiac rehab/monitor $29.72 93875 Extracranial study $121.27 93875 26 Extracranial study $12.18 93880 Extracranial study $296.42 93880 26 Extracranial study $33.88 93882 Extracranial study $195.27 93882 26 Extracranial study $22.35 93886 Intracranial study $353.89 93886 26 Intracranial study $51.20 93888 Intracranial study $241.38 93888 26 Intracranial study $34.97 93890 Tcd, vasoreactivity study $309.85 93890 26 Tcd, vasoreactivity study $54.60$ 93892 Tcd, emboli detect w/o inj $338.98 93892 26 Tcd, emboli detect w/o inj $61.77 93893 Tcd, emboli detect w/inj $338.10 93893 26 Tcd, emboli detect w/inj $62.21 93922 Extremity study $144.11 93922 26 Extremity study $13.64 93923 Extremity study $222.11 93923 26 Extremity study $25.03 93924 Extremity study $273.73 93924 26 Extremity study $28.52 93925 Lower extremity study $369.50 93925 26 Lower extremity study $32.28 93926 Lower extremity study $235.70 93926 26 Lower extremity study $21.99 93930 Upper extremity study $291.75 93930 26 Upper extremity study $25.83 93931 Upper extremity study $195.11 93931 26 Upper extremity study $17.05 93965 Extremity study $146.83 93965 26 Extremity study $19.36 93970 Extremity study $301.91 93970 26 Extremity study $37.94 93971 Extremity study $199.88 93971 26 Extremity study $25.10 93975 Vascular study $445.79 93975 26 Vascular study $101.20 93976 Vascular study $256.07

Page 140Page 140 Updated Fee Schedule - April 1

93976 26 Vascular study $66.99 93978 Vascular study $283.90 93978 26 Vascular study $36.42 93979 Vascular study $196.21 93979 26 Vascular study $24.30 93980 Penile vascular study $214.87 93980 26 Penile vascular study $71.75 93981 Penile vascular study $153.63 93981 26 Penile vascular study $24.36 93982 Aneurysm pressure sens study $46.26 93990 Doppler flow testing $231.67 93990 26 Doppler flow testing $13.57 94002 Vent mgmt inpat, init day $93.74 94003 Vent mgmt inpat, subq day $68.31 94004 Vent mgmt nf per day $49.90 94005 Home vent mgmt supervision $97.95 94010 Breathing capacity test $38.80 94010 26 Breathing capacity test $9.06 94014 Patient recorded spirometry $55.30 94015 Patient recorded spirometry $28.49 94016 Review patient spirometry $26.81 94060 Evaluation of wheezing $67.74 94060 26 Evaluation of wheezing $15.43 94070 Evaluation of wheezing $68.85 94070 26 Evaluation of wheezing $30.87$ 94150 Vital capacity test $26.55 94150 26 Vital capacity test $4.21 94200 Lung function test (MBC/MVV) $26.53 94200 26 Lung function test (MBC/MVV) $6.02 94240 Residual lung capacity $45.36 94240 26 Residual lung capacity $13.19 94250 Expired gas collection $28.79 94250 26 Expired gas collection $6.02 94260 Thoracic gas volume $37.22 94260 26 Thoracic gas volume $6.74 94350 Lung nitrogen washout curve $40.15 94350 26 Lung nitrogen washout curve $13.19 94360 Measure airflow resistance $50.56 94360 26 Measure airflow resistance $13.19 94370 Breath airway closing volume $38.53 94370 26 Breath airway closing volume $13.19 94375 Respiratory flow volume loop $42.53 94375 26 Respiratory flow volume loop $15.43 94400 CO2 breathing response curve $61.11 94400 26 CO2 breathing response curve $21.10 94450 Hypoxia response curve $58.37 94450 26 Hypoxia response curve $20.29 94452 Hast w/report $64.87 94452 26 Hast w/report $15.80 94453 Hast w/oxygen titrate $86.92 94453 26 Hast w/oxygen titrate $20.72 94610 Surfactant admin thru tube $69.57

