TABLE F. — OUTPATIENT FACILITY NATIONWIDE CHARGES BY CPT/HCPCS CODE PAGE 1 of 164 Multiple CPT/ Status/ Surgery Charge HCPCS Description Usage Charge Reduction Methodology 2 Code Indicator 1 Applies 10021 FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE $534.52 APC 10022 FINE NEEDLE ASPIRATION WITH IMAGING GUIDANCE $2,339.13 APC 10030 IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE $874.39 APC 10040 ACNE SURGERY $514.85 APC 10060 INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE $880.36 APC 10061 INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE $880.36 APC 10080 INCISION & DRAINAGE PILONIDAL CYST SIMPLE $880.36 APC 10081 INCISION & DRAINAGE PILONIDAL CYST COMPLICATED $4,924.22 APC 10120 INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE $1,539.42 APC 10121 INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL $6,504.69 APC 10140 I&D HEMATOMA SEROMA/FLUID COLLECTION $4,924.22 APC 10160 PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST $880.36 APC 10180 INCISION & DRAINAGE COMPLEX PO WOUND INFECTION $8,819.75 APC 11000 DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF $1,539.42 APC 11001 DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF $350.70 FAIR Health 11010 DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS $3,670.92 APC 11011 DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC $1,776.44 APC 11012 DBRDMT FX&/DISLC SUBQ T/M/F BONE $3,670.92 APC 11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< $1,539.42 APC 11043 DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/< $1,539.42 APC 11044 DEBRIDEMENT BONE MUSCLE &/FASCIA 20 SQ CM/< $3,670.92 APC 11045 DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM $1,039.81 FAIR Health 11046 DEBRIDEMENT MUSCLE &/FASCIA EA ADDL 20 SQ CM $1,663.70 FAIR Health 11047 DEBRIDEMENT BONE EACH ADDITIONAL 20 SQ CM $2,495.54 FAIR Health 11055 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 $514.85 APC 11056 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4 $514.85 APC 11057 PARING/CUTTING BENIGN HYPERKERATOTIC LESION >4 $530.00 APC 11100 BX SKIN SUBCUTANEOUS&/MUCOUS MEMBRANE 1 LESION $530.00 APC 11101 BIOPSY SKIN SUBQ&/MUCOUS MEMBRANE EA ADDL LESN $291.15 FAIR Health 11200 REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 $514.85 APC 11201 REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA EA 10 $350.70 MarketScan 11300 SHAVING SKIN LES 1 TRUNK/ARM/LEG DIAM 0.5CM/< $514.85 APC 11301 SHVG SKIN LES 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM $514.85 APC 11302 SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM 1.1-2.0 CM $514.85 APC 11303 SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2.0 CM $530.00 APC 11305 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/< $514.85 APC 11306 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6-1.0 CM $514.85 APC 11307 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 1.1-2.0 CM $514.85 APC 11308 SHAVING SKIN LESION 1 S/N/H/F/G DIAM >2.0 CM $530.00 APC 11310 SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0.5 CM/< $514.85 APC 11311 SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 0.6-1.0 CM $514.85 APC 11312 SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 1.1-2.0 CM $530.00 APC 11313 SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM >2.0 CM $530.00 APC 11400 EXC B9 LES MRGN XCP SK TG T/A/L 0.5 CM/< $1,776.44 APC 11401 EXC B9 LES MRGN XCP SK TG T/A/L 0.6-1.0 CM $1,776.44 APC 11402 EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2.0 CM $1,776.44 APC 11403 EXC B9 LES MRGN XCP SK TG T/A/L 2.1-3.0 CM/< $3,670.92 APC 11404 EXC B9 LES MRGN XCP SK TG T/A/L 3.1-4.0 CM $6,504.69 APC 11406 EXC B9 LES MRGN XCP SK TG T/A/L >4.0 CM $6,504.69 APC 11420 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.5 CM/< $3,670.92 APC NOTE: CPT Codes and descriptions only are copyright 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 1, 2 - See end of the table for notes regarding these fields. TABLE F. — OUTPATIENT FACILITY NATIONWIDE CHARGES BY CPT/HCPCS CODE PAGE 2 of 164 Multiple CPT/ Status/ Surgery Charge HCPCS Description Usage Charge Reduction Methodology 2 Code Indicator 1 Applies 11421 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM $3,670.92 APC 11422 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM $3,670.92 APC 11423 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM $6,504.69 APC 11424 EXC B9 LES MRGN XCP SK TG S/N/H/F/G 3.1-4.0CM $6,504.69 APC 11426 EXC B9 LES MRGN XCP SK TG S/N/H/F/G > 4.0CM $9,950.82 APC 11440 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< $1,776.44 APC 11441 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM $1,776.44 APC 11442 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM $3,670.92 APC 11443 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM $3,670.92 APC 11444 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 3.1-4.0CM $3,670.92 APC 11446 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M > 4.0CM $9,950.82 APC 11450 EXCISION HIDRADENITIS AXILLARY SMPL/INTRM RPR $9,950.82 APC 11451 EXCISION HIDRADENITIS AXILLARY COMPLEX REPAIR $9,950.82 APC 11462 EXCISION HIDRADENITIS INGUINAL SMPL/INTRM RPR $9,950.82 