Surgery Center of Oklahoma QUALIFIED PROCEDURES Reimbursement Schedule - updated 4-21-2021 Services include: pre-op, post-op, surgeon(s), anesthesia, pathology, implants (unless specified otherwise) & facility fees. Total joint replacement includes physical therapy and home health. CPT Procedure Fee 11401 Excision masses, shoulder, palm, breast x2 $2,365.00 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11402 $2,365.00 or legs; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11403 $2,365.00 or legs; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11404 $2,365.00 or legs; excised diameter 3.1 to 4.0 cm. Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11406 $2,365.00 or legs; excised diameter over 4.0 cm 11420 Excision masses, shoulder, palm, breast x2 $2,365.00 Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm benign lesion 11421 $2,365.00 including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 11426 Excision Benign Lesion $1,900.00 11440 Excision Preauricular Pits $2,800.00 11441 Excision Preauricular Pits $2,800.00 11442 Excision Preauricular Pits $2,800.00 11443 Excision Preauricular Pits $2,800.00 11444 Excision Preauricular Pits $2,800.00 11446 Excision Preauricular Pits $2,800.00 11451 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair. $2,365.00 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 11602 $1,900.00 cm 11620 Excision squamous cell carcinoma $4,000.00 11626 SKIN LESION $4,125.00 11642 Excision Malignant Lesion Lateral Nasal $4,300.00 11711 Excision of pilonidal cyst, extensive $3,400.00 11730 Avulsion of Digital Nail $2,350.00 11750 Removal of Toenail y; g $1,700.00 11750 x 4 hallux $2,365.00 11760 Repair of nail bed $2,805.00 11770 Pilonidal cyst $3,400.00 11771 Removal of Cyst Tailbone $3,400.00 13101 Scar Revision $1,900.00 13102 Scar Revision $1,900.00 14040 Small defect repair cheek or forehead $3,900.00 14041 Large defect repair check or forehead $5,250.00 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less $4,000.00 15260 Full thickness skin graft to nose $3,000.00 15630 Forehead flap takedown $3,300.00 15732 Graft $5,060.00 15822 Blepharoplasty (bilateral, upper eyelid) $4,150.00 15823 Blepharoplasty (bilateral) $4,150.00 19112 Excision of lactiferous duct fistula $2,365.00 19120 Mass - Excision / Biospy $3,365.00 19120-50 Bilateral Mass- Excision/ Biospy $5,315.00 19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single $2,365.00 19300 Mastectomy for gynecomastia $3,600.00 19301 Mascetomy $6,505.00 19302 Mastectomy with or without Node Dissection $7,505.00 19302-50 Bilateral Masctectomy with Node Dissection $11,200.00 19303 Mastectomy with sentinel lymph node biopsy $6,505.00 19303-50 Bilateral Mastectomy with nipple-sparing $16,400.00 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor 19307 $7,505.00 muscle, but excluding pectoralis major muscle 19316 Mastopexy (Single) $5,000.00 19318 Breast Reduction (one side) $5,900.00 19318-50 Bilateral Breast Reduction $9,500.00 19330 Removal Breast Implant Material $3,450.00 19340 Under Repair and/or Reconstruction Procedures on the Breast $5,555.00 19342 2nd stage; w/implant placement, single $4,235.00 19342-50 2nd stage: w/implant placement, bilateral $5,555.00 19350 Bilateral nipple reconstruction $3,000.00 19357 1st stage; reconstruction w/expanders $5,280.00 19357-50 1st stage; reconstruction w/expanders, bilateral $7,480.00 19361 Breast Recon w/ Latissuims Flap, single $11,400.00 20205 Tricep Muscle Biopsy $2,365.00 20605-50 TMJ Arthrocentesis Bilateral $3,200.00 20680 Hardware removal, Simple $2,530.00 20680 Hardware Removal, Complex $4,510.00 21014 Excision, tumor, soft tissue of face and scalp, subfacial, 2cm or greater $2,365.00 21029 Excision of frontal bone benign neoplasm $5,060.00 21121 Genioplsty (includes overnight; hardware is NOT included) $6,350.00 21141 Lefort 1, Simple (includes overnight; hardware is NOT included) $15,250.00 21196 Osteotomy Simple (includes overnight; hardware is NOT included) $14,600.00 21198 Osteotomy Complex (includes overnight; hardware is NOT included) $16,950.00 21240 TMJ Arthroplasty Unilateral $14,311.00 21240-50 TMJ Arthroplasty Bilateral $24,222.00 21242 TMJ Arthroplasty Unilateral $14,311.00 21242-50 TMJ Arthroplasty Bilateral $24,222.00 21310 Nasal Fracture Simple Closed $1,900.00 21320 Nasal Fracture w/Stabilization $1,900.00 21325 