Page 141Page 141 Updated Fee Schedule - April 1

94620 Pulmonary stress test/simple $82.60 94620 26 Pulmonary stress test/simple $33.19 94621 Pulm stress test/complex $186.21 94621 26 Pulm stress test/complex $76.62 94640 Airway inhalation treatment $16.12 94644 Cbt, 1st hour $41.16 94645 Cbt, each addl hour $16.12 94660 Pos airway pressure, CPAP $63.29 94662 Neg press ventilation, cnp $38.76 94664 Evaluate pt use of inhaler $17.74 94667 Chest wall manipulation $24.70 94668 Chest wall manipulation $23.15 94680 Exhaled air analysis, o2 $67.69 94680 26 Exhaled air analysis, o2 $13.19 94681 Exhaled air analysis, o2/co2 $74.35 94681 26 Exhaled air analysis, o2/co2 $10.14 94690 Exhaled air analysis $60.18 94690 26 Exhaled air analysis $3.78 94720 Monoxide diffusing capacity $60.23 94720 26 Monoxide diffusing capacity $13.19 94725 Membrane diffusion capacity $78.71 94725 26 Membrane diffusion capacity $13.19 94750 Pulmonary compliance study $83.88 94750 26 Pulmonary compliance study $11.66 94760 Measure blood oxygen level $3.38$ 94761 Measure blood oxygen level $6.63 94762 Measure blood oxygen level $35.35 94770 Exhaled carbon dioxide test $43.01 94770 26 Exhaled carbon dioxide test $7.90 95004 Percut allergy skin tests $6.88 95010 Percut allergy titrate test $19.76 95012 Exhaled nitric oxide meas $23.65 95015 Id allergy titrate-drug/bug $14.49 95024 Id allergy test, drug/bug $8.20 95027 Id allergy titrate-airborne $5.57 95028 Id allergy test-delayed type $13.11 95044 Allergy patch tests $7.40 95052 Photo patch test $8.28 95056 Photosensitivity tests $41.67 95060 Eye allergy tests $27.98 95065 Nose allergy test $25.41 95070 Bronchial allergy tests $51.70 95071 Bronchial allergy tests $64.00 95075 Ingestion challenge test $69.33 95115 Immunotherapy, one injection $12.61 95117 Immunotherapy injections $15.24 95144 Antigen therapy services $13.52 95145 Antigen therapy services $17.91 95146 Antigen therapy services $29.77 95147 Antigen therapy services $28.89 95148 Antigen therapy services $40.75 95149 Antigen therapy services $53.49

