Professional Documents
Culture Documents
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FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
Integumentary System
Skin, Subcutaneous and Accessory Structures
Incision and Drainage
10060
10080
10120
10140
10160
10180
11000
11010
11011
11012
11040
11041
11042
11043
11044
11050
11051
11052
11100
11300
11301
11302
11303
11305
11306
11307
11308
11310
11311
11312
11313
11400
11401
Page 1 of 113
3,640
840
2,800
3,640
3,640
3,640
3,640
5,560
840
840
840
840
1,260
2,800
2,800
2,800
2,800
4,300
10,540
5,040
5,500
10,540
5,040
5,500
11,980
5,880
6,100
12,120
6,720
5,400
3,640
3,640
5,680
8,020
8,020
840
840
1,680
2,520
2,520
2,800
2,800
4,000
5,500
5,500
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
3,640
840
2,800
5,560
1,260
4,300
3,700
1,344
2,356
8,020
2,520
5,500
8,440
2,940
5,500
5,560
1,260
4,300
3,700
1,344
2,356
8,020
2,520
5,500
8,440
2,940
5,500
3,700
1,344
2,356
8,020
2,520
5,500
8,440
2,940
5,500
8,260
3,360
4,900
3,640
840
2,800
3,640
840
2,800
11600
DESCRIPTION
Case Rate
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter over 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter over 4.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 0.5 cm or less
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter over 4.0 cm
Excision of skin and subcutaneous tissue for hidradenitis, axillary
Excision of skin and subcutaneous tissue for hidradenitis, inguinal
Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal
or umbilical
Excision - Malignant Lesions
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or
less
Professional Fee
Health Care
Institution Fee
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
4,108
1,008
3,100
4,108
1,008
3,100
4,108
1,008
3,100
4,108
1,008
3,100
4,108
1,008
3,100
4,108
1,008
3,100
8,020
8,020
2,520
2,520
5,500
5,500
8,020
2,520
5,500
5,560
1,260
4,300
11601
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0 cm
5,560
1,260
4,300
11602
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm
5,560
1,260
4,300
11603
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0 cm
5,560
1,260
4,300
11604
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 3.1 to 4.0 cm
5,560
1,260
4,300
11606
Excision, malignant lesion, trunk, arms, or legs; lesion diameter over 4.0 cm
5,560
1,260
4,300
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
Page 2 of 113
DESCRIPTION
3,640
5,560
3,640
3,640
840
1,260
840
840
Health Care
Institution Fee
2,800
4,300
2,800
2,800
3,640
840
2,800
9,300
2,100
7,200
3,640
840
2,800
5,560
9,300
3,640
5,680
1,260
2,100
840
1,680
4,300
7,200
2,800
4,000
Case Rate
Professional Fee
12001
3,640
840
2,800
12002
5,560
1,260
4,300
12004
5,680
1,680
4,000
12005
5,680
1,680
4,000
12006
5,680
1,680
4,000
12007
5,680
1,680
4,000
5,680
1,680
4,000
9,300
2,100
7,200
9,552
2,352
7,200
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
3,640
840
2,800
5,560
1,260
4,300
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
9,300
2,100
7,200
8,020
2,520
5,500
8,440
2,940
5,500
8,260
3,360
4,900
10,880
3,780
7,100
5,680
1,680
4,000
12011
12013
12014
12015
12016
12017
12018
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or
mucous membranes; 2.5 cm or less
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or
mucous membranes; 2.6 cm to 5.0 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or
mucous membranes; 5.1 cm to 7.5 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or
mucous membranes; 7.6 cm to 12.5 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or
mucous membranes; 12.6 cm to 20.0 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or
mucous membranes; 20.1 cm to 30.0 cm
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or
mucous membranes; over 30.0 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 2.5 cm or less
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 2.6 cm to 7.5 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 7.6 cm to 12.5 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 12.6 cm to 20.0 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 20.1 cm to 30.0 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); over 30.0 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5
cm or less
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6
cm to 7.5 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6
cm to 12.5 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 12.6
cm to 20.0 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 20.1
cm to 30.0 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; over
30.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 2.5 cm or less
Page 3 of 113
14000
14001
14020
14021
DESCRIPTION
Case Rate
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 2.6 cm to 5.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 5.1 cm to 7.5 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 7.6 cm to 12.5 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 12.6 cm to 20.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 20.1 cm to 30.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; over 30.0 cm
Adjacent Tissue Transfer or Rearrangement
Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0
sq cm
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect
10 sq cm or less
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect
10.1 sq cm to 30.0 sq cm
Professional Fee
Health Care
Institution Fee
5,680
1,680
4,000
8,020
2,520
5,500
8,020
2,520
5,500
8,260
3,360
4,900
8,260
3,360
4,900
9,700
4,200
5,500
12,120
6,720
5,400
12,120
6,720
5,400
10,540
5,040
5,500
11,980
5,880
6,100
14040
12,120
6,720
5,400
14041
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
27,120
15,120
12,000
8,260
3,360
4,900
8,260
3,360
4,900
21,940
9,240
12,700
21,940
9,240
12,700
21,940
9,240
12,700
30,740
13,440
17,300
30,300
16,800
13,500
30,300
30,300
16,800
16,800
13,500
13,500
14060
14061
14300
14350
15050
15570
Split graft, trunk, scalp, arms, legs, hands, and/or feet (except multiple
digits); 100 sq cm or less, or each one percent of body area of infants and
children (except 15050)
Split graft, face, eyelids, mouth, neck, ears, orbits, genitalia, and/or multiple
digits; 100 sq cm or less, or each one percent of body area of infants and
children (except 15050)
Full thickness graft, free, including direct closure of donor site, trunk; 20 sq
cm or less
Full thickness graft, free, including direct closure of donor site, scalp, arms,
and/or legs; 20 sq cm or less
Full thickness graft, free, including direct closure of donor site, forehead,
cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or
less
Full thickness graft, free, including direct closure of donor site, nose, ears,
eyelids, and/or lips; 20 sq cm or less
Application of allograft, skin
Application of xenograft, skin
Flaps (Skin and/or Deep Tissues)
Formation of direct or tubed pedicle, w/ or w/o transfer; trunk
15572
15100
15120
15200
15220
15240
15260
15350
15400
15574
15576
15580
15650
15732
15734
15736
15738
15740
15750
Page 4 of 113
18,000
8,400
9,600
30,740
13,440
17,300
30,740
13,440
17,300
30,300
16,800
13,500
21,940
9,240
12,700
21,940
9,240
12,700
47,340
26,040
21,300
47,340
47,340
47,340
26,040
26,040
26,040
21,300
21,300
21,300
38,640
38,640
21,840
21,840
16,800
16,800
DESCRIPTION
38,640
38,640
38,640
21,840
21,840
21,840
21,940
9,240
12,700
21,940
9,240
12,700
15820
15822
15823
Health Care
Institution Fee
16,800
16,800
16,800
10,120
10,120
11,980
4,620
4,620
5,880
5,500
5,500
6,100
15840
Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)
30,300
16,800
13,500
15841
Graft for facial nerve paralysis; free muscle graft (including obtaining graft)
30,300
16,800
13,500
15842
Graft for facial nerve paralysis; free muscle graft by microsurgical technique
38,640
21,840
16,800
15845
30,300
16,800
13,500
15920
30,740
13,440
17,300
15922
15931
15933
15934
15935
30,300
21,940
30,740
12,120
30,300
16,800
9,240
13,440
6,720
16,800
13,500
12,700
17,300
5,400
13,500
15936
38,440
19,740
18,700
37,800
21,000
16,800
12,120
6,720
5,400
21,940
9,240
12,700
30,740
30,300
13,440
16,800
17,300
13,500
38,440
19,740
18,700
11,980
21,940
21,940
5,880
9,240
9,240
6,100
12,700
12,700
30,740
13,440
17,300
31,140
17,640
13,500
38,440
19,740
18,700
8,260
30,740
3,360
13,440
4,900
17,300
9,700
4,200
5,500
15756
15757
15758
15760
15770
Case Rate
15950
15951
15952
15953
15937
15940
15941
15944
15945
15946
15956
15958
16010
16035
16040
17000
17200
17250
17100
17106
17110
17260
17261
17262
Page 5 of 113
Professional Fee
N/A
N/A
N/A
N/A
N/A
N/A
6,000
N/A
2,200
N/A
N/A
3,800
N/A
N/A
N/A
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
17304
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
9,300
2,100
7,200
9,300
2,100
7,200
9,300
2,100
7,200
9,300
2,100
7,200
9,300
2,100
7,200
9,300
2,100
7,200
8,020
2,520
5,500
3,640
9,700
840
4,200
2,800
5,500
3,640
5,560
840
1,260
2,800
4,300
8,440
2,940
5,500
8,260
3,360
4,900
8,020
2,520
5,500
Breast
Incision
19000
19020
8,020
2,520
5,500
19140
19160
19162
19180
19182
22,000
22,000
22,000
22,000
22,000
8,800
8,800
8,800
8,800
8,800
13,200
13,200
13,200
13,200
13,200
19200
22,000
8,800
13,200
22,000
8,800
13,200
22,000
8,800
13,200
46,500
25,200
21,300
55,000
33,600
21,400
58,800
37,800
21,000
37,800
21,000
16,800
37,800
21,000
16,800
30,300
16,800
13,500
37,800
21,000
16,800
19100
19101
19110
19112
19120
19125
19220
19240
19260
19271
19272
19340
19342
19350
19357
Page 6 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
55,000
33,600
21,400
55,000
55,000
33,600
33,600
21,400
21,400
19367
55,000
33,600
21,400
19369
55,000
33,600
21,400
30,300
37,800
16,800
21,000
13,500
16,800
4,108
3,504
1,008
504
3,100
3,000
10,880
3,780
7,100
18,000
8,400
9,600
9,700
4,200
5,500
12,540
23,300
30,740
7,140
12,600
13,440
5,400
10,700
17,300
8,020
2,520
5,500
5,560
1,260
4,300
9,300
2,100
7,200
9,300
2,100
7,200
19370
19371
20615
8,260
3,360
4,900
20650
8,020
2,520
5,500
20660
9,868
4,368
5,500
20661
20662
20663
20670
8,608
23,300
21,940
10,540
3,108
12,600
9,240
5,040
5,500
10,700
12,700
5,500
11,980
5,880
6,100
12,120
6,720
5,400
39,280
20,580
18,700
9,300
2,100
7,200
40,320
23,520
16,800
40,320
23,520
16,800
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
20827
23,300
12,600
10,700
20838
37,800
21,000
16,800
10,540
18,000
12,120
12,120
9,700
12,120
10,960
9,700
5,040
8,400
6,720
6,720
4,200
6,720
5,460
4,200
5,500
9,600
5,400
5,400
5,500
5,400
5,500
5,500
20200
20206
20220
20225
20240
20245
20250
20251
20520
20600
20605
20610
20680
20690
20692
20802
20805
20808
20816
20822
20824
20900
20902
20910
20912
20920
20922
20924
20926
Page 7 of 113
DESCRIPTION
20930
20931
12,120
18,420
6,720
8,820
Health Care
Institution Fee
5,400
9,600
20936
Autograft for spine surgery only (includes harvesting the graft); local (e.g.,
ribs, spinous process, or laminar fragments) obtained from same incision
10,540
5,040
5,500
20937
Autograft for spine surgery only (includes harvesting the graft); morselized
(through separate skin or fascial incision)
10,540
5,040
5,500
20938
Autograft for spine surgery only (includes harvesting the graft); structural,
bicortical or tricortical (through separate skin or fascial incision)
18,000
8,400
9,600
37,800
37,800
20,980
21,000
21,000
10,080
16,800
16,800
10,900
27,120
15,120
12,000
37,800
21,000
16,800
30,300
23,300
16,800
12,600
13,500
10,700
27,120
15,120
12,000
9,700
4,200
5,500
9,700
4,200
5,500
23,300
12,600
10,700
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
18,000
18,000
23,300
18,000
21,940
23,300
30,300
30,300
30,300
30,300
8,400
8,400
8,400
12,600
8,400
9,240
12,600
16,800
16,800
16,800
16,800
9,600
9,600
9,600
10,700
9,600
12,700
10,700
13,500
13,500
13,500
13,500
18,000
46,500
8,400
25,200
9,600
21,300
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
46,500
25,200
21,300
18,000
8,400
9,600
46,500
25,200
21,300
30,300
16,800
13,500
53,400
29,400
24,000
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
20955
20956
20957
20962
20969
20970
20972
20973
20982
Case Rate
Other Procedures
Bone graft w/ microvascular anastomosis; fibula
Bone graft w/ microvascular anastomosis; iliac crest
Bone graft w/ microvascular anastomosis; metatarsal
Bone graft w/ microvascular anastomosis; other than fibula, iliac crest, or
metatarsal
Free osteocutaneous flap w/ microvascular anastomosis; other than iliac
crest, metatarsal, or great toe
Free osteocutaneous flap w/ microvascular anastomosis; iliac crest
Free osteocutaneous flap w/ microvascular anastomosis; metatarsal
Free osteocutaneous flap w/ microvascular anastomosis; great toe w/ web
space
Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency,
percutaneous, including computed tomographic guidance
21025
Head
Incision
Arthrotomy, temporomandibular joint
Excision
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of face or
scalp
Excision of bone (e.g., for osteomyelitis or bone abscess); mandible
21026
21010
21015
21029
21030
21031
21032
21034
21040
21041
21044
21045
21050
21060
21070
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
Page 8 of 113
Professional Fee
21147
21150
21151
21154
21155
21159
21160
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
58,800
37,800
21,000
55,000
33,600
21,400
55,000
33,600
21,400
46,500
25,200
21,300
21172
55,000
33,600
21,400
21175
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
46,500
25,200
21,300
55,000
33,600
21,400
46,500
25,200
21,300
55,000
33,600
21,400
30,300
46,500
16,800
25,200
13,500
21,300
21179
21180
21181
21182
21183
21198
21206
21210
46,500
25,200
21,300
21215
55,000
33,600
21,400
46,500
25,200
21,300
30,300
16,800
13,500
46,500
25,200
21,300
46,500
25,200
21,300
55,000
33,600
21,400
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
21184
21188
21193
21194
21195
21196
21230
21235
21242
21243
21240
21245
21246
21244
Page 9 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
55,000
33,600
21,400
55,000
33,600
21,400
63,000
42,000
21,000
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
10,540
10,540
12,120
5,040
5,040
6,720
5,500
5,500
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
10,540
12,120
18,000
6,720
5,040
6,720
8,400
5,400
5,500
5,400
9,600
21,940
9,240
12,700
21,940
9,240
12,700
23,300
12,600
10,700
22,660
11,760
10,900
23,300
12,600
10,700
30,300
16,800
13,500
37,800
21,000
16,800
21,940
9,240
12,700
21356
23,300
12,600
10,700
21360
30,300
16,800
13,500
21365
37,800
21,000
16,800
46,500
25,200
21,300
20,980
10,080
10,900
21366
21385
21386
18,000
8,400
9,600
21387
37,800
21,000
16,800
31,580
14,280
17,300
31,580
14,280
17,300
18,000
20,980
31,580
8,400
10,080
14,280
9,600
10,900
17,300
31,580
14,280
17,300
21390
21395
21400
21406
21407
21408
21421
21422
Page 10 of 113
12,120
6,720
5,400
20,980
10,080
10,900
21435
21436
21440
21445
21450
21452
21453
21454
21461
21462
21465
21470
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
12,120
6,720
5,400
23,300
12,600
10,700
18,000
8,400
9,600
23,300
12,600
10,700
46,500
25,200
21,300
12,120
18,000
18,000
23,300
14,960
22,660
22,660
23,300
30,300
6,720
8,400
8,400
12,600
7,560
11,760
11,760
12,600
16,800
5,400
9,600
9,600
10,700
7,400
10,900
10,900
10,700
13,500
37,800
21,000
16,800
9,700
4,200
5,500
21480
21485
20,980
10,080
10,900
21490
21493
21495
21497
30,300
18,000
23,300
12,120
16,800
8,400
12,600
6,720
13,500
9,600
10,700
5,400
5,680
1,680
4,000
8,020
2,520
5,500
4,108
1,008
3,100
5,680
8,020
1,680
2,520
4,000
5,500
9,700
4,200
5,500
30,300
16,800
13,500
10,540
20,980
37,180
37,800
27,120
12,288
37,800
5,040
10,080
18,480
21,000
15,120
6,888
21,000
5,500
10,900
18,700
16,800
12,000
5,400
16,800
18,000
23,300
18,000
27,120
23,300
8,400
12,600
8,400
15,120
12,600
9,600
10,700
9,600
12,000
10,700
8,020
10,960
20,980
9,868
21,940
2,520
5,460
10,080
4,368
9,240
5,500
5,500
10,900
5,500
12,700
21550
21555
21556
21501
21502
21510
21557
21600
21610
21615
21616
21620
21627
21630
21700
21705
21720
21740
21750
21800
21805
21810
21820
21825
Page 11 of 113
DESCRIPTION
3,504
5,680
504
1,680
21935
Health Care
Institution Fee
3,000
4,000
23,300
12,600
10,700
22100
27,120
15,120
12,000
22101
27,120
15,120
12,000
22102
27,120
15,120
12,000
46,500
25,200
21,300
30,300
16,800
13,500
30,300
16,800
13,500
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
23,300
12,600
10,700
30,740
13,440
17,300
38,860
20,160
18,700
38,640
21,840
16,800
37,800
21,000
16,800
40,320
23,520
16,800
21920
21930
22110
22112
22114
22210
22212
22214
22220
22222
22224
22305
22310
22325
22326
22327
22548
Case Rate
Professional Fee
22554
53,400
29,400
24,000
22556
46,500
25,200
21,300
22558
46,500
25,200
21,300
53,400
53,400
29,400
29,400
24,000
24,000
53,400
29,400
24,000
22590
22595
22600
22610
30,300
16,800
13,500
22612
30,300
16,800
13,500
Page 12 of 113
DESCRIPTION
40,320
23,520
Health Care
Institution Fee
16,800
58,800
37,800
21,000
63,000
42,000
21,000
67,200
46,200
21,000
55,000
33,600
21,400
58,800
37,800
21,000
67,200
46,200
21,000
55,000
33,600
21,400
53,400
29,400
24,000
54,660
30,660
24,000
58,800
37,800
21,000
67,200
46,200
21,000
55,000
58,800
67,200
33,600
37,800
46,200
21,400
21,000
21,000
55,000
33,600
21,400
22849
53,400
29,400
24,000
22850
21,940
9,240
12,700
58,800
37,800
21,000
27,120
30,300
15,120
16,800
12,000
13,500
23,300
12,600
10,700
20,980
10,080
10,900
27,120
18,000
14,960
15,120
8,400
7,560
12,000
9,600
7,400
20,980
10,080
10,900
23,300
12,600
10,700
20,980
10,080
10,900
3,504
5,680
8,020
504
1,680
2,520
3,000
4,000
5,500
37,800
21,000
16,800
23,300
12,600
10,700
27,120
15,120
12,000
27,120
21,820
15,120
10,920
12,000
10,900
30,740
13,440
17,300
23,300
27,960
27,540
12,600
15,960
15,540
10,700
12,000
12,000
22630
22800
22802
22804
22808
22810
22812
22840
22841
22842
22843
22844
22845
22846
22847
22848
22851
22852
22855
22900
Case Rate
Professional Fee
Shoulder
Incision
23120
23125
23130
23140
20,980
10,080
10,900
23145
22,240
11,340
10,900
23000
23020
23030
23031
23035
23040
23044
23065
23075
23076
23077
23100
23101
23105
23106
23107
Page 13 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
23146
22,240
11,340
10,900
23150
30,740
13,440
17,300
31,580
14,280
17,300
31,580
14,280
17,300
20,980
21,820
10,080
10,920
10,900
10,900
23,300
12,600
10,700
21,400
10,500
10,900
21,652
10,752
10,900
21,820
10,920
10,900
21,820
27,120
27,120
27,540
37,180
10,920
15,120
15,120
15,540
18,480
10,900
12,000
12,000
12,000
18,700
40,320
23,520
16,800
53,400
29,400
24,000
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23221
23222
23330
Introduction or Removal
Removal of foreign body, shoulder; subcutaneous
5,560
1,260
4,300
23331
12,900
6,300
6,600
23332
14,960
7,560
7,400
22,240
23,300
27,120
21,940
23,080
20,980
22,240
21,148
11,340
12,600
15,120
9,240
12,180
10,080
11,340
10,248
10,900
10,700
12,000
12,700
10,900
10,900
10,900
10,900
23,300
12,600
10,700
21,940
20,980
9,240
10,080
12,700
10,900
37,800
21,000
16,800
38,860
38,860
37,180
20,160
20,160
18,480
18,700
18,700
18,700
23455
23460
23462
23465
37,800
21,000
16,800
23466
23470
40,320
48,180
23,520
26,880
16,800
21,300
53,400
29,400
24,000
27,120
15,120
12,000
28,380
16,380
12,000
27,120
15,120
12,000
27,120
15,120
12,000
23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23472
23480
23485
23490
23491
23500
23515
23520
23530
23532
23540
Page 14 of 113
8,020
2,520
5,500
12,456
7,056
5,400
10,880
20,980
3,780
10,080
7,100
10,900
27,120
15,120
12,000
8,020
2,520
5,500
DESCRIPTION
Open treatment of acromioclavicular dislocation, acute or chronic
Open treatment of acromioclavicular dislocation, acute or chronic w/ fascial
graft (includes obtaining graft)
Closed treatment of scapular fracture
Open treatment of scapular fracture (body, glenoid or acromion) w/ or w/o
internal fixation
21,940
9,240
Health Care
Institution Fee
12,700
20,980
10,080
10,900
8,020
