Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule Revised: 04/06/2016 January - 2016 Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 0054T Bone Srgry Cmptr Fluor Image NA $84.39 0055T Bone Srgry Cmptr Ct/Mri Imag NA $84.39 0178T 64 Lead Ecg W/I&R M M 0179T 64 Lead Ecg W/Tracing M M 0180T 64 Lead Ecg W/I&R Only M M 0190T Place Intraoc Radiation Src M M 0191T Insert Ant Segment Drain Int $379.27 $379.27 0195T Prescrl Fuse W/O Instr L5/S1 NA M 0196T Prescrl Fuse W/O Instr L4/L5 NA M 0198T Ocular Blood Flow Measure M M 0200T Perq Sacral Augmt Unilat Inj $987.92 $243.46 0201T Perq Sacral Augmt Bilat Inj $553.69 $120.64 0202T Post Vert Arthrplst 1 Lumbar $4,128.40 $288.24 0205T Inirs Each Vessel Add-On NA $63.19 0206T Cptr Dbs Alys Car Elec Dta $14.66 $14.66 0207T Clear Eyelid Gland W/Heat $136.47 $68.53 0208T Audiometry Air Only $17.43 NA 0209T Audiometry Air & Bone $20.80 NA 0210T Speech Audiometry Threshold $13.07 NA 0211T Speech Audiom Thresh & Recog $20.80 NA 0212T Compre Audiometry Evaluation $21.00 $18.42 0213T Njx Paravert W/Us Cer/Thor $107.57 $60.82 0214T Njx Paravert W/Us Cer/Thor $53.09 $34.47 0215T Njx Paravert W/Us Cer/Thor $53.29 $34.87 0216T Njx Paravert W/Us Lumb/Sac $97.66 $52.10 0217T Njx Paravert W/Us Lumb/Sac $48.93 $29.72 0218T Njx Paravert W/Us Lumb/Sac $49.13 $30.11 0219T Plmt Post Facet Implt Cerv $238.91 $129.56 0220T Plmt Post Facet Implt Thor $238.91 $129.56 0221T Plmt Post Facet Implt Lumb $236.14 $127.77 0222T Plmt Post Facet Implt Addl $97.66 $34.27 0228T Us Tfrml Edrl Inj Crv/T 1lvl M M 0229T Njx Tfrml Eprl W/Us Cer/Thor M M 0230T Us Tfrml Edrl Inj L/S 1 Lvl M M 0231T Njx Tfrml Eprl W/Us Lumb/Sac M M 0232T Njx Platelet Plasma M M 0234T Trluml Perip Athrc Renal Art M M 0235T Trluml Perip Athrc Visceral NA M 0236T Trluml Perip Athrc Abd Aorta M M 0237T Trluml Perip Athrc Brchiocph M M 0238T Trluml Perip Athrc Iliac Art M M 0249T Ligation Hemorrhoid W/Us M M 0253T Insert Aqueous Drain Device M M 0254T Evasc Rpr Iliac Art Bifur NA M **Effective Date will only be populated when the rate begins after the published fee schedule date Page 1 of 243 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule Revised: 04/06/2016 January - 2016 Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 0255T Evasc Rpr Iliac Art Bifr S&I 26 M M 10021 Fna W/O Image $69.14 $39.62 10022 Fna W/Image $79.24 $37.24 10030 Guide Cathet Fluid Drainage $438.59 $96.47 10035 Perq Dev Soft Tiss 1st Imag $300.72 $49.53 10036 Perq Dev Soft Tiss Add Imag $261.49 $24.96 10040 Acne Surgery $57.05 $49.72 10060 Drainage Of Skin Abscess $65.77 $54.68 10061 Drainage Of Skin Abscess $115.89 $101.43 10080 Drainage Of Pilonidal Cyst $100.63 $58.04 10081 Drainage Of Pilonidal Cyst $150.75 $96.08 10120 Remove Foreign Body $85.18 $58.44 10121 Remove Foreign Body $153.92 $105.19 10140 Drainage Of Hematoma/Fluid $91.52 $66.96 10160 Puncture Drainage Of Lesion $73.10 $54.28 10180 Complex Drainage Wound $138.87 $101.63 11000 Debride Infected Skin $30.51 $16.24 11001 Debride Infected Skin Add-On $12.08 $8.12 11004 Debride Genitalia & Perineum NA $332.02 