Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule April - 2018 Revised: 08/16/2018 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 0190T Place Intraoc Radiation Src M M 0191T Insert Ant Segment Drain Int $383.08 $383.08 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 $938.60 $233.16 0201T Perq Sacral Augmt Bilat Inj $538.44 $119.26 0202T Post Vert Arthrplst 1 Lumbar $4,013.51 $277.34 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 $17.83 NA 0209T Audiometry Air & Bone $21.39 NA 0210T Speech Audiometry Threshold $13.47 NA 0211T Speech Audiom Thresh & Recog $21.39 NA 0212T Compre Audiometry Evaluation $21.20 $18.42 0213T Njx Paravert W/Us Cer/Thor $106.58 $60.22 0214T Njx Paravert W/Us Cer/Thor $52.50 $34.27 0215T Njx Paravert W/Us Cer/Thor $52.89 $34.67 0216T Njx Paravert W/Us Lumb/Sac $96.67 $51.51 0217T Njx Paravert W/Us Lumb/Sac $48.53 $29.52 0218T Njx Paravert W/Us Lumb/Sac $48.53 $29.91 0219T Plmt Post Facet Implt Cerv $236.14 $127.97 0220T Plmt Post Facet Implt Thor $236.14 $127.97 0221T Plmt Post Facet Implt Lumb $233.56 $126.19 0222T Plmt Post Facet Implt Addl $96.47 $33.88 0228T Njx Tfrml Eprl W/Us Cer/Thor $105.59 $45.96 0229T Njx Tfrml Eprl W/Us Cer/Thor $105.59 $45.96 0230T Njx Tfrml Eprl W/Us Lumb/Sac $104.00 $45.96 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 10021 Fna W/O Image $68.74 $39.42 10022 Fna W/Image $79.24 $37.24 10030 Guide Cathet Fluid Drainage $317.75 $78.84 10035 Perq Dev Soft Tiss 1st Imag $291.41 $49.33 **Effective date will only be populated when the rate begins after the published fee schedule date. Page 1 of 233 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule April - 2018 Revised: 08/16/2018 Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 10036 Perq Dev Soft Tiss Add Imag $255.55 $24.37 10040 Acne Surgery $62.01 $40.61 10060 Drainage Of Skin Abscess $66.96 $55.27 10061 Drainage Of Skin Abscess $116.28 $101.82 10080 Drainage Of Pilonidal Cyst $101.43 $58.24 10081 Drainage Of Pilonidal Cyst $152.14 $96.47 10120 Remove Foreign Body $86.77 $58.84 10121 Remove Foreign Body $155.11 $105.19 10140 Drainage Of Hematoma/Fluid $92.91 $67.35 10160 Puncture Drainage Of Lesion $73.50 $54.08 10180 Complex Drainage Wound $139.86 $101.63 11000 Debride Infected Skin $30.90 $16.24 11001 Debride Infected Skin Add-On $12.08 $8.12 11004 Debride Genitalia & Perineum NA $330.63 11005 Debride Abdom Wall NA $448.50 11006 Debride Genit/Per/Abdom Wall NA $404.92 11008 Remove Mesh From Abd Wall NA $157.69 11010 Debride Skin At Fx Site $285.86 $162.44 11011 Debride Skin Musc At Fx Site $306.66 $171.95 11012 Deb Skin Bone At Fx Site $401.15 $243.27 11042 Deb Subq Tissue 20 Sq Cm/< $66.36 $35.26 11043 Deb Musc/Fascia 20 Sq Cm/< $129.36 $88.55 11044 Deb Bone 20 Sq Cm/< $177.10 $131.34 11045 Deb Subq Tissue Add-On $23.38 $15.06 11046 Deb Musc/Fascia Add-On $41.40 $32.09 11047 Deb Bone Add-On $70.13 $56.66 11055 Trim Skin Lesion $27.14 $9.11 11056 Trim Skin Lesions 2 To 4 $33.08 $12.88 11057 Trim Skin Lesions Over 4 $37.44 $17.04 11100 Biopsy Skin Lesion $59.43 $27.93 11101 Biopsy Skin Add-On $18.42 $14.26 11200 Removal Of Skin Tags <W/15 $50.52 $41.80 11201 Remove Skin Tags Add-On $10.90 $9.71 11300 Shave Skin Lesion 0.5 Cm/< $55.27 $20.21 11301 Shave Skin Lesion 0.6-1.0 Cm $67.75 $30.51 11302 Shave Skin Lesion 1.1-2.0 Cm $79.83 $36.05 11303 Shave Skin Lesion >2.0 Cm $88.15 $42.39 11305 Shave Skin Lesion 0.5 Cm/< $55.86 $22.19 11306 Shave Skin Lesion 0.6-1.0 Cm $68.94 $29.72 11307 Shave Skin Lesion 1.1-2.0 Cm $81.82 $38.23 11308 Shave Skin Lesion >2.0 Cm $85.38 $42.20 11310 Shave Skin Lesion 0.5 Cm/< $64.38 $27.14 11311 Shave Skin Lesion 0.6-1.0 Cm $63.00 $37.44 11312 Shave Skin Lesion 1.1-2.0 Cm $90.73 $44.57 11313 Shave Skin Lesion >2.0 Cm $105.19 $57.45 **Effective date will only be populated when the rate begins after the published fee schedule date. Page 2 of 233 Michigan Department of Health and Human Services Practitioner and Medical Clinic Fee Schedule April - 2018 Revised: 08/16/2018 Code Short Description Modifier Age Range Non Fac Fee Fac Fee Effective Date** 11400 Exc Tr-Ext B9+Marg 0.5 Cm< $70.92 $45.96 11401 Exc Tr-Ext B9+Marg 0.6-1 Cm $84.59 $59.03 11402 Exc Tr-Ext B9+Marg 1.1-2 Cm $94.30 $65.17 11403 Exc Tr-Ext B9+Marg 2.1-3cm $108.96 $83.99 11404 Exc Tr-Ext B9+Marg 3.1-4 Cm $123.42 $92.31 11406 Exc Tr-Ext B9+Marg >4.0 Cm $178.09 $140.85 11420 Exc H-F-Nk-Sp B9+Marg 0.5/< $69.34 $46.16 11421 Exc H-F-Nk-Sp B9+Marg 0.6-1 $88.75 $62.40 11422 Exc H-F-Nk-Sp B9+Marg 1.1-2 $99.84 $77.66 11423 Exc H-F-Nk-Sp B9+Marg 2.1-3 $113.71 $88.95 11424 Exc H-F-Nk-Sp B9+Marg 3.1-4 $132.13 $102.22 11426 Exc H-F-Nk-Sp B9+Marg >4 Cm $189.38 $157.09 11440 Exc Face-Mm B9+Marg 0.5 Cm/< $76.66 $58.64 11441 Exc Face-Mm B9+Marg 0.6-1 Cm $95.09 $74.68 11442 Exc Face-Mm B9+Marg 1.1-2 Cm $106.38 $82.41 11443 Exc Face-Mm B9+Marg 2.1-3 Cm $126.39 $101.03 11444 Exc Face-Mm B9+Marg 3.1-4 Cm $158.88 $128.96 11446 Exc Face-Mm B9+Marg >4 Cm $220.68 $185.03 11450 Removal Sweat Gland Lesion $217.51 $144.61 11451 Removal Sweat Gland Lesion $275.36 $185.03 11462 Removal Sweat Gland Lesion $212.36 $138.08 11463 Removal Sweat Gland Lesion $278.33 $186.02 11470 Removal Sweat Gland Lesion $234.15 $160.26 11471 Removal Sweat Gland Lesion $289.62 $199.49 11600 Exc Tr-Ext Mal+Marg 0.5 Cm/< $109.35 $68.15 11601 Exc Tr-Ext Mal+Marg 0.6-1 Cm $129.36 $84.79 11602 Exc Tr-Ext Mal+Marg 1.1-2 Cm $140.25 $93.31 11603 Exc Tr-Ext Mal+Marg 2.1-3 Cm $160.66 $111.93 11604 Exc Tr-Ext Mal+Marg 3.1-4 Cm $178.09 $123.02 11606 Exc Tr-Ext Mal+Marg >4 Cm $254.76 $183.04 11620 Exc H-F-Nk-Sp Mal+Marg 0.5/< $110.14 $68.94 11621 Exc S/N/H/F/G Mal+Mrg 0.6-1 $129.95 $85.38 11622 Exc S/N/H/F/G Mal+Mrg 1.1-2 $145.01 $97.66 11623 Exc S/N/H/F/G Mal+Mrg 2.1-3 $170.17 $121.24 11624 Exc S/N/H/F/G Mal+Mrg 3.1-4 $191.76 $137.28 11626 Exc S/N/H/F/G Mal+Mrg >4 Cm $230.39 $167.79 11640 Exc F/E/E/N/L Mal+Mrg 0.5cm< $113.51 $71.32 11641 Exc F/E/E/N/L Mal+Mrg 0.6-1 $134.31 $88.95 11642 Exc F/E/E/N/L Mal+Mrg 1.1-2 $153.33 $104.79 11643 Exc F/E/E/N/L Mal+Mrg 2.1-3 $180.67 $131.34 11644 Exc F/E/E/N/L Mal+Mrg 3.1-4 $223.06 $162.84 11646 Exc F/E/E/N/L Mal+Mrg >4 Cm $290.41 $225.44 11720 Debride Nail 1-5 $18.62 $8.32 11721 Debride Nail 6 Or More $25.55 $14.07 11730 Removal Of Nail Plate $59.63 $31.50 **Effective date will only be populated when the rate begins after the published fee schedule date.