2,520
5,500
20,980
10,080
10,900
23600
10,540
5,040
5,500
23615
23,300
12,600
10,700
47,340
26,040
21,300
9,700
4,200
5,500
23,300
12,600
10,700
10,540
41,160
27,120
5,040
24,360
15,120
5,500
16,800
12,000
11,980
5,880
6,100
27,120
15,120
12,000
12,120
6,720
5,400
27,120
15,120
12,000
9,700
4,200
5,500
12,456
7,056
5,400
37,180
18,480
18,700
30,300
27,120
16,800
15,120
13,500
12,000
3,100
23550
23552
23570
23585
Case Rate
23650
23657
23660
23665
23616
23620
23630
23670
23675
23680
23700
23800
23802
23900
23920
Professional Fee
23930
Incision and drainage, upper arm or elbow area deep abscess or hematoma
4,108
1,008
23931
5,560
1,260
4,300
21,940
9,240
12,700
22,360
9,660
12,700
20,980
10,080
10,900
24065
24075
3,504
5,680
504
1,680
3,000
4,000
24076
8,020
2,520
5,500
23,300
12,600
10,700
20,980
10,080
10,900
21,820
10,920
10,900
23,300
8,260
20,980
12,600
3,360
10,080
10,700
4,900
10,900
23,080
12,180
10,900
23,080
12,180
10,900
21,148
10,248
10,900
21,820
10,920
10,900
21,820
10,920
10,900
20,980
10,080
10,900
20,980
10,080
10,900
23935
24000
24006
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
Page 15 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
24136
20,980
10,080
10,900
24138
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
21,400
10,500
10,900
23,080
12,180
10,900
30,300
16,800
13,500
23,300
12,600
10,700
27,120
15,120
12,000
27,120
15,120
12,000
21,940
22,360
8,272
9,240
9,660
2,772
12,700
12,700
5,500
23,300
20,980
21,940
12,600
10,080
9,240
10,700
10,900
12,700
27,120
15,120
12,000
30,740
13,440
17,300
27,120
15,120
12,000
8,260
3,360
4,900
20,980
10,080
10,900
12,120
6,720
5,400
10,540
5,040
5,500
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
24140
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
24301
24305
24310
24320
24330
24331
24340
24341
24342
24350
24351
24352
24354
24356
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
12,120
6,720
5,400
27,120
15,120
12,000
37,180
18,480
18,700
27,120
15,120
12,000
38,640
21,840
16,800
21,940
27,120
20,980
9,240
15,120
10,080
12,700
12,000
10,900
20,980
10,080
10,900
23,300
12,600
10,700
23,080
12,180
10,900
24435
27,120
15,120
12,000
24470
22,360
9,660
12,700
24495
27,120
15,120
12,000
20,980
10,080
10,900
24498
24500
24515
Page 16 of 113
10,120
4,620
5,500
30,740
13,440
17,300
24587
24600
24615
24620
24635
DESCRIPTION
Case Rate
24640
24650
24665
24666
24670
24685
24800
24802
24900
24920
24925
24930
24931
24935
24940
25000
25020
25023
25028
25031
25035
25040
Professional Fee
Health Care
Institution Fee
30,740
13,440
17,300
10,120
4,620
5,500
27,120
15,120
12,000
12,456
7,056
5,400
32,000
14,700
17,300
10,880
3,780
7,100
27,120
15,120
12,000
18,000
8,400
9,600
10,880
3,780
7,100
18,000
8,400
9,600
27,120
15,120
12,000
22,660
11,760
10,900
37,800
21,000
16,800
10,540
23,300
5,040
12,600
5,500
10,700
10,880
3,780
7,100
21,940
9,240
12,700
4,000
5,680
1,680
10,880
3,780
7,100
20,980
10,080
10,900
27,120
15,120
12,000
10,880
3,780
7,100
21,940
9,240
12,700
27,120
15,120
12,000
28,380
16,380
12,000
18,000
8,400
9,600
12,120
6,720
5,400
10,960
5,460
5,500
14,960
14,960
12,120
27,120
7,560
7,560
6,720
15,120
7,400
7,400
5,400
12,000
10,540
5,040
5,500
18,000
8,400
9,600
14,960
7,560
7,400
10,880
3,780
7,100
10,120
4,620
5,500
12,120
6,720
5,400
10,120
4,620
5,500
Page 17 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
25065
25075
Excision
Biopsy, soft tissue of forearm and/or wrist
Excision, tumor, forearm and/or wrist area subcutaneous
3,504
5,680
504
1,680
3,000
4,000
25076
8,020
2,520
5,500
23,300
12,600
10,700
15,380
11,044
7,980
5,544
7,400
5,500
12,540
7,140
5,400
20,980
10,080
10,900
20,980
10,080
10,900
8,020
8,260
2,520
3,360
5,500
4,900
21,820
10,920
10,900
18,420
8,820
9,600
25105
25107
25110
25111
25077
25085
25100
25101
25115
25116
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25248
25250
25251
25260
25263
25265
25270
25272
25274
25280
25290
Page 18 of 113
9,952
4,452
5,500
21,940
9,240
12,700
20,980
10,080
10,900
21,820
10,920
10,900
21,820
10,920
10,900
9,952
4,452
5,500
12,900
6,300
6,600
12,900
6,300
6,600
21,940
9,240
12,700
21,940
9,240
12,700
21,940
9,240
12,700
27,120
5,932
22,360
10,540
15,120
1,932
9,660
5,040
12,000
4,000
12,700
5,500
10,540
5,040
5,500
8,260
21,940
30,740
3,360
9,240
13,440
4,900
12,700
17,300
10,540
5,040
5,500
8,260
3,360
4,900
10,120
4,620
5,500
10,540
5,040
5,500
8,260
3,360
4,900
10,540
5,040
5,500
10,880
3,780
7,100
10,880
3,780
7,100
DESCRIPTION
Case Rate
8,260
3,360
4,900
10,960
10,540
5,460
5,040
5,500
5,500
20,980
10,080
10,900
21,820
10,920
10,900
30,300
16,800
13,500
37,180
18,480
18,700
27,120
15,120
12,000
30,300
16,800
13,500
31,140
17,640
13,500
27,960
15,960
12,000
18,000
21,940
18,420
23,300
8,400
9,240
8,820
12,600
9,600
12,700
9,600
10,700
30,740
13,440
17,300
27,960
15,960
12,000
27,120
27,960
27,120
27,960
15,120
15,960
15,120
15,960
12,000
12,000
12,000
12,000
20,980
10,080
10,900
23,300
12,600
10,700
30,740
13,440
17,300
27,960
15,960
12,000
21,940
30,740
9,240
13,440
12,700
17,300
23,720
13,020
10,700
30,300
27,120
27,120
27,120
31,580
16,800
15,120
15,120
15,120
14,280
13,500
12,000
12,000
12,000
17,300
37,800
21,000
16,800
27,960
15,960
12,000
40,320
20,980
23,520
10,080
16,800
10,900
30,740
13,440
17,300
21,940
9,240
12,700
21,940
9,240
12,700
37,180
18,480
18,700
9,700
4,200
5,500
21,940
9,240
12,700
9,700
4,200
5,500
25449
25450
25455
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
25392
25393
25400
25405
25415
25420
25425
25426
25440
25441
25442
25443
25444
25445
25446
25447
25490
25491
25492
25500
25515
25520
Health Care
Institution Fee
Flexor origin slide (e.g. for cerebral palsy, Volkmann contracture), forearm
and/or wrist
Flexor origin slide (e.g. for cerebral palsy, Volkmann contracture), forearm
and/or wrist w/ tendon(s) transfer
Capsulorrhaphy or reconstruction, wrist, any method (e.g., capsulodesis,
ligament repair, tendon transfer or graft) (includes synovectomy,
capsulotomy and open reduction) for carpal instability
Arthroplasty, wrist, w/ or w/o interposition, w/ or w/o external or internal
fixation
Centralization of wrist on ulna (e.g., radial club hand)
Reconstruction for stabilization of unstable distal ulna or distal radioulnar
joint, secondary by soft tissue stabilization (e.g., tendon transfer, tendon
graft or weave, or tenodesis) w/ or w/o open reduction of distal radioulnar
joint
Osteotomy, radius distal third
Osteotomy, radius middle or proximal third
Osteotomy ulna
Osteotomy radius and ulna
Multiple osteotomies, w/ realignment on intramedullary rod (Sofield type
procedure) radius or ulna
Multiple osteotomies, w/ realignment on intramedullary rod (Sofield type
procedure) radius and ulna
Osteoplasty, radius or ulna shortening
Osteoplasty, radius or ulna lengthening w/ autograft
Osteoplasty, radius and ulna shortening
Osteoplasty, radius and ulna lengthening w/ autograft
Repair of nonunion or malunion, radius or ulna w/o graft (compression
technique)
Repair of nonunion or malunion, radius or ulna w/ iliac or other autograft
(includes obtaining graft)
Repair of nonunion or malunion, radius and ulna w/o graft (e.g.
compression technique)
Repair of nonunion or malunion, radius and ulna w/ iliac or other autograft
(includes obtaining graft)
Repair of defect w/ autograft radius or ulna
Repair of defect w/ autograft radius and ulna
Repair of nonunion, scaphoid (navicular) bone, w/ or w/o radial
styloidectomy (includes obtaining graft and necessary fixation)
Arthroplasty w/ prosthetic replacement distal radius
Arthroplasty w/ prosthetic replacement distal ulna
Arthroplasty w/ prosthetic replacement scaphoid (navicular)
Arthroplasty w/ prosthetic replacement lunate
Arthroplasty w/ prosthetic replacement trapezium
Arthroplasty w/ prosthetic replacement distal radius and partial or entire
carpus ("total wrist")
Arthroplasty w/ prosthetic replacement Interposition arthroplasty,
intercarpal or carpometacarpal joints
Revision of arthroplasty, including removal of implant, wrist joint
Epiphyseal arrest by epiphysiodesis or stapling distal radius or ulna
25315
Professional Fee
Page 19 of 113
25525
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
20,980
10,080
10,900
22,660
11,760
10,900
25675
25676
25680
25685
25690
25695
20,980
8,260
21,940
10,080
3,360
9,240
10,900
4,900
12,700
18,000
8,400
9,600
21,820
10,920
10,900
21,820
10,920
10,900
12,900
14,960
6,300
7,560
6,600
7,400
21,820
10,920
10,900
25900
18,000
8,400
9,600
25905
12,120
6,720
5,400
10,960
5,460
5,500
14,960
37,800
14,960
8,440
14,960
14,960
8,440
14,960
7,560
21,000
7,560
2,940
7,560
7,560
2,940
7,560
7,400
16,800
7,400
5,500
7,400
7,400
5,500
7,400
3,504
4,108
8,020
10,880
504
1,008
2,520
3,780
3,000
3,100
5,500
7,100
25526
25530
25545
25560
25574
25575
25600
25611
25620
25622
25628
25630
25645
25650
25660
25670
25800
25805
25810
25820
25825
25830
25907
25909
25915
25920
25922
25924
25927
25929
25931
26010
26011
26020
26025
Page 20 of 113
8,260
3,360
4,900
18,000
8,400
9,600
9,700
4,200
5,500
27,960
15,960
12,000
27,120
15,120
12,000
8,260
3,360
4,900
23,300
12,600
10,700
23,300
12,600
10,700
8,260
3,360
4,900
21,820
10,920
10,900
8,260
3,360
4,900
21,904
11,004
10,900
8,440
2,940
5,500
8,260
3,360
4,900
18,000
8,400
9,600
8,260
21,820
3,360
10,920
4,900
10,900
8,260
3,360
4,900
DESCRIPTION
10,540
5,040
21,940
9,240
12,700
14,960
21,940
12,120
12,120
10,540
9,700
7,560
9,240
6,720
6,720
5,040
4,200
7,400
12,700
5,400
5,400
5,500
5,500
10,880
3,780
7,100
10,880
3,780
7,100
8,260
3,360
4,900
26100
26105
26110
Health Care
Institution Fee
5,500
12,120
12,900
11,980
6,720
6,300
5,880
5,400
6,600
6,100
26115
20,980
10,080
10,900
23,300
12,600
10,700
27,120
15,120
12,000
27,120
15,120
12,000
22,660
11,760
10,900
8,260
3,360
4,900
22,660
11,760
10,900
12,984
6,384
6,600
12,984
6,384
6,600
15,380
7,980
7,400
11,980
5,880
6,100
8,440
8,260
15,380
12,624
2,940
3,360
7,980
7,224
5,500
4,900
7,400
5,400
21,940
9,240
12,700
12,120
6,720
5,400
15,380
7,980
7,400
21,940
9,240
12,700
15,380
7,980
7,400
26030
26034
26035
26037
26040
26045
26055
26060
26070
26075
26080
26116
26117
26121
26123
26125
26130
26135
26140
26145
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26350
26352
Case Rate
Page 21 of 113
Professional Fee
12,120
6,720
5,400
23,636
12,936
10,700
32,000
14,700
17,300
30,740
13,440
17,300
31,580
14,280
17,300
23,080
12,180
10,900
12,120
6,720
5,400
10,540
5,040
5,500
DESCRIPTION
Case Rate
Page 22 of 113
Professional Fee
Health Care
Institution Fee
10,880
3,780
7,100
10,880
3,780
7,100
10,880
3,780
7,100
10,880
3,780
7,100
10,540
5,040
5,500
11,132
4,032
7,100
10,880
3,780
7,100
10,880
3,780
7,100
8,260
3,360
4,900
8,260
3,360
4,900
10,880
3,780
7,100
8,692
3,192
5,500
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
10,880
3,780
7,100
10,540
8,020
8,440
8,020
5,040
2,520
2,940
2,520
5,500
5,500
5,500
5,500
8,440
2,940
5,500
8,440
8,440
8,440
8,260
10,880
8,440
8,440
8,440
2,940
2,940
2,940
3,360
3,780
2,940
2,940
2,940
5,500
5,500
5,500
4,900
7,100
5,500
5,500
5,500
8,440
2,940
5,500
8,440
2,940
5,500
10,880
3,780
7,100
8,260
3,360
4,900
8,260
3,360
4,900
10,540
10,960
10,540
10,540
8,428
18,000
21,940
10,880
5,040
5,460
5,040
5,040
3,528
8,400
9,240
3,780
5,500
5,500
5,500
5,500
4,900
9,600
12,700
7,100
10,120
4,620
5,500
12,900
8,428
6,300
3,528
6,600
4,900
DESCRIPTION
Cross intrinsic transfer
Capsulodesis for M-P joint stabilization single digit
Capsulodesis for M-P joint stabilization two digits
Capsulodesis for M-P joint stabilization three or four digits
Capsulectomy or capsulotomy for contracture metacarpophalangeal joint,
single, each
Capsulectomy or capsulotomy for contracture interphalangeal joint, single,
each
Arthroplasty, metacarpophalangeal joint single, each joint
Arthroplasty, metacarpophalangeal joint w/ prosthetic implant, single, each
joint
Arthroplasty interphalangeal joint, single, each joint
Arthroplasty interphalangeal joint, single, each joint w/ prosthetic implant,
single, each joint
10,960
10,540
12,120
18,000
5,460
5,040
6,720
8,400
Health Care
Institution Fee
5,500
5,500
5,400
9,600
10,880
3,780
7,100
5,628
3,752
1,876
4,788
3,192
1,596
Case Rate
26555
26556
26560
26561
Repair of syndactyly (web finger) each web space w/ skin flaps and grafts
26541
26542
26545
26546
26548
26550
26551
26553
26554
Professional Fee
8,020
2,520
5,500
18,000
8,400
9,600
20,980
10,080
10,900
8,428
3,528
4,900
8,428
3,528
4,900
8,428
3,528
4,900
10,880
3,780
7,100
10,540
5,040
5,500
8,428
20,980
3,528
10,080
4,900
10,900
30,300
16,800
13,500
30,740
13,440
17,300
27,120
15,120
12,000
14,960
27,120
18,000
7,560
15,120
8,400
7,400
12,000
9,600
20,980
10,080
10,900
30,740
13,440
17,300
23,300
23,300
23,300
20,980
20,980
23,300
30,740
30,740
20,980
21,820
12,600
12,600
12,600
10,080
10,080
12,600
13,440
13,440
10,080
10,920
10,700
10,700
10,700
10,900
10,900
10,700
17,300
17,300
10,900
10,900
21,820
10,920
10,900
26600
Repair of syndactyly (web finger) each web space complex (e.g., involving
bone, nails)
Osteotomy for correction of deformity metacarpal
Osteotomy for correction of deformity phalanx of finger
Osteoplasty for lengthening of metacarpal or phalanx
Repair cleft hand
Repair bifid digit
Reconstruction of supernumerary digit, soft tissue and bone
Repair macrodactylia
Repair, intrinsic muscles of hand (specify)
Release, intrinsic muscles of hand (specify)
Excision of constricting ring of finger, w/ multiple Z-plasties
Release of scar contracture, flexor or extensor, w/ skin grafts,
rearrangement flaps, or Z-plasties, hand and/or finger
Fracture and/or Dislocation
Closed treatment of metacarpal fracture, single
10,120
4,620
5,500
26607
12,900
6,300
6,600
26608
12,120
6,720
5,400
12,120
6,720
5,400
10,540
5,040
5,500
12,120
6,720
5,400
14,960
7,560
7,400
14,960
7,560
7,400
10,540
5,040
5,500
14,960
7,560
7,400
10,540
5,040
5,500
26562
26565
26567
26568
26580
26585
26587
26590
26591
26593
26596
26597
26615
26641
26645
26650
26665
26670
26676
26685
Page 23 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
11,980
5,880
6,100
10,540
5,040
5,500
14,960
7,560
7,400
12,540
7,140
5,400
10,120
4,620
5,500
14,960
7,560
7,400
14,960
7,560
7,400
10,120
4,620
5,500
12,540
7,140
5,400
10,120
4,620
5,500
14,960
7,560
7,400
12,120
6,720
5,400
10,880
3,780
7,100
12,540
7,140
5,400
12,540
7,140
5,400
26820
21,820
10,920
10,900
26841
20,980
10,080
10,900
20,980
10,080
10,900
21,940
9,240
12,700
20,980
10,080
10,900
20,980
10,080
10,900
21,820
10,920
10,900
20,980
10,080
10,900
21,820
10,920
10,900
12,120
6,720
5,400
11,980
5,880
6,100
21,940
9,240
12,700
6,720
5,400
26700
26706
26715
26720
26727
26735
26740
26746
26750
26756
26765
26770
26776
26785
26842
26843
26844
26850
26852
26860
26862
26910
26951
26952
26990
Incision and drainage, pelvis or hip joint area deep abscess or hematoma
12,120
26991
12,120
6,720
5,400
23,300
12,600
10,700
12,120
14,960
30,740
23,300
23,300
21,820
30,740
30,740
6,720
7,560
13,440
12,600
12,600
10,920
13,440
13,440
5,400
7,400
17,300
10,700
10,700
10,900
17,300
17,300
30,300
16,800
13,500
37,800
21,000
16,800
3,504
504
3,000
26992
27000
27001
27003
27005
27006
27025
27030
27033
27035
27036
27040
Page 24 of 113
DESCRIPTION
5,680
8,260
1,680
3,360
Health Care
Institution Fee
4,000
4,900
37,800
21,000
16,800
27,960
37,180
31,140
27,120
27,120
15,960
18,480
17,640
15,120
15,120
12,000
18,700
13,500
12,000
12,000
27,960
15,960
12,000
30,300
16,800
13,500
31,140
17,640
13,500
46,500
25,200
21,300
46,500
25,200
21,300
38,860
20,160
18,700
38,860
20,160
18,700
37,180
18,480
18,700
31,140
17,640
13,500
31,560
18,060
13,500
15,380
7,980
7,400
14,960
30,300
7,560
16,800
7,400
13,500
38,020
19,320
18,700
22,660
23,300
11,760
12,600
10,900
10,700
30,740
13,440
17,300
30,740
13,440
17,300
30,740
30,740
37,180
37,180
13,440
13,440
18,480
18,480
17,300
17,300
18,700
18,700
37,180
18,480
18,700
53,400
29,400
24,000
55,080
31,080
24,000
55,000
33,600
21,400
38,640
21,840
16,800
38,640
21,840
16,800
27,960
30,300
15,960
16,800
12,000
13,500
Case Rate
Professional Fee
27140
27146
27147
31,140
17,640
13,500
27151
37,180
18,480
18,700
38,020
19,320
18,700
37,800
31,140
21,000
17,640
16,800
13,500
37,180
18,480
18,700
31,140
17,640
13,500
23,300
12,600
10,700
30,300
16,800
13,500
27075
27076
27077
27078
27079
27080
27086
27090
27091
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138
27175
27176
27156
27158
27161
27165
27170
Page 25 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
31,140
17,640
13,500
31,140
17,640
13,500
31,140
17,640
13,500
37,180
18,480
18,700
27,960
15,960
12,000
31,140
17,640
13,500
27193
27,960
15,960
12,000
27200
27202
14,960
22,660
7,560
11,760
7,400
10,900
37,800
21,000
16,800
40,320
23,520
16,800
46,500
25,200
21,300
46,500
25,200
21,300
30,740
13,440
17,300
38,640
21,840
16,800
40,320
23,520
16,800
46,500
25,200
21,300
23,300
12,600
10,700
46,500
25,200
21,300
46,500
25,200
21,300
23,300
12,600
10,700
46,500
25,200
21,300
31,140
17,640
13,500
23,300
12,600
10,700
27,120
15,120
12,000
23,300
37,180
12,600
18,480
10,700
18,700
40,320
23,520
16,800
27215
27216
27217
27218
27220
27226
27227
27228
27230
27235
27236
27238
27244
27245
27246
27248
27250
27253
27254
27258
30,300
16,800
13,500
27259
37,180
18,480
18,700
18,000
8,400
9,600
37,800
27,960
37,800
21,000
15,960
21,000
16,800
12,000
16,800
40,320
23,520
16,800
46,500
30,300
25,200
16,800
21,300
13,500
27265
27280
27282
27284
27286
27290
27295
Page 26 of 113
DESCRIPTION
Case Rate
27323
27327
27328
27301
27303
27305
27306
27307
27310
27315
27320
27340
27345
27350
27355
27356
27329
27330
27331
27332
27333
27334
27335
27357
27358
27360
27365
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
27396
27397
27400
27403
27405
27407
27409
27418
27420
27422
27424
Page 27 of 113
Professional Fee
Health Care
Institution Fee
8,260
3,360
4,900
23,300
12,600
10,700
18,000
18,000
21,820
8,400
8,400
10,920
9,600
9,600
10,900
27,120
15,120
12,000
23,300
23,300
12,600
12,600
10,700
10,700
3,504
5,680
504
1,680
3,000
4,000
8,020
2,520
5,500
27,120
15,120
12,000
20,980
10,080
10,900
23,300
12,600
10,700
31,580
14,280
17,300
27,960
15,960
12,000
13,152
6,552
6,600
23,300
12,600
10,700
14,960
20,980
30,740
22,240
7,560
10,080
13,440
11,340
7,400
10,900
17,300
10,900
23,720
13,020
10,700
23,720
13,020
10,700
27,120
15,120
12,000
23,720
13,020
10,700
27,120
15,120
12,000
18,000
8,400
9,600
23,300
12,600
10,700
27,120
15,120
12,000
32,000
14,700
17,300
27,120
15,120
12,000
18,000
21,940
20,980
23,300
21,940
20,980
23,300
22,360
8,400
9,240
10,080
12,600
9,240
10,080
12,600
9,660
9,600
12,700
10,900
10,700
12,700
10,900
10,700
12,700
23,300
12,600
10,700
27,960
27,120
30,300
15,960
15,120
16,800
12,000
12,000
13,500
37,800
21,000
16,800
22,660
11,760
10,900
23,080
12,180
10,900
30,740
13,440
17,300
30,740
13,440
17,300
DESCRIPTION
27425
27427
21,820
30,300
10,920
16,800
Health Care
Institution Fee
10,900
13,500
27428
31,140
17,640
13,500
37,180
18,480
18,700
27,120
30,740
30,740
31,140
37,800
15,120
13,440
13,440
17,640
21,000
12,000
17,300
17,300
13,500
16,800
Case Rate
Professional Fee
27430
27435
27437
27438
27440
27441
38,640
21,840
16,800
27442
38,640
21,840
16,800
27443
39,480
22,680
16,800
27445
46,500
25,200
21,300
27446
39,480
22,680
16,800
27447
40,320
23,520
16,800
18,420
23,300
8,820
12,600
9,600
10,700
27,120
15,120
12,000
27,120
15,120
12,000
27,120
15,120
12,000
27,120
27,120
15,120
15,120
12,000
12,000
37,180
18,480
18,700
31,580
14,280
17,300
27,960
15,960
12,000
27475
30,740
13,440
17,300
27477
23,300
12,600
10,700
27,120
15,120
12,000
30,740
13,440
17,300
27429
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27479
27485
27486
53,400
29,400
24,000
27487
55,000
33,600
21,400
37,180
18,480
18,700
30,740
13,440
17,300
20,980
10,080
10,900
27488
27495
27496
