NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021. Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price No Show/Cancellation 00000 $25 $25 $15 CPM-No Show/Cancellation $50 00002 $50 $50 $30 Injection(s), platelet rich plasma, any site, incl 0232T 0361 $954 $288 $1,242 $745 Fine Needle Aspiration without Imaging 10021 0361 $182 $111 $293 $176 ACNE SURGERY MILIA CYSTS (10040) 10040 0361 $338 $248 $586 $352 Incision and Drainage of Abscess, single or simple 10060 0361 $580 $380 $960 $576 Incision and Drainage of Abscess, complicated or m 10061 0361 $585 $680 $1,265 $759 I&D PILONID CYS; SMPL (10080) 10080 0361 $572 $291 $863 $518 I&D PILONID CYST; CPLX (10081) 10081 0361 $3,306 $493 $3,799 $2,279 FB removal in sub q-simple 10120 0361 $955 $376 $1,331 $799 FB removal in sub q-complex 10121 0361 $5,114 $780 $5,894 $3,536 Incision and Drainage of Hematoma, Seroma or Fluid 10140 0361 $4,755 $497 $5,252 $3,151 Incision and drainage complex, post-op infection 10180 0361 $6,011 $753 $6,764 $4,058 DEBR EXZ/INF SKIN; 10% BS (11000) 11000 0361 $992 $76 $1,068 $641 DEBRIDE INFECTED SKIN ADD-ON =<10% BS (11001) 11001 0361 $338 $38 $376 $226 DEBR NECROTIZ ST - GENITALS & PERINEUM (11004) 11004 $1,654 $1,654 $992 DEBR NECROTIZ STISS - ABD WALL (11005) 11005 $2,277 $2,277 $1,366 DEBR W OPEN FX; SKIN & SQ Charge (11010) 11010 0361 $1,812 $1,164 $2,976 $1,786 Debride Skin to Muscle, Open FX 11011 0361 $1,532 $1,318 $2,850 $1,710 Deb skin bone at FX site 11012 0360 $1,796 $1,794 $3,590 $2,154 Debridement-skin, 20 Sq cm/< (11042) 11042 0361 $1,109 $208 $1,317 $790 Debridement-skin , sub q, muscle/fascia 20 Sq cm/< 11043 0361 $1,184 $977 $2,161 $1,297 DEB BONE 20 SQ CM/< (11044) 11044 0361 $2,938 $1,344 $4,282 $2,569 Deb Subq Tissue ADD-on=<20 Sq cm 11045 0361 $963 $74 $1,037 $622 DEB MUSC/FASCIA ADD-ON =<20 SQ CM 11046 0361 $963 $161 $1,124 $674 Deb Bone ADD-on =<20 Sq cm 11047 0361 $3,000 $280 $3,280 $1,968 Paring or cutting of benign hyperkeratotic lesion 11055 0361 $99 $99 $59 Paring or cutting of benign hyperkeratotic lesion, 11056 0361 $140 $140 $84 Paring or cutting of benign hyperkeratotic lesion, 11057 0361 $184 $184 $110 Removal Skin Tags 11200 0361 $326 $282 $608 $365 Removal Skin Tags 11200 0361 $326 $282 $608 $365 REMOVE SKIN TAGS ADD-ON =<10 LESIONS (11201) 11201 0361 $338 $44 $382 $229 SHAVE LES S/N/H/F/G; 0.6-1.0CM (11306) 11306 0361 $382 $191 $573 $344 SHAVE LES S/N/H/F/G; 1.1-2.0CM (11307) 11307 0361 $382 $245 $627 $376 EXC TR-EXT B9+MARG 0.5CM/< (11400) 11400 0361 $296 $296 $178 EXC BEN LES T/A/L; 0.6-1.0CM (11401) 11401 0361 $393 $393 $236 Exc. Benign Les T/A/L; 1-1-2.0 CM 11402 0361 $1,796 $455 $2,251 $1,351 EXC BEN LES T/A/L; 2.1-3.0CM (11403) 11403 0361 $558 $558 $335 EXC BEN LES T/A/L; 3.1-4.0CM (11404) 11404 0361 $247 $247 $148 EXC BEN LES T/A/L; > 4.0CM (11406) 11406 0361 $953 $953 $572 EXC BLES S/N/EX G; 0.5CM/< (11420) 11420 0361 $2,660 $218 $2,878 $1,727 EXC BLES S/N/EX G; 0.6-1.0CM (11421) 11421 0361 $2,767 $312 $3,079 $1,847 EXC BLES S/N/EX G; 1.1-2.0CM (11422) 11422 0361 $2,767 $381 $3,148 $1,889 EXC BLES S/N/EX G; 2.1-3.0CM (11423) 11423 0361 $5,319 $445 $5,764 $3,458 EXC BLES S/N/EX G; 3.1-4.0CM (11424) 11424 0361 $5,018 $632 $5,650 $3,390 EXC FACE-MM B9+MARG 0.5CM/< (11440) 11440 $372 $372 $223 EXC FACE-MM B9+MARG 0.6-1 CM (11441) 11441 $476 $476 $286 EXC FACE-MM B9+MARG 1.1-2 CM (11442) 11442 $531 $531 $319 EXC FACE-MM B9+MARG 2.1-3 CM (11443) 11443 $652 $652 $391 EXC FACE-MM B9+MARG 3.1-4 CM (11444) 11444 0361 $2,922 $839 $3,761 $2,257 EXC FACE-MM B9+MARG > 4 CM (11446) 11446 $1,210 $1,210 $726 EXC HIDRAD AXIL; CPLX REP (11451) 11451 $1,209 $1,209 $725 EXC HIDRAD AXIL; CPLX REP; Bilateral (11451-50) 1145150 $1,814 $1,814 $1,088 EXC H-F-NK-SP MAL+MARG 0.5 < (11620) 11620 0361 $2,922 $446 $3,368 $2,021 EXC S/N/H/F/G MAL+MRG 1.1-2 (11622) 11622 0361 $2,922 $627 $3,549 $2,129 Debride Nail 1-5 (11720) 11720 0361 $267 $54 $321 $193 Avulsion of nail plate, partial or complete, simpl 11730 0361 $617 $168 $785 $471 Excision nail matrix-ingrown nail 11750 0361 $720 $720 $432 Repair Nail Bed (11760) 11760 0361 $872 $470 $1,342 $805 Wedge Exc Nail Fold 11765 0361 $321 $266 $587 $352 Injection intralesional; up to and incl. 7 lesions 11900 $115 $115 $69 Injection, intralesional; more than 7 lesions (119 11901 $180 $180 $108 Simple Repair S/N/A/G/TR/E; 2.5CM/< (12001) 12001 0361 $367 $164 $531 $319 Simple Repair PS/N/A/G/TR/E; 2.6-7.5 CM 12002 0361 $469 $293 $762 $457 Simple repair S/N/G/TR/E; 7.6-12.5 CM 12004 0361 $451 $233 $684 $410 Repair, Intermediate S/T/Ext/2.5 cm/< 12031 0361 $560 $653 $1,213 $728 INTMD WND REPAIR S/A/T/EXT, 2.6-7.5 cm (12032) 12032 $709 $709 $425 INTMD WND REPAIR S/TR/EXT 7.6-12.5 CM (12034) 12034 0361 $872 $734 $1,606 $964 INTMD WND REPAIR S/A/T/EXT (12035) 12035 0361 $1,192 $693 $1,885 $1,131 INTMD WND REPAIR S/A/T/EXT (12036) 12036 0361 $1,146 $776 $1,922 $1,153 INTMD WND REPAIR S/TR/EXT 30.0+ CM (12037) 12037 $1,239 $1,239 $743 Repair, intermediate, wounds of neck, hands, feet 12042 0361 $1,146 $541 $1,687 $1,012 Repair, Complex, Trunk; 2.6 cm to 7.5 cm 13101 0361 $555 $439 $994 $596 Repair, complex, scalp, arms, and/or legs; 2.6 cm 13121 0361 $1,866 $985 $2,851 $1,711 Secondary closure of surgical wound or dehiscence, 13160 0361 $7,674 $3,360 $11,034 $6,620 ATT TRUNK; D 10 SQ CM/< (14000) 14000 0361 $5,270 $1,435 $6,705 $4,023 ATT TRUNK; D 10.1-30 SQ (14001) 14001 0361 $5,270 $1,863 $7,133 $4,280 ATT S/A/L; D 10 SQ CM/< (14020) 14020 0361 $5,270 $1,618 $6,888 $4,133 ATT S/A/L; D 10.1-30 SQ CM (14021) 14021 0361 $5,270 $2,037 $7,307 $4,384 Page 1 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021. Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ATT F/C/M/N/A/G/H/F; 10 SQ CM (14040) 14040 0361 $5,270 $1,791 $7,061 $4,237 ATT F/C/M/N/A/G/H/F; 10.1-30SQCM (14041) 14041 0361 $5,270 $2,193 $7,463 $4,478 ATT E/N/E/L; D 10 SQ CM (14060) 14060 0361 $5,270 $1,906 $7,176 $4,306 ATT E/N/E/L; D 10.1-30 (14061) 14061 0361 $5,270 $2,342 $7,612 $4,567 SKIN TISSUE REARRANGEMENT 30.1-60.0 SQ CM (14301) 14301 0361 $7,158 $2,514 $9,672 $5,803 SKIN TISSUE REARRANGE ADDL 30.0 SQ CM (14302) 14302 0361 $7,158 $625 $7,783 $4,670 WOUND PREP TRK/ARM/LEG 100 SQ CM/1% BA (15002) 15002 $628 $628 $377 WOUND PREP ADDL 100 CM (15003) 15003 $133 $133 $80 WOUND PREP F/N/HF/G 100 SQ CM/1% BA (15004) 15004 $770 $770 $462 WND PREP F/N/HF/G ADDL 100 SQ CM/1% BA (15005) 15005 $263 $263 $158 SKIN SPLT GRFT TRNK/ARM/LEG 100 SQ CM/1% BA (15100 15100 $2,062 $2,062 $1,237 SKIN SPLT GRFT T/A/L ADDL 100 SQ CM/1% BA (15101) 15101 $319 $319 $191 SKN SPLT A-GRFT FAC/NCK/HF/G 100 SQ CM/1% BA (1512 15120 $1,988 $1,988 $1,193 SKN SPLT A-GRFT F/N/HF/G ADDL 100 SQ CM/1% BA (151 15121 $379 $379 $227 SKIN FULL GRAFT SCLP/ARM/LEG =< 20 SQ CM (15220) 15220 $1,754 $1,754 $1,052 SKIN FULL GRAFT S/A/L ADDL =<20 SQ CM (15221) 15221 $206 $206 $124 SKIN FULL GRFT FACE/GENIT/HF =< 20 SQ CM (15240) 15240 $2,275 $2,275 $1,365 SKIN FULL GRAFT F/C/C/M/N/AX/G/H/F ADDL =<20 SQ CM 15241 $319 $319 $191 SKIN SUB GRAFT TRNK/ARM/LEG (15271) 15271 0361 $5,747 $339 $6,086 $3,652 SKIN SUB GRAFT T/A/L ADD-ON (15272) 15272 0361 $398 $66 $464 $278 SKIN SUB GRAFT FACE/NK/HF/G (15275) 15275 0361 $1,080 $396 $1,476 $886 SKIN SUB GRAFT F/N/HF/G ADDL (15276) 15276 0361 $398 $95 $493 $296 MUSCLE FLAP; TRUNK (15734) 15734 $3,821 $3,821 $2,293 MUSCLE FLAP; UPPER EXTREMITY (15736) 15736 $3,315 $3,315 $1,989 MUSCLE FLAP; LOWER EXTREMITY (15738) 15738 0361 $7,158 $3,593 $10,751 $6,451 EXC C P ULCER; W 1' SUTURE (15920) 15920 $1,756 $1,756 $1,054 EXC C P ULCER; W FLAP (15922) 15922 $2,250 $2,250 $1,350 EXC S P ULCER W SKIN FLAP (15934) 15934 $2,667 $2,667 $1,600 EXC S P ULCER PREP FOR FLAP (15936) 15936 $2,582 $2,582 $1,549 ESC I P ULCER W OSTECT & FLAP (15946) 15946 0361 $7,158 $4,724 $11,882 $7,129 EXC T P ULCER; W FLAP (15956) 15956 $3,207 $3,207 $1,924 DESTRUCT B9 LESION 1-14 (17110) 17110 0361 $382 $245 $627 $376 Mammaplasty, augmentation; with prosthetic implant 19325 0361 $2,431 $2,431 $1,459 Removal of mammary implant material (19330) 19330 0361 $2,382 $2,382 $1,429 Open periprosthetic capsulotomy, breast (19370) 19370 0361 $2,582 $2,582 $1,549 EXPL P WND; EXTREM (20103) 20103 0361 $3,851 $1,313 $5,164 $3,098 Excision epiphyeal bar 20150 0361 $3,942 $3,942 $2,365 MUSCLE BX; SUPERF (20200) 20200 0361 $5,319 $276 $5,595 $3,357 Biopsy, muscle deep 20205 0361 $628 $628 $377 MUSCLE BX; PERC NDL (20206) 20206 $162 $162 $97 BONE BX TR/NDL; SUPERF (20220) 20220 0361 $2,767 $198 $2,965 $1,779 Aspiration (biopsy) deep (femur, vertebral body) 20225 0361 $518 $518 $311 OPEN SUPERF BONE BX (20240) 20240 0361 $7,874 $626 $8,500 $5,100 Exc Bone BX;DEEP 20245 0361 $2,675 $2,675 $1,605 Removal of foreign body in muscle or tendon sheath 20520 0361 $1,726 $416 $2,142 $1,285 Injection Therapeutic Carpal Tunnel Charge (20526) 20526 0361 $955 $251 $1,206 $724 Injection Therapeutic Carpal Tunnel-Bilateral Char 2052650 0361 $1,447 $378 $1,825 $1,095 Injection Tendon Sheath, Ligament Charge (20550) 20550 0361 $955 $182 $1,137 $682 Injection Tendon Origin/Insertion Charge (20551) 20551 0361 $955 $182 $1,137 $682 Injection Trigger Point(s): 1 or 2 Muscle(s) Charg 20552 0361 $955 $176 $1,131 $679 Injection Trigger Point(s): 3 or more Muscle(s) Ch 20553 0361 $955 $176 $1,131 $679 NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES (205 20560 0361 $47 $47 $28 NEEDLE INSERTION W/O INJECTION 3 OR MORE MUSCLES