11005 Debride Abdom Wall NA $449.49 11006 Debride Genit/Per/Abdom Wall NA $402.94 11008 Remove Mesh From Abd Wall NA $158.08 11010 Debride Skin At Fx Site $277.14 $159.27 11011 Debride Skin Musc At Fx Site $301.31 $170.76 11012 Deb Skin Bone At Fx Site $402.54 $243.86 11042 Deb Subq Tissue 20 Sq Cm/< $65.37 $35.06 11043 Deb Musc/Fascia 20 Sq Cm/< $128.57 $88.55 11044 Deb Bone 20 Sq Cm/< $177.50 $131.93 11045 Deb Subq Tissue Add-On $22.98 $14.86 11046 Deb Musc/Fascia Add-On $41.40 $31.89 11047 Deb Bone Add-On $70.13 $56.85 11055 Trim Skin Lesion $26.55 $9.11 11056 Trim Skin Lesions 2 To 4 $32.49 $12.88 11057 Trim Skin Lesions Over 4 $36.65 $16.84 11100 Biopsy Skin Lesion $57.85 $27.73 11101 Biopsy Skin Add-On $18.42 $14.26 11200 Removal Of Skin Tags <W/15 $49.33 $41.40 11201 Remove Skin Tags Add-On $10.70 $9.51 11300 Shave Skin Lesion 0.5 Cm/< $54.28 $20.01 11301 Shave Skin Lesion 0.6-1.0 Cm $66.96 $30.51 11302 Shave Skin Lesion 1.1-2.0 Cm $78.84 $35.86 11303 Shave Skin Lesion >2.0 Cm $87.16 $42.39 11305 Shave Skin Lesion 0.5 Cm/< $55.47 $22.39 11306 Shave Skin Lesion 0.6-1.0 Cm $68.15 $29.52 **Effective Date will only be populated when the rate begins after the published fee schedule date Page 2 of 243 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule Revised: 04/06/2016 January - 2016 Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 11307 Shave Skin Lesion 1.1-2.0 Cm $80.43 $38.04 11308 Shave Skin Lesion >2.0 Cm $84.39 $42.00 11310 Shave Skin Lesion 0.5 Cm/< $63.39 $26.94 11311 Shave Skin Lesion 0.6-1.0 Cm $62.40 $37.44 11312 Shave Skin Lesion 1.1-2.0 Cm $89.74 $44.57 11313 Shave Skin Lesion >2.0 Cm $104.00 $57.25 11400 Exc Tr-Ext B9+Marg 0.5 Cm< $69.34 $45.36 11401 Exc Tr-Ext B9+Marg 0.6-1 Cm $83.40 $58.64 11402 Exc Tr-Ext B9+Marg 1.1-2 Cm $92.71 $64.58 11403 Exc Tr-Ext B9+Marg 2.1-3cm/< $107.57 $83.60 11404 Exc Tr-Ext B9+Marg 3.1-4 Cm $122.23 $92.12 11406 Exc Tr-Ext B9+Marg >4.0 Cm $176.31 $140.25 11420 Exc H-F-Nk-Sp B9+Marg 0.5/< $68.54 $46.16 11421 Exc H-F-Nk-Sp B9+Marg 0.6-1 $87.76 $62.20 11422 Exc H-F-Nk-Sp B9+Marg 1.1-2 $98.26 $76.66 11423 Exc H-F-Nk-Sp B9+Marg 2.1-3 $113.31 $89.15 11424 Exc H-F-Nk-Sp B9+Marg 3.1-4 $131.14 $102.02 11426 Exc H-F-Nk-Sp B9+Marg >4 Cm $187.60 $156.30 11440 Exc Face-Mm B9+Marg 0.5 Cm/< $75.48 $58.24 11441 Exc Face-Mm B9+Marg 0.6-1 Cm $94.10 $74.49 11442 Exc Face-Mm B9+Marg 1.1-2 Cm $105.39 $82.41 11443 Exc Face-Mm B9+Marg 2.1-3 Cm $125.79 $101.23 11444 Exc Face-Mm B9+Marg 3.1-4 Cm $158.08 $128.96 11446 Exc Face-Mm B9+Marg >4 Cm $219.69 $185.03 11450 Removal Sweat Gland Lesion $214.15 $143.23 11451 Removal Sweat Gland Lesion $272.98 $184.63 11462 Removal Sweat Gland Lesion $209.00 $136.69 11463 Removal Sweat Gland Lesion $276.15 $185.22 11470 Removal Sweat Gland Lesion $232.37 $159.87 11471 Removal Sweat Gland Lesion $286.85 $198.50 11600 Exc Tr-Ext Mal+Marg 0.5 Cm/< $107.77 $67.55 11601 Exc Tr-Ext Mal+Marg 0.6-1 Cm $128.17 $84.59 11602 Exc Tr-Ext Mal+Marg 1.1-2 Cm $139.07 $92.91 11603 Exc Tr-Ext Mal+Marg 2.1-3 Cm $159.07 $111.33 11604 Exc Tr-Ext Mal+Marg 3.1-4 Cm $176.90 $122.62 11606 Exc Tr-Ext