Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule July - 2015 Revised: 09/30/2015 9:58:24 AM Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 0054T Bone Srgry Cmptr Fluor Image NA $78.63 0055T Bone Srgry Cmptr Ct/Mri Imag NA $78.63 0099T Implant Corneal Ring M M 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 0182T Hdr Elect Brachytherapy M NA 0182T Hdr Elect Brachytherapy 26 M M 0182T Hdr Elect Brachytherapy TC M NA 0190T Place Intraoc Radiation Src M M 0191T Insert Ant Segment Drain Int M M 0195T Prescrl Fuse W/O Instr L5/S1 M M 0196T Prescrl Fuse W/O Instr L4/L5 M M 0198T Ocular Blood Flow Measure M M 0200T Perq Sacral Augmt Unilat Inj NA $322.66 0201T Perq Sacral Augmt Bilat Inj $484.00 $484.00 0202T Post Vert Arthrplst 1 Lumbar NA $854.70 0205T Inirs Each Vessel Add-On NA $63.19 0206T Cptr Dbs Alys Car Elec Dta $10.89 $10.89 0207T Clear Eyelid Gland W/Heat $136.47 $68.53 0208T Audiometry Air Only $17.23 NA 0209T Audiometry Air & Bone $20.60 NA 0210T Speech Audiometry Threshold $12.88 NA 0211T Speech Audiom Thresh & Recog $20.80 NA 0212T Compre Audiometry Evaluation $20.80 $18.03 0213T Njx Paravert W/Us Cer/Thor $107.17 $61.01 0214T Njx Paravert W/Us Cer/Thor $52.69 $34.27 0215T Njx Paravert W/Us Cer/Thor $53.09 $34.67 0216T Njx Paravert W/Us Lumb/Sac $96.67 $51.70 0217T Njx Paravert W/Us Lumb/Sac $48.73 $29.52 0218T Njx Paravert W/Us Lumb/Sac $48.93 $29.91 0219T Plmt Post Facet Implt Cerv NA $410.61 0220T Plmt Post Facet Implt Thor NA $410.61 0221T Plmt Post Facet Implt Lumb NA $410.61 0222T Plmt Post Facet Implt Addl NA $93.29 0223T Acoustic/Electr Cardgraphy M M 0224T Acstic/Elec Cardgrphy Av/Vv M M 0225T Acstic/Elec Cardgrphy Av + Vv M M 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 **Effective Date will only be populated when the rate begins after the published fee schedule date Page 1 of 248 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule July - 2015 Revised: 09/30/2015 9:58:24 AM Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 0233T Skn Age Meas Spctrscpy M M 0234T Trluml Perip Athrc Renal Art M M 0235T Trluml Perip Athrc Visceral M M 0236T Trluml Perip Athrc Abd Aorta M M 0237T Trluml Perip Athrc Brchiocph M M 0238T Trluml Perip Athrc Iliac Art M M 0240T Esoph Motility 3d Topography M NA 0240T Esoph Motility 3d Topography 26 M M 0240T Esoph Motility 3d Topography TC M NA 0241T Esoph Motility W/Stim/Perf M NA 0241T Esoph Motility W/Stim/Perf 26 M M 0241T Esoph Motility W/Stim/Perf TC M NA 0243T Intm Msr Bronchodil Wheeze M NA 0243T Intm Msr Bronchodil Wheeze 26 M M 0243T Intm Msr Bronchodil Wheeze TC M NA 0244T Cont Msr Bronchodil Wheeze M NA 0244T Cont Msr Bronchodil Wheeze 26 M M 0244T Cont Msr Bronchodil Wheeze TC M NA 0249T Ligation Hemorrhoid W/Us M M 0253T Insert Aqueous Drain Device M M 0254T Evasc Rpr Iliac Art Bifur M M 0255T Evasc Rpr Iliac Art Bifr S&I M NA 0255T Evasc Rpr Iliac Art Bifr S&I 26 M M 0255T Evasc Rpr Iliac Art