27497
21,820
10,920
10,900
27498
21,820
10,920
10,900
23,300
12,600
10,700
14,960
7,560
7,400
18,420
8,820
9,600
18,420
8,820
9,600
27499
27501
27502
27503
Page 28 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
30,740
13,440
17,300
30,740
13,440
17,300
37,180
18,480
18,700
18,420
8,820
9,600
37,180
18,480
18,700
37,800
21,000
16,800
30,740
13,440
17,300
23,300
12,600
10,700
22,660
11,760
10,900
20,980
10,080
10,900
20,980
10,080
10,900
18,420
8,820
9,600
30,740
13,440
17,300
27,120
15,120
12,000
10,540
5,040
5,500
21,820
10,920
10,900
10,540
5,040
5,500
27556
27,120
15,120
12,000
27557
27,960
15,960
12,000
27558
37,800
21,000
16,800
20,980
10,080
10,900
27,120
15,120
12,000
30,740
13,440
17,300
30,300
16,800
13,500
23,300
12,600
10,700
23,300
12,600
10,700
11,980
5,880
6,100
22,660
27,120
11,760
15,120
10,900
12,000
27560
27566
27580
27590
27591
27592
27594
27596
27598
27600
8,020
2,520
5,500
27601
8,020
2,520
5,500
8,260
3,360
4,900
4,108
5,680
12,540
18,420
1,008
1,680
7,140
8,820
3,100
4,000
5,400
9,600
20,980
10,080
10,900
21,940
9,240
12,700
22,660
11,760
10,900
3,504
504
3,000
27602
27603
27604
27605
27606
27607
27610
27612
27613
Page 29 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
27654
27656
27658
Repair or suture of flexor tendon of leg; primary, w/o graft, single, each
15,380
7,980
7,400
27659
18,000
8,400
9,600
27664
Repair or suture of extensor tendon of leg; primary, w/o graft, single, each
15,380
7,980
7,400
18,000
8,400
9,600
18,000
22,360
18,000
8,400
9,660
8,400
9,600
12,700
9,600
21,940
9,240
12,700
18,000
8,400
9,600
18,000
8,400
9,600
14,960
7,560
7,400
18,420
8,820
9,600
15,380
7,980
7,400
27615
27618
27619
27620
27625
27626
27630
27635
27637
27638
27640
27641
27645
27646
27647
27650
27652
27665
27675
27676
27680
27681
27685
27686
27687
27690
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
27720
27722
27724
27725
27727
27730
Page 30 of 113
20,980
10,080
10,900
5,680
8,020
1,680
2,520
4,000
5,500
12,900
6,300
6,600
18,420
21,940
8,820
9,240
9,600
12,700
4,000
5,680
1,680
14,960
7,560
7,400
21,940
9,240
12,700
21,940
9,240
12,700
18,420
8,820
9,600
18,000
8,400
9,600
23,300
22,660
23,300
12,600
11,760
12,600
10,700
10,900
10,700
21,940
9,240
12,700
23,300
12,600
10,700
21,820
5,680
10,920
1,680
10,900
4,000
18,000
8,400
9,600
23,300
12,600
10,700
18,000
8,400
9,600
27,120
31,140
37,180
21,820
21,940
18,000
22,660
15,120
17,640
18,480
10,920
9,240
8,400
11,760
12,000
13,500
18,700
10,900
12,700
9,600
10,900
23,720
13,020
10,700
27,960
15,960
12,000
18,000
8,400
9,600
20,980
10,080
10,900
21,820
10,920
10,900
22,660
11,760
10,900
23,300
21,820
12,600
10,920
10,700
10,900
DESCRIPTION
27732
20,980
10,080
Health Care
Institution Fee
10,900
27734
23,300
12,600
10,700
27740
23,300
12,600
10,700
22,660
11,760
10,900
31,160
13,860
17,300
12,120
6,720
5,400
12,120
6,720
5,400
21,820
10,920
10,900
22,660
11,760
10,900
27,120
15,120
12,000
10,960
5,460
5,500
12,120
6,720
5,400
10,960
5,460
5,500
22,660
11,760
10,900
27742
27745
27750
27752
27756
27758
27759
27760
27766
27780
27784
27786
27792
27808
27814
27816
27822
27823
Case Rate
Professional Fee
10,540
5,040
5,500
20,980
10,080
10,900
12,900
6,300
6,600
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
10,540
5,040
5,500
20,980
10,080
10,900
21,940
9,240
12,700
21,820
10,920
10,900
20,980
10,080
10,900
10,960
5,460
5,500
11,980
5,880
6,100
10,960
5,460
5,500
22,660
11,760
10,900
23,720
13,020
10,700
18,000
21,400
8,400
10,500
9,600
10,900
30,300
16,800
13,500
30,740
13,440
17,300
9,600
27882
18,000
8,400
27884
Amputation, leg, through tibia and fibula; secondary closure or scar revision
12,120
6,720
5,400
27886
23,300
12,600
10,700
23,300
12,600
10,700
27824
27826
27827
27828
27829
27830
27832
27840
27846
27848
27870
27871
27880
27881
27888
Page 31 of 113
27892
27893
27894
28001
28002
28003
28005
28008
28010
28011
28020
28022
28024
28030
28035
DESCRIPTION
21,940
9,240
Health Care
Institution Fee
12,700
18,000
8,400
9,600
18,000
8,400
9,600
18,420
8,820
9,600
5,680
1,680
4,000
8,260
3,360
4,900
9,700
4,200
5,500
10,540
5,040
5,500
12,120
8,260
10,540
6,720
3,360
5,040
5,400
4,900
5,500
12,900
6,300
6,600
8,260
3,360
4,900
8,260
3,360
4,900
11,132
18,000
4,032
8,400
7,100
9,600
Case Rate
Ankle disarticulation
Other Procedures
Decompression fasciotomy, leg; anterior and/or lateral compartments only,
w/ debridement of nonviable muscle and/or nerve
Decompression fasciotomy, leg; posterior compartment(s) only, w/
debridement of nonviable muscle and/or nerve
Decompression fasciotomy, leg; anterior and/or lateral, and posterior
compartment(s), w/ debridement of nonviable muscle and/or nerve
Foot and Toes
Incision
Incision and drainage, infected bursa, foot
Incision and drainage, infected bursa, foot deep dissection below fascia, for
deep infection of foot, w/ or w/o tendon sheath involvement; single bursal
space, specify
Incision and drainage, infected bursa, foot multiple areas
Incision, deep, w/ opening of bone cortex (e.g. for osteomyelitis or bone
abscess), foot
Fasciotomy, foot and/or toe
Tenotomy, subcutaneous, toe; single
Tenotomy, subcutaneous, toe; multiple
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
intertarsal or tarsometatarsal joint
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
metatarsophalangeal joint
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
interphalangeal joint
Neurectomy of intrinsic musculature of foot
Tarsal tunnel release (posterior tibial nerve decompression)
Excision
Professional Fee
28043
5,680
1,680
4,000
28045
8,020
2,520
5,500
28046
37,800
21,000
16,800
28050
28052
28054
28060
28062
28070
28072
28080
28086
28088
10,120
10,120
9,700
9,700
10,960
11,980
10,960
5,680
10,960
10,960
4,620
4,620
4,200
4,200
5,460
5,880
5,460
1,680
5,460
5,460
5,500
5,500
5,500
5,500
5,500
6,100
5,500
4,000
5,500
5,500
8,440
2,940
5,500
8,260
3,360
4,900
15,380
7,980
7,400
21,940
9,240
12,700
21,940
9,240
12,700
15,380
7,980
7,400
21,940
9,240
12,700
21,940
9,240
12,700
28090
28092
28100
28102
28103
28104
28106
28107
28108
14,960
7,560
7,400
28110
28111
21,940
18,420
9,240
8,820
12,700
9,600
18,420
8,820
9,600
18,000
8,400
9,600
20,980
10,080
10,900
28112
28113
28114
Page 32 of 113
DESCRIPTION
15,380
15,380
14,960
7,980
7,980
7,560
21,940
9,240
12,700
18,000
8,400
9,600
18,000
8,400
9,600
28126
28130
28140
28150
28153
Health Care
Institution Fee
7,400
7,400
7,400
12,540
22,660
18,000
12,120
12,120
7,140
11,760
8,400
6,720
6,720
5,400
10,900
9,600
5,400
5,400
28160
10,540
5,040
5,500
28171
30,740
13,440
17,300
28173
28175
22,660
21,940
11,760
9,240
10,900
12,700
18,000
8,400
9,600
18,000
8,400
9,600
12,540
7,140
5,400
12,540
7,140
5,400
10,880
10,960
10,880
10,960
10,960
10,880
11,132
3,780
5,460
3,780
5,460
5,460
3,780
4,032
7,100
5,500
7,100
5,500
5,500
7,100
7,100
18,420
8,820
9,600
12,540
12,540
12,540
18,000
7,140
7,140
7,140
8,400
5,400
5,400
5,400
9,600
20,980
10,080
10,900
12,120
6,720
5,400
12,120
6,720
5,400
12,900
6,300
6,600
20,980
10,080
10,900
15,380
7,980
7,400
21,940
9,240
12,700
15,380
7,980
7,400
20,980
10,080
10,900
21,820
10,920
10,900
21,820
10,920
10,900
22,660
11,760
10,900
22,660
11,760
10,900
22,660
11,760
10,900
28116
28118
28119
28120
28122
28124
28200
28202
28208
28210
28220
28222
28225
28226
28230
28232
28234
28238
28240
28250
28260
28261
28262
28264
28270
28272
28280
28285
28286
28288
28290
28292
28293
28294
28296
28297
Case Rate
Page 33 of 113
Professional Fee
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
28298
23,080
12,180
10,900
28299
23,080
12,180
10,900
21,400
10,500
10,900
20,980
15,380
10,080
7,980
10,900
7,400
18,420
8,820
9,600
28300
28302
28304
28305
28306
22,360
9,660
12,700
28307
22,360
9,660
12,700
28308
22,360
9,660
12,700
21,940
9,240
12,700
18,420
8,820
9,600
14,960
7,560
7,400
22,360
9,660
12,700
12,540
7,140
5,400
21,940
9,240
12,700
14,960
7,560
7,400
12,120
12,540
21,940
22,360
15,380
6,720
7,140
9,240
9,660
7,980
5,400
5,400
12,700
12,700
7,400
10,960
11,980
5,460
5,880
5,500
6,100
18,000
8,400
9,600
22,360
9,660
12,700
10,960
5,460
5,500
9,700
4,200
5,500
28315
28320
28309
28310
28312
28313
28430
28436
28445
15,380
7,980
7,400
28450
11,132
4,032
7,100
11,980
5,880
6,100
10,120
4,620
5,500
28470
10,880
3,780
7,100
28476
8,260
3,360
4,900
10,880
3,780
7,100
10,120
4,620
5,500
10,540
5,040
5,500
12,120
6,720
5,400
10,120
4,620
5,500
12,120
6,720
5,400
8,260
3,360
4,900
28322
28340
28341
28344
28345
28360
28400
28406
28415
28420
28456
28465
28485
28490
28496
28505
28510
28525
28530
Page 34 of 113
DESCRIPTION
28531
10,120
4,620
Health Care
Institution Fee
5,500
28540
8,260
3,360
4,900
12,540
7,140
5,400
12,540
7,140
5,400
10,880
3,780
7,100
12,540
7,140
5,400
18,000
8,400
9,600
10,960
5,460
5,500
12,540
7,140
5,400
18,000
8,400
9,600
Case Rate
28705
28715
28725
28730
28546
28555
28570
28576
28585
28600
28606
28615
28630
28636
28645
28660
28666
28675
28735
28737
28740
28750
28755
28760
28800
28802
28805
28810
28820
28825
Professional Fee
8,260
3,360
4,900
12,540
7,140
5,400
18,000
8,400
9,600
10,880
3,780
7,100
12,540
7,140
5,400
18,000
8,400
9,600
27,120
27,960
27,120
15,120
15,960
15,120
12,000
12,000
12,000
23,300
12,600
10,700
23,080
12,180
10,900
21,940
9,240
12,700
18,420
18,420
15,380
8,820
8,820
7,980
9,600
9,600
7,400
22,240
11,340
10,900
23,300
12,600
10,700
8,260
3,360
4,900
21,820
10,920
10,900
12,120
18,000
12,120
6,720
8,400
6,720
5,400
9,600
5,400
29000
10,540
5,040
5,500
29010
29015
29020
29025
29035
10,540
10,540
10,540
10,540
10,540
5,040
5,040
5,040
5,040
5,040
5,500
5,500
5,500
5,500
5,500
29040
10,540
5,040
5,500
29044
29046
29055
29058
12,120
12,120
9,300
5,560
6,720
6,720
2,100
1,260
5,400
5,400
7,200
4,300
29065
5,680
1,680
4,000
29075
5,560
1,260
4,300
Page 35 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
5,560
1,260
4,300
8,020
8,440
8,020
8,440
8,440
8,020
8,020
2,520
2,940
2,520
2,940
2,940
2,520
2,520
5,500
5,500
5,500
5,500
5,500
5,500
5,500
8,020
2,520
5,500
29435
29445
8,020
5,680
2,520
1,680
5,500
4,000
29450
5,680
1,680
4,000
18,000
8,400
9,600
20,980
18,000
10,080
8,400
10,900
9,600
Lower Extremity
Casts
29305
29325
29345
29355
29358
29365
29405
29425
29804
29815
Arthroscopy
Arthroscopy, temporomandibular joint, diagnostic, w/ or w/o synovial
biopsy
Arthroscopy, temporomandibular joint, surgical
Arthroscopy, shoulder, diagnostic, w/ or w/o synovial biopsy
29819
21,940
9,240
12,700
29820
29821
29822
29823
20,980
21,820
20,980
23,300
10,080
10,920
10,080
12,600
10,900
10,900
10,900
10,700
30,740
13,440
17,300
12,000
29800
29825
29826
27,120
15,120
29830
18,000
8,400
9,600
29834
21,940
9,240
12,700
29835
29836
29837
29838
29840
29843
29844
29845
20,980
21,820
20,980
23,300
12,120
21,940
20,980
21,820
10,080
10,920
10,080
12,600
6,720
9,240
10,080
10,920
10,900
10,900
10,900
10,700
5,400
12,700
10,900
10,900
23,300
12,600
10,700
29847
23,300
12,600
10,700
29848
23,300
12,600
10,700
29850
27,120
15,120
12,000
29851
27,120
15,120
12,000
29855
27,120
15,120
12,000
29856
27,960
15,960
12,000
29870
29871
18,000
20,980
8,400
10,080
9,600
10,900
29874
Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g.,
osteochondritis dissecans fragmentation, chondral fragmentation)
21,940
9,240
12,700
30,740
13,440
17,300
31,580
14,280
17,300
29846
29875
29876
Page 36 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
23,300
12,600
10,700
30,740
13,440
17,300
30,740
13,440
17,300
29882
27,120
15,120
12,000
29883
30,300
16,800
13,500
29884
23,300
12,600
10,700
23,300
12,600
10,700
27,120
15,120
12,000
23,300
12,600
10,700
37,180
18,480
18,700
38,860
20,160
18,700
21,940
9,240
12,700
20,980
10,080
10,900
20,980
10,080
10,900
21,820
10,920
10,900
5,560
5,560
1,260
1,260
4,300
4,300
5,680
8,020
9,700
1,680
2,520
4,200
4,000
5,500
5,500
9,700
4,200
5,500
29885
29886
29887
29888
29889
29894
29895
29897
29898
30000
30020
30100
30110
30115
30117
30118
9,700
4,200
5,500
12,900
12,900
6,300
6,300
6,600
6,600
8,020
8,020
2,520
2,520
5,500
5,500
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
12,900
6,300
6,600
30540
30545
30560
12,900
18,000
8,260
6,300
8,400
3,360
6,600
9,600
4,900
30580
12,120
6,720
5,400
30600
30630
12,120
12,120
6,720
6,720
5,400
5,400
9,700
4,200
5,500
30130
30140
30310
30320
30460
30462
30465
30520
30801
Page 37 of 113
30905
30915
30920
30930
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
9,700
4,200
5,500
8,020
2,520
5,500
12,120
12,120
9,700
6,720
6,720
4,200
5,400
5,400
5,500
31000
9,300
2,100
7,200
31002
31020
8,020
9,700
2,520
4,200
5,500
5,500
12,120
6,720
5,400
31084
31085
31030
31032
12,120
6,720
5,400
23,300
23,300
12,600
12,600
10,700
10,700
23,300
12,600
10,700
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
23,300
12,600
10,700
31086
23,300
12,600
10,700
31087
23,300
12,600
10,700
31090
23,300
12,600
10,700
12,120
12,120
12,120
46,500
53,400
6,720
6,720
6,720
25,200
29,400
5,400
5,400
5,400
21,300
24,000
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
31237
12,120
6,720
5,400
31238
31239
31240
12,120
12,120
18,000
6,720
6,720
8,400
5,400
5,400
9,600
31254
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
31040
31050
31051
31070
31075
31080
31081
31200
31201
31205
31225
31230
31231
31233
31235
31255
31256
31267
31276
31287
31288
31290
31291
31292
Page 38 of 113
DESCRIPTION
Case Rate
31360
31365
31367
31368
31370
31375
31380
31382
31390
31395
31400
31420
31293
31294
31300
Professional Fee
Health Care
Institution Fee
18,000
8,400
9,600
23,300
12,600
10,700
18,000
8,400
9,600
31,140
37,800
37,180
38,860
31,140
31,140
31,140
31,140
17,640
21,000
18,480
20,160
17,640
17,640
17,640
17,640
13,500
16,800
18,700
18,700
13,500
13,500
13,500
13,500
37,800
21,000
16,800
46,500
30,300
23,300
25,200
16,800
12,600
21,300
13,500
10,700
31515
31520
8,020
9,700
2,520
4,200
5,500
5,500
31525
8,020
2,520
5,500
31526
9,700
4,200
5,500
31527
8,020
2,520
5,500
31528
8,020
2,520
5,500
31529
8,020
2,520
5,500
31530
12,120
6,720
5,400
12,120
6,720
5,400
31535
12,120
6,720
5,400
31536
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
30,300
16,800
13,500
30,300
16,800
13,500
12,120
6,720
5,400
12,120
6,720
5,400
12,120
12,120
12,120
12,120
12,120
6,720
6,720
6,720
6,720
6,720
5,400
5,400
5,400
5,400
5,400
30,300
16,800
13,500
30,300
16,800
13,500
30,300
30,300
30,300
16,800
16,800
16,800
13,500
13,500
13,500
30,300
16,800
13,500
30,300
16,800
13,500
23,300
12,600
10,700
12,120
12,540
7,140
12,540
6,720
7,140
4,760
7,140
5,400
5,400
2,380
5,400
31531
31540
31541
31560
31561
31570
31571
31575
31576
31577
31578
31579
31580
31582
31584
31586
31587
31588
31590
31595
31600
31601
31603
31605
Page 39 of 113
DESCRIPTION
31610
12,540
7,140
Health Care
Institution Fee
5,400
31611
14,960
7,560
7,400
12,900
6,300
6,600
12,120
14,960
6,720
7,560
5,400
7,400
12,120
6,720
5,400
10,960
5,460
5,500
10,960
5,460
5,500
10,960
5,460
5,500
10,960
5,460
5,500
18,000
8,400
9,600
31612
31613
31614
31615
31622
31625
31628
31629
31630
Case Rate
Professional Fee
31631
18,000
8,400
9,600
31635
18,000
8,400
9,600
31636
31640
31641
31643
31645
18,000
8,400
9,600
30,300
16,800
13,500
30,300
16,800
13,500
18,000
8,400
9,600
23,300
12,600
10,700
5,560
1,260
4,300
23,300
12,600
10,700
37,800
37,800
53,400
55,000
55,000
55,000
46,500
53,400
37,800
55,000
23,300
37,800
8,440
9,700
21,000
21,000
29,400
33,600
33,600
33,600
25,200
29,400
21,000
33,600
12,600
21,000
2,940
4,200
16,800
16,800
24,000
21,400
21,400
21,400
21,300
24,000
16,800
21,400
10,700
16,800
5,500
5,500
1,260
840
420
10,540
5,040
5,500
10,540
5,040
5,500
7,980
5,320
2,660
12,120
18,420
31,140
37,800
6,720
8,820
17,640
21,000
5,400
9,600
13,500
16,800
37,800
21,000
16,800
37,800
37,800
21,000
21,000
16,800
16,800
32120
32124
Introduction
Catheterization for bronchography, w/ or w/o instillation of contrast
material
Catheterization w/ bronchial brush biopsy
Repair
Tracheoplasty; cervical
Tracheoplasty; tracheopharyngeal fistulization, each stage
Tracheoplasty; intrathoracic
Carinal reconstruction
Bronchoplasty; graft repair
Bronchoplasty; excision stenosis and anastomosis
Excision tracheal stenosis and anastomosis; cervical
Excision tracheal stenosis and anastomosis; cervicothoracic
Excision of tracheal tumor or carcinoma; cervical
Excision of tracheal tumor or carcinoma; thoracic
Suture of tracheal wound or injury; cervical
Suture of tracheal wound or injury; intrathoracic
Surgical closure tracheostomy or fistula w/o plastic repair
Surgical closure tracheostomy or fistula with plastic repair
Lungs and Pleura
Incision
Thoracentesis, puncture of pleural cavity for aspiration, initial or
subsequent
Thoracentesis w/ insertion of tube w/ or w/o water seal (e.g., for
pneumothorax)
Chemical pleurodesis (e.g., for recurrent or persistent pneumothorax)
Tube thoracostomy w/ or w/o water seal (e.g., for abscess, hemothorax,
empyema)
Thoracostomy; w/ rib resection for empyema
Thoracostomy; w/ open flap drainage for empyema
Thoracotomy, limited, for biopsy of lung or pleura
Thoracotomy, major; w/ exploration and biopsy
Thoracotomy, major; w/ control of traumatic hemorrhage and/or repair of
lung tear
Thoracotomy, major; for postoperative complications
Thoracotomy, major; w/ open intrapleural pneumonolysis
32140
37,800
21,000
16,800
32141
41,160
24,360
16,800
31710
31717
31750
31755
31760
31766
31770
31775
31780
31781
31785
31786
31800
31805
31820
31825
32000
32002
32005
32020
32035
32036
32095
32100
32110
Page 40 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
38,440
19,740
18,700
38,440
38,440
10,120
38,640
38,440
30,300
19,740
19,740
4,620
21,840
19,740
16,800
18,700
18,700
5,500
16,800
18,700
13,500
37,800
37,800
5,560
37,180
8,440
5,560
46,500
21,000
21,000
1,260
18,480
2,940
1,260
25,200
16,800
16,800
4,300
18,700
5,500
4,300
21,300
32442
55,080
31,080
24,000
32445
55,080
31,080
24,000
32480
41,160
24,360
16,800
46,500
25,200
21,300
46,500
25,200
21,300
55,080
31,080
24,000
53,400
29,400
24,000
41,160
24,360
16,800
40,320
23,520
16,800
53,400
53,400
29,400
29,400
24,000
24,000
32482
32484
32486
32488
32491
32520
32522
32525
53,400
29,400
24,000
32540
38,440
19,740
18,700
11,980
12,900
12,120
12,120
12,120
12,120
12,120
12,120
5,880
6,300
6,720
6,720
6,720
6,720
6,720
6,720
6,100
6,600
5,400
5,400
5,400
5,400
5,400
5,400
12,120
6,720
5,400
32660
32661
32500
32601
32602
32603
32604
32605
32606
32650
32651
32652
32653
12,120
6,720
5,400
30,300
16,800
13,500
41,160
24,360
16,800
38,640
21,840
16,800
38,640
21,840
16,800
38,640
21,840
16,800
41,160
24,360
16,800
41,160
24,360
16,800
32662
41,160
24,360
16,800
32663
32664
32665
46,500
41,160
41,160
25,200
24,360
24,360
21,300
16,800
16,800
23,300
12,600
10,700
32654
32655
32656
32658
32659
32800
Page 41 of 113
DESCRIPTION
Case Rate
Closure of chest wall following open flap drainage for empyema (Clagett
type procedure)
Open closure of major bronchial fistula
Major reconstruction, chest wall (posttraumatic)
Lung Transplant
Donor pneumonectomy(ies) w/ preparation and maintenance of allograft
(cadaver)
Lung transplant, single; w/o cardiopulmonary bypass
Lung transplant, single; w/ cardiopulmonary bypass
Lung transplant, double (bilateral sequential or en bloc); w/o
cardiopulmonary bypass
Lung transplant, double (bilateral sequential or en bloc); w/
cardiopulmonary bypass
Surgical Relapse Therapy; Thoracoplasty
Resection of ribs, extrapleural, all stages
Thoracoplasty, Schede type or extrapleural (all stages);
Thoracoplasty, Schede type or extrapleural (all stages); w/ closure of
bronchial fistula
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
46,500
46,500
25,200
25,200
21,300
21,300
55,000
33,600
21,400
63,000
64,680
42,000
43,680
21,000
21,000
65,520
44,520
21,000
65,520
44,520
21,000
46,500
46,500
25,200
25,200
21,300
21,300
46,500
25,200
21,300
30,300
16,800
13,500
5,560
1,260
4,300
8,020
9,700
2,520