Mal+Marg >4 Cm $253.57 $182.65 11620 Exc H-F-Nk-Sp Mal+Marg 0.5/< $108.96 $68.54 11621 Exc S/N/H/F/G Mal+Mrg 0.6-1 $128.96 $85.38 11622 Exc S/N/H/F/G Mal+Mrg 1.1-2 $143.82 $97.66 11623 Exc S/N/H/F/G Mal+Mrg 2.1-3 $168.98 $121.04 11624 Exc S/N/H/F/G Mal+Mrg 3.1-4 $190.57 $137.09 11626 Exc S/N/H/F/G Mal+Mrg >4 Cm $229.80 $168.19 11640 Exc F/E/E/N/L Mal+Mrg 0.5cm< $112.32 $70.92 11641 Exc F/E/E/N/L Mal+Mrg 0.6-1 $133.52 $88.95 **Effective Date will only be populated when the rate begins after the published fee schedule date Page 3 of 243 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule Revised: 04/06/2016 January - 2016 Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 11642 Exc F/E/E/N/L Mal+Mrg 1.1-2 $152.54 $104.99 11643 Exc F/E/E/N/L Mal+Mrg 2.1-3 $179.87 $131.34 11644 Exc F/E/E/N/L Mal+Mrg 3.1-4 $221.87 $162.64 11646 Exc F/E/E/N/L Mal+Mrg >4 Cm $290.22 $226.03 11720 Debride Nail 1-5 $18.03 $8.32 11721 Debride Nail 6 Or More $25.16 $14.07 11730 Removal Of Nail Plate $55.47 $28.92 11732 Remove Nail Plate Add-On $20.01 $11.49 11740 Drain Blood From Under Nail $27.73 $18.42 11750 Removal Of Nail Bed $101.23 $79.44 11752 Remove Nail Bed/Tip $182.25 $148.77 11755 Biopsy Nail Unit $74.88 $44.18 11760 Repair Of Nail Bed $108.96 $66.17 11762 Reconstruction Of Nail Bed $157.29 $104.20 11765 Excision Of Nail Fold Toe $93.70 $53.09 11770 Remove Pilonidal Cyst Simple $156.30 $105.39 11771 Remove Pilonidal Cyst Exten $323.10 $247.03 11772 Remove Pilonidal Cyst Compl $391.84 $327.66 11900 Inject Skin Lesions </W 7 $31.10 $17.83 11901 Inject Skin Lesions >7 $39.22 $27.54 11920 Correct Skin Color 6.0 Cm/< $95.29 $64.58 11921 Correct Skn Color 6.1-20.0cm $111.13 $76.47 11922 Correct Skin Color Ea 20.0cm $34.47 $16.84 11950 Tx Contour Defects 1 Cc/< $41.20 $28.92 11951 Tx Contour Defects 1.1-5.0cc $54.68 $40.81 11952 Tx Contour Defects 5.1-10cc $73.50 $55.07 11954 Tx Contour Defects >10.0 Cc $88.55 $65.17 11960 Insert Tissue Expander(S) NA $535.86 11970 Replace Tissue Expander NA $345.49 11971 Remove Tissue Expander(S) $263.47 $180.47 11976 Remove Contraceptive Capsule $80.03 $53.29 11980 Implant Hormone Pellet(S) $52.69 $31.89 11981 Insert Drug Implant Device $78.84 $46.95 11982 Remove Drug Implant Device $89.54 $57.05 11983 Remove/Insert Drug Implant $125.00 $98.85 12001 Rpr S/N/Ax/Gen/Trnk 2.5cm/< $49.92 $25.16 12002 Rpr S/N/Ax/Gen/Trnk2.6-7.5cm $60.82 $33.08 12004 Rpr S/N/Ax/Gen/Trk7.6-12.5cm $71.71 $41.40 12005 Rpr S/N/A/Gen/Trk12.6-20.0cm $90.53 $53.88 12006 Rpr S/N/A/Gen/Trk20.1-30.0cm $107.37 $66.17 12007 Rpr S/N/Ax/Gen/Trnk >30.0 Cm $125.40 $83.60 12011 Rpr F/E/E/N/L/M 2.5 Cm/< $61.21 $31.30 12013 Rpr F/E/E/N/L/M 2.6-5.0 Cm $63.99 $32.88 12014 Rpr F/E/E/N/L/M 5.1-7.5 Cm $74.88 $42.39 **Effective Date will only be populated when the rate begins after the published fee schedule date Page 4 of 243 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule Revised: 04/06/2016 January - 2016 Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 12015 Rpr F/E/E/N/L/M 7.6-12.5 Cm $90.73 $53.29 12016 Rpr Fe/E/En/L/M 12.6-20.0 Cm $115.29 $72.90 12017