Bifr S&I TC M NA 10021 Fna W/O Image $83.60 $39.62 10022 Fna W/Image $79.44 $37.64 10030 Guide Cathet Fluid Drainage $440.38 $91.32 10040 Acne Surgery $56.85 $49.72 10060 Drainage Of Skin Abscess $65.57 $54.48 10061 Drainage Of Skin Abscess $115.69 $101.23 10080 Drainage Of Pilonidal Cyst $100.83 $58.44 10081 Drainage Of Pilonidal Cyst $150.56 $95.68 10120 Remove Foreign Body $85.38 $58.44 10121 Remove Foreign Body $153.53 $104.60 10140 Drainage Of Hematoma/Fluid $91.52 $66.96 10160 Puncture Drainage Of Lesion $72.90 $54.28 10180 Complex Drainage Wound $138.47 $101.23 11000 Debride Infected Skin $30.51 $16.24 11001 Debride Infected Skin Add-On $11.69 $7.92 11004 Debride Genitalia & Perineum NA $330.43 11005 Debride Abdom Wall NA $446.12 11006 Debride Genit/Per/Abdom Wall NA $400.16 11008 Remove Mesh From Abd Wall NA $156.90 **Effective Date will only be populated when the rate begins after the published fee schedule date Page 2 of 248 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule July - 2015 Revised: 09/30/2015 9:58:24 AM Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 11010 Debride Skin At Fx Site $275.76 $158.68 11011 Debride Skin Musc At Fx Site $295.76 $168.58 11012 Deb Skin Bone At Fx Site $398.78 $241.68 11042 Deb Subq Tissue 20 Sq Cm/< $65.37 $34.87 11043 Deb Musc/Fascia 20 Sq Cm/< $127.77 $87.96 11044 Deb Bone 20 Sq Cm/< $177.10 $131.54 11045 Deb Subq Tissue Add-On $22.98 $14.86 11046 Deb Musc/Fascia Add-On $41.20 $31.89 11047 Deb Bone Add-On $69.53 $56.26 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 $57.45 $27.34 11101 Biopsy Skin Add-On $18.23 $14.07 11200 Removal Of Skin Tags <W/15 $49.13 $41.01 11201 Remove Skin Tags Add-On $10.50 $9.31 11300 Shave Skin Lesion 0.5 Cm/< $54.28 $19.81 11301 Shave Skin Lesion 0.6-1.0 Cm $66.56 $30.11 11302 Shave Skin Lesion 1.1-2.0 Cm $78.45 $35.26 11303 Shave Skin Lesion >2.0 Cm $87.16 $42.20 11305 Shave Skin Lesion 0.5 Cm/< $55.07 $21.99 11306 Shave Skin Lesion 0.6-1.0 Cm $67.75 $29.12 11307 Shave Skin Lesion 1.1-2.0 Cm $79.64 $37.24 11308 Shave Skin Lesion >2.0 Cm $83.80 $41.40 11310 Shave Skin Lesion 0.5 Cm/< $63.19 $26.55 11311 Shave Skin Lesion 0.6-1.0 Cm $62.40 $37.44 11312 Shave Skin Lesion 1.1-2.0 Cm $89.34 $44.18 11313 Shave Skin Lesion >2.0 Cm $103.41 $56.66 11400 Exc Tr-Ext B9+Marg 0.5 Cm< $69.14 $45.17 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 $64.38 11403 Exc Tr-Ext B9+Marg 2.1-3cm/< $107.17 $83.00 11404 Exc Tr-Ext B9+Marg 3.1-4 Cm $121.63 $91.32 11406 Exc Tr-Ext B9+Marg >4.0 Cm $175.71 $139.66 11420 Exc H-F-Nk-Sp B9+Marg 0.5/< $68.34 $45.76 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 $88.95 11424 Exc H-F-Nk-Sp B9+Marg 3.1-4 $131.34 $102.22 11426 Exc H-F-Nk-Sp B9+Marg >4 Cm $187.01 $155.71 11440 Exc Face-Mm B9+Marg 0.5 Cm/< $75.08 $57.85 11441 Exc Face-Mm B9+Marg 0.6-1 Cm $93.90 $74.09 11442 Exc Face-Mm B9+Marg 1.1-2 Cm $104.99 $82.01 **Effective Date will only be populated when