APC 11463 EXCISION HIDRADENITIS INGUINAL COMPLEX REPAIR $9,950.82 APC 11470 EXCISION H/P/P/U SIMPLE/INTERMEDIATE REPAIR $9,950.82 APC 11471 EXCISION H/P/P/U COMPLEX REPAIR $9,950.82 APC 11600 EXCISION MAL LESION TRUNK/ARM/LEG 0.5 CM/< $3,670.92 APC 11601 EXCISION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM $1,776.44 APC 11602 EXCISION MAL LESION TRUNK/ARM/LEG 1.1-2.0 CM $1,776.44 APC 11603 EXCISION MAL LESION TRUNK/ARM/LEG 2.1-3.0 CM/< $3,670.92 APC 11604 EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM $3,670.92 APC 11606 EXCISION MALIGNANT LESION TRUNK/ARM/LEG > 4.0 CM $6,504.69 APC 11620 EXCISION MALIGNANT LESION S/N/H/F/G 0.5 CM/< $3,670.92 APC 11621 EXCISION MALIGNANT LESION S/N/H/F/G 0.6-1.0 CM $3,670.92 APC 11622 EXCISION MALIGNANT LESION S/N/H/F/G 1.1-2.0 CM $3,670.92 APC 11623 EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM/< $3,670.92 APC 11624 EXCISION MALIGNANT LESION S/N/H/F/G 3.1-4.0 CM $6,504.69 APC 11626 EXCISION MALIGNANT LESION S/N/H/F/G >4.0 CM $9,950.82 APC 11640 EXCISION MALIGNANT LESION F/E/E/N/L 0.5 CM/< $3,670.92 APC 11641 EXCISION MALIGNANT LES F/E/E/N/L 0.6-1.0 CM $3,670.92 APC 11642 EXCISION MALIGNANT LES F/E/E/N/L 1.1-2.0 CM $3,670.92 APC 11643 EXCISION MALIGNANT LES F/E/E/N/L 2.1-3.0 CM/< $3,670.92 APC 11644 EXCISION MALIGNANT LES F/E/E/N/L 3.1-4.0 CM $6,504.69 APC 11646 EXCISION MALIGNANT LESION F/E/E/N/L >4.0 CM $9,950.82 APC 11719 TRIMMING NONDYSTROPHIC NAILS ANY NUMBER $175.13 APC 11720 DEBRIDEMENT NAIL ANY METHOD 1-5 $175.13 APC 11721 DEBRIDEMENT NAIL ANY METHOD 6/> $175.13 APC 11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 $530.00 APC 11732 AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL $350.70 MarketScan 11740 EVACUATION SUBUNGUAL HEMATOMA $175.13 APC 11750 EXCISION NAIL MATRIX PERMANENT REMOVAL $1,776.44 APC 11752 EXC NAIL MATRIX PRM RMVL W/AMP TUFT DSTL PHALANX $9,950.82 APC 11755 BIOPSY NAIL UNIT SEPARATE PROCEDURE $1,776.44 APC 11760 REPAIR NAIL BED $1,231.71 APC 11762 RECONSTRUCTION NAIL BED W/GRAFT $7,543.18 APC 11765 WEDGE EXCISION SKIN NAIL FOLD $514.85 APC 11770 EXCISION PILONIDAL CYST/SINUS SIMPLE $9,950.82 APC 11771 EXCISION PILONIDAL CYST/SINUS EXTENSIVE $9,950.82 APC 11772 EXCISION PILONIDAL CYST/SINUS COMPLICATED $9,950.82 APC NOTE: CPT Codes and descriptions only are copyright 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 1, 2 - See end of the table for notes regarding these fields. TABLE F. — OUTPATIENT FACILITY NATIONWIDE CHARGES BY CPT/HCPCS CODE PAGE 3 of 164 Multiple CPT/ Status/ Surgery Charge HCPCS Description Usage Charge Reduction Methodology 2 Code Indicator 1 Applies 11900 INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS $514.85 APC 11901 INJECTION INTRALESIONAL >7 LESIONS $514.85 APC 11920 TATTOOING INCL MICROPIGMENTATION 6.0 CM/< $2,366.57 APC 11921 TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM $2,366.57 APC 11922 TATTOOING INCL MICROPIGMENTATION EA 20.0 CM $1,798.29 MarketScan 11950 SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/< $2,366.57 APC 11951 SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC $2,366.57 APC 11952 SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC $2,366.57 APC 11954 SUBCUTANEOUS INJECTION FILLING MATRL >10.0 CC $1,231.71 APC 11960 INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ $12,413.37 APC 11970 REPLACEMENT TISS EXPANDER PERMANENT PROSTHESIS $18,179.63 APC 11971 REMOVAL TISS EXPANDER W/O INSERTION PROSTHESIS $9,950.82 APC 11976 REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES $1,776.44 APC 11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION $451.36 APC 11981 INSJ NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $451.36 APC 11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $451.36 APC 11983 RMVL W/RINSJ NON-BIODEGRADABLE DRUG DLVR IMPLT $451.36 APC 12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< $514.85 APC 12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM $514.85 APC 12004 SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM $514.85 APC 12005 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM $514.85 APC 12006 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM $1,231.71 APC 12007 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM $514.85 APC 12011 SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< $514.85 APC 12013 SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM $514.85 APC 12014 SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM $514.85 APC 12015 SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM $514.85 APC 12016 SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM $514.85 APC 12017 SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0 CM $514.85 APC 12018 SIMPLE REPAIR F/E/E/N/L/M >30.0 CM $514.85 APC 12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE $2,366.57 APC 12021 TX SUPERFICIAL WOUND DEHISCENCE W/PACKING $1,231.71 APC 12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< $1,231.71 APC 12032 REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM $1,231.71 APC 12034 REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM $1,231.71 APC 12035 REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM $2,366.57