4,200
5,500
5,500
32940
32960
33010
33015
33020
18,000
8,400
9,600
33025
33030
33031
33050
32,000
46,500
58,800
37,800
14,700
25,200
37,800
21,000
17,300
21,300
21,000
16,800
60,900
39,900
39,900
23,100
21,000
16,800
21,400
10,500
10,900
21,400
10,500
10,900
18,000
8,400
9,600
18,000
8,400
9,600
21,400
10,500
10,900
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
12,900
6,300
6,600
32,000
14,700
17,300
12,900
6,300
6,600
33120
33130
33200
33201
33206
33207
33208
33210
33211
33212
33213
33214
33216
33217
18,000
8,400
9,600
33218
23,300
12,600
10,700
33220
23,300
12,600
10,700
18,000
8,400
9,600
18,000
8,400
9,600
33222
33223
Page 42 of 113
33249
DESCRIPTION
Removal of transvenous pacemaker pulse generator
Removal of permanent of transvenous pacemaker electrode(s); single lead
system, atrial or ventricular
Removal of permanent of transvenous pacemaker electrode(s); dual lead
chamber
Removal of permanent epicardial pacemaker and electrodes by
thoracotomy; single lead system, atrial or ventricular
Removal of permanent epicardial pacemaker and electrodes by
thoracotomy; dual lead chamber
Removal of permanent transvenous electrode(s) by thoracotomy
Insertion or replacement of implantable cardioverter-defibrillator pulse
generator
12,900
6,300
Health Care
Institution Fee
6,600
23,300
12,600
10,700
32,000
14,700
17,300
30,300
16,800
13,500
37,600
18,900
18,700
30,300
16,800
13,500
18,000
8,400
9,600
18,000
8,400
9,600
30,300
16,800
13,500
30,300
16,800
13,500
12,900
6,300
6,600
21,400
10,500
10,900
18,000
8,400
9,600
Case Rate
Professional Fee
33250
37,600
18,900
18,700
33251
53,400
29,400
24,000
58,800
37,800
21,000
58,800
37,800
21,000
46,500
58,800
25,200
37,800
21,300
21,000
46,500
25,200
21,300
58,800
37,800
21,000
30,300
16,800
13,500
58,800
58,800
37,800
37,800
21,000
21,000
46,500
25,200
21,300
63,000
63,000
42,000
42,000
21,000
21,000
53,400
53,400
29,400
29,400
24,000
24,000
55,000
33,600
21,400
58,800
37,800
21,000
53,400
29,400
24,000
58,800
37,800
21,000
55,000
33,600
21,400
58,800
37,800
21,000
33300
33305
33310
33253
33261
33315
33320
33321
33322
33330
33332
33335
33400
33401
33403
33404
33405
33406
33411
33412
Page 43 of 113
33415
DESCRIPTION
Case Rate
33420
33422
33425
33426
33416
33417
Professional Fee
Health Care
Institution Fee
71,400
50,400
21,000
46,500
25,200
21,300
46,500
25,200
21,300
55,000
33,600
21,400
46,500
25,200
21,300
37,800
53,400
55,000
21,000
29,400
33,600
16,800
24,000
21,400
57,100
35,700
21,400
58,800
37,800
21,000
46,500
25,200
21,300
46,500
53,400
55,000
53,400
58,800
25,200
29,400
33,600
29,400
37,800
21,300
24,000
21,400
24,000
21,000
30,300
23,300
46,500
46,500
53,400
16,800
12,600
25,200
25,200
29,400
13,500
10,700
21,300
21,300
24,000
46,500
25,200
21,300
53,400
29,400
24,000
46,500
25,200
21,300
30,300
16,800
13,500
33502
30,300
16,800
13,500
33503
46,500
25,200
21,300
33504
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
53,400
53,400
55,000
58,800
58,800
58,800
29,400
29,400
33,600
37,800
37,800
37,800
24,000
24,000
21,400
21,000
21,000
21,000
53,400
29,400
24,000
33427
33430
33460
33463
33464
33465
33468
33470
33471
33472
33474
33475
33476
33478
33500
33501
33505
33506
33510
33511
33512
33513
33514
33516
33517
33518
Coronary artery bypass, using venous graft(s) and arterial graft(s); two
venous grafts (list separately in addition to code for arterial graft)
53,400
29,400
24,000
33519
Coronary artery bypass, using venous graft(s) and arterial graft(s); three
venous grafts (list separately in addition to code for arterial graft)
55,000
33,600
21,400
33521
Coronary artery bypass, using venous graft(s) and arterial graft(s); four
venous grafts (list separately in addition to code for arterial graft)
58,800
37,800
21,000
33522
Coronary artery bypass, using venous graft(s) and arterial graft(s); five
venous grafts (list separately in addition to code for arterial graft)
58,800
37,800
21,000
Page 44 of 113
33530
DESCRIPTION
Case Rate
Coronary artery bypass, using venous graft(s) and arterial graft(s); six or
more venous grafts (list separately in addition to code for arterial graft)
Reoperation, coronary artery bypass procedure or valve procedure, more
than one month after original operation (list separately in addition to code
for primary procedure)
Arterial Grafting for Coronary Artery Bypass
Professional Fee
Health Care
Institution Fee
58,800
37,800
21,000
63,000
42,000
21,000
33533
53,400
29,400
24,000
33534
Coronary artery bypass, using arterial graft(s); two coronary arterial grafts
53,400
29,400
24,000
33535
Coronary artery bypass, using arterial graft(s); three coronary arterial grafts
55,000
33,600
21,400
58,800
37,800
21,000
63,000
42,000
21,000
63,000
42,000
21,000
9,700
4,200
5,500
33536
33542
33545
33572
33600
46,500
25,200
21,300
33602
46,500
25,200
21,300
33606
53,400
29,400
24,000
33608
55,000
33,600
21,400
33610
55,000
33,600
21,400
33611
55,000
33,600
21,400
33612
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
63,000
42,000
21,000
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
58,800
46,500
37,800
25,200
21,000
21,300
55,000
33,600
21,400
55,000
33,600
21,400
21,400
55,000
10,500
33,600
10,900
21,400
33615
33617
33619
33641
33645
33647
33660
33665
33670
33681
33684
33688
33690
33692
Page 45 of 113
33702
33710
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
55,000
33,600
21,400
55,000
33,600
21,400
46,500
25,200
21,300
55,000
33,600
21,400
33720
53,400
29,400
24,000
33722
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
21,400
10,500
10,900
33736
46,500
25,200
21,300
33737
46,500
25,200
21,300
33750
30,300
16,800
13,500
33764
23,300
12,600
10,700
30,300
16,800
13,500
46,500
25,200
21,300
58,800
37,800
21,000
58,800
37,800
21,000
33730
33732
33735
33766
33767
33770
33771
33774
58,800
37,800
21,000
33775
60,900
39,900
21,000
33776
60,900
39,900
21,000
33777
60,900
39,900
21,000
33778
63,000
42,000
21,000
33779
65,100
44,100
21,000
33780
71,400
50,400
21,000
33781
71,400
50,400
21,000
58,800
55,000
37,800
33,600
21,000
21,400
21,400
10,500
10,900
21,400
23,300
10,500
12,600
10,900
10,700
33802
33803
Truncus Arteriosus
Total repair, truncus arteriosus (Rastelli type operation)
Reimplantation of an anomalous pulmonary artery
Aortic Anomalies
Aortic suspension (aortopexy) for tracheal decompression (e.g., for
tracheomalacia)
Division of aberrant vessel (vascular ring)
Division of aberrant vessel (vascular ring) w/ reanastomosis
33814
46,500
25,200
21,300
33820
33822
32,000
30,300
14,700
16,800
17,300
13,500
33786
33788
33800
Page 46 of 113
DESCRIPTION
Repair of patent ductus arteriosus; by division, 18 years and older
Excision of coarctation of aorta, w/ or w/o associated patent ductus
arteriosus; w/ direct anastomosis
Excision of coarctation of aorta, w/ or w/o associated patent ductus
arteriosus; with graft
Excision of coarctation of aorta, w/ or w/o associated patent ductus
arteriosus; repair using either left subclavian artery or prosthetic material as
gusset for enlargement
Repair of hypoplastic or interrupted aortic arch using autogenous or
prosthetic material; w/o cardiopulmonary bypass
Repair of hypoplastic or interrupted aortic arch using autogenous or
prosthetic material; w/ cardiopulmonary bypass
Thoracic Aortic Aneurysm
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension;
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension; w/ coronary reconstruction
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension; w/ aortic root replacement using composite prosthesis and
coronary reconstruction
Transverse arch graft, w/ cardiopulmonary bypass
Descending thoracic aorta graft, w/ or w/o bypass
Repair of thoracoabdominal aortic aneurysm w/ graft, w/ or w/o
cardiopulmonary bypass
Pulmonary Artery
Pulmonary artery embolectomy; w/ cardiopulmonary bypass
Pulmonary artery embolectomy; w/o cardiopulmonary bypass
Pulmonary endarterectomy, w/ or w/o embolectomy, w/ cardiopulmonary
bypass
30,300
16,800
Health Care
Institution Fee
13,500
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
46,500
25,200
21,300
55,000
33,600
21,400
58,800
37,800
21,000
71,400
50,400
21,000
71,400
63,000
50,400
42,000
21,000
21,000
71,400
50,400
21,000
46,500
30,300
25,200
16,800
21,300
13,500
53,400
29,400
24,000
33917
53,400
29,400
24,000
33918
30,300
16,800
13,500
33919
46,500
25,200
21,300
33920
58,800
37,800
21,000
46,500
25,200
21,300
18,000
8,400
9,600
46,500
25,200
21,300
33935
75,600
54,600
21,000
33940
46,500
25,200
21,300
33945
75,600
54,600
21,000
12,900
6,300
6,600
9,700
4,200
5,500
33973
21,400
10,500
10,900
33974
30,300
16,800
13,500
33975
46,500
25,200
21,300
33976
33977
33978
55,000
37,800
46,500
33,600
21,000
25,200
21,400
16,800
21,300
32,000
14,700
17,300
32,000
14,700
17,300
33824
33840
33845
33851
33852
33853
33860
33861
33863
33870
33875
33877
33910
33915
33916
33922
33924
33930
33970
33971
34001
34051
Case Rate
Page 47 of 113
Professional Fee
34401
34421
34451
34471
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
32,000
14,700
17,300
37,600
18,900
18,700
32,000
14,700
17,300
23,300
12,600
10,700
30,300
30,300
30,300
30,300
30,300
16,800
16,800
16,800
16,800
16,800
13,500
13,500
13,500
13,500
13,500
34501
34502
34510
34520
34530
35001
23,300
12,600
10,700
35002
30,300
16,800
13,500
35005
30,300
16,800
13,500
35011
18,000
8,400
9,600
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
34490
35013
35021
35022
35045
18,000
8,400
9,600
35081
46,500
25,200
21,300
53,400
29,400
24,000
53,400
29,400
24,000
35082
35091
Page 48 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
35092
55,000
33,600
21,400
35102
46,500
25,200
21,300
35103
53,400
29,400
24,000
35111
46,500
25,200
21,300
35112
53,400
29,400
24,000
35121
46,500
25,200
21,300
35122
53,400
29,400
24,000
35131
23,300
12,600
10,700
30,300
16,800
13,500
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
30,300
16,800
13,500
37,800
21,000
16,800
35132
35141
35142
35151
35152
35161
35162
35180
35182
35184
23,300
30,300
23,300
12,600
16,800
12,600
10,700
13,500
10,700
35188
23,300
12,600
10,700
35189
30,300
16,800
13,500
35190
23,300
12,600
10,700
18,000
18,000
18,000
46,500
30,300
18,000
18,000
23,300
18,000
8,400
8,400
8,400
25,200
16,800
8,400
8,400
12,600
8,400
9,600
9,600
9,600
21,300
13,500
9,600
9,600
10,700
9,600
35201
35206
35207
35211
35216
35221
35226
35231
35236
Page 49 of 113
DESCRIPTION
35241
35246
35251
35256
35261
35266
35271
46,500
30,300
23,300
18,000
23,300
18,000
46,500
25,200
16,800
12,600
8,400
12,600
8,400
25,200
Health Care
Institution Fee
21,300
13,500
10,700
9,600
10,700
9,600
21,300
35276
Repair blood vessel w/ graft other than vein; intrathoracic, w/o bypass
30,300
16,800
13,500
35281
35286
23,300
18,000
12,600
8,400
10,700
9,600
37,600
18,900
18,700
37,600
18,900
18,700
35321
35331
37,600
37,600
18,900
18,900
18,700
18,700
35341
37,600
18,900
18,700
35351
35355
30,300
30,300
16,800
16,800
13,500
13,500
35361
46,500
25,200
21,300
35363
23,300
12,600
10,700
35371
23,300
12,600
10,700
35372
23,300
12,600
10,700
30,300
16,800
13,500
35301
35311
35381
Case Rate
Professional Fee
35450
21,400
10,500
10,900
35452
35454
35456
21,400
21,400
21,400
10,500
10,500
10,500
10,900
10,900
10,900
21,400
10,500
10,900
35459
21,400
10,500
10,900
35460
21,400
10,500
10,900
12,900
6,300
6,600
35471
12,900
6,300
6,600
35472
35473
12,900
12,900
6,300
6,300
6,600
6,600
35474
12,900
6,300
6,600
12,900
6,300
6,600
12,900
6,300
6,600
35458
35470
35475
35476
35480
23,300
12,600
10,700
35481
35482
35483
23,300
23,300
23,300
12,600
12,600
12,600
10,700
10,700
10,700
23,300
12,600
10,700
23,300
12,600
10,700
21,400
10,500
10,900
35491
35492
21,400
21,400
10,500
10,500
10,900
10,900
35493
21,400
10,500
10,900
35494
21,400
10,500
10,900
35484
35485
35490
Page 50 of 113
DESCRIPTION
Case Rate
35601
35606
35612
35616
35621
35623
35626
In - Situ Vein
In-situ vein bypass; aortofemoral-popliteal (only femoral-popliteal portion
in-situ)
In-situ vein bypass;femoral-popliteal
In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal
artery
In-situ vein bypass; popliteal -tibial, peroneal
Other Than Vein
Bypass graft, with other than vein; carotid
Bypass graft, with other than vein; carotid-subclavian
Bypass graft, with other than vein; subclavian-subclavian
Bypass graft, with other than vein; subclavian-axillary
Bypass graft, with other than vein; axillary-femoral
Bypass graft, with other than vein; axillary-popliteal or -tibial
Bypass graft, with other than vein; aortosubclavian or carotid
35631
35582
35583
35585
35587
Professional Fee
Health Care
Institution Fee
21,400
10,500
10,900
37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
46,500
46,500
46,500
46,500
46,500
46,500
46,500
46,500
46,500
30,300
23,300
37,800
30,300
30,300
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
25,200
25,200
25,200
25,200
25,200
25,200
25,200
25,200
25,200
16,800
12,600
21,000
16,800
16,800
18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
21,300
21,300
21,300
21,300
21,300
21,300
21,300
21,300
21,300
13,500
10,700
16,800
13,500
13,500
30,300
16,800
13,500
23,300
12,600
10,700
46,500
25,200
21,300
37,800
21,000
16,800
37,800
21,000
16,800
37,800
21,000
16,800
37,600
37,600
37,600
37,600
37,600
37,600
46,500
18,900
18,900
18,900
18,900
18,900
18,900
25,200
18,700
18,700
18,700
18,700
18,700
18,700
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
37,600
37,600
46,500
37,600
46,500
37,600
30,300
23,300
30,300
30,300
25,200
18,900
18,900
25,200
18,900
25,200
18,900
16,800
12,600
16,800
16,800
21,300
18,700
18,700
21,300
18,700
21,300
18,700
13,500
10,700
13,500
13,500
30,300
16,800
13,500
23,300
46,500
12,600
25,200
10,700
21,300
35691
Bypass graft, with other than vein; splenorenal (splenic to renal arterial
anastomosis)
Bypass graft, with other than vein; aortoiliac or bi-iliac
Bypass graft, with other than vein; carotid-vertebral
Bypass graft, with other than vein; subclavian-vertebral
Bypass graft, with other than vein; aortofemoral or bifemoral
Bypass graft, with other than vein; axillary-axillary
Bypass graft, with other than vein; aortofemoral-popliteal
Bypass graft, with other than vein; axillary-femoral-femoral
Bypass graft, with other than vein; femoral-popliteal
Bypass graft, with other than vein; femoral-femoral
Bypass graft, with other than vein; ilioiliac
Bypass graft, with other than vein; iliofemoral
Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial,
or peroneal artery
Bypass graft, with other than vein; popliteal-tibial or -peroneal artery
Bypass graft; composite
Arterial Transposition
Transposition and/or reimplantation; vertebral to carotid artery
37,600
18,900
18,700
35693
37,600
18,900
18,700
35694
37,600
18,900
18,700
35695
37,600
18,900
18,700
35636
35641
35642
35645
35646
35650
35651
35654
35656
35661
35663
35665
35666
35671
35681
Page 51 of 113
35700
35701
35721
35741
35761
DESCRIPTION
Case Rate
Exploration
Reoperation, femoral-popliteal or femoral (popliteal) -anterior
tibial,posterior tibial, peroneal artery or other distal vessels, more than one
month after original operation (List separately in addition to code for
primary procedure)
Exploration (not followed by surgical repair), w/ or w/o lysis of artery;
carotid artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery;
femoral artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery;
popliteal artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery; other
vessels
Professional Fee
Health Care
Institution Fee
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
35800
9,700
4,200
5,500
35820
18,000
8,400
9,600
18,000
8,400
9,600
9,700
4,200
5,500
23,300
23,300
12,600
12,600
10,700
10,700
23,300
12,600
10,700
30,300
30,300
37,800
30,300
16,800
16,800
21,000
16,800
13,500
13,500
16,800
13,500
3,640
840
2,800
9,300
2,100
7,200
8,020
2,520
5,500
8,020
8,020
2,520
2,520
5,500
5,500
8,440
2,940
5,500
8,440
9,300
9,300
2,940
2,100
2,100
5,500
7,200
7,200
8,260
3,360
4,900
9,300
2,100
7,200
9,300
2,100
7,200
9,300
2,100
7,200
36013
36014
36015
35840
35860
35870
35875
35876
35901
35903
35905
35907
36010
36011
36012
36100
36120
36140
36145
36200
36215
36216
Intra-Arterial-Intra-Aortic
Introduction of needle or intracatheter, carotid or vertebral artery
Introduction of needle or intracatheter; retrograde brachial artery
Introduction of needle or intracatheter; extremity artery
Introduction of needle or intracatheter; arteriovenous shunt created for
dialysis (cannula, fistula, or graft)
Introduction of catheter, aorta
Selective catheter placement, arterial system; each first order thoracic or
brachiocephalic branch, w/in a vascular family
Selective catheter placement, arterial system; initial second order thoracic
or brachiocephalic branch, w/in a vascular family
36217
8,020
2,520
5,500
36245
9,300
2,100
7,200
36246
9,300
2,100
7,200
8,020
2,520
5,500
23,300
12,600
10,700
9,700
9,700
4,200
4,200
5,500
5,500
3,640
5,680
9,300
840
1,680
2,100
2,800
4,000
7,200
9,700
4,200
5,500
36247
36260
36261
36262
36430
36450
36481
36488
Page 52 of 113
DESCRIPTION
3,640
3,640
9,700
840
840
4,200
3,640
840
2,800
5,680
1,680
4,000
36781
Health Care
Institution Fee
2,800
2,800
5,500
9,300
2,100
7,200
36800
9,300
2,100
7,200
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
18,000
8,400
9,600
12,900
6,300
6,600
12,900
6,300
6,600
9,700
4,200
5,500
8,260
9,300
3,360
2,100
4,900
7,200
30,300
37,800
30,300
37,600
16,800
21,000
16,800
18,900
13,500
16,800
13,500
18,700
37,800
21,000
16,800
53,400
29,400
24,000
46,500
25,200
21,300
46,500
25,200
21,300
8,260
8,020
3,360
2,520
4,900
5,500
8,020
2,520
5,500
9,700
4,200
5,500
46,500
25,200
21,300
46,500
25,200
21,300
23,300
12,600
10,700
5,680
5,680
18,000
1,680
1,680
8,400
4,000
4,000
9,600
21,940
9,240
12,700
9,300
9,300
18,000
21,400
18,000
12,900
2,100
2,100
8,400
10,500
8,400
6,300
7,200
7,200
9,600
10,900
9,600
6,600
36510
36511
36568
36640
36660
36810
36815
36821
36822
36825
36830
36832
36834
36835
37140
37145
37160
37180
37181
37182
37184
37187
37200
37201
37202
37203
37204
37205
37207
37565
37600
37605
37606
37607
37609
37615
37616
37617
37618
Case Rate
Page 53 of 113
Professional Fee
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
9,300
12,900
2,100
6,300
7,200
6,600
9,300
2,100
7,200
12,900
6,300
6,600
18,000
8,400
9,600
37735
21,400
10,500
10,900
37760
21,400
10,500
10,900
37780
9,700
4,200
5,500
37788
37790
46,500
23,300
25,200
12,600
21,300
10,700
30,740
23,300
13,440
12,600
17,300
10,700
32,000
14,700
17,300
38115
30,300
16,800
13,500
38120
Laparoscopy
Laparoscopy, surgical; splenectomy
Bone Marrow or Stem Cell Services and Procedures
30,740
13,440
17,300
38205
10,880
3,780
7,100
38220
38230
10,880
18,000
3,780
8,400
7,100
9,600
37,800
21,000
16,800
8,260
30,300
30,300
30,300
3,360
16,800
16,800
16,800
4,900
13,500
13,500
13,500
5,680
1,680
4,000
5,680
1,680
4,000
8,260
3,360
4,900
9,300
2,100
7,200
9,300
9,300
21,940
2,100
2,100
9,240
7,200
7,200
12,700
37,800
21,000
16,800
46,500
25,200
21,300
27,120
15,120
12,000
38571
30,300
16,800
13,500
38572
Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and periaortic lymph node sampling (biopsy), single or multiple
58,800
37,800
21,000
27,120
30,300
30,300
23,300
15,120
16,800
16,800
12,600
12,000
13,500
13,500
10,700
38100
38101
38102
38240
38300
38380
38381
38382
38500
38505
38510
38520
38525
38530
38542
38550
38555
38570
38700
38720
38724
38740
Page 54 of 113
38765
38770
38780
39000
39010
39200
39220
39400
39501
39502
39503
39520
39530
DESCRIPTION
Axillary lymphadenectomy; complete
Thoracic lymphadenectomy, regional, including mediastinal and
peritracheal nodes
Abdominal lymphadenectomy, regional, including celiac, para-aortic and
venal caval nodes
30,300
16,800
Health Care
Institution Fee
13,500
37,800
21,000
16,800
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