the rate begins after the published fee schedule date Page 3 of 248 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule July - 2015 Revised: 09/30/2015 9:58:24 AM Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 11443 Exc Face-Mm B9+Marg 2.1-3 Cm $125.20 $100.44 11444 Exc Face-Mm B9+Marg 3.1-4 Cm $157.89 $128.77 11446 Exc Face-Mm B9+Marg >4 Cm $219.10 $184.23 11450 Removal Sweat Gland Lesion $214.94 $143.23 11451 Removal Sweat Gland Lesion $271.20 $183.24 11462 Removal Sweat Gland Lesion $207.81 $135.90 11463 Removal Sweat Gland Lesion $276.35 $184.63 11470 Removal Sweat Gland Lesion $230.39 $158.48 11471 Removal Sweat Gland Lesion $284.27 $195.92 11600 Exc Tr-Ext Mal+Marg 0.5 Cm/< $107.77 $67.55 11601 Exc Tr-Ext Mal+Marg 0.6-1 Cm $127.77 $84.19 11602 Exc Tr-Ext Mal+Marg 1.1-2 Cm $138.27 $92.31 11603 Exc Tr-Ext Mal+Marg 2.1-3 Cm $157.89 $110.34 11604 Exc Tr-Ext Mal+Marg 3.1-4 Cm $176.11 $121.83 11606 Exc Tr-Ext Mal+Marg >4 Cm $252.18 $181.26 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 $128.37 $84.59 11622 Exc S/N/H/F/G Mal+Mrg 1.1-2 $143.03 $96.87 11623 Exc S/N/H/F/G Mal+Mrg 2.1-3 $168.19 $120.25 11624 Exc S/N/H/F/G Mal+Mrg 3.1-4 $189.58 $136.09 11626 Exc S/N/H/F/G Mal+Mrg >4 Cm $228.81 $167.00 11640 Exc F/E/E/N/L Mal+Mrg 0.5cm< $111.93 $70.72 11641 Exc F/E/E/N/L Mal+Mrg 0.6-1 $132.93 $88.35 11642 Exc F/E/E/N/L Mal+Mrg 1.1-2 $151.55 $104.00 11643 Exc F/E/E/N/L Mal+Mrg 2.1-3 $179.28 $130.75 11644 Exc F/E/E/N/L Mal+Mrg 3.1-4 $220.68 $161.45 11646 Exc F/E/E/N/L Mal+Mrg >4 Cm $289.23 $224.84 11720 Debride Nail 1-5 $18.03 $8.32 11721 Debride Nail 6 Or More $25.16 $14.07 11730 Removal Of Nail Plate $55.27 $28.53 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 $125.40 $97.86 11752 Remove Nail Bed/Tip $182.25 $148.77 11755 Biopsy Nail Unit $74.49 $43.78 11760 Repair Of Nail Bed $128.17 $74.29 11762 Reconstruction Of Nail Bed $158.48 $104.99 11770 Remove Pilonidal Cyst Simple $155.11 $104.40 11771 Remove Pilonidal Cyst Exten $322.11 $246.04 11772 Remove Pilonidal Cyst Compl $391.45 $326.47 11900 Inject Skin Lesions </W 7 $30.90 $17.63 11901 Inject Skin Lesions >7 $38.83 $27.14 11920 Correct Skin Color 6.0 Cm/< $95.29 $64.38 **Effective Date will only be populated when the rate begins after the published fee schedule date Page 4 of 248 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule July - 2015 Revised: 09/30/2015 9:58:24 AM Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 11921 Corect Skin Color 6.1-20.0cm $110.94 $76.07 11922 Correct Skin Color Ea 20.0cm $34.27 $16.84 11950 Tx Contour Defects 1 Cc/< $43.78 $30.51 11951 Tx Contour Defects 1.1-5.0cc $59.23 $42.39 11952 Tx Contour Defects 5.1-10cc $71.91 $54.08 11954 Tx Contour Defects >10.0 Cc $88.75 $65.17 11960 Insert Tissue Expander(S) NA $533.29 11970 Replace Tissue Expander NA $344.30 11971 Remove Tissue Expander(S) $263.87 $180.27 11976 Remove Contraceptive Capsule $80.23 $53.49 11980 Implant Hormone