Page 142Page 142 Updated Fee Schedule - April 1

95165 Antigen therapy services $13.52 95170 Antigen therapy services $10.44 95180 Rapid desensitization $156.30 95250 Glucose monitoring, cont $156.32 95251 Gluc monitor, cont, phys i&r $42.95 95805 Multiple sleep latency test $499.11 95805 26 Multiple sleep latency test $99.00 95806 Sleep study, unattended $242.01 95806 26 Sleep study, unattended $87.70 95807 Sleep study, attended $587.43 95807 26 Sleep study, attended $86.82 95808 Polysomnography, 1-3 $765.69 95808 26 Polysomnography, 1-3 $139.01 95810 Polysomnography, 4 or more $909.31 95810 26 Polysomnography, 4 or more $183.34 95811 Polysomnography w/cpap $1,002.30 95811 26 Polysomnography w/cpap $196.89 95812 Eeg, 41-60 minutes $278.59 95812 26 Eeg, 41-60 minutes $58.36 95813 Eeg, over 1 hour $338.94 95813 26 Eeg, over 1 hour $92.79 95816 Eeg, awake and drowsy $254.93 95816 26 Eeg, awake and drowsy $58.36 95819 Eeg, awake and asleep $274.26 95819 26 Eeg, awake and asleep $58.36$ 95822 Eeg, coma or sleep only $273.18 95822 26 Eeg, coma or sleep only $58.36 95824 26 Eeg, cerebral death only $39.80 95827 Eeg, all night recording $445.83 95827 26 Eeg, all night recording $57.55 95829 Surgery electrocorticogram $1,416.80 95829 26 Surgery electrocorticogram $340.24 95830 Insert electrodes for EEG $200.96 95831 Limb muscle testing, manual $28.84 95832 Hand muscle testing, manual $26.94 95833 Body muscle testing, manual $39.50 95834 Body muscle testing, manual $46.68 95851 Range of motion measurements $18.80 95852 Range of motion measurements $14.80 95857 Tensilon test $46.06 95860 Muscle test, one limb $91.75 95860 26 Muscle test, one limb $53.66 95861 Muscle test, 2 limbs $131.87 95861 26 Muscle test, 2 limbs $85.27 95863 Muscle test, 3 limbs $157.10 95863 26 Muscle test, 3 limbs $102.16 95864 Muscle test, 4 limbs $181.24 95864 26 Muscle test, 4 limbs $109.12 95865 Muscle test, larynx $125.62 95865 26 Muscle test, larynx $88.05 95866 Muscle test, hemidiaphragm $103.24 95866 26 Muscle test, hemidiaphragm $70.06

Page 143Page 143 Updated Fee Schedule - April 1

95867 Muscle test cran nerv unilat $79.98 95867 26 Muscle test cran nerv unilat $43.35 95868 Muscle test cran nerve bilat $109.07 95868 26 Muscle test cran nerve bilat $64.59 95869 Muscle test, thor paraspinal $52.02 95869 26 Muscle test, thor paraspinal $20.52 95870 Muscle test, nonparaspinal $50.70 95870 26 Muscle test, nonparaspinal $20.52 95872 Muscle test, one fiber $181.41 95872 26 Muscle test, one fiber $149.24 95873 Guide nerv destr, elec stim $52.89 95873 26 Guide nerv destr, elec stim $21.84 95874 Guide nerv destr, needle emg $49.82 95874 26 Guide nerv destr, needle emg $20.96 95875 Limb exercise test $104.44 95875 26 Limb exercise test $59.59 95900 Motor nerve conduction test $60.85 95900 26 Motor nerve conduction test $23.20 95903 Motor nerve conduction test $70.71 95903 26 Motor nerve conduction test $32.62 95904 Sense nerve conduction test $54.01 95904 26 Sense nerve conduction test $19.00 95920 Intraop nerve test add-on $168.22 95920 26 Intraop nerve test add-on $116.85 95921 Autonomic nerv function test $82.26$ 95921 26 Autonomic nerv function test $48.13 95922 Autonomic nerv function test $99.65 95922 26 Autonomic nerv function test $51.91 95923 Autonomic nerv function test $132.71 95923 26 Autonomic nerv function test $48.94 95925 Somatosensory testing $137.62 95925 26 Somatosensory testing $29.95 95926 Somatosensory testing $135.05 95926 26 Somatosensory testing $29.58 95927 Somatosensory testing $138.50 95927 26 Somatosensory testing $30.39 95928 C motor evoked, uppr limbs $215.48 95928 26 C motor evoked, uppr limbs $80.38 95929 C motor evoked, lwr limbs $227.78 95929 26 C motor evoked, lwr limbs $80.82 95930 Visual evoked potential test $122.53 95930 26 Visual evoked potential test $19.36 95933 Blink reflex test $73.09 95933 26 Blink reflex test $32.64 95934 H-reflex test $53.99 95934 26 H-reflex test $27.77 95936 H-reflex test $47.38 95936 26 H-reflex test $30.38 95937 Neuromuscular junction test $64.27 95937 26 Neuromuscular junction test $37.17 95950 Ambulatory eeg monitoring $276.28 95950 26 Ambulatory eeg monitoring $81.49