37,800
21,000
16,800
37,800
21,000
16,800
18,000
8,400
9,600
23,300
12,600
10,700
37,800
41,160
21,000
24,360
16,800
16,800
14,960
7,560
7,400
37,800
21,000
16,800
40,320
23,520
16,800
40,320
23,520
16,800
40,320
23,520
16,800
40,320
23,520
16,800
Case Rate
Professional Fee
39531
40,320
23,520
16,800
39540
40,320
23,520
16,800
39541
46,500
25,200
21,300
40,320
23,520
16,800
5,560
8,020
8,020
8,020
1,260
2,520
2,520
2,520
4,300
5,500
5,500
5,500
23,300
12,600
10,700
30,740
13,440
17,300
8,260
3,360
4,900
9,700
9,700
4,200
4,200
5,500
5,500
9,700
4,200
5,500
37,800
21,000
16,800
37,800
21,000
16,800
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
40650
40652
40654
39545
40490
40500
40510
40520
40525
40527
40530
40700
40701
40702
40720
40761
Page 55 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
5,680
1,680
4,000
40808
Vestibule of Mouth
Incision
Drainage of abscess, cyst, hematoma, vestibule of mouth
Excision, Destruction
Biopsy, vestibule of mouth
5,680
1,680
4,000
40810
5,680
1,680
4,000
40818
8,440
2,940
5,500
9,300
2,100
7,200
40830
40831
40840
40842
40843
40844
5,680
5,680
12,120
12,120
12,120
18,000
1,680
1,680
6,720
6,720
6,720
8,400
4,000
4,000
5,400
5,400
5,400
9,600
40845
18,000
8,400
9,600
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,560
5,560
5,560
9,300
9,300
9,300
9,300
9,300
9,300
8,260
10,880
37,800
1,260
1,260
1,260
2,100
2,100
2,100
2,100
2,100
2,100
3,360
3,780
21,000
4,300
4,300
4,300
7,200
7,200
7,200
7,200
7,200
7,200
4,900
7,100
16,800
37,800
21,000
16,800
37,800
21,000
16,800
40,320
23,520
16,800
46,500
25,200
21,300
53,400
29,400
24,000
9,700
4,200
5,500
9,700
9,700
4,200
4,200
5,500
5,500
9,700
4,200
5,500
40800
40819
41250
41251
41252
41500
Incision
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; lingual
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; sublingual, superficial
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; sublingual, deep, supramylohyoid
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; submental space
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; submandibular space
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; masticator space
Extraoral incision and drainage of abscess,cyst,or hematoma of floor of
mouth; sublingual
Extraoral incision and drainage of abscess,cyst,or hematoma of floor of
mouth; submental
Extraoral incision and drainage of abscess,cyst,or hematoma of floor of
mouth; submandibular
Extraoral incision and drainage of abscess,cyst,or hematoma of floor of
mouth; masticator space
Excision
Biopsy of tongue; anterior two-thirds
Biopsy of tongue; posterior one-third
Biopsy of floor of mouth
Excision of lesion of tongue w/o closure
Excision of lesion of tongue w/ closure; anterior two-thirds
Excision of lesion of tongue w/ closure; posterior one-third
Excision of lesion of tongue w/ closure; w/ local tongue flap
Excision of lingual frenum (frenectomy)
Excision, lesion of floor of mouth
Glossectomy; less than one-half tongue
Glossectomy; hemiglossectomy
Glossectomy; partial, w/ unilateral radical neck dissection
Glossectomy; complete or total, w/ or w/o tracheostomy, w/o radical neck
dissection
Glossectomy; complete or total, w/ or w/o tracheostomy, w/ unilateral
radical neck dissection
Glossectomy; composite procedure w/ resection floor of mouth and
mandibular resection, w/o radical neck dissection
Glossectomy; composite procedure w/ resection floor of mouth, w/
suprahyoid neck dissection
Glossectomy; composite procedure w/ resection floor of mouth,
mandibular resection, and radical neck dissection (Commando type)
Repair
Repair of laceration 2.5 cm or less; floor of mouth and/or anterior twothirds of tongue
Repair of laceration 2.5 cm or less; posterior one-third of tongue
Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex
Other Procedures
Frenoplasty (surgical revision of frenum, eg, w/ Z-plasty)
Page 56 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
41510
9,700
4,200
5,500
41520
9,700
4,200
5,500
5,680
1,680
4,000
3,640
840
2,800
3,640
840
2,800
8,020
8,020
8,020
8,020
2,520
2,520
2,520
2,520
5,500
5,500
5,500
5,500
8,020
2,520
5,500
8,020
8,260
8,260
2,520
3,360
3,360
5,500
4,900
4,900
8,260
18,000
18,000
3,360
8,400
8,400
4,900
9,600
9,600
8,020
2,520
5,500
5,560
5,680
9,300
9,300
20,980
12,120
1,260
1,680
2,100
2,100
10,080
6,720
4,300
4,000
7,200
7,200
10,900
5,400
23,300
12,600
10,700
10,540
5,040
5,500
12,120
18,000
20,980
6,720
8,400
10,080
5,400
9,600
10,900
21,820
10,920
10,900
22,660
11,760
10,900
23,300
23,300
30,740
23,300
23,300
23,300
12,120
12,600
12,600
13,440
12,600
12,600
12,600
6,720
10,700
10,700
17,300
10,700
10,700
10,700
5,400
5,680
5,680
5,680
5,680
9,300
1,680
1,680
1,680
1,680
2,100
4,000
4,000
4,000
4,000
7,200
9,300
2,100
7,200
5,560
5,560
9,300
9,300
1,260
1,260
2,100
2,100
4,300
4,300
7,200
7,200
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
41800
41805
41806
42180
42182
42200
Excision, Destruction
Gingivectomy, excision gingiva
Operculectomy, excision pericoronal tissues
Excision of fibrous tuberosities, dentoalveolar structures
Excision of osseous tuberosities, dentoalveolar structures
Excision of lesion or or tumor (except listed above), dentoalveolar
structures
Excision of hyperplastic alveolar mucosa
Alveolectomy, including curettage of osteitis or sequestrectomy
Destruction of lesion (except excision), dentoalveolar structures
Other Procedures
Periodontal mucosal grafting
Gingivoplasty
Alveoloplasty
Palate and Uvula
Incision
Drainage of abscess of palate, uvula
Excision, Destruction
Biopsy of palate, uvula
Excision, lesion of palate , uvula; w/o closure
Excision, lesion of palate , uvula; w/ simple primary closure
Excision, lesion of palate , uvula; w/ local flap closure
Resection of palate or extensive resection of lesion
Uvulectomy, excision of uvula
Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty,
uvulopharyngoplasty)
Destruction of lesion, palate or uvula (thermal, cryo or chemical)
Repair
Repair, laceration of palate; up to 2 cm
Repair, laceration of palate; over 2 cm or complex
Palatoplasty for cleft palate, soft and/or hard palate only
42205
Palatoplasty for cleft palate, w/ closure of alveolar ridge; soft tissue only
41820
41821
41822
41823
41825
41828
41830
41850
41870
41872
41874
42000
42100
42104
42106
42107
42120
42140
42145
42160
42210
42215
42220
42225
42226
42227
42235
42260
42300
42310
42320
42325
42326
42330
42400
42405
42408
42409
42410
42415
42420
42425
Page 57 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
37,800
21,000
16,800
18,000
18,000
8,400
8,400
9,600
9,600
42500
18,000
8,400
9,600
42505
18,000
8,400
9,600
42507
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
8,260
8,260
3,360
3,360
4,900
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,020
8,020
8,020
8,020
8,020
8,020
2,520
2,520
2,520
2,520
2,520
2,520
5,500
5,500
5,500
5,500
5,500
5,500
18,000
8,400
9,600
18,000
8,400
9,600
18,000
18,000
18,000
18,000
8,400
8,400
8,400
8,400
9,600
9,600
9,600
9,600
10,540
5,040
5,500
12,120
6,720
5,400
12,120
6,720
5,400
8,020
8,020
37,800
2,520
2,520
21,000
5,500
5,500
16,800
46,500
25,200
21,300
53,400
29,400
24,000
20,980
20,980
23,300
10,080
10,080
12,600
10,900
10,900
10,700
8,020
2,520
5,500
12,120
18,000
37,800
6,720
8,400
21,000
5,400
9,600
16,800
43100
23,300
12,600
10,700
43101
37,800
21,000
16,800
43107
55,000
33,600
21,400
42508
42509
42510
42600
42665
42700
42720
42725
42800
42802
42804
42806
42808
42809
42810
42815
42820
42825
42830
42835
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
42953
42955
43020
43030
43045
Page 58 of 113
43112
43113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
58,800
37,800
21,000
59,640
38,640
21,000
63,000
42,000
21,000
43116
55,000
33,600
21,400
43117
55,000
33,600
21,400
58,800
37,800
21,000
55,000
33,600
21,400
55,000
33,600
21,400
58,800
37,800
21,000
46,500
25,200
21,300
23,300
12,600
10,700
37,800
21,000
16,800
10,540
5,040
5,500
43118
43121
43122
43202
10,540
5,040
5,500
43204
14,960
7,560
7,400
43205
14,960
7,560
7,400
43215
14,960
7,560
7,400
11,980
5,880
6,100
12,120
6,720
5,400
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
14,960
7,560
7,400
18,000
8,400
9,600
10,540
5,040
5,500
10,540
5,040
5,500
43123
43124
43130
43135
43200
43216
43217
43219
43220
43226
43227
43228
43234
43235
43239
10,540
5,040
5,500
43241
12,120
6,720
5,400
Page 59 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
43243
14,960
7,560
7,400
43244
14,960
7,560
7,400
43245
18,000
8,400
9,600
43246
18,000
8,400
9,600
43247
14,960
7,560
7,400
43248
18,000
8,400
9,600
43249
18,000
8,400
9,600
43250
11,980
5,880
6,100
43251
12,120
6,720
5,400
43255
14,960
7,560
7,400
43258
18,000
8,400
9,600
14,960
7,560
7,400
20,980
10,080
10,900
20,980
10,080
10,900
21,820
10,920
10,900
43259
43260
43261
43262
43263
21,820
10,920
10,900
43264
23,300
12,600
10,700
43265
30,740
13,440
17,300
43267
22,660
11,760
10,900
43268
22,660
11,760
10,900
43269
22,660
11,760
10,900
43271
23,300
12,600
10,700
Page 60 of 113
43272
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
46,500
25,200
21,300
30,300
16,800
13,500
30,300
16,800
13,500
46,500
25,200
21,300
53,400
29,400
24,000
46,500
25,200
21,300
43324
Laparoscopy
Laparoscopy, surgical, esophagogastic fundoplasty (e.g., Nissen, Toupet
procedures)
Repair
Esophagoplasty, (plastic repair or reconstruction), cervical approach; w/o
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), cervical approach; w/
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), thoracic approach; w/o
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), thoracic approach; w/
repair of tracheoesophageal fistula
Esophagogastrostomy (cardioplasty), w/ or w/o vagotomy and pyloroplasty,
transabdominal or transthoracic approach
Esophagogastric fundoplasty (e.g., Nissen, Belsey IV, Hill procedures)
46,500
25,200
21,300
43325
46,500
25,200
21,300
43326
43330
43331
43340
43341
48,600
37,800
46,500
37,800
46,500
27,300
21,000
25,200
21,000
25,200
21,300
16,800
21,300
16,800
21,300
43350
23,300
12,600
10,700
43351
30,300
16,800
13,500
43352
12,120
6,720
5,400
43360
58,800
37,800
21,000
43361
63,000
42,000
21,000
37,800
37,800
21,000
21,000
16,800
16,800
37,800
21,000
16,800
12,120
6,720
5,400
37,800
21,000
16,800
12,120
6,720
5,400
37,800
21,000
16,800
8,260
3,360
4,900
8,260
8,260
3,360
3,360
4,900
4,900
8,260
3,360
4,900
43280
43300
43305
43310
43312
43320
43400
43401
43453
43456
43458
43460
43496
9,700
58,800
4,200
37,800
5,500
21,000
30,300
38,020
16,800
19,320
13,500
18,700
38,020
19,320
18,700
38,020
19,320
18,700
43520
38,020
19,320
18,700
43600
43605
43610
Excision
Biopsy of stomach; by capsule, tube, peroral (one or more specimens)
Biopsy of stomach; by laparotomy
Excision, local; ulcer or benign tumor of stomach
8,260
30,300
38,020
3,360
16,800
19,320
4,900
13,500
18,700
43405
43410
43415
43420
43425
43450
43500
43501
43502
43510
Page 61 of 113
DESCRIPTION
38,020
63,000
67,200
67,200
55,000
55,000
63,000
63,000
19,320
42,000
46,200
46,200
33,600
33,600
42,000
42,000
Health Care
Institution Fee
18,700
21,000
21,000
21,000
21,400
21,400
21,000
21,000
63,000
42,000
21,000
67,200
46,200
21,000
37,800
21,000
16,800
46,500
25,200
21,300
18,000
8,400
9,600
21,940
9,240
12,700
18,000
8,400
9,600
8,020
5,560
2,520
1,260
5,500
4,300
37,800
63,000
46,500
53,400
37,800
21,000
42,000
25,200
29,400
21,000
16,800
21,000
21,300
24,000
16,800
Case Rate
Professional Fee
43800
43810
43820
43825
43830
43831
37,800
21,000
16,800
43832
37,800
21,000
16,800
46,500
25,200
21,300
55,000
33,600
21,400
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
63,000
42,000
21,000
58,800
37,800
21,000
63,000
42,000
21,000
46,500
58,800
25,200
37,800
21,300
21,000
58,800
53,400
37,800
29,400
21,000
24,000
37,800
21,000
16,800
43640
43641
43651
43652
43653
43750
43760
43840
43842
43843
43846
43847
43848
43850
43855
43860
43865
43870
43880
44005
44010
44020
44021
37,800
21,000
16,800
44025
37,800
21,000
16,800
44050
53,400
29,400
24,000
44055
55,000
33,600
21,400
Page 62 of 113
DESCRIPTION
Case Rate
Excision
Biopsy of intestine by capsule, tube, peroral (one or more specimens)
Excision of one or more lessions of small or large bowel not requiring
anastomosis, exteriorization, or fistulization; single enterotomy
Excision of one or more lessions of small or large bowel not requiring
anastomosis, exteriorization, or fistulization; multiple enterotomies
Professional Fee
Health Care
Institution Fee
18,000
8,400
9,600
37,800
21,000
16,800
46,500
25,200
21,300
44120
46,500
25,200
21,300
44125
46,500
25,200
21,300
53,400
29,400
24,000
58,800
58,800
37,800
37,800
21,000
21,000
58,800
37,800
21,000
58,800
37,800
21,000
56,680
35,280
21,400
58,800
37,800
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
67,200
46,200
21,000
67,200
46,200
21,000
67,200
67,200
67,200
46,200
46,200
46,200
21,000
21,000
21,000
44130
44140
44141
44143
44144
44145
44146
44147
44150
44151
44152
44153
44155
44156
44160
44180
18,000
8,400
9,600
44186
12,120
6,720
5,400
44187
12,120
6,720
5,400
44188
44202
44204
44205
44206
44207
44208
44210
44211
44212
44227
18,000
8,400
9,600
23,300
12,600
10,700
37,800
21,000
16,800
58,800
37,800
21,000
37,800
21,000
16,800
55,000
33,600
21,400
58,800
37,800
21,000
55,000
33,600
21,400
58,800
37,800
21,000
55,000
33,600
21,400
23,300
12,600
10,700
44300
18,000
8,400
9,600
44310
44312
44314
44316
44320
21,820
23,300
21,820
30,300
23,300
10,920
12,600
10,920
16,800
12,600
10,900
10,700
10,900
13,500
10,700
Page 63 of 113
44360
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
30,300
16,800
13,500
23,300
30,300
30,300
12,600
16,800
16,800
10,700
13,500
13,500
14,960
7,560
7,400
44361
14,960
7,560
7,400
44363
18,000
8,400
9,600
44364
18,000
8,400
9,600
44365
18,000
8,400
9,600
44366
18,000
8,400
9,600
21,940
9,240
12,700
21,940
9,240
12,700
21,940
9,240
12,700
18,000
8,400
9,600
18,000
8,400
9,600
21,940
9,240
12,700
14,960
7,560
7,400
14,960
7,560
7,400
14,960
7,560
7,400
14,960
7,560
7,400
14,960
7,560
7,400
14,960
18,000
18,000
7,560
8,400
8,400
7,400
9,600
9,600
18,000
8,400
9,600
21,940
9,240
12,700
21,940
9,240
12,700
8,020
2,520
5,500
37,800
21,000
16,800
37,800
21,000
16,800
44369
44372
44373
44376
44377
44378
44380
44382
44385
44386
44388
44389
44390
44391
44392
44393
44394
44500
44602
44603
Page 64 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
44604
37,800
21,000
16,800
44605
37,800
21,000
16,800
37,800
21,000
16,800
30,300
16,800
13,500
30,300
16,800
13,500
30,300
30,300
16,800
16,800
13,500
13,500
44640
44650
44660
37,800
21,000
16,800
44661
37,800
21,000
16,800
18,000
8,400
9,600
18,000
8,400
9,600
12,120
6,720
5,400
10,540
5,040
5,500
24,000
9,600
14,400
24,000
9,600
14,400
24,000
9,600
14,400
30,300
18,000
16,800
8,400
13,500
9,600
30,300
16,800
13,500
44615
44620
44625
44950
44960
44800
44820
44850
44900
44970
45000
45005
45020
Laparoscopy
Laparoscopy, surgical; appendectomy
Rectum
Incision
Transrectal drainage of pelvic abscess
Incision and drainage of submucosal abscess, rectum
Incision and drainage of deep supralevator, pelvirectal, or retrorectal
abscess
Excision
45100
23,300
12,600
10,700
45108
Anorectal myomectomy
30,300
16,800
13,500
45110
55,000
33,600
21,400
45111
55,000
33,600
21,400
55,000
33,600
21,400
45112
45113
58,800
37,800
21,000
45114
58,800
37,800
21,000
55,000
33,600
21,400
58,800
37,800
21,000
45116
45120
45121
58,800
37,800
21,000
45123
55,000
33,600
21,400
45130
53,400
29,400
24,000
55,000
33,600
21,400
12,120
6,720
5,400
55,000
33,600
21,400
18,000
8,400
9,600
18,000
8,400
9,600
45135
45150
45160
45170
45190
Page 65 of 113
45300
DESCRIPTION
Case Rate
Endoscopy
Proctosigmoidoscopy, rigid; diagnostic, w/ or w/o collection of specimen(s)
by brushing or washing
Proctosigmoidoscopy, rigid; w/ dilation, any method
Proctosigmoidoscopy, rigid; w/ biopsy, single or multiple
Proctosigmoidoscopy, rigid; w/ removal of foreign body
Proctosigmoidoscopy, rigid; w/ removal of single tumor, polyp, or other
lesion by hot biopsy forceps or bipolar cautery
Proctosigmoidoscopy, rigid; w/ removal of single tumor, polyp, or other
lesion by snare technique
Professional Fee
Health Care
Institution Fee
8,020
2,520
5,500
9,700
8,020
8,260
4,200
2,520
3,360
5,500
5,500
4,900
9,700
4,200
5,500
9,700
4,200
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
8,260
3,360
4,900
8,260
9,700
3,360
4,200
4,900
5,500
9,700
4,200
5,500
45334
10,540
5,040
5,500
45337
12,120
6,720
5,400
10,540
5,040
5,500
11,980
5,880
6,100
10,540
5,040
5,500
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
18,000
8,400
9,600
45303
45305
45307
45308
45309
45315
45317
45320
45321
45330
45331
45332
45333
45338
45339
45355
45378
45379
45380
45382
45383
14,960
7,560
7,400
45384
14,960
7,560
7,400
18,000
8,400
9,600
55,000
33,600
21,400
45385
45395
45397
55,000
33,600
21,400
45400
27,120
15,120
12,000
45402
30,300
16,800
13,500
45500
45505
45540
45541
45550
45560
45562
Repair
Proctoplasty; for stenosis
Proctoplasty; for prolapse of mucous membrane
Proctopexy for prolapse; abdominal approach
Proctopexy for prolapse; perineal approach
Proctopexy combined w/ sigmoid resection, abdominal approach
Repair of rectocele
Exploration, repair and presacral drainage for rectal injury;
18,000
18,000
27,120
27,120
30,300
18,000
23,300
8,400
8,400
15,120
15,120
16,800
8,400
12,600
9,600
9,600
12,000
12,000
13,500
9,600
10,700
45563
27,120
15,120
12,000
45800
30,300
16,800
13,500
Page 66 of 113
46040
46045
46050
46060
46070
46080
46083
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
DESCRIPTION
37,800
30,300
37,800
21,000
16,800
21,000
Health Care
Institution Fee
16,800
13,500
16,800
8,260
8,260
8,260
3,360
3,360
3,360
4,900
4,900
4,900
8,260
3,360
4,900
9,700
4,200
5,500
8,260
3,360
4,900
9,700
4,200
5,500
9,700
9,700
8,020
4,200
4,200
2,520
5,500
5,500
5,500
8,260
8,260
9,700
8,260
12,120
12,120
12,120
12,120
12,120
3,360
3,360
4,200
3,360
6,720
6,720
6,720
6,720
6,720
4,900
4,900
5,500
4,900
5,400
5,400
5,400
5,400
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
Case Rate
Professional Fee
46270
12,120
6,720
5,400
46275
12,120
6,720
5,400
46280
12,120
6,720
5,400
46285
12,120
6,720
5,400
46288
46320
18,000
12,120
8,400
6,720
9,600
5,400
5,680
1,680
4,000
5,680
5,680
5,680
1,680
1,680
1,680
4,000
4,000
4,000
8,020
2,520
5,500
8,260
3,360
4,900
46600
46604
46606
46608
46610
46611
46612
8,260
3,360
4,900
46614
8,020
2,520
5,500
46615
9,700
4,200
5,500
12,900
23,300
6,300
12,600
6,600
10,700
23,300
12,600
10,700
37,800
21,000
16,800
37,800
21,000
16,800
46,500
25,200
21,300
46700
46705
46715
46716
46730
46735
Repair
Anoplasty, plastic operation for stricture; adult
Anoplasty, plastic operation for stricture; infant
Repair of low imperforate anus; w/ anoperineal fistula ("cut-back"
procedure)
Repair of low imperforate anus; w/ transportation of anoperineal or
anovestibular fistula
Repair of high imperforate anus w/o fistula; perineal or sacroperineal
approach
Repair of high imperforate anus w/o fistula; combined transabdominal and
sacroperineal approaches
Page 67 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
30,300
16,800
13,500
53,400
29,400
24,000
58,800
37,800
21,000
46746
63,000
42,000
21,000
46748
63,000
42,000
21,000
46750
46751
14,960
23,300
7,560
12,600
7,400
10,700
46753
9,700
4,200
5,500
46754
46760
8,260
3,360
4,900
40,320
23,520
16,800
20,980
10,080
10,900
40,320
23,520
16,800
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
9,700
4,200
5,500
9,700
9,700
9,700
9,700
9,700
4,200
4,200
4,200
4,200
4,200
5,500
5,500
5,500
5,500
5,500
9,700
4,200
5,500
8,260
3,360
4,900
8,020
18,000
2,520
8,400
5,500
9,600
18,000
8,400
9,600
18,000
53,400
55,000
46,500
53,400
8,400
29,400
33,600
25,200
29,400
9,600
24,000
21,400
21,300
24,000
46,500
25,200