Nasal Fracture Complex Open $4,015.00 21330 Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation $4,015.00 21451 Fracture Simple, Closed (includes overnight; hardware is NOT included) $5,300.00 21461 Fracture Simple, Open (includes overnight; hardware is NOT included) $7,750.00 21462 Fracture Intermediate (includes overnight; hardware is NOT included) $12,200.00 21470 Fracture Complex (mandibular) (includes overnight; hardware is NOT included) $19,050.00 21552 Excision, tumor, soft tissue of neck or anterior thorax, subfascial, less than 3 cm or greater $2,365.00 21555 Excision, cyst, neck $2,365.00 21556 Excision, tumor, soft tissue of neck or anterior thorax, subfascial, less than 5 cm $2,700.00 21930 Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm $2,365.00 21931 Excision, tumor 3cm or larger (back) $2,365.00 21932 Excision Right Upper Back Mass $2,365.00 21933 Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater $3,740.00 22551 Anterior Cervical Discectomy with fusion 1 level $18,960.00 22552 Anterior Cervical Discetomy with fusion 2 level $25,360.00 22900 Excision mass abdomen $3,575.00 22902 Excision, tumor, soft tissue of abdominal wall, subcutaneous, less than 3 cm $2,365.00 22903 Excision mass lower abdomen $2,365.00 23071 Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greaterÿ $2,255.00 23120 Distal Clavicle Excision (Shoulder) $4,730.00 23170 Distal Clavicle Excision (Shoulder) $4,730.00 23410 Open Rotator Cuff Repair (Shoulder) $6,260.00 23430 Tenodesis of long tendon of biceps $4,950.00 23455 Bankhart Stabilization (Shoulder) $6,160.00 23466 Bankhart Stabilization (Shoulder) $6,160.00 23472 Total Shoulder Arthroplasty $15,499.00 23500 Closed treatment of clavicular fracture; without manipulation $400.00 23515 Open treatment of clavicular fracture, includes internal fixation, when performed. $6,375.00 23535 Open treatment of clavicular fracture, includes internal fixation, when performed. $ 6375 + implant fees 23552 Open AC Joint Reconstruction $6,375.00 23600 Open Reduction Internal Fixation, Simple $4,455.00 23615 Open Reduction Internal Fixation, Complex $6,375.00 23700 Manipulation shoulder / anesthesia $1,400.00 24105 Bursectomy $2,700.00 Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary 24341 $4,950.00 (excludes rotator cuff) (Shoulder) 24342 Distal biceps reattachment (includes hardware) $6,200.00 24357 Tennis Elbow (lateral debridement) $3,200.00 24358 Ulnar Nerve Trasposition / Epicondylectomy $4,510.00 24359 Tennis Elbow (lateral debridement) $4,300.00 24650 Closed treatment of radial head or neck fracture; without manipulation $400.00 24670 Closed treatment of ulnar fracture, proximal end; without manipulation $400.00 25000 Dupuytrens Contracture $2,950.00 25111 Ganglion Excision $2,750.00 25215 Proximal Row Carpectomy $5,400.00 25447 Suspenionplasty, Arthroplasty, interposition, intercarpal or carpometacarpal joints $4,650.00 25500 Closed treatment of radial shaft fracture; without manipulation $400.00 25530 Closed treatment of ulnar shaft fracture; without manipulation $400.00 25545 ORIF Ulnar Fx $4,455.00 25560 Closed treatment of radial and ulnar shaft fractures; without manipulation $400.00 25600 Closed treatment of distal radial fracture; without manipulation $400.00 25605 Closed Reduction and Casting $1,925.00 25608 open tx of distal radial intra-articular fracture w internal fixation 2 fragments $4,455.00 25622 Closed treatment of carpal scaphoid (navicular) fracture; without manipulation $400.00 25810 Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft) $8,300.00 26045 Fasciotomy, palmar (eg. Dupuytren's contracture); open, partial $2,950.00 26055 Trigger Finger $2,600.00 26110 Joint Arthrotomy Debridement $3,740.00 26113 excision mass of hand or finger, subfascial $2,750.00 26115 Excision masses, shoulder, palm, breast x2 $2,365.00 26116 Excision of tumor finger $2,750.00 Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin 26121 $2,950.00 grafting (includes obtaining graft). Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, 26123 $2,950.00 with or without Z-plasty, other local tissue rearrangement, or skin grafting Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each 26145 $2,950.00 tendon 26160 Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or f $2,750.00 26340 Manipulation, finger joint, under anesthesia, each joint.