Page 144Page 144 Updated Fee Schedule - April 1

95951 26 EEG monitoring/videorecord $324.15 95953 EEG monitoring/computer $461.66 95953 26 EEG monitoring/computer $177.24 95954 EEG monitoring/giving drugs $280.31 95954 26 EEG monitoring/giving drugs $122.13 95955 EEG during surgery $158.88 95955 26 EEG during surgery $53.71 95956 Eeg monitoring, cable/radio $829.98 95956 26 Eeg monitoring, cable/radio $166.46 95957 EEG digital analysis $298.47 95957 26 EEG digital analysis $107.31 95958 EEG monitoring/function test $431.53 95958 26 EEG monitoring/function test $229.45 95961 Electrode stimulation, brain $260.03 95961 26 Electrode stimulation, brain $174.84 95962 Electrode stim, brain add-on $236.30 95962 26 Electrode stim, brain add-on $179.22 95965 26 Meg, spontaneous $444.64 95966 26 Meg, evoked, single $221.09 95967 26 Meg, evoked, each addÆl $188.56 95970 Analyze neurostim, no prog $56.73 95971 Analyze neurostim, simple $63.81 95972 Analyze neurostim, complex $112.79 95973 Analyze neurostim, complex $60.95 95974 Cranial neurostim, complex $185.98$ 95975 Cranial neurostim, complex $102.93 95978 Analyze neurostim brain/1h $221.29 95979 Analyz neurostim brain addon $98.84 95980 Io anal gast n-stim init $43.88 95981 Io anal gast n-stim subsq $31.25 95982 Io ga n-stim subsq w/reprog $47.91 95990 Spin/brain pump refil & main $70.76 95991 Spin/brain pump refil & main $100.42 95992 Canalith repositioning proc $45.05 96000 Motion analysis, video/3d $93.42 96001 Motion test w/ft press meas $110.35 96002 Dynamic surface emg $21.96 96003 Dynamic fine wire emg $19.20 96004 Phys review of motion tests $119.59 96020 26 Functional brain mapping $194.23 96040 Genetic counseling, 30 min $48.69 96101 Psycho testing by psych/phys $91.08 96102 Psycho testing by technician $59.10 96103 Psycho testing admin by comp $52.81 96105 Assessment of aphasia $88.41 96110 Developmental test, lim $14.61 96111 Developmental test, extend $141.26 96116 Neurobehavioral status exam $103.83 96118 Neuropsych tst by psych/phys $119.20 96119 Neuropsych testing by tec $86.04 96120 Neuropsych tst admin w/comp $80.04 96125 Cognitive test by hc pro $103.98