21,300
55,000
33,600
21,400
55,000
33,600
21,400
18,000
8,400
9,600
47300
47350
23,300
12,600
10,700
47360
46,500
25,200
21,300
47361
37,800
21,000
16,800
46761
46762
46900
46910
46916
46917
46922
46924
46934
46935
46936
46937
46938
46940
46945
47000
47010
47015
47100
47120
47122
47125
47130
47134
47135
47136
Page 68 of 113
47370
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
37,800
21,000
16,800
18,000
8,400
9,600
47371
18,000
8,400
9,600
47380
47381
Other Procedures
Ablation, open, of or more liver tumor(s); radiofrequency
Ablation, open, of or more liver tumor(s); cryosurgical
9,700
9,700
4,200
4,200
5,500
5,500
47382
9,700
4,200
5,500
53,400
29,400
24,000
37,800
21,000
16,800
46,500
25,200
21,300
46,500
25,200
21,300
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
8,020
8,260
2,520
3,360
5,500
4,900
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
31,000
12,400
18,600
31,000
12,400
18,600
31,000
31,000
12,400
12,400
18,600
18,600
47400
47420
47425
47460
47480
47490
47510
47511
47525
47530
47552
47553
47554
47555
47556
47560
Biliary Tract
Incision
Hepaticotomy or hepaticostomy w/ exploration, drainage, or removal of
calculus
Choledochotomy or choledochostomy w/ exploration, drainage, or removal
of calculus, w/ or w/o cholecystotomy; w/o transduodenal sphincterotomy
or sphincteroplasty
Choledochotomy or choledochostomy w/ exploration, drainage, or removal
of calculus, w/ or w/o cholecystotomy; w/ transduodenal sphincterotomy or
sphincteroplasty
Transduodenal sphincterotomy or sphincteroplasty, w/ or w/o
transduodenal extraction of calculus
Cholecystotomy or cholecystostomy w/ exploration, drainage, or removal of
calculus
Percutaneous cholecystostomy
Introduction
Introduction of percutaneous transhepatic catheter for biliary drainage
Introduction of percutaneous transhepatic stent for internal and external
biliary drainage
Change of percutaneous biliary drainage catheter
Revision and/or reinsertion of transhepatic tube
Endoscopy
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing w/ biopsy, single
or multiple
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing w/ removal of
stone(s)
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing w/ dilation of
biliary duct stricture(s) w/o stent
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing w/ dilation of
biliary duct stricture(s) w/ stent
Laparoscopy
47562
47563
47564
46,500
25,200
21,300
47570
31,000
12,400
18,600
31,000
31,000
46,500
12,400
12,400
25,200
18,600
18,600
21,300
53,400
29,400
24,000
46,500
25,200
21,300
47561
47600
47605
47610
47612
47620
Page 69 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
47720
47721
47740
47741
47760
46,500
25,200
21,300
47765
53,400
29,400
24,000
46,500
25,200
21,300
53,400
29,400
24,000
46,500
25,200
21,300
37,800
37,800
46,500
21,000
21,000
25,200
16,800
16,800
21,300
23,300
12,600
10,700
46,500
25,200
21,300
46,500
25,200
21,300
37,800
21,000
16,800
12,120
6,720
5,400
9,700
30,300
4,200
16,800
5,500
13,500
46,500
25,200
21,300
53,400
29,400
24,000
53,400
29,400
24,000
46,500
25,200
21,300
47630
47700
47701
47711
47712
47715
47716
47780
47785
47800
47801
47802
47900
48000
48001
48005
48020
48100
48102
48120
48140
48145
48146
48148
23,300
12,600
10,700
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
58,800
37,800
21,000
55,000
46,500
33,600
25,200
21,400
21,300
37,800
46,500
53,400
53,400
21,000
25,200
29,400
29,400
16,800
21,300
24,000
24,000
48150
58,800
37,800
21,000
48152
55,000
33,600
21,400
63,000
42,000
21,000
58,800
37,800
21,000
63,000
42,000
21,000
63,000
42,000
21,000
55,000
33,600
21,400
30,300
23,300
46,500
16,800
12,600
25,200
13,500
10,700
21,300
46,500
25,200
21,300
48500
48510
48520
48540
48153
48154
48155
48160
48180
Page 70 of 113
DESCRIPTION
Pancreatorrhaphy for trauma
Duodenal exclusion w/ gastrojejunostomy for pancreatic trauma
Pancreas Transplantation
Donor pancreatectomy, w/ preparation and maintenance of allograft from
cadaver donor, w/ or w/o duodenal segment for transplantation
Transplantation of pancreatic allograft
Removal of transplanted pancreatic allograft
Abdomen, Peritoneum, and Omentum
Incision
53,400
53,400
29,400
29,400
Health Care
Institution Fee
24,000
24,000
30,300
16,800
13,500
30,300
23,300
16,800
12,600
13,500
10,700
49000
23,300
12,600
10,700
49010
23,300
12,600
10,700
23,300
12,600
10,700
8,260
3,360
4,900
23,300
23,300
12,600
12,600
10,700
10,700
8,020
2,520
5,500
23,300
12,600
10,700
8,260
3,360
4,900
37,800
21,000
16,800
53,400
29,400
24,000
46,500
25,200
21,300
23,300
12,600
10,700
9,700
9,700
4,200
4,200
5,500
5,500
5,680
1,680
4,000
48545
48547
48550
48554
48556
49020
49021
49040
49060
49080
49085
49180
49200
49201
49215
49220
49250
49255
Case Rate
49320
49321
49322
49323
Professional Fee
9,700
4,200
5,500
12,120
6,720
5,400
8,260
3,360
4,900
8,260
3,360
4,900
49425
18,000
8,400
9,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
49495
49496
49497
49500
49501
49502
49505
49507
49509
49520
49521
49522
49525
49540
49550
49553
49554
49555
Page 71 of 113
50010
50020
50040
50045
50060
50065
50070
50075
DESCRIPTION
Repair recurrent femoral hernia; incarcerated
Repair recurrent femoral hernia; strangulated
Repair initial incisional hernia; reducible
Repair initial incisional hernia; incarcerated
Repair initial incisional hernia; strangulated
Repair recurrent incisional hernia; reducible
Repair recurrent incisional hernia; incarcerated
Repair recurrent incisional hernia; strangulated
Repair epigastric hernia (e.g., preperitoneal fat); reducible
Repair epigastric hernia (e.g., preperitoneal fat); incarcerated
Repair epigastric hernia (e.g., preperitoneal fat); strangulated
Repair umbilical hernia, under age 5 years; reducible
Repair umbilical hernia, under age 5 years; incarcerated
Repair umbilical hernia, under age 5 years; strangulated
Repair umbilical hernia, age 5 years or over; reducible
Repair umbilical hernia, age 5 years or over; incarcerated
Repair umbilical hernia, age 5 years or over; strangulated
Repair spigelian hernia
Repair of small omphalocele, w/ primary closure
Repair large omphalocele or gastroschisis; w/ or w/o prosthesis
Repair large omphalocele or gastroschisis; w/ removal of prosthesis, final
reduction and closure, in operating room
Repair of omphalocele (Gross type operation); first stage
Repair of omphalocele (Gross type operation); second stage
Laparoscopy
Laparoscopy, surgical; repair of initial inguinal hernia
Laparoscopy, surgical; repair of recurrent inguinal hernia
Other Procedures
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
23,300
37,800
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
12,600
21,000
Health Care
Institution Fee
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
10,700
16,800
30,300
16,800
13,500
23,300
30,300
12,600
16,800
10,700
13,500
21,000
21,000
8,400
8,400
12,600
12,600
18,000
8,400
9,600
23,300
12,600
10,700
30,300
16,800
13,500
20,980
18,000
18,000
18,000
27,120
30,300
27,120
10,080
8,400
8,400
8,400
15,120
16,800
15,120
10,900
9,600
9,600
9,600
12,000
13,500
12,000
37,800
21,000
16,800
Case Rate
Omental flap (e.g., for reconstruction of sternal and chest wall defects) (list
separately in addition to code for primary procedure)
Free omental flap w/ microvascular anastomosis
Urinary System
Kidney
Incision
Renal exploration, not necessitating other specific procedures
Drainage of perirenal or renal abscess
Nephrostomy, nephrotomy w/ drainage
Nephrotomy, w/ exploration
Nephrolithotomy; removal of calculus
Nephrolithotomy; secondary surgical operation for calculus
Nephrolithotomy; complicated by congenital kidney abnormality
Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and
calyces (including anatrophic pyelolithotomy)
Professional Fee
50080
30,300
16,800
13,500
50081
30,300
16,800
13,500
30,300
18,000
18,000
16,800
8,400
8,400
13,500
9,600
9,600
23,300
12,600
10,700
31,580
14,280
17,300
8,020
18,000
2,520
8,400
5,500
9,600
27,120
15,120
12,000
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
50100
50120
50125
50130
50135
50200
50205
50220
50225
50230
50234
50236
Page 72 of 113
DESCRIPTION
Case Rate
Nephrectomy, partial
Ablation, open, one or more renal mass lesion(s), cryosurgical, including
intraoperative ultrasound, if performed
Excision or unroofing of cyst(s) of kidney
Excision of perinephric cyst
Renal Transplantation
Donor nephrectomy, w/ preparation and maintenance of allograft; from
living donor
Recipient nephrectomy
Renal allotransplantation, implantation of graft; excluding donor and
recipient nephrectomy
27,120
50365
50250
Professional Fee
15,120
Health Care
Institution Fee
12,000
9,700
4,200
5,500
20,980
20,980
10,080
10,080
10,900
10,900
27,120
15,120
12,000
23,300
12,600
10,700
46,500
25,200
21,300
61,320
40,320
21,000
50370
50380
30,300
53,400
16,800
29,400
13,500
24,000
50390
5,680
1,680
4,000
50391
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
8,260
3,360
4,900
30,300
16,800
13,500
37,180
18,480
18,700
23,300
18,000
12,600
8,400
10,700
9,600
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
10,540
9,700
30,300
27,120
5,040
4,200
16,800
15,120
5,500
5,500
13,500
12,000
27,120
15,120
12,000
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
8,692
3,192
5,500
8,260
3,360
4,900
10,880
3,780
7,100
8,104
2,604
5,500
50280
50290
50320
50340
50360
50392
50393
50395
50400
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
50547
50548
50551
50553
50555
50557
Page 73 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
50559
8,356
2,856
5,500
50561
9,700
4,200
5,500
50570
8,260
3,360
4,900
50572
8,260
3,360
4,900
50574
8,260
3,360
4,900
50575
9,700
4,200
5,500
50576
9,700
4,200
5,500
50578
9,700
4,200
5,500
9,700
4,200
5,500
50590
18,000
8,400
9,600
50592
9,700
4,200
5,500
12,120
12,120
21,820
20,980
21,820
6,720
6,720
10,920
10,080
10,920
5,400
5,400
10,900
10,900
10,900
21,820
10,920
10,900
20,980
10,080
10,900
21,820
10,920
10,900
50580
50700
Ureter
Ureterotomy w/ exploration or drainage
Ureterotomy for insertion of indwelling stent, all types
Ureterolithotomy; upper one-third of ureter
Ureterolithotomy; middle one-third of ureter
Ureterolithotomy; lower one-third of ureter
Excision
Ureterectomy, w/ bladder cuff
Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or
perineal approach
Repair
Ureteroplasty, plastic operation on ureter (e.g., stricture)
50715
21,820
10,920
10,900
50722
20,980
10,080
10,900
23,300
12,600
10,700
22,660
11,760
10,900
22,660
11,760
10,900
50740
50750
50760
23,300
27,120
21,820
12,600
15,120
10,920
10,700
12,000
10,900
50770
27,120
15,120
12,000
50780
27,120
15,120
12,000
50782
30,300
16,800
13,500
50783
50785
50800
37,800
30,300
30,740
21,000
16,800
13,440
16,800
13,500
17,300
50810
37,800
21,000
16,800
50815
37,800
21,000
16,800
50600
50605
50610
50620
50630
50650
50660
50725
50727
50728
Page 74 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
40,320
23,520
16,800
46,500
25,200
21,300
37,800
21,000
16,800
37,800
21,000
16,800
30,300
20,980
18,000
20,980
23,300
21,820
16,800
10,080
8,400
10,080
12,600
10,920
13,500
10,900
9,600
10,900
10,700
10,900
21,940
9,240
12,700
23,300
12,600
10,700
23,300
12,600
10,700
50951
8,260
3,360
4,900
50953
8,260
3,360
4,900
50955
8,260
3,360
4,900
50957
10,880
3,780
7,100
50959
9,700
4,200
5,500
50961
11,980
5,880
6,100
50970
8,260
3,360
4,900
50972
8,260
3,360
4,900
50974
8,260
3,360
4,900
10,880
3,780
7,100
9,700
4,200
5,500
11,980
5,880
6,100
5,680
1,680
4,000
9,700
4,200
5,500
9,700
4,200
5,500
9,700
10,540
4,200
5,040
5,500
5,500
50976
50978
50980
51010
51020
51030
51040
51045
Page 75 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
12,540
7,140
5,400
21,820
10,920
10,900
21,820
10,920
10,900
10,540
5,040
5,500
51500
30,300
16,800
13,500
51520
20,980
10,080
10,900
51525
27,120
15,120
12,000
51530
51535
51550
27,120
23,300
30,740
15,120
12,600
13,440
12,000
10,700
17,300
37,800
21,000
16,800
30,300
16,800
13,500
37,800
21,000
16,800
46,500
25,200
21,300
40,320
23,520
16,800
53,400
29,400
24,000
55,920
31,920
24,000
51555
51565
51570
51575
51580
51585
51590
51595
55,840
34,440
21,400
51596
58,800
37,800
21,000
51597
71,400
50,400
21,000
Introduction
51600
8,020
2,520
5,500
51720
8,020
2,520
5,500
51800
20,980
10,080
10,900
51820
27,120
15,120
12,000
20,980
10,080
10,900
30,740
13,440
17,300
20,980
10,080
10,900
12,120
10,880
23,300
23,300
30,300
30,300
30,740
12,120
6,720
3,780
12,600
12,600
16,800
16,800
13,440
6,720
5,400
7,100
10,700
10,700
13,500
13,500
17,300
5,400
30,300
16,800
13,500
30,300
16,800
13,500
8,260
3,360
4,900
51840
51841
51845
51860
51880
51900
51920
51925
51940
51960
51980
51990
51992
52000
Page 76 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
52005
9,700
4,200
5,500
52007
8,260
3,360
4,900
52010
8,260
3,360
4,900
Transurethral Surgery
52204
10,540
5,040
5,500
52214
11,980
5,880
6,100
52224
11,980
5,880
6,100
52234
20,980
10,080
10,900
52235
22,240
11,340
10,900
23,300
12,600
10,700
30,740
13,440
17,300
11,980
5,880
6,100
8,020
2,520
5,500
12,900
12,900
12,540
6,300
6,300
7,140
6,600
6,600
5,400
12,120
6,720
5,400
8,020
2,520
5,500
8,020
2,520
5,500
10,540
5,040
5,500
11,980
5,880
6,100
21,940
9,240
12,700
21,940
9,240
12,700
12,120
6,720
5,400
10,540
5,040
5,500
18,000
8,400
9,600
21,940
9,240
12,700
11,980
5,880
6,100
18,000
8,400
9,600
9,700
4,200
5,500
10,540
5,040
5,500
52270
52275
52276
52277
52240
52250
52260
52265
52281
52283
52285
52290
52300
52301
52305
52310
52317
52318
52320
52325
52327
52330
Page 77 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
10,540
5,040
5,500
9,700
4,200
5,500
52335
12,120
6,720
5,400
52336
12,120
6,720
5,400
21,940
9,240
12,700
21,940
9,240
12,700
12,120
6,720
5,400
21,940
9,240
12,700
23,300
23,300
12,600
12,600
10,700
10,700
12,120
6,720
5,400
37,800
21,000
16,800
18,000
8,400
9,600
21,940
9,240
12,700
21,940
9,240
12,700
20,980
10,080
10,900
37,800
21,000
16,800
20,980
10,080
10,900
27,120
15,120
12,000
27,120
15,120
12,000
37,800
21,000
16,800
18,000
8,400
9,600
52450
52500
52510
52337
52338
52339
52340
52601
52606
52612
52614
52620
52630
52640
53000
5,680
1,680
4,000
53010
8,260
3,360
4,900
53020
53025
53040
53060
53080
5,560
8,260
9,300
5,560
8,020
1,260
3,360
2,100
1,260
2,520
4,300
4,900
7,200
4,300
5,500
5,560
21,940
21,820
9,700
18,000
14,960
1,260
9,240
10,920
4,200
8,400
7,560
4,300
12,700
10,900
5,500
9,600
7,400
52647
52648
52649
52700
53200
53210
53215
53220
53230
53235
Page 78 of 113
DESCRIPTION
Marsupialization of urethral diverticulum, male or female
Excision of bulbourethral gland (Cowpers gland)
Excision or fulguration; urethral polyp(s), distal urethra
Excision or fulguration; urethral caruncle
Skene's glands
Skene's glands urethral prolapse
Repair
Urethroplasty; first stage, for fistula, diverticulum, or stricture (e.g.,
Johannsen type)
Urethroplasty; second stage (formation of urethra), including urinary
diversion
Urethroplasty, one-stage reconstruction of male anterior urethra
Urethroplasty, transpubic or perineal, one stage, for reconstruction or
repair of prostatic or membranous urethra
Urethroplasty, two-stage reconstruction or repair of prostatic or
membranous urethra; first stage
Urethroplasty, two-stage reconstruction or repair of prostatic or
membranous urethra; second stage
Urethroplasty, reconstruction of female urethra
Operation for correction of male urinary incontinence, w/ or w/o
introduction of prosthesis
Removal of perineal prosthesis introduced for continence
Urethroplasty w/ tubularization of posterior urethra and/or lower bladder
for incontinence (e.g., Tenago, Leadbetter procedure)
Operation for correction of urinary incontinence w/ placement of inflatable
urethral or bladder neck sphincter, including placement of pump and/or
reservoir
Removal, repair, or replacement of inflatable sphincter including pump
and/or reservoir and/or cuff
9,300
12,120
5,560
5,560
5,560
9,300
2,100
6,720
1,260
1,260
1,260
2,100
Health Care
Institution Fee
7,200
5,400
4,300
4,300
4,300
7,200
30,300
16,800
13,500
27,120
15,120
12,000
14,960
7,560
7,400
40,320
23,520
16,800
37,800
21,000
16,800
27,120
15,120
12,000
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
31,140
17,640
13,500
37,180
18,480
18,700
40,320
23,520
16,800
53449
18,000
8,400
9,600
53450
8,260
3,360
4,900
8,260
3,360
4,900
53502
53505
53510
9,700
9,700
10,540
4,200
4,200
5,040
5,500
5,500
5,500
53515
10,540
5,040
5,500
53520
8,020
2,520
5,500
53600
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
37,800
21,000
16,800
37,800
21,000
16,800
3,640
840
2,800
3,640
840
2,800
3,504
9,300
504
2,100
3,000
7,200
53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
53425
53430
53440
53442
53443
53445
53447
53460
53605
53665
53850
Case Rate
Professional Fee
54100
54110
54111
10,540
5,040
5,500
54112
11,980
5,880
6,100
54115
Removal of foreign body from deep penile tissue (e.g., plastic implant)
8,260
3,360
4,900
54120
54125
10,540
21,400
5,040
10,500
5,500
10,900
54130
37,800
21,000
16,800
53852
54015
54050
Page 79 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
46,500
25,200
21,300
1,260
1,260
840
840
420
420
1,260
840
420
1,260
840
420
54200
5,560
1,260
4,300
54205
5,680
1,680
4,000
54220
8,020
2,520
5,500
9,700
4,200
5,500
14,960
7,560
7,400
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
12,120
6,720
5,400
27,120
15,120
12,000
54150
54152
54160
54161
54300
54304
54308
54312
54316
54318
54322
54324
27,120
15,120
12,000
54326
27,120
15,120
12,000
30,300
16,800
13,500
37,180
18,480
18,700
37,180
18,480
18,700
37,180
18,480
18,700
18,000
8,400
9,600
20,980
10,080
10,900
37,800
21,000
16,800
30,300
16,800
13,500
37,180
18,480
18,700
37,800
21,000
16,800
12,120
6,720
5,400
12,120
6,720
5,400
8,260
3,360
4,900
12,120
6,720
5,400
3,504
5,680
504
1,680
3,000
4,000
54328
54332
54336
54340
54344
54348
54352
54380
54385
54390
54420
54430
54435
54440
54500
54505
Page 80 of 113
54700
54800
54820
54830
54840
54860
54861
DESCRIPTION
5,680
1,680
Health Care
Institution Fee
4,000
10,540
5,040
5,500
10,960
12,540
10,540
12,540
5,460
7,140
5,040
7,140
5,500
5,400
5,500
5,400
10,960
5,460
5,500
9,300
10,540
2,100
5,040
7,200
5,500
12,540
7,140
5,400
9,700
8,260
4,200
3,360
5,500
4,900
9,700
11,980
4,200
5,880
5,500
6,100
4,108
1,008
3,100
3,504
9,300
5,680
8,020
9,300
8,440
504
2,100
1,680
2,520
2,100
2,940
3,000
7,200
4,000
5,500
7,200
5,500
Case Rate
Professional Fee
54900
10,540
5,040
5,500
54901
18,000
8,400
9,600
3,504
504
3,000
9,700
18,000
4,200
8,400
5,500
9,600
9,700
4,200
5,500
3,504
9,300
9,300
4,108
504
2,100
2,100
1,008
3,000
7,200
7,200
3,100
5,560
1,260
4,300
5,680
1,680
4,000
Tunica Vaginalis
55000
55040
55041
55060
55100
55101
55110
55120
55150
55175
Incision
Puncture aspiration of hydrocele, tunica vaginalis, w/ or w/o injection of
medication
Excision
Excision of hydrocele; unilateral
Excision of hydrocele; bilateral
Repair
Repair of tunica vaginalis hydrocele (Bottle type)
Scrotum
Incision
Drainage of scrotal wall abscess
Drainage and debridement of Fourniers gangrene of the scrotum
Scrotal exploration
Removal of foreign body in scrotum
Excision
Resection of scrotum
Repair
Scrotoplasty
Vas Deferens
Incision
55200
5,680
1,680
4,000
55250
4,000
1,000
3,000
10,540
5,040
5,500
9,700
8,260
12,900
4,200
3,360
6,300
5,500
4,900
6,600
14,960
7,560
7,400
14,960
7,560
7,400
14,960
7,560
7,400
55400
55500
55520
55530
55535
55540
55550
Page 81 of 113
55700
55720
55801
55810
55812
55815
55821
55831
55840
55842
55845
55859
DESCRIPTION
10,120
4,620
Health Care
Institution Fee
5,500
18,000
18,000
8,400
8,400
9,600
9,600
9,300
5,680
2,100
1,680
7,200
4,000
38,860
20,160
18,700
46,500
25,200
21,300
48,180
26,880
21,300
48,180
26,880
21,300
38,860
20,160
18,700
30,300
16,800
13,500
46,500
25,200
21,300
48,180
26,880
21,300
48,180
26,880
21,300
18,000
8,400
9,600
Case Rate