Page 145Page 145 Updated Fee Schedule - April 1

96150 Assess hlth/behave, init $24.40 96151 Assess hlth/behave, subseq $23.68 96152 Intervene hlth/behave, indiv $22.52 96153 Intervene hlth/behave, group $5.30 96154 Interv hlth/behav, fam w/pt $22.16 96155 Interv hlth/behav fam no pt $24.36 96360 Hydration iv infusion, init $67.52 96361 Hydrate iv infusion, add-on $19.23 96365 Ther/proph/diag iv inf, init $82.14 96366 Ther/proph/diag iv inf addon $25.47 96367 Tx/proph/dg addl seq iv inf $40.77 96368 Ther/diag concurrent inf $23.80 96369 Sc ther infusion, up to 1 hr $180.61 96370 Sc ther infusion, addl hr $18.01 96371 Sc ther infusion, reset pump $88.23 96372 Ther/proph/diag inj, sc/im $24.44 96373 Ther/proph/diag inj, ia $20.85 96374 Ther/proph/diag inj, iv push $65.01 96375 Tx/pro/dx inj new drug addon $27.94 96401 Chemo, anti-neopl, sq/im $80.79 96402 Chemo hormon antineopl sq/im $43.61 96405 Chemo intralesional, up to 7 $99.23 96406 Chemo intralesional over 7 $136.84 96409 Chemo, iv push, sngl drug $134.25 96411 Chemo, iv push, addl drug $76.14$ 96413 Chemo, iv infusion, 1 hr $177.29 96415 Chemo, iv infusion, addl hr $39.25 96416 Chemo prolong infuse w/pump $194.10 96417 Chemo iv infus each addl seq $87.86 96420 Chemo, ia, push tecnique $129.84 96422 Chemo ia infusion up to 1 hr $210.23 96423 Chemo ia infuse each addl hr $93.34 96425 Chemotherapy,infusion method $207.15 96440 Chemotherapy, intracavitary $712.54 96445 Chemotherapy, intracavitary $332.85 96450 Chemotherapy, into CNS $243.36 96521 Refill/maint, portable pump $152.94 96522 Refill/maint pump/resvr syst $129.66 96523 Irrig drug delivery device $30.37 96542 Chemotherapy injection $158.49 96567 Photodynamic tx, skin $142.06 96570 Photodynamic tx, 30 min $63.14 96571 Photodynamic tx, addl 15 min $30.38 96900 Ultraviolet light therapy $23.59 96902 Trichogram $22.91 96904 Whole body photography $78.13 96910 Photochemotherapy with UV-B $76.17 96912 Photochemotherapy with UV-A $97.63 96913 Photochemotherapy, UV-A or B $135.51 96920 Laser tx, skin < 250 sq cm $187.67 96921 Laser tx, skin 250-500 sq cm $183.49 96922 Laser tx, skin > 500 sq cm $269.73

Page 146Page 146 Updated Fee Schedule - April 1

97001 Pt evaluation $77.62 97002 Pt re-evaluation $41.92 97003 Ot evaluation $82.82 97004 Ot re-evaluation $48.51 97010 Hot or cold packs therapy $5.17 97012 Mechanical traction therapy $15.90 97014 Electric stimulation therapy $15.13 97016 Vasopneumatic device therapy $17.33 97018 Paraffin bath therapy $9.13 97022 Whirlpool therapy $20.04 97024 Diathermy eg, microwave $6.05 97026 Infrared therapy $5.61 97028 Ultraviolet therapy $6.77 97032 Electrical stimulation $18.10 97033 Electric current therapy $27.68 97034 Contrast bath therapy $16.65 97035 Ultrasound therapy $12.70 97036 Hydrotherapy $28.84 97110 Therapeutic exercises $31.31 97112 Neuromuscular reeducation $32.26 97113 Aquatic therapy/exercises $38.93 97116 Gait training therapy $27.38 97124 Massage therapy $25.14 97140 Manual therapy $28.90 97150 Group therapeutic procedures $19.70$ 97530 Therapeutic activities $33.22 97532 Cognitive skills development $26.63 97533 Sensory integration $28.82 97535 Self care mngment training $33.14 97537 Community/work reintegration $29.62 97542 Wheelchair mngment training $30.06 97597 Active wound care/20 cm or < $67.35 97598 Active wound care > 20 cm $82.68 97605 Neg press wound tx, < 50 cm $38.80 97606 Neg press wound tx, > 50 cm $41.41 97750 Physical performance test $32.19 97755 Assistive technology assess $36.49 97760 Orthotic mgmt and training $36.08 97761 Prosthetic training $31.75 97762 C/o for orthotic/prosth use $38.68 97802 Medical nutrition, indiv, in $32.07 97803 Med nutrition, indiv, subseq $28.31 97804 Medical nutrition, group $14.14 97810 Acupunct w/o stimul 15 min $38.77 97811 Acupunct w/o stimul addl 15m $29.54 97813 Acupunct w/stimul 15 min $41.46 97814 Acupunct w/stimul addl 15m $33.46 98925 Osteopathic manipulation $30.87 98926 Osteopathic manipulation $42.33 98927 Osteopathic manipulation $54.58 98928 Osteopathic manipulation $64.16 98929 Osteopathic manipulation $73.74

Page 147Page 147 Updated Fee Schedule - April 1

98940 Chiropractic manipulation $26.99 98941 Chiropractic manipulation $37.20 98942 Chiropractic manipulation $48.50 98943 Chiropractic manipulation $25.62 98960 Self-mgmt educ & train, 1 pt $28.93 98961 Self-mgmt educ/train, 2-4 pt $13.99 98962 Self-mgmt educ/train, 5-8 pt $10.48 98966 Hc pro phone call 5-10 min $15.02 98967 Hc pro phone call 11-20 min $28.28 98968 Hc pro phone call 21-30 min $41.91 99091 Collect/review data from pt $59.22 99170 Anogenital exam, child $161.67 99173 Visual acuity screen $3.01 99174 Ocular photoscreening $30.68 99175 Induction of vomiting $30.96 99183 Hyperbaric oxygen therapy $215.12 99185 Regional hypothermia $68.26 99186 Total body hypothermia $90.11 99195 Phlebotomy $85.53 99201 Office/outpatient visit, new $41.79 99202 Office/outpatient visit, new $71.50 99203 Office/outpatient visit, new $103.04 99204 Office/outpatient visit, new $157.72 99205 Office/outpatient visit, new $198.34 99211 Office/outpatient visit, est $21.80$ 99212 Office/outpatient visit, est $42.23 99213 Office/outpatient visit, est $68.69 99214 Office/outpatient visit, est $103.48 99215 Office/outpatient visit, est $138.98 99217 Observation care discharge $72.97 99218 Observation care $68.13 99219 Observation care $112.63 99220 Observation care $158.07 99221 Initial hospital care $97.38 99222 Initial hospital care $132.89 99223 Initial hospital care $195.55 99231 Subsequent hospital care $40.51 99232 Subsequent hospital care $72.60 99233 Subsequent hospital care $103.53 99234 Observ/hosp same date $138.40 99235 Observ/hosp same date $181.28 99236 Observ/hosp same date $225.04 99238 Hospital discharge day $72.59 99239 Hospital discharge day $105.13 99241 Office consultation $55.02 99242 Office consultation $101.66 99243 Office consultation $139.59 99244 Office consultation $204.71 99245 Office consultation $251.32 99251 Inpatient consultation $52.91 99252 Inpatient consultation $82.38 99253 Inpatient consultation $125.08

Page 148Page 148 Updated Fee Schedule - April 1

99254 Inpatient consultation $180.30 99255 Inpatient consultation $220.20 99281 Emergency dept visit $21.65 99282 Emergency dept visit $42.14 99283 Emergency dept visit $65.70 99284 Emergency dept visit $122.52 99285 Emergency dept visit $182.42 99291 Critical care, first hour $280.04 99292 Critical care, addÆl 30 min $125.23 99304 Nursing facility care, init $87.41 99305 Nursing facility care, init $121.59 99306 Nursing facility care, init $155.70 99307 Nursing fac care, subseq $43.59 99308 Nursing fac care, subseq $66.22 99309 Nursing fac care, subseq $87.90 99310 Nursing fac care, subseq $129.48 99315 Nursing fac discharge day $63.31 99316 Nursing fac discharge day $82.58 99318 Annual nursing fac assessmnt $91.02 99324 Domicil/r-home visit new pat $59.42 99325 Domicil/r-home visit new pat $85.87 99326 Domicil/r-home visit new pat $140.68 99327 Domicil/r-home visit new pat $183.28 99328 Domicil/r-home visit new pat $215.67 99334 Domicil/r-home visit est pat $60.77$ 99335 Domicil/r-home visit est pat $93.51 99336 Domicil/r-home visit est pat $131.54 99337 Domicil/r-home visit est pat $188.41 99339 Domicil/r-home care supervis $81.99 99340 Domicil/r-home care supervis $113.90 99341 Home visit, new patient $59.42 99342 Home visit, new patient $85.87 99343 Home visit, new patient $137.52 99344 Home visit, new patient $179.96 99345 Home visit, new patient $216.11 99347 Home visit, est patient $57.81 99348 Home visit, est patient $86.50 99349 Home visit, est patient $125.62 99350 Home visit, est patient $174.67 99354 Prolonged service, office $100.45 99355 Prolonged service, office $99.20 99356 Prolonged service, inpatient $90.89 99357 Prolonged service, inpatient $91.70 99358 Prolonged serv, w/o contact $115.20 99359 Prolonged serv, w/o contact $55.61 99360 Physician standby services $64.88 99363 Anticoag mgmt, init $133.53 99364 Anticoag mgmt, subseq $45.94 99366 Team conf w/pat by hc pro $45.99 99367 Team conf w/o pat by phys $59.59 99368 Team conf w/o pat by hc pro $38.71 99374 Home health care supervision $73.65