Vesiculotomy;
Excision
Vesiculectomy, any approach
Excision of Mullerian duct cyst
Prostate
Incision
Biopsy, prostate; needle or punch, single or multiple, any approach
Prostatotomy, external drainage of prostatic abscess, any approach
Excision
Prostatectomy, perineal, subtotal (including control of postoperative
bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and
internal urethrotomy)
Prostatectomy, perineal radical;
Prostatectomy, perineal radical; w/ lymph node biopsy(s) (limited pelvic
lymphadenectomy)
Prostatectomy, perineal radical; w/ bilateral pelvic lymphadenectomy,
including external iliac, hypogastric and obturator nodes
Prostatectomy (including control of postoperative bleeding, vasectomy,
meatotomy, urethral calibration and/or dilation, and internal urethrotomy);
suprapubic, subtotal, one or two stages
Prostatectomy (including control of postoperative bleeding, vasectomy,
meatotomy, urethral calibration and/or dilation, and internal urethrotomy);
retropubic, subtotal
Prostatectomy, retropubic radical, w/ or w/o nerve sparing;
Prostatectomy, retropubic radical, w/ or w/o nerve sparing; w/ lymph node
biopsy(s) (limited pelvic lymphadenectomy)
Prostatectomy, retropubic radical, w/ or w/o nerve sparing; w/ bilateral
pelvic lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
Transperineal placement of needles, catheters or pellets into prostate for
interstitial radioelement application, with or without cystoscopy, ultrasound
or CT scan guidance
Professional Fee
55860
9,700
4,200
5,500
55862
18,000
8,400
9,600
23,300
12,600
10,700
46,500
25,200
21,300
55,000
33,600
21,400
5,560
9,300
9,700
9,300
1,260
2,100
4,200
2,100
4,300
7,200
5,500
7,200
9,300
2,100
7,200
9,300
12,120
23,300
27,120
2,100
6,720
12,600
15,120
7,200
5,400
10,700
12,000
30,300
16,800
13,500
55865
55866
55873
56405
56420
56440
56441
56501
56605
56620
56625
56630
56631
56632
37,800
21,000
16,800
56633
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
58,800
37,800
21,000
9,700
9,300
9,700
4,200
2,100
4,200
5,500
7,200
5,500
56634
56637
56640
56700
56720
56740
Page 82 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
57230
Vagina
Incision
Colpotomy; w/ exploration
Colpocentesis
Destruction of vaginal lesion(s)
Biopsy of vaginal mucosa
Colpectomy, obliteration of vagina; partial
Colpectomy, obliteration of vagina; complete
Colpocleisis (Le Fort type)
Excision of vaginal septum
Excision of vaginal cyst or tumor
Introduction
Insertion of uterine tandems and/or vaginal ovoids for clinical
brachytherapy
Repair
Colporrhaphy, suture of injury of vagina (nonobsterical)
Colpoperineorrhaphy, suture of injury of vagina and/or perineum
(nonobstetrical)
Plastic operation on urethral sphincter, vaginal approach (e.g., Kelly urethral
plication)
Plastic repair of urethrocele
12,120
6,720
5,400
57240
20,980
10,080
10,900
57250
57260
57265
57268
57270
57280
57282
20,980
23,300
30,300
23,300
27,120
27,120
27,120
10,080
12,600
16,800
12,600
15,120
15,120
15,120
10,900
10,700
13,500
10,700
12,000
12,000
12,000
27,120
15,120
12,000
30,300
30,300
20,980
23,300
16,800
16,800
10,080
12,600
13,500
13,500
10,900
10,700
30,300
16,800
13,500
20,980
30,300
23,300
30,300
10,080
16,800
12,600
16,800
10,900
13,500
10,700
13,500
8,260
3,360
4,900
27,120
15,120
12,000
8,020
8,260
9,700
2,520
3,360
4,200
5,500
4,900
5,500
57000
57020
57061
57100
57108
57110
57120
57130
57135
57155
57200
57210
57220
57284
57288
57289
57300
57305
57307
57310
57311
57320
57330
57415
57425
57452
57454
57460
12,120
5,680
5,680
5,680
23,300
30,300
27,120
9,300
9,700
6,720
1,680
1,680
1,680
12,600
16,800
15,120
2,100
4,200
5,400
4,000
4,000
4,000
10,700
13,500
12,000
7,200
5,500
9,700
4,200
5,500
8,020
2,520
5,500
10,540
5,040
5,500
12,120
6,720
5,400
57500
5,680
1,680
4,000
57510
5,680
1,680
4,000
9,700
4,200
5,500
12,900
6,300
6,600
57530
57540
18,000
30,300
8,400
16,800
9,600
13,500
57545
37,800
21,000
16,800
57550
23,300
12,600
10,700
37,800
21,000
16,800
39,900
23,100
16,800
9,700
18,000
4,200
8,400
5,500
9,600
11,000
4,400
6,600
57520
57522
57555
57556
57700
57720
58100
Page 83 of 113
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58300
58345
58346
58400
58410
58520
58540
58600
58545
58550
58552
58555
58558
58559
58560
58561
58562
58563
58565
58660
DESCRIPTION
11,000
4,400
Health Care
Institution Fee
6,600
23,300
12,600
10,700
18,000
8,400
9,600
30,000
12,000
18,000
30,000
12,000
18,000
30,000
12,000
18,000
30,000
12,000
18,000
55,000
33,600
21,400
71,400
50,400
21,000
30,300
30,300
16,800
16,800
13,500
13,500
37,800
21,000
16,800
46,500
25,200
21,300
46,500
37,800
25,200
21,000
21,300
16,800
46,500
25,200
21,300
46,500
25,200
21,300
2,000
800
1,200
18,000
8,400
9,600
9,700
4,200
5,500
23,300
12,600
10,700
27,120
15,120
12,000
23,300
37,800
12,600
21,000
10,700
16,800
4,000
1,000
3,000
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
9,700
4,200
5,500
12,900
6,300
6,600
18,000
8,400
9,600
Case Rate
Page 84 of 113
Professional Fee
18,000
8,400
9,600
23,300
12,900
12,600
6,300
10,700
6,600
12,120
6,720
5,400
5,680
1,680
4,000
21,400
10,500
10,900
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
58800
20,980
10,080
10,900
58805
20,980
10,080
10,900
58820
58822
58825
20,980
20,980
20,980
10,080
10,080
10,080
10,900
10,900
10,900
18,000
18,000
23,300
18,000
8,400
8,400
12,600
8,400
9,600
9,600
10,700
9,600
30,300
16,800
13,500
53,400
29,400
24,000
55,000
33,600
21,400
58,800
37,800
21,000
27,120
15,120
12,000
23,300
12,600
10,700
27,120
15,120
12,000
27,120
15,120
12,000
46,500
25,200
21,300
37,800
21,000
16,800
37,600
18,900
18,700
30,300
16,800
13,500
27,120
15,120
12,000
27,120
15,120
12,000
18,000
18,000
30,300
8,400
8,400
16,800
9,600
9,600
13,500
9,700
12,120
4,200
6,720
5,500
5,400
19,000
19,000
7,600
7,600
11,400
11,400
58661
58662
58670
58671
58672
58673
58700
58720
58740
58750
58760
58770
58900
58920
58925
58940
58943
58950
58951
58952
58960
59100
59120
59121
59130
59135
59136
59140
59150
59151
59320
59325
59350
59409
59411
59513
59514
Page 85 of 113
53,400
29,400
24,000
14,960
7,560
7,400
14,960
7,560
7,400
12,900
6,300
6,600
21,400
23,300
10,500
12,600
10,900
10,700
20,980
23,300
10,080
12,600
10,900
10,700
23,300
18,000
23,300
23,300
12,600
8,400
12,600
12,600
10,700
9,600
10,700
10,700
DESCRIPTION
30,000
12,000
12,120
6,720
5,400
19,000
7,600
11,400
11,000
11,000
4,400
4,400
6,600
6,600
12,120
6,720
5,400
3,504
504
3,000
8,260
8,260
20,980
31,000
3,360
3,360
10,080
12,400
4,900
4,900
10,900
18,600
31,000
12,400
18,600
31,000
12,400
18,600
31,000
12,400
18,600
60240
Health Care
Institution Fee
18,000
31,000
12,400
18,600
60252
31,000
12,400
18,600
60254
46,500
25,200
21,300
31,000
12,400
18,600
46,500
25,200
21,300
46,500
20,980
23,300
25,200
10,080
12,600
21,300
10,900
10,700
30,740
27,120
13,440
15,120
17,300
12,000
39,900
23,100
16,800
30,300
39,900
16,800
23,100
13,500
16,800
39,900
23,100
16,800
39,900
23,100
16,800
30,300
16,800
13,500
37,600
18,900
18,700
30,300
37,800
16,800
21,000
13,500
16,800
30,300
16,800
13,500
5,680
1,680
4,000
59525
59612
59620
59812
59814
59870
60000
60001
60100
60200
60210
60212
60220
60225
60260
60270
60271
60280
60281
60500
60502
60505
60512
60520
60521
60522
60540
60545
60600
60605
60650
61000
61020
61050
61105
61106
Case Rate
Page 86 of 113
Professional Fee
5,680
1,680
4,000
10,540
5,040
5,500
18,000
8,400
9,600
18,420
8,820
9,600
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
30,300
16,800
13,500
37,800
21,000
16,800
61120
23,300
12,600
10,700
61130
22,240
11,340
10,900
37,800
37,800
21,000
21,000
16,800
16,800
37,800
21,000
16,800
37,800
23,300
30,300
21,000
12,600
16,800
16,800
10,700
13,500
61304
37,800
21,000
16,800
61305
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
53,400
29,400
24,000
53,400
29,400
24,000
61140
61150
61154
61156
61250
61253
61312
61313
61314
61315
61320
46,500
25,200
21,300
61321
53,400
29,400
24,000
61330
61332
61333
46,500
53,400
53,400
25,200
29,400
29,400
21,300
24,000
24,000
61334
53,400
29,400
24,000
61340
37,800
21,000
16,800
53,400
29,400
24,000
46,500
46,500
25,200
25,200
21,300
21,300
53,400
29,400
24,000
53,400
29,400
24,000
61460
61470
55,000
55,000
33,600
33,600
21,400
21,400
61480
55,000
33,600
21,400
61490
46,500
25,200
21,300
55,000
37,800
33,600
21,000
21,400
16,800
55,000
33,600
21,400
63,000
42,000
21,000
53,400
29,400
24,000
53,400
29,400
24,000
65,100
44,100
21,000
67,200
46,200
21,000
71,400
50,400
21,000
71,400
50,400
21,000
61343
61345
61440
61450
61458
61500
61501
61510
61512
61514
61516
61518
61519
61520
61521
Page 87 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
55,000
33,600
21,400
55,000
33,600
21,400
75,600
54,600
21,000
75,600
54,600
21,000
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
53,400
29,400
24,000
61541
53,400
29,400
24,000
61542
67,200
46,200
21,000
63,000
42,000
21,000
53,400
29,400
24,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
37,800
46,500
46,500
46,500
21,000
25,200
25,200
25,200
16,800
21,300
21,300
21,300
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
53,400
29,400
24,000
55,500
31,500
24,000
75,600
54,600
21,000
75,600
54,600
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
61543
61544
61545
61570
61571
61546
61548
61550
61552
61556
61557
61558
61559
61563
61564
61575
61576
61580
61581
61582
61583
Transoral approach to skull base, brain stem or upper spinal cord for biopsy,
decompression or excision of lesion;
Transoral approach to skull base, brain stem or upper spinal cord for biopsy,
decompression or excision of lesion; requiring splitting of tongue and/or
mandible (including tracheostomy)
Surgery of Skull Base Approach Procedures
Anterior Cranial Fossa
Craniofacial approach to anterior cranial fossa; extradural, including lateral
rhinotomy, ethmoidectomy, sphenoidectomy, w/o maxillectomy or orbital
exenteration
Craniofacial approach to anterior cranial fossa; extradural, including lateral
rhinotomy, orbital exenteration, ethmoidectomy, sphenoidectomy and/or
maxillectomy
Craniofacial approach to anterior cranial fossa; extradural, including
unilateral or bifrontal craniotomy, elevation of frontal lobe(s), osteotomy of
base of anterior cranial fossa
Craniofacial approach to anterior cranial fossa; intradural, including
unilateral or bifrontal craniotomy, elevation or resection of frontal lobe,
osteotomy of base of anterior cranial fossa
Page 88 of 113
61585
61586
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
71,400
50,400
21,000
71,400
50,400
21,000
67,200
46,200
21,000
71,400
50,400
21,000
71,400
50,400
21,000
71,400
50,400
21,000
71,400
50,400
21,000
67,200
46,200
21,000
67,200
46,200
21,000
71,400
50,400
21,000
71,400
50,400
21,000
71,400
50,400
21,000
71,400
50,400
21,000
71,400
50,400
21,000
71,400
50,400
21,000
63,000
42,000
21,000
71,400
50,400
21,000
71,400
50,400
21,000
61590
61591
61592
61595
61596
61597
61598
61600
61601
61605
61606
61607
61608
61609
61610
61611
61612
61613
61615
71,400
50,400
21,000
61616
71,400
50,400
21,000
Page 89 of 113
61618
61619
DESCRIPTION
Case Rate
Secondary repair of dura for CSF leak, anterior, middle or posterior cranial
fossa following surgery of the skull base; by free tissue graft (e.g.,
pericranium, fascia, tensor fascia lata, adipose tissue, homologous or
synthetic grafts)
Secondary repair of dura for CSF leak, anterior, middle or posterior cranial
fossa following surgery of the skull base; by local or regionalized
vascularized pedicle flap or myocutaneous flap (including galea,temporalis,
frontalis or occipitalis muscle)
Endovascular Therapy
Professional Fee
Health Care
Institution Fee
67,200
46,200
21,000
63,000
42,000
21,000
61624
71,400
50,400
21,000
61626
55,000
33,600
21,400
63,000
42,000
21,000
61682
71,400
50,400
21,000
61684
63,000
42,000
21,000
61686
71,400
50,400
21,000
61690
61692
55,000
63,000
33,600
42,000
21,400
21,000
61700
71,400
50,400
21,000
61702
75,600
54,600
21,000
61703
23,300
12,600
10,700
71,400
50,400
21,000
37,800
21,000
16,800
63,000
42,000
21,000
67,200
46,200
21,000
67,200
46,200
21,000
67,200
46,200
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
30,300
16,800
13,500
61705
61708
61710
61711
61712
61720
61735
61750
61751
61760
61770
61790
37,800
21,000
16,800
61791
37,800
21,000
16,800
61793
63,000
42,000
21,000
61795
63,000
42,000
21,000
Page 90 of 113
DESCRIPTION
Case Rate
62000
62005
61850
61855
61860
61865
61870
61875
61885
62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
Professional Fee
Health Care
Institution Fee
53,400
29,400
24,000
67,200
46,200
21,000
58,800
37,800
21,000
46,500
25,200
21,300
58,800
37,800
21,000
67,200
46,200
21,000
37,800
21,000
16,800
30,300
16,800
13,500
37,800
21,000
16,800
46,500
25,200
21,300
71,400
50,400
21,000
37,800
21,000
16,800
46,500
25,200
21,300
53,400
29,400
24,000
58,800
55,000
30,300
30,300
30,300
30,300
53,400
37,800
33,600
16,800
16,800
16,800
16,800
29,400
21,000
21,400
13,500
13,500
13,500
13,500
24,000
53,400
29,400
24,000
55,000
33,600
21,400
62160
37,800
21,000
16,800
62161
46,500
25,200
21,300
62162
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
62180
37,800
21,000
16,800
62190
23,300
12,600
10,700
23,300
12,600
10,700
37,800
46,500
30,300
30,300
21,000
25,200
16,800
16,800
16,800
21,300
13,500
13,500
23,300
12,600
10,700
12,900
12,900
5,680
6,300
6,300
1,680
6,600
6,600
4,000
5,560
1,260
4,300
23,300
12,600
10,700
62163
62165
62192
62200
62201
62220
62223
62230
62268
62269
62270
62272
62287
Page 91 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
Catheter Implantation
62350
18,000
8,400
9,600
62351
37,800
21,000
16,800
9,700
4,200
5,500
18,000
8,400
9,600
23,300
12,600
10,700
46,500
25,200
21,300
55,000
33,600
21,400
53,400
29,400
24,000
37,800
21,000
16,800
37,800
21,000
16,800
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
55,000
33,600
21,400
46,500
25,200
21,300
53,400
29,400
24,000
46,500
25,200
21,300
62360
62361
62362
62464
63001
63003
63005
63011
63012
63015
63016
63017
63020
63030
63040
63042
63045
55,000
33,600
21,400
63046
53,400
29,400
24,000
63047
46,500
25,200
21,300
Page 92 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
63055
53,400
29,400
24,000
63056
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
37,800
21,000
16,800
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
53,400
29,400
24,000
58,800
37,800
21,000
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
53,400
53,400
57,520
29,400
29,400
36,120
24,000
24,000
21,400
55,000
33,600
21,400
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
49,020
27,720
21,300
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
37,800
21,000
16,800
55,000
33,600
21,400
63064
63075
63077
63081
63085
63087
63090
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
Page 93 of 113
DESCRIPTION
Case Rate
63650
63655
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63300
63301
63302
63303
63304
63305
63306
63307
63600
63610
63615
63685
63700
63702
63704
63706
63707
63709
63710
Page 94 of 113
Professional Fee
Health Care
Institution Fee
53,400
29,400
24,000
46,500
25,200
21,300
37,800
21,000
16,800
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
37,800
21,000
16,800
58,800
37,800
21,000
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
58,800
37,800
21,000
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
55,000
33,600
21,400
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
30,300
16,800
13,500
30,300
16,800
13,500
37,600
18,900
18,700
8,020
2,520
5,500
46,500
25,200
21,300
21,820
10,920
10,900
30,300
37,180
37,800
46,500
30,300
46,500
46,500
16,800
18,480
21,000
25,200
16,800
25,200
25,200
13,500
18,700
16,800
21,300
13,500
21,300
21,300
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
30,300
16,800
13,500
23,300
12,600
10,700
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
12,120
12,120
18,000
20,980
20,980
20,980
37,800
18,000
18,000
18,000
18,000
18,000
6,720
6,720
8,400
10,080
10,080
10,080
21,000
8,400
8,400
8,400
8,400
8,400
5,400
5,400
9,600
10,900
10,900
10,900
16,800
9,600
9,600
9,600
9,600
9,600
64727
30,300
16,800
13,500
9,700
9,700
9,700
9,700
9,700
12,120
9,700
12,120
21,940
4,200
4,200
4,200
4,200
4,200
6,720
4,200
6,720
9,240
5,500
5,500
5,500
5,500
5,500
5,400
5,500
5,400
12,700
21,940
9,240
12,700
18,000
9,700
8,400
4,200
9,600
5,500
18,000
8,400
9,600
18,000
8,400
9,600
37,800
30,300
21,000
16,800
16,800
13,500
8,020
8,020
8,020
8,020
9,700
8,020
8,020
2,520
2,520
2,520
2,520
4,200
2,520
2,520
5,500
5,500
5,500
5,500
5,500
5,500
5,500
9,700
4,200
5,500
8,020
2,520
5,500
18,000
18,000
18,000
18,000
12,120
8,400
8,400
8,400
8,400
6,720
9,600
9,600
9,600
9,600
5,400
20,980
10,080
10,900
18,000
8,020
18,000
18,000
18,000
8,020
18,000
8,400
2,520
8,400
8,400
8,400
2,520
8,400
9,600
5,500
9,600
9,600
9,600
5,500
9,600
20,980
10,080
10,900
18,000
8,400
9,600
64732
64734
64736
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
64766
64771
64772
64774
64776
64782
64784
64786
64788
64790
64792
64795
64802
64804
64809
64818
64820
64830
64831
64832
64834
64835
64836
64837
64840
64856
64857
Transection or Avulsion
Transection or avulsion of; supraorbital nerve
Transection or avulsion of; infraorbital nerve
Transection or avulsion of; mental nerve
Transection or avulsion of; inferior alveolar nerve by osteotomy
Transection or avulsion of; lingual nerve
Transection or avulsion of; facial nerve, differential or complete
Transection or avulsion of; greater occipital nerve
Transection or avulsion of; phrenic nerve
Transection or avulsion of; vagus nerve (vagotomy), transthoracic
Transection or avulsion of; vagi limited to proximal stomach (selective
proximal vagotomy, proximal gastric vagotomy, parietal cell vagotomy,
supra- or highly selective vagotomy)
Transection or avulsion of; vagus nerve (vagotomy), abdominal
Transection or avulsion of; pudendal nerve
Transection or avulsion of obturator nerve, extrapelvic, w/ or w/o adductor
tenotomy
Transection or avulsion of obturator nerve, intrapelvic, w/ or w/o adductor
tenotomy
Transection or avulsion of other cranial nerve, intradural
Transection or avulsion of other spinal nerve, extradural
Somatic Nerves
Excision of neuroma; cutaneous nerve, surgically identifiable
Excision of neuroma; digital nerve, one or both, same digit
Excision of neuroma; hand or foot, except digital nerve
Excision of neuroma; major peripheral nerve, except sciatic
Excision of neuroma; sciatic nerve
Excision of neurofibroma or neurolemmoma; cutaneous nerve
Excision of neurofibroma or neurolemmoma; major peripheral nerve
Excision of neurofibroma or neurolemmoma; extensive (including malignant
type)
Biopsy of nerve
Sympathetic Nerves
Sympathectomy, cervical
Sympathectomy, cervicothoracic
Sympathectomy, thoracolumbar
Sympathectomy, lumbar
Sympathectomy, digital arteries, w/ magnification, each digit
Neurorrhaphy
Microdissection and/or microrepair of nerve (list separately in addition to
code for nerve repair)
Suture of digital nerve, hand or foot; one nerve
Suture of digital nerve, hand or foot; each additional digital nerve
Suture of one nerve, hand or foot; common sensory nerve
Suture of one nerve, hand or foot; median motor thenar
Suture of one nerve, hand or foot; ulnar motor
Suture of each additional nerve, hand or foot
Suture of posterior tibial nerve
Suture of major peripheral nerve, arm or leg, except sciatic; including
transposition
Suture of major peripheral nerve, arm or leg, except sciatic; w/o
transposition
Page 95 of 113
DESCRIPTION
64858
64859
64861
64862
64864
64865
64866
64868
64870
18,000
8,020
20,980
20,980
20,980
20,980
23,300
23,300
23,300
8,400
2,520
10,080
10,080
10,080
10,080
12,600
12,600
12,600
Health Care
Institution Fee
9,600
5,500
10,900
10,900
10,900
10,900
10,700
10,700
10,700
64885
23,300
12,600
10,700
64886
Nerve graft (includes obtaining graft), head or neck; more than 4 cm length
31,580
14,280
17,300
30,300
16,800
13,500
30,300
16,800
13,500
23,300
12,600
10,700
31,580
14,280
17,300
27,120
15,120
12,000
30,300
16,800
13,500
23,300
12,600
10,700
31,580
14,280
17,300
8,020
8,020
20,980
20,980
2,520
2,520
10,080
10,080
5,500
5,500
10,900
10,900
12,120
12,120
12,120
12,120
12,120
6,720
6,720
6,720
6,720
6,720
5,400
5,400
5,400
5,400
5,400
37,800
21,000
16,800
38,640
21,840
16,800
39,480
22,680
16,800
10,960
5,460
5,500
10,960
5,460
5,500
Case Rate
65091
65093
65101
65103
65105
65110
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
65112
65114
65130
65135
Professional Fee
65140
11,980
5,880
6,100
65150
11,980
5,880
6,100
11,980
5,880
6,100
9,700
4,200
5,500
3,500
1,000
2,500
4,500
2,000
2,500
4,180
18,000
1,680
8,400
2,500
9,600
53,400
29,400
24,000
55,000
33,600
21,400
8,020
2,520
5,500
8,020
2,520
5,500
9,700
4,200
5,500
65155
65175
65205
65210
65222
65235
65260
65265
65270
65273
65275
Page 96 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
20,980
10,080
10,900
23,300
12,600
10,700
9,700
4,200
5,500
9,700
4,200
5,500
Anterior Segment
Cornea
Excision
65400
8,260
3,360
4,900
65410
65420
65426
8,020
8,260
9,700
2,520
3,360
4,200
5,500
4,900
5,500
8,020
2,520
5,500
65710
Biopsy of cornea
Excision or transposition of pterygium; without graft
Excision or transposition of pterygium; with graft
Removal or Destruction
Destruction of lesion of cornea by cryotherapy, photocoagulation or
thermocauterization
Keratoplasty (corneal transplant); lamellar
30,300
16,800
13,500
65730
30,300
16,800
13,500
65750
30,300
16,800
13,500
65755
30,300
16,800
13,500
65760
65765
65767
65770
65771
Other Procedures
Keratomileusis
Keratophakia
Epikeratoplasty
Keratoprosthesis
Radial keratotomy
65772
65450
N/A
N/A
N/A
10,540
18,000
30,300
14,960
5,040
8,400
16,800
7,560
5,500
9,600
13,500
7,400
14,960
7,560
7,400
65775
14,960
7,560
7,400
65780
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
65781
65782
65805
8,020
2,520
5,500
65810
9,700
4,200
5,500
9,700
4,200
5,500
23,300
23,300
12,600
12,600
10,700
10,700
12,120
6,720
5,400
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
12,120
8,020
5,040
6,720
2,520
5,500
5,400
5,500
8,260
18,000
3,360
8,400
4,900
9,600
18,000
8,400
9,600
65815
65820
65850
65855
65860
65865
65870
66130
66150
66155
65875
65880
65900
65920
65930
Page 97 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
66600
66605
66625
12,120
6,720
5,400
66630
12,120
6,720
5,400
18,000
8,400
9,600
14,960
7,560
7,400
11,980
11,980
11,980
11,980
5,880
5,880
5,880
5,880
6,100
6,100
6,100
6,100
10,540
5,040
5,500
12,120
6,720
5,400
10,540
5,040
5,500
12,120
6,720
5,400
8,260
3,360
4,900
66160
66165
66170
66172
66180
66185
66220
66225
66250
66500
66505
66680
66682
66700
66710
66720
66740
66761
66762
66770
66820
66821
66825
Lens
Removal Cataract
Discission of secondary membranous cataract (opacified posterior lens
capsule and/or anterior hyaloid); stab incision technique (Ziegler or
Wheeler knife)
Discission of secondary membranous cataract (opacified posterior lens
capsule and/or anterior
hyaloid); laser surgery (e.g., YAG laser) (one or more stages)
Repositioning of intraocular lens prosthesis, requiring an incision
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
27,120
15,120
12,000
30,300
16,800
13,500
30,300
16,800
13,500
12,120
23,300
6,720
12,600
5,400
10,700
14,960
7,560
7,400
10,540
10,540
5,040
5,040
5,500
5,500
12,120
18,000
6,720
8,400
5,400
9,600
18,000
8,400
9,600
66830
12,120
6,720
5,400
66840
16,000
6,400
9,600
66850
16,000
6,400
9,600
66852
16,000
6,400
9,600
66920
66930
66940
16,000
16,000
16,000
6,400
6,400
6,400
9,600
9,600
9,600
66982
16,000
6,400
9,600
66983
16,000
6,400
9,600
Page 98 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
16,000
6,400
9,600
16,000
6,400
9,600
16,000
6,400
9,600
16,000
6,400
9,600
66991
37,800
21,000
16,800
66992
66993
66994
66995
37,800
30,300
30,300
30,300
21,000
16,800
16,800
16,800
16,800
13,500
13,500
13,500
12,120
6,720
5,400
18,000
8,400
9,600
9,700
4,200
5,500
18,000
8,400
9,600
37,800
21,000
16,800
45,000
21,000
24,000
9,700
4,200
5,500
12,120
6,720
5,400
31,580
14,280
17,300
12,900
6,300
6,600
66996
66997
66998
66999
Posterior Segment
Vitreous
67005
67010
67015
67025
67027
67030
67031
67036
67038
67039
67040
67041
67042
67043
67044
67045
67046
67047
10,540
5,040
5,500
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
67048
46,500
25,200
21,300
67049
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
37,800
21,000
16,800
46,500
25,200
21,300
37,180
18,480
18,700
67050
67051
67052
67101
67105
Page 99 of 113
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
67107
46,500
25,200
21,300
67108
46,500
25,200
21,300
30,300
16,800
13,500
46,500
25,200
21,300
12,120
12,120
20,980
6,720
6,720
10,080
5,400
5,400
10,900
67110
67112
67115
67120
67121
67208
12,120
6,720
5,400
67210
12,120
6,720
5,400
67218
12,120
6,720
5,400
67220
12,120
6,720
5,400
67221
12,120
6,720
5,400
67222
12,120
6,720
5,400
67227
12,120
6,720
5,400
67228
12,120
6,720
5,400
12,120
6,720
5,400
10,120
4,620
5,500
12,120
6,720
5,400
12,120
6,720
5,400
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
21,940
9,240
12,700
11,980
5,880
6,100
22,660
11,760
10,900
18,000
9,700
8,400
4,200
9,600
5,500
9,700
4,200
5,500
Sclera
Repair
67250
Scleral reinforcement
Ocular Adnexa
67311
67312
67314
67316
67318
67320
67331
67332
67334
67340
67343
67345
67350
Extraocular Muscles
Strabismus surgery, recession or resection procedure (patient not
previously operated on); one horizontal muscle
Strabismus surgery, recession or resection procedure (patient not
previously operated on); two horizontal muscles
Strabismus surgery, recession or resection procedure (patient not
previously operated on); one vertical muscle (excluding superior oblique)
Strabismus surgery, recession or resection procedure (patient not
previously operated on); two or more vertical muscles (excluding superior
oblique)
Strabismus surgery, any procedure (patient not previously operated on),
superior oblique muscle
Transposition procedure (e.g., for paretic extraocular muscle), any
extraocular muscle (specify)
Strabismus surgery on patient w/ previous eye surgery or injury that did not
involve the extraocular muscles
Strabismus surgery on patient w/ scaring of extraocular muscles (e.g., prior
ocular injury, strabismus or retinal detachment surgery) or restrictive
myopathy (e.g., dysthyroid ophthalmopathy)
Strabismus surgery by posterior fixation suture technique, w/ or w/o muscle
recession
Strabismus surgery involving exploration and/or repair of detached
extraocular muscle(s)
Release of extensive scar tissue w/o detaching extraocular muscle
Chemodenervation of extraocular muscle
Other Procedures
Biopsy of extraocular muscle
Orbit
67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67550
67560
67570
67580
67581
67582
67583
DESCRIPTION
Case Rate
67830
67835
Repair of trichiasis; incision of lid margin, with free mucous membrane graft
67584
67585
67586
67700
67710
67715
67800
67810
67825
67840
67875
67880
67882
Professional Fee
Health Care
Institution Fee
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
10,960
10,960
5,460
5,460
5,500
5,500
53,400
29,400
24,000
12,120
6,720
5,400
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
5,680
5,680
5,680
1,680
1,680
1,680
4,000
4,000
4,000
5,680
5,680
1,680
1,680
4,000
4,000
5,680
1,680
4,000
3,640
840
2,800
9,300
2,100
7,200
5,560
1,260
4,300
5,680
1,680
4,000
5,680
1,680
4,000
8,020
2,520
5,500
18,000
8,400
9,600
18,000
8,400
9,600
20,980
10,080
10,900
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
67966
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
18,000
8,400
9,600
21,400
32,000
8,020
8,020
9,700
10,500
14,700
2,520
2,520
4,200
10,900
17,300
5,500
5,500
5,500
12,900
6,300
6,600
5,680
5,680
9,700
12,900
1,680
1,680
4,200
6,300
4,000
4,000
5,500
6,600
9,700
4,200
5,500
12,120
6,720
5,400
12,120
6,720
5,400
30,740
13,440
17,300
27,120
15,120
12,000
67971
30,300
16,800
13,500
67973
37,800
21,000
16,800
67974
37,800
21,000
16,800
30,300
16,800
13,500
5,680
8,020
8,020
8,020
1,680
2,520
2,520
2,520
4,000
5,500
5,500
5,500
10,540
5,040
5,500
12,120
6,720
5,400
14,960
7,560
7,400
18,000
8,400
9,600
14,960
7,560
7,400
21,940
9,240
12,700
18,000
8,400
9,600
6,100
68360
11,980
5,880
68362
Conjunctival flap; total (such as Gunderson thin flap or purse string flap)
11,980
5,880
6,100
68371
20,980
10,080
10,900
5,680
5,680
5,680
1,680
1,680
1,680
4,000
4,000
4,000
12,120
5,680
12,120
5,680
6,720
1,680
6,720
1,680
5,400
4,000
5,400
4,000
67975
68100
68110
68115
68130
68320
68325
68326
68328
68330
68335
68340
68400
68420
68440
68500
68510
68520
68525
68530
68540
N/A
N/A
18,000
N/A
8,400
9,600
DESCRIPTION
Excision of lacrimal gland tumor; involving osteotomy
Repair
Plastic repair of canaliculi
Correction of everted punctum, cautery
Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity)
Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without
tube
Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with
insertion of tube or stent
Closure of the lacrimal punctum; by thermocauterization, ligation, or laser
surgery
Closure of lacrimal fistula
Probing and/or Related Procedures
Probing of nasolacrimal duct; requiring general anesthesia
Probing of nasolacrimal duct; with insertion of tube or stent
Auditory System
External Ear
Incision
Drainage external ear, abscess or hematoma
Drainage external auditory canal, abscess
Excision
Biopsy external ear
Biopsy external auditory canal
Excision external ear; partial, simple repair
Excision external ear; complete amputation
Excision exostosis(es), external auditory canal
Excision soft tissue lesion, external auditory canal
Radical excision external auditory canal lesion; w/o neck dissection
Radical excision external auditory canal lesion; w/ neck dissection
Removal of Foreign Body
18,000
8,400
Health Care
Institution Fee
9,600
9,700
3,640
18,000
4,200
840
8,400
5,500
2,800
9,600
18,000
8,400
9,600
20,980
10,080
10,900
69200
69220
68550
68700
68705
68720
68745
68750
68760
68770
68811
68815
69000
69020
69100
69105
69110
69120
69140
69145
69150
69155
69222
69310
69320
Case Rate
Professional Fee
8,020
2,520
5,500
10,880
3,780
7,100
8,020
9,700
2,520
4,200
5,500
5,500
3,672
3,472
672
252
3,000
3,220
5,680
5,680
8,260
12,120
9,700
9,700
23,300
30,300
1,680
1,680
3,360
6,720
4,200
4,200
12,600
16,800
4,000
4,000
4,900
5,400
5,500
5,500
10,700
13,500
9,300
2,100
7,200
8,020
2,520
5,500
9,700
4,200
5,500
23,300
12,600
10,700
23,300
12,600
10,700
5,812
5,680
1,512
1,680
4,300
4,000
5,680
1,680
4,000
8,020
2,520
5,500
8,260
3,360
4,900
8,260
3,360
4,900
18,000
9,700
8,400
4,200
9,600
5,500
20,980
23,300
23,300
23,300
23,300
46,500
8,020
30,300
30,300
30,300
10,080
12,600
12,600
12,600
12,600
25,200
2,520
16,800
16,800
16,800
10,900
10,700
10,700
10,700
10,700
21,300
5,500
13,500
13,500
13,500
69601
Introduction
Eustachian tube inflation, transnasal; w/ catheterization
Eustachian tube catheterization, transtympanic
Incision
Myringotomy including aspiration and/or eustachian tube inflation
Myringotomy including aspiration and/or eustachian tube inflation
requiring general anesthesia
Tympanostomy (requiring insertion of ventilating tube), local or topical
anesthesia
Tympanostomy (requiring insertion of ventilating tube), w/ general
anesthesia
Middle ear exploration through postauricular or ear canal incision
Tympanolysis, transcanal
Excision
Transmastoid antrotomy ("simple" mastoidectomy)
Mastoidectomy; complete
Mastoidectomy; modified radical
Mastoidectomy; radical
Petrous apicectomy including radical mastoidectomy
Resection temporal bone, external approach
Excision aural polyp
Excision aural glomus tumor; transcanal
Excision aural glomus tumor; transmastoid
Excision aural glomus tumor; extended (extratemporal)
Repair
Revision mastoidectomy; resulting in complete mastoidectomy
23,300
12,600
10,700
69602
31,580
14,280
17,300
69603
69604
69605
23,300
23,300
23,300
12,600
12,600
12,600
10,700
10,700
10,700
12,120
6,720
5,400
69400
69405
69420
69421
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69550
69552
69554
69610
DESCRIPTION
69620
20,980
10,080
Health Care
Institution Fee
10,900
69631
30,740
13,440
17,300
69632
30,740
13,440
17,300
69633
30,740
13,440
17,300
46,500
25,200
21,300
47,340
26,040
21,300
69637
47,340
26,040
21,300
69641
46,500
25,200
21,300
69642
47,340
26,040
21,300
48,180
26,880
21,300
49,020
27,720
21,300
46,500
25,200
21,300
46,500
25,200
21,300
37,800
21,000
16,800
38,640
21,840
16,800
38,640
21,840
16,800
38,640
38,640
38,640
31,580
30,300
21,840
21,840
21,840
14,280
16,800
16,800
16,800
16,800
17,300
13,500
69700
10,540
5,040
5,500
69720
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
37,800
21,000
16,800
38,640
21,840
16,800
69635
69636
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69725
69740
69745
69801
Case Rate
Professional Fee
69802
39,480
22,680
16,800
69805
46,500
25,200
21,300
70010
70390
71090
72240
74300
74328
74329
74330
74340
74350
74355
74360
74363
74475
74480
74742
75600
75625
75630
DESCRIPTION
53,400
46,500
53,400
29,400
25,200
29,400
Health Care
Institution Fee
24,000
21,300
24,000
46,500
53,400
53,400
25,200
29,400
29,400
21,300
24,000
24,000
55,000
33,600
21,400
55,000
55,000
53,400
46,500
33,600
33,600
29,400
25,200
21,400
21,400
24,000
21,300
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
8,020
2,520
5,500
9,700
9,700
4,200
4,200
5,500
5,500
9,700
4,200
5,500
Case Rate
Professional Fee
75635
9,700
4,200
5,500
75650
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
75658
75660
75662
75665
75671
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
75722
9,700
4,200
5,500
75724
9,700
4,200
5,500
75726
9,700
4,200
5,500
75731
9,700
4,200
5,500
75733
9,700
4,200
5,500
75736
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
75756
9,700
4,200
5,500
75757
3,500
500
3,000
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
75825
9,700
4,200
5,500
75827
9,700
4,200
5,500
75831
9,700
4,200
5,500
75833
9,700
4,200
5,500
75840
9,700
4,200
5,500
75842
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
9,700
4,200
4,200
5,500
5,500
12,900
6,300
6,600
12,900
6,300
6,600
30,300
16,800
13,500
9,700
4,200
5,500
9,700
4,200
5,500
75741
75743
75746
75790
75801
75803
75805
75807
75810
75820
75860
75870
75872
75880
75885
75889
75900
75901
75902
75953
75954
75956
75957
75958
75959
75960
75961
75962
75966
75970
75978
75980
75982
75984
75989
75992
75994
75995
76003
76012
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
9,700
4,200
5,500
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
46,500
25,200
21,300
46,500
25,200
21,300
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
37,800
21,000
16,800
46,500
25,200
21,300
8,020
2,520
5,500
8,020
2,520
5,500
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
8,020
2,520
5,500
30,300
16,800
13,500
DESCRIPTION
Case Rate
76013
76080
76086
76095
76096
76355
76360
76362
76393
76394
76930
76932
76936
76940
76942
76965
76986
77261
77401
77401
77418
77421
77432
77600
77750
Professional Fee
Health Care
Institution Fee
30,300
16,800
13,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
18,000
8,400
9,600
3,000
2,000
800
800
2,200
1,200
5,680
1,680
4,000
30,300
16,800
13,500
30,300
16,800
13,500
12,120
6,720
5,400
5,680
1,680
4,000
77761
18,000
8,400
9,600
77776
18,000
8,400
9,600
5,680
1,680
4,000
9,700
4,200
5,500
3,640
840
2,800
77781
77789
79000
DESCRIPTION
Case Rate
79440
79445
79005
79200
79300
79403
88174
88331
Pathology Services
Cytopathology
Evaluation of aspirate (CT-guided biopsy) with or without preparation of
smears; immediate cytologic study to determine adequacy of specimen(s),
interpretation and report
Surgical Pathology
Pathology consultation during surgery; with frozen section(s), single block
90935
90945
88332
Professional Fee
Health Care
Institution Fee
8,020
2,520
5,500
9,700
4,200
5,500
9,700
4,200
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
5,680
1,680
4,000
5,680
1,680
4,000
9,700
4,200
5,500
4,000
500
3,500
4,000
500
3,500
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
30,300
16,800
13,500
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
53,400
53,400
53,400
29,400
29,400
29,400
24,000
24,000
24,000
21,400
10,500
10,900
21,400
10,500
10,900
30,300
16,800
13,500
12,900
6,300
6,600
18,000
8,400
9,600
Gastroenterology
91034
91037
91100
91105
92973
92975
92980
92981
92982
92986
92987
92990
92992
92993
92995
92997
93501
93503
93505
93508
93510
93511
93514
93524
9,700
4,200
5,500
23,300
12,600
10,700
9,700
4,200
5,500
18,000
8,400
9,600
18,000
8,400
9,600
18,000
23,300
8,400
12,600
9,600
10,700
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
18,000
8,400
9,600
23,300
12,600
10,700
93532
9,700
4,200
5,500
93533
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
23,300
12,600
10,700
9,700
4,200
5,500
93539
93540
93541
93542
93543
93544
93545
93555
9,700
4,200
5,500
93556
9,700
4,200
5,500
55,000
33,600
21,400
55,000
33,600
21,400
9,700
9,700
9,700
9,700
9,700
4,200
4,200
4,200
4,200
4,200
5,500
5,500
5,500
5,500
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
93620
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
93624
9,700
4,200
5,500
93631
9,700
4,200
5,500
93640
Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at
time of initial implantation or replacement;
9,700
4,200
5,500
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
93641
Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at
time of initial implantation or replacement; with testing of single or dual
chamber pacing cardioverter-defribrillator pulse generator
9,700
4,200
5,500
93642
Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator (includes defibrillation threshold evaluation, induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination,
and programming or reprogramming
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
7,280
1,680
5,600
5,560
1,260
4,300
8,020
2,520
5,500
5,560
1,260
4,300
3,640
840
2,800
8,020
2,520
5,500
1,500
600
900
2,150
860
1,290
650
260
390
6,500
2,600
3,900
8,000
3,200
4,800
5,000
2,000
3,000
6,500
2,600
3,900
1,750
500
1,250
93650
93651
93652
93660
96408
96440
96445
96450
96542
96567
ANC01
ANC02
59403
Chemotherapy administration
Chemotherapy administration into pleural cavity, requiring and including
thoracentesis
Chemotherapy administration into peritoneal cavity, requiring and including
peritoneocentesis
Chemotherapy administration into CNS, requiring and including spinal
puncture
Chemotherapy injection, subarachnoid or interventricular via subcutaneous
reservoir
Photodynamic Therapy
Photodynamic therapy by external application of light to destroy
premalignant and/or malignant lesions of the skin and adjacent mucosa
(e.g., lip) by activation of photosensitive drug(s), 1 or more phototherapy
exposure session
Benefit packages
Vaginal Delivery, Antepartum and Postpartum Care
Essential services during antenatal period (Antenatal Care Package)
Antenatal care services with intrapartum monitoring or labor watch
(without delivery) (infirmaries/dispensaries, birthing homes/maternity
clinics)
Intrapartum monitoring or labor watch (without delivery)
(infirmaries/dispensaries, birthing homes/maternity clinics)
Essential health services during antenatal, intrapartum and postpartum
period including antenatal care, intrapartum monitoring, normal delivery
postpartum care (Maternity Care Package) (hospitals)
MCP01
NSD01
99432
59402
87207
89221
89222
90375
N/A
N/A
600
2,500
1,500
3,000
N/A
600
2,500
1,500
3,000
DESCRIPTION
99246
P0001
P0000
Referral package
Resuscitation package
Case Rate
7,500
per quarter
4,000
4,000
Professional Fee
1,200
1,200
Health Care
Institution Fee
7,500
per quarter
2,800
2,800