Page 149Page 149 Updated Fee Schedule - April 1

99375 Home health care supervision $116.65 99377 Hospice care supervision $73.65 99378 Hospice care supervision $121.04 99379 Nursing fac care supervision $73.28 99380 Nursing fac care supervision $110.13 99381 Init pm e/m, new pat, inf $102.73 99382 Init pm e/m, new pat 1-4 yrs $111.06 99383 Prev visit, new, age 5-11 $110.18 99384 Prev visit, new, age 12-17 $119.68 99385 Prev visit, new, age 18-39 $119.68 99386 Prev visit, new, age 40-64 $139.55 99387 Init pm e/m, new pat 65+ yrs $152.99 99391 Per pm reeval, est pat, inf $85.33 99392 Prev visit, est, age 1-4 $94.83 99393 Prev visit, est, age 5-11 $94.39 99394 Prev visit, est, age 12-17 $103.15 99395 Prev visit, est, age 18-39 $103.59 99396 Prev visit, est, age 40-64 $113.09 99397 Per pm reeval est pat 65+ yr $126.98 99401 Preventive counseling, indiv $39.49 99402 Preventive counseling, indiv $67.33 99403 Preventive counseling, indiv $94.01 99404 Preventive counseling, indiv $120.68 99406 Behav chng smoking 3-10 min $14.22 99407 Behav chng smoking > 10 min $27.03$ 99408 Audit/dast, 15-30 min $36.32 99409 Audit/dast, over 30 min $71.25 99411 Preventive counseling, group $16.69 99412 Preventive counseling, group $22.05 99420 Health risk assessment test $11.35 99441 Phone e/m by phys 5-10 min $15.39 99442 Phone e/m by phys 11-20 min $28.28 99443 Phone e/m by phys 21-30 min $41.91 99460 Init nb em per day, hosp $60.80 99461 Init nb em per day, non-fac $94.58 99462 Sbsq nb em per day, hosp $32.53 99463 Same day nb discharge $82.14 99464 Attendance at delivery $76.43 99465 Nb resuscitation $157.80 99466 Ped crit care transport $251.49 99467 Ped crit care transport addl $125.30 99468 Neonate crit care, initial $938.90 99469 Neonate crit care, subsq $410.87 99471 Ped critical care, initial $841.44 99472 Ped critical care, subsq $415.71 99475 Ped crit care age 2-5, init $578.59 99476 Ped crit care age 2-5, subsq $343.81 99477 Init day hosp neonate care $366.33 99478 Ic, lbw inf < 1500 gm subsq $150.17 99479 Ic lbw inf 1500-2500 g subsq $131.64 99480 Ic inf pbw 2501-5000 g subsq $126.42 G0117 GLAUCOMA SCRN HGH RISK DI $23.26

Page 150Page 150 Updated Fee Schedule - April 1

G0204 DIAGNOSTICMAMMOGRAPHYDIGI $42.96 G0392 AV FISTULA OR GRAFT ARTER $1,046.38 G0393 AV FISTULA OR GRAFT VENOU $778.09

Page 151Page 151